Reproductive rights: equity, equality, and intervention.

Post-Cairo, reproductive health is argued to be a basic human right, and as such, is protected by existing international agreements on human rights, including documents on the rights of women and children and the rights of indigenous peoples. However, the delineation of rights and responsibilities in the area of reproductive and sexual health proves a difficult task. Why? Presently, the framework of reproductive rights depends heavily on the compliance of nation–states with the programmatic statements of international conventions they have signed. Yet, it is often in the traditional and marginalized communities in which anthropologists typically work where state laws have their least influence and where the state is least accountable. These communities, or some of their members, may themselves explicitly reject the concept of reproductive rights as conflicting with local law or community norms.

Additionally, the very concept of a "right" may be difficult for some members of more marginal communities to understand and operationalize. For example, Petchesky and colleagues found in a cross-cultural study that many women understand their "rights" ad hoc in terms of their desire to avoid conditions of suffering that they had experienced in the past. Furthermore, while the notion of reproductive rights is usually conceived of in terms of individual persons, reproduction never involves single individuals and rarely involves only two people. Instead, as many anthropologists to be cited in this review have shown, reproduction often lies at the intersection of group interests, including families, households, kinship, ethnic, and religious groups, states, and international organizations.

In discussions of the role of anthropology in reproductive health, anthropology has heretofore been conceived of as a tool for investigating and explicating local perspectives on reproductive health and rights in order to implement ideals of human rights. However, a critical medical anthropological perspective must question the exercise of power through reproductive health rights as leveraged by international law. For example, the right to contraceptive access is not necessarily met by the contraceptive method mix available or promoted in many developing countries.

Beyond the "rights" debate, a second important distinction—and one that is key to best providing reproductive health services for both men and women—is that between reproductive health equality and reproductive health equity. "Equality" emphasizes egalitarian reproductive health outcomes for all men and women, achieved ideally through equal or complementary services. "Equity", on the other hand, refers to an approach that emphasizes justice in reproductive health outcomes, achieved through services provided within the context of existing and recognized differences in reproductive physiology as well as inequalities in economic and social resources.

Because the concept of equity rests on subjective measures of fairness and justice, international stakeholders such as the World Health Organization (WHO) have tended to endorse goals of equality, as measured through more objective indicators such as maternal mortality. Implicit in discussions of equity is the realization that the reproductive and sexual needs of women are often culturally subordinate to those of men, and that men locally have rights over women's reproduction and sexuality. Thus, the achievement of equity could in many contexts require privileging the reproductive rights of women over those of men.

In these discussions of equality versus equity, particular notions of men's involvement in reproduction have been used to inform frameworks for incorporating men. Men have traditionally been portrayed, either explicitly or implicitly, as relatively unconcerned and unknowledgeable about reproductive health. They have been seen primarily as impregnators of women, or as the cause of women's poor reproductive health outcomes through STI exposure, sexual violence, and physical abuse. In addition, they have been regarded (often rightly so) as formidable barriers to women's decision-making about fertility, contraceptive use, and health-care utilization. Indeed, some of these generalizations about men have been empirically demonstrated across cultures. Relative to women, men tend to have more sexual partners over their lives, are more likely to have multiple partners simultaneously, are more likely to pursue commercial sex, are more likely to have extra-partner sexual relations, and are more likely to commit an act of violence against women, adolescents, and other men. Men have the option to be absent at childbirth, tend to commit smaller percentages of their income to children and childcare, and contribute less time to direct childcare

Yet, in examining some of these stereotypes in demographic research, show consistent exceptions to many of these generalizations. They find that (1) men may be more, equally, or less informed about contraceptives than women, (2) many men participate in birth control through male- and coital-dependent methods, (3) men's pronatalism varies, with average fertility preferences often differing little from women's and with wide variation between men from different regions, (4) men's dominance in reproductive decision-making varies, and may vary over the reproductive life-course of the couple, (5) men may not prevent women from covertly using contraceptives, and (6) men as well as women may have financial motives for sex, because children may legitimate partners’ claims to one another's resources.

An important advance in characterizing men's involvement has been the more explicit theorization of the role of power in sexual and reproductive relationships. A researcher distinguishes between the power of individuals within a social group and their relative power within dyadic sexual and reproductive relationships. She argues that the difference between power to (i.e., power as positive possibility for oneself) and power over (i.e., power as negative and limiting of others) is of particular importance in these relationships.

Recent attempts to conceptualize reproductive health interventions based on these observations about power have led to two major frameworks for the incorporation of men into programs and services. Basu (1996) has described the first framework—one that he finds in the programmatic statements of both the Cairo and Beijing conferences—as one of "Women's Rights and Men's Responsibilities". Namely, while women and men both have rights and responsibilities in the area of reproductive health, this framework addresses rights and responsibilities for men and women differently, because of existing power differentials and unequal distribution of resources between men and women. Extrapolating to the realm of reproductive health, women's and men's contributions to reproductive health are seen as unequal and their experiences of reproductive health are seen as fundamentally different. Interventions following from this framework, therefore, tend to focus on the reproductive health problems caused by men, along with approaches to empowering women. This framework focuses on the need for reproductive health equity rather than equality. Yet, as Basu points out, by focusing on equity versus equality, this framework may not achieve its goal; interventions that exclude men may do less to achieve reproductive health equity than those that include them.

Basu discusses explicitly the need for equality in addressing men's individual reproductive rights. Even so, he does not address men's rights as they involve other individuals. Because reproduction always involves more than one individual with rights, the discussion of reproductive rights must address the co-existing reproductive rights of men and women in relationship to each other. This is particularly important for integrating men into this perspective, given that men often have culturally explicit and implicit rights to women's sexuality and reproduction. Rather than discussing only men's responsibilities as partners, or their rights as individual reproductive actors, an anthropological perspective emphasizes men's rights regarding other reproductive participants, and how these rights, as derived from international treaties and conventions, may differ from locally defined notions of rights. To redirect the reproductive rights discussion in this way leads to numerous complex ethical questions. For example, do men have the right to withhold care or support from a pregnant mother? Is responsibility for care to be derived solely from genetic paternity, from consanguine or marital relations, or from some combination? Do men have the right to have multiple partners, or children with multiple partners? Do they have the right to withhold information about their STD status? Do they have the right to play a part in the termination of pregnancy? These questions will have to be addressed in future reproductive rights discussions.

A second framework for including men in reproductive health, "Men as Partners", emphasizes a client-based approach that seeks to provide sustainable reproductive health care for men without compromising (and hopefully improving) services for women. Such a perspective recognizes men's important contributions to reproductive health, as well as men's needs, and attempts to reconcile conflicting reproductive goals within the context of reproductive partnerships, primarily married couples. The approach adheres to the three avenues for involvement issued at the ICPD, with services provided through screening, education and counseling, and diagnosis and treatment. Such an approach focuses on men as partners—that is, as members of a family, usually as husbands, with a significant locus of responsibility for reproduction. The framework, therefore, envisions male involvement in reproduction and addresses men's own bio-reproductive and psycho-sexual needs.

However, given the explicit focus of this framework on the cooperation of men and women in reproductive decision-making, this framework downplays the different reproductive and sexual strategies and goals that men and women may pursue separately, including outside of the marital union. Greene and Biddlecom (2000) have observed that, in this approach, the ideological assumption of heterosexual monogamy with fidelity associated with reproductive health actually becomes a programmatic goal. This perspective, therefore, has been difficult to implement, because it requires a positive and more general definition of "partner". Additionally, it does not clearly answer whether or not a partner approach implies that services for men should be integrated or separate from those for women; this is a contentious issue that depends heavily on existing services as well as the kinds of services provided. The partner perspective also makes several implicit assumptions about men and reproductive health—namely, that educating men about men's and women's reproductive health needs will make men more sensitive and responsive to these needs, and that incorporating men into reproductive health programs will improve both men's and women's reproductive health outcomes. Such assumptions may not hold in all contexts.