Behind Bars: When the System Falls Apart

Kevin Osborne

Milena Stevanovic from Skopje, Macedonia, was a member of a medical team that was on duty in November 2008 when the police issued a court warrant to test arrested street commercial sex workers for STIs. This interview with Milena Stevanovic is part of the Behind Bars series by Kevin Osborne and the International Planned Parenthood Federation.

Milena Stevanovic from Skopje, Macedonia, was a member of a medical team that was on duty in November 2008 when the police issued a court warrant to test arrested street commercial sex workers for STIs. This interview with Milena Stevanovic is part of the Behind Bars series by Kevin Osborne and the International Planned Parenthood Federation.

“It was an example of the state system falling apart. The established counselling service was misused for a purpose contrary to its basic principles: that of guaranteed voluntary consent and confidentiality.

In November 2008, the Ministry of Interior began a campaign to eradicate the so-called ‘socio-pathological occurrence of male and female individuals giving sexual services for money.’

According to the Ministry the official grounds for the police intervention, arrest and detainment of sex workers was the existence ‘of certain indications that these persons might be carriers of different sexually transmitted diseases, and consciously transmit them to other persons, which is in violation with the existent laws in the Republic of Macedonia.’ Calling on the Criminal Code the Ministry provided a court order to perform medical examinations.

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The process started early in morning when the police called us on the telephone asking if we provided HIV and STI testing. Then they announced their intentions. Immediately I had a meeting with the director who said that we couldn’t perform such a service. When this fact was presented to the police it took them less than two hours to issue us with a court order.   

There followed a statement informing the public of the results of the compulsory testing of the sex workers. According to the analyses, ‘Seven of them were carriers of the virus HCV-Hepatitis C, an infectious disease transmitted by sexual and blood contact with an infected person.’ The ministry said that they instigated criminal charges because of reasonable suspicion that ‘they performed a criminal act of transmitting infectious disease.’ Given the resistance they showed during the implementation of the court order, it was argued, they were aware of the virus they carried, and therefore they were negligent. After one year’s legal process the sex workers were found guilty of transmitting STIs but were given probation.

It was an example of the state system falling apart. The established counselling service was misused for a purpose contrary to its basic principles: that of the guaranteed voluntary consent and confidentiality. So it was a paradox. As someone who helped develop that system – and its voluntary counselling and testing (VCT) protocols and services – I can’t understand why anyone would use that same system for that purpose, especially on a group of people, such as street sex workers, who were being counselled and tested on HIV and STIs. So if you ask me, that’s the greatest tragedy of this incident.

Or maybe the worst thing is that a health institution, which should have been protected by law, ended up exposing test results without the consent of its patients.

This leads me to the conclusion that someone had the aim of destroying everything we’ve achieved. You feel completely powerless. You feel as if the only thing you can do is to help lessen the consequences for those poor women.

Previously there had been no cases of HIV or other infectious disease being brought up in court. We can’t predict what would happen if criminalisation became an everyday reality. What I do know is that some people will suffer from double stigma: being HIV positive and coming from the different key populations.

There is absolutely no reason for criminalising HIV transmission.

Maybe we need a legal discussion on the pros and cons. Objectively, there is no reason why HIV should be treated as a criminal offence. The explanation is very simple: everyone is responsible for their own behaviour and risks – that’s the end of the story.

Here, the chance of someone not knowing their HIV status is very high. But if we are talking about something that is a criminal offence like rape, and if HIV is transmitted as consequence of a violent act, then that would be something else. But, again, the reason for prosecution should be the criminal act and not HIV

The criminalisation of HIV transmission has had a completely demoralising effect on me. It means that whatever you agree upon within the community, to adopt a document, to establish a state service, it is worthless. There is always someone who has the political power to destroy for their own political promotion.

Human rights in our context are a mockery. The main reason is because there is no implementation in everyday life.

They are often misused by the institutions responsible for protection of human rights. There is no rule of law when human rights are concerned and sometimes patients in Macedonia are not well informed and refer to the human rights legislative for trivial issues.
 
Rights, but also the obligations, should be the same for everybody. What do I mean by obligations? Everyone is responsible for their own actions and the risks of those actions. So this is the basic philosophy when we are talking about HIV. Otherwise you can easily enter in to a labyrinth leading to millions of questions. Hypothetically all of my patients can start a court procedure against the person responsible for their HIV status. So I ask myself, what would be the consequence of all of these court processes?

Here is an example: I had a case where the husband wouldn’t disclose his status to his wife. We tried everything we could to motivate him to inform his wife about the possibility of HIV transmission. But he didn’t want to and continued to live a ‘normal’ married life. So the woman was left to discover that she had become HIV positive on her own, when she became really sick. I had to live with the knowledge that someone’s life is in danger. However my team followed the protocol and we didn’t disclose the status of the patient to his wife. In the end, although it took some time, the husband decided to tell his wife. This case illustrates why everyone should be responsible for their own actions and protection.

Although this example is an argument for obligatory disclosure, I would say that we can discuss this option only within marriage, but when we are talking about different sexual relationships, I can’t see the purpose of making the disclosure obligatory. To be more precise, you can’t solve all of the HIV problems with adopting legal instrument for prosecuting people living with HIV (PLHIV).

If we insist that PLHIV disclose their status in every sexual encounter than we are insisting on an ideal society, a utopia. I can’t find a good reason why we should ask PLHIV to be extremely responsible if the rest of society is not behaving in the same manner. In the same way, we can’t ask that from any patient living with any other kind of disease.

The things here in Macedonia are going to change. We needed 20 years to ‘grow up’ and to face HIV. There were no PLHIV in the past, simply because they were dying.

Today we have people living with HIV. So we are just starting to go through the HIV issues that other societies have already faced. Hopefully we will use their experience to find easier solutions.”

Analysis Human Rights

El Salvador Bill Would Put Those Found Guilty of Abortion Behind Bars for 30 to 50 Years

Kathy Bougher

Under El Salvador’s current law, when women are accused of abortion, prosecutors can—but do not always—increase the charges to aggravated homicide, thereby increasing their prison sentence. This new bill, advocates say, would heighten the likelihood that those charged with abortion will spend decades behind bars.

Abortion has been illegal under all circumstances in El Salvador since 1997, with a penalty of two to eight years in prison. Now, the right-wing ARENA Party has introduced a bill that would increase that penalty to a prison sentence of 30 to 50 years—the same as aggravated homicide.

The bill also lengthens the prison time for physicians who perform abortions to 30 to 50 years and establishes jail terms—of one to three years and six months to two years, respectively—for persons who sell or publicize abortion-causing substances.

The bill’s major sponsor, Rep. Ricardo Andrés Velásquez Parker, explained in a television interview on July 11 that this was simply an administrative matter and “shouldn’t need any further discussion.”

Since the Salvadoran Constitution recognizes “the human being from the moment of conception,” he said, it “is necessary to align the Criminal Code with this principle, and substitute the current penalty for abortion, which is two to eight years in prison, with that of aggravated homicide.”

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The bill has yet to be discussed in the Salvadoran legislature; if it were to pass, it would still have to go to the president for his signature. It could also be referred to committee, and potentially left to die.

Under El Salvador’s current law, when women are accused of abortion, prosecutors can—but do not always—increase the charges to aggravated homicide, thereby increasing their prison sentence. This new bill, advocates say, would worsen the criminalization of women, continue to take away options, and heighten the likelihood that those charged with abortion will spend decades behind bars.

In recent years, local feminist groups have drawn attention to “Las 17 and More,” a group of Salvadoran women who have been incarcerated with prison terms of up to 40 years after obstetrical emergencies. In 2014, the Agrupación Ciudadana por la Despenalización del Aborto (Citizen Group for the Decriminalization of Abortion) submitted requests for pardons for 17 of the women. Each case wound its way through the legislature and other branches of government; in the end, only one woman received a pardon. Earlier this year, however, a May 2016 court decision overturned the conviction of another one of the women, Maria Teresa Rivera, vacating her 40-year sentence.

Velásquez Parker noted in his July 11 interview that he had not reviewed any of those cases. To do so was not “within his purview” and those cases have been “subjective and philosophical,” he claimed. “I am dealing with Salvadoran constitutional law.”

During a protest outside of the legislature last Thursday, Morena Herrera, president of the Agrupación, addressed Velásquez Parker directly, saying that his bill demonstrated an ignorance of the realities faced by women and girls in El Salvador and demanding its revocation.

“How is it possible that you do not know that last week the United Nations presented a report that shows that in our country a girl or an adolescent gives birth every 20 minutes? You should be obligated to know this. You get paid to know about this,” Herrera told him. Herrera was referring to the United Nations Population Fund and the Salvadoran Ministry of Health’s report, “Map of Pregnancies Among Girls and Adolescents in El Salvador 2015,” which also revealed that 30 percent of all births in the country were by girls ages 10 to 19.

“You say that you know nothing about women unjustly incarcerated, yet we presented to this legislature a group of requests for pardons. With what you earn, you as legislators were obligated to read and know about those,” Herrera continued, speaking about Las 17. “We are not going to discuss this proposal that you have. It is undiscussable. We demand that the ARENA party withdraw this proposed legislation.”

As part of its campaign of resistance to the proposed law, the Agrupación produced and distributed numerous videos with messages such as “They Don’t Represent Me,” which shows the names and faces of the 21 legislators who signed on to the ARENA proposal. Another video, subtitled in English, asks, “30 to 50 Years in Prison?

International groups have also joined in resisting the bill. In a pronouncement shared with legislators, the Agrupación, and the public, the Latin American and Caribbean Committee for the Defense of the Rights of Women (CLADEM) reminded the Salvadoran government of it international commitments and obligations:

[The] United Nations has recognized on repeated occasions that the total criminalization of abortion is a form of torture, that abortion is a human right when carried out with certain assumptions, and it also recommends completely decriminalizing abortion in our region.

The United Nations Committee on Economic, Social, and Cultural Rights reiterated to the Salvadoran government its concern about the persistence of the total prohibition on abortion … [and] expressly requested that it revise its legislation.

The Committee established in March 2016 that the criminalization of abortion and any obstacles to access to abortion are discriminatory and constitute violations of women’s right to health. Given that El Salvador has ratified [the International Covenant on Economic, Social and Cultural Rights], the country has an obligation to comply with its provisions.

Amnesty International, meanwhile, described the proposal as “scandalous.” Erika Guevara-Rosas, Amnesty International’s Americas director, emphasized in a statement on the organization’s website, “Parliamentarians in El Salvador are playing a very dangerous game with the lives of millions of women. Banning life-saving abortions in all circumstances is atrocious but seeking to raise jail terms for women who seek an abortion or those who provide support is simply despicable.”

“Instead of continuing to criminalize women, authorities in El Salvador must repeal the outdated anti-abortion law once and for all,” Guevara-Rosas continued.

In the United States, Rep. Norma J. Torres (D-CA) and Rep. Debbie Wasserman Schultz (D-FL) issued a press release on July 19 condemning the proposal in El Salvador. Rep. Torres wrote, “It is terrifying to consider that, if this law passed, a Salvadoran woman who has a miscarriage could go to prison for decades or a woman who is raped and decides to undergo an abortion could be jailed for longer than the man who raped her.”

ARENA’s bill follows a campaign from May orchestrated by the right-wing Fundación Sí a la Vida (Right to Life Foundation) of El Salvador, “El Derecho a la Vida No Se Debate,” or “The Right to Life Is Not Up for Debate,” featuring misleading photos of fetuses and promoting adoption as an alternative to abortion.

The Agrupacion countered with a series of ads and vignettes that have also been applied to the fight against the bill, “The Health and Life of Women Are Well Worth a Debate.”

bien vale un debate-la salud de las mujeres

Mariana Moisa, media coordinator for the Agrupación, told Rewire that the widespread reaction to Velásquez Parker’s proposal indicates some shift in public perception around reproductive rights in the country.

“The public image around abortion is changing. These kinds of ideas and proposals don’t go through the system as easily as they once did. It used to be that a person in power made a couple of phone calls and poof—it was taken care of. Now, people see that Velásquez Parker’s insistence that his proposal doesn’t need any debate is undemocratic. People know that women are in prison because of these laws, and the public is asking more questions,” Moisa said.

At this point, it’s not certain whether ARENA, in coalition with other parties, has the votes to pass the bill, but it is clearly within the realm of possibility. As Sara Garcia, coordinator of the Agrupación, told Rewire, “We know this misogynist proposal has generated serious anger and indignation, and we are working with other groups to pressure the legislature. More and more groups are participating with declarations, images, and videos and a clear call to withdraw the proposal. Stopping this proposed law is what is most important at this point. Then we also have to expose what happens in El Salvador with the criminalization of women.”

Even though there has been extensive exposure of what activists see as the grave problems with such a law, Garcia said, “The risk is still very real that it could pass.”

Commentary Sexual Health

Fewer Teens Are Having Sex, But Don’t Pop the Champagne Yet

Martha Kempner

The number of teens having sex may be less important than the number having protected sex. And according to recent data from the Centers for Disease Control and Prevention, condom use is dropping among young people.

Every two years, the Centers for Disease Control and Prevention’s Division of Adolescent and School Health (CDC-DASH) surveys high school students to gauge how often they engage in perceived risky behaviors. The national Youth Risk Behavior Surveillance (YRBS) is wide ranging: It asks about violence, guns, alcohol, drugs, seat belts, bicycle safety, and nutrition. It also asks questions about “sexual intercourse” (which it doesn’t define as a specific act) and sexual behaviors.

Started in 1991, this long-running study can provide both a picture of what high school students are doing right now and a historical perspective of how things have changed. But for more than a decade, the story it has told about sexual risk has been the virtually the same. Risk behaviors continually declined between 1991 and 2001, with fewer high school students having sex and more of them using condoms and contraception. But after the first 10 years, there has been little change in youth sexual risk behaviors. And, with each new release of almost unchanging data, I’ve reminded us that no news isn’t necessarily good news.

This year, there is news and it looks good—at least on the surface. The survey showed some significant changes between 2013 and 2015; fewer kids have ever had sex, are currently sexually active, or became sexually active at a young age. More teens are relying on IUDs and implants, which are virtually error-proof in preventing pregnancy.

In 2015, 41 percent of high school students reported ever having had sexual intercourse compared to 47 percent in 2013. The researchers say this is a statistically significant decrease, which adds to the decreases seen since 1991, when 54 percent of teens reported ever having had sexual intercourse.

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Another change is in the percentage of students who had sex for the first time before age 13. In 2015, 4 percent of high school students reported this compared to almost 6 percent in 2013. This is down from a full 10 percent in 1991. As for number of overall partners, that is down as well, with only 12 percent of students reporting four or more partners during their lifetime compared to 15 percent in 2013 and 19 percent in 1991. Finally, the percentage of students who are currently sexually active also decreased significantly between 2013 (34 percent) and 2015 (30 percent).

These are all positive developments. Delaying sex can often help prevent (at least temporarily) the risk of pregnancy or STIs. Having fewer partners, especially fewer concurrent partners, is frequently important for reducing STI risk. And those teens who are not currently having sex are not currently at risk for those things.

While I want to congratulate all teens who took fewer risks this year, I’m not ready to celebrate those statistics alone—because the number of teens having sex is less important to me than the percentage of teens having sex that is protected from both pregnancy and sexually transmitted infections. And that number is lower than it once was.

Among sexually active teens, there were no significant positive changes in measures of safer sex other than an increase in the number of sexually active high school students using the IUD or implant (up to 4 percent from 2 percent in 2013).

Moreover, some results indicate that today’s teens are using less protection than those who were teens a decade ago. The most telling finding might be the percentage of teens who used no method of contraception the last time they had sex. This decreased between 1991 and 2007 (from 17 percent to 12 percent), inched up to 14 percent in 2013, and stayed the same in 2015 (14 percent). There was also little to no change in the percentage of high school students who say that either they or their partner used birth control pills between 2013 (19 percent) and 2015 (18 percent) or those who say they used the contraceptive shot, patch, or ring (5 percent in 2013 and 2015).

For me, however, the most distressing finding is the backward progress we continue to see in condom use. The prevalence of high school students who used a condom at last sex went up from 45 percent in 1991 to 63 percent in 2003. But then it started to drop. In 2015, only 57 percent of sexually active high school students used condoms the last time they had sex, less than in 2013, when 59 percent said they used condoms.

It’s not surprising that teens use condoms less frequently than they did a decade ago. In the 1990s, the HIV epidemic was still front and center, and condoms were heavily promoted as a way to avoid infection. As this threat waned—thanks to treatment advances that now also serve as prevention—discussions of the importance of condoms diminished as well. The rise of abstinence-only-until-marriage programs may have also affected condom use, because these programs often include misinformation suggesting condoms are unreliable at best.

Unfortunately, some of the negative messages about condoms inadvertently came from public health experts themselves, whether they were promoting emergency contraception with ads that said “oops, the condom broke”; encouraging the development of new condoms with articles suggesting that current condoms are no fun; or focusing on teen pregnancy and the use of highly effective contraceptive methods such as long-acting reversible contraceptives (LARC). The end result is that condoms have been undersold to today’s teenagers.

We have to turn these condom trends around, because despite the decreases in sexual activity, young people continue to contract STIs at an alarming rate. In 2014, for example, there were nearly 950,000 reported cases of chlamydia among young people ages 15 to 24. In fact, young people in this age group represented 66 percent of all reported chlamydia cases. Similarly, in 2014, young women ages 15 to 19 had the second-highest rate of gonorrhea infection of any age group (400 cases per 100,000 women in the age group), exceeded only by those 20 to 24 (489 cases per 100,000 women).

While we can be pleased that fewer young people are having sex right now, we can’t fool ourselves into believing that this is enough or that our prevention messages are truly working. We should certainly praise teens for taking fewer risks and use this survey as a reminder that teens can and do make good decisions. But while we’re shaking a young person’s hand, we should be slipping a condom into it. Because someday soon (before high school ends, for more than half of them), that teenager will have sex—and when they do, they need to protect themselves from both pregnancy and STIs.