How did you get into sexual and reproductive health and rights (SRHR)?

I joined FPA India as a Jr. Medical Officer in one of the clinics serving women from slums and marginalized groups. I was a young, newly graduated doctor, who was looking for some experience, before starting my own practice. I had done residency in Surgical Stream and wanted to gain practical experience in family planning (FP) and maternal & child health (MCH). FPA India, provided me an opportunity to understand the public health and rights based perspective that was lacking during my medical education. Once, I was conscious of these issues, I was hooked. Then came the watershed moment of ICPD in 1994.  That’s where I got hooked in interpretation of rights in a service delivery context, planning strategies to expand the FPA India’s existing FP-MCH service mix into a broader SRH service delivery mix. My role changed from a medical provider to more planning, capacity building and supervisory role. After that, there was no looking back.

What was it like growing up in India when it came to SRHR?

I grew up in Mumbai city in a middle income family. My parents were teachers. My mom was a teacher and father was a professor and education was the most important thing in our life.

TV was not so popular in those days, but we saw a lot of films. It was a very common pastime to watch a movie. While I was growing up, almost all Hindi movies depicted romance between couples and that was a major source of information to us. There was no access to any SRHR related discussion in a formal manner. These were taboo topics. Very few books also provided information. It was not part of school teaching, I didn’t have any specific books or even any friends who knew about sex and sexuality.

It was only in my teens, I read a book that narrated sex between a couple. I still didn’t understand much after reading though I felt embarrassed and excited and I told my mom. She was speechless and just kept quiet. Love marriage was considered a very 'forward' behaviour, so was hanging out with boys. But when I started my medical college, the atmosphere was much relaxed there. Hanging out with boys was okay and I made many friends, with whom the friendship continues to this date. 

How open were your parents and society more generally about SRHR?

I didn’t have any understanding of SRHR during my childhood. Even then, I can say that I had a happy childhood. Although, I did sense that there was something forbidden that happens between male and female, I wasn’t sure what.

I also had a vague thought that it can only happen when you grow up. I absolutely didn’t have a clue about sex or rights or any such concept. I remember that my mom was very strict with us and didn’t allow sleepovers or overnight outings neither to me or my sisters or to my brother. She really was very careful, she would patiently explain that something wrong can happen to us and in her own way she explained the concept of good touch and bad touch. We were embarrassed and so was she. I remain thankful for that lesson and her protection. She also told me about menstruation. Not in detail but she told me that it was important to be careful, use pads and keep clean. Later, it was during a session conducted at school, I understood about the physiology and how it happened.

My father never put any restrictions on us and expected us to excel in education. He was in denial that we were girls and he would get upset if we did girly things like makeup etc. We were brought up to think that natural is normal and wearing make-up is cheap behaviour. I don’t remember hearing the word ‘sex’ or ‘sexuality’ or reproductive rights etc while growing up.

What taboos were there?

Discussing sex or sexuality was a big taboo. When I was eight or nine, I remember asking my gran ma about how children were born or came in to the world and she was livid. She said that I was a bad girl for asking such a question. In my teens, talking with boys was frowned upon, not so much by my parents but society. Sex before marriage was totally taboo. An unmarried girl getting pregnant was the worst scenario. Asking for information on sex was taboo. It was considered being slutty.

How did you and your friends find out about SRHR?

I read a book where it was described. Incidentally, it was a mills and boon romance. Around the same time, my friend was told about sex by her married cousin sister. She was our major source of information. We had many questions which she narrated to her cousin and we got some replies. It was a lot of fun ( I think now). At that time, it was just so much cloak and dagger stuff and we were so full of dread, excitement, fervour, embarrassment and curiosity off course.

What inspired or motivated you to get involved with SRHR?

This is from 1991. I was 25 years old. I had just started working in FPA India as the Medical Officer. One day, towards the closing time, this lady with a small baby in her arms for immunization. It wasn’t our regular day for immunization, the clinic was almost empty. We were just finishing paperwork and winding down. I remember the OPD nurse coming with a bit irritation and telling me that now that we have completed giving her child immunization dose, she wants to see you. I was met the lady. She asked me for a contraceptive method, specifically an IUD and wanted it immediately inserted. It was the right time, she had come on the fifth day of her menstrual period, which was the right time to insert, as per the practice in those days. After examining her, I realised that we could not insert an IUD as she had uterine prolapse. We discussed possibility of another contraceptive option.   

She already had six living children, two miscarriages and she didn’t want any more pregnancies. Her husband would not use a method and she could not talk to him about her problem. She was sure that she would die, if she had another pregnancy. I was helpless and I felt horrible. I failed that day as a doctor. I realized so many things that day. I had  treated and seen too many dowry deaths during my surgical residency. I did understand the gender inequality but this was the incidence that opened my eyes about women’s vulnerability and marginalization in context of SRHR. Women bear the consequences of having a uterus and are at a higher risk of death and disability. Yet, they don’t have choices and they can’t take decisions. She set me on this path.

 

When it comes to SRHR what does India need to focus on?

Gender equality and equity is a fundamental issue that India must prioritize. Then only, SRHR can be realised and policies and programme can become successful. India is a country of young people. That is the biggest cohort of people at this time in history. Within this group of young people, adolescent and young girls are the most marginalized group. The face of poverty in India is a young girl. Girls have fewer choices, options and opportunity. The gap between boys and girls in terms of access to SRH services and information is huge. Thus, we need to focus on young people, particularly young girls. Literacy rate remain low (females’ age 15-49 year in 2015-16 are total 68.4% and among the total urban literacy rate is 81.4% and rural literacy rate is 61.5%(Ref: NFHS-4) Education, Health and empowerment are the three priorities for young girls.

To what degree is CSE taught in schools?

The Adolescent Education Programme is a basic curriculum with very limited information. The newer initiative, Rashtriya Kishor Swasthya Karyakram ( RKSK, meaning national youth health programme) has a broad curriculum but it does not cover some modules like pleasure. In most schools, this is topic that is not taught. Teachers feel embarrassed and they avoid this topic. In many states, sexuality education is banned. Only 15 % young people (male and female learners, aged 15-24) have received sexuality education in India. Thus, provision of CSE and advocacy to ensure access is a priority.

What taboos still remain?

Sex and sexuality are still taboo topics. Access to SRH information and services for unmarried adolescent is another big taboo. Being sexually active is a taboo.

How have the issues around SRHR changed?

Now, due to technology is a universal access to all sort of information. This is not validated or there are very few opportunity to ask questions and /or have a discussion. Many young people access pornography as an alternative to sexuality education. Also, there is a lot of change in social norms and relationships. As the age of puberty attainment is getting younger ( 9-11 years for girls and 11-12 for boys), the average age at first sex is also declining, incidence of premarital sex is on the rise. As the public health care is improving for FP MCH, there is still a large unmet need for SRH services for young people.

How significant is the issue of opposition in India?

There is no significant organized opposition in India. However, there has been issue based opposition to Injectables from women’s organizations for over two decades. Now that has died down as DMPA Injectables have been included in the Govt. programme. There is no specific religious or ideological opposition for safe abortions. Yet, there is a restrictive movement for safe abortions from groups working on gender, due to declining sex ratio. In order to improve sex ratio, inadvertently groups have rationalised that restricting abortions would balance the sex ratio. This, off course is a flawed thinking. But, on the ground, strategies to balance gender ratio have resulted in restricting access to safe abortions.

How do you believe you can build a movement to change that

We are already working to create evidence, share case studies and work with partners through networks to change this perception. We are also working with policy makers and decision makers to ensure that safe abortion services remain accessible to all. Strategies to restrict sex selection do not impact safe abortions on the ground.

What change needs to happen?

The Amendments to the Medical termination of Pregnancy Act are being debated at the Parliament. We expect that the amendments would be enabling and empowering. There is need to work at the community level to change the gender norms and change the concept of son preference that drives sex selection. Most of this is being done through multiple government policies and sensitized programmes. But, it needs to be upscaled.

Aspirations of young people need to be the driving force changing mindsets and bring about gender empowerment.

How hard is it to bring change?

Change is constant yet it is difficult in context of socio-cultural norms. We see change in embracing the technology. Change is easier with young people. However, gender norms and stigma around sexual and reproductive health is difficult to change in short term. Also, gender based violence is another difficult area where changes are not easy to bring. Change happens through years, often in next generation of young people. Behaviours can change easily but attitudes take time. Yet, consistent and strategic engagement with people and communities does help in bringing change. Otherwise, there is no hope for progress and development.

What are your biggest areas of concern?

Women’s safety and well being is still not guaranteed in this day and age. Women still remain tied to their biology. It is said that ‘biology enables, culture binds’. All the medical and technical advances around the world still can not enable a women to make their own reproductive and sexual choices. Women remain shackled to their biology of becoming pregnant and delivering children. Any deviation from this societal expectation is stigmatized. That women are unable to enjoy scientific advances helping them to make SRH choices is one of my biggest concerns.

Second concern is Sustainability of not-for profit work is the other big concern I have. Interventions and services aimed at most poor are not self-sustaining. When services and commodities are at cost, the profile of people accessing them changes. I feel, that at scale, interventions for the most vulnerable and marginalized people would need to be supported. Existence of Non-profit movements depends largely on funding support. The funding support often drives the design and direction of the intervention. I feel that the role of developmental agencies is becoming more and more dependent. Innovation, design freedom and individuality of working with communities to find solutions is becoming challenging.

What do you think the biggest successes have been?

The biggest success has been legislative and programmatic priority towards women’s health. Even when the scope of these laws and policies remains a bit limited, it helps women to access education, health, livelihoods. This leads to multiple wins. Prioritizing adolescent girls and their health is another important win.

What are you doing to celebrate International Women's Day this year?

I will be attending a meeting as a speaker at young women’s institute. I would be speaking with them about empowerment and journeys women take to realize their rights.