• TABLE OF CONTENTS
HIDE
 Front Cover
 Introduction
 Initiating the process of...
 Project development at the institutional...
 Training themes
 Process of change among provid...
 Accomplishments to date
 Barriers to change
 Factors that have facilitated...
 Notes and acknowledgements
 Resumen en Espanol
 Resume en Francais
 About the authors
 Back Cover














Group Title: Quality/calidad/qualite
Title: Introducing sexuality within family planning
CITATION THUMBNAILS PAGE IMAGE ZOOMABLE
Full Citation
STANDARD VIEW MARC VIEW
Permanent Link: http://ufdc.ufl.edu/UF00088799/00001
 Material Information
Title: Introducing sexuality within family planning the experience of three HIVSTD prevention projects from Latin America and the Caribbean
Series Title: Qualitycalidadqualite
Physical Description: 28 p. : ill. ; 26 cm.
Language: English
Creator: Becker, Julie
Leitman, Elizabeth
Population Council
Publisher: Population Council
Place of Publication: New York
Publication Date: 1997
 Subjects
Subject: Birth control -- Latin America   ( lcsh )
Birth control -- Caribbean Area   ( lcsh )
Sex -- Latin America   ( lcsh )
Sex -- Caribbean Area   ( lcsh )
Sexually transmitted diseases -- Prevention -- Latin America   ( lcsh )
Sexually transmitted diseases -- Prevention -- Caribbean Area   ( lcsh )
HIV infections -- Prevention -- Latin America   ( lcsh )
HIV infections -- Prevention -- Caribbean Area   ( lcsh )
Sexual Behavior -- Latin America   ( mesh )
Family Planning Services -- education -- Latin America   ( mesh )
Sexually Transmitted Diseases -- prevention & control -- Latin America   ( mesh )
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
 Notes
Bibliography: Includes bibliographical references (p. 26).
Statement of Responsibility: by Julie Becker and Elizabeth Leitman ; introduction by Mahmoud F. Fathalla.
General Note: Caption title.
 Record Information
Bibliographic ID: UF00088799
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 37499376
lccn - 99208507

Table of Contents
    Front Cover
        Front Cover 1
        Front Cover 2
    Introduction
        Page 1
        Page 2
        Page 3
        Page 4
    Initiating the process of change
        Page 5
    Project development at the institutional level
        Page 6
    Training themes
        Page 7
        Page 8
        Page 9
        Page 10
    Process of change among providers
        Page 11
        Page 12
        Page 13
        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
    Accomplishments to date
        Page 21
    Barriers to change
        Page 22
    Factors that have facilitated change
        Page 23
        Page 24
        Page 25
    Notes and acknowledgements
        Page 26
    Resumen en Espanol
        Page 27
    Resume en Francais
        Page 28
    About the authors
        Page 29
    Back Cover
        Page 30
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Quality/Caliclad/Quialit6, a publication of the Population Council, highlights
examples of family planning and reproductive health programs that are providing
unusually high quality care. This series is part of the Council's Robert H. Ebert
Program on Critical Issues in Reproductive Health which, through scientific and
practical efforts, seeks to improve and expand the scope and quality of reproductive
health care. The philosophical foundation of the program, and of this series, is that
women and their partners have a fundamental right to respectful treatment, infor-
mation, choice and follow-up from reproductive health care providers. The pam-
phlets reflect one of the four main thrusts of the program: enhancing the quality of
family planning programs.
Projects are selected for documentation in the Quality/Calidad/QualitJ series
by an Advisory Committee made up of individuals who have a broad range of expe-
rience within the field of reproductive health and are committed to improving the
quality of services. These projects are making important strides in one or more of
the following ways: broadening the choice of contraceptive methods and technolo-
gies available; providing the information clients need to make informed choices and
better manage their own health care; strengthening the quality of client/provider
interaction and encouraging continued contact between providers and clients; mak-
ing innovative efforts to increase the management capacity and broaden the skills of
service providers at all levels; expanding the constellation of services and informa-
tion provided beyond those conventionally defined as "family planning;" and reach-
ing underserved and disadvantaged groups with reproductive health care services.
None of the projects documented in the series is being offered as a model for
replication. Rather, each is presented as an unusually creative example of values,
objectives and implementation. These are "learning experiences" that demonstrate
the self-critical attitude required to anticipate clients' needs and find affordable
means to meet them. This reflective posture is exemplified by a willingness to re-
spond to changes in clients' needs as well as to the broader social and economic
transformations affecting societies. Documenting the critical choices these programs
have made should help to reinforce, in practical terms, the belief that an individual's
satisfaction with reproductive health care services is strongly related to the achieve-
ment of broader health and population goals.








Publication of this edition of Qual- Statements made and views ex-
ity/Calidad/QualitW is made possible by pressed in this publication are solely the
support provided by the Ford Founda- responsibility of the authors and not of
tion, the John D. and Catherine T. any organization providing support for
MacArthur Foundation and the Swed- Quality/Calidad/Qualitc.
ish International Development Author-
ity (SIDA).


Number Eight 1997 ISSN 0-8734-057-2 Copyright Population Council 1997







Introducing Sexuality within

Family Planning:

The Experience of Three HIV/STD

Prevention Projects from

Latin America and the Caribbean

by Julie Becker and Elizabeth Leitman
Introduction by Mahmoud F Fathalla



Introduction
On reading this report about introducing sexuality within family planning, I recalled an in-
teresting encounter in India several years ago. I was participating in a scientific meeting on family
planning and I was approached by a group promoting a "novel" contraceptive method. They claimed-
and they were right-that the method can be 100 percent effective, is completely free from known
side effects, can be used by both men and women, and offers complete protection from sexually
transmitted infections. It can be used by anyone and there are no contraindications to its use. The
method, at the time, cost only thirty-five rupees (about one U.S. dollar).
The promoters were disappointed that, in spite of all these advantages, the method was not
selling. The brand name was "The Joy of No Sex," and it preached complete abstinence. The one-
time cost was for a little booklet that taught some yoga exercises to help with compliance with the
method. Apparently, when you stand on the head end of your body for a long time, you cannot think
much about the other end! The family planning movement did not go as far as advocating "The Joy of
No Sex," but for a long time it chose to ignore the reality that sex has got a lot to do with it. Family
planning is about sexuality. It is meant to allow women and men to enjoy mutually satisfying sexual
relationships without the fear of unwanted pregnancy.
Although it contradicts what some theologians may like to think, the dissociation of sex from
reproduction in the human species was a purposeful evolutionary act of nature. In the evolution of
homo sapiens, the temporal relationship between sex and reproduction has been completely severed.
In our fellow mammals, the female will only be attractive to the male and receptive to his advances if
she is ovulating and ready to conceive. In our fellow primates, the female never fails to advertise the
fact that she is ovulating-the external sexual organs undergoing a change in size and color that is
clearly visible-making her sexually attractive to the male. At other times, she will have little or no
appeal for him nor will she herself have any interest in him.
The sexual receptivity and attractiveness of the human female has completely been eman-
cipated from hormonal control. The human female has also succeeded, through evolution, to hide
completely all external evidence of ovulation. Sex was meant by nature for its own sake, not just as
a tool for reproduction. With the increasing adoption of the small family norm, sex is increasingly
becoming an important component of our psycho-social well-being and less and less a tool of re-
production.
Unfortunately it took the fatal pandemic of HIV infection for the family planning movement
to begin to wake up to the realities of people's sexual lives. But even then, it was not easy for a mostly
demographic-driven movement to see the point. HIV and sexually transmitted infections can be






considered-fortunately by few-as contributing to the easing of the world population problem.
Indeed, two of the most "successful" female tubal occlusion programs worldwide are, in fact, Chlamydia
trachomatis and Neisseria gonorrhoea infections. These diseases are not troubled by the need for
informed consent: the woman is sterilized without her even knowing about it!
But beyond recognition of the need to face the realities of people's sexual lives in light of the
global epidemic of sexually transmitted infections, what the family planning movement needed to do
was to put people, rather than population, at the center stage. It needed a change in focus from
"counting the people" to "people count." It needed a shift from demographic targets to individual
needs. It needed a wide-angle lens to look at the totality of sexual and reproductive health needs.
Despite arguments about the potential dilution of already limited resources and the inability
of family planning services to take on additional tasks, the consensus is now building that sexual and
reproductive health care should be an integrated package at the level of policy, management, and
administration-as well as at the level of service delivery. The Oxford Dictionary defines the word
"integrate" as to "complete (as an imperfect thing) by addition of parts; combine (parts) into a whole."
Integration, therefore, should be distinguished from what may be more appropriately called "bun-
dling" of services. The verb "bundle" (commonly used in computer jargon) is defined as to "tie in,
make up into, a bundle; throw confusedly in to any receptacle." When services are simply combined
or "bundled" together in one way or another, the result is not integration. When services are com-
bined or joined together as a strategy to provide a more complete package, with the client at the
center of and as the focus for services, this is "integration."
Sexual and reproductive health is about men's and women's relationship to each other, al-
though the issues are often of more concern to women. Women have less power in negotiating sexual
relationships and they are the ones who get pregnant. By definition, sexually transmitted diseases
(STDs) affect both men and women, but the disease burden on women is much heavier. A recent
World Bank report ranked sexually transmitted diseases as the second major cause (after maternity-
related causes) of the disease burden in young adult women in developing countries. Among males of
the same age group (15-45), STDs were not even among the first ten causes of the disease burden.2
For a mix of biological and social reasons, women are more likely to be infected by STDs, are
less likely to seek care, are more difficult to diagnose, suffer more severe disease sequelae, and are
more subject to social discrimination and repercussions. The most effective method available for
protection against STDs, the condom, is controlled by men-by definition, women cannot "use"
condoms. An effective method of protection that a woman can use without the need for her partner's
cooperation simply does not exist as yet. The fact that women have more at stake in sexual health than
men do does not, however, mean that men can be left out. Men have sexual health needs too, and
their sexual health is important for women's sexual health. Men can play a positive role in promoting
the sexual and reproductive health of their partners. But, unfortunately, many men are either not
informed of their role in, or exercise an adverse influence on, women's health.'
Change is never easy and it is particularly difficult when it means, or necessitates, changing
people. It is easier by far to impart new knowledge to service providers or to help them acquire new
technical skills. Much more challenging is actually changing their attitudes, particularly when the
issue is a subject such as sexuality, and when their effective involvement requires them to clarify and
possibly re-evaluate their own beliefs and behavior in such a sensitive area. But changing attitudes is
what counts most. Attitudes are never simply the addition of knowledge and skills. There is a multi-
plying factor. If the attitude to sexual safety and expression is zero, the result of whatever amount of
knowledge and skills imparted can still be zero.
Change takes leadership, innovation, and risk taking-which is just what three family plan-
ning associations in the Latin American and Caribbean region ventured to do when they sought to
introduce sexuality within family planning. They ended up, and rightly so, introducing family plan-
ning within sexuality. They deserve full credit for what they did, and their experience is worthy of
reading and learning from.






Background

Scene 1, a family planning clinic (1993):
It's a rainy Wednesday morning. Patricia, a street
vendor, arrives at the urban clinic seeking a fam-
ily planning method for the first time. After a short
wait, a counselor warmly greets the young woman,
repeats her name, and leads her to a private area
where they sit down together.
The counselor asks Patricia a series of ques-
tions and listens attentively to her responses.
Patricia says that she has never used family plan-
ning, but hears from a friend that the pill is a
good method. After the counselor restates what
Patricia says to confirm that she understands, she
asks her if she knows about other family plan-
ning methods.
When Patricia indicates that she only knows
a little, the counselor describes each method in
detail, explaining how each is used, how to insert
a diaphragm, what to do if you miss a pill, what to
do if you miss two. When she describes the con-
dom, she shows the young woman a small plastic
package. She says that condoms are good to use
if you forget to take a pill, and it is important to
use them for a while when you first start taking
the pill until it becomes effective. The counselor
then shows her the different pills available and
discusses the price. Patricia leaves the clinic with
a three-month supply of pills.

Scene 2, same clinic (1996): It's a rainy
Wednesday morning. Patricia, a street vendor,
arrives at the urban clinic seeking a family plan-
ning method for the first time. After a short wait,
a counselor warmly greets the young woman, re-
peats her name, and leads her to a private area
where they sit down together
The counselor asks Patricia a series of ques-
tions and listens attentively to her responses.
Patricia tells the counselor that she had never used
family planning, but her sister-in-law uses the pill
and she thinks that she would like to do the same.
The counselor spends a few minutes exploring
Patricia's life and individual situation. They dis-
cuss her family, her current partner, her previous
partners, and her level of satisfaction with her
sexual life. They discuss the fact that her husband
travels for work. The counselor asks her if she
thinks he might have other partners when he trav-
els and Patricia admits that he probably does. She
and the counselor then discuss the fact that this


could be putting her at risk of contracting human
immunodeficiency virus (HIV) or another sexu-
ally transmitted disease (STD). They discuss what
she knows about HIV and STDs, and the counse-
lor clarifies misinformation, making sure to de-
scribe the types of sexual activities that are safe
and unsafe.
The counselor reviews the benefits of con-
dom use, and demonstrates, on a penis model,
how to use a condom correctly, emphasizing that
condoms can be highly effective against preg-
nancy, HIV and STDs when used consistently and
correctly. She mentions some ways to make con-
dom use more appealing to a man by, for example,
putting it on for him and massaging his penis while
doing so.
The counselor asks Patricia whether she has
ever had an STD or any other infection and then
inquires as to whether she has ever discussed HIV
with her husband-or whether they have in fact
ever discussed their sexual life. Patricia admits
that they have not, but says she has wanted to.
She and the counselor then discuss strategies for
bringing up the subject in a non-threatening way.
Before the session ends, the counselor
briefly reviews the available family planning meth-
ods, emphasizing that it is necessary to use a con-
dom with all other methods to protect against HIV
and STDs. In the end, Patricia selects the pill as
her method and the counselor explains in detail
how to use it correctly. Patricia leaves the clinic
with a three-month supply of pills, and a free
sample of condoms to try.
*0* 0 0 V *
These "typical" family planning counseling
sessions are composite descriptions of sessions that
were observed shortly before (1993), and two years
after (1996), implementation of a new project to
integrate HIV/STD prevention into the existing
family planning programs and services of three
family planning associations (FPAs) affiliated with
the International Planned Parenthood Federation,
Western Hemisphere Region (IPPF/WHR).
By 1996, the typical counseling session had
evolved from mainly informational into a real ex-
change between counselor and client that ex-
plored the client's needs within a sexual and re-
productive health context. This edition of Qual-
ity, Calidad, Qualiti, highlighting the experiences
of BEMFAM/Brazil, ASHONPLAFA/Honduras,
and FAMPLAN/Jamaica, explores how the staff
of these three family planing associations (FPAs)





have been making the transition to a more client-
centered, sexually explicit approach to providing
family planning services, and what the transition
has meant to them and their clients.

Evolving Programs and Attitudes of
the Western Hemisphere's Family
Planning Associations

Throughout the history of family planning,
most programs have concentrated almost exclu-
sively on the delivery of contraceptive services.
Initially introduced in clinics, services later were
extended to community-based distribution and
commercial social marketing programs. However,
despite this movement outside of the clinic, ser-
vices remained based on a medicalized model
where clients' broader sexual and reproductive
health needs were rarely addressed nor were is-
sues of sexuality discussed. Those providing fam-
ily planning services often failed to consider the
realities of clients' sexual lives or the social and
cultural context in which sexual activity occurs.
Motivated by population control targets, many
programs emphasized the use of longer term,
"more effective" family planning methods, such
as IUDs and sterilization. Under these circum-
stances, condoms were rarely mentioned, let alone
made a priority method.
In recent years, the family planning field
has moved toward a greater awareness of gen-
der issues and the importance of quality of care;
now it seeks to broaden its focus to incorporate


sexual and reproductive health. The Interna-
tional Conference on Population and Develop-
ment (ICPD, 1994) in Cairo reaffirmed the idea
that sexual and reproductive health extends be-
yond the provision of family planning services
to encompass a broader range of care, including
the prevention and treatment of reproductive
tract infections (RTIs) and STDs, including HIV.
Determining how to implement this perspective,
however, has presented a challenge to both the
management and the staff of family planning
programs alike.
When the AIDS epidemic began, most
family planning associations in the Western
Hemisphere Region did not want to be involved.
Many perceived the epidemic as only affecting
marginal populations, not family planning cli-
ents, who were considered to be married wom-
en in long-term relationships. Even as the real-
ization grew that the epidemic was increasingly
affecting all women-including those in suppos-
edly monogamous, long-term relationships-
there remained the fear that offering HIV/STD
services would frighten away or in some way of-
fend family planning clients, and thus dilute the
mission of the FPAs. Similarly, they feared that
the cost of integrating HIV/STD services and
family planning would be prohibitive, potentially
thwarting efforts to increase income self-suffi-
ciency and sustainability. In the late 1980s and
early 1990s, those FPAs that did carry out HIV/
STD-related activities mainly addressed "high
risk groups" such as gay men, commercial sex


,I \ _i.





workers, or general populations outside their
own clinics. Few brought up the topic with their
own clientele or offered services under their own
roofs.
Beginning in the late 1980s, the overarching
theme of IPPF/WHR's regionally supported HIV-
prevention activities was reducing the stigma as-
sociated with AIDS prevalent at the time, and
helping FPAs to recognize the increasing threat
the epidemic posed to women in long-term re-
lationships-namely their clients. Although
these small-scale endeavors had limited impact,
they nonetheless paved the way for the devel-
opment of a more comprehensive, integrated
approach.
In 1992, the United States Agency for In-
ternational Development (USAID)2 provided
funding to IPPF/WHR to develop a pilot project
to integrate HIV/STD prevention in the programs
and services of three family planning associations
in Latin America and the Caribbean: BEMFAM/
Brazil, ASHONPLAFA/Honduras, and FAM-
PLAN/Jamaica. This new support provided an
opportunity to develop full-scale integrated pro-
grams within these FPAs.
When the project began, there was little ex-
perience integrating HIV/STD prevention and
family planning, so IPPF/WHR and the three
FPAs began the process of defining and develop-
ing HIV/STD/family planning integration pro-
grams without the benefit of models to follow.
This was actually positive because it allowed each
FPA to develop a unique program based on its
own service structure, the perceived needs of its
clients, and the particular interests and ideas of
its management and staff. As these programs ma-
ture over time, it is hoped that other FPAs in the
region-as well as family planning programs more
broadly-will be able to benefit from what has
been learned. For despite linguistic, cultural, and
programmatic differences between the three
FPAs, many of the issues they and their clients
face are remarkably similar.

INITIATING THE PROCESS OF
CHANGE

Counseling and Education Before
the Project
By 1993, most front-line staff in the regional
FPAs already possessed strong educational and


counseling skills, demonstrating empathy, listen-
ing actively, and truly reflecting on the expressed
needs of each client. Nonetheless, they utilized
these skills narrowly, with little attention to sen-
sitive issues such as sexual practices and personal
relationships. Although some group education and
other outreach work with clients was highly par-
ticipatory, individual "counseling" was more of-
ten than not the one-way provision of informa-
tion by the "counselor" to the client. Many FPA
staff did not feel comfortable discussing issues
related to HIV, STDs, and sexuality. They tended
to present condoms exclusively as a back-up
method as opposed to a valid option for family
planning and HIV/STD prevention.
When the project began, most FPA staff
were aware of the existence of AIDS, but few
possessed in-depth knowledge of the disease, nor
did they tend to link HIV/STDs with family plan-
ning and sexuality. Many held misconceptions
about how HIV is transmitted, and few were
aware that STDs could be asymptomatic. A fam-
ily planning counselor describes the approach to
counseling typically taken at her clinic prior to
the new program:
Typical services included advantages and
disadvantages of family planning methods,
giving the client the best method, and, well,
we didn't enter into prevention, but we did
mention that they had to take care of them-
selves. We sometimes mentioned protecting
oneself not only against pregnancy but
diseases as well, but it wasn't done with love,
it wasn't done to help people change their
opinions, it was simply information. It was
just advice that you had to avoid it. We
didn't really discuss it, only if the client
asked. It wasn't effective counseling.
-Thesla Bustillo,
ASHONPLAFA/Honduras
At the time, this limited scope of counsel-
ing seemed appropriate for family planning but,
when HIV/AIDS came into the picture, it was
soon apparent that this topic could not be effec-
tively addressed without taking a broader sexual
health approach. Addressing AIDS requires a
frank discussion of sexuality and sexual behaviors
and a more personalized approach to counseling.
Staff have found it impossible to help clients have
safer sexual relations without first addressing the
underlying factors that influence an individual's





ability to make decisions about and control his or
her sexual life. This new emphasis on sexuality is,
in turn, changing the way family planning services
are being rendered.
The goal of the program was not to add HIV/
STD prevention as simply another element of
family planning services. Rather, it was to improve
the overall quality of services by changing the
manner in which they are provided, not just merg-
ing two types of services-family planning and
HIV/STD prevention-or housing two separate
services under the same roof. The intent of the
project was to fundamentally alter the nature of
the client-provider interaction.


Staff Motivation for Change

While the decision of each FPA to take on
an HIV integration project at the institutional level
was essential, and the training provided to staff
served to launch the process, it was in fact a sense
of urgency about the AIDS epidemic itself that
actually made the shift in staff attitudes and ap-
proach possible. As one family planning counse-
lor recounts:
One of the factors [that motivated this
change] more than anything was the reality
that we are living. We cannot deny the fact
that in my city, San Pedro Sula, we have
the highest rate of AIDS. Now, every day,
I'm with a person who, if they don't have
AIDS, or their husband doesn't have AIDS,
they have some cousin, uncle, or brother
with AIDS or HIV I have had to see so many
cases that it's no longer strange. We have to
go beyond [what we are doing] to protect
our people, our country, and ASHON-
PLAFA itself.
-Yolanda Ruiz
ASHONPLAFA/Honduras

By 1993, AIDS was a reality, not a rumor.
In addition to inspiring staff to take action, the
epidemic itself also created client demand for in-
formation, counseling, and services related to
HIV/AIDS. Here an outreach worker from FAM-
PLAN/Jamaica describes the concern and fear
behind clients' increasing desire for assistance:
Before this girl died from the AIDS virus,
the HIV/AIDS, when you go to them boys,
they didn't really want to hear what you


have to say. But you see, since they know
that this girl died, and they hear she talked
about the amount of partners that she
usually have, everybody is so frightened.


PROJECT DEVELOPMENT AT
THE INSTITUTIONAL LEVEL

Each of the three FPAs is very different in
terms of size and structure. Accordingly, each has
developed a somewhat unique design for their
HIV/STD and family planning integration
projects, yet incorporated some common elements.
BEMFAM/Brazil has hundreds of staff working in
eight clinics and over one hundred health posts;
Honduras has five clinics plus a community sales
program; while FAMPLAN/Jamaica (with approxi-
mately twenty staff including administration) has
only two small clinics and a rural outreach program.
All three FPAs, however, serve both urban and
nonurban, middle-class and poor populations.
Since the project's inception, the three FPAs have
had opportunities to exchange experiences, and
they have made modifications and adopted ele-
ments based on one another's programs.
The course of development for each project
was determined, in part, by responses to needs
assessments conducted by IPPF/WHR staff and
FPA management. These included formal and
informal interviews with staff and clients, as well
as observations of counseling sessions. Using this
information, IPPF/WHR and FPA staff worked
together intensively to determine each FPA's pri-
orities, given the existing structure of their pro-
grams, resources, staffing configuration, and per-
ceived needs.

Step One-Staff Training

In each of the FPAs, a first step in initiating
the new projects was staff training carried out by
a combination of in-country consultants, FPA
staff, and IPPF/WHR staff, depending on the
needs and resources of the particular FPA. (Over
time, each FPA has developed some level of in-
house capability to provide training to its own staff
members.)
In all three countries, a wide variety of
staff-not just counselors and educators, but phy-
sicians, nurses, administrative staff, and support
staff, including drivers and cleaners-participated
in training sessions. Initial training, usually two















Yv


to three day-long sessions, focused on basic in-
formation about HIV/STD, sexuality, and related
education and counseling skills. Subsequent
training helped staff understand and define for
themselves the broader concept of sexual and re-
productive health; delve more deeply into issues
of sexuality; and learn new skills for communi-
cating with clients about such sensitive issues. Ses-
sions also included analysis of issues related to
gender and power and development of skills to
help clients communicate and negotiate with their
sexual partners. Specific training in specialty ar-
eas were held for smaller groups of staff. For ex-
ample, physicians and nurses received training in
STD diagnosis and treatment; staff who work with
groups received training in group facilitation skills;
and staff responsible for facilitating women's dis-
cussion groups received training in a more spe-
cialized type of group work methodology.
In order to help staff become more com-
fortable communicating about sexuality, they were
prompted to reflect upon their own feelings and
experiences, which helped to create a level of self-
awareness needed to positively affect their inter-
actions with clients. As one physician in Brazil
reflected upon her experience:
You can even have the knowledge, have
taken a thousand courses and prepared
yourself, but you have to want to do it. I
think that what is important about the


course...is this-first becoming aware and
sensitized. Previously acquired knowledge
is worthless if I am not sensitized.
-Dr. Vania Bastos Petti,
BEMFAM/Brazil

TRAINING THEMES

Although training sessions in each FPA were
geared toward the specific needs, levels of knowl-
edge, and skills of the participants, the following
are some themes that were common to all three
programs.

Comfort with Sexual Language

In order to effectively talk with clients about
sexual and reproductive health, it is necessary for
staff to become comfortable with the language of
sexuality. Participants from different countries, or
even within the same FPA, often varied tremen-
dously in their level of comfort with sexual lan-
guage. Therefore, training sessions usually began
with exercises to help participants verbalize a va-
riety of terms describing sexual acts and sexual
anatomy, using both formal language and local
slang. These exercises often involved an explora-
tion of the differences between the words used
by professionals and those known to clients, which
words are considered acceptable or unacceptable,


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and what terms best meet clients' needs in any
given setting.

Clarification of Values

Although many FPA staff had received pre-
vious training in values clarification, the level of
knowledge and sensitivity to issues related to sexu-
ality and sexual behavior required to address HIV,
along with the tremendous level of stigma associ-
ated with AIDS, called for a much more in-depth
exploration of deep-seated values.
One training exercise called for staff to ex-
amine a list of sexual behaviors such as oral sex
on a woman, oral sex on a man, group sex, anal
sex, extramarital relations, and prostitution. Par-
ticipants were asked to decide whether each be-
havior was acceptable for themselves, for others,
or simply not acceptable. Staff then discussed how
it feels to have someone else decide that an activ-
ity in which they themselves engage is unaccept-
able. In other exercises, staff listened to value-
laden statements such as: "People who have sexual
relations with members of their own sex are ab-
normal;" "Women without education are inca-
pable of making their own decisions about their
reproductive and sexual life;" or "Having more
than one sexual partner at a time is acceptable."
Participants were then asked to decide if they
agreed or disagreed with the statement, and then
to try to convince those with an opposite belief to
accept their point of view.


These exercises were very revealing as staff
uncovered their own biases and challenged those
of their colleagues. As members of the commu-
nities and cultures that they serve, FPA staff of-
ten reflect the values of the larger society. For
example, during these exercises, some staff
equated certain sexual behaviors with prostitu-
tion or homosexuality and expressed a judgmen-
tal attitude about the behaviors and the individu-
als who engage in them. At FAMPLAN/Jamaica,
staff encountered difficulty in discussing, let alone
accepting, what they considered to be deviant be-
havior, such as anal sex. However, once they
agreed that this is indeed a practice in which both
men and women engage in their country, in spite
of the associated stigma, they recognized the im-
portance of addressing it in their counseling work.
One staff member who felt strongly that oral
sex was abnormal behavior had difficulty sepa-
rating her own values concerning the behavior
from her discussion about what was safe or un-
safe in terms of transmission of HIV/STDs. Her
colleagues' efforts to help her separate the two
issues proved futile. Yet, despite her inability to
look beyond her own personal values during the
workshop, shortly thereafter she began actively
teaching clients how to cut a condom in half to
use it for protection during oral sex on a woman.
Clearly, she did hear, and eventually came to ac-
cept, the idea that it was her responsibility as a
health professional to address these issues despite
her personal values.


~ssaaL






Sexual Development

In addition to providing factual informa-
tion related to sexuality, many training exercises
helped participants recall their own experiences
learning about sex and how that affected their
sexual development emotionally and physically.
One exercise asked staff to close their eyes and
reflect upon how they first learned about sex in
their childhood and the circumstances around
their first sexual feelings as they grew up. They
were asked to remember the emotions they felt
as they grew and learned. In Honduras, staff
shared a wide range of remembered feelings,
both positive (happiness, curiosity, awakening
sensations, desire, and love) and negative (anxi-
ety, fear, shame, disgust, and sadness). This helped
staff to draw upon their own experiences as a
means of better understanding their clients' feel-
ings about sexuality.
Sexuality is the one area where staff at all
three FPAs consistently expressed a need for ad-
ditional training in terms of both technical infor-
mation and skills in handling sensitive issues. One
exercise asked participants to write out and sub-
mit anonymous questions about sexuality, which
revealed very fundamental concerns that individu-
als may not have felt comfortable expressing aloud.
Questions posed in one workshop included:
Can you practice anal sex with a female
partner?
Why did I bleed a lot during my first se-
xual relation?
Is masturbation bad?
Is oral sex satisfying?
Are there people who, although stimulated
sexually by their spouse, do not have orgas-
ins? What is this due to?
Why do some women have fear at the
moment of penetration?

Defining Sexual and Reproductive
Health

In some training sessions, staff explored the
variety of meanings behind the terms "sexual
health" and "reproductive health" in order to
come to a common understanding of the concepts
in the context of their own communities and work.
During a training in Honduras, participants de-
fined sexual health as: "The acceptance of our own


sex and general health... Having a positive atti-
tude, we will have sexual health free of contagion
with HIV/STDs... To have sexual health, we have
to be physically, psychologically, and emotionally
well." Under reproductive health, they added
"The well-being of the couple and the individual,
mentally, socially, emotionally, and economically...
These are optimal conditions for all human be-
ings to reproduce."
A physician from BEMFAM/Brazil re-
flected on what it means to provide more com-
prehensive sexual and reproductive health ser-
vices, noting that:
Someone can be a good professional, know-
ing how to insert an IUD correctly, knowing
exactly which medication should be given
for gonorrhea, but this [broader approach]
involves viewing a person as a whole-
tending to a client from a holistic perspective
of overall health and well-being. I feel that
BEMFAM's training served to give people
that vision.
-Dr Roberto Dias Fountes


The Client's Sexual Life and Risk
Perception

An important aspect of the training was to
help staff build skills for exploring their clients'
individual circumstances, including their sexual
lives. Using role playing, staff practiced how to
help clients articulate their true concerns about
their reproductive and sexual lives, and deter-
mine for themselves their own level of risk in
terms of HIV infection. One role playing exer-
cise calls upon a participant to take the part of a
counselor who knows nothing about the client's
situation. Another participant, who plays the cli-
ent, is given a situation which she/he reveals only
upon exploration by the counselor. In one such
session in Honduras, participants were asked to
explore the following client scenarios:
A client has deep religious beliefs and is
very ashamed. She is concerned about
STDs and HIV because she suspects that
her husband is unfaithful. She will only
discuss this with the counselor if she is
made to feel comfortable enough to
confide.
An adolescent visits a clinic to ask for






contraceptive methods. She has been ab-
used sexually by her uncle and is terrified
to speak about it.

A woman whose husband forces her to
have anal sex believes that her husband
might be homosexual.
In some cases, the "counselor" succeeded in
helping the "client" to open up and discuss real
feelings. However, when the "counselor" was less
successful in revealing the clients' actual situation,
all participants helped to analyze the situation,
identifying approaches that might have helped the
client to eventually articulate her true concerns.
Together, staff then defined the types of ques-
tions that can aid in the exploratory process.
Other exercises were designed to help staff
understand how clients perceive their own risk
and the factors that influence these perceptions.
Participants took part in role plays about typical
situations such as an interaction with a client who
has come to the clinic seeking a family planning
method but has never really thought about her
own risk of contracting HIV. Here the participant
playing the part of the counselor was asked to try
to understand the client's level of risk perception
and the factors that influence her perceptions, then
to help her recognize how these factors might put


her at risk. By analyzing these role plays together,
staff were able to develop strategies to help cli-
ents understand and evaluate their own risk.


Gender, Power, and Sexual
Relations

Together staff also looked at the ways in
which economic dependency and gender relations
can affect clients' reproductive health decisions,
practicing ways to help them consider the poten-
tial ramifications of their decisions. During a re-
cent training in Honduras, participants made a
list of factors that may affect clients' decisions,
including fear of pregnancy, fear of ending up
alone (losing their partner), fear of domestic vio-
lence, religious beliefs, and influence of or coer-
cion by spouses themselves.
Other training sessions helped staff analyze
the ways in which societal and personal gender
constructions affect the dynamics of sexual rela-
tionships. Here exercises included analyzing the
factors that can make relationships unbalanced
in terms of power and role playing scenarios of
sexual communication and negotiation in an un-
balanced relationship. In other exercises, staff
reflected upon the advantages and disadvantages
of being male or female in their own cultural con-
text, and how these social factors played out in
sexual relationships.

Safe Sex

During the training workshops, staff ex-
plored strategies for helping clients broach the
subject of sexual relations or condom use with
their partners. They learned how the timing and
circumstances under which the subject is raised
can make a difference in terms of what happens
next. For example, in Jamaica staff made a list of
the excuses people make to avoid using condoms
and then devised lists of counterarguments that
could be used in the negotiation process. In or-
der to better understand how difficult this can be
from a client's perspective, they acted out various
situations in which couples might negotiate the
terms of their sexual relations.
The training explored safe sex in a broad
sense-that is, not only in terms of protection
from HIV/STD transmission, but also in terms
of protection against unwanted pregnancy and






























the abuse of power. Participants discussed safe
forms of sexual expression and participated in
exercises to encourage their creativity in defin-
ing forms of sexual expression that do not in-
volve penetrative intercourse. The staff in Ja-
maica included in their lists of "sexual expres-
sions" activities such as massage, reading poetry,
and taking baths together.

Family Planning from a Sexual/
Reproductive Health Perspective

In these exercises, staff analyzed all family
planning methods in terms of not only their ef-
fectiveness in preventing pregnancy or STDs, but
also their effect on sexual relations and sexual plea-
sure. They explored issues related to use of con-
doms alone as a family planning method as well as
the possibilities of dual method use-using con-
doms along with other contraceptive methods.
More specific exercises helped staff to ex-
plore their own personal and professional biases
against condoms and determine ways to destig-
matize use of the method with their clients. Prior
to the training, many participants had little or no
experience demonstrating correct condom use.
So, with the aid of a penis model, they learned
everything from opening the package to proper
disposal techniques.


Sexually Transmitted Diseases

A basic understanding of STDs prevalent in
each setting, including a review of basic signs and
symptoms, has been an important component of
training for each FPA. Counseling staff have
learned to help clients recognize what is and what
is not normal, and to explore each client's history
of STDs. They have learned about the dangers of
providing IUDs to clients who are at risk of STDs,
and about asymptomatic infections-information
that was entirely new to many staff. STD training
for medical and nursing staff was more in-depth
and included clinical recognition of STDs, diag-
nosis, and treatment.

PROCESS OF CHANGE AMONG
PROVIDERS

I am aware that I am serving my clients with
more interest and dedication because I am
not talking just about a method, but rather
the prevention of disease. And this makes
me feel good.
Thesla Bustillo

It is clear from this statement that this coun-
selor takes great pride in her work. During the






past three years, staff from ASHONPLAFA/Hon-
duras and their counterparts at BEMFAM/Brazil
and FAMPLAN/Jamaica, have witnessed changes
in themselves as they have grown both profession-
ally and personally through their new mission at their
FPA. They have also witnessed startling changes in
the questions and concerns of their clientele as the
AIDS epidemic gains momentum and clients re-
spond to the FPA's new approach to service delivery.
Of course, change does not take place over
night-it is a process. The story behind these
changes begins to emerge in discussions with FPA
staff members-program coordinators, counselors,
outreach workers, physicians, and nurses-who
register genuine enthusiasm when they describe
how they go about helping clients with a range of
concerns that go beyond simple method selection.
For example, a physician from BEM-FAM/Brazil
describes how the new program has allowed his
role to expand beyond clinical treatment to incor-
porate clients' emotional concerns as well:
I am sure that at other clinics, probably the
majority of them, the physician inserts an
IUD as well as I do or prescribes a gonor-
rhea medication as well as I do. It's not too
difficult-you follow procedures, look in a
book and there you have it. But the issue of
preparing people emotionally... causes us to
think differently now, to deal with the
emotions of others. Now we work with
people's emotions, too. In this regard, we have
overcome our prejudices and limitations.
-Dr Roberto Dias Fountes

Beyond a new approach to counseling and cli-
ent interaction, staff describe a new level of self-
awareness among both themselves and their clients:
Before we used to talk about methods and
we'd arrive at an agreement with a client
on a method. But now we go much deeper
We ask if she has an infection...we look for
risk factors...we can talk about other things
such as sexual relations, about her sex life in
general, about her partners, right? There
have been times when I've asked clients who
takes the initiative in having sex, and how
she feels about it...I have discovered that
women want more...they want to know nure
about themselves...
Yolanda Ruiz


Rethinking Family Planning
Methods

Within this broader focus, providers have
changed the way they discuss family planning
methods, expanding their explanation of each
method to include its relationship to HIV/STD
transmission. Staff now highlight the dual ben-
efits of condom use for pregnancy and HIV/STD
prevention and they also discuss the option of dual
method use-the use of condoms in conjunction
with another family planning method. As the Ex-
ecutive Director of FAMPLAN/Jamaica notes:
Issues related to family planning methods
and the threat of HIV/STDs have become
more complex. Staff now have to discuss the
relationship between family planning
methods and HIV/STD transmission. Em-
phasis is placed on the importance of the
condom in that regard and the clients can
choose whether to use two methods or rely
on the condom as a dual protection method.
Peggy Scott,
FAMPLAN/Jamaica

In the past, staff were also less likely to ex-
plore factors that could pose potential complica-
tions for IUD use, such as multiple partners and
a history of STDs. According to Gloria Flores, a
counselor at ASHONPLAFA/Honduras, in the
past some women may have received IUDs who
should not have because attention was not paid
to their risk of STDs. Another staff member in
Honduras describes a situation where counsel-
ing helped an IUD user better protect herself by
also using condoms:
There was this woman, about 33, who had
been using condoms as her contraceptive
method for about 5 years. Her husband...
had been in Choluteca for about-I don't
know what she told me-8 or 9 months-
when she realized that he was involved with
another woman up there. When she learned
about this she had wanted to "reward
him"-her words-to give him a surprise
... to give him the gift of getting an IUD so
that he wouldn't have to keep using con-
doms. She wanted to get the IUD despite
the risk that she faced ofcontracting an STD
because of her husband's extramarital affair
And this was a woman with a high edu-

































national level, right? So we discussed this
for a while and she then arrived at the
conclusion that he would have to keep on
using condoms.
-Yolanda Ruiz
In addition to discussing the relationship
between family planning methods and disease
transmission, staff now talk about the ways in
which various methods can potentially enhance
sexual pleasure and relationships, depending on
an individual's preferences. They emphasize that
methods that provide a sense of security against
both unwanted pregnancy and disease can help
couples enjoy sex more because they will be less
worried about possible adverse consequences.

Rediscovering condoms

Perhaps the most striking changes have oc-
curred in the way in which providers themselves
now approach condom use in their personal as
well as professional lives. There is, within the fam-
ily planning field, a historical bias against con-
doms. This stems from traditional views of the
condom as a less effective method of family plan-
ning, although, when used consistently and cor-
rectly, condoms can be highly effective in pre-


venting pregnancy. However, concern about their
effectiveness with "typical use" (i.e., their being a
user-dependent method), and the higher value
given to longer-acting methods in terms of fertil-
ity reduction goals, prevented some providers
from actively promoting their use.
At the beginning of the project, program
directors at all three participating FPAs found
that staff expressed resistance to condom pro-
motion. While this response may in part have
been a concern about effectiveness, they ac-
knowledge that family planning professionals
have a tendency to judge condoms differently in
terms of their ability to prevent either pregnancy
or HIV/STDs.

We place different values on each use of
condos [pregnancy prevention vs. HIV/
STD prevention] because we come from a
family planning perspective. We are still
looking at things from an unwanted preg-
nancy point of view. It is clear that we are
judging and resisting changing our views
because of our history of family planning
provision.
-Rita Badiani
BEMFAM/Brazil



































When trainers in both Jamaica and Honduras
asked staff members how effective they thought
condoms were, their responses were generally
at or below the actual level of efficacy with typi-
cal use.
Before the new program began, staff pro-
moted the condom mostly as a back-up method,
or as a last choice when other methods were not
feasible. Some would mention the condom's role
in preventing STDs, but most had never opened
a condom package to let a client touch it nor had
they demonstrated how to use one correctly. One
counselor at ASHONPLAFA/Honduras recalls:
"Before we would talk about them in a very su-
perficial way without doing a demonstration...
Before, the truth is that we saw them as only a
means of preventing pregnancy...but not as effec-
tive as other methods."
Given this bias, how did staff attitudes about
condoms change? The Medical Director of
BEMFAM credits training with helping staff to
overcome their negative feelings:

In the stafftraining, use, storage, lubricants,
erotic aspects were all brought up. The


trainer even mentioned prostitutes putting
condoms on with their mouths! This has
changed the way that staff talk about
condoms. Before they said "here it is." Now
they have clients put them on a model and
explain how to store them. They explain that
condoms can enhance sexual relations
because women have the opportunity to
know men s bodies better and that condoms
can intensify sexual response. Now we see
an increase in condom use. After sensitizing
staff to condoms, they even began to request
them for their own use!
-Dr Ney Costa,
BEMFAM/Brazil
In fact, some providers who are condom
users themselves report that their own first hand
experience has made it easier for them to explain
proper use to clients. For example, an outreach
worker at FAMPLAN comments: "When you go
out there to talk to people, they usually ask the
question, 'are you using the condom?' Before you
go and tell them you have to start to practice. You
can't tell them 'yes' while you're not, so you have






to be honest with yourself." Another outreach
worker proudly tells the story of how her son asked
her for a condom and a pamphlet on proper use
so that he could bring it to school to share with
his friends at break time.
As their attitudes towards condoms have
changed, staff have developed innovative ways of'
promoting their use. The techniques that they use
and the information that they provide varies
greatly from what was once standard practice.
Before we used to distribute condoms with-
out explanation. Now wee encourage clients
to touch the condoms to see hotc soft they
are. We tell them that they too can partic-
ipate by putting them on their husbands as
part of a pleasurable sexual act. There was
resistance before. Women used to pass
condoms like a hot potato. Nowt they carry
them in their handbags. Now staff believe
in the use of condoms.
-Maria Elena de Perez,
ASHONPLAFA/Honduras

One counselor at BEMFAM/Brazil actually
collects condoms that have been used in demon-
strations and puts them in a box. During a group
intervention, she has the participants close their
eyes as they pass the box of condoms from one to
another. Each woman comments on what she feels
in the box. Clients use descriptions like "moist,"
"soft," "nice smell," and "strong" all of which dem-
onstrate positive connotations and help them to
redefine their opinion of condoms.
According to a staff member at BEMFAM/
Brazil, "These days, we dedicate time to anecdotes
and ideas about condoms. We work to try to de-
stroy prejudices against condoms, eroticizing
them and encouraging female participation in
their use." Another BEMFAM/Brazil staff mem-
ber commented, "We now try to counteract the
myth that condom use detracts from sexual plea-
sure by encouraging new techniques for pleasur-
able condom use as a part of the sex act."
Even the simple addition of a condom dem-
onstration using a wooden penis model has made a
fundamental difference in how staff communicate
with clients about condoms. First of all, the model
has served as an effective attention-grabber and
ice-breaker. According to one outreach worker at
FAMPLAN/Jamaica, "As soon as you go out there
and you take out the penis model, you get their


attention...and if people are passing and see it,
they come nearer to hear what is happening."
Jamaican outreach workers have also devel-
oped strategies for proving the condom's reliabil-
ity. Some put condoms under the water tap to
show that a condom can be completely filled with
water and still not burst while others ask a volun-
teer to put a condom over his foot as a vivid way
of demonstrating the condom's ability to stretch.
Still others blow them up like balloons. These
demonstrations have succeeded in making a seri-
ous topic fun and engaging. After experimenting
with different approaches, staff share successful
strategies with one another.
Over the past several years, there has also
been increased interest in condoms on the part of
FPA clients. When offered free samples, nearly all
accept them and some return for additional sup-
plies. Rural outreach workers in Jamaica marvel at
how eager some men are to get condoms. As mem-
bers of the same community they serve, the out-
reach workers have gained their neighbors' trust
by making themselves available to clarify informa-
tion or supply condoms even after official working
hours. In fact, according to several of them, it is
not uncommon for customers in desperate need
of condoms to wake them up in the middle of the
night: "At 3:00 in the morning, you hear them call-
ing, 'Nurse!' Late in the night, you hear them
knocking... They come and bawl for you and [say],
'sorry to wake you up but I don't have nothing
and I have to get something [for protection]" One
outreach worker noted that demand for her prod-
ucts increases during holidays: "Easter Monday
night, I couldn't sleep in peace at all!"

What's Sex Got to Do with It? A lot!

In order to understand a client's particular
situation or to provide specific information on
condom use, staff have been compelled to address
sexuality issues on a deeper level. Before the new
program, as most family planning staff had fo-
cused exclusively on the risk of unwanted preg-
nancy, they tended to concentrate on the biologi-
cal aspects of sexual intercourse rather than the
emotional aspects of sexuality. But the AIDS epi-
demic has forced a change in perspective.
The HIV/STD issue has helped us to deal
with sexuality in a more active way. When
we just offered family planning counseling,





we related sexuality to that limited per-
spective. The outcome [of integrated coun-
seling] has been to sexualizee" our work.
-Rita Badiani
Initially, many staff reported feeling uncom-
fortable discussing the range of sexual behaviors
in which people engage. They feared asking cli-
ents about their sexual lives, considering it to be
inappropriate or intrusive. One provider in Bra-
zil recalled finding it very difficult to accept fe-
male homosexuality: "I had strong prejudices in
this area and I worked on it... I think that while I
still have not reached 100 percent recovery, I have
reached about 90 percent when it comes to be-
ing able to deal with female homosexuality. That
was my greatest difficulty." Other staff members
found it difficult to accept teen sexuality. For ex-
ample, the receptionist at FAMPLAN/Jamaica
would send girls who arrived in school uniforms
home to change because she did not think that it
was appropriate to acknowledge that school girls
might be sexually active.
Over time staff have become more accept-
ing of the full range of sexual expression. At first,
some were surprised by how eager clients were
to talk about their concerns and reveal their feel-
ings about highly sensitive topics. For example,
outreach workers at FAMPLAN/Jamaica describe
their initial astonishment at clients' openness in
discussing so-called taboo subjects such as homo-
sexuality, anal or oral sex, extramarital affairs by
both men and women, impotence, premature ejac-
ulation, sexual abuse, and domestic violence:
What you're very surprised about some-
times, is when they're telling you what is
actually happening... There was this girl
who came and told me that she's a lesbian
and she wanted to buy the dental dam [for
protection against HIV transmission]. She
was not afraid to tell me. And knowing that
she was just seeing me for the first time.

Homework

For FPA staff, many of whom were raised
in conservative cultures where an open discus-
sion of sexuality was not encouraged, the new
approach does take some getting used to. In all
three countries, staff have requested additional
training in sexuality as there are times when they
still feel unable to address some of the serious
16


concerns their clients raise. On the other hand,
some even report that their increased level of
comfort in discussing sexuality at work has filtered
into their home life as well:
I was raised in an environment where there
wasn't...much information about it [sex-
uality]... My daughter who is 10 is coming
to me asking things that I didn't learn about
until I came here to ASHONPLAFA! So
now I approach it with such naturalness
that I don't feel embarrassed or ashamed
to talk about it...with any other person, not
my co-workers, the clients, my family, my
friends.
-Gloria Flores,
ASHONPLAFA/Honduras
The end result of "sexualizing" the coun-
seling session is that clients better understand
how their own sexual behaviors may place them
at risk of both unwanted pregnancy and HIV/
STD infection. Providers report that many wom-
en actually seem relieved to find an empathetic
person in whom they can confide.
Many providers report a sense of pride in
being able to help clients realize that their con-
cerns are in fact "normal" and that they are not
alone in their worries.


Sexual Decision Making

In the past, providers generally began coun-
seling sessions by giving a standardized lecture
on family planning methods. Now, in most cases,
they begin with an exploration of the individual's
circumstances, including her sexual life. As the
provider talks with the client about her current
relationships and sexual history, together they ex-
plore her level of risk-a shift that is not always
easy or comfortable for the provider.
But, despite the difficulty, providers take
comfort in the fact that by addressing sexuality in
a forthright manner they are ultimately helping a
woman protect herself from disease as well as
unwanted pregnancy. One counselor recounts a
session with a client that began in a routine man-
ner, and probably would have remained strictly
clinical had she not asked the client about her
reasons for requesting a pap smear.

When I asked her why she had come for the
exam, whether it was a routine check-up or































if she felt like she had a problem like vagi-
nal secretion...she said, "look miss, I have a
big problem that I've never told anyone
about. But now that you've begun to ask me
questions..." It turns out that she didn't come
for the exam to find out if she had a problem
but more than anything to find some sort of
help... She revealed that she had been raped
when she was 15 and that she got married
at 18. After six years of marriage-she was
now 24-she never knew what an orgasm
was...she never felt sexual desire.
Through responding to my questions
she felt like we had created an opening... I
think that if I hadn't asked her these things,
she probably wouldn't have had the op-
portunity [to talk] because they were about
to send her to pay and then to see the doctor,
and then that would have ended everything.
We would have talked about the results of
her exam, not what she really wanted to talk
about. In the first place, explore, right? She
didn't tell me right away that she had been
raped. It was through exploration that the
rape and all that came out.
-Gloria Flores
In one counseling session at FAMPLAN/Ja-
maica, by asking very direct questions about how


the client would feel if she knew that her partner
had other partners, the nurse learned that the cli-
ent in fact knew that her boyfriend had another
partner, his wife! She was the "other woman."
Through discussion, the client revealed a very low
level of self-esteem, and as the "other woman,"
she felt that she was in a powerless position to
demand condom use. In this case, the exploratory
process was critical to the counselor in under-
standing not only the client's feelings, but her
needs as well.
Many clients face considerable barriers-
social, cultural, economic, gender-based-to con-
dom use. Due to economic and emotional depen-
dence on men, many women lack the power to
insist that their partners use condoms. A program
coordinator from FAMPLAN/Jamaica explained
that: "Many of our clients are women of low so-
cioeconomic status. They lack power. Men will beat
them for sex. Men will beat women if they want
them to wear condoms." She emphasized that
within the Jamaican context, condom use becomes
critical in light of the fact that it is common for
both men and women to have additional partners
outside of a primary relationship, and often these
relationships are known to their partners.
A counselor at ASHONPLAFA/Honduras
describes how difficult it can be to break through
ingrained gender roles in Honduras that limit



































women's ability to negotiate method use with
their partners:
More than anything for our clients here, it
is difficult [for them to use methods] because
of gender issues... Generally it is the man
who makes decisions, he decides everything
and it is difficult because our men think,for
example, that using condoms has to be with
prostitutes or women on the street... It's
difficult when we talk with a woman and
because she has a partner she doesn't even
want to take a condom because she's thinking
all the time, "but what will my husband
say?..." The Honduran woman is extremely
oppressed, violated sometimes because she
is not even able to negotiate any aspect of
her home, much less her sexual life, her se-
xual intercourse, or her life itself.. It is
difficult for her to negotiate with men
because she is afraid that he is going to
withhold from her or leave or reject her
Yolanda Ruiz
In many instances, a first consideration for
a client may be to decide how she feels about the


possibility of a future pregnancy, while weighing
this against her perceived risk of disease. In a situ-
ation where abortion is unacceptable, inacces-
sible, or unsafe, the woman may need to assess
her ability to ensure that condoms are used cor-
rectly and on a consistent basis. The counselor
may explore the nature of the relationship the
woman has with her partner, considering both her
financial and emotional level of dependence.
If the woman fears that her partner will
refuse to use condoms, the counselor can help
her determine if she feels she might be able to
convince him to do so. Besides his potential re-
fusal, she may also fear that violence or sexual
abuse could result from her request. Providers
must understand that the woman may also risk
losing her partner altogether, which could be
emotionally or economically devastating.
In addition, the client may have biases of
her own against condom use both in terms of ef-
ficacy and acceptability. She may perceive them
as inhibiting sexual pleasure or view them as as-
sociated with prostitution or immorality. Finally,
certain economic or logistical considerations may
influence a woman's decision. For example, when
confronted with the decision to use two methods
or one, a client may make a decision based on her
financial situation, her inability or unwillingness
to purchase more than one method.
The following example of an actual coun-
seling interaction underscores the importance of
assessing the underlying factors that influence a
client's contraceptive decision and her ability to
protect herself from disease.
At ASHONPLAFA/Honduras, as soon as
the client sat down with a counselor, she requested
an IUD. However, after a few minutes of asking
questions, the counselor discovered that the cli-
ent was also concerned about contracting STDs
from her husband, who frequently traveled. In
response to the counselor's questions, she de-
scribed an infection that had been treated earlier
that year.
When the counselor asked if she had ever
used condoms, she explained that she felt as if
she could not ask her husband to use them, un-
less there was a medical reason that prevented
her from using any other family planning method.
She said that, otherwise, to ask her husband to
use condoms, would imply a lack of trust on her
part, and he would refuse to use them. Also, as a
mother of eight children, she hesitated to use con-






doms alone, fearing the risk of another pregnancy.
Therefore, protecting herself against pregnancy
was her highest priority.
Together with the counselor she decided to
have the IUD inserted, but to tell her husband
that she had been denied the IUD for medical
reasons so that he would have to use condoms. In
this way, she would be using two methods to meet
her needs for both pregnancy and disease pre-
vention, but without jeopardizing her relationship
with her husband.
An important questions here is, of course,
that by encouraging a client to adopt this solu-
tion, is the counselor failing to promote improved
communication between the client and her part-
ner? While open communication between part-
ners is a laudable goal, providers must weigh the
possibility of moving in this highly desirable direc-
tion against a client's possible need to protect her-
self at all costs. FPA staff must deal with dilem-
mas like this on a daily basis. In this case, the coun-
selor recognized that while many men in Latin Am-
erica support the concept of pregnancy prevention,
at the same time they feel threatened, accused, or
betrayed by a request to address the need for dis-
ease prevention. Men may perceive a woman's de-
mand for condom use as evidence that she is ques-
tioning his fidelity or perhaps is being unfaithful
herself-a double standard common in cultures
where male promiscuity is common and women
are more likely to be the monogamous partner.
A staff member at BEMFAM/Brazil told the
story of one client who attended the FPA's wom-
en's discussion group three times. At the first ses-
sion, the woman appeared anxious but remained
silent. During the second session, she asked some
specific questions about AIDS-related symptoms
in an emotional manner. After the session, she
requested individual counseling and during her
meeting with the counselor she revealed that she
was afraid that she might have AIDS. She de-
scribed suffering symptoms such as night sweats,
diarrhea, and weight loss since her husband's re-
cent confession of infidelity and requested an
HIV test.
Upon her return to the clinic fifteen days
later, she appeared greatly relieved to find out that
her test results were negative. Despite the scare
she had experienced, at the third and final ses-
sion, she admitted that she had not yet managed
to confront her partner about condom use: "I
know it's necessary, but I'm not brave enough to


ask him to use a condom. He's my husband and if
he admitted infidelity, at least he's honest." After
discussing issues of self-esteem with the client
once more, the staff member reported feeling ut-
terly hopeless in the face of the woman's ingrained
values, commenting: "Female passiveness is
something so internalized that it is greater than
the fear of death."

Group Dynamics

As there are clearly limits to what can be
accomplished in one individual session, BEM-
FAM/Brazil has found that small group sessions,
like those described above, are effective settings
for fostering communication and negotiation
skills. Known as the "Women's Project," these
small group discussions for women (in some cases
men attend as well) provide a safe environment
in which women can express their concerns, give
support to each other, and learn new communi-
cation skills. BEMFAM views them as a success-
ful complement to individual counseling, and,
based on the Brazilian model, the FPAs in Hon-
duras and Jamaica have begun developing their
own group intervention programs in both the
community and clinic settings.
Prior to receiving medical services, all wom-
en who attend BEMFAM/Brazil clinics in several
locations are invited to participate in a small group
discussion led by a specially trained facilitator.
Together, they read and discuss comic book-style
booklets that feature stories reflecting the reali-
ties of women's lives and exploring issues related
to HIV/STDs, risk perception, and partner com-
munication. The booklets are used to lead into
broader discussions about health, sexuality, and
relationships.
The sharing of life stories allows women to
recognize that they are not alone in their
feelings. The group setting permits women
to express themselves and practice more
assertive behavior in a nonthreatening en-
vironment, helping them to overcome
feelings of intimidation in communicating
with their partners about sexuality and
preventive practices.
-Rita Badiani
An example of the positive changes observed
in clients as a result of participation in group ses-
sions is a woman who attended two sessions where


































she expressed her desire to become less depen-
dent on her partner by seeking employment. She
came back the third time proudly reporting to the
group that she had found a job. Another woman
who, after participating in the group three times,
had successfully persuaded her husband to use
condoms told the group:
Afterfighting many times, I got my husband
to use a condom. I screamed and wailed. I
told him that his penis was thicker and more
pleasurable [with a condom]. He has been
using condoms now for three months. Now
I feel more secure and indeed feel pleasure.
In addition to helping clients to articulate
their concerns, both informal and formal group
work are often an effective way for clients' true
needs and interests to emerge. For example, dur-
ing a waiting room discussion in Jamaica about
HIV, STDs, and family planning, conversation
quickly turned to clients' deep concerns about
sexual abuse in their community. Although these
women were very concerned about the risk of HIV
transmission, it was clearly sexual abuse (and the
broader risks entailed, including HIV transmis-
sion) that they felt needed to be addressed.


INSTITUTIONAL IMPLICATIONS

Launching a new, innovative program such
as this has required more than simply training staff
to adopt new techniques. It has required that the
FPAs make changes at the institutional level, chal-
lenging existing management structures and staff-
ing patterns.

Commitment

Project Coordinators at all three FPAs have
emphasized that in order to achieve success, it is
essential to secure the FPA's commitment to the
new program and acceptance of its place within
the FPA's overall mission. According to Rita
Badiani from BEMFAM/Brazil, if an FPA's mis-
sion is to "provide high-quality sexual and repro-
ductive health services," then all programs and
services-including those related to HIV/STD
prevention and treatment-must contribute to at-
tainment of this larger objective. In other words,
an innovation's underlying philosophy must be-
come imbedded within the overall goals of the
institution. Along these lines, FAMPLAN/Jam-
aica's executive director comments:
Change has to be well-managed given the
resistance at any attempt to change old
methods and concepts. Top management
commitment to the program must be very
real and apparent from the beginning, and
this commitment must be sold to all staff,
especially those implementing the project.
Staff should be involved in every stage of
this process, program planning, implement-
ation, and evaluation.
-Peggy Scott

Structural Issues

The FPAs have discovered that the place-
ment of these projects within the organizational
structure of the FPA can influence the way in
which the new approach takes root within the
institution. For example, at ASHONPLAFA/
Honduras, it was found that when the program
was initially placed under the jurisdiction of a
new staff member hired expressly for that pur-
pose, other staff members perceived the pro-
gram as a separate and isolated effort. As a pro-
gram manager explains:






When they named a new coordinator for a
project on education and counseling, there
was staff resistance because there was a new
person receiving a salary. The thought was:
"This new person is responsible. I have my
own work already defined. Now that person
will do work in that [HIV/STD prevention]
area." It is hard to motivate people and to
make them understand that the project
belonged to the whole FPA and not to one
person or one department. It was a difficult
process. It took time... But people eventually
came around... Now I am convinced that the
staff have identified with the project as part
of the institution.
-Maria Roberta Bulnes

In fact, the main reason the new program
managed to flourish in Honduras was because of
the intense involvement of junior staff who orga-
nized themselves as a result of their shared per-
sonal commitment to HIV/AIDS prevention and
treatment. These staff, in turn, have been the cata-
lyst for management ultimately becoming com-
mitted to the new approach. On the other hand,
from the beginning BEMFAM/Brazil placed the
new initiative directly in the hands of existing high
level managers, so the program was readily imple-
mented and accepted by all staff.


Despite these administrative differences,
program managers at all three FPAs have found
that the new program has occasionally challenged
established lines of authority. As much of the
work is interdisciplinary and crosses depart-
ments, confusion over supervision has occurred
when program oversight or coordination rests
with one department while staff from many de-
partments within the organization are responsible
for implementation.

ACCOMPLISHMENTS TO DATE

Changes Observed

As described above, dramatic changes in the
manner in which services are provided have been
observed in all three FPAs in a relatively short
period of time-the three to four years since the
initiative began. While some positive changes
were apparent after initial training of only two
or three days, it has taken longer for staff to re-
fine skills, develop comfort with these issues, and
learn how to integrate the changes within the con-
straints of the clinic setting. Many counselors, for
example, first shifted from a focus on providing
information about contraceptives, to a focus on
giving information and advice about HIV/AIDS.
They then moved on to elicit information about






risk and then, over time and with ongoing feed-
back, they became comfortable using a two-way
process to explore the client's situation. Institu-
tionalization of the new approach has also been a
long-term process, involving a permanent change
in the manner in which family planning services
are provided. Staff have received ongoing train-
ing, feedback, and support from colleagues, su-
periors, and IPPF/WHR throughout the course
of the project. A mechanism must be planned to
assure refresher training and ongoing support
once funding is withdrawn.

Improvements in the Quality of
Family Planning Services

By far the most noticeable change has been
increased condom use. Although overall condom
distribution increased dramatically in the first year
of the project, many other factors related to con-
dom availability and access limited the numbers
distributed in subsequent years. Still, staff report
that clients are increasingly requesting condoms.
In Jamaica and Honduras, free samples are given
to all new clients and counselors report that over
90 percent accept them. Some clients indicate that
they are putting them in their partners' suitcases
or drawers, or giving them to their adolescent
children. In Brazil, 36 percent of clients adopt-
ing family planning for the first time now select
condoms, and 5 percent elect to use dual meth-
ods. Women who participate in group discussions
receive samples of condoms and many return for
additional supplies.

Effects on Staff's Personal Lives

Some staff have indicated that their expe-
rience with the program has assisted them in
their personal lives, particularly in terms of com-
munication within their own families. As one
staff member in Brazil reports: "I find that I have
become a better person, not just a better BEM-
FAM employee. Even my conversation at home
has improved in some cases." Program managers
in both Brazil and Honduras have also reported
that staff are increasingly requesting condoms for
their own use.
A physician from BEMFAM/Brazil de-
scribes how he has been able to relate his work to
his personal life:
The training certainly served not only for


my professional life, but for my personal life
as well, as a person loving, living, suffering,
enjoying. The truth is, working is like a
classroom in human relations. You relate
what you learn fromm working with clients]
to your relationship with your father, your
mother, your wife, your child, whomever
you are relating to...you can extrapolate
what you learn because the patient is a
human being.
-Dr Roberto Dias Fontes

BARRIERS TO CHANGE

The changes in staff practice called for un-
der this program have not always been easy to
institute, and each staff member has approached
the program with a different level of interest and
openness.

Staff Resistance

Some staff members, particularly those who
had carried out their work in a certain way over
many years, expressed an initial reluctance to al-
ter their approach and responsibilities and dem-
onstrated a certain level of resistance to change.
Peggy Scott of FAMPLAN/Jamaica stresses that:
"Change in the work environment inevitably
causes some amount of tension, and this was as
expected." Some staff felt hesitant to deal with
issues that directly addressed sexuality. For ex-
ample, at BEMFAM/Brazil some female physi-
cians were initially resistant to the idea of per-
forming STD examinations on male clients. The
medical director of the BEMFAM/Brazil charac-
terized their hesitation:
Their husbands did not like the idea ofthem
taking care of men and touching their
penises... Now women doctors are per-
forming [examinations] without a problem.
Only one woman has refused because of
pressure from her husband.
-Dr Ney Costa
More Work?

At the beginning, some staff at all three
FPAs were concerned that the new program
would mean extra work without additional com-
pensation. According to Joan Black of FAM-
PLAN/Jamaica, this initial perception was a diffi-






cult barrier to overcome: "The staff had mixed
feelings... Some said that they needed more
money because they worked more...they believed
that it took more out of them, so they should be
compensated." Once staff understood that rather
than taking on additional tasks, they were being
asked to change the way in which they carried
out the tasks they already performed, feelings
about increased compensation subsided. In Ja-
maica, job descriptions were simply revised at the
time regular salary increases were being given.

Not Enough Time?

With many clients to see daily, staff often
feel pressed for time and are acutely aware of
the number of clients in the waiting area. Ini-
tially, some staff feared that the new approach
would take additional time and lead to a backlog
of clients. Over time, however, they have found
that with practice, the new approach does not
necessarily entail longer sessions with clients. By
starting counseling with a focus on the particu-
lar circumstances of the client, counselors are
better able to tailor the counseling session to
meet their needs, eliminating extraneous infor-
mation that they previously would have included.
They have found that, in reality, time can often
be saved by centering the session around the par-


ticular needs of each client. In Brazil, increased
emphasis on group interventions in the clinics
has proved to be an effective and efficient use
of staff time.

FACTORS THAT HAVE
FACILITATED CHANGE

While training has been instrumental in fa-
cilitating attitude and practice change among FPA
staff, other factors have also contributed. Through-
out the gradual process of reconceptualizing and
redefining job descriptions based on the new ap-
proach, staff have identified several specific agents
of change.

The Changing Nature of the AIDS
Epidemic

As more and more people become directly
or indirectly affected by HIV/AIDS, staff have
changed their perceptions about who is at risk.
As they now view the situation as being "closer to
home" (i.e., that family planning clients are also
at risk), their attitudes have changed. They now
recognize the importance of addressing these is-
sues within their professional practice.
At the beginning, HIV/AIDS was perceived
as a homosexual disease, progressing to a






disease among the sexually promiscuous or
prostitutes. It was believed that hetero-
sexuals were in no danger especially if they
were married or in a steady relationship.
The FPA, realizing the increasing numbers
of persons succumbing to the disease, was
influenced to help counteract the spread of
the disease.
-Peggy Scott

A Sense of Personal Commitment

In many ways, AIDS itself, as a concrete
threat against which people can organize, has
served as a motivating factor for FPA staff. AIDS
has provided the catalyst for developing a true
understanding of the usefulness of working
within a framework of broader sexuality and
sexual health. AIDS has provoked deep concern
among staff, prompting them to assume responsi-
bility for protecting their clients and their com-
munities from disease. As a promotion supervisor
from ASHONPLAFA/Honduras, explains: "My
perspective has changed. Seeing people fighting
for their lives, I now feel a moral obligation to teach
others how to protect themselves." And a coun-
selor from ASHONPLAFA/Honduras reflects:
What has motivated me is that it is a very
beautiful social work. That it is a life that


we are going to save. This is something that
I am doingfor myself andfor my loved ones,
especially my daughter
-Thesla Bustillo

Many ASHONPLAFA/Honduras staff mem-
bers mention that they know someone who is cur-
rently infected with HIV or who has died of
AIDS.

Peer Influence

Staff members at all three FPAs have attrib-
uted, in part, the successful adoption of the new
approach to a sense of solidarity among their col-
leagues. As staff have witnessed changes in their
peers' attitudes and practices, they have been in-
fluenced to adopt a more integrated approach
themselves. For example, ASHONPLAFA/
Honduras's Equipos Motores (motivation teams)
work with FPA staff within each district. Contests
organized by these teams have resulted in the cre-
ation of murals, educational materials, poetry, and
short stories on themes of sexual health, thus cre-
ating a sense of healthy competition between the
various centers. According to a member of the
Equipos Motores, "As we acquire experience and
modify the way in which we approach problems
and address new issues, peer influence has been






an important source of change." Another adds:
"We spur each other on by always giving each
other support and by sharing experiences, more
than anything."
Similarly, a discussion with rural outreach
workers from FAMPLAN/Jamaica demonstrated
that there, too, staff members have relied upon
each other for support; they identified coworkers
as important sources of both encouragement and
new ideas on how to interact with clients.

Providing New Professional
Challenges

The demands of the new program have also
provided staff with new professional challenges.
Assuming new responsibilities has motivated
many to augment their professional development.
Many staff express a real sense of personal satis-
faction with their new roles. "Well, for me this
[project] has been a great help. You're now see-
ing the fruits, and this is satisfying, as an employee,
as a counselor, and as a person."
ASHONPLAFA/Honduras and FAMPLAN/
Jamaica have found that by involving support staff
in education and counseling activities they have
provided them with a greater sense of recognition
and participation that has boosted morale and en-
hanced client interactions. For example, at FAM-
PLAN/Jamaica receptionists and drivers have ex-
pressed enthusiasm over the informal discussions
that they now facilitate with clients in the waiting
room. At ASHONPLAFA/Honduras, a wide vari-
ety of staff, including the cytologist, drivers, and
administrative staff, have become more involved
in counseling and educational activities: when the
cytologist is not busy with pap smears, she now
comes out of the lab to initiate informal discus-
sions with clients in the waiting room; the drivers
have formed their own organization, initiating con-
versations with clients in waiting rooms and com-
munities; and administrative staff have participated
in special public awareness events, including health
fairs and World AIDS Day activities.

Lessons Learned

1. The importance of institutional com-
mitment to the sexuality concerns of clients
cannot be overemphasized. By placing re-
sponsibility for inclusion of the discussion of sexu-
ality directly under top managers, who carry sig-


nificant responsibility, such a controversial inno-
vation can secure institutional commitment. Un-
less there is commitment at the top levels, includ-
ing a willingness to devote the time and resources
required, an innovation of this magnitude could
never be accomplished. Likewise, management
must also provide a supportive environment in
which people can honestly explore their own at-
titudes on such an intimate subject and then sup-
port and encourage them as they begin to imple-
ment the often difficult transition into how they
interact with their clients on a daily basis.
2. Involving all staff in planning, imple-
mentation, and monitoring of the introduc-
tion of sexuality discussions with clients gives
them a sense of personal ownership. Even
staff who do not traditionally take responsibility
for direct client education greatly enjoy this added
dimension to their work-it makes them feel
more involved and that they are helping to for-
ward the goals of the organization. For example,
in Honduras everyone from the cytologist to the
drivers is involved in some aspect of counseling
and education; in Jamaica receptionists and driv-
ers express great satisfaction with the informal dis-
cussions they now carry on with clients in the wait-
ing room.
3. While training is essential, it alone is
not sufficient to change attitudes about cli-
ents' sexuality or the willingness to discuss
intimate matters with clients. As Dr. Fathalla
so clearly noted in his Introduction, "it is easier
by far to impart new knowledge to service pro-
viders or help them to acquire new technical
skills" than is "actually changing their attitudes,
particularly when the issue is a subject such as
sexuality." Attitude change is rarely instantaneous;
rather, it is an ongoing process. Providers need
the support of their supervisors as well as the
opportunity to share experiences with their col-
leagues on a regular basis.
4. Including a discussion of sexuality as
part of the counseling process, rather than
taking up precious time, actually saves time.
Because this approach allows individual clients
to come forward with their most immediate needs,
providers are able to zero in rather rapidly on what
information or behaviors the clients need ex-
plained. This saves time over the previous ap-
proach in which providers would recite the full
range of methods and services available irrespec-
tive of clients' specific needs.






5. Individualized counseling and service
delivery improves the quality of service of-
fered to each client and, at the same time,
gives providers a greater sense of accom-
plishment. The staff participating in these three
programs report a greater level of satisfaction with
their work since the discussion of sexuality was
included. They feel they are now making a differ-
ence in people's lives. Many also report that the
positive changes have carried over into their per-
sonal lives as well, making them more aware and
caring people.
6. Contrary to expectations, there is
very little difficulty getting clients to discuss
their sexual lives openly. In fact, many women
and men seem relieved to finally have someone
to talk to, to know they are not alone in facing
problems such as potential infection, lack of sexual
fulfillment, partners' infidelity, and the like. This
positive response has been a prime motivator for
staff to continue perfecting this new approach to
client interaction.
7. As a corollary to the willingness of
individuals to discuss their sexuality con-
cerns, it was found that group discussions of
sexuality were also highly acceptable-espe-
cially to women. Many women found the groups
empowering insofar as they could discuss issues
of human sexuality, gender inequity, and power
relationships with their peers in a forum where a
trained facilitator was available to lead the dis-
cussion, answer questions, and provide informa-
tion about sources of support and direction avail-
able in their community. At several BEMFAM/
Brazil locations, all women who come to the clinic
are invited to join a discussion group. Staff report
that the group setting not only allows them to ex-
press themselves in a safe environment but also
provides a forum for them to practice techniques
for being more assertive and communicating more
openly with their partners.
8. Adoption of a sexuality-based ap-
proach has resulted in a significant increase
in condom use. Prior to this project, condoms
were rarely promoted as a method and were usu-
ally recommended only as a backup to other con-
traceptives in all three FPAs. Today they are in
the forefront, with increased use by both clients
and staff. Where before many staff would not have


been able to demonstrate correct condom use,
today they are eager to show clients on a penis
model. So clients no longer leave with just a sealed
packet in their hands, but knowing how to put con-
doms on, how to dispose of used condoms, how
effective condoms are for pregnancy prevention
as well as protection from STDs, and tactics to ne-
gotiate condom use with a potentially reluctant
partner. Several clinics also report a growing num-
ber of clients who have decided on dual method
use (condom plus another contraceptive) in re-
sponse to own assessment of their needs in their
particular situation. And lastly, the number of con-
dom users among FPA staff has also increased.
In sum, through this project FPA managers
and staff feel that they are changing the way they
provide services for the better by increasing em-
phasis on clients' needs and the circumstances of
their sexual lives, which has greatly improved the
quality of their work.

Notes
1. The World Bank. 1993. World Development Report: Investing
in Health. New York: Oxford University Press.
2. The funding was provided through an add-on from the USAID
Office of Health to the USAID Office of Population-funded
Transition Project.
3. Quotes originally in Spanish were translated into English for
writing of this booklet. The process of translating the entire
article into Spanish may change the wording of some quotes.

Acknowledgements
We would like to extend our thanks to the entire staff from
BEMFAM/Brazil, ASHONPLAFA/Honduras, and FAMPLAN/Ja-
maica, and particularly to those who participated in the discussions,
in-depth interviews, and focus groups that assisted in preparing this
publication.
BEMFAM: Rita Badiani and Ney Costa, Project Coordinators.
Maria Jos6 Sabino, Angela Maria Dantas, Jane Nunes, Maria de
Fatima Oliveira. Gilson Oliveira, Edilma Costa, Francisca Moura,
Luciene Octacilio, Virginia Andrade. The focus group was conducted
by Katia Moura, Maria do Socorro Silva, Catarina M. Da Silva, Vania
Bastos Petti, Cleusa Souza dos Santos, Elizabeth Afonso, Maria Luiza
da Silva, Roberto Dias Fontes, Dilmara da Cruz Andrade, Jussara
Rocha, Gilda Maria Dutra, Lucia Maria Costa, Josenilda de Carvalho,
Katia Mora. Interviews were conducted by Maria Regina Oliveira
and Sonia Dantas.
ASHONPLAFA Maria Elena de Perez, Maria Roberta Bulnes,
Project Coordinators. Gloria Flores, Thesla Bustillo, Yolanda Ruiz.
Interviews conducted by Julie Becker.
FAMPLAN: Dunneth Willocks, Una Watson, Lames Small, Beverly
Ringrose, Melrose Jones, Carmen McKenzie, Lilieth Richards, Mar-
cia Broderick, Beverly Lambert, Yvonne Woodbine, Pauline Pen-
nant. The focus group was conducted by Maricela Urefio, Richard
Reid, and Joan Black.
We would like to acknowledge the following people who provided
invaluable assistance in preparing this publication: Maricela Urefo,
Claudia Mora, Judith Helzner, Ann Denise Brown, Elizabeth
Kirberger, Doris Bertzeletos, and Nicholas Frost.






Resumen en Espaiiol


Esta edici6n de QUALITY/CALIDAD/
QUALITE relata la experiencia de tres asociaciones
de planificaci6n familiar (APFs) afiliadas con la In-
ternational Planned Parenthood Federation/West-
ern Hemisphere Region (IPPF/WHR) que han tra-
tado de incorporar una estrategia de prevenci6n
del VIH/SIDA en su esquema de trabajo cotidia-
no. Se examine c6mo BEMFAM/Brasil, ASHON-
PLAFA/Honduras y FAMPLAN/Jamaica han lo-
grado una transici6n hacia una oferta de servicios
de planificaci6n familiar mis enfocada en los clien-
tes mismos y mis explicit en el tratamiento de te-
mas sexuales.
En 1992, cuando este proyecto tom6 march
con el apoyo de la U.S. Agency for International
Development (USAID), existia muy poca experien-
cia sobre la integraci6n de la prevenci6n del VIH/
SIDA con la planificaci6n familiar. Cada APF de-
bia elaborar una estrategia particular en base a sus
propias estructuras de servicio, sus propias percep-
ciones de las necesidades de los clients, y los inte-
reses y concepts particulares del personal. Al ini-
ciarse el proyecto eran pocos los trabajadores en
planificaci6n familiar que conocian de cerca al VIH/
SIDA. Con la aparici6n de la enfermedad, los tra-
bajadores en las APFs descubieron la importancia
de motivar a sus clients a que adoptaran comport-
amientos sexuales menos riesgosos. Pero tambi6n
vieron que no lo podrian hacer sin tender primero
a los factors subyacentes que influyen en la capa-
cidad de decision y control sexual de cada client.
En cada uno de los tres pauses, el personal de
las APFs recibi6 capacitaci6n especial que no s61o
los habilit6 para proveer informaci6n sobre el VIH/
SIDA, sino que tambiin les ayud6 a adoptar un
concept mis amplio de la sexualidad y la salud
reproductive en si. Dicha capacitaci6n tambi6n per-
miti6 que el personal indagara mis a fondo en los
aspects de la sexualidad, aprendiendo nuevas
maneras de manejar estos delicados temas con sus
clients. La capacitaci6n tambi6n trat6 temas de
g6nero y poder y proporcion6 t6enicas para ayudar
al client a comunicarse y negociar con su pareja.
Aunque hubo variaciones entire las tres APFs, cada
program de capacitaci6n trat6 los siguentes temas:
comodidad con el vocabulario sexual; clarificaci6n
de valores; desarrollo sexual; definiciones de salud
sexual y reproductive; vida sexual y percepciones
de riesgo del client; g6nero, poder y relaciones
sexuales; sexo sin riesgos; planificaci6n familiar des-
de una perspective sexual y de salud reproductive;
y enfermedades de transmisi6n sexual.
Entre las lecciones aprendidadas por las APFs
en Brasil, Honduras y Jamaica se destacan: 1) la
importancia de un compromise institutional en el


que la gerencia provee un ambiente que facility la
exploraci6n honest de actitudes sobre temas inti-
mos, apoyando a la vez el cambio paulatino de estas
actitudes y de modalidades de atenci6n del perso-
nal a los clients. 2) La importancia de incluir a to-
dos los niveles del personal en la planificaci6n,
implementaci6n y seguimiento del nuevo progra-
ma, dado que todos-desde el citologista hasta el
chofer-aprecian la oportunidad de participar en
algin aspect del asesoramiento y la educaci6n. 3)
La capacitaci6n, aunque es fundamental, no es su-
ficiente como para cambiar las actitudes del perso-
nal sobre la sexualidad de los clients, o para hacer
que los proveedores est6n mis dispuestos a discutir
cuestiones intimas con los clients. La evoluci6n de
las actitudes del personal ocurre de manera gradual
y continue, y s6lo cuando los supervisors apoyan el
cambio y proporcionan frecuentes oportunidades
para que los proveedores compartan experiencias
al respect entire si. 4) Aunque muchos suponen que
discutir la sexualidad con el client consume dema-
siado tiempo, en realidad estas conversaciones sue-
len ahorrarle tiempo al asesor. Esto ocurre porque
la discusi6n abre puertas y permit que el client
exponga sus necesidades mis urgentes, lo cual ayu-
da a que el proveedor identifique de inmediato la
informaci6n o el comportamiento que el client
necesita comprender. 5) Al contrario de lo que se
suele suponer, no es dificil lograr que los clients
hablen sobre sus vidas sexuales con franqueza. Es
mis, muchos hombres y muchas mujeres se mues-
tran aliviados cuando por fin pueden conversar con
alguien sobre estos temas. Resulta alentador des-
cubrir que uno no es el inico que enfrenta proble-
mas como la posibilidad de quedar infectado, la fal-
ta de satisfacci6n sexual, o la infidelidad conyugal.
6) Tambi6n se descubri6 que la discusi6n de temas
sexuales en grupo result muy aceptable-especial-
mente para mujeres. Muchas mujeres respondie-
ron con entusiasmo a la oportunidad de hablar so-
bre sexualidad, desigualdades de g6nero y las rela-
ciones del poder en un foro dirigido por una
facilitadora capaz de contestar preguntas y proveer
informaci6n sobre fuentes de apoyo y direcci6n en
sus propias comunidades. 7) La prestaci6n de ser-
vicios de planificaci6n familiar enfocada en la
sexualidad tambi6n ha resultado en un important
aumento en el uso de condones entire los clients.
Antes de este proyecto, las tres APFs casi nunca
promovian condones como m6todos anticon-
ceptivos, o s6lo los recomendaban como "respal-
do" para otros m6todos. En la actualidad los con-
dones son una de las principles opciones anti-
conceptivas ofrecidas por esas APFs, y el nivel de
uso ha aumentado tanto entire los clients como
entire el personal.






Resume en Frangais


Cette edition dderit l'exp6rience de trois as-
sociations de planification familiale (APFs) affili6es
a l'International Planned Parenthood/Western
Hemisphere Region (IPPF/WHR), dans l'int6gra-
tion de preoccupations sur le SIDA et le VIH dans
leur travail. Elle explore comment, dans la presta-
tion des services de planification familiale, le per-
sonnel de BEMFAM/Br6sil, ASHONPLAFA/Hon-
duras, et FAMPLAN/Jamaique a fait la transition
vers une approche qui soit centre davantage sur le
client et sexuellement plus explicit.
En 1992, quand le project a debut6 avec le sup-
port de l'Agence des Etats Unis pour le d6veloppe-
ment international, on avait tres peu d'exp6rience
dans l'intdgration de la prevention du SIDA dans le
planning familial. Cela veut dire que chaque APF
devait d6velopper une approche unique base sur
la structure de ses propres services, les besoins ap-
parents des clients, et, en particulier, les int6rets et
les id6es de sa direction et de son personnel. Quand
le project a commence, quelques-uns seulement des
membres du personnel connaissaient la maladie en
profondeur. Mais, quand le VIH/SIDA est devenu
plus prominent, le personnel a 6t6 incapable
d'aider les clients a avoir des relations sexuelles
moins risqu6es sans border, au pr6alable, les fac-
teurs sous-jascents qui influencent la capacity des
clients a controler leur vie sexuelle et a prendre de
bonnes decisions.
Dans les trois pays, en plus des informations
sur le SIDA et le VIH, une formation adequate a
permis au personnel de mieux comprendre et d6fi-
nir le concept plus global de sant6 sexuelle et sant6
en matiere de reproduction, d'explorer les questions
relies a la sexuality, et, d'acqu6rir de nouvelles
aptitudes a communiquer avec les clients sur ces
sujets d6licats. Les sessions contenaient 6galement
des questions relatives an genre, aux disparit6s de
pouvoir, et an d6veloppement de techniques pour
aider les clients a communiquer et A n6gocier avec
leur partenaire sexuel. Bien qu'il y avait des varia-
tions entire les trois APFs, les thames couverts par
chaque programme englobaient: l'aisance avec le
language sexuel, la clarification des valeurs, le d6-
veloppement sexuel, la definition de la sant6 sexuelle
et de la sant6 en matiere de reproduction, la vie
sexuelle du client et les risques percus, les in6gali-
t6s entire les sexes le pouvoir et les relations sexuel-
les, les precautions a prendre au niveau sexuel la
planification familiale du point de vue sant6 sexuelle/
sant6 de la reproduction, et les maladies sexuelle-
ment transmissibles.
Les lemons importantes apprises des exp6rien-
ces du Br6sil, de l'Honduras et de la Jamaique cou-
vrent les points suivants:


1) l'importance d'un engagement institutional
et la n6cessit6 de la direction de cr6er un cadre de
travail et environnement qui encourage le person-
nel a explorer leurs propres attitudes sur ces sujets
intimes et a les encourager lorsqu'il commence a
changer la nature de leurs interactions avec les
clients; 2) l'importance d'inclure tout le personnel
dans la planification, l'ex6cution, et le suivi du nou-
veau programme, ce qui lui donne un sens de res-
ponsabilit6 envers celui-ci: du cytologiste au chauf-
feur qui appr6cient le fait de participer a tous les
aspects du programme: que ce soit les consultations
ou l'6ducation; 3) la formation qui est essentielle mais
pas suffisante pour changer les attitudes des clients
envers la sexuality ou le d6sir des prestataires de dis-
cuter des affaires intimes avec leurs clients. Le chan-
gement d'attitude est un processus continue et les
prestataires ont besoin du support de leur supervi-
seur et de l'opportunit6 de partager leur experience
avec leurs colleagues de manihre r6gulifre; 4) inclure
une discussion de la sexuality dans le processus ame-
nant aux consultations ne prend pas de temps, il
permet plutht d'en gagner: ceci est dO au fait qu'il
donne a chaque client la possibility de partager leurs
besoins les plus imm6diats et qu'il aide les prestatai-
res a se focaliser sur les informations ou les compor-
tements sur lesquels le client a besoin d'explications;
5) contrairement a ce que l'on croit, il n'est
pas difficile d'amener les clients a parler de leur vie
sexuelle d'une manidre ouverte. En fait, de nom-
breux hommes et femmes semblent 8tre soulag6s
de pouvoir parler a quelqu'un, de savoir qu'ils/elles
ne sont pas seul(es) en face de probldmes tels qu'
une infection, un manque de satisfaction sexuelle,
ou l'infiddlit6 du partenaire;
6) on a aussi trouv6 que les discussions de
group sur la sexuality 6taient tout a fait accept6es
- surtout par les femmes. De nombreuses fem-
mes ont trouv6 que les groups les rassuraient dans
le sens oh elles pouvaient discuter de questions de
sexuality, d'indgalit6 entire les sexes et des relations
de pouvoir avec des collogues dans un environne-
ment oh un facilitateur habile est capable de diri-
ger la discussion, de rdpondre a des questions, et
de donner des informations sur les sources de sup-
port et de conseil disponibles dans la communautd;
7) l'adoption d'une approche base sur la sexuality
a 6galement eu comme rdsultat une augmentation
significative de l'utilisation du condom. Avant ce
project, les condoms 6taient rarement promus
comme m6thode contraceptive et 6taient g6ndrale-
ment recommends comme appui suppl6mentaire
a d'autres contraceptifs dans les trois APFs. Aujour-
d'hui, ils sont mis en avant, avec une utilisation ac-
crue de la part des clients et du personnel.






About the Authors


Julie Becker currently manages the HIV/STD Prevention Program of the Interna-
tional Planned Parenthood Federation, Western Hemisphere Region (IPPF/WHR).
Her work in public health, both domestic and international, has primarily focused
on sexual and reproductive health, HIV/STI prevention and sexuality.

At the time that this article was being written, Elizabeth Leitman was an indepen-
dent consultant in international women's reproductive health; she is currently the
Assistant Program Officer for Latin America at the International Women's Health
Coalition.

Mahmoud Fathalla is the Associate Director, Population Sciences Division at the
Rockefeller Foundationa and a Professor of Obstetrics and Gynecology at Assuit
University, Egypt.


QualitylCalidad/Qualit6 Advisory Committee


Ian Askew
Karen Beattie
Martha Brady
George Brown
Judith Bruce
Christa Coggins
Adrienne Germain
Joan Haffey
Nicole Haberland
Judith Helzner
Ann Leonard
Magaly Marques
Elizabeth McGrory
Kirsten Moore





Design:
Cover Photos:


Typography:
Printing:
Typesetting:


Nancy Newton
John Paxman
Geeta Rao Gupta
Julie Reich
Debbie Rogow
Jill Sheffield
Cynthia Steele Verme
Karen Stein
Kerstin Trone
Nahid Toubia
Gilberte Vansintejan
Beverly Winikoff
Margot Zimmerman






Ann Leonard
ASHONPLAFA/Honduras,
Julie Becker, Adriane Martin-Hilber,
Maricela Ureno
Heidi Neurauter
Graphic Impressions
Paul Constance


We invite your comments and your ideas for projects which might be included in
future editions of Quality/Calidad/Qialitd. If you would like to be included on our
mailing list, please write to Ann Leonard, Quality/Calidad/Qualitd, The Population
Council, One Dag Hammarskjold Plaza, New York, N.Y. 10017, U.S.A.





























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