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Complexity versus the technical fix or how to put sexuality back into sexual health Barbara Klugman
a
a
School of Public Health, University of the Witwatersrand, Johannesburg, South Africa Published online: 02 Jun 2014.
To cite this article: Barbara Klugman (2014) Complexity versus the technical fix or how to put sexuality back into sexual health, Global Public Health: An International Journal for Research, Policy and Practice, 9:6, 653-660, DOI: 10.1080/17441692.2014.917196 To link to this article: http://dx.doi.org/10.1080/17441692.2014.917196
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
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Global Public Health, 2014 Vol. 9, No. 6, 653–660, http://dx.doi.org/10.1080/17441692.2014.917196
Complexity versus the technical fix or how to put sexuality back into sexual health Barbara Klugman*
Downloaded by [University of Southern Queensland] at 07:10 11 October 2014
School of Public Health, University of the Witwatersrand, Johannesburg, South Africa (Received 29 November 2013; accepted 3 April 2014) These reflections consider the failure of the public health establishment to invest in evaluations of interventions that support community groups to shift individual and community behaviours in favour of sexual well-being, sexual rights and sexual satisfaction. This article queries the willingness to invest substantially in researching technical interventions without simultaneously assessing their potential unintended consequences for sexual health well-being; the associated lack of will to invest in social research is also queried. The paper proposes that part of the challenge is the research paradigm that fears complexity, despite growing recognition that sexuality and sexual health are products of a complex intersection of factors, and they require research and evaluation methodologies that recognise such complexity. The paper argues that given the wide-ranging efforts to promote shifts in community norms and practices in relation to sexuality, an opportunity is being lost due to the failure to use ongoing process and outcome evaluations to inform interventions that would provide implementers and groups in communities with resources and ideas to strengthen the quality of their efforts in different contexts, thereby failing to meet the promise of the International Conference on Population and Development. Keywords: complexity; sexual rights; evidence; research; policy
Introduction One of the most delightful moments I experienced at the 1994 International Conference on Population and Development (ICPD) in Cairo was during the working group to negotiate the draft language for reproductive health. We debated the phrase ‘a satisfying and safe sex life’, which was ultimately included in the definition (United Nations, 1994, para. 7.2). The honourable representative from Iran asked, ‘How are we going to measure a satisfying sex life’? Which brought a moment of hilarity into a somewhat tense negotiation. It was, however, an important question, and one that the global community of research institutions, funders and social and health programmers seems to have given only partial attention to in the years that have followed. The question I explore is whether, 20 years on, we would know more about what makes for a satisfying and safe sex life and indeed, what is necessary for sexual health and sexual rights. Sexual rights – or the application of human rights to the terrain of sexuality and sexual health – are the core of sexual well-being and satisfaction, as these cannot be achieved in contexts where people experience stigma, discrimination, coercion or violence, as noted in the Beijing Platform for Action, paragraph 96 (United Nations, *Email: [email protected] © 2014 Taylor & Francis
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1995). The abrogation of many of these rights takes place at the individual, family and community levels and is reinforced by local civil society and government organisations, such as religious institutions, schools and health services. Hence, the need to address these issues at the local or ‘community’ level. Since the negotiation of the two groundbreaking global agreements on these issues, first in Cairo and then with some further depth at the Fourth World Conference on Women in Beijing in 1995, there has been an exponential growth in interventions in the name of sexual and reproductive health. There have been far fewer on sexual or reproductive rights, and indeed, this terminology has not taken hold except amongst activists for social justice and human rights. Reproductive health programmes are still mostly called ‘family planning’ or ‘maternal health’ or some mix of these, or they are called ‘reproductive health’ but refer only to maternal health and contraceptive services, missing the inclusive and comprehensive intentions captured in the ICPD Platform of Action. These aims would cover broader health issues, such as cancers of the reproductive system, as well as underlying determinants of reproductive health and people’s ability to protect and promote their own reproductive health, such as inequitable power dynamics in sexual relationships and exposure to sexual violence. Similarly, while sexual health programmes have grown, by and large they are about preventing ‘risktaking’ and diseases, specifically sexually transmitted infections and HIV. They ignore the core dimensions of the ICPD definition of sexual health regarding emotional health and well-being, which recognise the central role of sexual maturation, sexuality and sexual relationships in shaping the human experience, including one of the mottos of the ICPD, which is the right to make decisions on these matters ‘free of discrimination, coercion and violence’ (United Nations, 1994, para. 7.3). ICPD particularly became apparent in a recent World Health Organization’s (WHO) systematic review of evidence on the effectiveness of sexual health counselling. Almost all the research findings focused on the extent to which such counselling resulted in an increased use of condoms or related indicators (WHO Guidelines Development Group & Troussier, 2013). Those who did consider questions of self-efficacy considered this as a factor that influences people’s ability to refuse unprotected sex and to use condoms. None went deeper. The researchers did not explore questions regarding sexual satisfaction or to what extent counselling interventions might build people’s ability to express their needs and navigate their sexual relationships in ways that contribute positively to their sexual well-being and that of their partners. In particular, they did not address questions regarding how sexual health counselling can help people address the impact of discrimination, violence and gendered power relations on decision-making and on pleasure in sexual relationships. They did not study the impact of counselling on the everyday concerns of young people and, indeed, adults, which undermine their sense of self and sexuality, such as concerns over their body shape and size, concerns regarding masturbation, concerns regarding expectations pertaining to their gender expression or sexual orientation or how to cope with the negative effects of certain medications on libido and sexual function. Failure to invest in evaluating existing innovative social interventions This does not mean that the efforts to develop and sustain interventions to promote sexual rights are not under way. Rather, it tells us something about the interaction of funding and research priorities. The sexual health research field has grown exponentially through the increased funding for HIV and AIDS research, and that is what has determined research
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agendas, or at least the agendas of those conducting the kinds of research and evaluations that produce high-quality evidence since these are usually expensive. It is not only our understanding of health service interventions that has been affected by this rather limited conception of sexual health. There is similarly a paucity of highquality evaluations of community-based interventions. While by now there is a global recognition that dynamics within community groups influence sexual health and wellbeing (WHO, 2010), whether these are framed as matters of ‘culture’ or ‘sexual scripts’ or ‘norms and values’, there is a paucity of evaluations that provide evidence of effective interventions at the community level. While there are innumerable interventions with a starting point of building the power of people in communities to take action individually and as groups to challenge abuses in their relationships and in communities more broadly and to build a culture that promotes sexual rights (whether using that specific language or not), funding for such interventions invariably fails to include funds for high-quality evaluation – both outcome evaluations, to assess if the intervention was effective in shifting individual and community norms and actions, and process evaluations, to assess why the interventions did or did not achieve the intended outcomes. Donors who fund interventions, despite increasingly looking for evidence of impact, are seldom willing to include in their budgets the costs of high-quality evaluations. The civil society groups who are largely responsible for such innovative interventions in this field seldom have the internal evaluation capacity for this work or the funds to commission it. In 2013, a Southern African donor keen to ensure that the community-based interventions it supports are drawing on lessons from the field as to what works and what does not, commissioned a search for evidence of effective interventions to promote sexual and reproductive health and rights for groups in communities (or health services). What is striking is that the search produced innumerable stories of change in the grey literature, but very few high-quality evaluations of the effectiveness of the interventions, let alone studies that were able to draw out to what extent specific interventions were reliant on local context or what kinds of adaptations made them effective in different contexts (Cooper & Klugman, 2013). There are but a handful of interventions that have been developed and tested in multiple sites and in which adaptations have been tested. Examples of efforts towards producing solid evidence are CARE’s Inner Spaces Outer Faces Initiative (Kambou, Magar, Hora, & Mukherjee, 2007) and Stepping Stones (Jewkes et al., 2007), both of which have been used within health services and among groups in communities, as well as Health Workers for Change, which focuses specifically on building health-care provider agency to treat clients with greater dignity and respect (Onyango-Ouma et al., 2001). A number of the other interventions identified had been reasonably well evaluated in particular contexts, but they had not produced any tools that would allow other groups to replicate them, let alone evaluated their effectiveness in diverse contexts. A case in point of an evidence vacuum is female genital mutilation (FGM; Johansen, Diop, Laverack, & Leye, 2013), a practice that has a direct impact on maternal mortality, sexual well-being and satisfaction (for women and men) and on the rights and dignity of girls and women. It has been a focal issue for the WHO, which, with others, has produced a fair amount about its health impacts. However, despite the fact that a range of civil society groups have developed and implemented diverse tools and models that appear to contribute towards a reduction in the practice, the groups have only produced anecdotal evidence. Neither funders nor research and evaluation institutions have chosen to give priority to supporting these interventions with solid evaluations that produce reliable
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evidence about what makes parents and communities stop the practice (Johansen et al., 2013). This gap in the evidence tells us that ‘many lessons of complex and innovative healthpromoting activities are being lost due to lack of research’ (Parkhurst, Weller, & Kemp, 2010, p. 1415). While there are initiatives across the globe that aim to empower people in communities and in health services to recognise and act to improve sexual and reproductive health and rights, including addressing harmful practices that undermine these rights, evaluating these initiatives is not on most mainstream donors’ or research institutions’ agendas. Those donors who have shown an interest in promoting sexual and reproductive rights tend not to have a research and evaluation bent, and they do not grasp that developing and testing interventions in diverse settings take substantial time and money. Hence, the projects they support come and go, some producing interesting stories or very basic evaluations that describe the experiences of participants in an intervention, but not findings that hold up to methodological scrutiny or allow for any degree of replicability. This is the case despite the exponential growth in donor commitment to monitoring and evaluating, and the frequently intolerable demands some donors make on implementing groups to report the minutiae of their outputs. Somehow the great desire for ‘results’ has not been translated into funding methodologically sound evaluations of both the process and the outcomes of interventions (Parkhurst et al., 2010). Yet, were such evidence produced, those shown to be effective could then be implemented without the stultifying effects of current monitoring models where implementers have to document every output at every stage. The more understanding there is of what factors facilitate and constrain programme impact, the more groups could have confidence in their interventions. The more evidence there is, the more local groups could draw on documented expertise to shape their interventions, and the more confidence donors could have regarding the chances of the interventions making a difference. At the moment, there is a vicious cycle in which a lack of evidence justifies a lack of investment. Some decisionmakers with money and vision need to fill this gap. Related to this point, where funders are funding the development and testing of interventions, they also need to fund the scaleup, that is, the production of tools that can be used by others – detailing the contextual conditions, processes, challenges and how they were addressed – and provide the funds to evaluate efforts to use these tools in diverse geographical, cultural or political contexts.
Failure to recognise the need for preventive social interventions The paucity of solid evaluations of grounded social interventions to promote sexual rights and reproductive rights also reflects the profound limitations of the dominant public health paradigm, which imagines that social and sexual life are similar to a disease that, with enough research, can be addressed with a single technical solution – a bed net, a vaccine and a pill. This belief allows major donors to take the risk of spending millions of dollars in search of such solutions – for example, for a vaginal microbicide to prevent HIV – knowing that there will be innumerable failures before there is success but that, if achieved, the intervention will make a significant contribution to HIV prevention. Yet these same donors, having supported substantial research efforts that show how gender, power and violence affect vulnerability to HIV, are not willing to take the risks and invest similarly in identifying and testing interventions to address the social and interpersonal dynamics that abrogate both sexual and reproductive health as well as sexual and reproductive rights.
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The blinders of epidemiology Part of the problem is the hegemony of traditional epidemiology in shaping global understandings of evidence, such that randomised controlled trials (RCTs) are believed to produce the most valid evidence despite the reality that societies are not controllable entities in the way that laboratories or organisms are. RCTs were developed for laboratory and clinical studies. Studies of cultural practices such as FGM are impossible to conduct in this way since one cannot randomise a cultural intervention without removing it from its cultural context and thereby rendering it meaningless. This limitation arises out of the failure of the dominant public health research community to embrace complexity and to test and validate research and evaluation methods that are appropriate to situations with complex social dynamics. Clinical and public health sciences tend to privilege some forms of knowledge over others (Rychetnik, Hawe, Waters, Barratt, & Frommer, 2004; Trostle, Bronfman, & Langer, 1999; Walby, 2005). The desire for simplicity, particularly from donors who fund research and evaluation, has led to a stunting of creativity in relation to research methodology despite increasing recognition among social and scientific disciplines of the complex nature of social reality (Cilliers, 2008). This limited understanding of how to produce high-quality evidence for complex matters affecting public health has allowed evaluators and researchers as well as public health decisionmakers (politicians, donors, development agencies and health service managers) to embrace solutions based on inadequate social research because of the almost religious fervour attached to the belief in the findings of RCTs. That said, the evaluation field has a lot to offer the public health domain because of its development of both theory and practice on how to assess social interventions in complex environments, including identifying limitations of and alternatives to the RCT for evaluating social interventions (Patton, 2012). The evaluation field’s attention to mixedmethod designs that bring together both diverse disciplines and conceptual frameworks, as well as diverse research tools, has allowed the production of high-quality evidence on social change processes (Bamberger, Rugh, & Mabry, 2012). Indecent haste in introducing interventions based only on RCT findings This raises the final focus of my reflections, which is on the circumstances under which research findings are used to inform policy and action. Substantial research shows that research findings, no matter how strong, are not invariably taken up in policy or practice because the values, political positioning and practical constraints experienced by decision-makers frequently intervene (Loewenson, 2010; Sutton, 1999; Trostle et al., 1999). Yet the results of three randomised trials on male circumcision published in early 2007 (Karim, 2007) were followed within months by the announcement of funding by the US President’s Emergency Plan for AIDS Relief of male circumcision programmes for 10 African countries (Loewenson, 2010). The findings from the three medical male circumcision trials were implemented with indecent haste, particularly in a context where interventions that had shown much higher levels of efficacy – condom use and the prevention of mother-to-child transmission – were still not well implemented in countries with a high incidence of HIV. In January 2007, ostensibly as part of the process of consultation by decision-makers on how to act upon the findings of the trials, a UNAIDS/CAPRISA Consultation on Social Science Perspectives on Male Circumcision for HIV Prevention was held. Social scientists at the meeting issued many cautionary warnings about the lack of information regarding the emotional, psychological, relationship and social dynamics that the
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introduction of medical male circumcision might foster, none of which had been studied in any depth in the three trials that were providing the rationale for implementation. They noted the need for further research:
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Different epistemologies (ways of knowing) can complement each other: we can learn from both existing randomised controlled trials and operations research during implementation of male circumcision programmes for HIV prevention;
. anthropological/social studies using dynamic contextual analysis should be integrated into male circumcision for HIV prevention programming to monitor any unintended effects; . traditionally circumcising regions of the world can inform discussions about rationale, acceptability, programme design, communications, etc. . multidisciplinary social science research on male circumcision for HIV prevention, outside a controlled trial environment, should be a priority rather than being sidelined as taking too long. (United Nations & AIDS [UNAIDS]/Centre for the AIDS Programme of Research in South Africa [CAPRISA], 2007, p. 6) These and related issues were detailed in a number of papers used as background for the meeting and subsequently published (Dowsett & Couch, 2007; Sawires et al., 2007). Key questions regarding the impacts on individuals’ experiences of masculinity and on their assumptions about safety in the context of the findings, having shown only partial protection, were raised as were questions regarding the potential impacts of male circumcision on women’s understanding of sexual safety and on their negotiating power in sexual relationships with circumcised men. Yet despite the absence of evidence on these issues, funds were rapidly raised and services rolled out. In response to a rising chorus of concerns, the WHO and the UNAIDS held a consultation on the implications of medical male circumcision for women and, out of this, produced an insert to accompany their information materials on medical male circumcision that notes the need to focus attention on these issues and presents an additional research agenda, including research into potential harm to women (WHO/UNAIDS, 2007). Yet neither this agenda nor the broader issues pertaining to emotional, psychological and social impacts raised in the social science consultation have become the subject of a concerted research effort. They are not even the focus of evaluations as implementation rolls out. I have dwelt on this example because it aptly illustrates the dominant research paradigm – the search for the quick fix and the confidence of those with power and influence in public health in findings that are the result of RCTs, despite that they have failed miserably to assess the personal, interpersonal and social consequences of an intervention. In many contexts, being circumcised or not being circumcised has meanings in relation not only to men’s masculinity and sexuality but also in relation to their place in society – in some cases, in relation to their adulthood, and in other cases, in relation to their belonging to a particular ethnic or religious group. To intervene in that space without paying serious attention to an intervention’s impacts on these issues reflects a profound disregard for the people’s dignity, for the cultural specificity and for the complexity of society. While funds have been used for a technical intervention involving the penis – male circumcision – the public health establishment has not attended to the intervention’s impacts on sexuality, sexual relationships, sexual and gender power dynamics and the social meanings of sexuality. What sort of priorities does this reflect?
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And so, 20 years after the ICPD, scant attention is given to the sexual and social dimensions of sexual health and rights, however contradictory that may sound. Similarly, there is very little evidence to support community groups in shaping actions that profoundly shift individual and group norms and action towards a culture of respect, dignity and empowerment in relation to sexuality and reproduction. Such a shift would save the world millions of dollars in costs to the public health system that results from people’s inability to protect and promote their own, their partner’s and their children’s sexual and reproductive health and rights; this shift would also substantially improve people’s ability to live their lives in a context of dignity and respect, enjoying the benefits of sexual and reproductive well-being and perhaps, even, satisfaction. This was the vision of the ICPD. Acknowledgements I would like to thank the peer reviewer for invaluable advice.
References Bamberger, M., Rugh, J., & Mabry, L. (2012). Real world evaluation: Working under budget, time, data and political constraints (2nd ed.). Thousand Oaks, CA: Sage. Cilliers, P. (2008). Complexity theory as a general framework for sustainability science. In M. Burns & A. Weaver (Eds.), Exploring sustainability science: A Southern African perspective (pp. 39–57). Stellenbosch: SUN Press. Cooper, D., & Klugman, B. (2013). Community-driven action for sexual and reproductive health and rights—learning from experience (Report of an expert think tank). Johannesburg: Southern African AIDS Trust. Dowsett, G. W., & Couch, M. (2007). Male circumcision and HIV prevention: Really enough of the right kind of evidence? Reproductive Health Matters 15(29), 33–44. doi:10.1016/S0968-8080 (07)29302-4 Jewkes, R., Nduna, M., Levin, J., Jama, N., Dunkel, K. I., Wood, K., & Duvvury, N. (2007). Evaluation of stepping stones: A gender transformative HIV prevention intervention [Policy brief]. Pretoria: Medical Research Council. Johansen, R., Diop, N., Laverack, G., & Leye, E. (2013). What works and what does not: A discussion of popular approaches for the abandonment of female genital mutilation. Obstetrics and Gynecology International. Vol. 2013, 10 p. Article ID 348248. Retrieved from http://dx.doi. org/10.1155/2013/348248 Kambou, S. D., Magar, V., Hora, G., & Mukherjee, A. (2007). Power, pleasure, pain, and shame: Assimilating gender and sexuality into community-centred reproductive health and HIV prevention programmes in India. Global Public Health, 2, 155–168. doi:10.1080/1744 1690601066375 Karim, Q. A. (2007). Prevention of HIV by male circumcision. Effective but integration with existing sexual health services remains the biggest challenge. British Medical Journal, 335, 4–5. doi:10.1136/bmj.39245.491169.BE Loewenson, R. (2010, November 16–19). Connecting the streams: Using health-systems research knowledge in low- and middle-income countries. Background paper commissioned by the World Health Organization for the Global Symposium on Health Systems Research, Montreux. Onyango-Ouma, W., Laisser, R., Mbilima, M., Araoye, M., Pittman, P., Agyepong, I., … Vlassof, C. (2001). An evaluation of health workers for change in seven settings: A useful management and health system development tool. Health Policy and Planning, 16(Suppl. 1), 24–32. doi:10.1093/heapol/16.suppl_1.24 Parkhurst, J., Weller, I., & Kemp, J. (2010). Getting research into policy, or out of practice, in HIV? The Lancet, 375, 1414–1415. doi:10.1016/S0140-6736(10)60585-5 Patton, M. Q. (2012). Essentials of utilisation-focused evaluation. Los Angeles: Sage. Rychetnik, L., Hawe, P., Waters, E., Barratt, A. & Frommer, M. (2004) A glossary for evidence based public health. Journal of Epidemiology and Community Health, 58, 538–545. doi:10.1136/ jech.2003.011585
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Sawires, S. R., Dworkin, S. L., Fiamma, A., Peacock, D., Szekeres, G., & Coates, T. J. (2007). Male circumcision and HIV/AIDS: Challenges and opportunities. The Lancet, 369, 708–713. doi:10.1016/S0140-6736(07)60323-7 Sutton, R. (1999) The policy process: An overview (Working paper 118). London: Overseas Development Institute. Retrieved November 29, 2010, from http://www.odi.org.uk/sites/odi.org. uk/files/odi-assets/publications-opinion-files/2535.pdf Trostle, J., Bronfman, M., & Langer, A. (1999). How do researchers influence decision-makers? Case studies of Mexican policies. Health Policy and Planning, 14(2), 103–114. doi:10.1093/ heapol/14.2.103 United Nations & AIDS [UNAIDS]/Centre for the AIDS Programme of Research in South Africa [CAPRISA]. (2007, January 18–19). Consultation on social science perspectives on male circumcision for HIV prevention (Summary report). Geneva and Durban: Author. United Nations. (1994, September 5–13). Programme of action of the international conference on population and development (Report of the international conference on population and development, para. 7.2, 7.3). UN Doc. A/CONF.171/13. United Nations. (1995, October 17). Platform for action of the fourth world conference on women, September 1995, para. 96, UN Doc. A/CONF.177/20. Walby, S. (2005). Gender mainstreaming: Productive tensions in theory and practice. Social Politics: International Studies in Gender, State and Society, 12, 321–343. doi:10.1093/sp/jxi018 WHO Guidelines Development Group, & Troussier, T. (2013). Systematic review on counselling and sexuality: How types of counselling adapt to sexuality. Conference of the World Association for Sexual Health. WHO/UNAIDS. (2007). Information package on male circumcision and HIV prevention: Implications for women. Insert 5. Geneva: Author. World Health Organization. (2010). Developing sexual health programmes – A framework for action, WHO/RHR/HRP/10.22. Geneva: Author. Retrieved from http://whqlibdoc.who.int/hq/ 2010/WHO_RHR_HRP_10.22_eng.pdf
Global Public Health: An International Journal for Research, Policy and Practice Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rgph20
Complexity versus the technical fix or how to put sexuality back into sexual health Barbara Klugman
a
a
School of Public Health, University of the Witwatersrand, Johannesburg, South Africa Published online: 02 Jun 2014.
To cite this article: Barbara Klugman (2014) Complexity versus the technical fix or how to put sexuality back into sexual health, Global Public Health: An International Journal for Research, Policy and Practice, 9:6, 653-660, DOI: 10.1080/17441692.2014.917196 To link to this article: http://dx.doi.org/10.1080/17441692.2014.917196
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [University of Southern Queensland] at 07:10 11 October 2014
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Global Public Health, 2014 Vol. 9, No. 6, 653–660, http://dx.doi.org/10.1080/17441692.2014.917196
Complexity versus the technical fix or how to put sexuality back into sexual health Barbara Klugman*
Downloaded by [University of Southern Queensland] at 07:10 11 October 2014
School of Public Health, University of the Witwatersrand, Johannesburg, South Africa (Received 29 November 2013; accepted 3 April 2014) These reflections consider the failure of the public health establishment to invest in evaluations of interventions that support community groups to shift individual and community behaviours in favour of sexual well-being, sexual rights and sexual satisfaction. This article queries the willingness to invest substantially in researching technical interventions without simultaneously assessing their potential unintended consequences for sexual health well-being; the associated lack of will to invest in social research is also queried. The paper proposes that part of the challenge is the research paradigm that fears complexity, despite growing recognition that sexuality and sexual health are products of a complex intersection of factors, and they require research and evaluation methodologies that recognise such complexity. The paper argues that given the wide-ranging efforts to promote shifts in community norms and practices in relation to sexuality, an opportunity is being lost due to the failure to use ongoing process and outcome evaluations to inform interventions that would provide implementers and groups in communities with resources and ideas to strengthen the quality of their efforts in different contexts, thereby failing to meet the promise of the International Conference on Population and Development. Keywords: complexity; sexual rights; evidence; research; policy
Introduction One of the most delightful moments I experienced at the 1994 International Conference on Population and Development (ICPD) in Cairo was during the working group to negotiate the draft language for reproductive health. We debated the phrase ‘a satisfying and safe sex life’, which was ultimately included in the definition (United Nations, 1994, para. 7.2). The honourable representative from Iran asked, ‘How are we going to measure a satisfying sex life’? Which brought a moment of hilarity into a somewhat tense negotiation. It was, however, an important question, and one that the global community of research institutions, funders and social and health programmers seems to have given only partial attention to in the years that have followed. The question I explore is whether, 20 years on, we would know more about what makes for a satisfying and safe sex life and indeed, what is necessary for sexual health and sexual rights. Sexual rights – or the application of human rights to the terrain of sexuality and sexual health – are the core of sexual well-being and satisfaction, as these cannot be achieved in contexts where people experience stigma, discrimination, coercion or violence, as noted in the Beijing Platform for Action, paragraph 96 (United Nations, *Email: [email protected] © 2014 Taylor & Francis
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1995). The abrogation of many of these rights takes place at the individual, family and community levels and is reinforced by local civil society and government organisations, such as religious institutions, schools and health services. Hence, the need to address these issues at the local or ‘community’ level. Since the negotiation of the two groundbreaking global agreements on these issues, first in Cairo and then with some further depth at the Fourth World Conference on Women in Beijing in 1995, there has been an exponential growth in interventions in the name of sexual and reproductive health. There have been far fewer on sexual or reproductive rights, and indeed, this terminology has not taken hold except amongst activists for social justice and human rights. Reproductive health programmes are still mostly called ‘family planning’ or ‘maternal health’ or some mix of these, or they are called ‘reproductive health’ but refer only to maternal health and contraceptive services, missing the inclusive and comprehensive intentions captured in the ICPD Platform of Action. These aims would cover broader health issues, such as cancers of the reproductive system, as well as underlying determinants of reproductive health and people’s ability to protect and promote their own reproductive health, such as inequitable power dynamics in sexual relationships and exposure to sexual violence. Similarly, while sexual health programmes have grown, by and large they are about preventing ‘risktaking’ and diseases, specifically sexually transmitted infections and HIV. They ignore the core dimensions of the ICPD definition of sexual health regarding emotional health and well-being, which recognise the central role of sexual maturation, sexuality and sexual relationships in shaping the human experience, including one of the mottos of the ICPD, which is the right to make decisions on these matters ‘free of discrimination, coercion and violence’ (United Nations, 1994, para. 7.3). ICPD particularly became apparent in a recent World Health Organization’s (WHO) systematic review of evidence on the effectiveness of sexual health counselling. Almost all the research findings focused on the extent to which such counselling resulted in an increased use of condoms or related indicators (WHO Guidelines Development Group & Troussier, 2013). Those who did consider questions of self-efficacy considered this as a factor that influences people’s ability to refuse unprotected sex and to use condoms. None went deeper. The researchers did not explore questions regarding sexual satisfaction or to what extent counselling interventions might build people’s ability to express their needs and navigate their sexual relationships in ways that contribute positively to their sexual well-being and that of their partners. In particular, they did not address questions regarding how sexual health counselling can help people address the impact of discrimination, violence and gendered power relations on decision-making and on pleasure in sexual relationships. They did not study the impact of counselling on the everyday concerns of young people and, indeed, adults, which undermine their sense of self and sexuality, such as concerns over their body shape and size, concerns regarding masturbation, concerns regarding expectations pertaining to their gender expression or sexual orientation or how to cope with the negative effects of certain medications on libido and sexual function. Failure to invest in evaluating existing innovative social interventions This does not mean that the efforts to develop and sustain interventions to promote sexual rights are not under way. Rather, it tells us something about the interaction of funding and research priorities. The sexual health research field has grown exponentially through the increased funding for HIV and AIDS research, and that is what has determined research
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agendas, or at least the agendas of those conducting the kinds of research and evaluations that produce high-quality evidence since these are usually expensive. It is not only our understanding of health service interventions that has been affected by this rather limited conception of sexual health. There is similarly a paucity of highquality evaluations of community-based interventions. While by now there is a global recognition that dynamics within community groups influence sexual health and wellbeing (WHO, 2010), whether these are framed as matters of ‘culture’ or ‘sexual scripts’ or ‘norms and values’, there is a paucity of evaluations that provide evidence of effective interventions at the community level. While there are innumerable interventions with a starting point of building the power of people in communities to take action individually and as groups to challenge abuses in their relationships and in communities more broadly and to build a culture that promotes sexual rights (whether using that specific language or not), funding for such interventions invariably fails to include funds for high-quality evaluation – both outcome evaluations, to assess if the intervention was effective in shifting individual and community norms and actions, and process evaluations, to assess why the interventions did or did not achieve the intended outcomes. Donors who fund interventions, despite increasingly looking for evidence of impact, are seldom willing to include in their budgets the costs of high-quality evaluations. The civil society groups who are largely responsible for such innovative interventions in this field seldom have the internal evaluation capacity for this work or the funds to commission it. In 2013, a Southern African donor keen to ensure that the community-based interventions it supports are drawing on lessons from the field as to what works and what does not, commissioned a search for evidence of effective interventions to promote sexual and reproductive health and rights for groups in communities (or health services). What is striking is that the search produced innumerable stories of change in the grey literature, but very few high-quality evaluations of the effectiveness of the interventions, let alone studies that were able to draw out to what extent specific interventions were reliant on local context or what kinds of adaptations made them effective in different contexts (Cooper & Klugman, 2013). There are but a handful of interventions that have been developed and tested in multiple sites and in which adaptations have been tested. Examples of efforts towards producing solid evidence are CARE’s Inner Spaces Outer Faces Initiative (Kambou, Magar, Hora, & Mukherjee, 2007) and Stepping Stones (Jewkes et al., 2007), both of which have been used within health services and among groups in communities, as well as Health Workers for Change, which focuses specifically on building health-care provider agency to treat clients with greater dignity and respect (Onyango-Ouma et al., 2001). A number of the other interventions identified had been reasonably well evaluated in particular contexts, but they had not produced any tools that would allow other groups to replicate them, let alone evaluated their effectiveness in diverse contexts. A case in point of an evidence vacuum is female genital mutilation (FGM; Johansen, Diop, Laverack, & Leye, 2013), a practice that has a direct impact on maternal mortality, sexual well-being and satisfaction (for women and men) and on the rights and dignity of girls and women. It has been a focal issue for the WHO, which, with others, has produced a fair amount about its health impacts. However, despite the fact that a range of civil society groups have developed and implemented diverse tools and models that appear to contribute towards a reduction in the practice, the groups have only produced anecdotal evidence. Neither funders nor research and evaluation institutions have chosen to give priority to supporting these interventions with solid evaluations that produce reliable
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evidence about what makes parents and communities stop the practice (Johansen et al., 2013). This gap in the evidence tells us that ‘many lessons of complex and innovative healthpromoting activities are being lost due to lack of research’ (Parkhurst, Weller, & Kemp, 2010, p. 1415). While there are initiatives across the globe that aim to empower people in communities and in health services to recognise and act to improve sexual and reproductive health and rights, including addressing harmful practices that undermine these rights, evaluating these initiatives is not on most mainstream donors’ or research institutions’ agendas. Those donors who have shown an interest in promoting sexual and reproductive rights tend not to have a research and evaluation bent, and they do not grasp that developing and testing interventions in diverse settings take substantial time and money. Hence, the projects they support come and go, some producing interesting stories or very basic evaluations that describe the experiences of participants in an intervention, but not findings that hold up to methodological scrutiny or allow for any degree of replicability. This is the case despite the exponential growth in donor commitment to monitoring and evaluating, and the frequently intolerable demands some donors make on implementing groups to report the minutiae of their outputs. Somehow the great desire for ‘results’ has not been translated into funding methodologically sound evaluations of both the process and the outcomes of interventions (Parkhurst et al., 2010). Yet, were such evidence produced, those shown to be effective could then be implemented without the stultifying effects of current monitoring models where implementers have to document every output at every stage. The more understanding there is of what factors facilitate and constrain programme impact, the more groups could have confidence in their interventions. The more evidence there is, the more local groups could draw on documented expertise to shape their interventions, and the more confidence donors could have regarding the chances of the interventions making a difference. At the moment, there is a vicious cycle in which a lack of evidence justifies a lack of investment. Some decisionmakers with money and vision need to fill this gap. Related to this point, where funders are funding the development and testing of interventions, they also need to fund the scaleup, that is, the production of tools that can be used by others – detailing the contextual conditions, processes, challenges and how they were addressed – and provide the funds to evaluate efforts to use these tools in diverse geographical, cultural or political contexts.
Failure to recognise the need for preventive social interventions The paucity of solid evaluations of grounded social interventions to promote sexual rights and reproductive rights also reflects the profound limitations of the dominant public health paradigm, which imagines that social and sexual life are similar to a disease that, with enough research, can be addressed with a single technical solution – a bed net, a vaccine and a pill. This belief allows major donors to take the risk of spending millions of dollars in search of such solutions – for example, for a vaginal microbicide to prevent HIV – knowing that there will be innumerable failures before there is success but that, if achieved, the intervention will make a significant contribution to HIV prevention. Yet these same donors, having supported substantial research efforts that show how gender, power and violence affect vulnerability to HIV, are not willing to take the risks and invest similarly in identifying and testing interventions to address the social and interpersonal dynamics that abrogate both sexual and reproductive health as well as sexual and reproductive rights.
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The blinders of epidemiology Part of the problem is the hegemony of traditional epidemiology in shaping global understandings of evidence, such that randomised controlled trials (RCTs) are believed to produce the most valid evidence despite the reality that societies are not controllable entities in the way that laboratories or organisms are. RCTs were developed for laboratory and clinical studies. Studies of cultural practices such as FGM are impossible to conduct in this way since one cannot randomise a cultural intervention without removing it from its cultural context and thereby rendering it meaningless. This limitation arises out of the failure of the dominant public health research community to embrace complexity and to test and validate research and evaluation methods that are appropriate to situations with complex social dynamics. Clinical and public health sciences tend to privilege some forms of knowledge over others (Rychetnik, Hawe, Waters, Barratt, & Frommer, 2004; Trostle, Bronfman, & Langer, 1999; Walby, 2005). The desire for simplicity, particularly from donors who fund research and evaluation, has led to a stunting of creativity in relation to research methodology despite increasing recognition among social and scientific disciplines of the complex nature of social reality (Cilliers, 2008). This limited understanding of how to produce high-quality evidence for complex matters affecting public health has allowed evaluators and researchers as well as public health decisionmakers (politicians, donors, development agencies and health service managers) to embrace solutions based on inadequate social research because of the almost religious fervour attached to the belief in the findings of RCTs. That said, the evaluation field has a lot to offer the public health domain because of its development of both theory and practice on how to assess social interventions in complex environments, including identifying limitations of and alternatives to the RCT for evaluating social interventions (Patton, 2012). The evaluation field’s attention to mixedmethod designs that bring together both diverse disciplines and conceptual frameworks, as well as diverse research tools, has allowed the production of high-quality evidence on social change processes (Bamberger, Rugh, & Mabry, 2012). Indecent haste in introducing interventions based only on RCT findings This raises the final focus of my reflections, which is on the circumstances under which research findings are used to inform policy and action. Substantial research shows that research findings, no matter how strong, are not invariably taken up in policy or practice because the values, political positioning and practical constraints experienced by decision-makers frequently intervene (Loewenson, 2010; Sutton, 1999; Trostle et al., 1999). Yet the results of three randomised trials on male circumcision published in early 2007 (Karim, 2007) were followed within months by the announcement of funding by the US President’s Emergency Plan for AIDS Relief of male circumcision programmes for 10 African countries (Loewenson, 2010). The findings from the three medical male circumcision trials were implemented with indecent haste, particularly in a context where interventions that had shown much higher levels of efficacy – condom use and the prevention of mother-to-child transmission – were still not well implemented in countries with a high incidence of HIV. In January 2007, ostensibly as part of the process of consultation by decision-makers on how to act upon the findings of the trials, a UNAIDS/CAPRISA Consultation on Social Science Perspectives on Male Circumcision for HIV Prevention was held. Social scientists at the meeting issued many cautionary warnings about the lack of information regarding the emotional, psychological, relationship and social dynamics that the
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introduction of medical male circumcision might foster, none of which had been studied in any depth in the three trials that were providing the rationale for implementation. They noted the need for further research:
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Different epistemologies (ways of knowing) can complement each other: we can learn from both existing randomised controlled trials and operations research during implementation of male circumcision programmes for HIV prevention;
. anthropological/social studies using dynamic contextual analysis should be integrated into male circumcision for HIV prevention programming to monitor any unintended effects; . traditionally circumcising regions of the world can inform discussions about rationale, acceptability, programme design, communications, etc. . multidisciplinary social science research on male circumcision for HIV prevention, outside a controlled trial environment, should be a priority rather than being sidelined as taking too long. (United Nations & AIDS [UNAIDS]/Centre for the AIDS Programme of Research in South Africa [CAPRISA], 2007, p. 6) These and related issues were detailed in a number of papers used as background for the meeting and subsequently published (Dowsett & Couch, 2007; Sawires et al., 2007). Key questions regarding the impacts on individuals’ experiences of masculinity and on their assumptions about safety in the context of the findings, having shown only partial protection, were raised as were questions regarding the potential impacts of male circumcision on women’s understanding of sexual safety and on their negotiating power in sexual relationships with circumcised men. Yet despite the absence of evidence on these issues, funds were rapidly raised and services rolled out. In response to a rising chorus of concerns, the WHO and the UNAIDS held a consultation on the implications of medical male circumcision for women and, out of this, produced an insert to accompany their information materials on medical male circumcision that notes the need to focus attention on these issues and presents an additional research agenda, including research into potential harm to women (WHO/UNAIDS, 2007). Yet neither this agenda nor the broader issues pertaining to emotional, psychological and social impacts raised in the social science consultation have become the subject of a concerted research effort. They are not even the focus of evaluations as implementation rolls out. I have dwelt on this example because it aptly illustrates the dominant research paradigm – the search for the quick fix and the confidence of those with power and influence in public health in findings that are the result of RCTs, despite that they have failed miserably to assess the personal, interpersonal and social consequences of an intervention. In many contexts, being circumcised or not being circumcised has meanings in relation not only to men’s masculinity and sexuality but also in relation to their place in society – in some cases, in relation to their adulthood, and in other cases, in relation to their belonging to a particular ethnic or religious group. To intervene in that space without paying serious attention to an intervention’s impacts on these issues reflects a profound disregard for the people’s dignity, for the cultural specificity and for the complexity of society. While funds have been used for a technical intervention involving the penis – male circumcision – the public health establishment has not attended to the intervention’s impacts on sexuality, sexual relationships, sexual and gender power dynamics and the social meanings of sexuality. What sort of priorities does this reflect?
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And so, 20 years after the ICPD, scant attention is given to the sexual and social dimensions of sexual health and rights, however contradictory that may sound. Similarly, there is very little evidence to support community groups in shaping actions that profoundly shift individual and group norms and action towards a culture of respect, dignity and empowerment in relation to sexuality and reproduction. Such a shift would save the world millions of dollars in costs to the public health system that results from people’s inability to protect and promote their own, their partner’s and their children’s sexual and reproductive health and rights; this shift would also substantially improve people’s ability to live their lives in a context of dignity and respect, enjoying the benefits of sexual and reproductive well-being and perhaps, even, satisfaction. This was the vision of the ICPD. Acknowledgements I would like to thank the peer reviewer for invaluable advice.
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