Entre Nous: the European magazine for sexual and reproductive health: no. 24: fatherhood in jeopardy: Cairo International Conference on Population and Development

• ENTRENous UNFPA The European Family Planning Magazine No. 24/0ctober 1993 Fatherhood in ie ENTRE Nous Sexuality and Family Planning Unit WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen 0 Denmark Tel.: 391714 51or3917 14 26 Fax: 39 17 18 50 Coordinator Dr Daniel Pierotti Editor Dr Beth L. Pedersen Administrator Dominique Dalsgaard Translators KenevaKunz Yvon Prigent ISSN 1014-8485 ENTRE NOUS is funded by the United Nations Population Fund (UNFPA), New York, with the assistance of the World Health Organization's Regional Office for Europe, Copenhagen. It is produced and distributed three times a year in English and French by the Sexuality and Family Planning Unit of the WHO Regional Office for Europe. Present distribution figures stand at 3900 English, 1500 French, 2000 Spanish, 2000 Portuguese, 500 Hungarian. 2 ENTRE NOUS is produced in: Spanish by the Instituto de la Mujer, Ministerio de Asuntos Sociales, Alma- gro 36, 28010 Madrid, Spain Portuguese by the General Directorate for Health, Alameda Afonso Henriques 45, P-1056 Lisbon, Portugal Hungarian by the Department of Ob- stetrics and Gynaecology, University Medical School ofDebrecen, P.O. Box 37, Debrecen, Hungary The Spanish and Portuguese issues are distributed through UNFPA repres- entatives and WHO Regional Offices to Portuguese-speaking countries in Africa and South America. Material from ENTRE NOUS may be freely translated into any national lang- uage and reprinted in journals, magazines and newspapers, provided due acknowl- edgment is made to ENTRE NOUS, UNFPA and the WHO Regional Office for Europe. Articles appearing in ENTRE NOUS do not necessarily reflect the views of UNFPA or WHO. Please address en- quiries to the authors of signed articles. For information on WHO-supported activities and WHO documents, contact the Sexuality and Family Planning Unit at the address given above. Please order WHO publications direct from the WHO sales agent in each coun- try or from Distribution and Sales, WHO, 1211 Geneva 27, Switzerland. MEMBERS OF THE EDITORIAL BOARD Dr AyseAkin Deputy Director-General Department of Maternal and Child Health and Family Planning Ministry of Health, Ankara, Turkey Dr Maria da Purificaaao Araujo Division of Maternal Health and Family Planning General Directorate for Health Lisbon, Portugal Dr Istvan Batar Head, Family Planning Centre University Medical School of Debrecen Hungary Dr Chantal Blayo Director of Research Institut National d'Etudes Demographiques Paris, France Professor Henry P. David Director ..., Transoo.tional Family Research Institute Bethesda, USA Dr France Donnay Gynecologist-Obstetrician Free lance consultant Brussels, Belgium Dr Dominique Hausser Directeur, Section SIDA Institut universitaire de medecine sociale et preventive Lausanne, Switzerland Professor Jerzy Z. Holzer Institute of Statistics and Demography Warsaw, Poland Dr Ellen Karro Chief Medical Officer Maternal Health and Family Planning Tallinn, Estonia Contents EDITORIALS Return to joint parental responsibility, by Daniel Pierotti ................................... 3 Guest Editorial: Fatherhood in crisis, by Evelyne Sullerot .............................. .4 FEATURES Fatherhood in jeopardy Cruelty to married men: myth or reality by Mara Nguyen .................................... 5 Extramarital paternity: fatherhood at risk, by M1111e-Therese Meulders-Klein 6 Substitute fathers, in rearranged families, by Frarn;oise Hurstel..: ............ 8 Family Planning in the Maghreb: Redefining Responsibility, by Alanna Armitage .... .. ...................... 10 Men and family planning in Portugal, by Ana Vicente .................................... 11 The AIDS era: new challenges and new roles for sexually active teenagers, by Pierre-Andre Michaud ... 12 Mr Thomas E. Kennedy Chief of International Affairs Danish Medical Association Copenhagen, Denmark Dr Evert Ketting Deputy Director of the Netherlands Institute of Social Sexological Research (NISSO) Utrecht, Netherlands Ms Susan F. Newcomer Statistician Center for Population Research Bethesda, USA Ms Mary Porter Head of Education and Training Family Planning Association London, United Kingdom Dr Andrej A. Popov Research Associate Center for Demography and Human Ecology, Russian Academy of Sciences Moscow, The Russian Federation Ms Hanne Risoer Chairman Danish Family Planning Association Hellerup, Denmark Mr John Rowley Editor, People & the Planet International Planned Parenthood Federation London, United Kingdom tj,r. Eitan Sabatello Director Division for Demography, Population Health and Immigrants Absorption The Central Bureau of Statistics Jerusalem, Israel Dutch boys on their role in prevention, by Paul Vennix, Evert Ketting and Petra Curfs ....................... 13 EUROPEAN NEWS The impact of voluntary induced abortions on fertility in Israel, by Eitan Sabatello ................................ 15 UNFPA FILE Statement by Dr Nafis Sadik ............... 16 RESOURCES The Portuguese Commission for Equality and Women's Rights ............. 18 Books ................................................... 18 Documents ... .... .. ........ ... ..... .................. 19 Magazines/Newsletters ........................ 20 Videos ...... ... .................... ..................... 20 Country Profiles ................................... 20 Cover Photo: Susanne Mertz=/Billedhuset ENTRE NOUS 24, October 1993 © World Health Organization 1993. All rights reserved. IN THIS ISSUE Return to joint parental responsibility by Daniel Pierotti At the limits of the frontiers of the former Soviet empire, along the Silk Route, in the smooth shadow of the ranges of Zeravshan, in the land of the mysterious Yeti, in the rich valleys of Leninabad, young women die every day in the arms of resigned gynaecologists. These women, stricken by serious medi- cal conditions preventing any child- bearing, are condemned to die by the obligation to reproduce. Their uterus·is still family property, their free will is nonexistent. They have to keep on giving birth year after year, until they reach menopause. Even more tragically, in Colmar in the heart of Europe, a child aged 15 years was savagely killed by her father, broth- ers and mother because of cultural trea- son. Too well integrated into her new country, whose customs she had en- dorsed, she wished to live like all the young girls of her age, and died as a result. These divergent occurrences seem to resurface from the extreme depths of past ages. Europe remains a privileged oasis, where women can flourish and express themselves with complete inde- pendence. The war in Bosnia, however, reminds us that we are not completely safe from the resurgence of the flames of barbarity. Through its political blunders an over- cautious Europe has covered itself with shame and failed to take the appropriate and generous measures which would be capable of responding to the violent situ- ations which are evolving at its very heart. We all live with a memory layered with the acquired experiences accumulated during the course of our lives. In spite of this, even our firmest assumptions are sometimes swept aside by the course of time which races on and threatens us. I will never be able to sufficiently thank my Catalan friends who, in 1992, with a mere routine invitation to a discussion on the role of males in family planning, caused me to dramatically rethink my views on the role of the European male in reproductive affairs . I have always given almost exclusive priority to contraceptive information ENTRE NOUS 24, October 1993 After fj.ve years as WHO/EURO Regional Adviser for Sexuality and Family Planning, and coordinator for Entre Nous, Dr Pierotti is moving to WHO headquarters in Geneva as Chief for Family Planning and Popu- lation in the Family Health Division. Entre Nous thanks him for his invaluable contribution in relaunching this successful magazine. In the next issue of Entre Nous, Dr Pierotti will summarize five years of experience in family planning in Europe. All of us congratulate him on his brilliant promotion and wish him all the best in his new exciting position. intended for young women, to the detri- ment of that intended for the boys, because it is the girls who give birth, abort, abandon their studies because of pregnancy, and die of it. My friend Dr. Maecha, who fifteen years ago reigned with an iron hand in the paradise Cormorien of Ylang Ylang with his outdated male chauvinism, expelled pregnant nursing students from his schools reminding them of his favour- ite saying, that they must learn to choose "between making out and making the grade". By this unfair and sexist deci- sion, the women were badly punished and their male partners acquitted. I never forgot. Even at the moment when her sensual- ity may have led her astray, a woman alone must protect herself from un- wanted pregnancies, and this may, in certain cases, be a question of individual survival or even of legitimate defence. In the course of preparing myself better for the conference in Barcelona I reviewed the last twenty years of work of the Sexuality and Family Planning Unit on the theme of the male and fami- ly planning in Europe. To my great sur- prise, the harvest was a very lean one, several seminars on the responsibility of the young man, one unassuming study of the changing role of males, and that was all. In fact the problem of the role of the male in Europe remains one of biblical simplicity, as with the exception of the rare immigrant families confronted by an insurmountable cultural shock and a few religious extremists, the paterfamili- as of old, so ponderous and omnipotent, has been toppled from his pedestal. ' The advent of modem methods of contraception delivered the first fatal blow to this inviolable fortress, abortion on demand caused its confidence to crumble; the divorce laws give women an advantage, and the situation regarding custody of children which almost univer- sally excludes the father have totally marginalized him. To be sure, there are ~ebels who tear themselves apart and tlestroy their family, organizations for the defence of the rights of the father have sprung up almost everywhere, and havens even exist for battered men. In vitro fertilization was the final blow. An article in Newsweek on June 21, 1993 on the city of Aspen, strong- hold of American lesbians, reported that more and more use is being made of this modem technology, reducing the male to the original sperm cell. Haven't we gone too far? Shouldn't we worry about the deviations of high- flying gynaecologists of the jet-set soci- ety relishing the thought of impregnating grandmothers with the semen of their sons-in-law? Money can do anything, and money kills everything. The history of mankind has always maintained human reproduction as a privileged and wondrous domain; man transcends himself and projects himself into immortality through his progeny. Good Lord, ladies! Let us. return to more simple practices, let us not go on with experiments and save a tiny bit of space in your hearts and your homes for those men so much loved and so much hated at the same time - it took you a long time to acquire your rightful ben- efits. Can we not pause here, and make the relations between men and women a little more equal in the context of the family, of its life together, and of joint parental responsibility? Dr D. Pierotti 3 FATHERHOOD IN JEOPARDY GUEST EDITORIAL strengthened by and in accordance with the raised level of education and the more extensive participation of women in society. They have thereby taken on to a greater and greater extent roles former- ly allotted to fathers alone - providing children with pocket money, meeting their teachers, deciding the course of the children's studies, etc. Fatherhood in Crisis by Evelyne Sullerot The year 1994 will be declared "International Year of the Family". Will we be able to seize the opportunity to bring about a serious diagnosis of the unprecedented ills from which the fami- ly is suffering, especially in western Europe? Will we be able to affirm our wish to find remedies for them? There are so many sociologists and politicians who, following the ideas and feelings of utopia of the 1970s, still refuse to consider how dangerous the breakdown of the nuclear family is for our society and especially for its most vulnerable members. On the contrary, they persist in viewing this breakdown as a liberation of individuals vis-a-vis institutions, a liberation of women vis-a.- vis men - and welcoming it. They have no wish to consider how the increase in family splits, which is accompanied today by a weakening of family solidar- ity, is going to increase the number of outcasts, thereby increasing the numbers of poor for whom the State must assume responsibility, just as they will have to accept the responsibility for the conse- quences of the educational disadvantage affecting the children of single parent households. Everyone has certainly realized the way in which the developments which first appeared in the Scandinavian coun- tries from 1965 onwards have swept southwards over Europe and reached the Iberian peninsula around the mid-1980s: withdrawal from or refusal of marriage, unions becoming increasingly fragile, a drop in the number of births, a steep increase in the number of couples with children who separate (both married and unmarried). These factors contribute to the breaking apart of family groups in ever greater numbers? But these devel- opments have only ever been analysed from the point of view of women, who henceforth became the mistresses of their own fertility thanks to effective con- traception and the availability of induced abortion; women who initiated actions for divorce or separation in proportions ranging from 67% to 76%, depending upon the country; women who were entrusted with custody of the children following a marriage breakdown in proportions ranging from 75% to 90%. Extremely little concern has been shown for the fathers, who are often replaced in their role towards the children by a mother's new partner. Scant attention has been paid to the reasons for the absence of the fathers or the conse- quences. 4 Patriarchy is dead in Europe and no one laments the fact. The family hier- archy in which the father is the supreme head and the sole provider is fast disap- pearing in Europe and no one regrets its passing. But the enormous increase in the number of children who are estranged from their fathers right from birth or during the course of their childhood is a very pi:essing problem. The more so as it haSi been accompanied by a revolt and suffering of the estranged fathers to which insufficient attention has been paid: in all the European countries, asso- ciations of divorced or separated fathers have been formed who proclaim that their right to act as fathers has been un- fairly limited, that they have been pushed into the background and excluded from their educational responsibilities, that their paternal love has been frustrated, that they have been reduced by court verdicts to the roles of mere providers of Conversely, fathers have been asked to fulfil more of the traditional maternal roles and to take part in the domestic duties and care of the children, even of babies. Although the interchangeability of roles is far from being a universal reality, one cannot deny that more and more young fathers are on an everyday basis more available, closer and more attentive to the needs of their children than their own fathers were. Yet society, paradoxically, seems to give them no thanks. Employers demand from them a greater professional commitment from the moment they become fathers. Social measures in their favour are nonexistent or merely pro forma. Judges in divorce courts have followed and even increased the tendency to award custody of a child to its mother in cases of separation, following the revisions of civil law which took place in all the countries of Europe in the 1970s. Even certain psychologists and paediatricians have lamented the disruption of the paternal and maternal roles which has resulted The number of children who are estranged from their fathers is a very pressing pro- blem. Photo Jens Olaf Lastheinc/2maj support. All of them complain of the little attention paid to the role of the biological father in the life of the child, in comparison to the tremendous impor- tance accorded to the biological mother. They witness a lamentable tendency to devalue paternity, which is gradually depriving the fathers of their respon- sibilities, making them feel unwanted, so that they gradually withdraw and disappear. Even in stable families, it is not easy for fathers to find their place. Naturally it was inevitable and only right that the role played by the mother towards the children should be expanded and from systematic separation. In conclu- sion, while some people blame fathers for not being "nurturing" enough, others refuse to recognize their duty or even right to do so. This juridical and psychological malaise has broken down or totally destroyed some fathers. But this is noth- ing as compared to the damage which the absence of tne father or separation from him threatens to inflict on the children, especially in the case of the boys. Children need a father throughout the course of their childhood and espe- cially at the time of their adolescence. Continue on page 5 ENTRE NOUS 24, October 1993 Continued from page 4 They need to know him, to see him often enough and for long enough to be able to come into conflict with him or to use him as a role model - or both. To form a sense of their own identity they need their biological father, who serves as an indispensable pattern to follow and who cannot be replaced in that role by even the best of substitutes. Of this, European society does not yet appear to be convinced, despite the growing evi- dence: the social ills, flights into drug addiction and growing delinquency of adolescents who are faced with a pater- nal deficiency, whether the father has deserted them or has been rejected by the mother. These cases are growing in number and will continue to multiply if our societies do not put a stop to the decline of fatherhood which has accompanied the unravelling of the family fabric over the past twenty years. An awakening is need- ed. This is happening in the countries which were affected first. In these countries efforts are being made to restore the ties of filial contact (between mother and child and father and child) which have for a long time been overshadowed by the sexual and emotional ties between the couple. We must remember that the child has only one father and one mother and should be loved and raised by them even though they have separated, or both remarried to new partners. They remain "the parental couple" of the child or children which they have had together. In separation we must keep these priorities in mind. Fam- ily mediation and counselling, which is spreading fast, can help the parents to build up the future of their separation while upholding their co-parental role. The laws on divorce should be amended both in letter and in practice, so that they implement firstly the Right of the Child, which is~o know both its parents and to be rai~ed by them as far as possible. Joint custody should thus be awarded more often and more imagination is call- ed for in the solutions proposed and Cruelty to married men: myth or reality In English (and many other languages) the word "man" can be used to mean both "male"and "human". It is not mere- ly a linguistic coincidence, but rather symbolic of a tradition which hearkens back to the Greco-Roman era where the male appeared as the most accomplished being, perfection itself, thus justifying his total domination of the female. The poor male at the end of this centu- ry has come a long way from those for- mer, very different concerns. Buffeted about and even knocked off his feet by the feminists, frustrated by discrimina- tory legislation, he is going through a severe moral identity crisis, from which he is having difficulty in emerging. Every child is born of a father and a mother. If the mother rejects the right of the father to be a father, the latter can only bow to her wishes or torture him- self by pursuing incredibly complex legal action, which will most often be in vain. Some males cannot bear their forced exit from the family and self- destruct, having lost their paradise. In Canada and Sweden, then in England and now in France, special reception centres have been created to take charge of these males, left out in the re-dealing of the social and family cards for a game in which they can no longer take part. Conjugal violence sometimes remains the only existing form of communica- tion, practised mainly against females, but most surprisingly sometimes against males. The Parisian association, "SOS Males and Private Violence", tries to ENTRE NOUS 24, October 1993 prevent this violence, contain it and treat it. This association was founded in 1986 and it'follows the course marked out by the principles of Canadian R. Philippe, who opened the first refuge for males ten years ago in his native Quebec. Basically the programme consists of listening, giving direction if necessary and ensuring a therapy especially adapt- ed to the problem, often in the form of lengthy psychoanalysis. The first step for a humiliated male is to take himself in hand, which takes the form of a tele- phone call of appeal followed by an ini- tial appointment. Those seeking help are received by a member of the associa- tion who listens carefully and support- ively to their complaints, offers legal counsel, and gives them direction if necessary. The men take part in an average of three listening sessions. At the end of the interviews, the association can form a diagnosis and define the personality type, on which any proposal for treat- ment is based. Certain cases are moving towards neuropsychiatric treatment, others are verging on the pathological under the influence of stressful situations, but all of them are suffering, tom asunder, and bewildered. Conjugal violence, like incest, has presumably always existed, but it was hidden and shameful, as it ran contrary to the virile image of the strong and controlled male, protector of his wife and children. Conjugal violence which occurred in private life was not enumer- ated in official statistics. FATHERHOOD IN JEOPARDY social assistance available, in ways that will consolidate the ties of the child to both of its parents. A woman should no longer be permit- ted to refuse to name the father of her child (which is still legal in numerous European countries), as in so doing she deprives the child of both father and all the paternal family: grandparents, cous- ins, uncles and aunts, etc. Biological proof of paternity is today both possible and definitive, and every man must face up to his responsibilities if he has placed himself in the situation of being a father. Ms Evelyne Sullerot Sociologue Conseiller Economique et Social Honoraire de la Republique Fran~aise 95, Bd Saint-Michel F-75005 Paris France Over the last twenty years, the advent of exultant and shameless media has allowed the lifting of all prohibitions, spreading over the television screens and newspaper pages the most intimate af- fairs of married life. Through this phe- ni menon of transference, conjugal vio- leace has moved out of the shadows and begun to be a factor which is steadily becoming better known. The work of the association "SOS Males and Private Violence" is set through planning sessions and from the informa- tion gathered with respect to the indiv- iduals and events in question. Specifical- ly concerning the aspect of prevention and treatment of violence, in a period of four years, the association received 859 telephone appeals from males, 310 of them coming from perpetrators of vio- lence, and 75 from its victims. This very limited and non-representa- tive statistic places conjugal violence in a more traditional perspective, where the male appears more often as the author of violence than its victim. It is no less true however, that even though they may appear as relatively isolated phenomena, males who are victims of marital cruelty and anguish do exist, they are sending out distress signals and need help and special support adapted to their individ- ual cases. Neither God nor father Such is the lot of modem man. Evicted from his conjugal paradise he is the motivator of family violence sometimes a victim, sometimes a tortur- er he can't get accusromed to playing a supporting role. Ms Mara Nguyen Journalist 5 FATHERHOOD IN JEOPARDY Extramarital paternity: fatherhood at risk by M.T. Meulders-Klein For almost the past three decades now the numbers of love affairs, cohabiting couples and other alternative forms of family life have been increasing, and by the same token, so have break-ups, sepa- rations and divorces. Under pressure from the sexual revolution, the institu- tion of marriage has become, we are told, seriously ill. It it is a natural conse- quence of demand for the freedom of the individual, for the right to personal fulfilment and for a private life, rather than to conjugal or social causes. Such are the buzz words of the new wave. The reality, however, is somewhat different. In actual fact, it is less the institution of marriage than the relationship of the couple themselves, wed or unwed, which has become so fragile that only the emo- tion of love remains as its foundation. If this sentiment dies, the relationship dies, and the break-up of a de facto household is no less painful, no less complicated than that of a marriage. Too few people know this, and will learn it too late ... Too many men are also ignorant of the risks of extramarital paternity and of their own legal status. There was a time when the man was king. Master of his wife and child, his power was almost monarchical. Every- one obeyed him. He could procreate with impunity. The entire burden rested on the woman. This time is now past. Since then science and justice have formed a curi- ous union which has reversed the roles. From now on it is the woman who is master. Master of conception and of fil- iation; especially extramaritally. With the help of contraception and contragestion, it is the woman who, from now on, has been accorded the right to decide the paternity or non-paternity of a man. Science and medical technology have provided her with the means to do so. The law has given her the right. But husbands have this right, too. It is quite another question, however, when it comes to establishing paternity, and to the consequences. Establishing extramarital paternity Here marriage retains certain advant- ages, because the legal paternity of a husband never depends upon the confirm- ation of the female. In every country the law presumes that the husband is, per se, father to the children of the wife to whom he is or was married at the time of conception or birth. At the risk of find- ing out the truth, he may contest this presumption of paternity if it is contrary to the truth. 6 For an extramarital couple, there is no such thing. In all cases paternity and maternity must be established separately. As far as maternity is concerned, the matter is generally simple. In the major- ity of European countries maternity is established by right by the fact of the birth alone or the reporting of the name of the mother on the certificate of birth, a report which is generally compulsory. In certain countries, however, such as Franc~, Luxembourg, Italy and Portugal, thi mother is allowed to declare the birth without giving her name. The child of an anonymous mother can never be traced by its father, even if he so desires. Since it is not based on legal presump- tion, extramarital paternity can only be established in two main ways: • by voluntary acknowledgement; • by a ruling which certifies the paternity. An indication of the reversal of trends: acknowledgement, which for- merly was left to the discretion of the father, is no longer done so today in a large number of countries where it is subject to the agreement of the mother and/or of the child from a certain age onwards. With the exception of France, neither desire nor biology is sufficient. A mother is always a mother. But a father is not always a "good enough" father. Should the mother refuse, it may be left to a tribunal to issue a ruling, but even this recourse is not always possible. Such is the case, in varying degrees, in the Netherlands, Belgium, Germany, Greece, Spain, Luxembourg, Portugal. In countries following Common Law (e.g. England, Ireland) the acknowledge- ment of paternity does not exist. It must be proved in court, by a civil suit of some sort, and it is never settled once and for all, except in the case of a judi- cial declaration of parenthood on the demand of the child only. As regards the registration of the name of a male as father on the birth certificate, a registra- tion which can only be made with the consent of the mother, it is not sufficient in itself to establish paternity. Furthermore, by agreeing to the acknowledgement of a child by a male other than the father with whom she was involved, the mother is able to choose the father she prefers and often effective- ly prevents the establishment of true paternity. The best interests of the moth- er and child are cited as reasons, in order that the new de facto or legal union established by the mother, should not be disturbed ... whatever the father's attach- ment to the child and the care and affection which he may have shown it before the break-up with the mother. Such is life. Conversely, where legal measures to investigate paternity directed against an unmarried father were previously sub- jected to very restrictive conditions, even totally prohibited (in France, Belgium, Germany, for example) or limited to demands for support for the infant without establishing a parental connec- tion, the new legislative trend, which is inspired by the principle of equal treat- ment for all children whatever the cir- cumstances of their birth, generally paves the way for actions instigated by the mother or the children themselves, generally represented by the mother in her capacity of the parental authority. All means of proof are now admitted, and time limits have been thrown wide open. Curiously enough, in countries such as Belgium or the Netherlands, it is even possible for a mother who has re- fused to agree to a father's acknowledge- ment of his child to legally claim sup- port from him and, again in Belgium, she can oppose legal action taken by the father to establish his paternity even if it is true, by claiming this would not be in the child's interest. Finally, mention must be made of cases of medically assisted conception. In countries which have not adopted legis- lation in this area, the situation is effec- tively such that a mother, whose cohab- 1. iting partner agreed to artificial insemi- nation using donor semen, can later refuse to agree to his acknowledgement of the child, or contest it as false acknowledgement. It is sufficient in this case to demonstrate nonpaternity bio- logically, and obtaining expert evidence of this will be easy. An unmarried father thus appears to be deprived, vulnerable and even discrimi- nated against in relation to the mother, if he lacks the meaningful link created by the matrimonial union of parents with regard to the children born to them. This is the first aspect of the fragility of extramarital paternity. But there are others which appear regarding filiation. The consequences of extramarital paternity Even supposing that paternity is actually established, this does not lead to the assumption that the father and mother will be on equal footing with regard to the exercise of their parental authority. Here inequality appears •to be the rule and equality the exception. Although the father and the mother are equal in their exercise of parental auth- ority during the marriage, at least if they are living together, should they not be married it is the mother who finds her- self the sole parental authority, even if the father is obliged to pay support for the child and even if he has voluntarily acknowledged him. Such is the case, to varying degrees and occasionally tempered by legal precedence, in France, Germany, the Netherlands, Greece, Portugal, England and Ireland. • ENTRE NOUS 24, October 1993 In certain countries, such as Germany, the joint exercise of parental authority in a de facto household is completely precluded by law and legal precedence. According to the Federal constitutional court, individual liberty implies the right not to marry, but it is the father who must bear the consequences and not the mother, because she is closer to the child who has need of her. In the Netherlands, guardianship of the infant automatically accrues to the moth- er and to her alone. The Hoge Raad has, however, admitted that the authority may be extrcised jointly by both parents, but on the assumption that a judge verify that certain conditions are fulfilled (both parents are in agreement, there is suffici- ent consensus regarding the raising of the child, that it is in the interest of the child, etc.). In Greece, parental authority is accord- ed in principle jointly to the father and the mother, if the latter has acknowl- edged the child. But the mother alone exercises it. The father can only obtain it if the parental care of the mother has ceased or if she is incapable of exercis- ing it. In any case, he can request that a tribunal confirm the exercise of his care, wholly or partly, along with the mother, if she consents to it. The tribunal bases· its decision on the interest of the child. In Portugal, when the double filiation of the child has been established by parents who are not married, the law makes provision for parental authority to be accorded to the parent who has in fact custody of the child, but then establishes a presumption according to which the mother has this guardianship. The father can only exercise his parental authority if he manages to reverse this presumpti- on or if he lives with the mother. In that case the law permits them to make a joint declaration before a public official affirming their common agreement - which presumes the accord of the mother. Generally speaking, a judicial decision is required for division of authority to be permitted, and in any case the agree- ment of the mother must be duly attest- ed. If this agreement is lacking, the father can only obtain parental authority by a judicial decision and if such is in the interest of the child. The same never applies to the mother. In contrast, Belgium, Spain and Italy seem to have provisions which discrimi- nate less between married and unmarried couples and accordingly between an unmarried mother and father. In these three countries, in fact, the rules that are followed ~epend basically on whether the parents live together or not. In the formet instance, joint exercise is com- pulsory. In the latter, the parent who actually has the custody of the child has the exclusive exercise of parental author- ity, unless there is a court decision to the contrary, with the other parent retain- i~g. visiting rights and the right of super- v1s10n. In France, the law of January 8, 1993 has taken a small step forward. From that date parental authority is to be com- monly exercised if the parents of a natu- ral child have both acknowledged it before it has reached the age of one year and live together at the time of declara- tion or'of the second declaration. Failing this, authority rests exclusively with the mother. Of course, in the case of a break-up, it is practically always the mother to FATHERHOOD IN JEOPARDY whom the child is entrusted. Finally, concerning the giving of a name, a child born extramaritally generally takes its mother's name. It only bears its father's name by virtue of a joint declaration of the parents or, in some countries, if paternity is establish- ed at the same time as maternity, which assumes a paternal acknowledgement from the same time as the declaration of birth, with the agreement of the mother if this is required, or a simultaneous acknowledgment by both parents. Thus, the situation of an unmarried father has become a rather strange one. If he does not want to accept his pater- nity, it is always possible to force him to do so. Which is only fair. But if he wishes to accept it, it is not certain that he will always be able to do so if the mother is opposed to it and prefers another man. And even if paternity has been established, he will not necessarily have the full rights of a father. Only marriage can assure him ofthis. No doubt less for reasons of morality than because of the fact that marriage implies a formal obligation for the future, whether or not things will, in fact, turn out that way. The child may also be better off. J},f s Marie-Therese Meulders-Klein ]frofessor Universite Catholique de Louvain, Director Centre de Droit de la Famille Place Montesquieu 2 B-1348 Louvain-la-Neuve Belgium For almost three decades the number of break-ups, separations and divorces has been increasing. Photo Klaus Holstingc/2maj ENTRE NOUS 24, October 1993 7 FATHERHOOD IN JEOPARDY Substitute fathers in rearranged families by Franc;oise Hurstel New family forms have become numeri- cally important in France, as in other parts of Europe, since 1970. Sociologists called them "broken families" and later, more positively, "rearranged families". They are the offspring of the growing divorce rate. In such families, where the mother has the custody of the child, a child can be in the situation of having more than one man assuming distinct paternal functions. In such a case the child only sees its legal father, who is usually also its "bio- logical father", at intervals. The child lives from day to day with its mother's partner, who thus assumes the function of "child raiser". What is the psychological situation of a child who recognizes such a man as a "father" ... that is to say forms emotional ties with him and accepts his authority? Under what circumstances can a man emotionally adopt the child of his part- ner and fulfil a role as father of that child? I will begin with a clinical case study to obtain answers to some aspects of these questions. Pierre, Christine, Anne and the others ... or to put into words the unspoken Pierre and Christine have been living together for five years. There are three children in their household, Fanny, Clau- dia and Anne. The first two were born to Pierre and Christine as a couple. Anne is Christine's daughter by a previous mar- riage. The couple lives in a commonlaw relationship. What position does Pierre, Christine's partner, hold for Anne? How do Pierre and Christine carry out their family rela- tionship, i.e. do they discuss with the children the bonds which exist between them? The case is simple from a sociological point of view: for Anne, the family net- work has been divided into a household of origin and the present household. From a psychological point of view, however, the case is a complex one: this is shown by Anne's history, as reflected in the accounts of different characters. First stage: Pierre is rejected by Anne Anne is very attached to her legal father, Yves, as although her mother Christine has custody of her, the child continues to see her father regularly (twice a week). She "is very fond of Pierre (her moth- er's partner)", she says. At the time of the interview Anne is ten years of age; she was five when Pierre came to live 8 with them. But she doesn't seem to remember exactly what happened at that time, which is surprising, as Christine (her mother) relates that, when Pierre came to live with them, Anne, who up until that time had always known him as a friend and "liked him very much", had rejected him harshly. "Each time she shouted at him, "Go away, I don't like you any more!" ... she demanqed the return of her father, who had been gone for more than a year ... she1 cried a great deal. And now she says she remembers nothing!" Second stage: Pierre begins to "make friends with" Anne: they accept each other as "members of a family" He talked to her. "One particular time I remember saying to myself, "I am going to talk to her". Anne was a very aggres- sive little girl. I told her that I had also suffered as she had, as I had also gone through a separation (his own divorce). I explained to her that Christine and Yves had separated because they had been unhappy together. And that for them it was the least painful solution. I told her Continue on page 9 New and different family forms have been numerically important since 1970. Photo Hakan Pienlowski~/2maj ENTRE NOUS 24, October 1993 To distinguish the legal father from the mother's pdrtner is an important step for the child. Photo WHO!l¢rgen Schytte0 Continued from page 8 that Christine and I loved each other and that now it was our tum to try and make a life together. I told her above all that I did not wish to take the place of her daddy." ~hat were they actually talking about, Pierre and Anne? About love and suffer- ing, of the possibilities and impossibil- ities of life together. Pierre recognized both Anne's and his own suffering, he put into words the unspeakable aspects of a situation not expected by a child and one she scarcely understood. Finally, he spoke to her of the position of each of them: that he, Pierre, would not usurp the place of Yves, Anne's father. "I am not your father." Such statements are of fundamental importance for a child, who recalls that her "father" and her "moth- er's husband" were one and the same man. Thus, for Anne, if Pierre becomes "like" her mother's husband he will assume, at the same time as he takes on this function, the role of Yves. He moves into the position of father. The distinc- tion which Pierre made, of knowing that he was Christine's partner, but that he was not Anne's father, served to calm part of the child's anguish. Because she could keep her father and her mother in their position as parents and still perhaps be able, now, to find room for Pierre. A child harbours another emotion with regard to the "family rearranging". Anne had spent more than a year alone with her mother: she has had her all to her - self. She feels jealousy, rivalry, abandon- ment: will he come to take my place? Anne has been obliged to make room between herself and her mother for the new partner. But on one condition: that the child's mother allow room for her partner to speak his mind. Third stage: the mother, Christine, talks to Anne She told Anne that she was not the only one who has been in this situation. That many children have their daddy in one ENTRE NOUS 24, October 1993 house and their mummy in another. Christine also had a very clever idea. She wrote on a scrap of paper the names of all Anne's friends who were in the same situation. "That night, Anne slept clutching the list in her hand." And it was after this discussion that she could begin to make peace with Pierre. Christi- ne had removed Anne's sense of guilt; she told her that she was not abnormal. She also told her that her name was writ- ten on a sheet of paper where other chil- dren c_ould also put their names. She had, in some way, symbolised Anne's situation. A novel sort of document in a parental relationship. Yes, but those who know the problem are the ones most likely to find a solution. Intangible words might not be sufficient for a five-year-old girl who was suffering and did not under- stand things; no doubt she needed the firm evidence, which the writing provided. Fourth stage: Anne speaks Today Anne does not long for the time when she was alone with her mother. When asked, she replied that she "would prefer Pierre to stay rather than to leave them." She whispers it, like a secret. "Does she feel there is much difference between her father and Pierre?" "Not much difference." "Can both of them scold you?" "Yes." Later she said of Pierre, "in any case it is he who is always saying silly things and telling jokes", indicating the playful side of their relationship, connected to the dimension of authority. Of her father she says, "I look forward to the day (when she sees him) very much." What is Anne saying? That both her father and Pierre exercise authority over her, she loves her father and misses him. She plays with Pierre. But both of them "can scold her". Both of them are fathers, but with different functions. FATHERHOOD IN JEOPARDY Discussion: The recognition of a father, a "psychological task" Why does Anne not remember the first episodes of her encounter with Pierre? ... Despite this, she shows no symptoms which would indicate a repressed dis- comfort. She is cheerful, sociable and happy; so why worry? Christine has never ceased to see Yves "for the good of the child" she says ... "It is strange, I feel almost anaesthetized, I never regard him as anything but Anne's father. I care for him as one who loves my child ... " What Christine intends by this is what, in France, since 1987 ("loi Malhuret"), has been written in the legal code: "the parental couple can have an existence distinct from that of the sexual couple." What Christine is saying, is the wish (painful, as can be heard in the term "anaesthetized") to achieve this disasso- ciation of what has hitherto gone togeth- er, legally, mentally and ideologically: that the parents of a child are not neces- s~ly those who form the sexual couple. Pierre has always exercised discretion and above all refrained "from playing the seducer". He found Anne's rejection "hard to take", but he "understood it". Not to "play the seducer", the words raise the question of incest. But incest is forbidden territory in this story. Because a father is not "a boyfriend". It is some- ~1,1-e who is placed at a different genera- ti?mal level from that of the child. The bond formed between them is the bond of filiation. To say what each individual's proper place is, what the family reality is, to distinguish the legal father from the mother's partner, these are the first steps towards making possible the mutual psychological "adoption" between the child and the mother's partner living in the home. But this exchange of opinions is not a neutral process, it is there that one of the major difficulties lies for the members of these families. For the mother's partner to be able to "make it" as a father four conditions appear to me as necessary: • that he himself wishes to do so; • that the child's mother recognizes the authority of her partner's opinion, as a "possible" father for her child; • that the child accept him; • that the child's legal father accept the fact that the mother's companion will assume certain aspects of the paternal role. · These four conditions should enable a small child who has travelled the diffi- cult path leading from the divorce of the parents to the family rearrangement to live better in the new situation. Ms Fran~oise Hurstel Maitre de conferences Psychanalyste Universite 1 Strasbourg France 9 FATHERHOOD IN JEOPARDY Family Planning in Maghreb: Redefining responsibility by Alanna Armitage In Magmeb it is clear that men play a prominent role in decision-making related to fertility and family planning. However, the nature of male responsibil- ity must be redefined to incorporate equality in decision-making as women's control of their own fertility is an inte- gral element in their emancipation. Contrary to the case in other regions, notably in Europe and North America, where men seem to have little respon- sibility and influence on decisions related to family planning, in Maghreb men often influence not only a woman's decision to tum to family planning, but also the contraceptive method she chooses. Although the populations of most countries of Maghreb have become largely urban and increasingly educated over the past few decades, and many Maghreb women make decisions related to their fertility autonomously, there are many parts of Maghreb where traditions concerning the status of women within the family have changed very slowly. The traditional family model, which valorizes the early marriage of women and the production of many children is still powerful, and decisions regarding fertility and family planning remain strongly influenced by male partners. The dominant role of man in decision- making related to family planning has been illustrated in surveys undertaken within the region. A survey conducted in Algeria demonstrated that among 47% of married women within the age of procreation who had never used con- traception, 12% cited opposition of their partner as the principal reason. In addit- ion, 4% of women who had abandoned contraception cited partner pressure as the motivating factor. Moreover, re- search has shown that women prefer oral contraceptives because they can be taken without consulting the husband, contrary to the IUD for which women fear an eventual discovery. Many women adopt a contraceptive method in hiding, espec- ially when the use of contraceptives has been refused by their husband. In terms of male involvement in sterili- zation and abortion, there is a variation between countries in Maghreb. With respect to tubal ligation, the husband is required (de jure in the case of Morocco and de facto in the case of Tunisia and Algeria) to sign a written consent form allowing the procedure to take place. Regarding access to and male involve- ment in abortion, Tunisia is the only country within Maghreb which allows 10 abortion on request. Abortion is granted until the third month of a woman's preg- nancy, without the consent of her part- ner. In Algeria and Morocco abortion is illegal and is conducted only for mater- nal health or legal reasons and only with the husband's approval. As the Moroc- can sociologist, Soumaya Naamane- Guessous, underlines, this last condition precludes all abortion on unmarried ... women and removes all autonomy from marrled women. In Libya and Mauri- tania, access to abortion is even more strict, granted only to save a woman's life. The nature of male responsibility in the Maghreb Male involvement in family planning within Maghreb has deep roots in tradit- ion. Religious and cultural customs, and in many cases the law, emphasize the responsibility of males for the mainten- ance of their wives and family. A wife, for her part, is expected to obey her hus- band and respect him in his capacity as head of the household. As all important decisions relating to the family are tradit- ionally taken by the husband, it is not surprising that, within many Maghrebi households, a husband assumes the re- sponsibility to decide for his wife on the use of contraception. Family planning practitioners feel that the fact that males often hold the contra- ceptive decision-making power, even when their wives desire no more chil- dren, should not be viewed within the framework of "responsibility", but rather within that of control over women, as many women do not have the right to decide on the use of contraception or on the contraceptive method best suited to their needs. Sarnia Benia, a midwife working in a Maternal and Child Clinic in Algiers, provides an illustrative example. "Yesterday I placed an IUD in a woman from Ain Defia (a village 150 km from Algiers) who is currently hospitalized for hyperthyroid syndrome. She is 46 years old, has 12 children (the youngest is one year old), is illiterate and married to an illiterate man without a profession. For medical reasons I made the decision to place an IUD, as the pill is contraind- icated for a person with her health status. It would have been preferable that she undergo a tubal ligation, but this requires the signature of her husband, and she refused. This woman told me that she has sexual relations at least 7 to 10 times a week because, if she refuses, she is beaten by her husband. The last time she got pregnant she hid the pregnancy from her 28-year-old son until the child was six months old, fearing he would re- proach her for still having sexual relati- ons at her age. Today she came back to the clinic to emove the IUD, fearing that it would be found and preferring to con- front the reality of her difficult existence than having to justify the use of contra- ception to her husband. This is not necessarily a typical case in Maghreb. However, cases like the one above exist, and find legitimacy in relig- ious and cultural tradition surrounding the status of women. The Algerian soci- ologist, Souad Khodja, argues that wom- en have traditionally used their fertility as an instrument of negotiation for their place within the family. Within the traditional Maghrebi extended family, complex power relations exist between the members of the family; mother-in- law, father-in-law, son, daughter-in-law. Producing offspring (preferably sons) constitutes the only source of power for the daughter-in-law. Risking to be repudiated at any moment, she negotiates her fertility in the attempt to maintain her marital links. Responsibility redefined The important role of men as decision- makers underlines the necessity for pro- grammes targeting men. But, unlike the base of Europe or North America, where programmes need to focus on the involve- ment of men in family planning and on male methods of contraception, pro- grammes developed in Maghreb must focus on increasing acceptability of fam- ily planning and on sensitizing male partners to give their wives freedom in decision-making. As Khodja underlines, a woman's control of her own fertility is an integral element in her emancipation. In Morocco a study on male attitudes towards family planning has found that men are becoming less reticent about the use of family planning and are com- municating more with their wives about it. A programme of sensitizing men on family planning issues is now being real- ized by the Moroccan Association for Family Planning. In Tunis a new pro- gramme oriented towards males has been developed by the Ministry of Pub- lic Health, the National Office for the Family and UNFPA. The programme focuses on educating, sensitizing, and motivating the husband on issues surrou- nding family planning to convince him Continue on page 11 ENTRE NOUS 24, October 1993 FATHERHOOD IN JEOPARDY Men and family planning in Portugal Although family planning services are open to everybody, male and female, whatever their marital status or their age, and that they are free of charge, it is mostly women who are using the services. This is not surprising since family planning services integrated maternal health care and official policy consider- ed family planning as a means to im- prove maternal and child health and not as a factor of population policy. Between October 1978 and December 1981 the Commission for the Portuguese Commission for Equality and Women's Rights (then under the name of Commis- sion on the Status of Women) implemen- ted a family planning information, edu- cation and communication project. The project was granted technical and finan- cial aid by the United Nations Fund for Population Activities. The Commission has been working for 8 years with the Ministry of Health in the training of family doctors and nurses in the area of family planning. They con- firm that men very seldom use the fami; ly planning services and sometimes, even oppose their wives' use of these services. A true story of men and family plan- ning During a training course for a group of 12 women which took place in the small town Vialonga near Lisbon in 1992, the trainees were asked to describe both "man" and "woman". The following words were used: Man: "Power, king, bossy, manipula- tive, sexual, independent, free, vio- lent, boss, strength, height." • Women: "Mother, slave, dependent, outcast, manipulative, wife, tender- ness, sweetness, affectionate". Concerning family planning, all wom- en said that their husbands did not play any role. They had never gone with them Continued from page 10 of the significance of family equilibrium and, more importantly, the necessity to give his wife the freedom to choose the contraceptive method of her choice. Within this context, partner communi- cation is essential. This is particularly the case in rural areas where discussions surrounding family planning are taboo. Studies in the region have shown a posi- tive correlation between contraceptive use and communication between hus- band and wife As Samia Benia points out, "A contraceptive method will never be sustainable unless there is consent by both parties. Once you have mutual con- sent, everything works". Lack of partner communication is per- petuated by female illiteracy, particularly ENTRE NOUS 24, October 1993 to a family planning consultation at the health service, The choice of the method was their sole responsibility. One of the women took the pill without her husband knowing. She was afraid of him. All the others undertook entire and exclusive responsibility for the choice of the method, and in the majority of cases without the husband knowing. Use of contraceptive methods Most women use the pill (17.6%) and a large number (28%) practice "coitus interruptus". Condom users amount to 5.7%. Other methods such as IUD (7.3%) natural methods (~.6%) spermicides (2.6%) diaphriJ.gm (0.3%) and sterilization (fe- male 3.6%; male 0.3%) are considerably less relevant. This data was gathered by the General Direction of Primary Health care, and is based on data supplied by the local health services. The data is from 1988. In 1992 the Commission published a study on social representations of men and women by Adelia Costa, which was carried out in 1991 (1). In the area of family planning 638 men and 882 women were asked about re- sponsibility for and access to family planning. The data obtained led us to conclude that: • undoubtedly the responsibility for family planning is no longer exclus- ively associated to women; • young, single people are largely in favour of family planning information sessions; • the lack of parental permission does not hinder young people from acced- ing to family planning. The fact that the majority does not agree with the idea that only married persons should have access to family planning is also revealing. high in the rural areas of Maghreb. The Algerian demographer, Ali Kousouci, notes that whether it is a question of communication with the husband about a subject as insignificant as a television programme or as important as the use of contraception, the wife's educational level plays a key role. The higher a woman's education, the more she is able to communicate, choose with her hus- band, or even impose her choice on questions related to her fertility. Women in Maghreb establish a close link between their degree3 of power within the family and control of their fertility. Within this context, program- mes promoting male responsibility in family planning must be careful not to perpetuate existing imbalances in decisi- The Law's point of view The Portuguese Constitution states (art. 67, subparagraph d) that "the State shall promote a wider knowledge of family planning methods and shall set up legal and technical organizations to further the exercise of responsible parenthood". The Health Secretary of State ordered the integration of family planning in the National Health Service in 1976. Law no. 3/84 of March 24th - "Sex Education and Family Planning" and Government Order no 52/85, of January 26th constitute the legal framework of family planning practice, the first of which attributes the duty of cooperating with other services and associations in campaigns and actions to publicize fami- ly planning methods. The Commission for Equality and Wom- en's Rights has been implementing information, education and communica- tion activities in this area since 1976. One of the members of the Consultative Council is the Association for Family Planning which has also been working on spreading information, training and counselling in this area since it was founded in 1967. Dr Ana Vicente President Commission for the Equality and for Women's Rights Ministerio do Emprego e da Seguram;:a Social Av. da Republica, 32, 1 P-1093 Lisbon Codex Portugal References: (1) "Representa~oes Sociais de Homens e Mulheres - Portugal 1991", Costa, Adelia, Comissao para a igualdade e para os direitos das mulhe- res, Ministerio do Emprego e da Segu- ran~a Social on-making power. The redefinition of male responsibility, to incorporate equality in decision-making, provides the opportunity not only to increase family planning acceptability in the region, but also to promote the role and status of women within the family and society. Ms Alanna Armitage Programme Officer United Nations Population Fund (UNFPA) B.P. 833 1600 Alger Gare Algeria 11 FATHERHOOD IN JEOPARDY The AIDS era: New challenges and new roles for sexually active teenagers by Pierre-Andre Michaud A global impression is that, although sex behaviour has remained quite stable for many years, let's say from 1970 to 1986, the AIDS'epidemic has brought impor- tant changes and contributes to a new definition of the roles of boys and girls in this area. This article highlights some of those changes and concludes what should be done next, both in terms of health care programmes and preventive activities. For the past twenty years the Univers- ity Institute for Social and Preventive Medicine as well as the Public Health . Service of the Canton of Vaud in Lau- sanne (Switzerland) have conducted several surveys on the health behaviour of teenagers. During the same period, this Canton also ran a school sex educa- tion programme for pupils aged 10 to 19 years (Service d'education sexuelle, Centre medico-social Pro Familia). . Both the surveys and the programme offered a good opportunity to observe sex behaviour changes within this age group. The AIDS issue: more trouble for boys and girls For the majority of teenagers who do not yet have a stable affective situation, the issue of sexuality and sexual intercourse is - consciously or unconsciously - close- ly linked with the fear of getting an HIV infection. We know from the dis- cussions we have had with them - within health care structures or preventive pro- grammes - that adolescents have difficul- ty in coping with the concept of fear, defiance or cautiousness linked with AIDS and at the same time other con- cepts linked with love, such as spontane- ity, confidence, tenderness. Ten years ago, in one of the first surveys, love af- fairs ranked in tenth position within a list of health matters that troubled them. In 1992, the same item ranks in third position: 35.8% of the girls and 28.2% of the boys feel they need help to solve their problems in this field. In 1982, the percentages were around 18% and 15%. According to what adolescents say during the discussions brought up by the sex education programme, the problem is not just to discuss AIDS or condom issues when considering sexual inter- course. It is more to discuss how to behave, how to use the condom effect- ively and regularly, without giving the impression that the confidence is broken. And, where as girls were, some years ago, above all concerned with the con- traception issue, boys are now very much involved in the AIDS/ STD pre- vention process: we thus observe a shift from the pill issue to the condom issue! 12 Discussing contraception issues: the involvement of boys Since 1987, the Swiss Federal Office for Public Health and the cantonal govern- ments have launched an important pre- vention campaign against AIDS, the "STOP-AIDS" campaign. Among other themes like fidelity in the couple, or acceptance of HIV-infected persons, the campaign has stressed the use of con- doms, specially in the messages directed to young people. As a result, both con- traception and specific use of condoms have iincreased considerably during the last year: in 1987, only about 50% of adolescents would use any contraception at their first intercourse. The percentage is now around 75%, which is still far from excellent. The percentage of boys who claim they use condoms on a regu- lar basis has been raised from 22% in 1987 to 43% in 1992. In 1987, at the beginning of the campaign, some people feared that such a strategy would increa- se the number of adolescents engaging in sexual life and in some way promote promiscuity. It has, indeed, proven not to be the case: the proportion of teenagers haviq.g had one, two or more partners has remained steady since 1987, around one-third in each category. There may, however, be a slight increase in the num- ber of girls engaging in sexual life at an earlier age (15-16 years) because of the increased availability of condoms. In other words, before 1987, boys tended to engage in sexual life earlier than girls, but this difference now tends to disap- pear. The "gap" between boys and girls is closing. The consequences: new roles and behaviour for boys What can be learned from these studies? Surely, the role of boys vis-a-vis girls has changed and will change dramatically: he is now much more concerned with contraceptive issues, and the "moral ob- ligation". To discuss these matters before engaging in sexual intercourse is more and more accepted. Sexual matters, in general, are also discussed more openly, both by the adolescents and the rest of the society. This change may also bring a modification of the affective exchanges in the couple: we have testimonies that, although in the 1970s, girls would be more romantic and boys more "prag- matic" toward sexuality, in the 1990s, this may no longer hold true. That is, more and more boys express their needs and urges in the field of love, not only in physical exchanges. And, of course, this trend is not only linked with the AIDS epidemic, but also with the new definition of the gender role within the couple and society. The "macho", still present, is - fortunately - an endangered species ... Implications: what should be done? In several French-speaking cantons of Switzerland, we have recently set up workshops, the objective being to define future options and actions regarding the health of adolescents. The "grid method" used, was developed by the Adolescent health programme of WHO in Geneva. In these multidisciplinary groups, made up of adults and young people, it was stressed that, for many years, girls had had their own location to discuss sexual and health matters: the family plannipg clinics/centres. But the boys do not have such services available. It was thus hoped that in the future, either the family planning clinics or more globally the health care structure would offer the boys a proper location to discuss sexual matters on a personal level. Of course, these groups also discussed the problem of condom accessibility and proposed that condoms should be avail- able in the schools, for instance within the school health services, as well as at the many events and in places where teenagers go: discos, clubs, youth centres etc. They finally stressed the importance of encouraging discussions and exchanges around the theme of AIDS and contra- ception: one of the dangers of the pres- ent situation is to discuss the HIV issue too much and forget completely the many other aspects of sexuality. Indeed, the use of the condom does not automat- ically imply the abandonment of the pill. The current policy in our country is to encourage the use of both: we may other- wise face more unwanted pregnancies since the condom still remains less effi- cient than the pill. Finally, our medical concerns (HIV, pregnancy) should not make us forget that sexuality is above all a human exchange, rooted in our lives and which should bring us happiness, love and humour. In the present situation, this challenge, to consider sexuality as glo- bally as possible, is not only that of the adolescents: it is also the challenge of health care providers! Dr P.-A. Michaud, Medecin adjoint lnstitut universitaire de medecine sociale et preventive (IUMSP) Rue du Bugnon 17 CH-1005 Lausanne Switzerland ENTRE NOUS 24, October 1993 Dutch male teenagers on their role in prevention by Paul Vennix, Evert Ketting and Petra Curfs Until recently very little was known about male teenagers' role in prevention, as almost all research focused on girls and women. During 1991-1993 a research project was carried out by the Netherlands Insti- tute of Social Sexological Research (NISSO), to find out how Dutch male teenagers perceive and fulfil their role in preventing unwanted pregnancy and STD. A combined, quantitative and qualita- tive strategy was chosen in designing the research. A structured, written question- naire was administered to a random sample of 215 boys in the age-range 18-22 years. They were asked to report retrospectively on their preventive behav- iour at the time of their first sexual experiences. In order to gain more in- sight into aspects of the development of preventive behaviour, the research was extended to include 22 depth-interviews. Contrast was looked for in selecting respondents from the sample for these interviews. Media - an important source of information Youths draw their information about contraception and the prevention of STDs above all from the media and in- structional material. These information channels are the least threatening: boys do not have to expose themselves. Parents, in particular fathers, do not gen- erally play a significant role in their ob- taining information. Knowledge mostly comes in dribs and drabs, picked up here and there. Alongside the formal channels, much of the information about contraception is obtained in the course of their social lives. Contraception is one of the talk- ing points among boys. Yet while they may have a good deal of information from these various sources, their girl- friend still seems to supply important supplementary information. On the other hand, knowledge about STDs comes mainly through formal channels. They are less often a topic of conversation among boys. It is clear that the information usually reaches its goal. Youths are fully aware of the risks involved in unprotected love- making, both of pregnancy and of STD. Youths' views about contraception and the prevention of STDs do not seem to be related to church affiliation, level of education or other demographic vari- ENTRE NOUS 24, October 1993 ables. This indicates that in this respect one can speak of there being a 'mono- culture' in the Netherlands - though one should note that the presence of certain categories of young men, such as those with a strong church affiliation and immigrants, was very rare in our sample. .. Prewention: a joint responsibility Practically all the boys hold the view that contraception and the prevention of STDs are properly the joint responsibil- ity of the young man and young woman. Youths who have no experience as yet of intercourse, are full of good intentions about making love on the first occasion with the protection of a condom. Sexual intercourse for the first time follows a particular scenario for most of the boys. In principle, he has a condom ready. Each of the couple checks wheth- er the other might have an STD. Before anything happens, the girl says whether or not she is on the pill. If she is not, a condom is used. If she is, the scenario becomes looser. Although the majority of boys still think that a condom should be used, most of them do not expect the girl to be thinking the same way. More over, in such a case, sexually experienc- ed boys are significantly less likely than inexperienced boys to think that a condom should be used. The typical age at which boys first have sexual intercourse is 16 to 17. Many of those with a lower level of education become experienced somewhat earlier. One in four of the boys have had just one sexual relation. Two-thirds of them have a steady relationship. On average, they will have had a relationship with a girl for one month before intercourse occurs. However, one in three of them will have intercourse within a week, and one in ten on the day of first meeting. Generally, either a condom (46%) or the pill (33%) is used; rarely (7%) both. In more than one in ten instances of first '{intercourse 'nothing' is used. When the lgirl is not on the pill, one in four of boys still do not use a condom. Starting sex: mixed feelings Youths find first intercourse both excit- Continue on page 14 Sexually inexperienced male teenagers are full of good intentions about using a condom for protective purposes on the first occasion of making love. Photo Sonja Iskov0!2maj 13 Continued from page 13 ing and scary. One in three of them are surprised by this. Girls take the initiative as often as they do. The stereotypical image of boys as the 'great seducers', well able to find their way into bed, does not fit the facts. Because of uncertainty or fear of failure they sometimes try to avoid the matter altogether. And often first intercourse is no more than an awk- ward reconnaissance, in which some- times-high hopes are not realized. Only as a relation progresses does making love gradually become better and more enjoyable. When a youth goes to bed with a girl for the first time nothing is said, usually, about the prevention of STDs. That is not an issue for him. Only half of all couples clearly negotiate beforehand what kind of contraception will be used. Particularly, when it is a casual contact, contraception, is often not raised. For some of the boys it is a hard and fast rule that they will use a condom. They find it unnecessary to bring the matter up beforehand, and they produce the condom during love-making without further ado. Would she take the pill? In steady relationships, boys are often curious whether the girl is on the pill; but they do not always dare to ask her directly, because they are afraid that it will give the impression that they 'are only after sex'. As a result, they keep putting off any discussion of contracept- ion. Furthermore, intercourse itself can be so threatening that they deliberately do not raise the matter of contraception. In practice, all this means that quite a few boys do not know until just before intercourse whether the girl is taking any precautions. To be on the safe side they have condoms to hand. Only during love-making do they eventually ask the girl. Sometimes it is already too late. Anticipations of intercourse, and the accompanying excitement, tension and uncertainty, frustrate any thoughts of raising the matter of contraception. Even when the girl herself raises the question, some boys do not take it up. It then depends entirely on the girl whether they make love safely or not. The condom itself also appears to pose a problem for quite a few boys. In prac- tice, it often does not come up to expect- ations. Experienced boys find it cumber- some to use and an interference during love-making. Moreover, buying condoms creates some diffidence towards them. Youths are afraid that they will be spotted, or wonder what the shop-assistant is thin- king. For many of them, having con- doms to hand has negative connotations of "being after sex". Finally, quite a few do not know how to manage a condom during love-making and are afraid that it will all go wrong. 14 Talking about STD spoils the atmos- phere Condoms are almost exclusively introdu- ced as a protection against pregnancy. To use them to prevent STDs does not seem quite right. Generally, STDs are not talk- ed about at all. If the matter does arise, it is only in passing and indirectly. It is generally assumed that instruct- ional material about STDs is meant for someone else. No one knows anybody with an STD. Because first intercourse is itself so all-engrossing, no attention is paid to the possible negative consequen- ces. Furthermore, when it is a casual contact, nobody wants to refer to STDs and spoil the atmosphere. Asking a girl if she perhaps has an STD is not done. It gives the appearance of having little trust in her and risks implying that she is immoral. In as much as boys do think about the risk th~y run of an STD, it is mostly only to explain it away. For most of them there is only a chance of STD if the girl has had a good many different sexual relations. And if she had contacted STD, she would certainly say so. Moreover, they assume that in a faithful or steady relationship STD cannot occur. Rapid transition from condom to pill In the course of the first steady sexual relation only a few boys (18%) appear to use a condom. If the pill is not already being used, most couples - usually after intercourse has taken place just a few times - begin to use it. The inconvenience and relative unreliability of the condom are the most important reasons for aban- doning it. Furthermore, despite the ideo- logy of joint responsibility, most boys prefer the girl to take care of contracep- tion. Nevertheless, despite the fact that use of the condom is often a disappointment, boys rarely take the initiative to change to the pill. They do not think that they can ask such a thing of a girl. Choosing the pill, then, is almost always, either a joint decision or the initiative of the girl. Although boys think that changing to the pill is a matter of course, they generally assume that the girl should indicate if and when she wants to do so. However, they do try to exert some influence on her by making it plain that they dislike condoms. No way back to the condom Once the girl is on the pill, boys do not generally think about it any more. They believe that she can take care of the mat- ter herself. Bothering themselves with it is sign of distrust and interference. Fur- thermore, most of them have complete trust in the pill. In addition, most assume that, if the girl gives up the pill, she must have a very strong reason for doing so. To stop using the pill without giving a reason is not accepted. In such a case, quite a few think that there must be something wrong with the relationship. Even when the girl complains about the pill because of side-effects, boys are not quick to switch to condoms. Mostly they think that the complaint will wear off or can be quickly remedied. Only when the girl decides to stop taking the pill because of persistent symptoms which the doctor can do little about, are they generally, albeit reluctantly, ready to use condoms once again. Policy implications From the research it seems clear that, in the area of contraception, boys are con- fronted with a number of issues which they do not know how to deal with. In part, this is because sex education in the Netherlands is directed mainly at girls. They learn to defend themselves against boys' sexual desires. As a result boys' sexuality becomes suspect. Insofar as sex education is aimed at boys, it is dom- inated by the issues of sexual violence, AIDS and macho-behaviour. And in this way the negative image of their sexuality is reinforced. It also perpetuates the myth that taking the initiative and being self- assured and rational are important ingre- dients in the way boys are dealing with contraception and the prevention of STDs. Many boys will not recognize this picture of themselves - it is a camouflag- ed view of reality boys try to uphold for the outside world. At the core, they are afraid and uncertain. l3ecause they often cannot identify with sex education, it is necessary that information that is given about sexuality should be better geared to their experi- ence. Preferably it should be given by other men. It needs to be made clear to boys that the chance of STD is greater than they think. Consequently, in educational mat- erial less explicit attention should be given to AIDS and more to the prevent- ion of other STDs, such as chlamydia and gonorrhea. In this way, the chance of contracting STD will be more realist- ically appreciated than when people think only of AIDS. The condom needs to be promoted in the first instance as a means of preventing various kinds of STDs and only in the second instance as a contraceptive measure. Paul Vennix, Evert Ketting and Petra Curfs are researchers working with the Netherlands Institute of Social Sexological Research (NISSO) P.O. Box 5018 3502 JA Utrecht The Netherlands. Paul Vennix, Petra Curfs, Evert Ketting, Condroomschroom; jongens over seksu- aliteit, anticonceptie en SOA-preventie (condom-shy; boys on sexuality, contra- ception and STD prevention; in Dutch), Eburon, Delft, 1993. ENTRE NOUS 24, October 1993 EUROPEAN NEWS The impact of voluntary induced abortions on fertility in Israel by Eitan F. Sabatello Israel has a relatively high aggregative index of fertility. In 1990 the rate was an average of three births per woman of childbearing age. The Jewish majority is less prolific than the arab minority (which comprises 18% of the popula- tion), but the total fertility rate is still high, 2.7 births among Jewish women, and shows variations of up to 25% with- in various cultural and demographic groups. In spite of the raised level of fertility, in certain circles voluntary induced ab- ortions are held to be responsible for the decreasing tendency of the fertility rate which began in the 1950s. This tenden- cy, however, may well be attributed to other causes, notably to the growing use of contraceptives and to the reduction in the number of marriages among the Jewish population since the beginning of the 1970s. In other words, voluntary in- duced abortions are likely to have played only a minor role in the decrease in fertility. Abortion law in Israel We can briefly review the history of the abortion law in Israel. Dating from 1977, it sets four conditions under which the granting of an abortion is authorized: (1) the age of the woman (under 17 years of age - the legal age fof marriage - or over 40 y~ars of age), (2) the cause of the pregnancy (rape, incest or extramarital relationship), (3) malformation of the foetus, ( 4) threat to the state of health of the mother posed by the pregnancy. The length of the gestation period which has elapsed is not mentioned as a restrictive condition. Women wishing to terminate their pregnancies are required to complete an application form which they submit to medical committees for abortion, located in 28 public and private hospitals ap- proved by the Ministry of Health. Since 1988 these forms have been collected and deposited with the Bureau of Stati- stics and represent the statistical infor- mation base. According to the figures for the years 1980 to 1990, between 15 and 16 thou- sand legal abortions were performed in Israel annually. The general legal abortion rate showed a slight decrease during this period, from an average of 18-20 volun- tary induced abortions per 1000 women from 1979 to 1983 to approximately 15 from 1987 to 1990. ENTRE NOUS 24, October 1993 The grounds given in the requests for abortions can be grouped as follows: (1) pregnancy resulting from an extram- arital relationship (40% of applications); (2) threatening to the state of the moth- er's health (27-29% of cases); (3) malformation of the foetus, which is cilied more frequently than in the past (an increase from 15% to 20 to 22% of applications, probably due to progress made in the detection of defects); ( 4) age of the mother ( about 10% of cases). It should be pointed out that not all of the applications are necessarily accepted: in 1990, for example, there were 18 000 applications, 16 400 were accepted ( about 91 % ), of which 15 300 were actually performed (86% ). One may assume that the 1600 applicants that were rejected were forced to tum to the "black market" for abortions, which do not figure in reported statistics. According to the figures for 1988 to 1990 regarding the number of applica- tions for a voluntary induced abortion, one women in two in Israel between 15 to 44 years of age undergoes an abortion during the course of her life. The propor- tion of abortions corresponds to 18% of births as compared to 10% in the Neth- erlands, 32% in Sweden and 70% in Czechoslovakia. Israel thus shows a rate of voluntary induced abortions compar- able to that of the Scandinavian countries, the US (white population), England and Wales; it is higher than the rate in the Netherlands. It is much lower, however, than the rates reported in the former republics of the USSR, as well as in Hungary and Czechoslovakia. Impact on fertility Our intention is to evaluate the impact of non-therapeutic abortions on the general level of fertility. According to the hypoth- esis that every non-therapeutic abortion which is refused will automatically result in a birth, one should observe an increase in the aggregative index of fertility of 10-12%. This assumption is too simplis- tic. In the first place, a certain number of women resort to abortion to control the timing of their births and not in order to limit the number of their children. In such cases, and assuming that the un- wanted pregnancy is not terminated, it will eventually result in a birth in the course of time. But it then follows that the women will take measures to avoid a new unwanted pregnancy. Thus the abor- tion was avoided in the first instance, but ultimately it means the substitution of one pregnancy for another one expected at a later date. Furthermore, even if it were possible to avoid all non-therapeu- tic abortions, a certain number of preg- nancies would end up as miscarriages. Finally, during the interval consisting of nine months of gestation ending in a birth, followed by two or three months of postpartum infertility, a woman who refuses the responsibility of her pregnan- cy could, at least from a biological point of view, become pregnant several times and, theoretically, undergo an abortion in each case. In this case, it would be necessary to prevent an average of 1.4 abortions to increase the number of births by one. Thus the postulated increase in the aggregative index of fertility of from 10-12% is an overestimate, and would give an aggregative index of fertility which was 7% to 8% higher than the actual index. If it were possible to avoid all non-therapeutic abortions the aggre- gative index of fertility would be raised to an average of 3.2 to 3.3 births per woman instead of the actual figure of 3.0 to 3.1 births per woman. The differ- ence between the two figures is an esti- mation of the impact of voluntary indu- ced non-therapeutic abortions on the level of fertility in Israel. From this one can conclude that the impact would remain extremely limited. Refusal of abortion Who are the women who must be per- suaded to keep their babies instead of undergoing an abortion? The rate of voluntary induced abortions in propor- tion to known pregnancies is highest among women over the age of 40 years (about 40% of these pregnancies are terminated by an abortion) and among those less than 20 years 6f age (33%). They comprise only 10% of the women of prime childbearing age. The chances of refusal are greatest for applications for non-therapeutic abortions submitted by women aged 20 to 39 years, as the committees are more understanding with regard to very young or older women. In fact the former do not fulfil, at first glance, any of the conditions which would permit an induced voluntary abortion, i.e. they are married and at an ideal age (according to the criteria of the medical committees) to have children. Continue on page 17 15 UNFPA FILE A statement by Dr Nafis Sadik International Conference on Population and Development ICPD '94 Cairo Conference on Population and Development In September 1994 the Third Interna- tional Conference on Population and Development will take place in Cairo. Population will be the main focus within the context of economical, social and environmental issues. Other themes such as the empower- ment of women, the aging population, etc., will not be forgotten. Dr Nafis Sadik, Executive Director of UNFPA and Conference General Secretary has provided Entre Nous with the following summary state- ment she wrote for the Second Ses- . sion of the Preparatory Committee of the International Conference on Popu- lation and Developµient, held at UN Headquarters in Ney,, York, last May 1993. Today marks the start of two weeks in which we must all cpmmit ourselves to working cooperatively and constructive- ly to set in place the basic structure for our Conference. The mandate whicp bas been given to our Conference - to ;i!.pdress the inter- relationship of popul~tton issues with economic and social i.ictivity within the context of sustainability - is a very challenging ~me. Wltblh this mandate whicb has ptlen set fqrtp as "population, sustained e~onomic irtiwth and sustain- able develgpJUent" ..ye fDUSt all ensure that populaii.pn is urn;l~rstood as the central PllfPOSe of ~ a (;:onference and accordingl~ the aspe~tij of sustained economic fOwth and ~µ,&tainable develop- ment need to be addr~~~ed in terms of their interrFlijtionship t~ population concerns. I I As we take up PHr work it is - impg!,1ant to ~~p in mind the bro11,per conte~f ifl which we are worpng. The '¥Qrld has changed dra'llatically stn1ie the interna- tional colllfPunity met f P Mexico City in 16 1984 for the International Conference on Population. We have witnessed and con- tinue to see significant shifts in the atti- tudes of many countries towards their peoples, both collectively and individu- ally. Such change is often political, fre- quently economic and always of clear significance in social terms. A particu- larly encouraging aspect of such changes is reflected in the willingness of the great majority of countries to address population issues openly, within the con- text of national policies and priorities. There is in many quarters a new willing- ness to recognize the interrelationship of population issues with economic and social concerns, and their connection with the main stream of political life. - I Our Conference is to take place towards the end of 1994 which the United Nations has desig-nated as the Year of the Family. The fami- ly, in all its many different confi- gurations, must be at the centre of our deliberations. We undertake our work here in the knowledge that our decisions will be of profound importance to fami- lies everywhere. I am most conscious that our work and the outcome of our efforts in Cairo should be seen as important contribut- ions to the two major international gather- ings which are scheduled for 1995 - the World Summit for Social Development and the Fourth World Conference on Women'. Without wishing to prejudge preparations for these important events, we should acknowledge many shared objectives - not least the wish to improve opportunities for the disadvantaged, among whom women are often a large majority. I There have been many differing - perceptions of what we should have ten years after the Mexico Conference. While the 1994 Con- ference will be the third interna- tional conference on population conven- ed by the United Nations, it should be seen both as a confirmation of the impor- tance of the 197 4 and 1984 international population conferences and a departure from them. I As authorized by ECOSOC reso- - lution 1991/93, six expert group meetings on the key clusters of issues we are addressing have been held. Alongside expert groups, each of the five United Nations regions has held a conference as part of preparations for the International Conference on Population and Development. It has been my privilege to attend and participate in each of these five confer- ences. All have underscored what I would call !he evolving perspective of the international community on popula- tion and its place on the political and social agenda. Naturally there have been quite distinct regional variations. The European Population Conference was, despite its name a meeting of developed countries from Europe and North Ameri- ca. For the great majority of its partici- pants, the issues were not those of rapid population growth but of fertility decline, aging and international migration. On the other hand, conferences in the other regions were much more concerned with issues of population growth and distribu- tion. The Arab and Latin American and Caribbean Conferences gave much attention to issues relating to internatio- nal migration. In the case of Asia and the Pacific, Alfrica and the Arab region there have be'en important commitments to specific goals on a range of population issues. At last week's Latin American and Caribbe- an Conference a commitment was made to the preparation of a regional plan of action which I expect will include clear goals for that region. To me what has been particularly encouraging however is the substantial degree of commonality which does exist in all regions. There has, for example, been a common reaf- firmation of the imperative that couples Continue on page 17 Dr Nafis Sadik. Executive Director of the United Nations Population Fund ENTRE NOUS 24, October 1993 Continued from page 16 and individuals must have the right to determine the size of their families and the spacing of their children. Similarly, there is common recognition of the role of women in all aspects of population and sustainable development and the need to ensure equality of opportunity for women and young girls in all social and economic spheres. The interrela- tionship of population, the environment and economic activity has also been clearly recognized, as has the vital role of enhanced international cooperation in all areas related to population and devel- opment. It has also been most encourag- ing to see recognition of the positive contribution of nongovernmental and community groups in the implementation of population programmes and activities. - I It is not my intention to speak in any detail on specific issues. I do wish, however, to outline what I see to be important perspectives which I hope will assist your thinking on key issues. The first key concern I have is to ensure the centrality of the individual in all our activities and decisions. I am suggesting that when the essential needs of the individual are addressed, those of larger groups such as the family, the community, the nation and indeed the planet are more likely to be kept in the right perspective. One of the key chal- lenges of our Conference will be to reach agreement on the appropriate balance between individual rights and responsib- ilities on the one hand and societal rights and obligations on the other. This will be true not only when we address the proposed guiding principles,. but throughout much of our work. From my perspective this issue comes down to the vital need to invest in hu- man beings, particularly in women and girls who, in this day and age, still fall far behind their male counterparts when Contiuned from page 15 If one adds the illegal abortions, the proportion of non-therapeutic abortions in the 20 to 39 year age group would doubtless be higher. The modem, western cultural milieu, with which Israelis tend to identify, ad- vocates the freedom of the woman and her spouse in questions of family plan- ning. This attitude runs counter to the restrictive measures which can be ap- plied legally against non-therapeutic ENTRE NOUS 24, October 1993 it comes to economic, social and politi- cal equality of opportunity. I am a firm advocate of investing in women. In eco- nomic and social terms the returns are enormous. But most of all in terms of basic human rights the imperative for such investment is unchallengeable. Nowhere is such investment more bene- ficial than in improved health services, including family planning, which enable women to take greater control of their lives, their wellbeing and their futures. Alongside efforts to enhance opportu- nities for women, it is equally important to involve men in all aspects of program- mes aimed at raising the status and im- proving the choices available to women. At the family level, this includes taking responsibility for fatherhood, and for contraception. In the community, it includes providing job opportunities for womeQ., on an equal basis with men; inv9lving women on an equal basis in local government and development; and protecting women from abuse in the home and elsewhere. At the national level, it includes sweeping away the ves- tiges of legal discrimination and provid- ing the services essential for women's and society's development. Our policy and programmes should both address women and men as equals, and contribu- te to making them truly equal. I I I wish to see our Conference - adopt a comprehensive, opera- tional set of recommendations. It would be my hope that these will ' be more than a reaffirmation of where we are now. They should be for- ward looking, operational and visionary. Equally they should be formulated in such a way that they can be readily understood by people at large and there- fore can be used to mobilize support for the implementation of our Conference's recommendations. To this end I am suggesting that they might include a set of goals - not targets - to be achieved by all countries over the abortions. Were a law legalizing them to be introduced and fully implemented, it would have only a minor effect on the general level of fertility of women in Israel. Bibliography: Eitan F. Sabatello, 1993, "The impact of induced abortions on fer- tility in Israel", Social Science and Medicine, Vol. 36, No 5, p. 703-709. next 20 years. I would envisage goals being set for issues such as maternal mortality, infant mortality, education especially for women and girls, gender equality, and availability of and access to a full range of modem, safe and effective family planning services to enable the exercise of choice. Global fertility and population trends will depend on what we achieve in regard to these goals. It would be my suggestion that all countries commit themselves to reach, or assist others to reach, the average of the developed countries in each of these areas within a 20 year timeframe. We have ample evidence that such goals can be achieved with the necessary commit- ment and support. Naturally different regions and subregions may require dif- ferent interim goals. These would hope- fully serve to focus attention on areas of highest need. - I This Conference finally is about choices and responsibilities - for the individual, the community, the nation and the world. Its aim is to widen our freedom of choice - choice in the matter of family size, choice in population policy and pro- grammes, choice in development philo- sophy and practice. If we wish for a wider range of choice, we must also recognize and accept responsibility. Men must take respon- l sibility for contraception and fatherhood, communities for the weaker and most vulnerable members, nations for the wellbeing of their people and the global community for the future of the environ- ment on which all else depends. Dr N afis Sadik Executive Director United Nations Population Fund and Secretary-General of the Inter- national Conference on Population and Development Dr Eitan F. Sabatello Director of the Division for Demography, Population, Health and Immigrants Absorption The Central Bureau of Statistics; and: The Hebrew University, School of Public Health and Community Medicine P.O. Box 1305 Jerusalem 91130 Israel 17 RESOURCES The Portuguese Commission for Equality and Women's Rights The Commission for Equality and Women's Rights (CIDM) is an official Department under the Ministry of Employment and Social Security. The main objective of the Commission is to achieve equality of rights and opportunities for women: • by working towards a change in the attitudes of both men and women, so that every person may achieve full human dignity; • by achieving effective co-responsibility of women and men at all levels of family, professional, social, cultural, economic and political life; • by encouraging society to regard maternity and paternity as of funda- mental social importance and to accept the responsibilities resulting therefrom. There is an Advisory Council compris- ing representatives of other official departments and of nongovernmental organizations. The main activities of the CIDMare: Studies and training The Commission established Women's Studies in Portugal, as it was necessary to study the situation on a scientific basis. During the International Women's Year (1975) the first general survey of discrimination against women was made. Studies have been drawn on the image of women in the media and in advertis- ing, discrimination against working women, stereotypes in schoolbooks and children's literature, etc. The CIDM has implemented many projects of vocational training for wom- en and young people, including projects for women emigrants. Documentation and information There is a specialized documentation centre open to the public, with extensive bibliographical support. The centre car- ries out information and education activ- ities through the mass-media and by means of audiovisual and printed materi- als. Legal issues The Commission has an active role per- taining legislation that concerns wom- en's rights and opportunities, and main- tains a free legal information service, available to the public. 18 Cooperation with other institutions The CIDM works in close cooperation with other official departments and NGOs, as well as with national mecha- nisms for equality in other countries, the European Community, the Council of Europe and the United Nations Organi- zation. Publications edited by CIDM Periodicals: Newsletter (quarterly) Bibliographical information (every two months) Series: Colec,;ii.o "Cadernos Condi,;ao Femini- na" (Reports on the Status of Women) 33 title&1available Coloc,;ii.o "lnformar as Mulheres" (Information for Women) 13 booklets published on: divorce, mar- riage, adoption, violence against women, sexual harassment at work, etc. Colec,;ii.o "Planeamento Familiar" (Family Planning series). This series has been adapted for African Portuguese speaking countries. They can also be used by emigrant communities in Euro- pe. Colec,;ii.o "Ditos & Escritos" (Things spoken and written series) Most of these publications are available free of charge upon request from: The Portuguese Commission for Equality and Women's Rights, Av. da Republica, no. 32, 1, P-1093 Lisbon Codex, Portu- gal.Tel: 797 60 81 (or 84). Fax: 793 76 91 FAREGINHAS MEMORIA DE UM PROJECTO BERTINA SOUSA GOMt:S COMlssl.o PARA A IGUALDAOE E PARA OS DIREITOSDAS NUlHERES M,r,.$1M,odoEmpregoeda Seguran.;a SoctaJ Books Quels peres ? Quels Fils ? (What fathers? What sons?) (1992), E.Sullerot. A review on the role and rights of fathers of the XX th century in France and its neighbouring countries, followed by comments from the 15-18 year olds who will be the fathers of the XXIth century. Edition Fayard, 75 rue des Saints Peres, F-75006 Paris, France. Price 130 French francs. ISBN 35-8287-1-92-IV. Cramponnez-vous les peres (Hang on fathers) (1992), C. Castelain-Meunier has met parents from the younger gene- rations. She notes that fathers are getting better in marking off their territory. She encourages them, however, to keep on defending their rights, and their identity so that parenthood in the future does not develop without them. From: Editions Albin Michel, S.A., 22 rue Huyghens, 75014 Paris, France. Price: 98 French francs. ISBN 2-226-05856-7. Christine Castelain-Meunicr Cramponnez,vous les peres I. Les hommes face a leur femme et a leurs enfants Albin \lichcl Les actes du colloque international Fecondite & Insularite (1993). Proce- edings from the international symposium on Fertility and Islands organized by the Conseil General de la Reunion and held in Saint Denis, Reunion Island, from 11 to 15 May 1992. From: A.F.I., 2, avenue Georges Brassens, F-97488 Saint Denis Cedex, La Reunion. Price: 180 French francs (for the 2 volumes). ISBN 2-9503 094-1-0 WOMEN and HIV/AIDS (1993), Edited and written.by Marge Berer with Sunanda Ray. Information, action and resources on women and HIV/AIDS, reproductive health and sexual relation- ships. Published in English by Pandora Press, Harper Collins, 77-85 Fulham Palace Road, Hammersmith, London W6 8JB. Price: 14.99 Pounds. ENTRE NOUS 24, October 1993 Documents Mannergewalt (1993). A report on experiences, results and perspectives on men and violence. From: Arbeitsgeme- inschaft humane sexualitat, Ohlauerstr. 30, 1000 Berlin 36, Federal Republic of Germany. Price DM 10,-. The State of World Population 1993, Dr Nafis Sadik, Executive Director, UNFPA. The theme of the 1993 Report from the United Nations Population Fund is migration. The Report suggests that "reduction in population pressures will limit the potential for migratory movement and enhance progress towards a sustainable future in the developing world". For this purpose, a balanced development, including health and edu- cation especially for women and girls, and family planning, is most critical. From: UNFPA/United Nations Popula- . tion Fund, 220 East 42nd Street, New York, NY 10017, USA. Tit£ STATE Of WORLD POPULATION MMilll! The Prevention and Management of Unsafe Abortion (1993) Report of a Technical Working Group held in Geneva 12-15 April 1992. From: Divis- ion of Family Health, WHO, 20 Avenue Appia, 1211 Geneva 27, Switzerland. SIDA 1993, L'infection par le virus de l'immunodeficience humaine en prat- ique medicale quotidienne, G. Levass- eur and P. Lecorps. HIV positive does not necessarily mean AIDS but it isol- ates and frightens just the same. This practical guide is intented for all those who deal with persons infected by HIV. From: Ecole Nationale de la Sante Pub- lique, Avenue du Pr. Leon Bernard, F-35043 Rennes Cedex, France. Adolescencia, a report in Spanish for adolescents about their body, love, sex and reproduction. La mujer y el sida, is also a well writ- ten and illustrated report in Spanish ENTRE NOUS 24, October 1993 about transmission of HIV/AIDS. Both reports are available from: Ministerio de Asuntos Sociales, Instituto de la Mujer, Almagro 36, 28010 Madrid, Spain. Use of the Rapid Evaluation Method for Evaluating Maternal and Child Health and Family Planning Services. The Rapid Evaluation Methodology (REM) which is action oriented, focuses on services. It provides qualitative and quantitative information to assist deci-. sionmakers and programme managers m improving the quality of care and adapt- ing services to community needs. From: Maternal and Child Health, Division of Family Health, World Health Organiza- tion, 1211 Geneva 27, Switzerland. Global Population Assistance: A Report Card on the Major Donor Countries (1993). This new report from Population Action International exam- ines tile need for population assistance, evaluates the current efforts of the 20 major donor countries to meet the need, and presents concrete financial and po- licy recommendations for bridging the gap between where we are today and where we need to be by the end of the decade. From: Population Action Inter- national, 1120 19th Street, NW, Suite 550, Washington, DC 20036, USA. Demographic and Social Effects of Population Policies in Europe (1993), H.P. David and D. Pierotti. Following a consultation on Third Child in Europe this paper describes types of population policies and historical concerns along with below-replacement fertility levels and the likely reasons for this. Pronata- list incentives and disincentives are cited and the effect of immigration is briefly mentioned along with political conside- rations. Of particular relevance is con- tinuing access to modern contraceptives and safe legal abortion. Finally, the question is raised on whether a pronata- list population policy is advisable and DEMOGRAPHIC AND SOCIAL EFFECTS OF POPULATION POLICIES IN EUROPE what alternatives exist. From: Sexuality and Family Planning unit, WHO Region- al Office for Europe, Scherfigsvej 8, 2100 Copenhagen 0, Denmark. Evaluation des programmes de plani- fication familiale (Evaluation of family planning programmes) (1993). A peda- gogical module intented for profession- als working with family planning pro- grammes in public services or nongo- vernmental organizations.Written by Professors Coue, Jourdain and Lecorps, from the National School of Public Health in Rennes, France. From: Sexua- lity and Family Planning unit, WHO Regional Office for Europe, Scherfigsvej 8, 2100 Copenhagen 0, Denmark. EVALUATION DES PROGRAMMES. DE PLANIFICATION FAMILIALE IYA:'.'S ' biannual report details the orga- nization's work over the last two years to improve women's access to safe abortion care. From: IPAS, 303 East Main Street, P.O. Box 100, Carrboro, NC 27510, USA. High-Risk Births and Maternity Care. A report from the Demographic and Health Surveys programme based on data from 28 developing countries. The findings reveal that millions of women are in need of contraception to safeguard their health and survival and that of their children. From: DHS, Macro Interna- tional, 8850 Stanford Boulevard, Columbia, Maryland 21045, USA. Contraception: Your choices is a 26 page booklet with basic information about contraceptive methods. From: FPA, 27-35 Mortimer Street, London WIN 7NJ, United Kingdom. Magazines/ Newsletters IPPF Open File is a monthly newsletter produced by the International Planned Parenthood Federation, cover- ing international, national and IPPF events, with various subheadings: Law and Policy, Medical File, Status of Women as well as a broad section for Resources and Meetings. Write to: IPPF, Regent's College, Inner Circle, Regent's Park, London NWl 4NS. 19 Magazines Reproductive Health Matters is a new international journal published twice a year in English. It offers in-depth anal- ysis of reproductive health matters from a women-centred perspective. This proj- ect is supported by a grant from the Ford Foundation (USA), under the auspices of the Appropriate Heath Resources and Technologies Action Group (England). Subscriptions: Group/organization Pounds 24/$40 per year, Individual Pounds 18/$30 per year, supporting sub- scription Pounds 36/$60 per year, pay- able to: Reproductive Health Matters (A/C payee), 1 London Bridge Street, London SEl 9SG, United Kingdom. Tel. 44.71.357.0136 Fax 44.71.357.0137. Population and Development Review is a quarterly journal published by The Population Council, examining popula- tion dynamics and socioeconomic change. Subscription rates: US$24.00/ year or US$40.00/2 years, payable to Population and Development Review, The Population Council, One Dag Ham- marskjold Plaza, New York, NY 10017, USA. Partnerships - the family education exchange is a magazine published by the Community Education Development Centre, Lyng Hall, Blackberry Lane, Coventry CV2 3JS, United Kingdom. .... Videos Learning about sex "Sexuality - magic word, taboo word. Sexuality interests everybody, at every age, yet it is also the most secret aspect of everybody's life." With these words, the French Committee for Health Educa- tion (CFES) has launched four new documents and three videos aimed at informing people, of all ages, about sex. For six to eight-year-olds, there is a cas- sette called "The happiness of life," and RUSSIAN FEDERATION Contents Page Summary 2 The country, its people and economy 3 Health status 6 Lifestyles 21 Environment 24 Health care services 26 International collaboration 29 References 32 HIGHLIGHTS ON HEALTH IN THE RUSSIAN FEDERATION for seven to 11-year-olds a booklet cal- led "Girls and boys." For ten to 15-year- olds, there is a short brochure entitled "Human sexuality," and for older chil- dren and their parents, a 64-page brochure called "Loving means being informed," and a video called "Love, love." Directed at those responsible for teaching sex to children are a guidebook, "How to talk to adolescents about AIDS," and a video film "Sex, love, words." For further information, contact: CFES, 2 rue Auguste Comte, F-92170 Vanves, France. Tel (33) 1.4645.4500, fax (33) 1.4644.0664. Sex - A guide for the young. Colourful animation with humour and a frank approach are the elements used to introduce a difficult subject - the first sexual experience. Available from: Edu- cation media film and video limited, 235 Imperial Drive, Rayners Lane, Harrow, Middlesex HA2 7HE, United Kingdom. Tel (81) 868.1908, fax: (81) 868.1991. Jogos de Crescer. A 30 minutes video on sexual education in Portuguese. Available from APF, Rua Artilharia Um, 38, 2 Dto, P.1200 Lisbon, Portugal. ,J 1. Country "highlights" give an over- view of the health and health re- lated situation in a given country and compare, where possible, its position in relation to other coun- tries in the WHO European Reg- ion. The "highlights" have been developed for operational purposes and do not constitute a formal sta- tistical publication. They are based on information provided by Mem- ber States and other sources as listed. The "highlights" are regu- larly updated in close collabora- tion with Member States. "Highlights" can be ordered from: Ms Mirvet H. Abou Shabanah Technical Officer Epidemiology, Statistics and Health Information World Health Organization Regional Office for Europe Scherfigsvej 8 2100 Copenhagen 0 Denmark ENTRE NOUS 24, October 1993 Q) E "' :i: Q) a: E :, c:: (/) -0 "' :::ie >, .c -"' .; · E c: Q) 0 .!: -0 $ c: it