An Overview of Sexual and Reproductive Health in the Context of Public Health Ethics
Abstract and Keywords
Sexual and reproductive health is an important aspect of individual health and well-being, as well as a significant determinant of public health. This chapter uses a public health ethics lens to illuminate three examples of moral complexity arising in sexual and reproductive health: social justice, contested views of harms and benefits, and self-determination. The chapter also provides an overview of the four chapters in this dedicated section of The Oxford Handbook of Public Health Ethics. The section’s chapters provide a focused examination of public health ethics in the context of STI control measures, contraception, abortion, and pregnancy-related services.
Since the mid-1990s, the concept of sexual and reproductive health has evolved from a limited focus on discrete health issues, such as maternal and child health, to a broad understanding of the many factors, such as gender inequality, that can affect people’s sexual and reproductive lives. The move toward a more expansive vision of sexual and reproductive health is frequently traced to the landmark 1994 United Nations International Conference on Population and Development (ICPD). In a paradigm shift, the ICPD replaced traditional fertility control programs, which emphasized demographic goals, with a “Programme of Action” (PoA) that not only placed the sexual and reproductive health of individuals—and particularly women and girls—at its core, but also affirmed sexual and reproductive health, reproductive rights, and gender equality as human rights and cornerstones of sustainable development (UN, 1994).
The PoA committed ICPD member states to providing universal access to a core set of health services: education related to sexuality and reproduction, prevention of sexually transmitted infections (STIs), family planning, safe abortion, and maternal and newborn care. Despite occasional setbacks, efforts to build on that vision continue. The United Nations 2030 Agenda for Sustainable Development includes universal access to sexual and reproductive health as a target (UN, 2015), and the 2018 report of the Guttmacher-Lancet (p. 372) Commission on Sexual and Reproductive Health and Rights calls for universal access to sexual and reproductive health, comprehensively defined as a state of “physical, emotional, mental, and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction, or infirmity” (Starrs et al., 2018, 11).
Sexual and reproductive health is an important aspect of individual health and well-being, but it also functions as a significant determinant of public health. The intersection between the deeply personal consequences of sexual and reproductive ill health, and its profound affect on public health outcomes, is reflected in the chapters of this section of The Oxford Handbook of Public Health Ethics, which examines public health ethics in the context of STI control measures, contraception, abortion, and pregnancy-related services. Some of the ethical complexities arising across the spectrum of sexual and reproductive health more generally are highlighted below.
Individual and public health outcomes associated with sexual and reproductive health have generally improved worldwide as a consequence of greater support for gender equality, wider access to educational opportunities, higher rates of contraceptive use, and lower incidences of maternal morbidity and mortality (Snow, Laski, and Mutumba, 2015). When examined through the lens of public health ethics, however, a number of moral considerations come into greater focus (Childress et al., 2002). Three of the many areas of moral complexity are highlighted as examples: social justice, contested views of harms and benefits, and self-determination. Although there is interplay between these moral considerations, they are presented individually for ease of understanding.
While improvements in aggregate sexual and reproductive health outcomes are noteworthy, they can conceal considerable global inequalities. Often, these disparities stem from economic, social, cultural, and structural determinants of health, several of which are briefly highlighted in the discussion that follows.
Wealth inequality is a significant determinant of sexual and reproductive health, both between and within countries. Women in low-income countries are more likely than those in high-income countries to have unmet contraceptive needs, unintended pregnancies, unsafe abortions, and inadequate maternity care (Singh, Darroch, and Ashford, 2014). Within countries, women living in poverty are similarly disadvantaged as compared to their wealthier counterparts (Singh, Darroch, and Ashford, 2014).
Globally, the most significant risk factor for poverty is female gender (Rogers, 2006). Gender norms continue to limit women’s access to education, information, employment, and health services. As a result, women remain disproportionately represented among the global poor. The “feminization of poverty” can prevent women from gaining influence (p. 373) and authority to challenge societal gender-power imbalances, which only reinforces the gender norms at the crux of their poverty (Pearce, 1978, 28).
Women who are socially and economically dependent on men generally have less power to negotiate condom use and access contraception. Although they are at heightened risk for contracting STIs and having unintended pregnancies (Glasier et al., 2006), their social and financial dependency diminishes their ability to access sexual and reproductive health care services (Cottingham and Ravindran, 2011). They consequently face higher than average rates of morbidity and mortality associated with STI-related complications, unsafe abortions, and unattended births (Starrs et al., 2018). Women who carry unintended pregnancies to birth are also more likely to lose economic, educational, and social opportunities (Cook and Dickens, 2009)—the very same factors that contribute to poverty, gender inequality, and dependency. Inequality begets further inequality, and women can become trapped in a socially unjust cycle from which it is increasingly difficult to escape.
Some populations are more likely than others to confront barriers to sexual and reproductive health information and services, and in turn to experience adverse health outcomes. Individuals whose communities view their sexual activities and identities as unacceptable (e.g., sex workers, men who have sex with men) are among those at highest risk because social stigma, discrimination, violence, and fear of criminal penalties can deter them from seeking health services (Starrs et al., 2018). Survivors of gender-based violence also report forgoing medical and legal services because of community perceptions of gender-based violence as a private matter, justified, or even a reason to shun or punish the survivor (Glasier et al., 2006).
Contested Views of Harms and Benefits
Sexual and reproductive health practices, programs, and policies raise some of the most contested issues in public discourse. Is it ethically permissible to provide HIV-prevention drugs to at-risk adolescents without parental consent? To require employers to provide employees with insurance that covers contraception? To use reproductive technology to enhance offspring? These and similar questions prompt disputes in health clinics and courts, religious venues and voting booths, and private conversations and public protests. Often at the crux of such debates are differing views about what constitutes harm, and what types of benefits, if any, can outweigh that harm.
Although moral considerations of harms and benefits are well-marked features on the “terrain of public health ethics” (Childress et al., 2002, 170), addressing them in the context of sexual and reproductive health can prove especially challenging in several respects. The first is that sexuality and reproduction frequently implicate personal preferences, sociocultural attitudes, and religious beliefs in ways that can provoke visceral responses and reveal deep—and sometimes irreconcilable—divides about what constitutes harm. Public policies and laws involving sex education, same-sex marriage, and abortion are notoriously contentious in this regard, because they collide with contested values related to sexual activity, marriage, and human life itself.
(p. 374) A second, related difficulty involves how to assess competing harms and benefits, particularly when they are incommensurate. Sex education in public schools is proven to reduce adolescent pregnancy and STI transmission, but opponents argue that it violates their religious liberty by normalizing premarital sex. How should decision-makers resolve conflicts between the harms set forth by each side? Are some harms, such as intrusion on religious liberty, absolute constraints on government action? Or can public health benefits justify such an intrusion in some circumstances? Without concrete ethical guidance (Childress et al., 2002), it is unclear how to resolve such conflicts.
These challenges are compounded when population benefits are offered as a justification for government interventions in sexuality and reproduction. Throughout history, governments have appealed to the common good to justify policies that employ coercion, incentives, and disincentives to alter fertility rates. Some policies have deprived individuals of their ability to reproduce, based on factors such as race, class, or perceived mental health (e.g., US state sterilization laws), while other policies have forced women to continue pregnancies (e.g., Romania’s ban on contraception and abortion) or terminate pregnancies (e.g., China’s one-child policy) against their will. Collectively, they are a reminder that governments, and those subject to their policies, may have conflicting views about what constitutes population benefit.
Self-determination is a significant determinant of sexual and reproductive health. Often used interchangeably with “autonomy,” self-determination is the individual freedom to live in accordance with one’s own values and decisions. Much of the literature about self-determination focuses on whether a specific individual has the rational capacity to make a certain decision, from a set of options, in an informed and reasonable manner and without external coercion. That model, however, can overlook the range of ways in which background social conditions—such as poverty and gender inequality—can limit, or even eliminate, an individual’s ability to exercise self-determination with regard to a particular choice (Sherwin, 1998).
In the context of sexual and reproductive health, a number of factors can affect self-determination, three of which are mentioned here. To make informed decisions, individuals must have access to comprehensive and scientifically accurate information. Evidence-based sex education for adolescents is critical in this respect, as it dispels myths, confronts biases, and fosters informed decision-making (Starrs et al., 2018). Conversely, policies that prevent the dissemination of information about abortion availability, as well as laws that require the distribution of scientifically inaccurate information (e.g., a claim that abortion increases the risk of breast cancer), undermine informed decision-making and self-determination.
To exercise self-determination, individuals must be respected as persons with authority to make choices about their sexual and reproductive life, without discrimination, coercion, or violence. Laws and customs that require spousal consent before married women can (p. 375) access contraception, abortion, and sterilization services deny women authority to determine if and when they will have children, and also fail to respect them as persons. Stigmatization, discrimination, and the threat of violence—as well as laws that criminalize same-sex sexual activity, ban same-sex marriage, and require sterilization before transgender and intersex people can obtain birth certificates that match their preferred gender—constrain the choices of people with nonconforming sexual orientations and identities. Cultural practices such as child marriage and female genital cutting can also negatively impact self-determination by precluding girls, and the women they will become, from decisions that profoundly affect their sexual and reproductive health.
Self-determination not only requires access to information and the authority to make choices, but also the socioeconomic means to access those choices. A woman who continues her pregnancy because she cannot afford an abortion, the cost of which may include travel to a distant clinic (sometimes more than once) and child care expenses, has not made a fully autonomous choice. Her socioeconomic circumstances limit her to one option: pregnancy.
The chapters in this section of The Oxford Handbook of Public Health Ethics provide a public health ethics perspective in each of four areas of sexual and reproductive health: STI control measures, contraception, abortion, and pregnancy-related services.
In “Sexually Transmitted Infections and Public Health Ethics,” Mary A. Ott and John Santelli examine STI control, which the authors define as public health programs, policies, and practices that aim to prevent, treat, and limit the transmissibility of STIs. Mandatory reporting, contact tracing, and outreach education are examples of STI control activities. In striving to maximize population sexual health, however, STI control activities can pose significant ethical challenges. Ott and Santelli offer thoughtful approaches that strive to balance the sexual health and well-being of populations with the liberty and equality interests of individuals.
In “Contraception and Public Health Ethics,” Saumya RamaRao and John Townsend focus on contraception, not only as a core component of public health, but also as a locus for ethical conflict between population goals and individual rights. Relying on the ethical principles of respect for persons, beneficence, and justice, they explore how tensions between public health goals and individual rights unfold in two contexts: routine contraceptive services and contraceptive research. The authors highlight the consequences of these tensions for health systems, providers, and contraceptive users, optimistically concluding that the relevant stakeholders can manage these conflicts in ways that are beneficial to all.
In “Abortion and Public Health Ethics,” Mahmoud F. Fathalla offers a global public health ethics perspective on abortion. Given the magnitude of public health harms resulting from unsafe abortion, and the health inequities and social injustices stemming (p. 376) from insufficient access to safe abortion, Fathalla argues that the global community has an obligation to address, and ultimately eliminate, unsafe abortion. That responsibility is heightened, he contends, by women calling on governments to address unsafe abortion, an international consensus that eliminating unsafe abortion is central to the global reproductive agenda, and economic data demonstrating that greater access to safe abortion produces cost savings. Fathalla concludes that the global community must stand with women as they assert their right to health.
In “Access to Pregnancy-Related Services: Public Health Ethics Issues,” Anne Drapkin Lyerly, Elana Jaffe, and Margaret Olivia Little address ethical challenges that arise when the value or utility of pregnancy-related services are contested. They first identify features of pregnancy-related care that contribute to such conflicts. For example, some pregnancy-related services, such as pregnancy termination due to fetal abnormality, involve a complex interplay between public health programs (e.g., prenatal screening) and individual women’s values, which are known to differ. Using prenatal testing and modes of childbirth to ground their discussion, the authors explore how societal and cultural values affect access to pregnancy-related care.
Since the mid-1990s, the international community has made progress toward the goals set forth at the ICPD, but the promise of universal access to sexual and reproductive health services remains elusive in much of the world. Public health ethics sheds light on the moral complexities involved in achieving that goal. It recognizes that factors such as poverty and gender inequality can lead to a cycle of systematic disadvantage, in which sexual and reproductive ill health is the result, and the cause, of other deprivations. Public health ethics also highlights tensions that arise when sexual and reproductive health issues collide with contested values, and it draws attention to the far-reaching political, economic, and individual health implications of those conflicts. Despite, and because of, these challenges to achieving universal sexual and reproductive health, a renewed and bold commitment to the ICPD’s vision is essential.
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