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COMMISSION ON HUMAN RIGHTSFifty-fifth sessionItem 12 (a) of the provisional agenda INTEGRATION OF THE HUMAN RIGHTS OF WOMENAND THE GENDER PERSPECTIVE Report of the Special Rapporteur on violence against women, itscausesand consequences, Ms. Radhika Coomaraswamy, in accordancewith Commission on Human Rights resolution 1997/44 Policies and practices that impact women's reproductive rights and contribute to, cause or constitute violence against women Reproductive health consequences of violence against Violence within the context of reproductive health policy44 - 79 Violations resulting from direct State action 48 - 65 Violations resulting from State failure to meet minimum core The present report examines policies and practices that impact women's reproductive rights and contribute to, cause orconstitute violence against women. Many forms of violenceagainst women result in violations of women's reproductive rightsbecause such violence often imperils their reproductive capacitiesand/or prevents them from exercising reproductive and sexualchoices. Similarly, many reproductive rights violations constituteviolence against women per se, defined as "any act of gender-based violence that results in, or is likely to result in, physical,sexual or psychological harm or suffering to women, includingthreats of such acts, coercion or arbitrary deprivation of liberty,whether occurring in public or in private life". / Declaration on the Elimination of Violence against Women,proclaimed by the General Assembly by its resolution 1998/104 of20 December 1993./ Inadequate levels of knowledge about humansexuality and inappropriate or inadequate reproductive healthinformation and services, culturally-imbedded discriminationagainst women and girls, and limits on women's control over theirown sexual and reproductive lives all contribute to violations ofwomen's reproductive health.
While such practices may be sanctioned by moral or Harmful Traditional Practices Affecting the Health of Women and Children, Fact Sheet No. 23, UnitedNations, Geneva, 1995./ they nonetheless violate a woman'sfundamental right to reproductive health and may constituteviolence against women. Reproductive rights are a fundamentaland integral part of women's human rights, and, as such, areenshrined in international standards that transcend cultural,traditional and societal norms.
As defined and recognized by Governments at the International Conference on Population and Development("ICPD") in 1994, reproductive health entails that people have theability to have a satisfying and safe sex life and that they have thecapability to reproduce and the freedom to decide if, when andhow often to do so. Implicit in this definition is "the right of menand women to be informed and to have access to safe, effective,affordable and acceptable methods of their choice for regulation offertility which are not against the law, and the right of access toappropriate health care services that will enable women to gosafely through pregnancy and childbirth and provide couples withthe best chance of having a healthy infant". / Programme of Actionof the International Conference on Population and Development,para. 7.2. In Report of the International Conference on Populationand Development, Cairo, 5-13 September 1994, (United Nationspublication, Sales No. E.95.XIII.18), chap. 1, resolution 1, annex./ Reproductive rights rest on recognition of the basic right of all couples and individuals to have the information and means todecide freely and responsibly the number, spacing and timing oftheir children, and the right to attain the highest standard of sexualand reproductive health, free of discrimination, coercion andviolence. The Platform for Action adopted at the 1995 FourthWorld Conference on Women further recognizes that "equalrelationships between women and men in matters of sexualrelations and reproduction, including full respect for the integrityof the person, require mutual respect, consent and sharedresponsibility for sexual behaviour and its consequences". / Platform for Action of the Fourth World Conference on Women, para. 96. In Report of the Fourth World Conference onWomen, Beijing, 4-15 September 1995 (United Nations document,Sales No. E.96.IV.13), chap. I, resolution 1, annex I. / The right to reproductive health implicates the right to sexuality and sexual autonomy. While sexual and reproductivehealth rights are linked, they are not coterminus. Underscoring therecognition in the Cairo Programme of Action of the right to havea satisfying and safe sex life, paragraph 96 of the Beijing Platformfor Action states that, "the human rights of women include theright to have control over and decide freely and responsibly onmatters related to their sexuality, including sexual and reproductivehealth, free of coercion, discrimination and violence". Sexualrights include the right to information, based upon which one canmake informed decisions about sexuality; the rights to dignity, toprivacy and to physical, mental and moral integrity in realizing asexual choice; and the right to the highest standard of sexualhealth. / Yasmin Tambiah, "Sexuality and human rights", in Margaret Schuler, From Basic Needs to Basic Rights, 1995, p. 37./ Reproductive and sexual health rights under international human rights law derive from a number of separate human rights.
The Convention on the Elimination of All Forms of Discriminationagainst Women ("CEDAW Convention") recognizes that theability of a woman to control her own fertility is fundamental toher full enjoyment of the full range of human rights to which she isentitled. In this vein, article 12 provides for equality in access tohealth care, including family planning, appropriate services inconnection with pregnancy, confinement and the post-natal period,granting free services where necessary, as well as adequatenutrition during pregnancy and lactation.
The CEDAW Convention also contains several provisions that, in addressing the exploitation of women, are relevant towomen's reproductive health. For instance, article 6 requires Statesto take all appropriate measures to suppress all forms of traffickingand exploitation of prostitution, while article 16.2 requires States to specify a minimum age for marriage and to make theregistration of marriages in an official registry compulsory.
Recognized as customary international law, the fundamental human rights to be free from torture, to be free from genderdiscrimination and the inherent right to life, are directly applicableto the issue of violence against women and women's reproductivehealth. / Freedom from torture is reflected, inter alia, in article 7 of the Universal Declaration of Human Rights, article 7 of theInternational Covenant on Civil and Political Rights, and article 37of the Convention on the Rights of the Child; freedom from genderdiscrimination is reflected, inter alia, in article 2 of the UniversalDeclaration of Human Rights, article 2.2 of the InternationalCovenant on Economic, Social and Cultural Rights, article 2.1 ofthe International Covenant on Civil and Political Rights, article 3of the Convention on the Elimination of All Forms ofDiscrimination against Women; the right to life is reflected, interalia, in article 3 of the Universal Declaration of Human Rights,article 6 of the International Covenant on Civil and PoliticalRights, article 6 of the Convention on the Rights of the Child./ Inaddition to these basic norms, international human rights lawcontains non-discrimination provisions crucial to the realization ofwomen's human rights, including, for example, the right to modifycustoms that discriminate against women. / Convention on theElimination of All Forms of Discrimination against Women, article2 (f) and (g) and article 5 (a); Convention on the Rights of theChild, article 24.3./ Working to further the goals of the CEDAW Convention, the Committee on the Elimination of Discrimination against Women(CEDAW) has focused particularly on ending discriminationagainst women in national AIDS strategies and has called on Statesparties to give special attention to the subordinate position of women in some societies which makes them especially vulnerableto HIV infection. / by the Committee on the Elimination of All Forms ofDiscrimination against Women (ninth session, 1990) (seeA/45/38)./ Together with the Sub-Commission on Prevention ofDiscrimination and Protection of Minorities, the Committee haspaid special attention to the area of traditional practices harmful tothe health of women. Such practices include, but are not limited to,female genital mutilation, dangerous birth practices and sonpreference. The Committee has called on States parties to takeappropriate measures to eradicate the practice of female genitalmutilation, which could include the introduction of appropriateeducational and training programmes and seminars, thedevelopment of national health policies aimed at eradicatingfemale genital mutilation in public health facilities, and theprovision of support to national organizations working for thesegoals. / General Recommendation No. 14, adopted by the Committee on the Elimination of All Forms of Discriminationagainst Women (ninth session, 1990). Ibid./ The world conferences have helped to articulate the legal framework and policy goals for the enforcement of women's rightto reproductive health. For instance, with respect to the question ofabuse by health workers, the ICPD Programme of Action urgesGovernments at all levels "to institute systems of monitoring andevaluation of user-centred services with a view to detecting,preventing and controlling abuses by family-planning managersand providers and to ensure a continuing improvement in thequality of services" (para. 7.17). To this end, Governments shouldensure conformity to human rights and to ethical and professionalstandards in the delivery of family planning and relatedreproductive health services aimed at ensuring responsible,voluntary and informed consent.
The Beijing Platform for Action, in turn, urges Governments to "ensure that all health services and workers conform to humanrights and to ethical, professional and gender-sensitive standards inthe delivery of women's health services aimed at ensuringresponsible, voluntary and informed consent; encourage thedevelopment, implementation and dissemination of codes of ethicsguided by existing international codes of medical ethics as well asethical principles that govern other health professionals" (para. 106(g)). Moreover, recognizing that confidentiality and accessibility ofinformation are critical to the realization of women's reproductiverights, the Platform for Action directs Governments to "redesignhealth information, services and training for health workers so thatthey are gender-sensitive and reflect the user's . right to privacyand confidentiality" (para. 106 (f)).
The world conferences on human rights and women's rights have also addressed specific practices violative of women's humanrights, which directly impact women's reproductive health. Forinstance, the Beijing Platform for Action declared that "anyharmful aspect of . traditional, customary or modern practices thatviolates the rights of women should be prohibited and eliminated"(para. 224).
Other relevant practices specifically addressed in world conference documents include gender-based violence and all formsof sexual harassment and exploitation, child marriages and femalegenital mutilation. / Action (VDPA) adopted by the World Conference on HumanRights (A/CONF.157/23), Part I, para. 18 and Part II, para. 49;ICPD Programme of Action, para. 5.5./ The Beijing Platform forAction also addressed the problems of early pregnancy associatedwith child marriage, urging Governments "to enact and strictly enforce laws concerning the minimum legal age of consent and theminimum age of marriage and raise the minimum age for marriagewhere necessary" (para. 274).
Moreover, in order to facilitate the realization of women's human rights, the World Conference on Human Rights stressed theimportance of "working towards the . eradication of any conflictswhich may arise between the rights of women and the harmfuleffects of certain traditional or customary practices, culturalprejudices and religious extremism" (VDPA, Part II, para. 38).
A. Reproductive health consequences of violence against women Serious violations of a woman's right to reproductive health can result from practices that themselves constitute violenceagainst women. Examined below are the reproductive healthconsequences that result from rape, domestic violence, femalegenital mutilation, early marriages and early childbearing, sex-selective abortions, female infanticide, and trafficking and forcedprostitution. Each of these practices jeopardizes women'sreproductive freedom and rights. The following forms of violencemay have devastating physical and psychological healthconsequences. States have an obligation to address violenceagainst women by enacting and effectively implementing andenforcing laws prohibiting and punishing all forms of suchviolence as well as by enacting policies and programmes to avertits commission. Numerous international instruments haverecognized State responsibility in this regard.
As the Special Rapporteur has pointed out, rape as the ultimate violent and degrading act of sexual violence, constitutes"an intrusion into the most private and intimate parts of a woman'sbody, as well as an assault on the core of her self". / Scully and Joseph Marolla, "Riding the bull at Gilley's: Convictedrapists describe the rewards of rape", in Pauline B. Bart and EileenGeil Moran (eds.), Violence Against Women: The BloodyFootprints, 1993, p. 42. Cited in E/CN.4/1997/47, para. 19./ Whilerape commonly occurs as a manifestation of extreme sexualviolence against individual women, rape is increasingly used as aweapon of war, political repression, or ethnic cleansing.
United Nations and other sources have documented numerous cases of rape in the context of armed conflict. During theconflict in the former Yugoslavia, for example, tens of thousandsof Muslim women were held in "rape camps" where they wereraped repeatedly and forced to bear children against their will.
Genocidal rape, often followed by murder, was carried out againsteven larger numbers of Tutsi women during the 1994 conflict inRwanda. During the recent riots in Indonesia in May 1998, therewas widespread rape of ethnic Chinese women. Rape may be usedto make women "unmarriageable" in the communities in whichthey live. Rape may be used not only to punish the victim, but alsoto punish male family members, who are often forced to witnessthe act.
Rape committed as a part of political repression is prohibited under international law as torture or cruel, inhuman or degradingtreatment. The International Covenant on Civil and Political Rightsand the Convention against Torture and Other Cruel, Inhuman orDegrading Treatment or Punishment both promote the dignity and physical integrity of the person and prohibit torture and cruel,inhuman, or degrading treatment. The Convention on theElimination of All Forms of Discrimination against Women hasalso been interpreted by CEDAW to prohibit all forms of violenceagainst women, including rape. Finally, the Inter-AmericanConvention on the Prevention, Punishment and Eradication ofViolence against Women also specifically prohibits rape and otherforms of violence.
Numerous international authorities have also recognized rape as a form of torture when rape is used to punish, coerce orintimidate, and is performed by State agents or with theiracquiescence. Moreover, rape committed as a weapon of war isexplicitly prohibited under international humanitarian lawgoverning both international and internal conflicts. The RomeStatute of the International Criminal Court (the ICC Statute)explicitly defines, for the first time under internationalhumanitarian law, rape, sexual slavery, enforced prostitution,forced pregnancy, enforced sterilization and other forms of sexualviolence as both crimes against humanity and war crimes. / Rome Statute of the International Criminal Court, adopted by the United Nations Diplomatic Conference of Plenipotentiaries onthe Establishment of an International Criminal Court on 17 July1998 (A/CONF.183/9), arts. 7 and 8./ The ICC Statute places rapeand other sexual violence on par with serious international crimesand rejects previous references under earlier humanitarian lawtreaties to sexual violence as exclusively "crimes against honour"and "outrages upon personal dignity" rather than violence.
Whatever the motive, rape may have a devastating effect on a woman's reproductive health. Often, the physical andpsychological harm caused by rape temporarily or permanentlyaffects women's sexual and reproductive autonomy and has lasting reproductive health consequences for the victims. Globally, thephysical consequences of rape and sexual violence account forapproximately 5 per cent of disease among women. / International Family Planning Perspective, vol. 22, No. 3, September 1996, p. 118. Rebecca J. Cook and Mahmoud F.
Fathalla, "Advancing Reproductive Rights Beyond Cairo andBeijing"./ Numerous surveys done in the United States indicatethat up to 30 per cent of women who are raped acquire a sexuallytransmitted disease (STD) as a result. Rape victims are at a higherrisk of STDs, such as AIDS, gonorrhoea, syphilis, genital herpesand chlamydia, as well as the long-term health consequences ofSTDs such as pelvic inflammatory disease and cervical cancer.
Women biologically are more vulnerable to acquiring STDs andthe consequences are more serious and life-threatening for womenthan for men. Further, they are exposed to the risk of unwantedpregnancy.
Rape can also cause profound emotional trauma that manifests itself in depression, inability to concentrate, sleep andeating disorders, feelings of anger, humiliation and self-blame, aswell as severe sexual problems, including problems of arousal, fearof sex, and decreased sexual functioning. The adult pregnancy rateassociated with rape is estimated to be 4.7 per cent. / Disease Control, National Center for Injury Prevention andControl, Rape Fact Sheet./ For a woman impregnated by rape,abortion may be legally denied, practically obstructed orunacceptable to the woman herself on religious or cultural grounds,thus compounding the woman's physical and emotional traumawith a constant physical reminder of her rape.
Domestic violence can have serious repercussions for women's reproductive health, particularly where the batteredwoman is pregnant. Studies indicate that domestic violencedirectly affects women's use of family planning and contraception.
This dynamic is exemplified by the case of M, a married Ugandanmother who was beaten by her husband for not producing morechildren, and further beaten when her husband discovered that shewas using contraceptives. / L. Heise, J. Pitanguy and A. Germaine,"Violence Against Women: The Hidden Health Burden". WorldBank Discussion Papers, 1994, p. 10./ In a survey of women inTexas, more than 12 per cent of the 1,539 respondents had beensexually abused by a current or former male partner after the age of18. Of these 187 women, 12.3 per cent reported that they had beenprevented from using birth control, and 10.7 per cent stated thatthey had been forced to get pregnant against their will. / Ibid./ Sexuality and reproduction is one of many ways in which batterers seek to exercise power and control over battered women.
In exercising their reproductive rights and seeking reproductivehealth services, battered women often risk their physical andpsychological safety, making them vulnerable to increasedviolence. Battered women have gone to great lengths to preventunwanted pregnancies by their abusers when their access tocontraceptives has been limited, in some cases resorting toclandestine and unsafe abortions.
The battering may escalate during and immediately after pregnancy, resulting in severe health problems for both the motherand the baby. Interviews with battered women in Santiagoindicated, for example, that for 40 per cent of these women, thebattering increased during pregnancy. Studies further indicate thatin Malaysia, 68 per cent of battered women were pregnant, / Rashida A. Abdullah, Gender Based Violence as a Health Issue: The Situation and Challenges to the Women's HealthMovement in Asia and the Pacific, 1997./ while in the UnitedStates, 25 per cent of battered women are beaten during pregnancy.
In addition to the physical injury resulting from the battery,battering during pregnancy can result in premature labour,miscarriages, recurrent vaginal infections, delivery of premature orlow-birth-weight infants with reduced chances for survival, sexualdysfunction, fear of sex, and sexually transmitted diseases.
Because pregnancy may be the only time when some women comeinto regular contact with health-care providers, prenatal care visitsmay provide a good opportunity to screen for physical violence.
Each year, thousands of young girls and women all over the world are trafficked into forced prostitution. They may be abductedor lured by traffickers with promises of higher-paying jobs thanthey can find locally, only to be sold to a brothel owner and forcedinto prostitution. Using a combination of threats, physical force,illegal confinement and debt bondage, brothel owners preventescape or negotiation by these women Unable to negotiate the terms of sex, women trafficked into forced prostitution find themselves increasingly exposed to serioushealth risks, including sexually transmitted diseases. These womenhave virtually no say in whether or not to service a particularcustomer, how many customers to accept in a given day, condomuse, or the type of sex. / Trafficking of Nepali Girls and Women to India's Brothels, p. 66./Preliminary medical research suggests that the younger the girl, themore susceptible she may be to HIV because the mucousmembrane of the genital tract, being thinner than that of a grownwoman, serves as a less efficient barrier to viruses. In many cases, brothels restrict the use of condoms, as clients are willing to payhigher rates for unprotected sex. Sexual intercourse with multipleclients can lead to painful vaginal bruises and abrasions, whichincreases the women's exposure to STDs. Moreover, subjected, ineffect, to multiple rapes, these women suffer serious psychologicalconsequences from their repeated victimization.
Apart from the risk of infection through sexual intercourse with numerous clients, the increasing use of contraceptiveinjections in brothels puts these women at further risk of disease,as brothel owners often use the same, possibly contaminated,needle multiple times. The contraction of AIDS could lead todeath, and other STDs contracted by these women may ultimatelyleave them infertile. In cultures in which the primary purpose ofmarriage is procreation, infertility can render these womenunmarriageable, as can pre-marital sex or perceived promiscuity.
Shunned by their communities as a result, these women may beforced to return to prostitution in order to support themselves, thuscontinuing the vicious cycle of sexual servitude. Reports alsoindicate that there have been cases of forced sterilization of brothelinmates, hysterectomies during abortion being the most typical.
Some cultures that place a high value on women's sexual and reproductive capacities seek to control these capacities throughpractices that violate women's reproductive rights and constituteviolence against women. Blind adherence to these practices, lackof information and education regarding their health consequences,and State inaction with respect to their elimination all contribute tothe perpetuation of these practices, with harmful consequences forwomen's reproductive health.
The Convention on the Elimination of All Forms of Discrimination against Women, the Convention on the Rights ofthe Child, the Declaration on the Elimination of Violence againstWomen, and the Beijing Declaration and Platform for Action allrequire States to refrain from invoking any custom, tradition, orreligious consideration to justify cultural practices that constituteviolence against women and violations of women's reproductivehealth. The following analysis examines ways in which States'failure to meet this requirement has led to severe, adverse healthconsequences violative of women's reproductive rights.
Female genital mutilation (FGM) has been recognized by the Special Rapporteur as a form of violence against women. Femalegenital mutilation is the act of partially or totally removing theexternal female genitalia. It is estimated that 130 million womenworldwide have undergone FGM, and that nearly 2 millionundergo the procedure every year. / Law and Policy, "Reproductive Freedom in Focus - Legislation onFemale Genital Mutilation in the United States", October 1997, p.
2./ Female genital mutilation is practised in approximately 40countries, primarily in East and West Africa, countries in theArabian Peninsula, and in Asia. An increasing number amongimmigrant communities in Australia, Canada, Europe and theUnited States of America also practise this custom. The frequencyand extent of the mutilation varies from country to country.
Female genital mutilation results from patriarchal power structures that legitimize the need to control women's lives. Thepractice "arises from the stereotypical perception that women are the principal guardians of a community's sexual morality and alsothe primary initiators of unchastity". / Rebecca J. Cook,"International Protection of Women's Reproductive Rights", NewYork University Journal of International Law and Politics, vol. 24,Winter 1992, No. 2, p. 682./ Female genital mutilation curtailswomen's sexual expression in order to ensure women's chastity. Insome cultures, FGM is considered necessary for the best interest ofthe girl, in that it prepares the girl for the pain of childbirth. Thesymbolic significance marks the girl's rite of passage intowomanhood and the acceptance of her responsibilities towards herfuture husband and her community, thus improving her"marriageability".
The ritual significance of the practice often masks the devastating physical and psychological effects it has on thewoman. Traditionally performed by birth attendants who use crudeand unhygienic instruments, the "operation" creates a serious riskof local and systemic infections, abscesses, ulcers, delayed healing,septicaemia, tetanus and gangrene. Short-term complications caninclude severe pain and haemorrhage that can lead to shock oreven death, while long-term complications can include urineretention, resulting in repeated urinary infections; obstruction ofmenstrual flow, leading to frequent reproductive tract infectionsand infertility; and prolonged and obstructed labour. / Reproductive Law and Policy, "Women's Reproductive Rights inMexico: A Shadow Report", December 1997, p. 24 (prepared forthe Eighteenth Session of the Committee on the Elimination of AllForms of Discrimination against Women). / Furthermore, FGMcan result in psychological problems such as chronic anxiety anddepression. The cycle of pain continues when cutting andrestitching is carried out to accommodate sexual intimacy andchildbirth.
Because the procedure can render sexual intercourse extremely painful, FGM fulfils the social goal of suppressingwomen's sexual desire. A major study in Egypt has suggested that,in communities where FGM is practised, women's sexuality isaffected by both the degree to which the inhibition of sexualexpressions are internalized through socialization, as well as by thetype of FGM operation women undergo. / are taught to inhibit their sexuality in preparation for marriagebecause of the social value that requires "respectable" women tonot appear "lustful". / Abdel Halim, "Female Circumcision and theCase of Sudan", p. 253, in Margaret Schuler, From Basic Needs toBasic Rights, 1995./ Studies also suggest that circumcised womenliving outside of communities where FGM is practised may haveproblems developing their sexual identity. / Ibid./ The practice of female circumcision has been condemned as a violation of the rights of women and girls. Female genitalmutilation affects women's enjoyment of their lives andreproductive health in a manner that denies liberty and security towomen, and subjects them, usually at a young age, to physicalviolence and serious health problems. In an effort to prevent suchviolations, the ICPD Programme of Action urges Governments toprohibit FGM where it is practised and to give "vigorous support toefforts among non-governmental and community organizations andreligious organizations to eliminate such practices" (paras. 4.22,5.5 and 7.40).
The Beijing Declaration and Platform for Action emphasizes the importance of education to aid understanding of the healthconsequences of the practice. Numerous African countries,including Ghana, Burkina Faso, Egypt and the Gambia, as well assome countries with significant African immigrant populations,such as the United Kingdom, Sweden, France, Australia and the United States, have criminalized the practice. The ineffectivenessof such laws in decreasing the prevalence of FGM attests to theneed for Governments to engage in education and communityoutreach efforts aimed at addressing the deeply ingrained culturalattitudes that continue to foster the practice in the face of thepotential criminal penalties. Moreover, there is a need to addressthe medicalization of FGM. In many urban areas of Africa and theMiddle East, FGM is increasingly practised by trained healthpersonnel. The procedure is done by personnel working athospitals and health centres and include those trained byinternational non-governmental organizations.
Though declining in frequency, child marriage remains a serious problem in many countries. In Nigeria, a quarter of allwomen are married by the age of 14, one half by the age of 16 andthree quarters by the age of 18. In Botswana, 28 per cent of womenwho have ever been pregnant were pregnant before reaching theage of 18. In Jamaica, one third of all births are to adolescentmothers, while in Peru, Colombia and El Salvador 13 per cent or14 per cent of women between 15 and 19 are already mothers. / Center for Reproductive Law and Policy, "Women of the World: Laws and Policies Affecting Their Reproductive Lives -Latin America and the Caribbean", 1997, p. 13./ Based on the view that virginity is essential in a bride, in some societies, girls are married off at a young age, often to mucholder men. As a result of the early marriages, these young girls aretraumatized by adult sex and are forced to bear children beforetheir bodies are fully mature. A number of human rights treatiesrequire that marriage be entered into with the free consent of men and women of full age. A young bride lacks the maturity andknowledge to consent not only to the marriage itself, but also to thesexual acts she would be forced to engage in once married.
Moreover, laws and policies allowing for a lower age of marriagefor women stereotypes women as childbearing machines anddenies them equal standing with men with respect to their right toconsent to marriage.
Early marriage can lead to early childbearing and frequent pregnancies, resulting in physical stress for the young mother andunderweight babies, which in turn accounts for the high infantmortality rates in regions where early marriages are the norm. It isestimated that without obstetric care, women who give birth beforethey reach the age of 18 are three times as likely to die in childbirthas women aged 20-29 under similar circumstances. / 13 p. 117./ Prolonged or obstructed labour due to underdevelopedpelvic bones can cause vesico-vaginal (VVF) or recto-vaginalfistula (RVF), or the tearing of the walls between the vagina andthe bladder or the rectum. If left untreated, this condition can causea woman to leak urine and faeces. This condition usually results ininfertility. In many cases, VVF victims are abandoned by theirhusbands and, in some cases, forced into prostitution to supportthemselves. Moreover, the lengthening of a woman's reproductiveperiod caused by early marriage can have other adverse effects onher health, including malnutrition.
Sex-selective abortion/female infanticide A cultural preference for sons can result in violence against female foetuses and girl children. In many cultures, a son isconsidered an asset to the family as it is he who carries the lineageforward, whereas a daughter is considered a social and economic burden to the family. These pressures compel pregnant women toresort to sex-selective abortions to abort female foetuses. Incommunities in which women do not have access to sex-selectiveabortions –for example, where the amniocentesis or sonogramtechnology necessary to detect the sex of the foetus is lacking, orwhere abortion is prohibited –women and men may resort tofemale infanticide to avoid having to raise a daughter.
Critical to the effectiveness of government policies undertaken to address sex-selective abortions and femaleinfanticide is a comprehensive understanding of the culturalattitudes that promote the practice. For instance, studies indicatethat failure of the "cradle scheme" used in certain regions in India– under which mothers can leave unwanted female infants in theircradles, to be given to other families – is attributable to strongviews regarding caste and community. In these regions, parentsmight prefer the death of the foetus or infant over the thought oftheir child growing up with people of another community or caste.
The strong preference for sons can leave women vulnerable to abuse by unscrupulous health-care workers. In Haryana, India,for example, more than 50 per cent of the 80 doctors in town makemoney from sex determination tests and abortions, and 50 per centof the ultrasound tests are carried out by ultrasound operators withno special training. The ultrasound tests may be carried out as earlyas the second month of pregnancy – when it is impossible to detectthe sex of the foetus – pronounced as female and aborted.
Sex-selective abortions and female infanticide can have an adverse impact on the reproductive health of future generations ofwomen in the community. The sex ratio of the population maygradually become tilted against females, and result in burdening the available fewer number of women to produce the requirednumber of children to sustain the community.
Both the ICDP Programme of Action and the Beijing Declaration and Programme for Action call for the elimination ofall forms of discrimination against the girl child and the rootcauses of the harmful and unethical practices of female infanticideand prenatal sex selection.
Violence within the context of reproductive health policy Violence against women may occur within the context of reproductive health policy. Violence and violations of women'sreproductive health may result either from direct State action, viaharmful reproductive policies, or from State failure to meet its coreobligations to promote the empowerment of women. Direct Stateaction violative of women's reproductive rights can be found, forexample, in government regulation of population size, which canviolate the liberty and security of the person if the regulationresults in compelled sterilization and coerced abortion or incriminal sanctions against contraception, voluntary sterilizationand abortion. State failure to meet its core obligations, on the otherhand, can be found, for example, in a failure to effectivelyimplement laws prohibiting FGM, or a failure to set a minimumlegal age for marriage. This failure to empower women thus leaveswomen vulnerable to the numerous forms of violence perpetratedby private individuals and institutions.
Within the context of reproductive health policy, reports indicate that State policies contribute to violence against women,manifested in forced abortions, forced sterilization and contraception, coerced pregnancy, and unsafe abortions.
Potentially – if not actually – resulting in the death of the victim,all of these practices violate a woman's right to life. Indeed, theWorld Health Organization estimates that 75,000 women a year diefrom excessive bleeding or infection caused by unsafe abortionsalone. Forced abortions, forced contraception, coerced pregnancyand unsafe abortions each constitute violations of a woman'sphysical integrity and security of person. In cases, where, forinstance, government officials utilize physical force and/or detainwomen in order to force them to undergo these procedures, thesepractices may amount to torture and cruel, inhuman and degradingtreatment.
Governmental neglect of preventable causes of violence against women also constitutes an affront to women's humanrights. In order to be truly universal, international human rights lawmust be applied both to require States to take effective preventiveand curative measures with regard to violence against women, andto afford women themselves the capacity to achieve their ownempowerment, security and self-determination. Specifically,international human rights treaties require States to take measuresto ensure women's rights, including women's rights to be free,through their empowerment, from all forms of discrimination andviolence; to achieve their rights to liberty and security; and to haveaccess to health care, including health information and education,and social services necessary to treat and prevent victimization byall forms of violence. / Women: Enforcing and Improving Legal Measures" (paperpresented at the WHO/Federation of Gynaecology and Obstetrics(FIGO) Pre-Congress Workshop on the Elimination of ViolenceAgainst Women: In Search of Solutions, WHO Regional Office,Copenhagen, 30-31 July 1997)./ Implicit in the promotion of these rights is the State's obligation to act with due diligence to prevent, investigate, andpunish violations. States whose Governments leave privateviolations of human rights unaddressed breach their duty underinternational law to protect human rights. States must also facilitaterealization of these rights by employing governmental means toafford individuals the full benefit of human rights, including takingappropriate legislative, administrative, judicial, budgetary,economic and other measures to achieve women's full realizationof their human rights. / 1. Violations resulting from direct State action Examined below are State policies that deny women their dignity and right to self-determination by diminishing theircapacity to make reproductive choices according to their ownwishes and life circumstances. The denial of these rights can leadto devastating health consequences – in many cases, compromisinga woman's right to life and security of person.
State policies that encourage or sanction forced abortions violate a woman's right to physical integrity and security of person,and the rights of women to control their reproductive capacities.
State policies aimed at controlling population growth can result incoerced abortions.
China's one-child policy demonstrates this linkage between reproductive health policy and violence. Through this policy theChinese Government restricts the number of children a married couple may have, and, at times, violently enforces this policythrough forced abortions. Under the one-child policy, singlewomen and migrant women unable to return to their home regionsare subject to compulsory abortions. Family planning officials inChina allegedly employ intimidation and violence to carry out thepolicy, sometimes removing women from their homes in themiddle of the night to force them to have abortions. Former familyplanning officials reported having detained women who werepregnant with "out-of-plan" children in storerooms and offices foras long as necessary to "persuade" them to have an abortion. Oncea woman relented, the official would escort her to the hospital andwait until the doctor could provide the official with a signedstatement documenting that the abortion had been performed.
Relatives of those attempting to avoid forced abortion are alsosubject to detention and ill-treatment.
A severe violation of women's reproductive rights, forced sterilization is a method of medical control of a woman's fertilitywithout the consent of a woman. Essentially involving the batteryof a woman – violating her physical integrity and security – forcedsterilization constitutes violence against women. AmnestyInternational has condemned such actions as amounting to cruel,inhuman and degrading treatment of detainees or restricted personsby government officials.
In countries where there is widespread sterilization of women for contraceptive purposes, many women either do not sign theconsent form or are not aware that they are consenting to besterilized. Most are not informed about the irreversible nature ofthe operation or of alternative contraceptive methods. When discussing contraceptive methods, health care workers oftenpressure women to undergo sterilization. Reports indicate that inPeru, in an effort to meet Government-imposed sterilization quotasthat offer promotions and cash incentives, State health workerspromise women gifts of food and clothing if they agree to undergosterilization. In so doing, these health workers take advantage ofpoor rural women, many of whom are illiterate and speak onlyindigenous Indian languages. Women who refuse to consent tosterilization face threats that their food and milk programmes willbe terminated. Those coerced into undergoing sterilization arereportedly then operated upon under unsanitary conditions.
In China, forced sterilization has been carried out by or at the instigation of family planning officials against women who aredetained, restricted, or forcibly taken from their homes to have theoperation. Official family planning reports and regulations indicatethe use of forced sterilization. For example, a 1993 county reportby family planning officials in Jiangsi Province stated that"[w]omen who should be subjected to contraception andsterilization measures will have to comply". Reports also indicatethat despite the assurances by the State Family PlanningCommission that "coercion is not permitted", there has been noindication of sanctions being taken against officials who perpetratesuch violations.
Forced contraception/provision of unsafe or inappropriate The manner in which contraceptive methods are delivered may result in a denial of a woman's right to bear children or maypunish her for exercising that right. / "Crime, Race and Reproduction", Tulane Law Review, vol. 67, 1993./ For instance, certain policies, such as those recently passedby the United States Government, which base welfare funding onthe number of children a woman has, in effect penalize women onwelfare for having babies, and thereby limit a woman's right todecide the number of children she wants to bear. SomeGovernments use less subtle means to force women to usecontraception.
Contraception may be coerced or forced by virtue of a refusal by health workers to remove contraceptive devices. For instance,because Norplant must be surgically inserted and removed, awoman who wishes to have the device removed can find herself atthe mercy of health workers. In Bangladesh, only 15 per cent ofwomen with Norplant were even aware that Norplant could beremoved on request. Moreover, those who attempted to requestremoval after suffering serious side effects were routinely denied,and even subject to verbal abuse. In the United States, African-American women in rural Georgia reported that Government-funded Medicaid would pay for Norplant implants but would onlyremove them for "medical reasons". Yet, when various womencomplained of continuous bleeding, headaches, massive hair lossand heart palpitations, the local medical authorities consideredthese "inconveniences" rather than medical problems. If womenhad these implants removed before the end of two years, theywould have to pay $300 to reimburse the State for the cost ofinsertion. / Internation Reproductive Rights Research ActionGroup, Statement and recommendations, prepared in response toSpecial Rapporteur's request for comments, September 1998, p.
14./ Forced contraception may also be used to punish women criminal offenders. For example, Norplant is used to punish femaleoffenders and women who use drugs during their pregnancy – even where there is no connection between the punishment and thecrime – thereby punishing the woman not for her illegal use ofdrugs, but for her reproductive capacity. Indeed, research hasrevealed that drug-addicted women who are pregnant receiveharsher sentences than drug-addicted women who are not pregnant.
In the United States, courts have offered low-income femaleoffenders release on probation in exchange for their consent tolong-acting contraceptive implants. / Sterilization of Women with an Intellectual Disability", Universityof Tasmania Law Review, 1990-91, p. 10./ These practices sendthe disturbing message that certain groups in society do notdeserve to procreate.
Denial of contraception/coercive pregnancy While forced sterilization is a form of violence within the context of reproductive health, so is the restriction on andprohibition of access to voluntary contraception. Acts deliberatelyrestraining women from using contraception or from having anabortion constitute violence against women by subjecting womento excessive pregnancies and childbearing against their will,resulting in increased and preventable risks of maternal mortalityand morbidity. According to the International Planned ParenthoodFederation, in a number of countries in French-speaking Africa, forexample, a 1920 French law punishing the advertising, sale anddistribution of contraception as well as "incitement to abortion"remains on the books, chilling the free exercise of reproductivechoice.
Social pressures, combined with the threat of domestic violence, may result in restrictions on a woman's ability to exercisereproductive and sexual autonomy. A woman's ability to bear children is linked to the continuity of families, clans and socialgroups, and, as such, has been the object of regulation by families,religious institutions and governmental authorities. The importanceof procreation to a particular community can put enormouspressure on women to bear children. The social stigma attached tothe use of birth control – i.e. the implication that a woman whouses birth control must be promiscuous, or the belief that birthcontrol is an affront to her partner's masculinity – may also serve,in effect, to limit women's access to birth control.
In countries where abortion is illegal or where safe abortions are unavailable, women suffer serious health consequences, evendeath. Women with unwanted pregnancies are forced to resort tolife-threatening procedures when an abortion performed underappropriate conditions would otherwise be safe.
Of countries with populations greater than 1 million, 52 countries permit abortion to save the life of a woman, 23 topreserve physical health, 20 to preserve mental health, 6 foreconomic and social reasons and 49 on request. / Reproductive Law and Policy, The World's Abortion Laws, 1998./Many countries such as Austria, France, Italy, the Netherlands andCanada have enacted liberal abortion laws, which are consistentwith women's right to liberty, health, life and security. However,countries such as Chile, Nepal and El Salvador consider abortioncriminal. For example, the El Salvador Penal Code, which enteredinto effect in January 1998, considers abortion a "crime relating tothe life of a human being in formation", and eliminates allexceptional circumstances in which abortion was previouslyallowed and increases the penalties for abortion. / Supra note 25, p. 98./ In Germany, the State can discipline women and even usecriminal sanctions to require women to bring their unwantedpregnancies to term. / Supra note 20, p. 705./ WHO estimates that there are approximately 40 million abortions annually, of which 26 to 31 million are legal and 20million are illegal and thus unsafe. / World Population 1995 United Nations Population Fund, p. 47./Women of financial means may have access to safe abortionswhile poor women must resort to clandestine abortions inextremely unsafe conditions. Even where abortions are legal, thescarcity of available facilities and the potentially prohibitive costof legal abortions may compel women to seek clandestineabortions by untrained practitioners utilizing crude abortionmethods.
The difficulties associated with obtaining an abortion in India, where abortion is legal, is demonstrative of these problems.
In India, only 1,800 of the 20,000 primary health centres haveMedical Termination of Pregnancy facilities. Moreover,government authorities insist on a sterilization procedure after theabortion, and while abortion is technically free of charge, thecharges incurred for blood, saline and drugs, in addition to the costof bribing hospital employees, cause women to seek the services ofillegal practitioners. Women with unwanted pregnancies are forcedto rely on low-cost alternatives which are often undertaken byuntrained practitioners under unsanitary conditions.
Not only is there an urgent need for safe and affordable abortion, but there is also a need for assurances that the abortionswill be kept confidential, especially given the stigma associatedwith abortion in certain cultures. Protests and even death threats by anti-choice extremists, such as those belonging to "OperationRescue" in the United States of America, pose another seriousobstacle to obtaining safe abortions. The efforts of anti-choiceextremists are not limited to local clinics, but threaten to renderinaccessible abortions abroad. For example, the "global gag rule",which has been introduced and narrowly defeated in the UnitedStates Congress during each of the past four legislative sessions,would prohibit any overseas non-governmental organization ormultilateral organization from receiving United States funds if thatorganization uses its own funding to provide abortion-relatedservices or engage in pro-choice lobbying efforts. If passed, suchlegislation would obstruct crucial dialogue among policy makersand non-governmental organizations on the issue of how to combatunsafe abortion and how to respond to violence against women,which may require provision for abortions in, for example, cases ofrape.
The unavailability of safe, confidential and affordable abortion services can have severe consequences for women withunwanted pregnancies. Nearly 20,000 Indian women die everyyear due to unsafe abortions. / India Today, 31 August 1996./ Attempts to induce abortionthrough the use of herbs or roots through the vaginal route, theinjection of acid-like fluids into the womb, the use of caustic soda,arsenic and double doses of contraceptive pills, and the insertion ofsurgical probes, plant stems, wires and toothpicks have harmfulreproductive health consequences and may fail to result insuccessful abortions.
Crude abortions can have serious health complications, including allergic reactions, death by kidney or respiratory collapsedue to highly toxic fluids, or even death. WHO estimates that,globally, 75,000 women die from excessive bleeding or infection caused by unsafe abortions every year. A far greater numbercontract infections that cause fever, pain and, in many cases,infertility – which can be devastating in cultures where a woman'sworth depends on her ability to produce children, particularly sons.
Most women who undergo an unsafe abortion require some formof subsequent health care, yet most developing country healthsystems do not provide emergency medical care for womensuffering from abortion complications and, as a result, treatment isoften delayed and ineffective, with life-threatening consequences.
2. Violations resulting from State failure to meet minimum coreobligations Just as direct State action can result in violence against women, a State's inaction or failure to meet minimum coreobligations can result in further violence against women.
Government failure to take positive measures to ensure access toappropriate health-care services that enable women to safelydeliver their infants as well as to safely abort unwantedpregnancies may constitute a violation of a woman's right to life, inaddition to the violation of her reproductive rights. Along the samelines, government failure to provide conditions that enable womento control their fertility and childbearing, as well as to bringvoluntary pregnancies to term, constitutes a violation of a woman'sright to security of the person.
Failure to provide comprehensive health services Government funding for research into women's reproductive The key to the development of effective policies addressing a minimum core of obligations is a showing by the State that it hasbased its reproductive policies on reliable data regarding theincidence and severity of diseases and conditions hazardous towomen's reproductive health, and on the availability and costeffectiveness of preventive and curative measures. As underscoredin the Beijing Platform for Action (para. 109 (h)), "[Governments should] (h) Provide financial and institutionalsupport for research on safe, effective, affordable and acceptablemethods and technologies for the reproductive and sexual health ofwomen and men, including more safe, effective, affordable andacceptable methods for the regulation of fertility, including naturalfamily planning for both sexes, methods to protect againstHIV/AIDS and other sexually transmitted diseases and simple andinexpensive methods of diagnosing such diseases, among others.".
All too often, State policies derive from the perceived moral requirements of the community, or even the needs and priorities ofthe health profession, rather than a careful epidemiological andsocial assessment of women's health needs. As a result institutionsdedicated to promoting women's reproductive health lack adequateaccess to scientific resources to contribute to the understanding offactors relating to reproductive health and to expand reproductivechoice. Research into the prevention, detection and treatment ofmammary, cervical and uterine tumors would significantlyimprove women's morbidity and mortality rates, as these threediseases account for almost half the deaths caused by malignanttumors in women aged between 15 and 64.
Government failure to prevent maternal mortality compromises a woman's right to life and her right to security ofperson. In spite of information from the international SafeMotherhood initiative demonstrating the preventability ofpregnancy-related deaths, many States fail to take the necessarysteps to reduce maternal mortality.
Maternal deaths are deaths among women who are pregnant or who have been pregnant during the previous 42 days. / Supra note 20, p. 646./ The risks and complications related to pregnancy and childbirth are among the leading causes of maternaldeaths. Most maternal deaths are preventable. While somecountries have taken steps to reduce maternal mortality, / Mexico, Ethiopia, South Africa, Argentina, Bolivia and Guatemala have implemented strategies to train rural midwives,provide protection to women during pregnancy and breastfeeding,train health professionals and educate women on the risks ofpregnancy./ it is estimated that over 585,000 deaths occur amongwomen of reproductive age due to preventable complications inpregnancy, childbirth, or unsafe abortions. These are not meremisfortunes or unavoidable natural disadvantages of pregnancy butrather preventable injustices that Governments are obliged toremedy through their political, health and legal systems. / Rebecca J. Cook "Advancing Safe Motherhood Through Human Rights", December 1997, p. 1./ Ninety-nine per cent ofthese deaths happen in developing countries. Of these, South Asiancountries contribute the highest number of maternal deaths,followed by African countries and Latin American countries. Onein every 10,000 women dies in Northern Europe compared to 1 in21 women in Africa. / International Solidarity Network, "Women'sReproductive Rights in Muslim Communities and Countries", 1994, p. 47./ A woman's lifetime risk of dying from pregnancy-related complications or during childbirth is 1 in 48 in thedeveloping world, versus 1 in 1,800 in the developed world. / Population Reference Bureau, "Making Pregnancy and Both the ICPD Programme of Action (para. 8.21) and the Beijing Platform for Action (para. 106(i)) urge Governments toreduce maternal mortality by one half of their 1990 levels by theyear 2000, and to cut the levels by an additional one half betweenthe years 2000 and 2015. However, as the target date nears,maternal deaths remain a common occurrence. The most commoncauses for the great number of maternal deaths are the woman'sage, spacing of pregnancies, and the desirability of the pregnancy.
The woman's health, dietary needs, financial resources and herunequal status in society, and the resulting poor schooling andearly marriage of girls, are also relevant factors, as is the lack ofadequate training for health care workers in the areas of prenatalcare, delivery and post-partum care. Moreover, cultural andreligious beliefs may serve to mask the incidence of maternaldeaths that could be prevented by inexpensive and availableinterventions.
Broad-ranging social and economic reforms have had an adverse effect on maternal mortality. In the Latin American andCaribbean region, structural adjustment policies during the 1980sand early 1990s and health care reform resulted in a shift from theGovernment as a key provider of health services to a promoter ofeither private or public general health insurance. This has had anadverse impact on the ability of low-income groups – especiallyrural and indigenous people – to gain access to health careservices. / Supra note 19, p. 10./ As a result, rural and urbanclinics do not have the facilities to perform Caesarean operations or to treat other complicated births. The staff lack training infamily planning methods, and the nurse-to-patient and doctor-to-patient ratios are very high. Even where adequate medical facilitiesexist, the cost of these services can be prohibitive. With respect tothe Asian region, the recent economic crisis has had an impact onmaternal care. / Asia-Pacific Regional Consultation with theUnited Nations Special Rapporteur on Violence against Women,Colombo, 11-12 August 1998./ (iii) Non-provision of contraceptive information A failure of Governments and service providers to recognize a woman's right to control her fertility may translate into a failureto provide accurate and objective information regarding the fullrange of contraceptive methods. Non-provision of contraceptionand contraceptive advice may also result from discrimination in thedelivery of health services. In some societies, contraceptive adviceis not given to unmarried persons or adolescents. Even where awoman is married, in the absence of authorization by her husbandor male partner, she may be denied access to reproductive healthservices and health services more generally.
Because husbands often take little or no responsibility for contraception and vasectomy is rarely mentioned or considered asa contraceptive measure, women must act to control their fertilityin order to preserve their own health. Most women have some ideaabout contraceptive methods, be they traditional ways or modernmethods. However, misinformation and fears of the ill effects ofcontraceptive methods on the health and the ability to bear childrenoften deter women from using them.
The unmet need for family-planning services is substantial. It is estimated that 350 million out of 747 million married women ofreproductive age are not using contraceptives. One hundred millionwould prefer to space their next birth or not have any morechildren. Twenty-five per cent would prefer to delay or avoidpregnancy. / Cook and Fathalla, supra note 13, p. 119./ In China contraceptive use is prevalent (91 per cent), but knowledgeof how contraceptive methods work and are used is limited. Thestory of a newlywed Chinese girl who was not using contraceptioneven though she did not want a child provides a telling account.
When asked why she did not use contraception, she replied, "I read in a journal that recently married couples would not getpregnant because the successful meeting of mature sperm and eggtakes over 48 hours. We are newly married and have sexualintercourse almost every night. I thought that with old and newsperm eating each other, none of them would survive more than 48hours. Therefore, I thought no pregnancy would happen." / Reproductive Health Matters - Promoting Safer Sex, Number In order to provide full recognition of a woman's right to reproductive autonomy, reproductive health care must providecomplete and impartial information regarding the full range ofcontraceptive methods and reproductive health issues generally.
Failure to address physical and psychological violence In some countries, physical and psychological violence against women of low socio-economic status occurs in public health facilities. These violations are often ignored or inadequatelyaddressed by administrative and judicial authorities. A recentreport documents numerous cases in Peru of physical andpsychological violence against women who use publicreproductive health services, including rape, assault, and numerousforms of verbal abuse. For example, María testified that: "the doctor made me enter and didn't let my sister or my fathercome in and told the nurse to stay outside. Then he told me to takeoff my clothes, my pants and blouse, and to lay down on the table.
There I was without clothes. Then the doctor told me: 'So you arepregnant? Who could you have been with?' I felt him put hisfingers in my private parts. He was hurting me a lot, and then Irealized that both his hands were on my waist and he was thrustinghimself into me and hurting me. He was abusing me. I was scaredand he told me that 'that is how it is'. Then I pushed him away andstarted to cry, he told me that I had nothing wrong with me and toput on my clothes." / Center for Reproductive Law and Policy andLatin American and Caribbean Committee for the Defense ofWomen's Rights, Silence and Complicity: Violence againstWomen in Peruvian Public Health Facilities (forthcoming 1999)./ Even in the relatively few cases in which women were willing to file formal complaints, health officials and the judicialsystem failed to provide adequate remedies to the victims. Suchviolations are clearly extreme examples of government failure tomeet core obligations to provide comprehensive and qualityreproductive health care services to all women, regardless of theirsocial and economic status in their societies.
States should ratify all international human rights instruments. States should withdraw any reservations to theseinstruments, particularly those regarding the human rights ofwomen.
States must ensure that the foremost concern in the formulation and implementation of reproductive health and familyplanning programmes is respect for the individual rights of women.
States should create and promote a process of cross-sectoral and interdisciplinary collaboration, focusing on training andcapacity-building for treaty bodies, agencies and non-governmental organizations on the issue of women's reproductiveand sexual health.
States must exercise due diligence to prevent violence against women in order to protect their human rights, including, amongothers, specific laws to combat rape, domestic violence, traffickingand forced prostitution, female genital mutilation, sex-selectiveabortions and female infanticide.
States should pass and enforce a minimum legal age limit for marriages. States must undertake training programmes to sensitizehealth workers providing reproductive health services – includingthose who work in antenatal clinics, maternity services and familyplanning services – to the possibility of gender violence amongtheir clients.
States should take all measures necessary to eradicate discrimination and violence against women who use public health care services, and to guarantee institutional settings in whichwomen's human rights are respected.
States should provide increased education to health workers and ensure easy availability of information about the human rightsimplications of reproductive health, including State obligationsunder international law.
States should provide training to health workers in women's reproductive rights, including training with respect to how toidentify violations during physical examinations, as well as how toprovide appropriate intervention information.
States should implement training programmes to provide those who work in minority communities with linguistic andcultural training sensitive to the differences of their clientele.
States must take appropriate measures to monitor reproductive health services and ensure that these services areoffered without any form of discrimination, coercion or violence,and that information disseminated by health workers iscomprehensive and objective.
States should provide financial and institutional support for the creation of support groups, shelters, crisis centres withcounselling and legal assistance, and women-only police stationswith trained workers and 24-hour hotlines.
States should provide financial and institutional support for research on safe and effective methods for the regulation offertility, protection against sexually transmitted diseases, includingHIV/AIDS, and confidential testing and diagnosis of STDs.
States should provide financial and institutional support for research into the prevention, detection and treatment of illnessesassociated with women's reproductive health, particularly thosewith the highest indicators of maternal mortality and morbidity.
States should engage in systematic research and collection of data with respect to the incidence of violations of women'sreproductive and sexual health, and use such data to inform futureState policies that impact women's rights to reproductive andsexual health.
States should provide financial and technical support for organizations and institutions dedicated to promoting women'sreproductive and sexual health, and engage in collaborativerelationships with such institutions and organizations in theformulation of government reproductive health policies.
Copyright 1996-2000
Office of the United Nations High Commissioner for Human Rights
Geneva, Switzerland


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