“Different Causes, Shared Anger”
“ا نا ياض ق ةددع ت م ان ب ض غو دحاو”
Navigating reproductive justice for women through an evaluation of
sexual and reproductive health and rights quality:
A Lebanese case study
Elyse Hoekstra
MSc International Development Studies
Graduate School of Social Sciences
July 2018
i
Navigating reproductive justice for women through an
evaluation of sexual and reproductive health and rights quality:
A Lebanese case study
In partial fulfillment of the requirements of the
Master International Development Studies
Graduate School of Social Science
Master’s Thesis: 2017-2018
04/07/2018
Elyse Hoekstra (HoekstraElyse@gmail.com)
Student ID: 11758449
Supervisor: Esther Miedema
– University of Amsterdam
Second Reader: Anke van Dam
– Ministry of Foreign Affairs
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Abstract
Stigmatized and neglected, sexual and reproductive health and rights in
Lebanon has seen little process within the past ten years. Lebanon
’s state
infrastructure has been notoriously unreliable and now nearing 7 years into the
Syrian refugee crisis, the state
’s public services and provisions are continuing to
suffer from the strain. With political tensions high and strong patriarchal tendencies
built into Lebanese society, women are faced with both state and societal challenges
in regards to SRHR. Drawing from qualitative research methods, this study aims to
give an overview of what type of sexual and reproductive health and rights quality is
available to the women of Lebanon. With this, I explored the varying aspects of
quality SRHR that both women and health providers perceive is being provided in
Lebanon.
The data indicated that state obstructions, such as Lebanon
’s restrictive
personal status laws, impedes on women
’s access to health and rights, while
societal influences have harbored discriminatory attitudes towards female sexuality.
However, with various NGOs, CSOs, and activists advocating to help fight sexual
stigmatization across the country, there are also stakeholders in Lebanon working to
improve gendered health needs. Access and adaptability of SRHR were found to be
the most pressing concerns within the quality scheme. However, ultimately the
research concluded that large obstructions of reproductive justice for vulnerable
women across the state heightened their needs for sexual and reproductive
healthcare and reduced the type of quality that was received.
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Acknowledgments
Mom and Dad, thank you for being my guiding force in all aspects of my life, but
especially so during this year in Amsterdam. My bank account also appreciates you.
Big shout-out to Poppy, my co researcher and roommate in Beirut. I wouldn
’t have
enjoyed this process as much without you. You PLUS the ice cream shop up the hill
from our house in Beirut. You two were the best.
Thank you to Esther, my supervisor. I appreciate all the time and effort you put into
my thesis feedback and advice. Your guidance throughout this whole process was
greatly appreciated.
Finally thank you to all the women, activists and health care providers that
participated in this research. Your tireless efforts in approving the lives of women
and vulnerable populations in Lebanon is much admired.
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Table of Contents:
Abstract………..…..……….…ii
Acknowledgments……….……..…...iii
List of Figures and Appendices………..………..……….……..…vi
List of Acronyms………..…….……...vii
1. Introduction………..…..…….….1
2. Theoretical Framework……….…..…..…..3
2.1Introduction……….…..……...3
2.2 Inclusive Development and Gender Inclusiveness………..….3
2.3Connell’s Relational Health Theory……….……….…………5
2.4Comprehensive Look into Sexual and Reproductive Health and Rights…...7
2.5 An Introduction to Reproductive Justice……….………...….9
2.6Tomasevski Quality Framework………...…..10
2.7Concluding Remarks……….….……..12
3 Contextual Framework….……….………...……….…..13
3.1 A Snapshot of Lebanon……….……..13
3.2 Results of the Past………...………14
3.3 Refugees in Lebanon and the Effects of the Syrian Crisis………...…...15
3.4 Gender in Lebanon……….……….18 3.5 Women’s Health……….……….……..….……..20 4 Research Methodology………22 4.1 Introduction………22 4.2 Research Questions……….……22 4.3 Research Location………..……….22
4.4 Unit of Analysis and Sampling Method……….……23
4.5 Research Methods and Data Collection………..24
4.6 Conceptual Scheme……….………25
4.7 Data Analysis ………..……….26
4.8 Limitations………..………27
4.9 Ethical Considerations………...……….28
5 Societal Influence on SRHR in Lebanon and Various Services Available……..…………29
5.1 Introduction………..….29
5.2 SRHR Stigmatization in Lebanese Society………..29
5.3 Sexual and Reproductive Health Misconceptions………..………30
5.4 SRHR-Related Providers………..…………..32
5.5 Services Provided……….………33
5.6 Concluding Remarks………..……….39
6 Obstacles and Challenges in Service Provision // Addressing the Needs of Disadvantaged Women in Lebanon………..………40
6.1 Introduction………40
6.2 Main Challenges of Service Providers……….……….40
6.3 A Shared Frustration: The Lebanese Legal System………...………43
6.4 Main Challenges of Women seeking Care in Lebanon………..…………45
6.5 Representation of Differently Positioned Women……….…..48
6.6 Concluding Remarks……….…………..51
7 Discussion of Findings……….…52
7.1 Introduction………...….52
7.2 Acceptability and Availability: How CSOs in Lebanon are paving the way for improvements in SRHR services……….…..52
7.3 Availability and Accessibility: The impact of state and societal impediments on SRHR progress……….54
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7.5 Population Disparities: Incorporating Reproductive justice into the
conversation………..………57
7.6 The State and Gender……….58
7.7 Concluding Remarks………..……….60
8 Concluding Remarks and Suggestions……….62
8.1 Suggestions……….………..……62
8.2 Final Thoughts……….……….64
9 Appendices………65
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List of Figures and Appendices:
___________________________________________________________________
Figure 1: SPARK’s conceptual figure of Reproductive Justice Figure 2: Adapted 4A Scheme for SRHR Quality
Figure 3: UN Crisis Response Plan’s: “Impact on Poverty”
Figure 4: Photo of informal refugee settlement in the Bekaa Valley Figure 5: Map of Beirut and Lebanon
Figure 6: Conceptual Scheme
Figure 7: Photo of SRHR Educational Tools and Handouts
Figure 8: Clip of video created by Marsa on the proper usage of a condom
Figure 9: Clip of a video created by LebMash on "coming out" to families in Lebanon Figure 10: Images from the 2018 Beirut Women’s March
Figure 11: Target sector needs 2017: UNFPA Figure 12: Post research conceptual scheme
Appendices
Appendix Figure 1: Operationalization table: pulled from original research proposal Appendix Figure 2: Tomasevski 4-A scheme chart
Appendix Figure 3: List of women participants, pseudo names and details Appendix Figure 4: List and details of participant observation data
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List of Acronyms:
Abaad (Means Dimensions) in Arabic CSO - Civil Society Organizations DV: Domestic Violence
HIV: Human Immunodeficiency Virus GBV: Gender Based Violence
IPV: Intimate partner violence
KAFA: (Enough) Violence and Exploitation (in Arabic) LebMASH: Lebanese Medical Association for Sexual Health
LGBTQI- Lesbian, Gay, Bi sexual, Trans, Queer, Questioning and Intersex MENA: Middle East and North Africa
MDGs: Millennium Development Goals NGO: Non-Governmental Organizations NSS: The National Social Security Fund PLO: Palestinian Liberation Organization SDGs: Sustainable Development Goals SRH: Sexual and reproductive health
SRHR: Sexual and reproductive health and rights
SIDC: Soins Infirmiers et Developpement Communautaire UN: United Nations
UNDP: United Nations Development Programme UNFPA: United Nations Populations Fund
UNHCR: United Nations Refugee Agency WHO: World Health Organization
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1. Introduction:
To me, Lebanon is a country unlike any other. It is difficult to put my description of the country’s complexities into words. I had made assumptions and formed ideas in my head of what was to be expected when I started my research in Beirut; however I quickly realized that the complexities of Lebanon were more vast and ever-changing than I had ever imagined. There is a famous Lebanese joke that roughly translates to: “If you think you understand Lebanon, someone has done a bad job explaining it to you.”
A heterogeneous country, Lebanon plays host to a varied religious and ethnically diverse population. Lebanon has been the crossroads of many different cultures and has typically served as a commercial hub in the Middle East. However, it has also often remained at the center of conflict (BBC, 2018). Lebanon has served as a battleground for diverging philosophies and beliefs, but as a result, it has also suffered from relentless civil unrest (Salhani, 2012). “Lebanon has been, and continues to be, a country affected by violence - surrounding its borders, within its own boundaries, and in its own homes” (Abirafeh, 2013). The presence of violence within the state not only relates directly to a history of military intervention, but even more so by cases of systematic and structural violence that are embedded through a past of political instability and weak state infrastructure.
The shape of the state and what it has transpired to become today, is also
interconnected with the current conflict in Syria and the rest of the MENA region. The Syrian refugee crisis has been recognized as the longest and largest humanitarian crisis since World War II (UNICEF, 2017). With an estimated 1.5 million Syrian refugees that have migrated into Lebanon and now, 7 years into the crisis, the state continues to crumble under the pressure of the massive population influx. “Lebanon is facing a potential nightmare: a perfect storm of economic, political and social instability. This crisis has infused life into old tensions and given birth to a range of newer crises” (Jolicoeur, 2015). With already strained infrastructures, this influx has proven to weigh heavily on population dynamics and public services.
The weakness of the state is now felt in most public sectors, including health. I had also originally assumed that this strain on health services would have impacted sexual and reproductive health services -as in many cases worldwide- it is including in the public health sector. With these assumptions, I entered the field aiming to evaluate how the effects of the refugee crisis had impacted “local women’s” ability to access quality sexual reproductive health and rights (SRHR) . I believed that due to the large amount of international attention and funding going to the development of the Syrian refugees, that the needs of the
2 members of the Lebanese population believed: “Everyone wants to help the Syrians, but what about us?” states Rana Suleiman, a school teacher in the Bekaa region of Lebanon (Osserian & Soloman, 2017). Were the Lebanese really being neglected? And if so, how does this related to SRHR services? However, after the beginning phases of data collection, this assumption on SRHR services was quickly proven wrong. As the empirical evidence will later explain, many of the SRHR-related organizations did not feel that their service provision had suffered due to the crisis. I thus focused my research to address a different knowledge gap.
As sections of this thesis will later describe, the needs of Syrian refugee women remain highly publicized and reported in international media outlets, however a Lebanese country-wide evaluation on gendered needs remains highly unreported. Although I
recognized how the needs of Syrians were important, I wanted to dive deeper into the shared experiences of all women in Lebanon . There was especially little information available on issues related sexuality and sexual health in Lebanon. This lack of information resulted in the formation of the central research question: What are the perceptions of providers, activists, and women on the quality of SRHR-related services? Following this main question, the research also questions what conclusions might be drawn in terms of reproductive justice in Lebanon. The first stages of my research, along with these new emerging questions, is why my research focus shifted to evaluating the quality of sexual and reproductive health and rights in Lebanon for all women living within the state.
As this research focused specifically on the needs of women, the role of gender in Lebanon had a significant impact on this evaluation. The narrow confines of the “nuclear family” in Lebanon transcends the barriers of gender and health development. Lebanon’s gender affairs are based in a patriarchal society that typically recognizes the superior status of men. It is also broadly acknowledged that despite many gained advantages and acquired rights, “Lebanese women continue to face discrimination at numerous levels, keeping gender equality in Lebanon an elusive objective” (USAID, 2012; World Bank, 2015). Pulling from feminist and development theory, this research will attempt to evaluate how gender roles have shaped women’s access SRHR-related services. In doing so, I definitely do not claim to have a full understanding of Lebanon (I’ve learned from experience that this is almost impossible) however, I intend to contribute to creating an improved understanding of the unique reported experiences of women and allies that aim to promote gender equality and sexual and reproductive health and rights for women in Lebanon.
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2. Theoretical Framework
2.1 Introduction:
This chapter will cover the theoretical framework that will guide the later research discussion. First, the chapter will discuss the importance of implementing inclusive approaches to development work and then will specifically look into the aspect of gender inclusiveness. This will lead into an introduction RW Connell’s feminist relational approach to health development. Connell’s theory will discuss the intersections of gender and health and their linkages to society. Following this, a comprehensive introduction to sexual and
reproductive health is included and its role thereof in international development. A brief discussion on the topic of reproductive justice will next be applied and a basic understanding of how this theory relates to sexual and reproductive health and rights quality in Lebanon. Finally, I will explain how I will access the quality of SRHR by the implementation of Katarina Tomasevski’s 4-A Scheme. Her original quality scheme, originally designed to measure education, has been adapted to assist in understanding exactly what type of sexual and reproductive health quality is available to women in Lebanon.
2.2 Inclusive Development and Gender Inclusiveness
What is growth but for if not to watch ordinary people thrive? -Winnie Byanyima (WEF, Henry Taylor)
Inclusive Development
International development is an ever changing sector and therefore approaches to the field itself are ever-evolving. In the aftermath of mass colonialism, developing nations struggled to regain sovereignty and integrate into the international trade and financial system; as a result, a new need was presented for a more inclusive international order. The establishment of the group of 77 (G771) in 1964 helped these countries begin to find more representation and bring awareness of the challenges of North-South relations2. However, it was not until 2008 that the term “inclusive development” became an integral part of literature and international interventions (Gupta et al, 2015, pg 36).
Inclusive methods, along with the introduction of South- South development, has resulted in local populations utilizing their own sustainable community approaches and local interventions (Gupta et al, 2015). While different theorist associate “inclusive development” with varying definitions, a similar theme was brought to light in an evaluation of inclusive
1
G77 is a coalition of 134 developing nations created to help increase their individual economic growth, as well as advance their voices in the UN and similar international conferences.
2
North- South relations incorporates the global “north” as the wealthy and industrial nations of the world, in comparison to the developing “south”. This term typically refers to sustainable approaches being implemented in the “south” that have originated from “northern” influence, funding, or previous development interventions.
4 development by Gupta et al, (2015). The authors claimed that the common theme among all interpretations of the term, resides in the idea that “inclusive development is about
countering exclusiveness” (pg. 38).
The integration of inclusive approaches aims to empower both the world’s
impoverished and over-looked populations by boosting their participation and including their voice in human capital (Gupta, et al 2015). In order to achieve such empowerment, inclusive development must be approached with a multifaceted understanding. UNDP (2016) states that vulnerable populations are generally excluded from development conversations because of their gender, ethnicity, age, sexual orientation, disability or poverty level, which all contributes to the rising levels of global inequalities. This overarching theme points to the emphasis on integrating all members of the community into local development discussions, especially those who have been most typically segregated from such conversations in the past.
As Oxfam notes, “Foreign aid works best as a tool in the hands of the right local leaders – those trying to solve their own problems in their own nations and neighborhoods” (“Inclusive Development,” 2016). Has this proven to be the case in Lebanon? How are the leaders of Lebanon shaping their development solutions? Through their own civil disputes, and throughout the last eight years of the refugee crisis, Lebanon is a country has seen large many civil, international and governmental development interventions. This research will look into what type of inclusive approaches or lack of inclusive approaches are playing a role in shaping the current level of specifically SRHR development in Lebanon.
Gender Inclusiveness
Women and girls continue to face systematic discrimination and violence across the globe through social, economic, political and civil life challenges (PATH, 2017). Improving these inequality levels have been clarified as a priority within the international aid community through a series of reports and recommendations that work to accommodate gender into development initiatives. An example of where gender inclusion has been prioritized can be seen through the United Nations’ original Millennium Development Goals (MDGs), and then more explicitly in the recent Sustainable Development Goals (SDGs) (UN, 2015). Within the SDGs, the inclusion of women has been specifically emphasized through: “Goal 5: Achieve gender equality and empower all women and girls” (UN, 2015).
Gender inclusiveness aims specifically to involve local women in their own development conversations. In their academic article, Inclusive Development: a multi-disciplinary approach, authors Nicky Pouw and Joyeeta Gupta (2016), look into individual aspects of inclusivity, such as gender, and its role in development through Koralagama’s
5 Multi-disciplinary Guiding Framework for Analyzing Inclusive Development. This framework questions the role of access, allocation, and wellbeing of women, along with how women’s involvement in their own community interventions shifts the inclusive development paradigm. This shift ultimately raising the overarching question of how and why does inclusive
development affect development enhance outcomes for women? (p.105). Many authors and scholars have answered this question through their participation in gender inclusive
techniques and the implications of such techniques have been proven time again as a multiplier effect that works to improve global levels of economic growth, prosperity and competitiveness among other development attributes (European Commission, 2017).
The concept of gender inclusion was particularly applicable to the research project, as the focus of the data collection looked specifically into women’s perspectives and challenges. It will further question whether and how Lebanon is lacking gender
inclusiveness. UN Women had found that gender inclusive approaches and attempts at advances in gender equality schemes, generally lacked the direct technical capacity, as well as awareness and institutional will that was needed in order to see progress on inclusion (UN Women, 2016). Similar concepts surrounding contextual capacity, social inclusion, as well as lack of institutional-will will be further discussed and applied throughout the thesis in the case of Lebanon. Specifically, the next section will assist theoretically in linking
institutions and societal influences directly to gendered health issues, like SRHR, to issues of gender inequality in Lebanon.
2.3 A Feminist Relational Approach to Health:
“It is now common to say that gender ‘intersects’—better interacts—with race and class. We might add that it constantly interacts with nationality or position in the world order” (Connell, pg 75, 2005).
As implied by the previous section, having gender inclusive methods in development is essential to creating inclusive sustainable solutions. With lessons learned from these lack of gender inclusion, one can see how gender equality and female empowerment are
fundamental to accelerating women and their community’s quality of life, especially in regards to health. This study looks into how linking both health and gender to relational dependency theory can help illustrate how gender relations can be used to explain women’s health issues across the country (Bottorff, 2011, p. 11). Gender scholar, RW Connell connects how these gender relations continuously produces health effects on bodies, but also acknowledges how perspectives in health are typically recognized as a problem area that extends beyond reproductive biology (Connell, 2012).
6 Public policy on gender and health has generally relied on a categorical
understanding of gender that has now been deemed irrelevant, as current ideas of gender are interpreted as more fluid than previous (Connell, 2012). Gender analysis in health is not only necessary to understand anatomical problems, but also the social constructions that are linked to health relevant practices. Connell’s article, Health, Gender and Theory (2012), suggests shifting away from the commonly accepted “post structuralist” approach to
gendered health issues, towards embodying a more relational approach towards gender and health (Botoroff, 2011). This approach treats gender as a “multidimensional structure
operating as a complex network of institutions”, meaning that gender constructs have formed in relation to the impact that people, categories and institutions have had on them (Connell, 2012, pg1).
As Connell explains, a relational health approach “gives a central place to the patterned relations between women and men that constitute gender as a social structure. It explores social practices that are shaped by, address and modify this structure.” (Connell, 2012, p. 1677). In the case of Lebanon, this evaluation will look at the gender relations of the state as a social structure that have thereby shaped social practices on health. Connell’s relational technique can be strongly applied to the study, considering how it incorporates the negative repercussions from globalism, colonialism, gendered institutions (including state agencies within the health sector) and the affects these have on local health in community structures (Connell, 2012). Considering the huge impact that civil and international conflict has had on the current status of Lebanon, it seems appropriate to apply an approach that takes these socially constructed state aspects into consideration.
Connell additionally emphasizes how a range of social, political, and economic factors typically lead to poor public health outcomes and leaves disadvantages individuals, susceptible to social health problems. In this case, to combat the impact gender biased institutions have on society- aid organizations, CSOs and state actors have started to prioritize gendered health problems, such as the incorporation of sexual and reproductive health and rights. By implementing Connell’s relational approach to the case study in Lebanon I will link the actions of institutions and stakeholders in Lebanon directly to the health outcomes of women in the state. By creating these linkages, potential solutions can be found when looking towards uncovering underlying social factors that lead to SRHR related problems. Relating specifically to the case of Lebanon, this applies to the importance of evaluating how gender relations and social aspects play a role in shaping sexual and reproductive health and rights. This approach will be looking into how state, private and religious institutions, as well as the influential role that society can have on general approaches to women’s health in Lebanon.
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2.4 A Comprehensive Look into Sexual and Reproductive Health and Rights -
“Right in principle, smart in practice and plain strategic for sustainable development: the most pressing question cannot be “why should governments invest in human rights for sexual and reproductive health?” but rather “why haven’t they?” -International Planned Parenthood Foundation (2015)
Sexual and reproductive health and rights
Sexual and reproductive health and rights (SRHR) draws links between the human right to health and issues within gender inequality, as many women do not receive the care and resources they need to preserve and protect these rights. “Sexual reproductive health and rights” broadly covers and includes the ability to access health services and the legislation protecting these services, of all individuals in regards to their sexual or
reproductive needs (UN Foundation, 2015). The World Health Organization defines sexual and reproductive health and rights as follows:
“Sexual and reproductive health and rights encompass efforts to eliminate preventable maternal and neonatal mortality and morbidity, to ensure quality sexual and reproductive health services, including contraceptive services, and to address sexually transmitted infections (STI) and cervical cancer, violence against women and girls, and sexual and reproductive health needs of adolescents.” (WHO, 2014)
Other aspects of SRHR look at access to education, the right to bodily integrity, consensual marriage and sexual relations, abortion and access to safe, affordable and discriminatory- free services (IPPF, 2015). A range of social, political, and economic factors also typically leads to poor health outcomes for women, which generally leaves those most susceptible to social problems, also most vulnerable to a neglect in sexual and reproductive health access. In regards to the focus of SRHR within the study, the research discusses the aspects of SRHR that relates to the needs specifically of women in Lebanon. It is also important to note that poor sexual and reproductive health not only affects women and girls, but also men, children, families, and communities (PATH, 2017).
How is SRHR Relevant to Development?
Sexual and reproductive health and rights was first prioritized in development during the 1993 Cairo Programme of Action and in 1995 during the UN’s Fourth World Conference on Women. These conferences first introduced SRHR as an issue of international policy and thereby indicated that one of the human rights of women was to maintain freedom over their bodily decisions and decide responsibly on matters relating to their sexuality (UN, 2015).
8 The Sustainable Development Goals also showed the prioritization of reproductive health needs through Goal 5 as well as goal 3 “Good Health and Well Being,” which has a target objective of focusing on Reproductive, maternal, newborn and child health. (UN, 2015). These agendas have helped create normative and proactive discussions on international SRHR development. It is on this foundation that women and girls can begin to invoke their rights to health and ability to choose. The prioritization of quality SRHR is integral to
achieving progress towards many of the other Sustainable Development Goals (UN, 2015). Sexual and reproductive health and right tie into achievements in education, economy, gender equality, environment and aspects of the broader health agenda (“Health in the Post 2015 Health Agenda”, 2012).
Examples of these successes have been expressed by International Planned Parenthood Foundation (IPPF), an NGO that focuses on providing and advocating for SRH services across the world, through its relation to economics and community development. IPPF stated that when SRHR quality is upheld, “total claims on a country’s health budget are reduced while economic productivity and growth are stimulated...that boosts both economic growth and individual wellbeing” (IPPF, 2015). In addition, it has been proven that by preventing unintended pregnancies, community poverty levels are reduced, as it increases women’s participation in academic, social, and economic spheres (IPPF,2015). With such examples, it is clear that by integrating SRHR strategies into local communities, other aspects of local sustainability can follow suite.
It has been 20 years since the enactments in Beijing and Cairo and progress on the prioritization of SRHR services have been made, however it is still clear that sexual health development has struggled to gain recognition in most developing communities (WHO, 2018). The limited control many women have over their sexual and reproductive lives across the world, presents the international community with harsh realities on global communities view SRHR’s prioritization. Violations of these rights often become deeply engrained in societal principles and tradition. Poor attention to SRHR can result in harmful effects on their general health and therefore their community’s growth and development (IPPF, 2015).
These connections further enforce the ties that institutional and societal influences can have on gendered-related injustices, such as poor SRHR. The international community now begins to evaluate the repercussions of poor quality SRHR and in perspective of women’s ability to access and achieve available health services.
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2.5 An Introduction to Reproductive Justice -
“What good is a right if you cannot access the services that right has provided?“ (Ahmed, & Gamble, 2017).
This research on sexual and reproductive health and rights will not focus only on the statistics and reported care being provided, but also the social injustices that all women in Lebanon are afflicted with. Poorly constructed and implemented rights surrounding sexual and reproductive health relate directly into a different kind of obstruction of rights. This obstruction can be described in relation to the concept of “reproductive justice”.
Originally coined in 1994 by Loretta Ross, along with a caucus of black women in the United States during the Pro-choice conference3; the term’s aim was to provide a more
intersectional approach to reproductive health and rights (Roberts, 2015). This term was initially implemented as many women of color felt common law was lacking representation. Since its origin, the intention of the term was to spread awareness on the needs of
vulnerable communities -especially poor communities of color- and to include a representation of historical reproductive abuses (Silliman, 2004, pg 13). The
acknowledgment of reproductive justice abuses, links a woman’s access to rights to the social, political and economic challenges that affect a woman’s ability to receive quality services (Ahmed & Gamble, 2017). Aspects of this care could include, but are not limited to: access to safe abortions, sex education, knowledge/ access to contraceptives or freedom from all forms of gender based violence (GBV). The introduction of this framework has repositioned SRHR within a political context that intersects aspects of race, gender and class oppression (Roberts, 2015). With these intersections in mind, this research will acknowledge how quality of SRHR is measured, not just by the actions of women and healthcare providers, but also recognizing that these actions are an extension of women’s daily interactions and experiences with their environments and societies.
From its origin, Ross broadly defined reproductive justice as, “the complete physical, mental, spiritual, political, economic, and social well-being of women and girls” (Stephens, 2012, p 58). Since then, reproductive justice has been built from this recognition and been more extensively defined by other members of academia or social justice stakeholders. The approach that will be adopted in this research has been developed by SPARK, a US based-organization that focuses on reproductive justice advocacy and education. The based-organization defines the term “as a social justice movement, rooted in the belief that individuals and communities should have the resources and power to make sustainable and liberatory
3 SisterSong Women of Color Reproductive Justice Collective is US national based membership organization. It aims to build
networks and organizations to improve the reproductive lives or marginalized communities. The organization was formed in 1997 by 16 organizations of women of color.
10 decisions about their bodies, genders, sexualities, and lives” (SPARK, 2010). With these considerations, they have also acknowledged the impact that other community-based and societal forms of structural violence can have on the level of reproductive injustices. The figure below, constructed by SPARK visually indicates the different types of societal pressures that can impact the identified forms of reproductive justice.
Figure 1: Reproductive Justice SPARK
This interpretation of reproductive justice has been included as it addresses the varying influences of, for example, institutions and systems on gender-based outcomes of SRHR. Such cases of gendered hierarchies and discrimination are relational to community health injustices, in particular injustice for women.
2.6 Tomasevski
’s 4-A Scheme: Evaluating Quality
“Once a pledge becomes a human rights obligation, failure to attain agreed ends by
specified means becomes a violation, to be redressed by compensating victims and making sure it does not happen again. (Education Denied, 2003, pg 101) “
Incorporating reproductive justice into the evaluation of sexual and reproductive health and rights, allows for an evaluation of quality of SRHR services in a more human-centric way. As this research looks specifically at “quality”, I will be utilizing an adaptation of Katrina
Tomasevski’s 4-A scheme to continue measuring quality from a human rights perspective. In Tomasevski’s Human rights obligations in education: the 4-A scheme, she explains how the obligation for human rights is intertwined into her evaluation of education. She describes the aim of her scheme as the following, “ to enable people to recognize human rights violations in education...There are many, everywhere, but most of them remain unrecorded” (Klees et
11 al, 2007, pg 499).Considering her incorporation of development needs, the scheme itself captures a full range of characteristics (Karlsson, 2012). It does this by dividing the notion of the right to education into four sections: Acceptability, Adaptability, Accessibility, and
Availability. Tomasevski’s original scheme and definitions under the 4A’s can be found in “Appendix Figure 2”.
To conceptualize the measurement used for SRHR quality in Lebanon, the 4-A’s will embody Tomasevski’s initial conceptualization of the scheme, but the alterations will shift from the right to education, to now address the right of sexual and reproductive health. Framing SRHR indicators under the headings has been widely adopted and implemented variety of setting in research and academia. An example of this type of study can be seen through David Karlsson and Jonas Grimheden’s research, in “Measuring the Right to Reproductive Health” a reproductive study that took place in Indonesia (Karlson et al, year). The two authors claimed that, “Tomasevski’s acute sense of methodology and pedagogics made her develop such approaches: tools that would be practical and concrete, yet
attractive and memorable” (Karlson et al, 2015). With considerations from Tomasevski, Karlson & Grimheden, and SRHR implications, this research will utilize a new adaptation of the 4-A scheme. Below is the adapted scheme that had originated from Tomasevski’s “Human Rights Obligations in Education: the 4-A Scheme”.
Figure 2 Adapted 4A Scheme
This scheme itself indicates what criteria of quality SRHR are covered under the heading of each A. The scheme above has simply altered Tomasevski’s framework to match the rights
12 of sexual and reproductive health in the broader sense of international development;
however, it is important to note that this interpretation will be applied to the context of Lebanon. A contextual example of this utilization can be made under the scheme of
Adaptation in Lebanon. Considering the large number of refugee women now currently living in Lebanon, when evaluating the idea of adaptation, the integration of such refugees will be largely taken into consideration. Other Lebanese-specific contextual considerations, such as the example provided, will later emerge throughout the presentation of the data in the
empirical sections. In addition, the inclusion of aspects of my original research proposal operationalization table was also taken into consideration when evaluating quality. This table took considerations from the Guttmacher Institute, a leading research organization dedicated to advancing SRHR, as well as aspects of Tomasevski’s framework. This operationalization can be found as “appendix figure 1” in the later appendices chapter.
2.7 Concluding Remarks
This research will aim to connect the theories discussed in this chapter to the further empirical data later presented on sexual and reproductive health and rights in Lebanon. With various ethnicities, religions and classes, Lebanon has a wide variety of individuals and women accessing SRHR services in different ways. In the implementation of inclusive development methods, the research is able to assess which members of society are involved in their own development interventions and how they perceive the impact their voices have on the growth of Lebanon. Furthermore, by incorporating gender inclusiveness, the research specifically applies how the patriarchal state incorporates women’s voices into Lebanon’s future. By implementing a feminist relational approach to this research, issues within state society, infrastructure and institutions can be directed related to the type of quality that will be evaluated. Connell’s method encourages cultural aspects to be incorporated into this gendered approach, which allows the research to further associate Lebanon’s contextual aspects in relation to its gendered disparities.
Finally, with the connections made to gender inclusiveness and within the foundation of Tomasevski’s quality scheme, women’s SRHR quality will be evaluated in relation to the 4-A’s. By doing so, the quality scheme emphasizes the main focus on the fundamental and human rights of these women seeking health services in Lebanon. Examples of reproductive injustices occurring within the state will also be incorporated into such evaluations.
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3. Contextual Framework
The Republic of Lebanon is a small country in the Middle East, bordering the Syrian Arab Republic and occupied Palestine. The nation itself is only approximately 10,400 square kilometers, which allows one to travel from the top to the bottom in generally less than 3 hours (Encyclopedia of the Nations) . Lebanon is a unique country with its populations varying in ethnic and religious diversity; four languages are spoken throughout, including Arabic, French, English and Armenian. As the most religiously diverse country in the Middle East, Lebanon recognizes 18 different religious sects, mainly consisting of Muslim (Sunni and Shi’i) and varying Christian populations. This chapter will provide a brief history on Lebanon’s independence movement, civil conflicts, and state infrastructure. It will also give an overview of the current refugee crisis in Lebanon, which will describe the status and conditions of both Syrian and Palestinian refugees within the state. Following this, I will discuss gender roles in Lebanon and how women are viewed under the law. Finally, the last section will touch base on women’s rights to health in Lebanon and describe their different forms of health protection.
3.1 A Snapshot of Lebanon
The Formation of the State
Historically part of the Ottoman Empire and then subject to French colonization, Lebanon did not officially gain independence until 1943 (BBC, 2018). Despite its late independence, Lebanon is a country with a long historical past.
In forming the government, Shia, Sunni, and Maronite Christian populations negotiated to create the National Pact4, which aimed to build the political foundations of modern Lebanon. It was at this point that Lebanon’s governmental system was established as a parliamentary democracy. This government includes confessionalism, which is the combination of religion and politics. Seats in parliament were originally divided on a 6-to-5 ratio of Christians to Muslims, which was based on a 1932 census. This state census
concluded that 60% of the population was Christian and therefore won the higher majority of parliamentary seats.
4
Unwritten agreement that laid the foundation of Le a o ’s ulti o fessio al state. Was egotiated et ee Shia, Sunni and Maronite leaders
14 Shortly after gaining independence, Lebanon entered another period of unrest
(Promundo, 2017). The aftermath of the 1948 Arab-Israeli War5 and Palestinian exodus, also known as Nakba (ةبكنلا ), resulted in 700,000 Palestinian Arabs expelled from their homes. As a bordering country, an estimated 100,000 Palestinians arrived in Lebanon as refugees (Raidy, 2013). This shift in demographic and additions to Lebanon’s fine balance of religious communities, played a role in the next period of instability.
The conflict followed three decades later in 1975 was an outbreak of civil war. The 15-year conflict was a result of religious and ethnic tensions, particularly between Muslims and Christians. Before French succession, parliamentary structure favored Christians, therefore after independence, elite Maronite Christians remained a leading position in parliament, with a stronger governmental influence. The large Muslim population and pan-Arabists6 opposed the uneven divide in government and along with the addition of
Palestinians to the local population, the religious demographics of the state had shifted in favor of the Muslim population. The conflict between the Maronite’s and pan-Arab groups (Palestinian and PLO7 forces) brought alongside the involvement foreign allies and
involvement, as well as peace keeping forces. Finally, in 1989 a Tariff Agreement signaled the beginning steps of reconciliation. In 1991, most militias were dissolved, except for the remaining Shi’i Party, Hezbollah8.
A major aspect of the agreement helped to shift the parliamentary majority away from the Maronites and the ratio officially changed to half and half. There has not been another “official” census conducted in Lebanon since the original in 1932. Some data reports that the current Christian population has shrunk to a low 37%, however the ratio in parliament
remains even (Economist, 2016). As religious tensions throughout the country still lays in a fine balance, many claim that “A new census would upset the order of things” (Economist, 2016).
This section is included in efforts to provide a brief understanding of the complex past and history of tensions, religious and ethnic groups in Lebanon have undergone. It also aims to display that a hierarchy of various religious communities and beliefs remain largely
embedded in Lebanese state and politics.
5
War between Israeli and the seven- e er Ara League, i ludi g Le a o i a atte pt to reate a e U ited State of Palesti e . The Ara League as ot su essful in their attempts.
6
Pan Arabism supports the unification of the MENA region. It is closely connected to Arab nationalism.
7
The Palesti ia Li eratio Orga izatio ai s to represe t the Palesti ia people a d li erate Palesti e through armed conflict. Was once considered a terrorist organization by the US, but now holds legitimized representation and diplomatic relations with over 100 countries
8
Both a political party and a militant group, Hezbollah is even considered a terrorist organization by some ou tries. Hez ollah as fou ded to origi all ser e Ira i their Israel pro o fli t, ut the o ai to put a e d to a olo ist e tit i Lebanon. (cite)
15
Results of the Past
Lebanon’s state impediments continued to worsen after the initial civil war, as they continued into a pattern of civil unrest. A member of the Lebanese Parliament, Mr. Ghassan Mokhieber described that, “Lebanon has returned from the Civil War in a sense of self-destruction. This history is a history of despairs“ (EDALLC, 2018). This civil destruction can be pointed to the state’s inability to develop sufficient infrastructure in a post-conflict
Lebanon. Under Syrian occupation until 2005 and with continuing arising conflicts between Hezbollah, Israel9 and the PLO, Lebanon has remained the center of political upheaval. With attention on military action, poor state infrastructure has remained a pattern. This can be seen through the government’s failure to provide basic services, including garbage removal, power supply, water sanitation and effective public services. Some also blame the poor status of public services on mass privatization in Lebanon. Issues surrounding
privatization has resulted in a slow growing economy, but also increases of power within the political factions that reap the benefits of it (Raidy, 2013). The oligarchic system in place has thus been riddled with patterns of corruption. In the Washington- based NGO, World Justice Project’s yearly “Rule of Law Index,” Lebanon continued to rise two positions higher in terms of constraints on government powers, as most countries involved indicated a decrease in constraints (Rule of Law Index, 2017). As a result of all of these state obstacles, official statistics and data in Lebanon remains difficult, if not impossible to achieve.
In addition to consistent themes of corruption, religious and ethnic tensions still dictate Lebanese politics and progression. An example of isses that have arose within the sectarian-ran state can be seen from 2014-2016 when Lebanon was without a president for over two years. Lebanese Parliament failed to agree on a presidential candidate who was acceptable to all blocs; 45 vote attempts were made before electing Michel Aoun in 2016 (Aljazeera, 2016). Adding to the complexities of Lebanese politics, their modern legislation system is still intertwined with discriminatory and exclusionary rhetoric. This can be seen through many aspects of Lebanese policies, including the enforcement of the Kafala law (legislature that exploits and neglects migrant workers from achieving labor law protections). Additionally, the sectarian personal status laws also allow for interpretation under individual religious sects. Finally, most state legislation does not recognize or protect minority groups in Lebanon, this especially in regards to refugee rights.
3.2 Refugees in Lebanon and the Effects of the Syrian Crisis
Palestinian Refugee Overview
9
The Israeli-Lebanese Conflict began after Palestinian refugees entered Lebanon. The PLO was using Lebanese land to operate attacks on Israel. This conflict resulted in the death of around 2,000 Lebanese and Palestinians.
16 Palestinian refugees and their descendants still reside in refugee camps in Lebanon today and have typically been systematically denied access to rights since their arrival in 1948. Without an updated census, modern population estimates of current Palestinians in Lebanon vary. UNRWA (United Nations Relief and Works Agency) has estimated around 450,000 Palestinians were still living in Lebanon in 2014, while a 2017 census by the Lebanese government claimed only 174,000 registered Palestinians remained (Sewell, 2017). As Palestinian refugees do not have access to Lebanese citizenship, they are legally barred from owning property or working in desirable and sustainable employment
opportunities (UNHCR, 2016). Palestinian camps have also been notorious to suffer from overcrowding, poor housing conditions, and unstable infrastructures (UNHCR, 2016). Due to these poor circumstances, Palestinian refugees in Lebanon rely heavily on UN relief services, as well as non-profit support for fundamental services, such as education, healthcare, and legal rights.
Syrian Refugee Crisis Overview
The arrivals of refugees into Lebanon drastically increased with the escalation of the Syrian Civil war in 2011. As a bordering country, thousands of Syrians fled their homes in seek refuge in Lebanon. Today, there is an estimated 1.5 million Syrian refugees are living in Lebanon, thus totaling in a population of over 2 million displaced individuals in the small state (Promundo, 2017, p. 12). These estimates include both registered and non-registered refugees. As Lebanon was only a small population of an estimated 4.3 million in 2012, refugees now account for almost ⅓ of the entire population (Echo, 2017). With this refugee influx, Lebanon become the country that hosts the most refugees per capita worldwide (Promundo, 2017 p.12).
Syrian refugees struggle with the same, if not escalated, obstacles than that of Palestinians. Discriminatory and restrictive laws make it difficult, if not impossible to integrate normally into any community. Based on Lebanon’s current “no camp” policy, these displaced individuals are scattered across the country in various basic housing units. However many have found refuge in informal settlements (Echo, 2017). Housing opportunities that are typically available to refugees are generally located in the most vulnerable and
underprivileged neighborhoods in Lebanon. According to UNHCR 70% of Syrian refugees are living below the poverty line in Lebanon (Promundo, 2017 p.32). One reason for the high poverty level in Syrian refugees can be pointed back to Lebanon’s restrictive residency policies10, which makes it difficult for Syrians to maintain legal status, access rights, and
10
These regulations, enacted in 2015, imposed more financial and legal requirements in renewing residency permits for refugees. “Human Rights Watch found that prohibitive paperwork requirements and fees, combined
17 most importantly access forms of employment, healthcare, and education (“Lebanon
Overview,” 2017). It is estimated that around 70% of Syrians lack legal residency (“Lebanon Overview,” 2017).
The drastic population influx has strained Lebanon’s already struggling public services. Health and education sectors are especially struggling, jobs are hard to find, and housing prices have skyrocketed (Cousins, 2014). The crisis has also proven to worsen poverty levels among Lebanese locals, as well as widen income inequality. In particular, it is estimated that as a result of the Syrian crisis, some 200,000 additional Lebanese have been pushed into poverty (Crisis Response Plan, 2016). Below is a figure from the UN’s crisis action plan that visually displays the increase in impoverished individuals in Lebanon since 2011.
Figure 3 Impact on Poverty Lebanon Crisis Response Plan 2017-2020
An additional 250,000 to 300,000 Lebanese citizens are estimated to have become unemployed during the crisis, most of them unskilled youth (Crisis Response Plan, 2016). This strain has also caused increased tension between the various communities with arbitrary application of the regulations, effectively bar Syrians in both categories from renewal.”(HRW residency rules)
18 throughout the country. Several reports of attacks against Syrians have been claimed by citizens and government officials alike (HRW, 2017). With the exhaust of social services, and a digressing economy, the groups in Lebanon facing the largest burdens are refugees and rural populations, who were already in a position of precarity.
Figure 4 Informal Settlement in Bekaa Valley. Source: The Globe and Mail
3.3 Gender in Lebanon
“For women, there is often the expectation of sexual chastity and, through it, family or community ‘honour’; for men, they may be expected to be the protector and breadwinner of their family or community, and thereby to have a sense of personal ‘honour’.” (Kattab et al, 2014)
Despite a history of armed conflict and poor state stability, Lebanon has seen some growth in terms of women’s rights and is typically interpreted to be progressive in
comparison to other countries in the MENA region. Women in Lebanon are generally active in almost all areas of society, yet stigmatization and restrictive provisions remain embedded in laws, criminal codes, and conservative perspectives. The continuing and lingering effects of political instability, and subsequent migration, further jeopardizes women’s welfare. (Promundo, 2017) In a study on Lebanese masculinities, conducted by Promundo (an NGO that focuses on incorporating men into discussion of masculinities and gender equality) and the UN, it was found that large percentages of men and women in Lebanon support gender equality, yet many men continue to hold inequitable views (Promundo, 2017). The limited support of women’s growth in Lebanon can been seen throughout various realms of Lebanese society.
Social and family pressures have played a large in shaping these gender roles today. In Lebanon, and most countries in the MENA region, children are typically brought up seeing their parents play structured traditional gender roles. Men and women in Lebanon are
differently socialized to fit their expected gender roles. The patriarchal society in Lebanon sets a double standard for women by encouraging their educational opportunities, but
19 limiting their primary labor role to household and family duties. Serving the role of the mother and housekeeper also results in Lebanese men as the main financial provider for the
household. With these expectations, patterns of machismo and masculinity complexes are embedded in Lebanese society and as a result, women have not only suffered in a loss of unequal laws, but also reportedly high levels of GBV and intimate partner violence (IPV) (UNESCO, 2016).The Promundo survey in Lebanon found that some men across the state held harmful values in relation to sex and sexual violence. One- fourth of research
participants had also heard of an honor killing in their local communities within the past year (Promundo, 2017).
However, even with burdening gender roles, Lebanese women remain highly
educated with a literacy rate of 91.8 and high net school enrolment ratios. But despite these improvements, Lebanese women’s economic participation remains low. Dr. Dima Dabbous, a research and lecturer at Lebanese American University, claimed that “Most studies
estimate that only 30% of women in Lebanon work, and that’s a lot less than the percentage of working men. It is quite alarming that more women are getting an education, but not many are joining the workforce” (qtd in Bechara, 2018). Some believe these low rates of female economic participation are a result of the way children are the gender roles girls and boys are taught to follow (Bechara, 2018).
Gender and the Law
Social constructs on gender roles in Lebanon have also largely impacted the treatment of women under Lebanese Law. With the help of gender inclusive NGO and activists, there has been progress in reforming and creating legislature that better supports gender equality. However, the sectarian system has allowed gaps and room for
interpretation to form in such legislation, as the Lebanese state neglects necessary changes to discriminatory policies. Some of these will be further discussed in the presentation of the empirical data.
Religious courts also add arbitrary rules for women in Lebanon, subjecting them to face an unequal status, within the law, in comparison to men. Instead of a civil code regulating personal status matters, Lebanon has 15 separate personal status laws, each recognized in a different religious community. This system was created in order to protect Lebanon’s religious diversity in ensuring each citizen was respected in their religious belief under the law. Each set is administered by separate religious courts and enjoy a great deal of autonomy from state involvement (HRW,2015, pg. 28) However, these sectarian courts have been highly criticized in Lebanon and internationally, as they are known to typically harbor discriminatory and unequal legislation for women. Under these laws women face
20 inequalities in regards to access to divorce, residence of children after divorce, and property rights (HRW, 2017). For example, in 2014 a law on the Protection of Women and Family from Domestic Violence was established to create protection measures and criminalize gender based violence and IPV. However, several articles within the law were rejected, including those that criminalized marital rape (HRW, 2017).
3.4 Women
’s Health
The failure to establish legislation that protects and defends the autonomy of women in Lebanon, has had a large impact on their daily lives and wellbeing. This impact is
especially so when these forms of legislation play a role in making bodily decisions for women. An example of this restriction can be seen in Article 541 of the Lebanese Penal Code, which criminalizes abortion and effectively denies women the ability to control and make decisions in regards to their future health. Laws such as this, along with many others, can have a direct impact on the quality of healthcare women in Lebanon are receiving.
Infrastructure issues surrounding health and public healthcare in Lebanon has also remained a heated topic of discussion, even before the inception of the crisis. Now, with the additional strain on the public sector, women seeking health care and organizations aiming to provide care, face significant heightened challenges. The World Health Organization has claimed that, “The proliferation of the private sector during the war years at the expense of the wounded public sector is still dragging in consequences till now” (WHO, 2006, pg. 3). Since the Lebanese healthcare system has been mainly reliant on the private sector and offers limited capacity to those uninsured, women have struggled to find sufficient coverage (Raidy, 2013).
The different forms of insurance in Lebanon can provide or limit women’s access to healthcare. Health insurance options consist of an employment based social security program (The National Social Security Fund, NSSF), private insurance coverage, or an out-of-pocket option. As exact statistics on coverage in Lebanon remains highly incomplete and outdated, reports claim that many employees have not registered with the NSSF, or as self-employed individuals, they cannot access employment based coverage (Kukrety, 2016). For Lebanese households, medical expenses comprised on 15-20% of total expenditures in 2016 (Kukrety, pg 15).
Refugees access health care separately than the rest of the population(s). For registered Syrians, the UNHCR covers 75% of medical costs for cases that match their criteria. However as many Syrian refugees remain unemployed, the additional 25% places a large burden on households (Kukrety, 2016). Additionally, large number of refugees remain
21 unregistered due to Lebanon’s restrictive laws, which eliminates their potential coverage under UNHCR. In these cases, their only options are to pay exorbitant out-of-pocket fees.
The protracted crisis has also created a change in demand on healthcare providers, including those specifically focusing on women’s care. An integral aspect of women’s health looks specifically at sexual and reproductive health and rights (SRHR). In the early 2000’s Lebanon had briefly made maternal and reproductive health a priority as a result of the creation of the UN’s Millennium Development Goals. However the inclusion of sexual health within these discussions and interventions generally remained unmentioned. In addition, since the inception of the crisis, updated information on the current standing of SRHR
drastically reduced. Despite the inclusion of SRHR policy in many NGO platforms, there has been very little data collected on the topic and how it affects the status of women’s general health as a whole in Lebanon.
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4. Research Methodology
4.1 Introduction
This chapter begins by outlining the qualitative process that was undertaken to serve the goals of the research project. The chapter details the research question, sub-question(s), location, the unit of analysis and sampling strategies. The employed methods of data
collection and analysis will then be clarified. This section also briefly discussed how I sought to meet important criteria for good quality qualitative research, followed by the limitations and ethical considerations.
4.2 Research question(s)
Main Research Question:What are the perceptions of providers, activists, and women on the quality of SRHR-related services and what conclusions might be drawn in terms of reproductive justice in Lebanon?
Sub Question 1: What type of SRHR care and services are available for women in in
Lebanon?
Sub Question 2: How has Lebanese state and society perceptions of gender
influenced SRHR-related services?
Sub Question 3 : What obstacles/challenges do women in Lebanon face in
achieving quality SRHR?
Sub Question 4: What obstacles/challenges do health providers face in serving
quality SRHR in Beirut?
All questions above relate to the whole of Lebanon, except for question 4, which relates to only Beirut. This is because the providers involved in the research process were all located in and around Beirut.
4.3 Research Location
The majority of this research took place in Beirut, the capital of Lebanon. As indicated in the figure below, Beirut is located right in the center of the Lebanese coast. Although known to be somewhat of a conservative country, the city of Beirut has been arguably well-known as a modern and progressive city within the Arab states.
With large numbers of refugees flowing into the city and country, exact populations within the state are typically inaccurate, however the population of Beirut currently stands at an estimated 1,900,000 million (approximately ⅓ of the total population) (Echo, 2017). While, the research itself was not limited to individuals living in Beirut, however due to the
23 Beirut, the majority of the research and interviews were conducted within or around it.
Participatory research and secondary data were gathered country-wide.
Figure 5 Photo of Beirut and Lebanon (Source: BBC, 2016)
4.4 Unit of Analysis and Sampling Method
This research provided multiple perspectives of SRHR quality, which is why the research included various perspectives on SRHR from both providers and activists working to improve SRHR and women SRHR services.
Sampling in the field was mainly purposive, meaning that respondents were selected on the basis that they met certain criteria. For service providers, this criteria involved
participation or active employment in a SRHR-related field. These actors could be male or female. Before leaving to the field I spoke to numerous people in hopes of making
professional and academic connections. I had anticipated how and with who this research would come into play, however upon arrival in Beirut, I quickly realized how gaining access would be more difficult than I had originally expected. Without a defined collaboration with an organization or local supervisor, I relied on individual an independent interviews to create a pool of various SRHR-related actors in Beirut. Since this field of health is relatively new and small in Lebanon, members of this community are very familiar with one another and were eager to help pass along contact information. Despite having gained access to what, at some levels, appeared to be a tight knit group, options of providers that could and were willing to participate in the research were limited. This was due to the fact that the SRHR providers that were willing to participate were all members of this small and limited pool of
24 NGO and CSO providers. This limitation is why all providers involved in the research were in support of improving SRHR and generally held holistic approaches to the topic. Other
general practitioners I reached out to did not want to participate or simply did not respond. The interviews with local women as well as non-native Lebanese women also proved to be more difficult than expected. Because issues of privacy were of the utmost importance to NGOs and CSOs working in the SRHR field and healthcare providers, they were unable to connect me to their clients for interviews or focus groups. In Lebanon - as in many other settings- sexual health is not something that a stranger can casually approach you to speak about, therefore most of the interviews that eventually took place came about through informal social contacts. Therefore sampling in this case of opportunistic. In many of these cases, female peers I had interacted with, openly and freely spoke about their experiences or opinions about sexual reproductive health services or rights in Lebanon without
prompting. These social contacts proved to be helpful as the participants felt more comfortable discussing issues regarding sexuality in their own safe spaces.
I concluded the research with 20 in-depth interviews. Eleven of such were from providers and activists. These interview accounts also included anonymous stories from women, as well as commonly expressed perceptions of SRHR from patients. All provider-participants were female, except for two. Nine interviews were conducted with women living in Lebanon. The majority of women participants lived in Beirut and nearly half of them
identified as “student”. The details of their professions, marital status, age and hometown are listed in Chapter 9: Appendices under “Appendix Figure 3”.
4.5 Research Methods and Data Collection
In view of the various feelings, values, and perceptions involved in perceptions of SRHR this research drew on qualitative methods. During the ten weeks of fieldwork, data was collected and analyzed in multiple phases. These central methods of data collection were:
A. In-depth semi-structured interviews B. Unstructured interviews
C. Participant observation and field notes
D. Analysis of secondary data/ sources (policies, academic papers, reports, etc.)
Semi-structured interviews were used to gain a deeper understanding of subjectivity of the interviewees and to gain a better understanding of participant’ perceptions and
experiences. Most discussions were based off a pre-developed interview guide, however the participant’s answers also steered the focus of discussion topics. The implementation of unstructured interviews warranted more ‘genuine’ results, however, keeping in mind potential ethical problems that could have arose, informed consent was confirmed at the beginning and end of discussions. Interview questions were catered to the knowledge or expertise of
