Workshop on the Framework for Sexual and Reproductive Health

March 27 and 28, 2001, Sydney, British Columbia

Summary of Recommendations, June 26, 2001

This is a joint report prepared by Planned Parenthood and the Pro-Choice Action Network.

The Pro-Choice Action Network, in partnership with Planned Parenthood of British Columbia, has embarked on a ground-breaking sexual and reproductive health-care restructuring consultation project.

Return to Summer 2001 Special Edition of Pro-Choice Press.

Introduction

In 1999, Health Canada released a document entitled “A Report from Consultations on a Framework for Sexual and Reproductive Health”. The Report provided a synthesis of discussions held with federal, provincial and territorial government agencies, and some national non-government organizations, structured into a set of priorities, guiding principles and strategic directions.

After the report was released, Planned Parenthood BC met with a number of provincial government agencies to determine where the lead role would reside for action on the Framework in the province. Those discussions revealed considerable interest in the issues, but no clear and coherent focal point for action, coordination or facilitation. Planned Parenthood BC’s proposal to provide a stimulus for follow-up was well received, and the organization proceeded to organize a consultation process among a wide range of interested organizations and individuals.

Initial consultations took place with over one hundred organizations and individuals. They focussed on eliciting perspectives around the principles enunciated in the Framework and understandings of their meaning and implications, an elaboration of the priorities participants thought should be established and ideas about policy, program and operational actions that should be taken to address those priorities. This step preceded a workshop of fifty participants held on March 27 and 28, 2001, in Sidney, BC. The goals of the Workshop were:

• To take stock of the status of sexual and reproductive health policies, programs and services in the province
• To identify key policy and program enhancements that would improve the sexual and reproductive health of British Columbians
• To determine what practical, collaborative next steps could be taken to achieve those changes.

This report presents a summary of the recommendations arising from the Workshop discussions. The intention from this point forward is to encourage and support further development of policy, program and service initiatives that will move the document from recommendation to reality. The subsequent steps will involve many more participants and interests than could be accommodated at the Workshop, and will hopefully stimulate an array of networks and partnerships supporting improved sexual and reproductive health in BC.

British Columbia is the first province in Canada to set such a process in motion. The initiative has been financially supported by the BC Ministry for Children and Families, Health Canada, Status of Women Canada, and Planned Parenthood BC. Funding from Status of Women Canada was provided through the Pro-Choice Action Network (ProCAN), and included additional support to ProCAN for the facilitation of Workshop participation, and follow-up activities to establish a coalition of women’s organizations.

The Framework in Perspective

As a precondition to understanding the recommendations that arose from the Workshop it is necessary to recognize what many participants considered to be a lack of analytical intensity in the Framework, from the perspectives of gender, racial and cultural diversity, sexual identity and orientation, socio-economic status, and ability. The reasons for this are various, and include the predominant culture of the health system, the tendency of government to express issues as generically as possible and general unfamiliarity in social systems with at least some of the analytical issues and approaches involved. As a consequence, many Workshop participants concluded that it is not possible to apply the Framework directly as a realistic statement of the ideal or desired state of Canadians’ entitlement to sexual and reproductive health. It is a starting point from which significant additional research and analysis is required, and to which many other practical adjustments in policy, programs and services must be made across all dimensions and sectors of the health and social systems.

Another perspective that emerged from the Workshop discussions is the importance of creating and supporting continuing structures and processes for carrying out the work that needs to be done. The structures should be coalitions of government, service providers, consumers, community and non-profit organizations, and representatives of all relevant populations (aboriginal, LGBT, ethnic communities, youth, etc). The processes should be community-and grass roots based, open to both qualitative and quantitative analyses, and strongly oriented to feedback and dialogue. Further, it is seen as crucial that the processes eliminate judgmentalism from the area of sexual and reproductive health, that they demystify and de-stigmatize all discussions about this important aspect of life.

Finally, the Workshop participants highlighted the importance of making a statement as Canadians about our global accountability and responsibilities in this area of health, arising in large part from the privilege we enjoy as a society, whatever the shortcomings we might express about the systems we employ. In many parts of the world women and infants routinely die due to a lack of access to basic sexual and reproductive health services. Canada and BC have a role to play in preventing these unnecessary deaths.

Recommendations and Discussion

For the purposes of synthesis, the many recommendations generated have been grouped according to complementary Principles of the Framework.

Principle 1: All individuals are sexual beings throughout their lives

and

Principle 8: Families and communities share responsibility in providing a physical and psychosocial environment that enables all its members to maintain their sexual and reproductive health

The recommendations in this group reflect a comprehensive approach involving individuals, groups, and the education system as a whole (formal, informal and professional elements).

1. Support groups should be encouraged as an effective and safe mechanism for promoting learning and discussion for a wide array of target populations.
2. Attitudinal change in individuals and communities is an important aspect of an enabling environment. The media, and in particular the ethnic media are a good vehicle for effecting attitudinal change and linking to community programming.
3. All individuals need to encounter in teachers, physicians, nurses, social workers and others a supportive professional environment that demonstrates understanding of sexuality through the life cycle. This understanding needs to be addressed in both initial and continuing education. Certification programs can be a useful mechanism with respect to the latter. Similar programs are also important in the training of volunteers in all the relevant service sectors.
4. Education programs must be tailored in content, context and medium to the specific target groups being addressed. To do so requires a good knowledge of how and where the groups access information, and initiatives that are innovative and creative to attract and retain attention. Options include the use of peer educators (very effective in some settings), using work environments to reach adults, and making full use of information technologies (from the Internet to MTV).

Principle 2: Individual autonomy and responsibility should guide all aspects of decision making.

and

Principle 6: Access to sexual and reproductive health programs and services should be equitable, responsive to diversity, and not limited because of discrimination based on gender. Age, race, ethnicity, marital status, sexual orientation, religion, culture, language, socioeconomic status, disability or geographic location

The recommendations arising from the review of these principles include a number of significant public policy concerns, ranging from basic protections and equity for women to better access and unequivocal informed consent to services and products.

1. At the broadest level, universal child care is considered to be a fundamental determinant of the options available to women to improve their socio-economic status, autonomy and scope of decision-making.
2. While some measures are in place to reduce the harassment and intimidation women may experience when accessing certain reproductive health services, particularly abortion services, the current situation in BC continues to permit various forms of inequity. The problem may be a hospital that limits the services provided, a physician that will not make a referral, a parade of placards near a service site, or other subtle and overt forms of pressure to limit individual choice and autonomy. Strong, comprehensive legislation is required to fill the gaps that remain. As well, it is recommended that some redress mechanism (structure and process) be established for assessing, regulating and amending any failure to provide unbiased, non-judgmental service by any individual or agency service provider.
3. “Power bottleneckers” have a negative impact on policy making and access to education and services. They may be found on a local school or hospital board, a community funding agency or other body whose decisions affect the status of sexual and reproductive health in the community. The recommendation here is addressed largely to the other centres of power and influence in the community, to encourage processes by which the values and expectations of the community at large prevail against them.
4. Policy changes are recommended in the health system to address two other barriers to equity in remote and rural areas. First, women who must travel significant distances at considerable cost in order to receive services should have those costs defrayed. Second, health funding, health personnel, scope of practice and other policies need to support strategies that ensure every area has adequate providers of the full spectrum of reproductive health services.
5. Additional efforts are required to promote outreach to distant parts and populations of the province by all reproductive health service providers. In some cases the issue is geography, but there are some populations who are remote even though they may live close at hand, such as street women, who do not receive adequate reproductive health care. Improved women-centred services in accessible delivery modes are recommended for them. In other cases the issue may be training and resources: a case in point is the lack of rape kits and trained service providers in a number of communities. In all cases, improved access to information technology is recommended.
6. It is recommended that (pro-choice) pre-and post-abortion counselling services outside the abortion clinic setting be established, to enhance accessibility for some women, and to counterbalance the presence of anti-choice counselling services.
7. The arguments supporting a recommendation to introduce no-cost birth control speak to economic well-being of individuals and society, to the sustainability of the health and social welfare systems, and to individual physical, social, and psychological health. The significant benefits involved make this public policy decision a compelling one.
8. A medical policy review of the use of Depo-Provera is in order, to address concerns regarding its use in marginalized populations without proper consent or a full understanding of the implications of its use by those receiving it.
9. Education is a cornerstone of individuals’ capacity to practice autonomy and responsibility. A comprehensive, non-judgmental program of age-appropriate sexual and reproductive health education from kindergarten to grade 12 is recommended. Also recommended are concerted efforts to make sexual and reproductive health education accessible to persons with disabilities and to ensure the cultural competency of educators dealing with diverse audiences. There are significant gaps in access to sexual and reproductive health information, education and services in First Nations communities, that need to be closed.

Principle 3: The promotion of sexual and reproductive health and prevention of problems will reap the greatest benefit.

and

Principle 7: Individuals should be protected from diseases and hazardous environments that can adversely affect their sexual and reproductive health.

The balance of promotion, prevention and protection reflects the essential challenge of sexuality and reproductive health. For example, sex-positive messaging is vitally important, but needs to be accompanied by age-appropriate information, and other measures, that adequately safeguard individuals. Education, research and regulation play important roles in achieving this balance, as reflected in the following recommendations.

1. Noting that resources for promotion and prevention are relatively scarce in the health system, mapping of all services being provided is recommended, to avoid and address duplication of effort.
2. It is recommended that all necessary steps, including legislative mandating be taken to support the essential nature of reproductive health education (CAPP) for young people in all schools and grades.
3. A component of strengthening sexuality education in schools is the establishment of an appropriate accountability framework. In this regard, it is recommended that the CAPP program be given a comprehensive review for content and outcome assessment, that teachers engaged in teaching sexual and reproductive health be certified in some manner, and that all education programs be evaluated on a regular cycle for effectiveness and suitability.
4. It is recommended that the base of support for education policies and programs be strengthened with inclusive social coalitions to effect and maintain change. This can be achieved in several ways. Open dialogue and discussion should be established with religious communities, self-help groups, parents groups, community service organizations and others. As well, existing activities and programs of community and professional development can be enhanced to include education about the importance of promoting and maintaining sexual and reproductive health.
5. Examples exist of successful development of targeted, standardized media campaigns to promote health and social issues (such as the “end the violence” campaign done with the Association of BC Broadcasters, and drinking and driving campaigns). These campaigns reach wide audiences with effective, professionally developed messaging.
6. Health promotion programs must be targeted to their intended audiences. In this regard, it is recommended that particular attention be given to the needs of immigrant women and the development of health promotion programming to meet their needs. In the Workshop particular attention was given to Asian communities, and several issues were highlighted. There is a scarcity of educational materials and trained facilitators and educators available in many of the languages involved. A number of health professionals in these communities also need to have their knowledge base enhanced in this subject area. Asian women tend to live in male-dominated households; for this and other cultural reasons, they live under a “cone of silence” with regard to discussion of any sexuality and reproductive health issues. Asian youth live in two cultures, with all their attendant stresses. Any efforts to address the gaps involved should include the entire family unit, and the community, as well as the individual.
7. Consumers need adequate protection with respect to the safety and efficacy of new products and devices. It is recommended that the federal Minister of Health ensure that adequate resources in that Department are allocated to pre- and post-market evaluation and surveillance of new products and devices with a potential impact on sexual and reproductive health.
8. Research needs cover a wide spectrum of concerns. Additional research is particularly recommended in respect of new and safer reproductive technologies and pharmaceuticals for women (protection from STD’s, contraception), and the implications of environmental hazards (toxoplasmosis, chlorine, choramines, etc) on reproductive health. In addition, more effort is recommended to determine best practices and assess health and related outcomes, and to disseminate research findings to the public, policy makers, service providers and other stakeholders.

Funding for the programming and research that supports and achieves the balance of promotion, prevention and protection is the subject of the remaining recommendations related to these principles.

9. It is recommended that all stakeholders build on new opportunities in BC for research funding, such as the Michael Smith Research Foundation.
10. The corporate sector should be targeted for supporting funding for this agenda and the implementation of workplace programming, on the basis of the contribution that sexual and reproductive health makes to the well being of every person in the workforce.
11. It is recommended that community organizations dedicate a certain percentage of funds raised to sexual and reproductive health programs in their own organizations.

Principle 4: Health interventions should be safe, effective and evidence-based, and individuals should be fully informed before making decisions.

and

Principle 5: The simplest and least invasive intervention that is appropriate and effective should be used in delivering health care.

New research, and the application of existing research findings, are two themes around which several recommendations are proposed.

1. A thorough economic analysis is required to describe the benefits and opportunity costs related to provision of accessible birth control, ECP, medical abortion and surgical abortion services in relation to unwanted pregnancies. Previous analysis indicates that the progression from prevention to intervention is associated with rising cost and worsening risk/ benefit relationship, but the data to date do not appear to carry the strength necessary to guide policy decisions related to how resources can be allocated more effectively in the health system.
2. There are a number of issues around which there is a gap between the evidence provided by research for clinical decision making, and the prevailing patterns of decisions being made. They include such surgical interventions as Caesarian Sections, hysterectomy and continence surgery, and a range of clinical issues related to menopause and midlife. Concerted efforts are needed to develop and disseminate up-to-date information to medical professionals to support evidence- and practice-based decisions, and to the public, to support fully informed consent.
3. Two corollary recommendations call for implementation of alternative payment systems for physicians to allow more time for adequate counseling and care, particularly where patients are faced with several options, and the advancement of primary health care reform as one solution for improving access to timely and adequate reproductive health care.

Definitional issues persist around key aspects of sexual and reproductive health. Two other recommendations address the need for collaboration and consistency.

4. The broad issue of consent needs attention in two aspects. First, it is recommended that a policy workshop be convened to discuss consistency in the definition of the age of consent, and harmonization of federal and provincial legislation affecting the age of consent. Similar policy discussions, involving stakeholders, are recommended to address and clarify all principles and contextual characteristics of informed consent.
5. Definitional issues arise with respect to abortion as well. It is recommended that key health information source agencies develop a common language for abortion statistics to reduce misunderstanding and misinterpretation by policy makers, the media, the public, and both proponents and opponents of abortion services.

Consumer access to enhanced information and education is recommended in several areas.

6. It is recommended that new products be developed to provide consumers with access to home testing for sexually transmitted infections. The policy and ethical groundwork for this development has been thoroughly established in the context of HIV/AIDS. Access to such information in this manner offers increased empowerment and an opportunity to inform and guide individual decision-making without the sense of stigma that may be associated with outside clinical settings.
7. Noting that information about condoms is now packaged with oral contraceptives, it is recommended that information about ECP be packaged with condoms. This measure would increase awareness of the appropriate use of ECP and measures available in the event of failure or misuse of the condom.
8. There is a need for more positively framed educational material about RU486 and ECP.
9. It is recommended that enhanced effort be made in the education system to link the provision of sexuality education with other teachable moments that occur, particularly in programs for anger, bullying and violence for school-aged boys, and at the time of hepatitis B vaccination (grade 6). For health professionals in all settings, periodic health examinations, and events involving entries in the child health record, provide teaching opportunities that can oriented to both parents and children.
10. Also recommended are targeted education programs for boys and men. An example given of a possible thematic approach was the question “Who’s in charge of your penis?”.
11. The importance of the popular press in conveying knowledge should not be overlooked. An informative work of fiction (along the lines of a J K Rawling book, perhaps) could attract a wide readership and could be an effective vehicle for imparting and discussing information related to sexual and reproductive health, and encouraging informed decision making.

Other Significant Issues and Concerns

Several other issues and concerns of importance emerged during the Workshop discussions, and in the post-Workshop evaluation of those discussions. They are outlined below, some as recommendations, others as observations that need to be taken fully into consideration in subsequent activities.

1. A host of issues related to the health status, social marginalization, geographic isolation, historical issues of abuse, and other dimensions of First Nations communities were identified, but only minimally addressed in the Workshop. Clearly, specific and substantive steps are needed to develop and support a strong First Nations sexual and reproductive health component to the post-Workshop agenda. There must be unequivocal assurances from this point forward that First Nations populations and participants will not be silenced, marginalized or made token by either the process of dialogue, or the outcomes. There is significant potential, if the right approach is sustained, to empower current and future aboriginal populations with regard to the issues at hand.
2. Sexual pleasure is one aspect of sex-positive messaging that remains a policy, program and communications challenge. The paradox is that it is a pervasive focus of popular media depictions of sexuality, but in the context of sexuality education for young people the subject faces strong acceptance barriers among parents and some education authorities. Acceptance of sexual pleasure for women is a problem in some cultural communities as well. Among other things, an open approach to sexual pleasure, particularly for women, has an impact in dealing with issues of unequal power and sexual exploitation.

Participants stressed the importance of building networks and community-level partnerships in the pursuit of all of the recommendations from the Workshop. These strategies are seen as critical tools for overcoming resistance (the “power bottleneckers” referred to earlier), and for breaking down the isolation with which a number of smaller organizations in more isolated communities must contend. One key feature of these coalitions must be their capacity for self-governance and sustainability, so they can effect the transition of ideas into action. Another is the ability of groups to be reinforced with cultural and spiritual perspectives as appropriate for the communities they represent.