Commentary Abortion

Institutionalized Stigma in Ghana

Stigma Shame and Sexuality Series

A confluence of cultural, religious and geographical factors in Ghana create a sensitive environment where issues of sexual and reproductive health, especially abortion, have remained highly taboo for decades.

This post is by Jessica Mack, and is part of Tsk Tsk: Stigma, Shame, and Sexuality, a series hosted by Gender Across Borders and cross-posted with Rewire in partnership with Ipas.

Earlier this year, 28-year old Abigail Agborku became pregnant unexpectedly. Already a struggling mother of three, she sought to terminate her pregnancy. But something went wrong. She didn’t get the right advice, didn’t have adequate access, and didn’t know where to turn. She ended up in the hands of a quack, as too many women do, and died soon after.

Abortion has been legal in Ghana under a wide range of circumstances — including to protect a woman’s mental health — since 1985, making it one of the most progressive laws in Sub-Saharan Africa. Yet unsafe abortion still contributes to nearly one-third of maternal deaths. Access is chronically denied, and knowledge of the abortion law among women and health-care providers alike is scant. In Ghana, the issue of abortion is taboo. In the silence surrounding it, misinformation and stigma thrive.

Nearly 85 percent of the country identifies as Christian, and in a recent survey, almost 90 percent of Ghanaians reported that abortion was morally wrong. Yet abortion stigma must be placed within the context of even broader taboos around sex and sexuality. “In Ghana, we are sort of in denial about contraceptives. If someone is on family planning, for instance, and you ask her, ‘are you on family planning?’ She’ll say no. When you ask her, ‘well how do you space your children?’ She’ll say, ‘It is God’s grace,'” said Rose Asante, a reproductive health worker in Accra.

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“Talking about sex or family planning, or going to get a contraceptive method, people think it means that you are promiscuous,” she continues. “Our society is not a society where you can talk about sex openly. Everybody grows up knowing this is a no-go area. And especially abortion has a lot of stigma and silence around it; nobody wants to talk about it.”

Women in Ghana who seek abortions are seen as more than just promiscuous. They are considered heartless or careless. “People think you must be a really bad woman to have an abortion,” said Richard Oye*, a reproductive health clinic manager in Ghana’s Ashanti Region. “People don’t want to have it, and people who do want to hide it. That’s why the quacks are in good business. They provide services quietly in the back streets.” Though it is impossible to know exactly what role stigma played in Abigail Agborku’s fatal decision to seek an unsafe abortion, it was almost certainly a major contributor.

Enter Helms

A confluence of cultural, religious and geographical factors in Ghana create a sensitive environment where issues of sexual and reproductive health, especially abortion, have remained highly taboo for decades. Yet in 1973, the United States Congress put in place a foreign policy that would serve only to reinforce such stigma over the next forty years.

The Helms Amendment to the Foreign Assistance Act, named for the late Senator Jesse Helms (R-NC), prohibits the use of US foreign aid for the “performance of abortion as a method of family planning” or to “motivate or coerce any person to practice abortions.” Essentially, any developing country government or NGO in the world that receives USAID money is prohibited from using those funds to provide abortions, even if it is legal in their country.   

The Helms Amendment is an affront to reproductive freedom for several reasons, but perhaps the real peril of the policy is its vague and elusive wording. What is ‘abortion as a method of family planning’? What does it mean to ‘motivate or coerce’? The language is difficult to interpret, and therefore put into practice.

An amendment added in the 1990s was meant to clarify that information and counseling for safe abortion is indeed allowed. But according to recent Ipas research in both Ghana and Nepal, this is largely being ignored in favor of near-universal censorship. NGOs and governments receiving U.S. funding fear for their job and funding security, and as a result often won’t even talk about abortion services.

“Pervasive silence and stigma around abortion is the real damage of the Helms Amendment, not so much from the law itself but as a result of its widespread misapplication,” says Patty Skuster, Ipas senior policy advisor.

While the Helms Amendment doesn’t explicitly foster abortion stigma at the community level, the way it isolates abortion services from the continuum of reproductive health care contributes to an environment of shame. Further, the policy perpetuates an institutionalized stigma at the highest levels — among the ranks of privileged and well-resourced NGO professionals, policymakers, and providers.

“Because of this rule, I don’t dare go near any abortion clinic, because it will look like I’m involved with abortion. Even if I’m just there to talk to the client about family planning — to empower her to make a decision to prevent an unintended pregnancy — because of the rule and my ‘salary,’ I will not ever go there. I don’t want to be part of it and I don’t want to be seen as being part of it,” says one USAID-funded reproductive health professional.

There is a long legacy of institutionalized abortion stigma and censorship in U.S. foreign aid. Before its repeal in 2009, the Mexico City Policy (global gag rule), saw numerous NGOs defunded by USAID for their association with abortion services. At press time, a vote on the permanent repeal of the Mexico City Policy was pending in the U.S. House.

The implications of institutionalized stigma can be disastrous for women at the community level, and for reproductive health advocates working to improve access to safe abortion. While advocates are working at the grassroots level to expand access to safe abortion services, censorship and prejudice is being reflected back to the community from the highest institutional levels. The Helms Amendment prevents doctors who should be providing and NGOs that should be advocating from doing so, both explicitly and implicitly.

Although researchers and advocates are just coming to understand the full effects of abortion stigma in Ghana, there are signs that a sea change, however slow, is possible. Says Rose Asante: “Now it’s changing; 20 years ago it wasn’t like today.  At that time you couldn’t even mention ‘abortion,’ but now you can go in, give a talk and even tell people that if you are pregnant and you don’t want to be, don’t take any drug, don’t attempt, just come to the hospital and ask for the service and there are people that can help.”   

Abortion stigma is not insurmountable. This, perhaps, is the most empowering thing we can understand as advocates. “Abortion stigma is used to control and punish women. But it’s just a social construct. It simply doesn’t have to be the reality,” says Leila Hessini, director of community access for Ipas. “We as advocates need to reflect on our own contribution to stigma, and how we are all creating it. When we legitimize some abortions — early versus late or those that don’t need public funding versus those that do — we collectively stigmatize abortion. Let’s deconstruct what we’ve learned and create a new paradigm, where women’s rights are upheld.” This, of course, would be a world where Abigail would live happily to see her three children grow.

This post is adapted from an article appearing in the Fall 2011 issue of Because, the Ipas magazine that connects U.S. readers to women around the world, highlighting reproductive health and rights and making connections between U.S. policy and global health. For a free subscription to Becauseclick here. *All names have been changed.

News Politics

Clinton Campaign Announces Tim Kaine as Pick for Vice President

Ally Boguhn

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

The Clinton campaign announced Friday that Sen. Tim Kaine (R-VA) has been selected to join Hillary Clinton’s ticket as her vice presidential candidate.

“I’m thrilled to announce my running mate, @TimKaine, a man who’s devoted his life to fighting for others,” said Clinton in a tweet.

“.@TimKaine is a relentless optimist who believes no problem is unsolvable if you put in the work to solve it,” she added.

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

Kaine signed two letters this week calling for the regulations on banks to be eased, according to a Wednesday report published by the Huffington Post, thereby ”setting himself up as a figure willing to do battle with the progressive wing of the party.”

Charles Chamberlain, executive director of the progressive political action committee Democracy for America, told the New York Times that Kaine’s selection “could be disastrous for our efforts to defeat Donald Trump in the fall” given the senator’s apparent support of the Trans-Pacific Partnership (TPP). Just before Clinton’s campaign made the official announcement that Kaine had been selected, the senator praised the TPP during an interview with the Intercept, though he signaled he had ultimately not decided how he would vote on the matter.

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Kaine’s record on reproductive rights has also generated controversy as news began to circulate that he was being considered to join Clinton’s ticket. Though Kaine recently argued in favor of providing Planned Parenthood with access to funding to fight the Zika virus and signed on as a co-sponsor of the Women’s Health Protection Act—which would prohibit states and the federal government from enacting restrictions on abortion that aren’t applied to comparable medical services—he has also been vocal about his personal opposition to abortion.

In a June interview on NBC’s Meet the Press, Kaine told host Chuck Todd he was “personally” opposed to abortion. He went on, however, to affirm that he still believed “not just as a matter of politics, but even as a matter of morality, that matters about reproduction and intimacy and relationships and contraception are in the personal realm. They’re moral decisions for individuals to make for themselves. And the last thing we need is government intruding into those personal decisions.”

As Rewire has previously reported, though Kaine may have a 100 percent rating for his time in the Senate from Planned Parenthood Action Fund, the campaign website for his 2005 run for governor of Virginia promised he would “work in good faith to reduce abortions” by enforcing Virginia’s “restrictions on abortion and passing an enforceable ban on partial birth abortion that protects the life and health of the mother.”

As governor, Kaine did support some existing restrictions on abortion, including Virginia’s parental consent law and a so-called informed consent law. He also signed a 2009 measure that created “Choose Life” license plates in the state, and gave a percentage of the proceeds to a crisis pregnancy network.

Regardless of Clinton’s vice president pick, the “center of gravity in the Democratic Party has shifted in a bold, populist, progressive direction,” said Stephanie Taylor, co-founder of the Progressive Change Campaign Committee, in an emailed statement. “It’s now more important than ever that Hillary Clinton run an aggressive campaign on core economic ideas like expanding Social Security, debt-free college, Wall Street reform, and yes, stopping the TPP. It’s the best way to unite the Democratic Party, and stop Republicans from winning over swing voters on bread-and-butter issues.”

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.