Sexual and reproductive health and rights in France: Successes and challenges Annelle Despres On March 8th, 1956, is created “la Maternite heureuse” (= the happy Maternity) in a France where maternity begins to be heard as a political issue and where sexuality upsets the institutional frames of marriage and family, especially for young people. Sometimes reluctant (for example among minors’ access to contraception), the association still more or less relieves youth and women’s demands. In 1960, it becomes “le Mouvement Francais pour le Planning Familial” (MFPF = the French Movement for Family Planning), the main French association ever for sexual and reproductive health and rights. In 1956, they were 23 women; half a century later, MFPF groups together 20 regional federations and 69 departmental associations, while managing 30 “centres de planification et d’education familiale” (CPEF = centers for family planning and education). Its members hard fought and fight for women’s right to contraception and abortion. MFPF is definitely the core of the French feminist struggle for free disposal of women’s own bodies. Today, the State is also involved in family planning services. But some progresses are still to be done and MFPF remains organized to face the regular attempts to women’s rights. Centres de planification et d’education familiale Between 1961 and 1967, MFPF illegally opened the first centers for family planning, where information about birth control was provided, and sometimes even contraceptive means such as diaphragms, spermicidal gels or pills (coming from the US). Although it was forbidden by the law, that was an undeniable success. In 1967, a law authorizing the provision of contraceptives for major people on prescription is passed; and in 1974, minors also legally reach this right. Then, in 1972, the Government allows the creation of centers for family planning and information. Nowadays, there is at least one CPEF (commonly called “le Planning Familial”) in each department (there are 100 departments in France); most of them are now run by the local institutions (the Department and the Municipality) and hospitals, but some still depend on MFPF (as seen previously). How does it work? These centers provide professional advice from gynecologists or counselors concerning sexuality, contraception, abortion or IST. All the most intimate topics may be reached without problems. To fill everyone’s needs, they welcome women during the day but also put in place help lines (some of them being free). Recently, some CPEF have also introduced Messenger- permanence. For example, in the department of Marseille, each Wednesday, from 2 pm to 5 pm, it’s possible to ask for “instantaneous information” through Windows Live Messenger. The success of these CPEF rests on the fact that professionals don’t only provide gynecological consultation but are also really socially involved. That is to say that doctors and counselors don’t “do the job and leave”, they are here to help women to be able to decide on their own in the matters of sexuality or contraception. They do take time to explain issues and solutions. Concretely, in centers for family planning, one can receive free information, free condoms, and free emergency contraception without prescription. Doctors are also allowed to prescribe contraceptive pill and to offer pre-abortion consultation (one of the two compulsory consultations in case of abortion). Finally, these centers now can perform HIV and other IST- tests. The case of minors CPEF are particularly useful for minors. Because teenagers also have right to privacy and to health, they are provided all these services above for free and anonymously. No money is asked, neither any paper. A minor can use regular contraceptives freely and without having to tell it to anyone. That was a real progress for teenagers to be able to decide about their sexual and reproductive life on their own, without fearing any adult pressure. As far as majors are concerned, they do have to pay for such services, but the “Securite Sociale” (the healthcare institution) gives them money back (more or less, depending on the services). Nevertheless, it is worth noticing that major people who don’t benefit from Securite Sociale (for example foreigners without any French paper) are not asked to pay for anything neither. Actually, minors’ rights to privacy and health have to be respected in every part of the sexual and reproductive health system. So, for example, when a minor girl is asking for emergency contraceptive in a pharmacy, she HAS to benefit from it without paying and without being compelled to say who she is. It also supposes that she doesn’t have to prove her age (because in that case she would be obliged to show her ID). The law precises that the pharmacist, in this case of a minor, has to lead an interview with her to know if her situation corresponds to emergency criteria and has to give her information about regular contraceptives, IST prevention and CPEF. Furthermore, school midwives have to be able to furnish emergency contraception whenever needed. Minors’ rights have then consequently increased in the last years. And even the abortion system ensures the respect of secrecy. Abortion After le Manifeste des 343 Salopes (= Manifesto of the 343 bitches) 1, after the famous “proces de Bobigny”2 and a long battle led by MFPF and MLF3, abortion is finally decriminalized in 1975. Seven years later, the operation is told cost-free for women, the Securite Sociale ensuring refund. But at this time, in the 80’s and the beginning of the 90’s, anti-abortion groups are seriously virulent. They organize “anti-abortion commandos” (term given by media) that they are calling “operation rescue”, largely inspired by north-American “prolife” activists. The action consists in chaining themselves with handcuffs or locks in 1 This manifesto is published by Le Nouvel Observateur, on April 5, 1971, by the initiative of the MLF. The text demands the legalization of abortion and is signed by 343 more or less famous women who claimed having had an abortion. Text available in French on: http://tempsreel.nouvelobs.com/actualites/societe/20071127.OBS7018/le_manifeste_des_343_salopes_paru_dan s_le_nouvel_obs_en.html 2 In october and november 1972 took place the Bobigny trial, led by the feminist lawyer Gisele Halimi. It concerned a young girl, Marie-Claire C., 16 years old, who fell into pregnancy after rape. Her mother, raising her three children alone with a few money, and three friends of hers, helped Marie-Claire C. to abort. But she suffered from complications and had to go to the hospital, where the mother had to pay a big amount of money. At the same time, the raper, arrested after a theft, denounced the girl, hoping that policemen would be more conciliatory with him. The police then went to Marie-Claire and her mother’s house, where the young girl confessed what she’s done. Their trial takes place; this is an open battle against the ban of abortion. The media get hold of the issue and a national debate is opened. Finally, the five accused are almost not condemned. And the story leads to the decriminalization of abortion. 3 Mouvement de Liberation des Femmes. This organization did an important job for women’s rights. It doesn’t exist anymore. surgical units where abortions take place, to prevent the operation. However, in 1993, a law is created to penalize the hindrance to abortion. And in 1994, four “commando participants” are for the first time sentenced to 3 months’ imprisonment (+ 15 months of suspended sentence). Moreover, in 1995, presidential elections occurred. Yet traditionally, the elected Head of State has the right to amnesty people. A debate is opened at this moment concerning commando members. Can they be amnestied or not? A socialist deputy then proposes an amendment to the amnesty law, excluding anti-abortion activists from this right. After passionate debates, the text is finally adopted by the National Assembly, which represented a clear political choice. Eventually, a law is voted in 2001, extending the right to abortion (the deadline is extended from 10 to 12 weeks; the hindrance to abortion is more strongly condemned). How does it work? Only the pregnant woman has the right to ask for abortion. Both surgical and medicinal abortions are allowed. The latter can be performed until the end of the 5th week only and can be done out of a hospital (the woman is having the medicines in a doctor office and can then go home). Though, abortion is not considered as a “usual” operation and psychological help must be proposed to each woman, before and after the intervention. However, if a psycho- social discussion with a familial counselor was compulsory before 2001, it’s not true anymore, except for minors. The right to confidentiality A minor woman, if pregnant, is ALSO the only one to have the right to ask for abortion. Her parents’ refusal can’t be a reason to cancel the operation if she still wants it. And if she doesn’t want to tell her parents (or legal guardian), she doesn’t have to neither. But though, she must be accompanied in her move by a major person, whoever she wants (friends, family, social educators, health professionals …), to guarantee that she’s not alone and that she can talk to someone if she feels such a need. Also, the doctors and especially the counselor she meets have to try to convince her to tell her parents. If she keeps refusing, they have to help her choosing the accompanying person. Furthermore, if the Securite Sociale ensures the costs of the abortion for major people, how does it work for minors who are still under the responsibility of their parents? If those ones know that she’s getting an abortion, there is obviously no problem, and if they don’t know, absolutely NO fees can be asked to the girl concerned for medical or psychological consultation and for the operation in itself. It’s free, entirely free. Then, it can also happen that a major woman wants to hide the abortion to the people close to her. In this case, there are some hospitals which exempt patients from paying in advance. It means that one doesn’t have to pay and to be given the money back after, the Securite Sociale directly pays the hospital, guaranteeing anonymity. Sometimes, abortion out of hospital doesn’t allow this procedure, but the different papers and the reimbursement are done in a specific way which permits to keep secrecy among the family circle. All these adjustments to ensure confidentiality AND free access have been established to prevent pregnant women having unsafe abortion out of the healthcare system. It is the only way to allow women to get free disposal of their own bodies, without fearing pressure of parents, husband or friends. After having undergone the abortion, women are compelled to use contraceptives. Contraception In 1920, a law is created to ban all means of contraception. As said previously, this is repealed in 1967, with a law authorizing contraception for majors only. Then, in 1974, the contraceptive pill becomes accessible for minors in centers for family planning and education, freely and anonymously. Actually, many contraceptives are now allowed in France 4. But though, only the contraceptive implant is entirely cost-free, i.e. reimbursed by Securite Sociale. However, the most spread mean of contraception is the pill, well-known and which offers the possibility to stop the treatment whenever wanted. Some pills are free, some are not. In fact, French women seem to be still reluctant among “new” contraceptives, such as the implant, which is not very known. Even young women fear that it might cause problems yet not foreseen by the doctors. There is still an obvious lack of information about contraception. Also, for example, according to an enquiry led by INSEP5, 22% of French people think that the pill may make the women infertile. That is why French feminist associations fight for extending information about contraceptives and for the entire free access to all contraceptives. Sterilization has also been recently admitted. In 1996, an enquiry showed that 30 to 40,000 sterilizations were illegally practiced per year6. In 1999 then, a law first authorized therapeutic sterilization. And sterilization as contraception is finally allowed for both men and women in 2001, which is quite late. But that’s not often used though. And most of the time, the one submitting sterilization is the woman. Actually, there is a true lack of knowledge concerning this practice. The particular case of conscience clause The French law allows doctors not to practice abortion or contraceptive sterilization if it appears contrary to their ethics. Mainly, that are the catholic doctors who are concerned by this exception to women’s rights. However, if one refuses to practice abortion or sterilization, he/she HAS the duty to inform about another possibility to get the operation (i.e. guiding towards a doctor or a hospital where the intervention will be possible). It is worth noticing that pharmacists can’t use the conscience clause. The insertion of emergency contraceptive, sold in pharmacies, raised this question. But finally, in 1998, jurisprudence stipulated that ethical reasons could not be a sufficient ground not to deliver emergency contraceptive. Only the two cases of abortion and sterilization authorize the conscience clause. It means that a doctor can’t refuse to provide for contraceptives because of his/her religion or morals. But though, it happens. And for example, when the only doctor available in a mountain village refuses to deliver the pill to a woman, her only solution is to drive to the next village. It perhaps doesn’t appear as so grave but going somewhere else at least demands time and oil, 4 The government texts count 12 contraceptives: coil, pill, patch, implant, feminine condom, masculine condom, ring, diaphragm, cervical cap but also feminine and masculine sterilization and emergency contraceptive. Condoms and morning-after pills don’t demand medical prescription, all of the others do. And all the contraceptives which don’t suppose an operation are sold in pharmacies, except of the diaphragm, issued in CPEF. 5 Institut National des Sports et de l’Education Physique : http://sante- medecine.commentcamarche.net/contents/contraception/00_etat_des_lieux_statistiques.php3 6 Data found on ANCIC’s website (ANCIC is one of the most famous association for reproductive rights In France): http://www.ancic.asso.fr/etatactueldelalegislation.php although women shouldn’t be compelled in any case to support the economic price of contraception. Sexual education Sexual education has been the topic of many debates in France. The MFPF soon claimed for a need to educate young people, as far as sexuality was concerned. But they were not heard. However, the 70’s brought new considerations about sexuality, contraception and even abortion. The “may 68” movements carried a sincere will of consideration from youth. And these events are seen as a breaking point with traditional views of family, sexuality and love. They are the symbolic beginning of “morals’ liberation”. Trying to be in conformity with social evolutions, the National Assembly adopted guidelines concerning sexual education, asking school headmasters to organize lessons in colleges. But the practical realization of the law was hard. Many parents and teachers meetings took place but it seemed too difficult to agree on what parents should do on one part and what would be the school’s task on the other part. Nonetheless, the emergence of AIDS in the 80’s reopened the debate. A sexual education resting on a partnership of health professionals, social educators, teachers and familial circle became considered as definitely necessary. In 1998, a law made it compulsory for schools to organize informative lessons about AIDS prevention and sexual education for 14 and 15 years-old pupils7. Then, because it was not enough, another law has been adopted in August 2004, which stipulates that: “Information and education about sexuality are given in primary, secondary and high schools. Three sessions must be organized per year and homogeneous age groups. These sessions could associate health professionals and other external relevant stakeholders. Some pupils trained by an organism depending on the Ministry of Health could also be involved”8. Nevertheless, no official text precises what is to be taught, then it entirely depends on the open-mindedness of the teacher and the persons he/she invites to intervene. Yet, as before, the real practice of the law is not as ambitious as theoretically. Primary schools As far as primary schools are concerned, almost none of them does organize sexual education. Indeed, school teachers fear that they might be accused of immoral behaviour with children and consequently fired from their work. In fact, many people are shocked by this idea of giving sexual education to little children and wrongfully think that it would conduce to younger and younger intercourse. School headmasters, whose priorities are most of the time avoiding troubles with families, don’t insist to put in place such lessons. Nevertheless, in the town of Lyon, successful operations concerning sexual education in primary schools have been led. An association called “Education a la vie” (= education to life) intervenes among 1,700 children (in 28 schools) at three periods of a child life: at 5 years old9 (the end of the oedipal phase), 8 years old10 (latency period) and 10 years old11 (a rupture period, 7 In what are called in France “the 4th” and “the 3rd” class years (= 2nd and 3rd classes in polish gymnasium) 8 This translation is not an official one. To see the original French text, please see on the official website: http://www.legifrance.gouv.fr/affichCodeArticle.do?cidTexte=LEGITEXT000006071191&idArticle=LEGIART I000006524776&dateTexte=&categorieLien=cid 9 In the class of « grande section » (= Kindergarten) 10 In the class of CE2 (= the 2nd class in Poland) 11 In the class of CM2 (= the 4th class in Poland) approaching puberty). Of course, they try to adapt their speeches and their methods of work to the age of the children concerned. They can use fairytales, debates, role games, videos. According to the responsible for education to health in The Division for Prevention among Children of the municipality of Lyon, Marie-Françoise Sommer-Peytavin, « [they] approach sexuality in its large meaning : [they] talk about body, feelings, respect and listening. But the stress remains put on prevention. The aim is to recognize and to be able to express what is pleasant or not, what is allowed or forbidden, to be warned of the different forms of sexual exploitation »12. Moreover, this association organizes meetings with the parents to reassure them, to allow them to share their experiences as parents, to help them talking with their children about sexuality. Apparently, this initiative gets a larger and larger success and everyone seems to get something out of it (children, educators, teachers and parents). It seems really important to intervene about sexual education from primary school even it may appear quite early. Actually, some people assume that the sooner it is, the better it is. Indeed, sexuality is mainly approached with adolescents. The problem is that it is exactly the moment when they feel directly concerned and aimed at. They may feel too embarassed or pressured.On the contrary, children can take more distance to a speech about sexuality and can integrate more easily what « safe sex » is. If they are permitted to grow up with concepts of gender relationships and equality, of homo/trans/hetero/bisexuality, of IST risks, then they will be more prepared for safe and wanted sexuality in the future. Unfortunately, sexual education still concerns very few primary schools. But we can hope that this practice will extend. Meanwhile there are many comics for children talking about sexuality very easily, often with crude language which precisely avoids taboos about this subject. Secondary and high schools As far as secondary and high schools are concerned, there are more interventions about sexual education, but still consequently less than foreseen by the law. Most of the schools organize one lecture per year, not more, some of them even none. These interventions are made by external stakeholders, who are often young and who organize the lesson as they want. Most of the time, it is based on the principle of questions-answers. It means that pupils write a question or more on a paper, anonymously, and then, each question is told loudly and a discussion is opened between teenagers and professionals. However, adolescents often feel uncomfortable and don’t dare to ask what they really want to. If it is right that young people have to be directly involved in sexual education, the problem is that it’s not easy for any adolescent to speak about his/her sexual life in front of his/her classmates. For example, if one asks a question about homosexual relations, he/she knows that others may lead an “investigation” to know who in the class is homosexual. Moreover, some professionals, following this will to make teenagers participate, directly questions the class, which puts pupils under stress. This way of doing doesn’t seem to be fully satisfying. Then, most of the time, the stakeholders finally lead the lesson as they want. It appears that the topics approached are mainly contraception (chiefly condoms, the regular pill and emergency contraceptives), abortion and IST. But we can be sorry about the fact that the called “sexual education” is still based on a biological and a heterosexual point of view. If issues concerning IST and contraception are approached in their biological meanings, these courses still don’t come up to social facts and interrogations, they don’t put into question the gendered behaviours and the consequences it may have on sexual and reproductive health and 12 These information come from a magazine website: http://www.vousnousils.fr/page.php?P=data/pour_vous/temoignages/en_pratique/&key=itm_20021122_113935_ education_sexuelle_au_primaire_l.txt rights. Moreover, issues of homosexuality and homophobia certainly begin to be considered at school (more and more LGBT organizations are allowed to intervene in scholar frames). However, it appears that homophobia is more studied than homosexuality. It means that if there is an education emphasizing on the social problem of homophobia (homosexuality seen in its “negative” aspect, how discriminated it is), which is already a good march, there is still a lack of “homosexual” education in its positive aspects, how happily and safely it could be lived. Transsexuality is still less approached. And then, even the current sexual education doesn’t seem to be fully efficient. Indeed, an INSEP enquiry showed that 1 young between 16 and 25 years old out of 10 thinks that the pill does protect from IST13. It is then clear that efforts have to be done to organize complete sexual education, paying attention to all aspects of a sexual life, emphasizing on undoing all the presuppositions about gender roles and “normal” sexuality, and respecting young people privacy. Even if the initiatives of the sexual educators are worth welcoming, there are still improvements to be done. Current challenges Since the 60’s, the French law allows a larger and larger access to sexual and reproductive health and rights for women. Consequent progresses have been done, concerning abortion, contraception and sexual education. Also, the will to respect young people privacy and dignity is real. Nevertheless, we have to bear in mind that these advances are constantly put into question. Anti-abortion movements The number of Catholics “pro-life” (how they call themselves) is not decreasing. Even if their actions are less violent and less visible, they still do organize demonstrations and some of them have built strong relationships with extreme right-wing political parties who bring consequent funds. Moreover, a new movement has been recently created, whose name is “Les Survivants”14 (=the Survivors) and who appears quite dangerous because it rests more on “modern” views than on catholic traditional moral. This association indeed clearly differs from other anti-abortion groups in many forms. Firstly, they claim not to have any linkage with religion and politics. Then, its members are exclusively young (born after 1975). Thirdly, their methods of action consist in doing pacific, “funny” and “colorful” protests, and organizing parties. Finally, their demonstration against abortion doesn’t rest on catholic conceptions but assumes that it is such a shame that many “babies” are not born on account of abortion, because if they were here, they would have been more to party together and it would have been more fun. This association cannot be said really influential. However, we can see that since its decriminalization, there has always been an “anti-abortion side”, more or less virulent, more or less influential. And the right of abortion is not as established as we could wish. Legislation Furthermore, the defenders of reproductive and sexual health and rights claim for a clearer writing of the law. Indeed, it may sometimes be interpreted in an anti-abortion point of view. 13 Institut National des Sports et de l’Education Physique : http://sante- medecine.commentcamarche.net/contents/contraception/00_etat_des_lieux_statistiques.php3 14 http://www.survivants.com/index.php3 For example, in February 2008, the Superior Judicial Court (Cour de cassation) recognized the possibility for fetus dead before 22 weeks of amenorrhea to be registered on the Registry Office, allowing parents to give her/him a name, to organize funeral and to benefit from some rights. But this recognition may lead to legally consider an abortion as a murder. That’s why feminists fully disagreed on this conclusion. Doctors’ power on women’s bodies Eventually, the number of gynecologists cruelly decreased. Less and less medicine students choose this speciality. And less and less doctors agree to practice abortion which remains bad- paid and bad considered within the medical field. In work-periods, there is already a lack of staff, and it’s worst in summer, when doctors are leaving for holidays: hospitals and clinics systematically don’t succeed to fulfill the needs of women who want to abort. And many see their appointments delayed. Yet, when a woman has taken the decision to abort, it is very difficult for her to wait. Furthermore, women constantly depend on the good will of doctors. The website of “avortement-IVG: pour le droit au libre choix” (= Abortion: for the right to decide freely) publishes testimonies of women. One of them explains that her abortion occurred when the fetus was 10 weeks, although she had decided to abort when it was 1 week. First, she went to see a gynecologist who didn’t answer when she asked for an abortion as soon as possible. 2 weeks later, during the 2nd appointment, the same gynecologist told her “congratulations, your baby is going very well!”. She was afraid to tell him again that she didn’t want to keep it. And when she did, he explained that he disagreed on giving medical contraceptive to women but that he could call a clinic where this could be practiced. He also missed to propose her psychological help. Finally, she went to the clinic but caught by panic, she went away just before the intervention. She then called her gynecologist to have the number of centers for pregnant women, what he did while telling her that he would soon leave for holidays but that someone would replace him. Unfortunately, the two phone numbers he gave were not available anymore. The woman was on total panic, she didn’t have anyone to talk. Nobody understood her and she was ashamed of her will to have an abortion. Finally, after having thought again, she decided to get the abortion for sure and called back the gynecologist. But it turned out that no one was replacing the one gone in holidays. Though, she had to find a practitioner as soon as possible. She called several hospitals where she was always answered the same things: “no place anymore”, “you should have thought before!”, “the doctor is on holidays”, “I can find a place available in a month”… Finally, that’s her familial doctor who found her a place in a hospital where she could undergo the abortion15. This fact to be dependent on doctors’ will and availabilities is unbearable. Also, as long as the abortion will be considered as shameful, dirty and taboo, as long as women will be made guilty for not wanting a baby, as long as they won’t be allowed to live abortion in good physical and psychological conditions, then this right would be endangered and the free disposal of women’s own bodies a myth. That’s why feminist associations as MFPF keep vigilant to ensure that rights acquired with difficulties remain rights, fight to make abortion recognized as a positive right to life, health and dignity and not as a shameful right to be hidden, and fight to make abortion the decision of the woman, not of her doctor. Thus, although there is still some resistance on the way towards women’s access to reproductive and sexual rights and health, we can notice a constant progress since the 15 Testimony available in french on http://www.svss-uspda.ch/fr/temoignages_opinions/andree.htm 60’s, especially thanks to feminist organizations which hard fought and fight to gather women and make their voices heard.