United Nations Permanent Forum on Indigenous Issues, International Expert Group Meeting: Sexual health and reproductive rights: articles 21, 22 (1), 23 and 24 of the United Nations Declaration on the Rights of Indigenous Peoples
Indigenous Women’s Sexual and Reproductive Health in Asia
Written by Asia Indigenous Peoples Pact (AIPP)
In the light of existing inequities in health care provision that impact negatively on the health of indigenous peoples in general, and indigenous women in particular, a research project was undertaken to look into the Sexual and Reproductive Health and Rights (SRH) Gaps among Indigenous Peoples in Asia. This study was commissioned by Plan International Asia and coordinated by Asia Indigenous Peoples Pact (AIPP).
Indigenous Peoples and Areas Covered by the Research
The research focused on indigenous peoples in four countries of Asia, most of whom live in remote areas. The varying locations of the 28 communities covered imply different levels of outside social, cultural, political and economic influences, access and rights to natural resources, and access to sexual and reproductive and other health services and information.
|Country||Indigenous Peoples Groups||Communities covered|
|Philippines||Buhid, Tau-buid, Alangan and Iraya, four tribes among the Mangayan peoples in the remote, interior forest of Mindoro Island in central Philippines||10 indigenous communities in the 5 municipalities of Mamburao, Sta. Cruz, Sablayan, Calinataan and Rizal in the Province of Mindoro Occidental|
|Thailand||Moken and Moklen people, 2 sub-groups of the ‘Chao Lay’ or ‘sea gypsies’ living in the coast of the Phang-nga and Ranong provinces in southern Thailand||5 communities of the Moken and Moklen, namely Lao island and Chang island in Ranong Province and Namkhem, Thab Tawan and Thung wah in Phang-nga Province|
|Vietnam||Mong, Dao, Tay and Nung people in the mountainous Hoang Su Phi district, Ha Giang province in Vietnam||8 villages of the Mong, Tay, Dao and Nung indigenous peoples in 4 communes in Hoang Su Phi district, Ha Giang Province, Vietnam|
|Pakistan||Potohari indigenous peoples from the Potohar region residing near the capital Islamabad, Pakistan||7 villages of the Punjabi Potohari communities in Rawalpindi and Islamabad districts, Pakistan, namely Bari Imam, Golra Sharif, Saidpur, Malpur, Baroha, Karlot and Shahdra|
The following results were concluded from research conducted within indigenous communities in the Philippines, Thailand, Vietnam and Pakistan, though the following themes are a reflection of the situation of SRH for indigenous women in Asia as a whole.
Common Themes of Indigenous Women’s Reproductive Health and Rights in Asia
Concept of Sexual and Reproductive Health
The indigenous peoples covered by the research generally define sexual and reproductive health as having a healthy family life wherein mothers give birth without any problems and babies grow up to be healthy children. They connect this to the intactness of their community and to the health of the environment, which is the source of their food security. They also believe that a stable social support system is essential for the sound and healthy flow of the reproductive processes.
Sexual and reproductive health is interrelated with the rest of the indigenous peoples’ make-up. It must thus be analyzed and understood in the light of its interconnectivity with existing traditional and/or influenced socio-economic, cultural and political environs and structures in indigenous communities.
Through our research, AIPP found that the most popular birth control methods among Moken-Moklen women, of Southern Thailand, are contraceptive pills, injection and implants. Other forms such as female sterilization, emergency contraception and condom are not as popular. There is a belief that certain birth control methods like sterilization and contraceptive implants have adverse health impacts and reduce their strength, preventing them from performing strenuous work. Birth control is considered the duty of women
rather than men.
Moken-Moklen women are too shy to be examined by a male doctor and most have never undergone gynecological examinations. It was found that pregnant women generally do not take special care of themselves during pregnancy. In communities located near a local health center, such as Thungwah, Thab Tawan and Namkhem, women can attend pre-natal clinic without travelling, which is convenient for them. However, the Moken women on the isolated Lao Island and Chang Island do not usually go to pre-natal clinic or have regular checkup. Some women did not have information on the importance of pre-natal clinic.
The changing perspectives on sexuality, marriage, pre-marital sex, gender roles and divorce are clearly observed. The gradual loss of indigenous knowledge and practical know-how on giving birth, pre-natal and post-natal care, and indigenous herbal and medicinal plants is also evident among the Tau-buid and Buhid communities of the Philippines. The imposition of the health center as the center for childbirth is a factor in the loss of traditional birthing methods, which have long been proven effective, culturally appropriate and socially relevant. External cultural influences and discrimination have changed the attitude of younger generation. Today, pre-marital sex is considered a common practice among all tribes.
In the communities studied in Vietnam, the majority of women do not use contraceptive methods voluntarily. Rather, contraception is imposed by administrative policies and ordinances for the birth-control program. In this case, ethnic women are more inclined to take the initiative to use contraceptive methods rather than ethnic men. Majority of them still possess the belief that family planning is the principal responsibility of women. Patriarchal concepts widely exist among ethnic communities in the district.
In Pakistan, the concept of SRH in the studied communities is limited to family planning and childbirth, which are seen as a woman’s responsibility. Men never disclose or seek treatment for their reproductive problems because this goes against the male ego. The birth of a male child is considered a must to carry on the name of the family or clan. A woman may stop having children if she has three or four sons. But with as many or more daughters, she will continue to have more births in the hope of having a male child. Sexual violence by the husband is perceived as being part of family life and is rarely reported. Women continuously suffer sexual violence and forced sex with their husbands. Major cases of sexual violence like child sexual abuse or rape are reported only if the perpetrator is not from the family. Close relatives abusing young girls usually get away with it, as girls are too afraid to disclose the incident.
Traditional Knowledge and Practices
Indigenous women exhibit similar characteristics in their knowledge, attitudes and practices related to sexual and reproductive health. For one, indigenous women possess traditional knowledge and practices that reflect their perspective and depth of understanding on health and causes of disease, which are not purely based on metaphysical beliefs, but rather on a holistic outlook on health. They are aware that health is the interrelated condition, not just of the physical but also of the mental, emotional, social and spiritual self.
Indigenous women continue to hold on to their traditional beliefs, knowledge and practices on reproductive health that were passed onto them by their ancestors. These traditional knowledge and practices have to do with courtship, marriage, sexual relations, family life, gender relations, pregnancy, birth, post-natal care, childcare, child rearing, healing and divorce.
The indigenous women studied in the research all possess and continue to practice traditional healing knowledge and child birth methods such as the use of traditional midwives or birth attendants, use of herbal medicine and other healing materials and rituals, which have been passed on to them from their ancestors and transmitted through generations, from the mother to the child.
In the past, there was little mention of sexual and reproductive health among the Moken-Moklen people, from Southern Thailand. These issues were considered private, which people were expected to learn by themselves. Nevertheless, almost all Moken-Moklen communities have certain reproductive health knowledge and practices on general health care, pregnancy, birth control and post-delivery health care that conform to their long-standing beliefs. Moken and Moklen women are recognized as spiritual leaders, traditional midwives and traditional health care providers. Their traditional wisdom, however, is at risk of disappearing because only the elders still practice this traditional knowledge. In the past, there were traditional midwives on the island to give the Moken women advice and health care. Now, the number of midwives has diminished and none exist in some communities.
The Mokens still prefer to give birth at home rather than going to a hospital. Most women think pregnancy does not affect their work because they can perform their work at a normal pace or at a slightly reduced pace. In the past, Moken-Moklen women would usually lie by a fire after giving birth and take herbal medicine for health rehabilitation. Now, Moken-Moklen women who live in the coastal areas usually go to a hospital to give birth and the practice of lying by a fire is neglected. Many adults are of the opinion that new mothers do not recover as fast or as well as in the past. Moken-Moklen women on Lao Island and Chang Island who still use the services of a traditional midwife and lie by a fire after giving birth do not have many health problems, with the exception of child nutrition.
Threats to Traditional Knowledge
The loss of plants, animals and forests where herbal medicines are found, and the dying out of elders who possess such knowledge are factors that have hindered the transmission of invaluable traditional knowledge. Moreover, health programs that recognize, promote and develop traditional knowledge and practices are sorely lacking.
It is no wonder that much of the traditional knowledge and values on reproductive health are now at risk of disappearing. There has been a marked decline in the use of traditional medicinal practices among the indigenous communities, as well as a rise in reproductive health problems, as new cultures, modern technology, and economic, political and social pressures impinge on these communities. Concepts, knowledge and practices of sexual and reproductive health have changed, as the indigenous communities experience varying degrees of cultural assimilation. In more urbanized areas, especially those near tourist areas, the changing society and greater freedom given to youth in recent years have led to an increase in pre-marital sex without the use of protection from early pregnancy and sexually-transmitted infections, and increased their vulnerability to sexual abuse and exploitation.
In the Philippines, It was observed that the early age of marriage, the presence of elders, and the close-knit interaction among families and kin of up to 5 generations, have had a positive bearing on the oral transmission of history, culture and rich indigenous knowledge systems and practices. However, the inter-generational transmission of culture was disrupted by the gradual cultural assimilation experienced by almost all the communities. Various religious, non-government and government entities have entered the communities. These interventions have changed the worldviews and weakened the collective decision-making of the tribes.
Generally Poor Conditions of Healthcare Services
The extremely poor condition of general healthcare services available to indigenous peoples is still the most fundamental problem that indigenous peoples face in relation to sexual and reproductive health. National health systems have neglected and failed to deliver the necessary basic health services to these remote indigenous communities, making basic health care and sexual and reproductive health services unavailable, inaccessible, unaffordable and inadequate for these indigenous peoples.
The overall education, economic and health situation of the indigenous communities is extremely poor and hence, sexual and reproductive health is much neglected. Health centers are located far away from the villages and many indigenous women are unable to avail of pre- and post-natal check-ups; for example, 40% of Orang Asli villages in Peninsular Malaysia are not even accessible by land transportation, therefore preventing women in these communities from accessing health services. The rugged and difficult terrain and the remoteness of their communities make it extremely difficult for indigenous peoples to access or avail of health services and treatment especially during emergency. Lack of medical equipment, or non-functional equipment, unavailability of drugs and other health commodities, absent or poorly trained staff, and negative attitudes on the part of service providers, also contribute to the poor quality of health services in areas where indigenous peoples live.
Our research found that Moken-Moklen women receive reproductive health information from doctors, nurses or public health personnel. However, there are very few reproductive health personnel and they have heavy workloads, and thus cannot perform regular proactive services to local people. At times, village health volunteers do not provide correct information on health care for pregnant women, gynecological examination and sexually transmitted diseases.
Almost all respondents from the Iraya and Alangan tribes, in the Philippines, have inadequate access to medical services and records are severely lacking. Records from Balangabong among the Tau-buid people revealed that about 25% of the children are underweight while 9% are severely underweight. Common illnesses in the communities are preventable such as diarrhea, malaria, respiratory ailments, skin diseases and parasitism. Almost all communities have poor or no sanitation facilities. All communities told stories of how they were rejected by hospitals or how they were treated harshly and inadequately by health professionals. Others were too meek to speak out because they are easily intimidated and do not know how to answer queries of the hospital staff.
The incidence of gynecological diseases is high among ethnic women in Vietnam. This is due to changes in the living environment, unclean water sources, low personal hygiene and carelessness in sexual activities. Sexually transmitted diseases include gonorrhea, herpes, syphilis and fungal viruses. People suffering from these diseases prefer home treatment rather than going to the hospitals and medical centers.
Awareness of HIV/AIDS and STDs is very limited among ethnic groups. Some ethnic girls and boys aged 16 years and above have already engaged in sexual activities without proper protection and knowledge of RH.
Non-Recognition of Indigenous Peoples in the National Legal Policy Framework
Another factor that affects the accessibility of health services is the particular legal policy framework and legal status of indigenous peoples that prevent them from claiming their right to adequate health care. In the Philippines, there is no systematic recording or registration of births among all Mangyan communities studied. This is a barrier for them to access the much-needed health services, which are unaffordable, aside from the inconvenience of travelling long distances and the language barrier.
Similarly, the lack of citizen rights has been a long-standing problem of indigenous peoples in Thailand, according to David Feingold, coordinator for the Bangkok-based Trafficking and HIV/AIDS Project at the UN Educational Scientific and Cultural Organization (UNESCO), almost four out of 10 indigenous peoples in Thailand do not have citizenship, which makes them ineligible to access basic social services, including health care and education as well as income generating activities.
In the project areas in Thailand, access to information on health services and reproductive health is quite limited, especially among non-literate women or those who cannot read or write in Thai. Despite this, many Moken-Moklen women are knowledgeable about various modern methods of birth control. The main problem in accessing health and reproductive health services is the absence of a national identity card, especially for the Moken groups on Lao Island and Chang Island. This prevents them from getting the needed health services, which are unaffordable, aside from the inconvenience of traveling. The Moklen in the other communities do not have problems of legal citizenship status, but these people pay less importance to healthcare than to earning a living to feed their families. The changing society and excessive freedom given to children in recent years have led to an increase in pre-marital sex among the youth without the use of protection from early pregnancy and sexually-transmitted infections.
In Vietnam, the government has issued a significant number of policies regarding Medical, Health and Reproductive Health (RH) services. However, these policies are not fully implemented and have limited accessibility among the people. For instance, National Medical and Health Insurance in Vietnam provides free medical treatment, health services and medicines to people with Medical and Health Insurance cards living in poor communities. The four communities studied in the research are categorized as poor household communities and are supposed to be supported 100% of their Medical Insurance premium. However, due to limited budget allocations, this support could not be extended to the local ethnic people in Hoang Su Phi district.
The majority of the local ethnic people, especially women and poor households in the remote parts of the villages, are not fully aware of these regulations and support. Local people holding Medical Insurance cards do not know how to maximize the National Medical Insurance Priority regulations in availing of free diagnosis, check-up, examinations, medicines and healthcare treatment. The right to public health care is not fully understood among ethnic communities.
In Pakistan, laws based on custom or religion exists alongside state legislation, and do not identify or count indigenous people. Such laws frequently restrict women’s rights within the family, in marriage, on access to health, family planning, divorce and the right to inherit property. Although much effort has been made during last two decades to achieve better conditions for women in the private and public spheres, discrimination and gender injustice remain prevalent in both urban and rural areas.
Education on SRH and the rights and status of women are among the most neglected areas of policy-making. Although a lot of legislation has been passed during the last few years to protect women from violence and sexual harassment, education of men and women on SRH remains inadequate.
Barriers to Access of Sexual and Reproductive Health Care Services
Other hindering factors that prevent indigenous peoples access to sexual and reproductive health care are social discrimination, cultural shyness, religious dominance, lack of education, and minimum economic resources. Some communities have experienced rejection by hospitals or harsh and inadequate treatment by health professionals. Other reasons cited by indigenous women for not seeking health services are their extremely busy lives, weak position in decision-making, and the economic costs entailed in going to a distant health center and buying medicines. Moreover, sexual and reproductive health is considered private and is rarely discussed.
Added to this is the lack of understanding and awareness of sexual and reproductive health because access to information on health services and reproductive health among local indigenous people is quite limited. Materials on reproductive health issues are generally not available in local languages or format that are attractive and understandable to indigenous women. This is especially so among indigenous women, who cannot read, write or speak the national language. Many indigenous women who are confined to the home can hardly access information on sexual and reproductive health.
It is apparent that the current situation in all the indigenous communities studied leaves much to be desired in terms of the delivery of basic and reproductive health services, and access to information on sexual and reproductive health. This situation attests to the denial and violation of indigenous peoples’ rights to health in general, and to sexual and reproductive health, in particular.
In Vietnam, due to rugged and difficult terrain in the research sites, it is very difficult for local ethnic people to access or avail of health services and treatment. It takes them at least 40 minutes by motorbike to go to the Medical Station during dry season. They have even more difficulties during rainy season. Most of the time, local ethnic people especially women have to walk for at least 3 hours to reach the Medical Stations, passing through rugged mountainous terrain and high cliffs.
In serious cases, ethnic people have to carry their patients to Hospitals and Medical stations for admission. Most commune Medical Stations have the standard medical and health equipment, facilities and functional rooms, but these are of low-grade quality. Medical Stations are only able to accommodate 3 patients at one time. There is no pharmacy in the four communities studied. Due to limited supplies, facilities, equipment and professional qualifications of medical staff, there are a lot of difficulties in diagnostic and health care treatment in remote communities.
Wider Social Realities of Indigenous Peoples that Affect SRH and Rights
The above-mentioned problems of sexual and reproductive health are but manifestations of the wider socio-economic, political, cultural and environmental conditions that beset indigenous communities as a whole. They reflect the core problem of poverty and vulnerability of indigenous peoples arising from their marginalization and their unrecognized legal status and rights in the countries they find themselves in. The major social factors that pose barriers to the delivery of adequate sexual and reproductive health and the recognition of SRH rights of indigenous peoples include: Deprivation of land rights and displacement; Continuous degradation of the environment leading to the disintegration of the interrelatedness of the economic, social, political and cultural life of the indigenous peoples – according to the International Fund for Agricultural Development (IFAD), more than 40 percent of indigenous women and girls in Thailand who migrate to cities for work end up in the sex industry; worsening food insecurity; loss and/or dwindling sources of livelihood and self-sufficient productivity; persisting discrimination; inequities and lack of social services for indigenous peoples; absence of a local comprehensive community-based health program; low representation of indigenous peoples in decision-making processes of the local government; cultural assimilation and continuous loss of culture and indigenous knowledge systems and practices; and weakening of inter-generational transmission of culture.
For the Moken/Moklen people, today’s rapid economic and social changes prevent many families from forming close relations as before. Parents now spend less time with their children. There are very few families wherein the mother can stay home to look after the children. Child-rearing responsibilities have increasingly shifted to grandparents, relatives or neighbors. Mothers or relatives take care of infants, while children of school-age attend school during daytime. Many school-age children sometimes leave school to help the family earn a living. This has resulted in changing attitudes regarding sexual relationships and marriage especially among the youth.
The Moklens of Thungwah Community live next to a major tourist attraction, Khao Lak, which has had significant impacts on their lifestyles and livelihood. During the tourist season, both men and women usually go out to work and thus have less family time. Many teenagers leave school at a young age of 11-12 years old, and tend to assimilate new cultures for lack of close adult supervision and advice. Some children in the community have become alienated from their own families, forming gangs, riding around on motorcycles and getting addicted to computer games, pornography and even drugs. After the decline of tourists in Khao Lak in the past few years, the employment rate has dropped and many adults who cannot find permanent jobs turn to alcohol and gambling. These changes have had adverse impacts on Moklen families leading to poor quality of life, family violence, community conflicts, and family breakup.
According to the Hmong Women’s Network of Thailand, patrilocal practices and the spiritual beliefs of Hmong communities in Northern Thailand, often lead to health issues for unwed and divorced women. For example, an unwed mother is not allowed to give birth within her parents’ house. In remote communities where home births are often necessary due isolation from hospitals or medical centers, this often leads to unsafe birthing practices. In addition, the social hierarchy of Hmong communities, in fact most indigenous communities, generally necessitates the women doing manual labor, including farming and field work. It is not uncommon for women to miscarriage due to heavy workloads, and many Hmong women are known to give both in the field/farm.
Recommendations for States, non-government agencies and health service providers;
1. For States to recognize the legal status, particular rights and conditions of indigenous peoples, especially in remote areas and to formulate appropriate health policies and strategies to rectify the historical neglect and disproportionate attention given to the health needs of indigenous peoples. Steps should be taken to eliminate the barriers to the effective delivery of and access to basic and suitable health services to indigenous peoples and indigenous women.
2. The formulation of health policies and programmes should include the full and effective participation of indigenous leaders and experts on the health and wellbeing of indigenous peoples in order to account for the experience, views, knowledge, concerns and needs of indigenous peoples.
3. Recognize indigenous health systems as alternative or complimentary to State health systems. This means the complementation of both systems should be strengthened in meeting the needs of indigenous peoples, especially women and girls. Steps should be taken to prevent or arrest the negative factors leading to the loss of traditional knowledge and healing practices through environmental degradation, displacement from lands and resources, and weakening of traditional social values. Simultaneously, attention should be paid to the discontinuation of both traditional and modern health-related practices and beliefs that have proven to be harmful to women and children.
4. The conduct of widespread and appropriate information and education campaigns in indigenous communities on SRH and rights of indigenous women shall be developed with the participation of indigenous leaders and women. This shall take into account appropriate methods, forms and communication strategies based on the level of literacy and understanding of indigenous communities and may include traditional communication approaches such as storytelling, plays, songs where appropriate.
5. Steps should be taken to strengthen the capacity and cultural sensitivity of national and local government institutions and personnel responsible for the delivery of SRH services to indigenous peoples by increasing their budget allocation and resources, improving equipment and facilities appropriate for indigenous women, that include training and raising their awareness on the particular concerns, needs and conditions of indigenous peoples. Where possible, consideration should be given to the training of indigenous health service providers and their integration in health institutions.
6. The role and contributions of indigenous women in the enhancement of traditional knowledge and sustainable resource management should be fully recognised along with the respect for the rights to their land, resources, livelihoods and environment. This will provide an enabling environment for the continuing survival and development of indigenous peoples alongside their access to basic and appropriate health and social services for their good health and well-being.