SEXUAL HEALTH (SH) AND REPRODUCTIVE HEALTH (RH)

Sexual health is the possibility of enjoying mutually satisfying sexuality, free from abuse, harassment or sexual coercion, of being safe from sexually transmitted diseases and the possibility of achieving or preventing an unwanted or unplanned pregnancy¹⁰.

The concept of reproductive health is one of the milestones in the social history of the 20th century. It was developed as a result of experience during the 1970s and 1980s and became universally valid with the consensus of the 1994 International Conference on Population and Development in Cairo. The difference between women in rich and poor countries lies in the level of RH^7,8.

The understanding of RH has advanced significantly in recent decades. The field of RH is different from other health fields. The involvement of society at large and the consequences for that society are different in other areas of medicine and health and for no less reason than human reproduction; it is the means by which each society perpetuates itself and its traditions. No society, religion, culture, or national system of law has been neutral on the issue of human reproduction. Progress in RH, much more than any other field of health, requires input and good performance from health care providers, health policy makers, legislators, lawyers, human rights activists, women's groups, and society in general¹⁰.

GENDER CONSIDERATIONS

Despite advances in SRH and health sector reforms, due consideration has not yet been given to the fact that men and women present differences in their health, since women have greater needs for services, due to their biology and reproductive function. On the other hand, there is still discrimination, inequity and exclusion of a significant number of women, especially the poorest ones, which puts their health at serious risk². If SRH is to be achieved, people must be given information so that they can exercise control over their lives and access to related health services must be guaranteed. While these rights and the ability to exercise them are an important value in themselves, they are also a condition for well-being and development. The neglect and disorganization of SRH services and associated rights are the cause of many health-related problems around the world. Incidentally, the burden of disease in RH is 20% in women and 14% in men^10,12.

Many of the health problems related to sex or sexuality depend on the nature of power relations between men and women. A key indicator of the differences between men and women is maternal death (MM). As we know, there is no "paternal death" related to pregnancy or childbirth, because this only occurs in women. One of the main causes of MM is abortion, which men do not suffer either². To the above we must also add that women suffer more gender-based violence¹³, a greater burden of STIs, that HIV infection is increasingly frequent at the point of departure of heterosexual relations; and as if that were not enough, women suffer more social and economic inequalities, having less education, less economic capacity and less decision-making capacity.

COMMITMENT OF THE MEDICAL-SCIENTIFIC SOCIETIES

In 2002, during the Latin American Congress of Obstetrics and Gynecology held in the city of Santa Cruz de la Sierra, Bolivia, the Latin American Federation of Obstetrics and Gynecology Societies (FLASOG, by initials in Spanish) officially created the Committee on Sexual and Reproductive Rights and in that same Congress, the FLASOG Assembly approved the Declaration of Santa Cruz, in which it assumed the defense of the following sexual and reproductive rights:

Right to a healthy and safe motherhood, without risk of death.

The right to a sexual life free of violence and the risk of contracting a sexually transmitted infection and unwanted pregnancy.

Right to regulation of fertility through access to contraceptive methods including emergency contraception

The right to termination of pregnancy within the framework of the law.

The right to information on sexual and reproductive health.

The right to access sexual and reproductive health services.

To these rights, as part of this work, we must add the health of adolescent girls.

Taking as a framework the list of rights whose defense has been assumed by FLASOG and, therefore, by the Peruvian Society of Obstetrics and Gynecology, this article aims to clarify the concept of sexual and reproductive health, to situate SRH within Human Rights and, as a consequence, within Sexual and Reproductive Rights, discuss some gender issues, examine the situation of SRHR in our country¹⁴, which we hope for the coming years after making some approaches for its improvement and meeting the Sustainable Development Goals¹⁵.

RIGHT TO FAMILY PLANNING (FP)

Sigmund Freud, even before the definition of SRH and SRR, said "One of the greatest triumphs of humanity would be to elevate the responsibility for the act of reproduction to the level of voluntary and intentional action", as if to say that the reproductive function should be subordinated to the decision and will of individuals and not to a fortuitous fact, imposed by third parties or by society. It is precisely family planning -and contraceptionthat plays an important role in this issue. The Population Reference Bureau maintains that every pregnancy should be desired and that, thanks to the revolution in technology, fertility today should be achieved by choice, which has led to a significant decrease in the fertility rate and therefore to a decrease in the risk posed by pregnancy and childbirth³³.

FP is an effective primary prevention measure to reduce unwanted pregnancy. From the available data it can be stated that 1/4 to 2/5 of MM can be eliminated if these pregnancies are avoided through contraception¹⁸.

In Peru, there has also been progress in FP until the beginning of the first decade of the present century, when the corresponding program not only weakened, but disappeared as such, and FP activities suffered some setbacks, such as logistical difficulties, shortage of supplies, extreme reduction in the supply of surgical contraception, and reduction of training and supervision activities³⁴.

According to the DHS 2000, the total fertility rate has been progressively decreasing and today stands at 1.9 children per woman at the end of her reproductive years, and the interval between births is an average of 62.2 months. The prevalence of contraceptive use is apparently high (77.4%), 55% of which corresponds to modern methods, among which injectable contraceptives are the most widely used (17.1%). Long-acting contraceptive methods (LARC) hardly appear in the public sector, although their frequency of use is higher in the private sector, very similar to that of emergency contraception. Traditional methods are used with a frequency of 22.3%, with the periodic abstinence method being the most widely used, with the exception that only 50% of the women who use it know their ovulatory days. Of all women of childbearing age, 52% no longer wish to have children, 6.1% have an unmet demand for contraceptives, 52.1% have had unwanted pregnancies and the total demand for contraceptives is 87.1%^18).

To fulfill this right, there are still pending issues in FP in Peru after the bicentennial³⁴:

Expand FP services, starting at the first level of care.

Ensure good logistics that diversify contraceptive methods.

Improve SRH information for women.

Improve the quality of care and user choice.

Reduce unmet need for contraception.

Facilitate voluntary surgical contraception in public services.

Availability of a wider range of contraceptive methods, including emergency contraception and long-acting reversible methods³⁵.

RIGHT TO ENJOY A SEXUAL LIFE FREE OF VIOLENCE

The World Health Organization (WHO) defines violence against women as any act of gender-based violence that results in physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life. Six out of 10 women suffer physical or sexual violence in their lifetime, 7 to 36% of women suffer sexual violence in childhood, and 6 to 59% of women suffer sexual violence after the age of 15. Intimate partner violence is the most common form of violence against women worldwide³⁶.

According to the ENDES 2020, 54.8% of women were victims of violence perpetrated at some time by a husband or partner, with a tendency to be higher in urban area residents (55.3%) compared to rural area residents (52.3%). Among the forms of violence, psychological and/or verbal violence stands out (50.1%), which is aggression through words, insults, slander, shouting, insults, scorn, mockery, irony, situations of control, humiliation, threats and other actions to undermine self-esteem, followed by physical violence (27.1%), which is aggression exercised through hitting, pushing, kicking, slapping, among others. And finally, sexual violence (6.0%), which is the act of coercing a woman to perform sexual acts that she does not approve of, or forcing her to have sexual relations¹⁸. However, these figures correspond to women of childbearing age who are in union and leave out those under 15 years of age and those over 49 years of age.

Age is not a barrier that prevents violence, since girls, adolescents and adult women can suffer physical and psychological injuries and, in extreme cases, death. However, it is women of reproductive age who may face the greatest consequences. If a woman is a victim of violence, she may suffer lifelong repercussions, and those who are abused as children are at even greater risk of becoming victims as adults¹⁹.

Social tolerance of violence makes it difficult for women to report physical and sexual abuse and therefore statistical information becomes questionable. On the other hand, health professionals, due to their eminently biomedical orientation, do not inquire about the women they treat, do not give it due importance, because they consider it a private matter, and women who have been sexually abused avoid making a complaint because they do not trust health providers or those who impart justice¹⁹.

One of the most common forms of violence against women is abuse by their husbands or intimate partners, who use it as a form of control over them and an expression of power imbalance. Sexual coercion exists as a continuum, from forced rape to other forms of pressure that push girls and women to have sex against their will. For many women, sexual initiation was a traumatic event accompanied by force and fear¹⁹.

Studies carried out in the community and within reproductive health services in Peru reveal that the rates of sexual violence against women are relatively high when compared to other regions of the world^37,38. Violence against women in any form occurs at any time in their lives and pregnancy is not a protective factor. Violence during pregnancy is more frequent than any of the gestational pathologies. What happens is that it is not detected or, if it is, it is not given due importance. Reproductive health services in Peru find that violence in any of its forms occurs in 31.9% of pregnant women; psychological violence in 23.3%, physical violence in 7.4% and sexual violence in 7.1%, although with some frequency two or three types of violence can coexist on the same woman³⁹.

The repercussions of violence against women are well identified. It can have fatal consequences, such as homicide, suicide, maternal death or death due to HIV/AIDS. It can also have non-fatal consequences on general physical health, mental health, chronic injuries and disabilities, and sexual and reproductive health problems. Sexual violence can result in shortand longterm health consequences for women, including physical trauma, such as vaginal fistula, HIV infection, unwanted pregnancy, and unsafe abortion. Vulnerability to STIs, including HIV may be higher than in consensual sex, due to genital trauma and in the case of multiple perpetrators. The resulting psychological trauma may have a negative effect on sexual behavior and relationships, the ability to negotiate safer sex, and a potential increase in substance abuse^40-43.

In relation to sexual violence, it is important to recognize that timely and quality care has a positive and significant impact on addressing the consequences and preventing complications of rape, which affect quality of life by perpetuating emotional, biological and social damage, including forced pregnancy and sexually transmitted infections⁴³. Notwithstanding this statement, in much of Latin America and specifically in Peru, there are still no comprehensive care services for victims of sexual violence that ensure early attention.

In addition to the early approach to these cases, the following should be expected after the bicentennial¹⁴:

Effective legislation to comprehensively manage sexual violence (SV) requires functioning medico-legal linkages to enable the enforcement of justice and the provision of health services for survivors.

The health sector must provide post-rape care services and collect and deliver evidence to the justice system.

Services should be integrated through referrals, using guidelines and consultation pathways, treatment protocols and standardized medico-legal procedures.

The health sector is the nexus between prevention, treatment and rehabilitation following SV. This sector should provide clinical treatment, preventive therapy, psychological support, information and counseling, and coordinate referral of victims to specialized services.

Empower women.

Expand and improve SRH services.

Detect cases of violence against women in the daily care routine.

Provide early and comprehensive care for sexual violence.

Coordinate with other health and legal services so as not to re-victimize women.

RIGHT TO TERMINATION OF PREGNANCY WITHIN THE FRAMEWORK OF THE LAW

Despite high contraceptive prevalence and the existence of safe and effective methods of abortion, millions of unsafe abortions continue to occur worldwide each year. This is not only because all contraceptive methods occasionally fail and because people do not use them consistently, resulting in unwanted pregnancies, but also because millions of women around the world do not have access to safe abortion services when they choose to terminate a pregnancy within the framework allowed by law. Where abortion is legally restricted, some women will have unwanted children; however, most women end up having unsafe abortions. Whatever the method of termination used, abortion can be incomplete or lead to serious complications; hence the need for good postabortion care in a timely manner, because its delay threatens women's lives and health(14). According to Lancet, between 2015-19 there were 121 million unintended pregnancies (UIP) worldwide annually, which corresponds to 64 UIP per 1 000 women aged 15-49 years. Sixty-one percent of those UIPs ended

in abortion (totaling 73.3 million abortions annually and corresponding to a global abortion rate of 39 per 1 000 MEF. In countries where abortion was restricted, a higher proportion of UIPs ended in abortion⁴⁴.

We do not know the exact figures for abortion in Peru, since it is a clandestine practice. However, Ferrando's studies, using indirect methodology, which has proven to be effective, have been able to determine that more than 370,000 induced abortions occur in the country each year. This means the occurrence of more than 1 000 abortions per day, a rate of more than 50 per 1 000 women in fertile age, higher than the average for Latin America. The vast majority of these abortions are unsafe, causing complications and eventually maternal deaths(45). Precisely, to avoid deaths and severe complications, it is necessary to provide early, efficient and humanized care for women who come to a health facility with complications arising from an abortion and not subject them to unnecessary delays for proper care, since this can lead to death⁴⁶.

On the other hand, most abortion complications that come to the hospital are mild or moderate bleeding and are managed with uterine curettage or manual vacuum aspiration. Nowadays they can also be successfully treated by oral or sublingual administration of misoprostol, without the need for surgical management⁴⁷.

In recent years there have been extremely important interventions in Peru for the prevention and management of abortion. Chronologically, we will first cite the FIGO Initiative for the prevention of unsafe abortion carried out in 43 countries in the world, one of which was Peru, with the co-participation of SPOG and MINSA, with flattering results⁴⁸. Then we will cite the approval by MINSA of the National Guidelines for Termination of Pregnancy up to 22 weeks²⁰ and, finally, the SPOG-FIGO project being developed in Peru for therapeutic abortion advocacy.

In addition to the above-mentioned interventions, we should expect to see several activities after the bicentennial to prevent the occurrence of unsafe abortion and its serious consequences:

Do sex education early in the life of girls.

Improve FP services and supply.

Implement the National Therapeutic Abortion Guidelines with a strong commitment from health professionals.

Reformulate the legislation on therapeutic abortion and include serious congenital malformations and pregnancies resulting from rape as grounds for abortion.

Promote the clarification of values among health professionals.

Humanized care for incomplete abortion, respecting the privacy of the user.

Develop post-abortion contraception, promoting LARCs.

ADOLESCENTS' RIGHT TO SEXUAL AND REPRODUCTIVE HEALTH

Adolescent girls' sexuality is characterized by difficulty in agreeing on a behavioral model with their partners, as well as by unstable relationships, emotional conflicts, secrets, rebellious attitudes and, frequently, unprotected sexual relations, especially in the early stages of their sexual activity. Adolescent girls are also frequently exposed to gender based violence (GBV) and especially to sexual violence. As a result of these conditions, many unwanted pregnancies occur during adolescence, when girls and their partners become sexually active without considering the need for contraception or having access to appropriate services⁴⁹.

Adolescent reproductive behavior is an issue of recognized importance, not only in terms of unwanted pregnancies and abortions, but also in relation to the social, economic and health consequences. Pregnancies at a very early age are part of the cultural pattern of some regions and social groups. They usually occur in couples who have not started a life together, or take place in situations of consensual union, which brings physical, emotional and social consequences, including the loss of continuity in their studies and employment difficulties. It usually forces couples to take refuge in the family home and unfortunately ends with the abandonment of the woman and child, thus configuring the social problem of the single mother. On the other hand, many of these pregnancies end in abortions performed by people without proper professional training and in inadequate sanitary conditions, since specialized medical services are scarce and expensive. In addition, abortion is illegal in Peru⁵⁰. Of the total number of adolescents aged 15 to 19 years, 8.2% had ever been pregnant; of these, 6.5% were already mothers and 1.7% were pregnant for the first time. Of all adolescents aged 12 to 17 years, 2.3% had ever been pregnant; of these, 1.7% were already mothers and 0.6% were pregnant for the first time. Contraceptive use is still low from the beginning of their sexual life¹⁸.

Given the adverse repercussions of adolescent pregnancy, in 2013 MINSA approved the Multisectoral Plan for its reduction²¹, in addition to other interventions by MINSA, international organizations and civil society institutions. However, there are still activities to be carried out after the bicentennial:

Provide early information and education to adolescent girls at school.

Promote gender equity.

Promote self-esteem among adolescent girls.

Provide adolescent-friendly sexual and reproductive health services.

Provide counseling on safe motherhood, sexually transmitted diseases and violence.

Respect privacy and confidentiality.

Protect adolescents from potential sexual assault.

Facilitate provision of modern contraceptives, including emergency contraception.

Provide humane abortion management.

Offer voluntary termination of pregnancy services in cases established by law.