Abortion, girls, young women and gender queer people
By Marion Stevens (WISH Associates)
Within South Africa, more than 20 years post democracy, the legal provisions on reproductive health and sexual orientation have been recognisable gains. It is a challenge though that these legal rights are not well realised and the struggles of many girls, young women and gender queer people remain unrealised in reproductive justice.
Reproductive justice is a framework that points out the possible limits of focusing on rights without addressing the contextual justice issues that are barriers to accessing these rights. While not negating the concepts of sexual and reproductive health and rights, which have taken us a good distance, reproductive justice adds an intersectional texture and contextual understanding.
The Reproductive Justice framework analyses how the ability of any woman to determine her own reproductive destiny is linked directly to the conditions in her community-and these conditions are not just a matter of individual choice and access. Reproductive Justice addresses the social reality of inequality, specifically, the inequality of opportunities that we have to control our reproductive destiny. Moving beyond a demand for privacy and respect for individual decision making to include the social supports necessary for our individual decisions to be optimally realized, this framework also includes obligations from our government for protecting women’s human rights.[i]
Within South Africa, whilst abortion is legal it is not accessible. In 2014 less than 40% of surgical designated abortion facilities were operational. Medical abortion guidelines are only available for the Western Cape. Medical abortion drugs are not on the essential drug lists of all the provinces. Training for health professionals in sexual and reproductive health is adhoc and not planned for in terms of providing comprehensive contraception, nor is training provided in the provision of abortion. Stigmatising attitudes in relation to abortion are a challenge from managers and leaders in the Health Department to health care providers on the ground. There are some instances of women reporting being forcibly sterilized[ii] following accessing an abortion. Black women still die from abortions in South Africa. See https://awethu.amandla.mobi/petitions/reproductive-justice-now
Information on abortion has not been provided regarding the provisions on the Choice on Termination of Pregnancy[iii] Act in schools during comprehensive sexuality education nor in pamphlets and information campaigns by the National Department of Health. No information on abortion is provided on flagship mhealth[iv] programmes, Mom Connect and BWise. In reality, schools fall desperately short in the provision of comprehensive sexuality education.[v]
Essentially driven by donors’ response to the HIV epidemic[vi] and to enable a population control[vii] approach, women are largely only responded to in programming as mothers. Maternal mortality remains a challenge over 30% of deaths continue to be from AIDS related causes. If you are HIV positive in South A, you have access to Prevention of Mother to Child Transmission (PMTCT) and are expected to deliver a baby following your HIV positive pregnancy (and take responsibility for ensuring you have an HIV negative child). The thought of offering an abortion to a woman who finds out they are pregnant and HIV positive on the same day, is not part of clinical protocols, despite the focal point two of the protocol of PMTCT being the ‘prevention of unintended pregnancies’. While deaths from unsafe and septic abortion decreased following the liberalisation of our law, deaths from abortion have risen to about 10% of all maternal deaths. The data and indicators in the confidential maternal mortality report have changed and while there are deaths reported from abortions, it is unclear whether HIV positive women or women with AIDS who present in hospitals bleeding and septic following abortions are recorded as deaths from AIDS or abortion[viii]
We have the rights to abortion in South Africa and if you are a middle class girl, young woman or gender queer person with access to information to determine you have an unintended pregnancy and resources to access medical care in the first trimester you should be able to find your way. The case study below tells another story.
A REFERRAL FROM 2014
But if you are a middle class adolescent in Johannesburg who has been violated repeatedly by a family member and have been threatened that if you break confidence he will start on your little sister you could well fall in between the cracks. You do now believe that you are pregnant after all the abuse and only when your aunt takes you aside and listens to you establish that you are 19 weeks pregnant and have the right to abortion. Your well-resourced aunt cannot access an abortion for you as there are no providers, your uncle is in jail and social workers are counselling you to ‘give your baby up for adoption’. It is only when at 23 weeks of pregnancy your determined aunt requests an ultrasound that it is determined that the foetus is not viable and you are then induced for labour as no health professionals are willing to provide you with a surgical abortion with anaesthesia
We do not live single issue lives and as such we might find ourselves fitting a number of boxes. Often the LGBTI focus has been in single issues for example gay marriage or ARV treatment access. Yet there are layers of complexity and nuance.
Abortion access for girls and young women is a challenge, it is even more so for queer people including lesbians and trans men. Comprehensive sexuality education does not address sexual orientation and gender identity at all well[iv] and health workers are not welcoming nor well trained in relation to LGBTI persons health care.[ix] The stigma, judgement and harassment that LGBTI persons receive in public health care settings has been well documented. It demands enormous courage to walk into a clinic if one presents gender queer or non-conforming[x].
Queer people do have unintended or unsupportable pregnancies and some will want to choose to have an abortion. How they got pregnant is not the business of a health provider and should not be questioned. The question should be to the client in front of the health worker, is: ‘how can I assist you and what information would you like?’ The challenge is that for health providers are not equipped to address those presenting for abortion whatever their sexual orientation or gender identity.
Reproductive justice adds layers framing an intersectional approach that understands where people are from and the contextual challenges that ground us. Consideration is given to systemic challenges that are barriers in how we are provided with information in schools or clinics and in how health providers adequately welcome us and implement our care. As young girls, women or queer folks, our fertility is not often welcomed particularly if we are black or poor. [xi] We should be able to have supportable pregnancies of our choice and not be hindered. [xii]
[xi] http://www.unaids.org/en/resources/presscentre/featurestories/2016/june/20160624_south-africa, http://www.thepresidency.gov.za/pebble.asp?relid=22280