RHO archives : Topics : Gender and Sexual Health

Program Examples

The programs described below illustrate some of the strategies that family planning, reproductive health, and women's organizations have developed to address various sexual health and gender issues in developing countries.

Submit your own program example.

• Bolivia: Integrating a gender perspective into the delivery of sexual and reproductive health services.
• Brazil: Delivering free condoms, STI treatment, and gynecological services to urban sex workers with a mobile clinic and outreach workers.
• Ghana: Incorporating health services for sex workers into Ministry of Health institutions in order to reduce the transmission of HIV/AIDS and other STIs.
• India: Designing health services that empower sex workers at Calcutta's Sonagachi Project.
• Latin America and the Caribbean: Incorporating sexual health and gender issues in family planning and STI counseling at three IPPF affiliates.
• Mexico: Overcoming judicial and health service barriers that prevent victims of rape and sexual assault from receiving legal abortion services.
• Peru (Mestanza case): Using international human rights litigation and political advocacy to bring about changes in reproductive health policies and practices.
• Peru (ReproSalud): Empowering women and their communities to confront gender-based barriers to reproductive health.
• South Africa: Training in gender awareness and gender violence for primary health care nurses in rural areas.
• Venezuela: Identifying and treating victims of domestic violence at PLAFAM's family planning clinics.
• Zimbabwe: Combating violence against women with a mixture of advocacy, research, training, and support services at the Musasa Project.
• Worldwide: A BBC/IPPF collaboration to broadcast accurate information about sexual health to radio audiences worldwide, especially young people.
• Worldwide: Promoting gender equity, social change, and individual decision making and communication skills with the Stepping Stones training package.

Click here to view a list of gender-related program examples available on other websites.

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Bolivia

The Programa de Coordinación en Salud Integral (PROCOSI) is a network of NGOs that works for health and development in Bolivia. After initial efforts to integrate a gender perspective into service delivery faltered, PROCOSI launched a formal Gender Program in 2000 with funding from the USAID Mission in Bolivia. Seventeen affiliates involved in sexual and reproductive health care participated.

Defining and incorporating a gender perspective in service delivery can be difficult, and PROCOSI did not attempt to tackle this task on its own. Instead, PROCOSI adapted relevant instruments and indicators from the International Planned Parenthood Federation’s Manual to Evaluate the Quality of Care from a Gender Perspective (www.ippfwhr.org/publications/download/monographs/qoc_gender_e.asp).

The Gender Program took a problem-solving approach to gender issues. A trained evaluation team at each PROCOSI affiliate conducted a baseline evaluation to identify problem areas. Then the team worked with the organization’s entire staff to decide which service delivery issues to focus on and to develop a detailed action plan. After implementing the action plans from March 2002 to June 2003, each team conducted a follow-up evaluation to assess progress and create a new action plan for the following year.

The evaluations gathered data from client and provider interviews, observations of consultations and the facility, and a review of institutional documents. These data were used to assess 71 indicators covering every aspect of service delivery, including, for example, the percentage of management positions assigned to women, the existence of services requiring the husband’s consent, and the percentage of visits during which the provider explores sexual and reproductive health topics.

The action plans generally targeted about half of the 71 indicators and proposed more than 100 specific actions. Commonly proposed actions included the following:

• Institutional policies and practices: Reviewing and adapting the institutional mission, vision, guidelines, and regulations.
• Provider practices: Mentioning sexual and reproductive health topics, particularly breast exams, Pap smears, and contraception.
• Client comfort: Placing doors in consulting rooms and baskets for depositing clinic histories for the next patient so nurses do not enter and interrupt the visit, giving audible and visual privacy to the visit.
• Client satisfaction: Evaluating clinic personnel to assess the degree to which they treat clients with respect and attention.
• Gendered language: Observing and supervising the practice of avoiding diminutive language.
• Information, education, and communication: Displaying posters with gender-related concepts in consulting and waiting rooms.
• Monitoring and evaluation: Installing suggestion and complaint boxes in the waiting room.

PROCOSI helped participating NGOs implement the Gender Program by: training the evaluation teams; leading workshops on sexuality, violence, and other subjects that were a common focus for action plans; developing posters, flipcharts, and other client education materials; distributing videos for client waiting areas; and providing US$3,500 in funding to each organization.

Perhaps the greatest challenge was convincing NGO staff at all levels of the need for the Gender Project. At the beginning, many staff members—including the directors of the NGOs and the clinic managers—did not understand what incorporating a gender perspective into service delivery meant and therefore they did not understand the reason for the project. Indeed, many believed that their services already were gender-sensitive and that existing quality of care evaluations already met the Gender Program’s objectives.

The Gender Program also faced some practical challenges. Creating and implementing the action plans was time-consuming and required busy personnel to take on additional responsibilities. Many clinics also pointed to staff turnover as a problem.

Achievements

An operations research project conducted by the Frontiers in Reproductive Health Program documented the achievements of the Gender Program, which include the following:

• Increased staff consciousness regarding labor rights, greater teamwork, greater emphasis on following rules that guarantee service quality, and more gender-inclusive language.
• Changes in the personal views and behavior of staff at all levels, with positive effects on their home life as well as their work.
• Demands by female staff for greater respect on the job from male staff.
• More frequent discussion of women’s sex lives, breast cancer, domestic violence, and other sexual and reproductive health issues during consultations.
• More systematic screening of women’s reproductive health needs, contributing to a 35 percent drop in unmet need for contraceptive services.
• Greater exploration of women’s relationships with their partners during consultations.
• Positive shifts in couple communication, decision making, and attitudes toward sexual and reproductive rights.
• Modest improvements in client comfort, client satisfaction, and the quality of care, although these did not translate into increased demand for services.

The largest expenses for the PROCOSI affiliates were staff time and costs associated with training. Overall, implementing the Gender Program cost US$23,148 per NGO.

PROCOSI is searching for new funds to consolidate the gender approach in its programs and services. Future strategies include an accreditation and certification process as well as implementing the gender approach in 13 new member organizations.

For more information, please contact: Dr. Ignacio Carreño (icarreno@procosi.org.bo) or Lizzy Montaño (lizzymontano@yahoo.com) at PROCOSI.

This case study is based on: Palenque E, Montaño L, Vernon R, Gonzales F, Riveros P, Bratt J. Effects and Cost of Implementing a Gender-Sensitive Reproductive Health Program. FRONTIERS Final Report. Washington, D.C.: Population Council; 2004. Available at: www.dec.org/pdf_docs/PNACX723.pdf or www.popcouncil.org/pdfs/frontiers/FR_FinalReports/Bolivia_PROCOSI_Gender.pdf.

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Brazil

In 1993 the Municipal Health Secretariat of Santos, Brazil joined with the NGO Organização de Apoio ao Portador do Virus da AIDS to launch a sexually transmitted infection (STI) program for sex workers and their male clients. At the time, the busy port of Santos had the highest incidence of AIDS cases in Brazil at 287 per 100,000. From 1,200 to 1,400 sex workers were concentrated in the harbor area, where they served a large population of sailors, truck drivers, and harbor workers. There was concern that the sex workers might spread the disease to the large numbers of tourists who visit Santos in the summer.

The program offers clinical services and outreach education to accomplish its goal of encouraging sex workers and their clients to use condoms consistently and to seek treatment for STIs. Using condoms, medicines, and leaflets provided by the government health service, NGO staff provide HIV counseling and tests, STI treatment, prenatal care, clinical care for women's health problems, free condoms, and safer sex workshops. Initially, the medical services were offered at a public health clinic in the red-light district, but sex workers were reluctant to visit the clinic because it meant taking considerable time away from work and a consequent loss of earnings. In 1995, the health ministry sponsored another NGO, Assoção Santista de Pesquisa Prevenção e Educação em DST/AIDS, to open a mobile clinic that could bring STI services to sex workers in their own neighborhoods. The mobile clinic provides lab tests and free drugs for STIs, Pap smears, and breast cancer screening.

Outreach workers complement clinic services with a range of educational efforts. During visits to night clubs, bars, hotels and motels, and escort agencies, they distribute condoms and leaflets to sex workers and male clients. They also hold group discussions about safer sex, prenatal care, family planning, and human rights. Over a four-year period, outreach workers held 642 workshops at 52 commercial sex sites, reaching more than 5,600 sex workers and clients.

Initially, the project employed peer educators but their role was eliminated after the first year. Sex workers were not committed to their work as peer educators: they had difficulty fitting peer education activities into their schedule, could earn more doing sex work, and did not always pay attention during training sessions. Today, the project staff consists solely of health professionals, including psychologists and social workers as well as physicians and nurses. Each staff member receives 80 hours of training in public health, safer sex, prostitution, drugs and harm reduction, human rights, street theater, intervention techniques, and other topics.

Obtaining the sex workers' cooperation and participation posed a serious obstacle when the program first began operating. There was no social or political organization among Santos' sex workers that program personnel could negotiate with and use for health purposes. In fact, the circumstances of the sex workers' lives deters the development of any such organization: for the most part, they are poorly educated, hide their jobs from their families, lack time for social activities, and compete with one another for clients. When sex workers proved reluctant to visit the health clinic, program staff began outreach activities to publicize the health services. They distributed condoms and leaflets and held meetings in sex workers' homes. Sex workers' attitudes gradually changed, and now they appreciate the health services available.

The project's greatest achievements have been to increase condom use and the availability of health care. Project personnel regularly meet with and distribute condoms to 800 women; 714,000 condoms have been distributed so far. Over a three-year period, almost two-thirds of sex workers have sought gynecological care, and nearly 9,000 clients have been referred for STI treatment. While program leaders would like to expand the project, finding funds to pay outreach workers has proven difficult and the program has had to rely on volunteer health workers. However, the Municipal Health Secretariat has once again become a sponsor, with resources from the World Bank.

Lessons learned from this experience include:

• To avoid the need for lengthy training, it is better to recruit health workers who already have experience working with sex workers or at least have experience working within the health system.
• Health programs for sex workers must understand and respond to psychological and cultural aspects of sex work, such as low self-esteem and limited social organization.
• Questionnaires, focus groups, and observations are among the ways planners can learn about the target population, including the power relations that shape their work.
• Regular communication between health care professionals and sex workers is necessary so that health workers can respond promptly to rumors, misinformation, complaints, and other feedback from sex workers.

For further information, please contact:

Neide Gravato da Silva, Programa Municipal de DST/AIDS, Pca Rui Barbosa 23, 4o andar, Centro, Santos SP 11010-130, Brazil. Tel: 55 13 2194536. Fax: 55 13 2194536. Email: grasilva@uol.com.br .

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Ghana

In 1996, the Ghana component of the West Africa Project to Combat AIDS (WAPTCA) launched an STI-AIDS intervention program targeting sex workers in Accra and Tema. To ensure the program's sustainability, WAPTCA personnel worked with local health authorities to offer services to sex workers through the Ministry of Health's service delivery system. They recruited MOH nurses and trained them in health education and communication, STI management, and working with vulnerable groups.

A baseline study identified two different categories of sex workers in Ghana: older, home-based workers known as "seaters," and younger, mobile workers known as "roamers." Because roamers, who operate in hotels, night clubs, and on the streets, are difficult to reach, the program initially directed its efforts to seaters. The first step was to identify and build relationships with the leaders and gatekeepers of the sex workers' community, including landlords, "queen mothers," hotel owners, and pimps. After explaining the purpose and potential benefits of the program to the landlords and queen mothers, they, in turn, sensitized and mobilized the sex workers. Once the seaters became involved in the intervention, they introduced project personnel to the roamers' community.

The program combines outreach and clinic-based services. Community health nurses visit seaters in their homes to educate them about health issues, teach them negotiation skills, distribute information, education, and communication (IEC) materials, and promote and sell condoms. They also encourage sex workers to attend the clinics for medical care and STI screening. To reach roamers, the project turned to peer educators. Sex workers and their leaders helped identify potential peer educators, who then received two days of training on reproductive physiology, STIs, project interventions, and interpersonal communications. Peer educators receive about US$50 a month for their work and continue to receive training on the job.

The program also operates clinics where sex workers can seek treatment for general ailments as well as STIs. They pay for this treatment, although drugs are sold to them at cost. The syndromic approach is used to manage STIs, and complicated cases are referred to a specialist. During their clinic visits, patients also are shown slides and counseled on STIs and encouraged to buy condoms.

To encourage sex workers to come the clinic for active screening, outreach workers schedule visits at their convenience and offer free treatment for any medical problems discovered. Screening begins with a health talk explaining its benefits and the procedures involved. Health workers then record each woman's sexual and medical history, perform a general and gynecological examination, and collect a variety of specimens. Women who test positive for STIs, excluding HIV, are called back for treatment. Following this initial screening, sex workers are asked to return quarterly for follow-up screening during which no samples are taken.

Few sex workers in Ghana want to know their HIV status, and HIV testing is not made compulsory despite its high prevalence among sex workers (75 percent of seaters and 25 percent of roamers have tested positive for HIV). Women who do want to know their HIV status are counseled beforehand as well as afterward.

In order to recover costs and become sustainable, the project sells condoms to sex workers instead of distributing them for free. Before launching the condom distribution effort, staff asked sex workers which types of condoms they used and preferred. The project stocks two brands of well-known latex condoms, so that the sex workers have a choice, and sells them at cost. More recently, the project has introduced the female condom to sex workers in Ghana. Twenty-seven peer educators were trained to sensitize their colleagues about this newly available method.

The program also engages in advocacy with local police officials, explaining how they can contribute to preventing AIDS in vulnerable groups, and organizes IEC activities on STIs and HIV/AIDS for the general population, in hopes of reaching the clients of sex workers. These IEC sessions have helped raise the general level of awareness about reproductive health issues and have increased patronage at project clinics.

WAPTCA's many achievements in Ghana include:

• Building a strong relationship with the community of sex workers and their leadership.
• Attracting an increasing number of sex workers to the clinics for both screening and treatment. Clinic attendance more than doubled over the first three years of the project, rising from 1,695 in 1997 to 4,041 in 1999, and it jumped once again in 2000, when clinic providers saw 5,365 people during the first six months of the year.
• Obtaining the cooperation of the sex workers, so that they introduce new sex workers to the clinic, bring in colleagues with symptoms of AIDS, and bring their regular partners for STI services.
• Encouraging condom use among sex workers. Condom sales have increased sharply over the course of the project, rising from 300,000 in 1997 to 2,540,000 in 2002, which is 16 percent of all condom supplies in the country. Sex workers now make special trips to clinics to purchase condoms; seaters routinely eject clients who refuse to use condoms; and groups of sex workers join together to beat up clients who intentionally tear condoms.
• A 1999 evaluation of the project concluded that the intervention had considerably decreased the number of new HIV infections among sex workers and their clients, thus slowing the increase in the overall prevalence and incidence of AIDS in Ghana.

Initially, WAPTCA had to maintain a low profile because sex work was a sensitive issue in Ghana. Impressed by the project's results, however, the MOH has recognized it as an important intervention in the control and prevention of STIs and HIV/AIDS. At the request of the MOH, the project has replicated its activities in four other towns in different regions of the country, including Kumasi, the second largest city in Ghana. The project's activities have been received enthusiastically by local sex workers, and WAPTCA is considering expanding its efforts to still more regional and district towns. There are now 12 sex-worker-friendly clinics located in eight out of Ghana's ten regions. The clinics, which are located on the premises of public-sector health facilities, serve as resource centers for university and nursing school students and for local and international project partners. The project also has begun to help sex workers who want to quit prostitution by supporting their efforts to generate other sources of income, for example, in batik, soap, and gari processing.

Lessons learned from this experience include:

• Integrating services for sex workers within existing MOH institutions, staffed by MOH personnel, maximizes the likelihood of success and of sustainability.
• Charging for condoms and for treatment visits contributes to sustainability, but free drugs and treatment are an important and effective incentive for sex workers to come for screening.
• Sex workers will collaborate with an STI intervention provided that the health team takes the initiative to go where sex workers live and work, treats them with respect and dignity, and offers affordable services and drugs.
• Peer educators are more effective in reaching roamers than health staff.
• A national policy legalizing prostitution, banning police harassment, and funding health screening for sex workers is needed.
• HIV/AIDS interventions that target sex workers are probably among the most cost-effective measures in public health.

For further information about WAPTCA, which is funded by the Canadian International Development Agency (CIDA), please contact:
Dr. Khonde Nzambi, CIDA-AIDS Project, P.O. Box 710, Achimota-Accra, Ghana. Tel: 233-21-241452. Fax: 233-21-233340. Email: nkhonde@ncs.com.gh

Dr. Jacques Ppin, CRC-CUSE, 12th North Avenue, Universit de Sherbrooke, 3001, Sherbrooke, Qubec J1H5N4, Canada.
Email: jpepin01@courrier.usherb.ca

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India

Approximately 6,000 sex workers serve more than half a million male clients a year in Sonagachi, a red-light district in central Calcutta. In 1992 the All India Institute of Hygiene and Public Health launched a program to reduce the transmission of HIV/AIDS in Sonagachi. The project began with two key interventions: a health clinic and outreach by peer educators. It has since triggered a broader self-empowerment movement by sex workers in the state of West Bengal.

From the first, it was clear that the project's original focus on the prevention and treatment of STIs, including HIV/AIDS, was too narrow. Indeed, the first nine sex workers who sought medical advice from a project doctor wanted help with infertility—a common problem among sex workers who contract multiple STIs. Therefore, the Sonagachi clinic was designed to offer a full range of primary health care services to sex workers, their children, and other local people. During its first 15 months of operation, the clinic drew more than 4,500 clients, over three-quarters of them women. A second clinic was opened during evening hours to target sex workers who commuted to work in Sonagachi and their male clients. The project has since expanded into other red-light districts and now operates 13 health clinics in Calcutta and Howrah.

Hundred of peer educators carry the project's message directly to sex workers, madams, and pimps in their homes and brothels. Peer educators are current and former sex workers from the local community who are paid to work four hours a day, during clinic hours, although they volunteer far more time than that. They receive extensive training in:

• transmission and treatment of STIs, including HIV/AIDS;
• negotiation skills needed to persuade clients to use condoms;
• reproductive health;
• treatment and prevention of common communicable diseases;
• lab training to carry out general medical tests; and
• local laws and the legal system as it pertains to the sex trade and women's rights.

Because rapid growth has strained program resources, volunteers are now recruited to supplement the efforts of paid peer educators.

The peer educators, who are easily recognized by the green medical jackets they wear over their saris, visit sex workers at home during the day to educate them about HIV/AIDS and other STIs, to distribute condoms, and to motivate them to visit the project's clinics and to return for follow-up care. Initially, madams and pimps resisted the peer educators' efforts, because they believed that insisting on condoms would drive customers away. The peer educators persisted and eventually convinced the madams that condoms would be good for business since they keep sex workers healthy and working.

As the peer educators gained experience and confidence, they played an increasingly important role in every aspect of the project, participating in strategic planning, policy formulation, implementation, and monitoring. They also sparked a broader empowerment movement among Sonagachi's sex workers. Literate peer educators began teaching uneducated sex workers how to read and write in the clinic courtyard each day. Later, they tackled other problems, such as police raids, police corruption, and violence against sex workers. With the encouragement of project leaders, the peer educators and other sex workers established the Durbar Mahila Samanwaya Committee (DMSC), or Women's Collaborative Committee, in 1995. DMSC acts as a trade union and now has 30,000 dues-paying members throughout West Bengal, including more than half of the sex workers working in Sonagachi. Since 1999, it has run the STI/HIV prevention project, having taken over from the consortium of NGOs and government agencies that first implemented it.

Organizing gave sex workers the power to challenge the local madams, pimps, and hoodlums who preyed on them. Peer educators and other DMSC members have successfully pressured reluctant madams into accepting a condom-only policy, rescued children who are sold or duped into prostitution, picketed police stations to demand action against criminals who injure sex workers, and staged a protest march against police corruption. In 1998, sex workers and their children began staffing the Positive Hotline for sex workers and other people in Calcutta who are HIV-positive. Positive Hotline teams make home visits to offer counseling, medical and legal referrals, and social support and to sensitize the local community. In addition, the DMSC has formed its own financial cooperative so that sex workers can borrow money at reasonable rates, and it operates a nursery and other programs for sex workers' children.

Under the banner of DMSC, Sonagachi peer educators work after hours to network with other red-light districts in West Bengal, to explain the importance of unionism, to promote social marketing of condoms, and to fight the trafficking of women. They founded a regional network of sex workers in 1998 and have developed links with sex worker projects in Nepal and Bangladesh, where many Sonagachi workers come from.

In 1997, the DMSC organized the first of its annual conferences of sex workers from all over India to highlight their problems and demand recognition from the government. The conference manifesto Available at: www.bayswan.org/manifest.html or at www.walnet.org/csis/groups/nswp/conferences/manifesto.html ) explores issues of gender, poverty, and sexuality that define and limit sex workers' existence and reduce the quality of their lives. With slogans like, "Sex work is real work, we demand workers' rights," the conference sought an independent governing board that would recognize prostitution as a means of livelihood and address corruption.

While it has branched out from its original health objectives, the Sonagachi project has made a major health impact. Its many achievements include:

• Condom use by sex workers in Sonagachi increased from 3 percent in 1992, to 70 percent in 1994, to 90 percent in 1998. In fourteen catchment areas outside of Sonagachi that are served by DMSC clinics, condom use rose from 30 percent in 1996 to 52 percent in 1998.
• HIV prevalence among sex workers in Sonagachi has remained steady at about 5 percent since 1992, while HIV rates among sex workers in most parts of India have increased dramatically.
• STI rates have dropped: the proportions of sex workers with recent syphilis and genital ulcers fell from 28 percent and 7 percent, respectively, in 1993 to 11 percent and 2 percent in 1998.

The project has accomplished this at a relatively low cost by relying heavily on part-time peer educators and DMSC volunteers and by selling condoms at bulk rates rather than distributing them free.

An even greater accomplishment, however, has been the project's success in building self-esteem, self-reliance, and self-respect among sex workers. The Sonagachi project relies on the three R's: respect for, reliance upon, and recognition of sex workers. Active participation in planning and implementing the Sonagachi project helped sex workers realize that they had the power to fight all forms of social exploitation. The result has been a community movement, under the leadership of DMSC, that has improved all aspects of sex workers' lives. DMSC also has expanded the network of health clinics for sex workers in West Bengal by opening clinics in 19 red-light districts outside of Sonagachi and by launching an HIV-intervention program for street-based sex workers and their clients. The government of India also plans to replicate the Sonagachi model in other cities, but it is not clear how well it can succeed in places like Bombay, which lacks Calcutta's strong tradition of trade unionism and where the sex trade is controlled by organized crime.

Among the many lessons learned by the Sonagachi project are:

1. Information and a supply of condoms is not enough to change the sexual behavior of sex workers. Sex workers must value themselves before they will take steps to protect their health; they must overcome the fear of losing clients and income to other sex workers; and they must be able to enforce condom use by the client. This requires self-confidence, negotiation skills, and the cooperation of madams and pimps. The goal of the Sonagachi project was to create an enabling environment, so that sex workers as a community could practice safer sex.

2. Sex workers' health needs reach beyond STI prevention and treatment to the full range of primary health care services for themselves and their children. Broader social and economic issues, such as sex workers' uncertain legal and social status, create or exacerbate some of their health problems.

3. Health care is not enough. Sex workers also need the social and political power to protect themselves from being victimized by corrupt policemen, exploitative madams and pimps, violent clients and criminals, greedy money lenders, and so on.

4. To make an impact, project leaders must continually negotiate with the people who hold power within the community and control the sex trade. These include politicians, gang leaders, brothel landlords, madams, and pimps.

Sonagachi workers also attribute the success of their efforts to:

• working to reduce the harm caused by sex work rather than to abolish the sex trade;
• taking a positive judgmental stand toward sex workers and their profession;
• using a noncoercive approach;
• giving priority to the perceived needs of sex workers;
• involving sex workers throughout the planning, design, and implementation process;
• supporting the sex workers' fight against social exploitation and injustice;
• being flexible in planning and executing programs so that adjustments can be made at the field level;
• designing strategies that fit the local power base, culture, and functioning of sex trade rather than looking for universal solutions; and
• relying on the syndromal management of STIs.

Further information about the Sonagachi project and DMSC activities is available online in the UNAIDS Best Practice Collection (www.unaids.org) and at www.walnet.org/csis/groups/nswp/dmsc/index.html .

For more information, please contact:
Dr. Smarajit Jana, Project Director, STI/HIV Intervention Programme (SHIP), 8/2 Bhawani Dutta Lane, Calcutta 700 073, India. Phone: 00 91 33 241 6200; Fax/phone: 00 91 33 241 6283; Email: sjana@giascl01.vsnl.net.in

Mrs. Putul Singh, Secretary, DMSC, 8/2 Bhawani Dutta Lane, Calcutta 700 073, India. Fax: 0091 33 241 6283; Email: ship@cal.vsnl.net.in

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Latin America and the Caribbean

IPPF affiliates in Brazil (BEMFAM), Honduras (ASHONPLAFA), and Jamaica (FAMPLAN) have incorporated sexual health and gender issues into everyday counseling as part of a program to integrate HIV/STI services with family planning (Becker et al. 1997 ). Planners found it was impossible to address HIV/AIDS and STI issues effectively without examining the risks and realities of clients' sexual lives. Thus the HIV/STI initiative, under way since 1992, has fundamentally altered the nature of the client-provider interaction in these three FPAs (FPAs), each of which has learned from the others' experiences.

Training was a critical element in embracing the sexual health approach. Although providers had strong educational and counseling skills, they were used to providing information rather than having two-way discussions with clients. Furthermore, they had no experience counseling clients on sexual practices and personal relationships, they were uncomfortable discussing sexuality and HIV/AIDS, they viewed condoms purely as a back-up family planning method, and they lacked in-depth knowledge of HIV/AIDS.

In addition to giving providers needed technical information on HIV/AIDS and STIs, the training courses sensitized providers to the sexual health and gender issues that affect clients' STI and pregnancy risks and their ability to negotiate with their partners. During the training sessions, providers learned to:

• be comfortable with sexual language;
• recognize their own values regarding sexuality, including biases against sexual practices such as oral sex and homosexuality;
• discuss sexual development and counsel clients on other sensitive issues;
• define sexual and reproductive health;
• explore the client's sexual life in order to assess her risks of unwanted pregnancy and STIs;
• understand the importance of gender and power in sexual relations;
• advise clients how to negotiate with their partners on safe sex issues;
• analyze family planning methods in terms of their effect on sexual relations and sexual pleasure and reassess the role of condoms; and
• understand STIs, including HIV/AIDS.

Providers now take a different approach to counseling. Rather than opening with a lecture on family planning methods, they begin by exploring the unique circumstances of the client's life, including her sexual history and current relationships. This allows them to determine the client's level of risk, identify her individual needs, and judge how gender roles may limit her freedom of action. It took time before providers felt comfortable talking about the emotional aspects of sexuality and alternative sexual practices. Indeed, they requested additional training in sexuality. They were surprised to find, however, that most clients were eager and open in discussing supposedly taboo subjects like anal and oral sex, impotence, premature ejaculation, sexual abuse, and domestic violence.

Over a three- to four-year period, there have been dramatic changes in how BEMFAM, ASHONPLAFA, and FAMPLAN provide services and in clients' questions and concerns as they respond to the FPA's new approach. Yet change did not come easily. Staff members were reluctant to address sexuality in counseling sessions, they feared the new program would mean extra work without additional compensation, and they worried that longer counseling sessions would create backlogs of clients. The growing HIV/AIDS epidemic, however, convinced providers that clients were indeed at risk, and providers felt a responsibility to protect them. Staff solidarity also facilitated change, as did providers sense of professional growth as they assumed new roles and responsibilities.

The lessons learned by these three FPAs include:

• Institutional commitment is essential because a sexual health approach means redefining the organization's mission and goals. The support of top managers also is needed to sell such a controversial program to the staff.
• New programs take root more easily when existing high-level managers are placed in charge.
• Staff involvement at every step in developing, implementing, and monitoring a new program increases their commitment to it.
• Changing providers' attitudes so that they are willing and able to discuss sexuality and personal relationships with clients is a long-term process that requires ongoing training, feedback from supervisors, and the support of peers.
• Including sexuality in the counseling process saves time because it allows the provider to zero in rapidly on the client's needs.
• Individualized counseling improves the quality of services and increases providers' satisfaction with their jobs.
• Clients are willing to discuss their sexual lives openly, both in individual counseling sessions and in groups.
• A sexuality-based approach to counseling can increase condom use significantly.

For more information, please contact:
Sociedad Civil Bem-Estar Familiar no Brasil (BEMFAM), Avenida Republica do Chile, No 230-17 Andar, Centro Rio de Janeiro CEP 20031-170, RJ, Brazil. Phone: +55 (21) 210-2448, Fax: +55 (21) 220-4057, email: info@bemfam.org.br

Associación Hondurea de Planificación de la Familia (ASHONPLAFA), Apt. Post 625, Tegucigalpa, Honduras. Phone: +504 (2) 32 2178, Fax: +504 (2) 32 5140

Jamaica Family Planning Association, P.O. Box 92, St. Ann's Bay, Jamaica. Phone: +1 (876) 972 2515, Fax: +1 (876) 972 2224

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Mexico

Abortion is legal in cases of rape throughout Mexico, and public-sector hospitals throughout the country have an obligation to make services available to women rape survivors who request an abortion. Lack of clear legal procedures, health-care protocols, and training for providers, however, has strictly limited access to legal abortion services. Furthermore, national or institutional norms do not exist for comprehensive services for women who experience sexual violence.

The situation improved in Mexico City in August 2000, when the Legislative Assembly there broadened the grounds for legal abortion in the penal code and clearly defined the responsibility of the judicial and health sectors to authorize and carry out legal abortions. The Assembly’s action prompted the Ministry of Health and Justice Department of Mexico City to issue rules and procedures for providing legal abortion services and also stimulated discussion of the issue nationwide. The legislative process in Mexico City has served as a model for activism in other states, since abortion laws vary from state to state.

Ipas Mexico has been working with public-sector health institutions and judicial authorities since 1998 to improve the availability, accessibility, acceptability, and quality of care of legal abortion services, within the context of comprehensive services needed by women who have survived sexual violence. To assess the nature and extent of the problem, Ipas staff first conducted:

• Assessments of health care provider attitudes, knowledge, and practices related to legal abortion.
• Sensitization workshops for health care providers.
• Inter-institutional workshops linking professionals from the health and judicial sectors.
• Interviews with women rape survivors who requested and received a legal abortion.
• Discussions with NGOs experienced in violence against women, training health care providers, and human rights.

Based on the information collected, Ipas Mexico has developed and implemented a step-by-step strategy to make comprehensive services, including legal abortion, available to Mexican women who survive sexual violence. Its work with NGOs and with state Ministries of Health and Justice Departments has included:

• Organizing national and international conferences aimed at obstetrician/gynecologists on the impact of violence against women and the need for legal abortion services.
• Developing a comprehensive model of care for women who experience sexual violence, including detection of violence, counseling, medical care, legal abortion, and psychological and legal support, as well as educational and health promotion activities to prevent violence.
• Designing educational and training materials for professionals who work with rape survivors in the judicial and health sectors.
• Conducting consciousness-raising and informational workshops in seven states on the legal context of abortion in Mexico for health professionals.

Workshop participants expressed strong support for legal abortion services: 78 percent of physicians said they were willing to provide abortion services to rape victims if their institutions supported their efforts. Building on this support, Ipas staff worked to create multidisciplinary teams at interested hospitals and invited them to attend an intensive, one-week course on providing specialized services to survivors of sexual violence. Over 300 participants from 56 hospitals, institutions, and organizations attended the course. Ipas is continuing to provide technical assistance to nine hospitals interested in implementing the comprehensive model of care for sexual violence. As a result of these activities, hospitals are developing the skills and strategies needed to provide post-violence and abortion care and coordinate the many services victims require.

More recently, Ipas Mexico has extended its work to the medical schools that train physicians throughout the country. Staff are collaborating with the faculties of these medical schools to review and modify the curriculum on sexual and reproductive health. The goal is to assure that medical students are taught the information and skills needed to offer integrated, high-quality care, including abortion services, to women who are victims of violence.

For more information, please contact:
Claudia Moreno, Senior Training Associate, or Deborah Billings, Senior Associate, Research and Evaluation, Ipas Mexico, AC Pachuca 92, Colonia Condesa, Mexico DF, CP 06140, Mexico
Telephone: 52-55-5211-8381; Email: claudiam@ipas.org.mx or debbieb@ipas.org.mx

This case study is based in part on: Billings D et al. Constructing access to legal abortion services in Mexico City. Reproductive Health Matters. 2002;10(19):86–94; and Gasman N et al. Building a comprehensive model of care for women victims/survivors of sexual violence that includes legal abortion: Ipas experience in Mexico. Dialogue. 2003;7(2):1-2. Available at: www.ipas.org/publications/en/dialogue/dialogue_13_en.pdf.

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Peru (Mestanza case)

Women’s rights organizations documented a pattern of coercive sterilizations in Peru from 1996 to 1998 during the presidency of Alberto Fujimori, who made population control a priority in his second term of office. To focus attention on the rights violations in Peru, women’s rights advocates decided to take the case of Maria Mamerita Mestanza Chavez to court. This poor, rural woman had a tubal ligation in 1998 after health center staff repeatedly pressured her, even threatening to report her to the police for the supposed crime of having more than five children. Her rights were further violated when health personnel bypassed her and gave her partner sole power to decide whether she should undergo sterilization, did not examine her before the operation, did not give her a consent form until the day after the operation, did not read the consent form to her although they knew she was illiterate, and refused to provide follow-up care when she developed complications. She died at home nine days later.

After failing to get justice in the Peruvian legal system, three NGOs petitioned the Inter-American Commission on Human Rights about Mestanza’s case in 1999. Under the American Convention on Human Rights, the Inter-American Commission has the power to hear individual complaints, determine the international responsibility of member states charged with a violation, negotiate a friendly settlement, or, failing that, refer the case to the Inter-American Court of Human Rights. The three original petitioners—the Latin American and Caribbean Committee for the Defense of Human Rights (CLADEM, www.cladem.com), the Office for the Defense of the Rights of Women (DEMUS, www.demus.org.pe), and the Association for Human Rights (APRODEH, www.aprodeh.org.pe)—were later joined by the Center for Reproductive Rights (CRR, www.reproductiverights.org) and the Center for Justice and International Law (CEJIL, www.cejil.org).

In the Mestanza case, the Inter-American Commission negotiated a settlement in which the government of Peru admitted violating its international human rights obligations. The government agreed to pay damages to Mestanza’s family; to identify and punish those responsible; and to change the laws, policies, and practices that led to unsafe and coerced sterilizations. Women throughout Peru gained when the government agreed to implement a series of recommendations made by the Peruvian Human Rights Ombudsman (www.ombudsman.gob.pe). The ombudsmen’s recommendations included:

• Improving pre-operative evaluations for women being sterilized.
• Better training for health personnel.
• Establishing procedures to handle patients’ complaints on a timely basis.
• Implementing procedures to ensure genuine informed consent, including a 72-hour waiting period before a woman is sterilized.

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Peru (ReproSalud)

The ReproSalud Project has taken an innovative approach to promoting reproductive health among poor, marginalized women living in the Andean highlands and Amazon basin. Rather than delivering health care services, ReproSalud works to empower women and their communities to confront gender-based barriers to reproductive health, to become informed consumers of reproductive health services, and to advocate for changes in the health care system to meet womens needs. The project, launched in 1995, is implemented by the Movimiento Manuela Ramos (MMR), a Peruvian feminist organization, with funding from USAID.

Community mobilization and education lie at the heart of the project. ReproSalud selects a community-based womens organization (CBO) as a partner in each site. The CBO first conducts an "auto-diagnóstico" (self-assessment) with about 15 to 20 of its members: over five sessions, these women reflect on personal and community perceptions, attitudes, and experiences regarding sexual and reproductive health, gender norms and inequities, and available health services. They identify a priority reproductive health problem and then work with ReproSalud staff to design a 6- to 10-month intervention to address it. Most communities have selected reproductive tract infections, unwanted pregnancies, or complications of delivery as their top priority. Women themselves call these problems "white menses," "too many children," and "suffering during childbirth," respectively. Almost all communities also identify domestic violence as a serious problem. Information collected through the auto-diagnóstico process has shed light on womens beliefs about how their bodies function, how they experience reproductive illness, and how these, in turn, shape their decisions.

During the next phase, selected CBO members receive training from ReproSalud to become community promoters and then repeat the educational program for other CBOs and local groups. In this way, community promoters take the program to other audiences in a cascade approach to training. Using participatory and popular educational techniques, ReproSaluds educational program discusses anatomy and physiology, gender roles and reproductive rights, the communitys priority reproductive health problem, and available resources to address it . Women are encouraged to take care of their own health, for example, by practicing good nutrition and hygiene and by making more use of government health services for prenatal care and delivery, Pap smears, contraception, and the like. The need for more equitable gender relations is stressed with male as well as female audiences so that, for example, couples discuss STIs and family planning and reject domestic violence. ReproSalud has designed training guides oriented toward rural and peri-urban women and men, which have been used by other health reproductive programs.

Complementing the educational program are income-generating activities that empower women by providing access to credit via village banks and by organizing them to produce goods for North American markets.

Over its first five years, ReproSalud established partnerships with 240 CBOs, which have carried its educational and training programs to 90,000 women and 50,000 men. Although quantitative data on the impact of the project is not yet available, health facilities at 30 project sites have observed an increase in the number of reproductive health clients, and community promoters have saved lives by referring women to local health centers for prenatal exams and emergency obstetric care. Qualitative analyses provide a fuller picture of ReproSaluds effects. They indicate that educational sessions have increased peoples knowledge of reproductive health and helped them to overcome feelings of fear and shame around sexual and reproductive health concerns. In addition, women have developed greater self-esteem and self-confidence, become aware of their rights, acquired new skills, and taken on new decision-making roles in their families and communities. One result is that they are less timid and more likely to ask questions when consulting health care providers. The educational sessions have also contributed to reductions in alcohol abuse, domestic violence, and sex on demand.

However, ReproSaluds emphasis on localized and participatory interventions has created certain challenges. It is difficult to assure the consistent quality of activities that are designed and implemented by a multitude of community organizations. Locally driven projects also have varied intermediate objectives and outcomes, which may be more difficult to assess than those of a larger-scale, one-size-fits-all intervention. Participatory methods are unfamiliar to both ReproSalud staff and community members, who are accustomed to vertical programs that assign passive roles to local people; it is easy for them to slip back into old roles. The value of participatory methodologies also must be balanced against the desire to lower costs, expand coverage, and simplify management by standardizing interventions, as has happened with the education and training program. Working with community groups, which have few management skills and little experience of real autonomy, requires building their management capacity. ReproSaluds community approach carries two other risks: First, indirect pressures to improve the quality of services through consumer demand may not be sufficient without more sustained engagement with institutional actors. Second, it is not clear how well participants can maintain, internalize, and translate new ideas into sustainable new behavior. In short, inadequate funding and unrealistically short time frames make true efforts at social change nearly impossible to achieve.

Lessons Learned

• Although more time-consuming and resource-intensive than other approaches, well-designed participatory methodologies enhance the sustainability of project outcomes because they help individuals and communities assimilate new knowledge and skills, make decisions and take actions on their own behalf, and act collectively to bring about fundamental social change.
• Popular education techniques can introduce and address complicated topics among people with little formal education and help meet local information needs
• Working with and building the capacity of pre-existing community organizations, particularly those committed to ending womens subordination, is an effective way to promote community involvement and empowerment..
• Raising community members consciousness and knowledge of reproductive health concerns and rights enables them to advocate for improved health services that meet locally identified needs.
• Directing large-scale reproductive health projects to womens NGOs promotes democracy and womens rights.
• To overcome weaknesses in community outreach, the delivery of appropriate information, and the promotion of clients rights, government reproductive health policies and programs should listen and respond to womens articulation of the problems they face.

ReproSaluds educational and mobilizing interventions have laid the foundation for its current advocacy efforts in participating communities. To accomplish this, ReproSalud is promoting a new level of organization at the district level. Community promoters are forming district networks, thus making it easier to update their knowledge and skills on a regular basis. CBO leaders are being trained to work together in district reproductive health advocacy committees. Operating at a district level will strengthen the ability of CBOs and community members to negotiate with health care personnel for improvements in the quality of care.

For more information about ReproSalud, please contact:

Susana Moscoso (for requests in Spanish), Technical Coordinator, ReproSalud Project, Movimiento Manuela Ramos, Av. Juan P. Fernandini 1550, Pueblo Libre, Lima 21, Peru. Tel: 511-423-8840. Fax: 511-431-4412. Email: smoscoso@manuela.org.pe

Carmen Yon (for requests in English), Principal Investigator, ReproSalud Project, Movimiento Manuela Ramos, Av. Juan P. Fernandini 1550, Pueblo Libre, Lima 21, Peru. Tel: 511-423-8840. Fax: 511-431-4412. Email:
cyon@manuela.org.pe

Sandra Vallenas (for requests in English), Political Coordinator, ReproSalud Project, Movimiento Manuela Ramos, Av. Juan P. Fernandini 1550, Pueblo Libre, Lima 21, Peru. Tel: 511-423-8840. Fax: 511-431-4412. Email: svallenas@manuela.org.pe

This case study is based on Anna-Britt Coe, Health, Rights and Realities: An Analysis of the ReproSalud Project in Peru. Takoma Park, Maryland: Center for Health and Gender Equity (April 2001). Copies in English may be obtained by contacting Ronda Logan, Administrative Associate, Center for Health and Gender Equity at rlogan@genderhealth.org. Copies in Spanish may be obtained by contacting the author, Senior Program Associate, Center for Health and Gender Equity at annab@terra.com.pe.

Analyses of the information gathered in the ReproSalud auto-diagnósticos are available in Spanish in the following two volumes: Anderson, Jeanine. Teniendo Puentes: Calidad de Atención de la Perspectiva de las Mujeres Rurales y los Proveedores de los Servicios de Salud. Movimiento Manuela Ramos (2001); and Yon, Carmen. Hablan las Mujeres Andinas: Preferencias Reproductivas y Anticoncepción. Movimiento Manuela Ramos (2001).

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South Africa

South Africa's 200,000 nurses form the largest category of health personnel in the country and are widely distributed in rural areas. They are ideally placed to help battered women, who may seek emergency care after being assaulted, treatment for the long-term effects of abuse, or routine care for themselves and their children. To tap this resource, the Health Systems Development Unit (HSDU) and Agisanang Domestic Abuse Prevention and Training (ADAPT) have collaborated on a gender awareness/gender violence training program for primary health care nurses.

HSDU is a rurally based health systems research and development program associated with the University of Witwatersrand Department of Community Health. It has been training nurses to work in rural areas of South Africa since 1982. ADAPT is a non-governmental organization founded in 1994 to fight domestic violence. It offers counseling and support to battered women and rape victims, conducts training workshops for health workers and the police, educates community groups, and engages in advocacy.

In 1998, HSDU and ADAPT conducted focus group discussions on domestic violence with a class of 38 nurses enrolled in a one-year training program in Northern Province, one of the poorest and most rural provinces in South Africa. These 29 female and 9 male nurses had already completed their basic nursing training and had several years' experience working in local clinics and out-patient departments, where they were responsible for the full range of primary health care services.

The focus groups found that nurses perceived gender violence to be an extremely common and widely condoned phenomenon in their communities. Female nurses generally expressed the belief that such violence was harmful and oppressive to women. Moreover, they clearly acknowledged that rape could take place within marriage. However, they also believed that women were responsible for certain behaviors and attitudes which could "provoke" domestic violence and rape, and many felt that domestic violence was a private matter which should, if possible, be resolved in the home. They also revealed that, in spite of their professional and income-earning status, their own personal experiences of physical, sexual, and emotional abuse were not significantly different from the women they saw in their clinics, and they felt unable to exert any meaningful control over their own economic resources.

During the focus groups, male nurses listed a wide variety of occasions that justified beating a woman—including not obeying or respecting their husband, shortcomings in household duties or child care, and infidelity—and described beating as a means of expressing love or forgiveness for a woman's perceived transgressions. They completely rejected the concept of marital rape and expressed great reluctance to involve outside agencies, such as the judicial, health, or welfare systems, in cases of domestic violence, believing it to be a family matter.

Based on these findings, HSDU and ADAPT developed a gender violence training module and piloted it five months later as part of these same nurses' four-week reproductive health curriculum. The four-day module on gender violence initially focused on the nurses' experiences as women and men, not as professionals, and explored their attitudes, beliefs, and personal histories of violence. Popular sayings and wedding songs were deconstructed to help the nurses understand gender stereotypes and conditioning. There were same-sex and mixed-sex group discussions, role plays, a film screening, and individual, peer, and group counseling.

The final day of training focused on the nurses' responsibilities as health professionals. The nurses brainstormed about how they could address the issue of domestic violence as part of their work, identified barriers to action, and discussed methods for overcoming them. They also reviewed practical skills involved in detecting cases of abuse and considered how they might introduce such a protocol into their own health care settings. Finally, the nurses discussed how they could use their roles as respected community members, educators, and church members to raise awareness of domestic violence.

Afterwards, nurses completed a questionnaire that documented changes in their knowledge and attitudes. For the female nurses, training's greatest impact was to raise awareness about their own oppression and to personally acknowledge—often for the first time—their own experiences of abuse. Many described this experience as being simultaneously painful, empowering, and healing. As for the male nurses, hearing the experiences of their female colleagues and examining their own attitudes and experiences proved to be both disturbing and challenging. After training, none believed that beating a woman was ever justified, most accepted the concept of marital rape, and some had begun to question the role of traditional practices such as lobola (bride price) in maintaining abusive practices against women.

The questionnaire also confirmed high levels of violence in nurses' own lives. Fully 92 percent of the female nurses had experienced at least one form of abuse by an intimate partner: more than one-third had been physically abused, equal numbers had been sexually abused, and most had been psychologically and emotionally abused. Three-quarters of the male nurses admitted being abusive to an intimate partner: half had engaged in physical abuse, 38 percent in sexual abuse, and 75 percent in emotional abuse.

All of the nurses believed the training module on gender violence was valuable; for some, it marked a turning point in their personal and professional lives. All wanted to see such training formally incorporated into the nursing curriculum.

After finishing the one-year training program, the nurses dispersed and returned to their home clinics. It is not yet known how the domestic violence training has affected their on-the-job performance. One nurse, however, has established a support group for abused women at her own clinic.

Although this program is still in its early stages, several valuable lessons have emerged:

• Nurses share the same cultural values as the larger society, and their attitudes can be potentially damaging to abused women.
• Nurses experience similar, or perhaps higher, levels of violence as the clients they are expected to counsel and treat. This may make it difficult or impossible for them to deal with domestic violence on a professional basis.
• Gender violence training strategies for health workers cannot focus exclusively on professional knowledge and skills. Such training also must view health workers in their role as community members, question their attitudes toward domestic violence, and help them deal with their own experiences as the victims or perpetrators of violence.
• More research is needed on the male perspective on gender violence, especially the attitudes and experiences of male health workers and other professionals who come into contact with abused women.
• Local NGOs that have worked in the field of gender violence can make a valuable contribution to any research or training effort. Their collaboration ensures that the training content and materials reflect local understandings and beliefs regarding domestic violence. Their staff also can help health workers admit their own experiences with violence and begin the healing process.

Additional information about this research is available in: Kim, J. and Motsei, M. "Women enjoy punishment": attitudes and experiences of gender-based violence among PHC nurses in rural South Africa. Social Science & Medicine 54:1243-54 (2002).

For more information, please contact:
Dr. Julia Kim, HSDU, P.O. Box 2, Acornhoek 1360, South Africa. Phone: +27-13-797-0778; Fax: +27-13-797-0082; Email: jkim@soft.co.za

Ms. Mmatshilo Motsei, ADAPT, P.O. Box 39127, Bramley 2018, South Africa. Phone: +27-11-786-6608 or +27-11-885-3305; Fax: +27-11-885-3309

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Venezuela

The Asociacin Civil de Planificacin Familiar (PLAFAM) began designing a program to address violence against women in Venezuela in 1996. Impetus for the program came from two directions. Clients' comments about their husbands and their home life, together with staff observations of their injuries, made PLAFAM personnel increasingly aware of the impact of violence on their clients' lives. At the same time, the International Planned Parenthood Federation (IPPF) decided to launch a series of pilot projects in Latin America to integrate the early identification of gender-based violence into family planning and reproductive health services. Together with the IPPF affiliates in the Dominican Republic and Peru, PLAFAM has become such a pilot center.

It took two years of patient, systematic work to design and launch the program. The first step was to investigate the issue of gender-based violence in published materials, including books, magazines, and research papers. Next, PLAFAM identified organizations in Caracas that worked with women suffering from violence and tapped their experience. The final step was to develop a training curriculum and support materials on gender-based violence, including two booklets especially designed for Venezuelan women, with the help of two IPPF consultants.

By June 1998, PLAFAM was ready to train its staff members to identify and attend the victims of violence. PLAFAM's Education Department and the IPPF consultants spent one week training the physicians, nurses, and social workers who come into direct contact with clients. The curriculum explained how to detect violence by asking questions, listening effectively, and observing physical and behavioral symptoms. It also discussed the psychological and physical effects of violence on women's lives. Training has increased staff motivation and commitment to identify abuse and strengthened their interviewing skills.

The training process faced many obstacles, however. Initially staff members felt uncomfortable discussing gender-based violence; for some, the topic touched on sensitive areas of their own family history. Staff were afraid to bring up the issue of violence with clients because they lacked the information, tools, and skills to counsel women who admitted having a problem. Staff also had to address the risk that women would face even more violence at home because they sought help. Throughout the course, trainers had to work to overcome cultural attitudes that staff members shared with the larger society, because Venezuelan culture normalizes violence against women.

In 1998, PLAFAM began offering medical treatment to battered women at its three family planning clinics in Caracas. Its services have since expanded to include psychological counseling, a documentation center, and an educational service. Since November 2000, PLAFAM also has sponsored emotional support groups for the victims of violence; women meet with a psychologist and social worker in a series of two-hour group sessions and discuss the psychological and social consequences of gender-based violence. More than 100 women have attended the support groups, and some have been trained as group leaders themselves. This kind of group intervention is not only effective, it also conserves resources so that program personnel can help more women.

Detecting gender-based violence has become a routine part of the health interview, especially since the September 1999 introduction of a simple screening tool developed by IPPF/WHR. Staff members ask every woman who attends a PLAFAM clinic whether they have experienced psychological, physical, or sexual violence or sexual abuse in childhood. Providers find it easier to screen clients with the standardized tool, partly because it eliminates the need for them to phrase difficult questions and partly because it reassures clients that they are not being singled out. Since the introduction of the screening tool, about 30 percent of PLAFAM clients have been identified as the victims of violence, compared with a detection rate of 8 percent beforehand. While most of the victims of violence whom PLAFAM helps are identified during routine screening, some women have begun to ask directly for an interview with the psychology service after seeing a PLAFAM poster or booklet on gender-based violence. Other women are referred by the police and other government offices that receive domestic violence complaints from women and underage girls and boys. The majority of the women suffer from domestic violence, but PLAFAM staff also counsel victims of rape and sexual abuse.

At the start of its program against violence, PLAFAM developed a referral network of 26 local agencies to meet victims' other needs, especially legal advice and help in filing police complaints. In May 2000, however, PLAFAM realized its plans to offer legal services in its Caracas clinics. This initiative came in response to the passage of a new Venezuelan law on violence against women and the family—a law that PLAFAM actively advocated for. A female lawyer now meets individually with women and their parents, explains their sexual and reproductive rights, and often goes to court to seek legal interventions to ensure their safety. The lawyer also has helped create informational materials about the new law and has joined with a social worker and psychologist to lead educational activities in universities, health centers, and communities. PLAFAM is still working on another long-term goal: to help victims become economically independent and gain the confidence and assertiveness they need to escape their situations.

Four factors have enabled PLAFAM to launch its program against gender-based violence:

• internal support from the organization's leadership, including the executive director and top managers;
• external support and technical assistance from IPPF and the McArthur Foundation;
• PLAFAM's existing service infrastructure, on which the new services build; and
• the links PLAFAM has forged with other organizations in Venezuela that serve the victims of violence.

PLAFAM continues to network with local, national, and international organizations to strengthen its knowledge and resources and expand its efforts against gender-based violence. For example, PLAFAM is now helping local governments in Alcaldía de Baruta and Alcaldía de Chacao incorporate services for the victims of violence into local health centers and legal defenders offices. PLAFAM also stepped in when the Universidad Central de Venezuela experienced a rash of sexual assaults in 2002. In addition to caring for student rape victims, PLAFAM has advocated for increased security for students, educated students about their human and legal rights and the psychological consequences of sexual assault, and supported students who complained about sexual harassment by professors.

Further information about IPPFs regional program to combat gender-based violence in Latin America is available at www.ippfwhr.org/programs/program_gbv_st_1_e.html. Also available online is a chapter (www.ippfwhr.org/publications/download/monographs/gbv_venezuela_case.pdf) from Responding to Cairo: Case Studies of Changing Practice in Reproductive Health and Family Planning that details the development of PLAFAMs services for the victims of violence.

For more information on PLAFAM's program, please contact:
Fabiola Romero, GBV Project Coordinator, PLAFAM, Central Center, Urb. Las Acacias, Calle Minerva, Quinta PLAFAM, Caracas, Venezuela.
Telefax: 582-6939358, 6935262, 6936032; Email: plafamcc@cantv.net or fromero@plafam.org

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Zimbabwe

Since its founding in 1988, the Musasa Project has worked to challenge the cultural values and community attitudes that condone and justify violence against women in Zimbabwe and tried to reform the institutions that help perpetuate it. In Zimbabwe, as elsewhere, women are reluctant to seek help because they feel guilt and shame, fear ridicule and stigma, want to protect their children, and fear aggravating the problem. When women do seek help, relatives, friends, and clergy counsel patience or blame them for the situation, while health care providers and the police generally ignore the problem. Musasa, which is a non-governmental organization, has developed multiple strategies to change this situation.

Raising public awareness. Musasa stages annual media campaigns, conducts radio discussions, participates in local agricultural shows, and sponsors many other activities to heighten awareness of gender-based violence and to change prevailing social attitudes. For example, the project has broadcast two television series that featured personal testimonials from survivors of violence and debates on society's views of domestic violence.

Research. There was virtually no information about the extent or dynamics of gender-based violence in Zimbabwe until Musasa began conducting research on the topic. Its 1996–97 household survey established the prevalence of physical, sexual, psychological, and economic violence; analyzed risk factors; and documented health consequences. Six of seven women surveyed reported experiencing some type of violence, and violence was associated with poor mental health status, increased use of health services, and a history of miscarriage or the death of a child. More recently, Musasa's research unit has investigated the links between violence and HIV/AIDS infection.

Support for survivors of violence. Since its founding, Musasa has offered free drop-in counseling and legal advice for women experiencing violence. In 1996, it opened the first shelter for abused women and children in Zimbabwe. A growing number of women seek help from Musasa. In 1998, the project recorded 2,790 counseling sessions, two-thirds of which were cases of domestic violence. Musasa advisors also helped women with inheritance and maintenance problems and counseled the victims of rape and incest.

Improving the public sector response to violence. Ad hoc efforts to sensitize health workers, the police, and the judiciary to the issue of gender-based violence have culminated in a three-year project to integrate the subject of domestic violence into training curricula at the national level. When abused women seek help from health care providers and the police, they frequently find themselves ignored, blamed, or stigmatized by these workers, who share prevailing social attitudes that condone violence. Even sympathetic workers are uncertain how they can help. Musasa is working to develop new curriculum modules on domestic violence for the government health care system and the police force. The modules are designed to change workers' attitudes and to teach them how to identify, support, and refer women who have experienced violence. Once the modules are field tested, they will be introduced nationwide as a refresher course for existing government personnel, and they will be added to the pre-service training curriculum for new personnel.

The Musasa Project faces many challenges to its activities:

• While Musasa has broken the silence about gender-based violence in Zimbabwe, it lacks the resources to offer services to survivors of violence throughout the country.
• In the absence of laws against domestic violence, most cases are treated as trivial.
• Judicial judgments are ineffective because of the lack of law enforcement.

Lessons learned from Musasa's wide-ranging research and practical experience include:

• There is a connection between gender violence, STIs, and women's susceptibility to HIV/AIDS.
• Because of the culture of dependency on the husband and social fear of stigmatization, even educated women will stay in abusive relationships.
• Programs against violence should identify and focus on specific target groups to allow for monitoring and impact evaluation.
• Collaborating with decentralized government agencies, such as the health care sector and the police, is an effective way to address the issue of violence at a national level.
• To ensure the continuity and sustainability of services for women who have experienced violence, front-line workers should participate in the development and implementation of all activities, and the service organization should take ownership of the program.

For more information, please contact:
R.C. Tshuma, Programme Officer Midlands Province, The Musasa Project, Box 2022, Gweru, Zimbabwe. P
Telephone: 263-54-22166; Fax: 263-54-22796

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Worldwide (Sexwise)

Working together, the BBC World Service and the International Planned Parenthood Federation (IPPF) developed the Sexwise radio program to bring listeners unbiased and accurate information about sexuality and reproductive health. The radio program and accompanying book are designed to:

• improve listeners' knowledge and understanding of their bodies and emotions;
• increase discussion of individual and community sexual and social concerns;
• respond to listeners' anxieties about their sexual health;
• promote equality and mutual respect within sexual relationships;
• help listeners make more informed choices about their sexuality; and
• dispel myths, stereotypes, and associated guilt about sex.

Sexwise materials address sensitive issues that are not frequently discussed openly, including foreplay, intimacy, masturbation, homosexuality, unsafe abortion, sexual coercion, prostitution, HIV/AIDS, STIs, and family planning.

Sexwise began as a pilot project in 1996 when radio programs were broadcast in eight languages throughout South Asia; about 75,000 listeners wrote in requesting more information and copies of the Sexwise book. The next series of broadcasts took place in 1999, when the BBC broadcast Sexwise in ten languages throughout Europe and Eurasia and distributed over 185,000 books with a focus on youth issues. Most recently, Sexwise was broadcast globally from June to December 2000 in eleven languages, including Arabic, Chinese, French, Hausa, Indonesian, Portuguese, Spanish, Swahili, and Vietnamese. The programs reached more than 60 million listeners in Africa, the Arab world, Latin America, South East Asia, and China.

BBC producers consulted with IPPF staff and national family planning associations (FPAs) to tailor Sexwise programs in different languages to the needs of specific regions. Each edition of Sexwise was researched and recorded in different countries, with local interviews and discussions of local issues. For example, Sexwise programs in Africa covered harmful health practices such as female genital mutilation and dry sex, while programs in Europe and Eurasia discussed the rising incidence of syphilis and abortion. In this way, the Sexwise project combined locally driven and culturally appropriate programming with the global power of mass communication.

In collaboration with IPPF and national FPAs, the BBC also produced a publicity poster and book in each broadcast language. The book serves as a stand-alone educational and informational tool; it can be downloaded online in 22 languages (www.bbc.co.uk/worldservice/sci_tech/features/health/sexwise/languages.s html). The BBC also has posted interactive versions of the Sexwise guide at English (www.bbc.co.uk/worldservice/sci_tech/features/health/sexwise/index.shtml ) and Spanish (www.bbc.co.uk/spanish/seriesexo.htm). Written in the form of travel guides, these include audio clips and Internet links as well as basic information on sexual safety, well-being, choices, and rights.

National FPAs have played a critical role throughout the Sexwise project, helping design the radio programs, generating publicity, and providing services to listeners. They have publicized the BBC broadcasts by displaying posters and banners, distributing car stickers to taxi drivers and bus conductors, distributing fliers to target groups such as young people, and having clinic staff and youth counselors wear Sexwise T-shirts and baseball caps. During and after broadcasts, national FPAs have supported listeners by sponsoring Sexwise telephone hotlines, offering counseling and health services to individuals, and distributing the accompanying Sexwise books on request.

FPAs have also enlisted the support of local media representatives, respected and influential politicians, community and religious leaders, businessmen, artists, and sports personalities.

National FPAs also are responsible for extending the reach and impact of the Sexwise program beyond the original BBC broadcasts. They are working to:

• encourage popular local radio stations to rebroadcast the radio series and report on sexual, reproductive and rights issues raised by the programs;
• have other NGOs play cassettes of the program in health centers, clinics, and schools; and
• obtain more funding so they can distribute the Sexwise book to young people and other special audiences.

For more information about Sexwise, please contact:
Dr Heidi Marriott, IPPF Youth Programme Coordinator,
Telephone: 44-20-7487 7828; Fax: 44-20-7487 7969; Email: hmarriott@ippf.org

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Worldwide (Stepping Stones)

The Stepping Stones training package promotes social change and gender equity as a way to improve sexual and reproductive health. A series of community-based workshops develops individual decision making and communication skills, improves relationships between men and women, and creates a supportive environment for sexual and reproductive well-being. Stepping Stones was created in sub-Saharan Africa from 1993 to 1995 in response to the HIV/AIDS epidemic, but it works from a broad gender and human rights perspective. Therefore, it addresses a wide variety of issues, ranging from gender-based violence to alcohol abuse to sharing household finances.

The Stepping Stones process begins by meeting with community leaders to explain the program and invite their support; these leaders then invite community members to participate. The workshops follow a fission-fusion model: peer groups (older women, older men, younger women, and younger men) meet separately to discuss their varying experiences and perspectives, but periodically come together in joint plenary sessions to exchange views and find common ground.

The original Stepping Stones manual includes 18 three-hour workshops held over a period of three or four months, covering four themes: group cooperation, HIV and safe sex, why we behave the way we do, and ways in which we can change. All of the workshops employ participatory, non-formal learning, and the discussions, role plays, and drawing exercises do not require participants to be literate. During workshops, participants analyze local issues based on their own experiences and develop locally appropriate solutions. At the program’s end, the peer groups come together, perform dramas illustrating key lessons, and make formal “requests for change” to the entire community. In Uganda, for example, one such request was for older men to stop waiting outside schools to pick up girls and take them to bars.

Evaluations, both formal and informal, of Stepping Stones workshops in many countries have identified a variety of positive changes in attitudes and behavior, including:

• Greater knowledge of reproductive health issues.
• Enhanced decision making and communication skills that, for example, enable women to refuse unwanted sex and men to resist peer pressure.
• Mutual respect, dialogue, and improved relationships between partners and between generations. For example, men may share domestic chores more often, while parents may talk openly about sexuality with their children.
• Reduced alcohol consumption and gender-based violence.
• Greater prevalence of safer sex practices, including abstinence, condom use, fewer sexual partners, and less extra-marital sex.
• More equitable sharing of household resources.
• Less stigma and discrimination directed toward people living with HIV/AIDS and their caregivers.

Many organizations have translated and modified the Stepping Stones manual for use in other countries, mostly in Africa and Asia but also in Russia and Latin America. They have developed new modules to address local priorities, including reproductive rights, gender violence, teenage pregnancy, contraception, infertility, abortion, puberty, menopause, and sexual problems. To support the use of Stepping Stones by partners around the world, ActionAid International (www.actionaid.org) provides guidelines and advice on how to train people as facilitators and adapt the manual, shares information about users’ experiences, and links organizations that are using Stepping Stones with one another.

Lessons Learned

Experience with Stepping Stones in a wide variety of settings has concluded:

• Dividing participants into peer groups by age and gender encourages them to speak freely and allows them to explore attitudes, behaviors, and vulnerabilities in a safe and comfortable environment.
• Working in separate peer groups ensures that Stepping Stones captures the varying perspectives, needs, concerns, and insights of different gender and age groups.
• The fission-fusion model encourages better and more assertive communication across sex and age lines, but it has the potential to create conflict between peer groups unless carefully managed.
• Communication between partners and between generations is more likely to improve if both partners or all family members participate in the workshops, but it may be difficult to persuade them to do so.
• Formally requesting the community to make changes creates a supportive environment and positive peer and community pressure for behavior change.
• Because the participatory approach makes participants feel valued and respected, it helps bring about behavior change.
• A team of well-prepared and skilled facilitators (ideally two women and two men) is essential, but the program may need to recruit and train people to fill the positions.
• Sustaining change over time requires further meetings, facilitator and peer support, and continuing reflection and action.

Further information about Stepping Stones is available at www.actionaid.org and www.steppingstonesfeedback.org. The program is reviewed in:
Gordon G, Welbourn A. Stepping Stones: highlighting male involvement in a gender and HIV/AIDS training package. In: IGWG. Three Case Studies: Involving Men to Address Gender Inequities. Washington, DC: Population Reference Bureau; 2003:50–67. Available at: www.phishare.org/documents/IGWG/982/.

For more information, please contact:
Linnea Renton, HIV/AIDS Best Practice Adviser, ActionAid International, Hamlyn House, Macdonald Road, London N19 5PG, UK
Telephone: 44-0-20-7561-7537; Fax: 44-0-20-7561-7516; Email: LRenton@actionaid.org.uk

The Stepping Stones manual can be ordered from TALC.
Telephone: 44-0-1727-853-869; Email: info@talcuk.org; Website: www.talcuk.org

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