Preliminary Findings

Initial findings from the project “Political Determinants of Sexual and Reproductive Health: Criminalisation, health impacts and game changers”

The project investigates health effects of criminalizing sexual and reproductive behaviour and health services, and analyses the political dynamics that drive, hamper and shape the uses of such criminal law in nine African countries, including both  predominantly Christian Sub Saharan countries (Uganda, Malawi, Ethiopia, Kenya, Mozambique, Zambia, South Africa) and North African Muslim countries (Sudan and Tunisia). Within each group there are countries with a long tradition of abortion on demand as well as countries where it is strictly criminalized – and on homosexuality the cases range from Mozambique, where same-sex relations were legalized in 2007 to legal provisions for the death penalty in Sudan.

The project aims to develop insights into political game changers that can improve conditions for sexual and reproductive health. Global health actors have sought to push for de-criminalisation of abortion and same sex relations but external pressure seems to trigger local resistance and backlash, and once abortion and homosexuality become politicized, public health evidence seems to have little traction among legislators and policy makers. And even when laws change, health policies, services and outcomes often do not. An effective de-criminalisation agenda requires better insights into the political and social dynamics – inside the health system as well as outside – and the proposed project aims to contribute to filling this gap.

Study investigating attitudes to homosexuality

A study investigating attitudes to homosexuality between and within African countries based on available survey data found that 8 in 10 Africans express anti-gay attitudes, but that:
law matters. People are less anti-gay in counties where same-sex relations are decriminalized and longitudinal data show that decriminalization is followed by decline in homophobia
religion matters. Anti-gay sentiments increase with religiosity. At individual level, there are small differences between denominations, but where overtly homophobic religions are strong (Evangelicals, Conservative Islam) more people of all beliefs are anti-gay.
poverty matters. Populations of poor countries are more anti-gay, as are the poorest segments within each country. At individual level, education is strongly associated more liberal attitudes.

Different attitudes across our ten case countries

Donor-supported LGBT rights activisms, triggered backlash in Zambia in 1998 (with claims that homosexuality is a Norwegian conspiracy). Activists switched to a health strategy, piggy-backing on HIV/AIDS programs. But our survey of 600 Zambian policymakers (parliament and local council candidates) cast doubt on the effectiveness of health framings. The vast majority opposes programs for LGBT even when presented with data on the high HIV rates.

Senegal was traditionally tolerant of goor-jiggens (men-women), but when the LGBT movement developed as part of HIV/AIDS programs for men who have sex with men (MSM) sexuality came center stage, triggering homophobia.

‘Closet activism’ (movement building, sensitization) is common in harsh conditions, such as in Sudan, where activists fear backlash from a homophobic society and a regime that codifies sodomy as a crime against God.

Kenya’s constitutional drafters included sexual orientation and gender identity as prohibited grounds of discrimination, and triggered mobilization by conservatives who brought in a clause defining marriage as a union between adults of the opposite sex. Judges attitudes to homosexuality has become a focus in appointments. But legal strategies remain central and have brought advances.

Criminalization and politicization may have severe effects on mental and physical health. A survey of 1000 LGBT in Ethiopia found that sexual- and mental health problems were their main concerns, yet mental health is rarely a focus of MSM programs.

Findings from Kenya echo this: Criminalization and politicization creates fears that affect health seeking behavior. Non-use of services, non-disclosure, misdiagnosis; and poor data for needs assessment in turn impact design and implementation of health programming and the availability of acceptable, efficient services.

Liberalization of abortion

Abortion liberalization does not automatically bring health benefits. In Tunisia abortion laws have been liberal since the 1970s, but resource constraints have reduced access.

Ethiopia made abortion more accessible in 2005. Substantial gains are made, but barriers remain due to restrictive social norms and low awareness.

Political leadership was key when South Africa (1995) and Mozambique (2014) decriminalized abortion, despite resistance to universalization of access, providing autonomy to women’s choice. How conscious objection is understood by health care workers, is a focus of ongoing work.


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