Would having a vasectomy make some men more likely to have unprotected sex? If they see contraception as just a protection against HIV (and perhaps other sexually transmitted infections), the vasectomy shouldn't, logically, result in a reduction in condom use. But I suspect it would be a good excuse for not using condoms.
If they see condom use and/or vasectomies as a means of reducing unplanned pregnancies, having a vactomy could well result in men having unprotected sex. They could see condoms having a dual purpose, but many HIV prevention and other types of health programs have made little effort to emphasize this dual purpose.
If male circumcision was also involved, how would that affect condom use? Of course, mass male circumcision campaigns do drone on about having to use condoms for circumcision to be effective. But I don't see many men getting circumcized if they don't think they can reduce their condom use, perhaps even dispense with them altogether.
If programs that aim at reducing heterosexual HIV transmission are combined with programs that aim at reducing a country's population, this could result in a very mixed message indeed. Who is going to undergo both circumcision and a vasectomy and still use condoms?
If circumcision in conjunction with condom use is intended to reduce sexual HIV transmission, this sort of program might best be kept separate from a program that aims purely at population control.
Besides, people who are not in a position to, or don't see themselves as being in a position to make family planning related choices that we in the Western world take for granted, may require a more subtle approach than 'offering' them vasectomies.
There must be a lot more to family planning than merely reducing the probability of conception in as many ways as possible. This smacks of the eugenicist subtext that seems to be hidden in much of the public health programs one hears about in developing countries.
Apparently Rwanda is combining its population growth program with its circumcision program, which is intended to reduce HIV transmission. Yet, the respective merits of each strategy, circumcision, condom use and vasectomies, are themselves matters for debate.
There is little doubt that correct and consistent use of condoms plays a large part in reducing unplanned pregnancy. But will people continue to use them if they think there is an alternative, or if they take care of unplanned pregnancy?
But it is far less clear that mass male circumcision has a significant impact on heterosexual HIV transmission outside of (relatively) carefully controlled trials. And even those trials only claim that circumcision reduces female to male transmission, which is a lot less common than male to female transmission, which it may even increase.
And a vasectomy may well reduce conception, perhaps even eliminate it completely. But the ethics of encouraging large numbers of people to have vasectomies, perhaps young men, should be considered carefully. And maybe those advocating the combination of all three should also look at the potential incompatibilities involved.
Programs designed to, or even programs that happen to reduce conception need to be accompanied by programs that aim to improve health services and even health education, nutrition, water and sanitation, working condititions, living conditions and everything else that make up the determinants of health.
Rwanda still has high infant, under five and maternal mortality. Life expectancy is low and most premature deaths are due to treatable and preventable conditions. Even HIV positive people tend to die of treatable and preventable conditions. Under such circumstances, the only viable form of family planning is to have big families.
Health programs that ignore the broader determinants of health will have little positive impact and may do a lot of damage. And the combined contraception/HIV reduction/vasectomy approach suggested for Rwanda sounds entirely unethical, as well as ineffective.
Showing posts with label family planning. Show all posts
Showing posts with label family planning. Show all posts
Monday, April 4, 2011
Sunday, January 10, 2010
PSI: Throwing Bad Money After Bad
At one time, the leading paradigm of development was the control of population, the belief that poor countries would develop if they would only have fewer children. One of the foremost organizations persuading people to use condoms and employ other family planning techniques was Population Services International (PSI). They were not very successful and family planning and reproductive health in developing countries is still woeful, despite large sums of money being thrown at these problems.
PSI is still a powerful organization with lots of money to throw at the problems of development. But now, much of their money goes into HIV, where they (along with various other powerful and rich organizations) have also been relatively unsuccessful. PSI's aim is to use the 'power of marketing' to persuade people to change their sexual behaviour and use condoms and other modern contraceptive methods.
Strangely enough, PSI don't seem to know that the road up is also the road down, that contraception to prevent unplanned pregnancy can also prevent sexually transmitted infections (STI), such as HIV. The goal of reducing unplanned pregnancy was lost in the scramble to persuade people to change their sexual behaviour to avoid being infected with HIV (never mind about other STIs). However, many HIV positive women having babies did not plan to get pregnant in the first place. And the whole issue of sexual activity and reproduction has become so confused that people are apt to concentrate on one thing, such as unplanned pregnancy, and completely ignore two other important considerations: HIV and other STIs.
Not that long ago, it was reported that many women would prefer to run the risk of contracting HIV than that of getting pregnant. They would have unprotected sex with a partner, often a person they didn't know very well, then they would resort to emergency contraception (EC). This EC is not appropriate as a general contraceptive and it does not protect from HIV or other STIs.
Why would people be willing to take this risk? Is it because they simply don't see contracting HIV as a very high risk? They could be right, they may be more likely to become pregnant than to contract HIV or some other STI, but the risk is still there and the odds go against them the longer they continue to have unprotected sex. Actually, the chances of becoming pregnant also become higher the longer they continue to use EC as a substitute for more appropriate contraception.
I'm singling out PSI because they have been big fans of marketing EC in developing countries and because of their dependence on marketing. Marketing may well be appropriate in the commercial world, where everything has to seem cooler or newer or better than what went before. But contraception, family planning, reproductive health and things like that are not good because they are cool or funky or with it, they are good because they work.
If PSI have been successful at marketing EC, they have done so irresponsibly. After all their decades in developing countries they should know by now that what people need is good basic education, good basic health services and good sexual health services, particularly for women and girls. Fancy (and expensive) marketing is not a substitute for proper education and health. The message has now been fluffed, so that people have all sorts of muddled ideas about contraception, sexualy behaviour, pregnancy and anything else organizations like PSI have been involved in.
If organizations like PSI are really interested in people's health and welfare, they should pay a little less attention to marketing expensive products and services and spend some time advocating for the levels of health and education spending that countries like Kenya really need. Contraception such as condoms is not cool, it's vital for people to be able to live their lives without risking serious disease or unplanned pregnancy.
People, adults and children alike, just don't know enough about HIV, reproductive or sexual health. There is no amount of advertising and campaigning that will give them access to the information, services and products they need to ensure their sexual and reproductive health. HIV, and even high levels of unplanned pregnancies, are not emergencies. They are part of everyday life and a factor of how little has been done to improve people's health and education over the past few decades.
Contraception of any kind is useless without adequate levels of spending on education and health, especially those relating to sexual and reproductive health.
PSI is still a powerful organization with lots of money to throw at the problems of development. But now, much of their money goes into HIV, where they (along with various other powerful and rich organizations) have also been relatively unsuccessful. PSI's aim is to use the 'power of marketing' to persuade people to change their sexual behaviour and use condoms and other modern contraceptive methods.
Strangely enough, PSI don't seem to know that the road up is also the road down, that contraception to prevent unplanned pregnancy can also prevent sexually transmitted infections (STI), such as HIV. The goal of reducing unplanned pregnancy was lost in the scramble to persuade people to change their sexual behaviour to avoid being infected with HIV (never mind about other STIs). However, many HIV positive women having babies did not plan to get pregnant in the first place. And the whole issue of sexual activity and reproduction has become so confused that people are apt to concentrate on one thing, such as unplanned pregnancy, and completely ignore two other important considerations: HIV and other STIs.
Not that long ago, it was reported that many women would prefer to run the risk of contracting HIV than that of getting pregnant. They would have unprotected sex with a partner, often a person they didn't know very well, then they would resort to emergency contraception (EC). This EC is not appropriate as a general contraceptive and it does not protect from HIV or other STIs.
Why would people be willing to take this risk? Is it because they simply don't see contracting HIV as a very high risk? They could be right, they may be more likely to become pregnant than to contract HIV or some other STI, but the risk is still there and the odds go against them the longer they continue to have unprotected sex. Actually, the chances of becoming pregnant also become higher the longer they continue to use EC as a substitute for more appropriate contraception.
I'm singling out PSI because they have been big fans of marketing EC in developing countries and because of their dependence on marketing. Marketing may well be appropriate in the commercial world, where everything has to seem cooler or newer or better than what went before. But contraception, family planning, reproductive health and things like that are not good because they are cool or funky or with it, they are good because they work.
If PSI have been successful at marketing EC, they have done so irresponsibly. After all their decades in developing countries they should know by now that what people need is good basic education, good basic health services and good sexual health services, particularly for women and girls. Fancy (and expensive) marketing is not a substitute for proper education and health. The message has now been fluffed, so that people have all sorts of muddled ideas about contraception, sexualy behaviour, pregnancy and anything else organizations like PSI have been involved in.
If organizations like PSI are really interested in people's health and welfare, they should pay a little less attention to marketing expensive products and services and spend some time advocating for the levels of health and education spending that countries like Kenya really need. Contraception such as condoms is not cool, it's vital for people to be able to live their lives without risking serious disease or unplanned pregnancy.
People, adults and children alike, just don't know enough about HIV, reproductive or sexual health. There is no amount of advertising and campaigning that will give them access to the information, services and products they need to ensure their sexual and reproductive health. HIV, and even high levels of unplanned pregnancies, are not emergencies. They are part of everyday life and a factor of how little has been done to improve people's health and education over the past few decades.
Contraception of any kind is useless without adequate levels of spending on education and health, especially those relating to sexual and reproductive health.
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