Twenty years ago, representatives from governments, civil society and United Nations (UN) agencies convened in Cairo for the International Conference on Population and Development (ICPD). Other UN conferences on population had preceded the ICPD, but this one turned out to mark a major turning point in forging a new global consensus. Governments around the world agreed that discussion of the issue of population growth should be placed firmly in a development context and that, for the first time, the rights and needs of women must reside at the center of efforts to accelerate development. Specifically, 179 countries negotiated and endorsed a 20-year Programme of Action toward meeting a series of goals related to promoting women’s health and rights, and to supporting sustainable development.

To both commemorate the Cairo conference and to assess progress on its agenda, a number of events and activities have taken place around the world over the last few years, culminating in a UN General Assembly Special Session in September 2014. The global review process leading up to this event has highlighted not only how much progress has been made, but what more remains to be done to fulfill the vision set forth in the Programme of Action.

Historic Agreement

Against the backdrop of countries’ efforts to reach demographic targets or control the size of their populations—often through coercive measures—the 1994 Cairo conference shifted the global conversation on population policies. Specifically, the Programme of Action established women’s reproductive health and rights as a goal in and of itself, as well as a fundamental and guiding principle that must underlie governmental policies relating to population growth, environmental sustainability and development. Such policies spanned a range of issues, including those related to girls’ education, the political and economic status of women, maternal and child mortality, migration and violence against women.

Not only did the ICPD consensus delegitimize top-down governmental efforts that ignored or violated women’s human rights, it recognized that policies on development in fact could not succeed without ensuring such rights. Accordingly, the Programme of Action enumerated a set of principles related to nondiscrimination and free and informed decision making regarding the right to control one’s own fertility.

Since 1994, the basic principles in the Programme of Action have endured and even expanded. During the ICPD negotiations, governmental delegates struggled mightily to finally agree on the importance and meaning of sexual and reproductive health and reproductive rights (see box). Over the last 20 years, however, the world has evolved so that a large and growing body of international jurisprudence, governmental agreements and policy experts now view sexual and reproductive health and rights as interrelated and interdependent—that is, including not only reproductive, but also sexual rights—and advocate for comprehensive and universal access to these services and rights.

Defining Terms

At its core, sexual and reproductive health and rights means that all individuals should have the rights and means to make decisions concerning their reproductive lives and sexuality, free from coercion, discrimination and violence. Because the individual components of sexual and reproductive health and rights are interconnected, international agreements that define these components have relied on overlapping and repetitive language. Definitions for reproductive health and reproductive rights have been widely approved in agreements negotiated between governments, whereas sexual health and sexual rights have won varying levels of official and unofficial endorsement.

Building on the World Health Organization’s (WHO’s) approach to defining health,1 the ICPD Programme of Action defines reproductive health in broad and holistic terms. Beyond these broad terms, the Programme of Action identifies other key facets of reproductive health, such as the right to information and services needed to control fertility, ensure safe pregnancy and prevent or manage a range of reproductive health problems. It also notably includes sexual health. Specifically, it states:

Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.…It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases.2

The definition of reproductive rights immediately follows:

Bearing in mind the above definition, reproductive rights embrace certain human rights that are already recognized [including] the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence.2

The official delineation of these rights certainly remains a critical and lasting contribution of the Programme of Action. Still, governments only reached agreement on these formulations after hard-fought negotiations with conservative delegations, which left certain issues significantly compromised. For example, although the document acknowledges the health impacts of unsafe abortions, it stops short of endorsing safe, legal abortion as a necessary strategy to prevent them. In regard to adolescents, the Programme of Action recognizes their right to reproductive health information and services that safeguard privacy and confidentiality, yet it does not call for the removal of mandatory parental consent policies.

Similarly, although the concept of sexual health is included in the Programme of Action, it is not well defined, and sexual rights are altogether missing. Since then, WHO has put forth an unofficial working definition of sexual health that is more comprehensive:

Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.3

Although there is not a universally agreed upon definition of sexual rights, the governmentally negotiated agreement from the 1995 UN Conference on Women held in Beijing—considered a ground-breaking conference on women’s human rights—offered a starting point by supporting the right to have control over and decide freely and responsibly on matters related to sexuality.4 Since then, the international understanding of what sexual rights encompasses has evolved—with the endorsement of WHO and other UN bodies, many governments and civil society organizations—to include other rights, such as the right to information, the right to choose one’s partner and the right to have a satisfying, safe and pleasurable sexual life.3,5,6

Taking Stock

Every five years since 1994, the UN—through the leadership of the United Nations Population Fund (UNFPA)—has led global review processes to evaluate progress on the implementation of the ICPD Programme of Action, and has convened periodic conferences where governments have reaffirmed and in some cases broadened their commitments to the ICPD agenda. In 2010, the UN General Assembly called for a continuation of the Programme of Action beyond 2014 and agreed to hold a special session in September 2014 to assess progress toward meeting the Cairo benchmarks. To carry out this assessment, governments, UN agencies and civil society have been participating in a multilayered, years-long review process (see timeline). Key steps in this stock-taking process have included a global survey by UNFPA of progress in implementing the ICPD Programme of Action in all of its member states; a summary report of this survey by the UN Secretary General; thematic consultations on issues significant to ICPD, such as adolescents, human rights and women’s health; five regional meetings; and the April 2014 session of the UN Commission on Population and Development. All of these events feed into the ICPD review process, though a few are worth highlighting for the ways they reflect the advancements that the world has made since 1994, as well as the fault lines that have persisted or materialized since then. As a whole, they highlight where action is needed to achieve the ICPD agenda moving forward.

Global Survey and Summary Report

In February 2014, the UN released a report that documents the achievements, gaps, challenges and emerging issues related to implementation of the Programme of Action.7 This global review, conducted by UNFPA, surveyed 176 member states and gathered evidence from civil society and academic research. A synopsis of this review forms the basis for a summary report by the UN Secretary General that is a critical input in the overarching ICPD review process.8 The summary report covers a wide range of population and development issues, such as the human rights of those who face poverty, gender discrimination or other inequalities; gaps in an array of health sectors, including maternal and child health, sexual and reproductive health, STIs and noncommunicable diseases; domestic and international migration trends; good governance systems; and climate change and other environmental impacts.

Overall, the report concludes that while there has been substantial progress on the ICPD agenda, it has been unequal and fragmented; moreover, new challenges and opportunities have arisen over the last 20 years. In regard to sexual and reproductive health, specifically, the report notes that the substantial progress made in terms of access to and quality of services at the global level masks deep disparities both within and among countries. For instance, the global contraceptive prevalence rate—that is, the proportion of married or cohabiting women of reproductive age who are using any contraceptive method—increased from 58% in 1994 to 64% in 2012.8 Yet, in certain poor countries, that rate hovers under 10%.7 Moreover, the unmet need for contraception among married or cohabiting women of reproductive age—meaning, the proportion who want to delay or prevent childbearing but are not practicing any contraception—has only fallen slightly since 1994. Nine in 10 women with unmet need live in developing countries.8 Another example of disparities across countries is adolescent birthrates, which are greatest in poorer nations; within all countries, rates are highest among the poorest and least educated adolescents.7 Regarding abortion, the report notes that progress has been made since 1994 in reducing deaths from unsafe abortion, particularly as countries have changed policy and practice to address abortion as a public health issue, including through increased access to safe abortion, postabortion care and counseling. Yet, the vast majority of abortions in Africa are clandestine and unsafe, defined by WHO as those performed by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.

The UN Secretary General’s report makes forward-looking recommendations to address the clear remaining challenges. In the case of adolescents, it stresses that universal access to sexual and reproductive health services, including youth-friendly services, and comprehensive sexuality education from an early age are essential for young people to protect themselves and lead healthy lives. Regarding abortion, the report is unequivocal: “Governments are encouraged to remove legal barriers preventing women and adolescent girls from access to safe abortion, including revising restrictions within existing abortion laws.”8 Moreover, the Secretary General’s report goes beyond the original ICPD Programme of Action to endorse the full spectrum of sexual and reproductive health and rights, thereby explicitly including sexual rights as part of the agenda moving forward.

Regional Reviews

Arguably, some of the most critical, interesting and groundbreaking aspects of the ICPD review process played out in the context of the regional review meetings. In many ways, these meetings and their outcome documents carry more weight than some of the other processes, because the negotiations were conducted by government delegations and the conclusions they reached express the priorities and views of countries and key advocates in these regions. Consequently, certain regional conferences included unprecedented policy language that set a high-water mark—not only for that region, but for global aspirations to advance the ICPD agenda.

Of the five regional consultations that took place,9–13 the three that have been most highlighted by women’s rights advocates occurred in Latin America and the Caribbean, Asia Pacific and Africa. (Participants at the regional conference for Europe opted to produce just a summary of its proceedings, and the outcome document from the Arab region, in many ways, took a step backwards from ICPD. Because of its historical, social and economic ties, the United States is a member of several regional commissions, but is most closely aligned with the European region.)

The outcome from Latin America’s regional conference is the most forward-looking, touching on all the perennially contentious issues such as abortion, adolescents, sexual rights, and sexual orientation and gender identity. For example, in regard to abortion, the outcome document from Latin America goes further than the 1994 Programme of Action—which says that when abortion is not against the law, it should be safe—by recommending that not only should abortions be safe, but that care must be of good quality. Moreover, it includes a call to action for governments to consider amending their “laws, regulations, strategies and public policies relating to the voluntary termination of pregnancy in order to protect the lives and health of women and adolescent girls, to improve their quality of life and to reduce the number of abortions.”9 The Asia Pacific conference report also urges governments to review their abortion laws and, specifically, to “repeal laws that punish women and girls who have undergone illegal abortions…as well as end their imprisonment for such acts.”10 By contrast, the Arab region’s declaration ignores the issue of unsafe abortion altogether, including the need to treat complications—a step back from the 1994 ICPD.

All five of the regional conference documents speak to the need for adolescents’ access to sexual and reproductive health information and services, but the Latin America and Asia declarations notably endorse adolescents’ sexual and reproductive rights as well. Similarly, all of the regions except the Arab conference call for comprehensive sexuality education, with the Europe, Latin America and Asia Pacific documents detailing more specifics, such as the importance of providing accurate information on human sexuality and of designing programs that are gender-sensitive and youth-friendly.

In the area of sexual rights, the declaration in Latin America represents a major milestone by putting forth a stand-alone definition of sexual rights, a term that does not even appear in the ICPD Programme of Action. The Latin America agreement is also the only one to mention the particular vulnerability of lesbian, gay, bisexual and transgender individuals, specifically in the context of sexual violence. And it repeatedly highlights sexual orientation and gender identity as an issue of concern, particularly as a basis for discrimination. That sentiment is echoed in the Asia Pacific outcome document, which commits governments to eliminating discrimination based on sexual orientation and gender identity, among other vulnerable statuses.

Although the negotiations around language on sexual orientation and gender identity were highly contentious at all of the regional reviews, they were most controversial in Africa. This dynamic reflects, in part, the highly inflammatory domestic debates on these issues occurring in a region inflicting a spate of harsh antihomosexuality rhetoric and policy. As a result, government representatives at the Africa consultation were so hypersensitive to these topics that they even opposed certain broader policy language on nondiscrimination and human rights, in part due to fear that these were code words for protecting sexual orientation and gender identity. In many ways, this suspicion is reminiscent of the resistance that conservative governments mounted in 1994 in Cairo—and continue to this day—to the terms “reproductive health” and “reproductive rights,” out of fear that they were code for abortion rights exclusively.

Despite the fractures that persist for now on sexual rights, the ICPD review process has focused attention on how far the world has progressed since 1994. First, most of the world recognizes the fact that adolescents’ special needs— especially for comprehensive sexuality education, and for information and access to reproductive health care—cannot be ignored. Although the argument over abortion rights remains contentious, more and more countries now acknowledge the toll that unsafe abortion takes on women’s health and lives. The fact that, since 1994, more than 30 countries have broadened the grounds under which abortions are legally allowed14 is another reflection of concrete progress even on this unremittingly difficult issue. Finally, sexual health and sexual rights now firmly occupy a central part of the debate around the forward-looking women’s health agenda—indeed, the broader human rights agenda. Even the regional declaration from Africa endorses the concept of sexual and reproductive health and rights, although it supports a less expansive definition than other regions.

Forging the Forward Path

Following the regional reviews, the UN Commission on Population and Development convened its annual meeting in April 2014 with this year’s theme focused on reviewing ICPD at 20 years. The assembled governmental delegates reaffirmed the ICPD Programme of Action and approved a guide map for attaining social and economic development that depends on ensuring the rights and health of women in all countries.15 Reproductive rights advocates and delegates representing some of the countries and regions that had adopted more progressive stances had hoped for an outcome incorporating some of the gains they had won at the regional consultations. That did not happen this time around, with most participants attributing the failure, at least in part, to process more than to a rejection of the substance, necessarily. The recurrent themes and key elements identified in the April meeting were included in an index report issued by the UN Secretary General in August.16 On health, the report summarized: “Governments from all regions hold a common perspective that universal access to comprehensive, quality and integrated sexual and reproductive health is one of the highest priorities for the global development agenda beyond 2014.”16

The final official step in the review process is a UN General Assembly Special Session in September to commemorate 20 years since the landmark conference. At that session, governments will renew their political commitment to achieving the goals of the ICPD. At that point, the ICPD agenda must be incorporated into the larger global discussion on the post-2015 development framework.

As the current framework—known as the Millennium Development Goals (MDGs)—approaches its expiration in 2015, the global community of governmental and nongovernmental actors is in the midst of developing the next set of goals and targets to end poverty and promote development. Given that the MDGs currently fail to recognize the broad spectrum of sexual and reproductive health and rights, advocates have been agitating to rectify that in the post-2015 architecture. The fact that governments from all regions of the world have recommitted themselves to upholding the priorities, principles and contributions of the ICPD agenda lays important groundwork for carrying these forward via the post-2015 framework for development.

Nonetheless, vigilance is needed. Opponents of sexual and reproductive health and rights—led by the Vatican, Iran, Malta, Russia and other conservative delegations—continue their efforts to thwart progress. Moreover, apathy on the part of key stakeholders is another threat, as sexual and reproductive health and rights must compete with the myriad other pressing global issues for a spot at the post-2015 table. The stakes are high because donors and recipient countries alike will look to this framework to help guide them in the allocation of funding and other resources.

But this does not mean the ICPD Programme of Action is no longer relevant or important. It still serves as a critical tool in articulating how fundamental sexual and reproductive health and rights are to women, men and society at large. And it has empowered and emboldened a global movement to promote the broader sexual and reproductive health and rights agenda—one that includes addressing the importance of access to safe abortion care, attention to the special needs of adolescents, prevention and treatment of HIV and the promotion and guarantee of sexual rights. Despite the Programme of Action’s limitations, the human rights principles enshrined therein have proven over time to be as relevant, indispensible and visionary now as they were two decades ago. As the next phase of the global conversation on poverty, development and sustainability gets underway, policymakers must reaffirm and carry forward these underlying principles in the post-2015 framework.

REFERENCES

1. World Health Organization (WHO), WHO definition of health, 1948, <http://www.who.int/about/definition/en/print.html>, accessed Aug. 20, 2014.

2. United Nations (UN), Report of the International Conference on Population and Development, New York: UN, 1995, <http://www.unfpa.org/webdav/site/global/shared/documents/publications/2004/icpd_eng.pdf>, accessed Aug. 21, 2014.

3. World Health Organization (WHO), Defining Sexual Health, Geneva: WHO, 2006, <http://www.who.int/reproductivehealth/publications/sexual_health/defining_sexual_health.pdf>, accessed Aug. 20, 2014.

4. United Nations (UN), Report of the Fourth World Conference on Women, New York: UN, 1996, <http://www.un.org/womenwatch/daw/beijing/pdf/Beijing%20full%20report%20E.pdf>, accessed Aug. 21, 2014.

5. World Health Organization, Defining sexual health, 2010, <http://www.who.int/reproductivehealth/topics/sexual_health/sh_definitions/en/>, accessed Aug. 20, 2014.

6. International Planned Parenthood Federation (IPPF), IPPF Charter on Sexual and Reproductive Rights, London: IPPF, 1996, <http://www.ippf.org/resource/IPPF-Charter-Sexual-and-Reproductive-Rights>, accessed Aug. 21, 2014.

7. United Nations (UN), Framework of Actions for the Follow-up to the Programme of Action of the International Conference on Population and Development Beyond 2014: Report of the Secretary-General, New York: UN, 2014, <https://www.unfpa.org/webdav/site/global/shared/documents/ICPD/Framework%20of%20action%20for%20the%20follow-up%20to%20the%20PoA%20of%20the%20ICPD.pdf>, accessed Aug. 21, 2014.

8. United Nations Economic and Social Council, Framework of Actions for the Follow-up to the Programme of Action of the International Conference on Population and Development (ICPD) Beyond 2014: Report of the Secretary-General, New York: United Nations, 2014, <http://icpdbeyond2014.org/uploads/browser/files/sg_report_on_icpd_operational_review_final.unedited.pdf>, accessed Aug. 21, 2014.

9. Economic Commission for Latin America and the Caribbean and United Nations (UN), Montevideo Consensus on Population and Development, 2013, New York: UN, <http://www.unfpa.org/sites/default/files/resource-pdf/Montevideo%20Consensus-15Aug2013.pdf>, accessed Aug. 21, 2014.

10. United Nations Economic and Social Council, Report of the Sixth Asian and Pacific Population Conference, New York: United Nations, 2013, <http://icpdbeyond2014.org/uploads/browser/files/report_of_the_sixth_appc.pdf>, accessed Aug. 21, 2014.

11. League of Arab States et al., Cairo Declaration: Development Challenges and Population Dynamics in a Changing Arab World, New York: United Nations Population Fund, <http://arabstates.unfpa.org/webdav/site/as/shared/docs/2013_Cairo_Declaration_English.pdf>, accessed Aug. 21, 2014.

12. United Nations Economic Commission for Europe and United Nations Population Fund (UNFPA), Enabling Choices: Population Priorities for the 21st Century, 2013, <http://icpdbeyond2014.org/uploads/browser/files/regional_conference_on_icpd_beyond_2014_chairs_summary_final.pdf>, accessed Aug. 21, 2014.

13. United Nations Economic Commission for Africa, African Union Commission and United Nations Population Fund (UNFPA), Addis Ababa Declaration on Population and Development in Africa Beyond 2014, New York: UNFPA, 2013, <http://icpdbeyond2014.org/pages/view/6-africa>, accessed Aug. 21, 2014.

14. Center for Reproductive Rights (CRR) and United Nations Population Fund (UNFPA), ICPD and Human Rights: 20 Years of Advancing Reproductive Rights Through UN Treaty Bodies and Legal Reform, New York: CRR and UNFPA, 2013, <http://unfpa.org/public/home/publications/pid/14456>, accessed Aug. 21, 2014.

15. Economic and Social Council, Commission on Population and Development, Assessment of the Status of Implementation of the Programme of Action of the International Conference on Population and Development, Resolution 2014/1, New York: United Nations, <http://www.un.org/en/development/desa/population/pdf/commission/2014/documents/CPD47_Resolution_2014_1.pdf>, accessed Aug. 21, 2014.

16. United Nations (UN), Recurrent Themes and Key Elements Identified During the Sessions of the Commission on Population and Development: Report of the Secretary-General, New York: UN, 2014, <http://icpdbeyond2014.org/whats-new/view/id/119/secretary- generals-index-report-is-live>, accessed Aug. 21, 2014.