Dr Duarte Vilar
Posted 12th May 2016
What is the biggest sexual health challenge facing Portugal today?
Actually that’s quite a difficult question to answer; on the face of it, basic sexual and reproductive health indicators are good – according to UNFPA, Portugal has the world’s second highest level of contraceptive prevalence – 95% of women in Portugal who want to use contraceptives are doing so. Equally, on the face of it, sexual and reproductive rights are fairly well respected and protected; we have same-sex marriage, and same-sex couples can adopt children. Fertility treatment can be hard to access. An additional problem is that we have good data on some sexually transmitted infections (STIs) but not others; data collection is, for example, good for syphilis, but not chlamydia. Rates of HIV, which were previously quite high, due, in part, to prevalence among female sex workers, have declined overall, but rates are still rising among young gay men. One of the major challenges we face in Portugal is that most people want to have more children, but they can’t, because there isn’t enough certainty in their lives to have more, due to the ongoing social and economic crisis in Europe. Birth rates over the last four years have collapsed - they haven’t decreased, they’ve collapsed – from more than 105,000 births per year to something like 88,000. That’s a brutal fall. People say they have an ideal family size of 2.3 children; the actual family size now is 1.2. People adapt: most families now have only one child, but it’s not what people want.
APF has now started to talk about the right to conceive. This applies to all people who wish to have children or more children than they have, but they can’t. So they have this right, but it is constrained for social and economic reasons, And, in the case of lesbian, gay, bisexual and transgender (LGBT) people for legal reasons. Access to assisted reproduction for single women or lesbians is currently being discussed in the parliament. We hope that this barrier may be removed.
You paint a fairly positive picture on the policy side. Are you optimistic that sexual and reproductive health and rights will continue to advance in Portugal?
The major challenge is funding, particularly for smaller NGOs in Southern European countries like Portugal. For example, my organisation – Associação para o Planeamento da Família (APF) – used to receive a grant from the Ministry of Health. Until 2009, it took the form of unrestricted, core funding for our work. Since then, only project funding has been available – we have to respond to calls for proposals, and even then, we need to raise 20-25% of co-funding from other sources. That’s very hard on organisations that need trained staff to carry out projects effectively. We also need to remember that, while a positive policy environment is necessary, it isn’t sufficient to advance rights; legal change is not always followed by the changes in attitudes necessary for social progress. For example, laws may, and in Portugal they do, now exist which say that you can’t discriminate against the LGBT community, but discrimination still takes place in practice. In April this year, our armed forces chief General Carlos Jerónimo resigned, days after being summoned to explain negative comments about gay young boys made by the deputy head of the military college.
Is Portugal doing enough to safeguard the sexual health of young people?
There’s been quite a lot of progress. In 2009, Parliament approved a very detailed and progressive law on sex education; possibly one of the world’s most advanced in terms of content and values. In general, sex education has vastly improved, and is delivered in the context of health and/or citizenship education. Obviously while some schools have good programmes, there are some schools that do nothing, and others just get speakers in from outside, which isn’t recommended, as there’s no follow-up knowledge and expertise available to students after the talk. Having said that, during the last three years, the quality of sex education in schools has gone down; while the last government didn’t revoke the law, opportunities to implement it fully and creatively decreased because less funding was available for this work and also because curricular areas that were used to promote sex education, were cut by the former minister. I would say that providing sex education is more difficult now than it was five years ago.
Young people are not accessing the services they need; teenage births are down, but the abortion rate among teenagers is not. Access to contraception is theoretically relatively good, although several youth friendly services were closed in recent years, and available data on young people’s access to services is not up to date.
How is Portugal addressing HIV testing?
Testing is obligatory for pregnant women, but is not compulsory for others. NGOs are quite heavily involved; the Ministry of Health has put out calls for proposals for screening and is funding several APF projects which include screening for HIV, hepatitis and syphilis in male and female sex workers. With respect to HPV, there is good national screening for cervical cancer, and HPV vaccines are routinely given to girls; there is lobbying to extend this to boys and men, and to women over the age at which girls currently receive it.
Are there any HIV challenges not being addressed?
The main challenge is to identify new HIV cases and refer people for treatment as early as possible; too many people present too late in the hospitals. Access to treatment is fairly good and is government funded, but in some more remote parts of the country, the hospital providing the treatment can be quite far away. APF is a member of the Portuguese Civil Society Forum on HIV/AIDS, which plays an effective watchdog role, and funding of treatment has been protected throughout the economic crisis.
What SRH services are available for men?
APF has a men who have sex with men (MSM) project in Oporto where we go into bars and saunas and provide preventive materials, such as condoms and gels. We published a study on MSM in Porto and, although the project was due to end after four years, we won an extension which guaranteed the continuation of the work. The involvement of men more generally in sexual healthcare isn’t great. Male sterilisation is very rare; between 0.3 – 0.4% of men have had vasectomies. Male involvement in family planning is a challenge; most projects are aimed at women. The Ministry of Health has no projects directed towards men except those related to HIV. It’s never had a programme on vasectomy; if you wanted a vasectomy, you’d have to look pretty hard to find it. I would say that the lack of involvement of men is a problem – 20% of contraceptive users use condoms. That’s a bit low for a country with super-easy access to condoms; they’re available in supermarkets and petrol stations, etc. Condoms are most used by young people below the age of 19. Girls aged between 20-24 years tend to start to use the Pill, and after that, condom usage is low. It’s selective; condoms are used at the start of a relationship, but then women tend to take control, and the method used switches away from condoms as the relationship becomes more established. Condom use has remained relatively stable in Portugal.
On a related issue, we also have a project on transsexual sex workers in Lisbon; we have a dedicated street brigade that engages with them to provide relevant services. We are also working more generally with transsexual and intersex people, and the problems they face. Transsexuals frequently experience difficulties accessing surgery; in Portugal such surgery is only available in one hospital, and waiting lists are long. The problems faced by intersex people are now being publically discussed for the first time in Portugal. APF houses an organisation – AMPLOS – which is especially for parents of lesbians and gay men, working with them to overcome difficulties some parents experience in openly accepting the sexuality of their children. This is a new initiative.
How do issues related to gender-based violence impact on the work of APF?
APF is doing a lot of work on female genital mutilation; we have quite a large community from Guinea-Bissau, and approximately 8000 girls in Portugal have experienced some kind of excision or other genital mutilation, or are at risk. Most of them are living in the Lisbon area. APF carries out training activities with change agents within these communities, and we are involved in the creation of a European a website on this issue which will be translated into ten languages. APF also works in collaboration with other NGOs on gender-based violence and killings; support for such work has increased, despite austerity measures. Project activities include the provision of shelter homes and police training, as well as participating in the development and evaluation of national plans to address issues such as gender-based violence, gender equity, child marriage, and FGM. Another issue we’re working on is early and/or forced marriage, although it can be very difficult to identify victims. It is most prevalent in Roma and migrant communities, but they tend to say that early or forced marriage doesn’t exist; they talk instead about “arranged” marriages. It can, therefore, be difficult to identify an entry point for the work, as there is often no visible “victim”.
What kinds of sexual and reproductive health issues are particularly relevant for migrants in Portugal?
Migrants are considered to be particularly vulnerable to HIV. Unplanned pregnancies are also a challenge; 17% of abortions in the country are to migrants, who make up 5% of the population. Overall, the number of migrants coming to Portugal is decreasing; Portugal is not a preferred European destination. It was more popular in the 1990s, when massive infrastructure projects, such as motorway construction, were underway; migrant workers have since tended to return to their countries, or move to other European countries, such as the UK or Germany. Portugal’s migrant communities tend to come from Portuguese-speaking African countries, or from Brazil; migration to Portugal from Eastern Europe is decreasing. Abortions are free of charge, and migrants are clearly accessing contraceptive services, otherwise the abortion figures would be higher. There are specific healthcare services and helplines for migrants.
Ageing is an issue of increasing concern; are you involved in any initiatives in this area?
Yes! You’ve hit on an issue I think is very important. I’m currently involved in some qualitative research on ageing, sexuality and quality of life, looking in particular at service delivery to older people and at issues related to privacy and intimacy. The research involves in-depth interviews with older people, living at home or in institutions. APF wants to provide training for staff working in institutions dealing with older people; often they do not know how to deal with sexuality issues, especially those related to older men. Sometimes couples are separated; there is no major research on this issue.
Tell us about the initiative you’re involved with at the moment that you’re most proud of, from which other European countries could learn.
Well, the thing I’m most proud of is APF’s role in reversing the July 2015 legislative change which sought to restrict access to abortion. APF led a platform which united 29 NGOs against the change, and organised a complaint to the ombudsman. In October 2015 there were elections in Portugal, and the first act of the new government was to reverse the legal change voted through in July.
I’m also quite proud that Portugal’s national telephone helpline on issues related to sex and sexuality and sexual and reproductive health, which is staffed by APF professionals, is about to celebrate its 18th anniversary.
But I’m especially pleased that APF now has quite a lot of experience working in an area of relevance throughout Europe – trafficking. Nearly twenty years ago, APF opened a centre in Oporto for sex workers, providing legal and healthcare services. We soon discovered that we had to deal with trafficking, and we became the most experienced NGO working on this issue. The government proposed that APF open a shelter for the victims of trafficking, and, in 2013, we were contracted by the Secretary of State for Equity to establish four teams working nationwide to provide legal and logistical support to victims. We’ve won several awards for our work. In Portugal now, people trafficked are mostly from Romania, and are trafficked mostly for labour exploitation, not sex work.
You just mentioned APF’s role in reversing the July 2015 restrictive change in the abortion law in Portugal recently, which included measures such as compulsory counselling and making women pay for abortions. What actually happened in the country during the four months that the new law was in operation?
Very little! The law was changed in July and the change was revoked in November, which had the effect of restoring the law to what it was in 2007. That law is fairly permissive, allowing abortion on request in the first 10 weeks. Overworked service providers didn’t rush to implement the change; in fact anecdotal evidence from a large hospital suggests that the number of abortions during that period may have increased!
Are there wider lessons that other European countries could learn from APF’s experience in sexual and reproductive health and rights?
I think that several Southern European countries face similar challenges to those we face in Portugal, and that this is definitely the case for relatively small NGOs working on sexual and reproductive health and rights. To a certain extent we are victims of our own success, in that several NGOs working in this area pioneered sex education in our countries and were the first to offer family planning services. We now have relatively high contraceptive prevalence, and, at first glance, it looks as though our work is done. Southern Europe contains some of the poorer nations in the European Union; we’re on the “periphery of the centre”, and we have fewer resources. All NGOs have been badly hit by the financial crisis, and the national austerity budgets that, in its wake, slashed the funding available to civil society organisations. In December 2010, APF had 63 members of staff; we now have 25. That’s a 60% cut. Downsizing actually costs money at a time when NGOs have less funding at their disposal, the major part of which is project funding which is simply not available for redundancy payments, etc. Survival depends on services and other goods NGOs can sell; innovation is the key to survival. At this time, there is no governmental funding available in Portugal for sex education, family planning or other sexual and reproductive health services; there is only money for screening for HIV, and even then only for screening for specific “vulnerable groups”.
We found that the route to survival for us is to provide services, maximising the use of our own resources, and taking advantage of good overseas contacts to forge partnerships at home and abroad to guarantee the continuation of services. It’s difficult to expect board members, all of whom are volunteers, to be enthusiastic about new projects in a climate of fear for the future, but you have to find a model of self-reliance to guarantee continuity of care to people who rely on the services you provide.
EB: If you had one message for sexual and reproductive health practitioners and policy-makers in Europe today, what would it be?
Search for unmet needs; see beyond the myth that sexual and reproductive health and rights have been achieved in Europe. Be innovative; find the barriers, whether they relate to disadvantage, sexual orientation, age – there’s still lots to do to advance sexual and reproductive health and rights. We have to fight the idea that our work is done; it isn’t!
The eFeature interview was conducted by Karen Newman on behalf of MEDFASH.
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