NATTAYA BOONPAKDEE

Thailand,

Nattaya Boonpakdee is prompting mainstream Thai society to talk about sexual health and rethink gender roles in order to create large-scale behavioral change. By eliminating sexual stereotypes and misinformation among at-risk groups, their communities and service providers, she is enabling people to make more informed choices in a supportive environment.

This profile below was prepared when Nattaya Boonpakdee was elected to the Ashoka Fellowship in 2012.

INTRODUCTION

Nattaya Boonpakdee is prompting mainstream Thai society to talk about sexual health and rethink gender roles in order to create large-scale behavioral change. By eliminating sexual stereotypes and misinformation among at-risk groups, their communities and service providers, she is enabling people to make more informed choices in a supportive environment.




THE NEW IDEA

Gender equality is recognized in public settings, but heteronormative gender roles dominate Thai culture and remain the root cause of many sexual health problems in Thailand. Recognizing that sexual health problems are inseparable from cultural norms, Nattaya is creating a pervasive cultural shift to change sexual health behavior, as a preventive approach to sexually-transmitted diseases, unplanned pregnancy and sexual violence. She founded the Women’s Health Advocacy Foundation (WHAF) to identify leaders of behavioral change in strategic cultural settings and augment their impact. In collaboration with these partners, Nattaya is developing a collection of adaptable strategies to push people to think outside “the gender box”, encouraging Thais to think outside traditional aggressive male and submissive female gender roles. Nattaya’s organization provides seed funding, continued mentorship and networking to accelerate the development of new conversations and behavioral changes. WHAF has established camps for parents and grandparents who raise teenagers, public high school theater clubs focused on peer-to-peer sex education, and house visits to reach stay-at-home wives. Nattaya is working with healthcare providers at public hospitals to integrate existing services and establish a referral system, resulting in a more supportive environment for women and youth at One Stop Crisis Centers, a government program implemented in 2006 at every public hospital in Thailand. As a result of Nattaya’s work, an estimated 10 million people in 40 provinces across Thailand are changing behaviors and receiving accurate information about sexual health, thus able to safeguard their own sexual health and that of others. Nattaya is developing a facilitating environment for these behavioral changes to spread nationally, through national media campaigns, reallocation of local government budgets, and legislative changes.




THE PROBLEM

Sexual health problems in Thailand have been addressed in a disparate manner, more focused on cures rather than prevention. Victims of sexual abuse are provided emergency shelters, but no long-term care. People with sexually transmitted diseases receive drugs, but no adequate education. Preventive care for sexual health has had limited success, due to societal definitions of propriety. For instance, sex education does not reach most young Thai people, who are presumed by society to be sexually inactive. As a result, young people have the highest HIV transmission rate of all Thais, and their transmission rates of other sexually transmitted diseases are also on the rise.

In Thai society, it is improper for women to discuss issues related to their reproductive health. In contrast, boys are encouraged at a very young age to talk about their reproductive organs and their sexuality. As a result, women receive little or inaccurate information about sexual health and are unconfident in asserting their reproductive and sexual rights. This results in unplanned pregnancy and increased rates of sexual violence against women. Studies show that most Thai women let their male partners decide when to have sexual intercourse and when to have children. A 2006 study of Thai women with unplanned pregnancies found that almost 30 percent of women became pregnant because they lacked information about birth control, while 20 percent of women did not use birth control because they were under the impression they would not get pregnant. A 2012 study by the Institute for Population and Social Research revealed that two thirds of Thai women are coerced by partners into having sexual intercourse for the first time. This power imbalance is also reflected in widespread social acceptance of sexual violence towards women. It is common in the news, for example, to hear law enforcement officials and reporters blame female rape victims for dressing seductively.
Women from poor socioeconomic backgrounds are at greater risk of unplanned pregnancies and face serious consequences because of them. Various social institutions further punish women for the power imbalance in sexual relationships. Many government agencies and most private sector employers have internal regulations that ban employing unmarried women who are pregnant, with the penalty of dismissal for those already employed. High schools also scorn pregnant students, and either suspend the student or force her to drop out. Meanwhile, male students are not punished for jointly causing unplanned pregnancies.

The Thai legal institution further limits the options for a woman with unplanned pregnancy. Abortion is illegal, except in the case of rape or when the abortion is deemed medically necessary by a health professional because of the mother’s physical or mental health problems. Among Thai healthcare providers, it is common practice to discourage women from having abortions even under circumstances which make the abortion legal. Nurses and therapists at rape crisis centers say they encourage rape victims to continue their pregnancies, because abortion is considered more sinful than rape. Moreover, rape victims who apply for legal abortions must endure a lengthy and complex procedure of paperwork and regulations, often to find that their requests are denied. Some hospitals refuse to provide an abortion until the lawsuit against the rapist receives a verdict. Regardless of the cause for pregnancy, women with unplanned pregnancy report being scorned as ignorant or “bad women,” sometimes to the point of being sexually harassed by healthcare providers.

Without sufficient information or proper access to sexual health services, Thai women seldom make important choices about their own sexual health, until it is too late. Most of the estimated 300,000 abortions each year are unsafe and occur outside hospitals, causing some 50,000 women each year to enter hospitals with infections and other health complications as a result. Thailand also has one of the highest death rates in the world from abortion. Thai women continue to suffer from poor sexual health, and continue to be blamed for their suffering.




THE STRATEGY

Understanding that sexual health is difficult to address due to cultural norms, Nattaya has developed a mechanism to generate new conversations and behavioral changes at an unprecedented scale, while maintaining the sensitivity of her programs, which are customized to each target population and cultural setting.

In 2002, Nattaya founded the Women’s Health Advocacy Foundation to identify leaders of behavioral change and create a facilitating environment to broaden their impact. Nattaya’s team first conducts workshops and field observations to study community mechanisms of information transfer, which enables her team to identify the most influential leaders to instigate new conversations and behavioral changes in different cultural settings, such as government health volunteers who work in rural and peri-urban communities, owners of barber shops and general stores, parents and guardians of teenagers, high school teachers, and high school students.

Nattaya works closely with these leaders to develop the most effective communication techniques to dispel myths and deliver accurate sexual health information to each target population. For instance, Nattaya supports leaders to organizes Family Camps for parents, grandparents and teenagers under their care to develop new and replicable techniques to talk about sexual health in family conversations in gentle but effective ways. She has developed a series of conversation starters for families that help parents discuss the qualities their children look for in relationships. Nattaya has supported these parents to organize the Network of Families who Talk about Sex and provides communication techniques and technical information, enabling these parents to encourage other parents to do the same. Nattaya’s team has created and refined these communication techniques in close collaboration with her various constituencies and with the support of cultural institutions and education experts. When working with teenagers, Nattaya asks young men and women to draw their faces, then to draw their reproductive organs. This exercise is meant to illustrate the lack of information regarding their sexual health. Nattaya’s organization tackles this issue by providing seed funding and mentorship for youth to invent new communication programs. For example, WHAF contributes 1,000 baht (about US$33) for each high school student group that wants to set up a “Healthy Sexuality Club”, which produces skits and provides peer-to-peer counseling about sexual health. WHAF holds training workshops for club leaders and supervising teachers, while introducing them to similar efforts in other schools.

In working to create behavioral changes among adult women, Nattaya works with government community health volunteers and informal communication agents, such as owners of barber shops and general stores. She is giving these local leaders the tools to dispel discriminatory beliefs that lead women to endanger their own sexual health. Nattaya is helping them combat misconceptions about women’s own sexual organs, dispel the beliefs that a good woman lets her husband make decisions about sexual intercourse and abolish the notion that sexual and domestic abuse is a normal occurrence between partners. Nattaya targets lower-income communities in rural and peri-urban areas, where sexual health problems are more visible. She engages community health volunteers, who help spread Nattaya’s message to the household level. These partnerships allow her to leverage existing community health resources including health facilities and equipment at village health centers and public health databases. As a result of her successful collaboration with community health volunteers, some local governments are beginning to allocate annual municipality health budgets to support Nattaya’s programs, such as informal community education programs at the household level to prevent sexually-transmitted diseases, unplanned pregnancy and sexual violence.

In addition to enabling at-risk groups to make more informed decisions about their sexual health, Nattaya works with health service providers to change strategies and create a more supportive environment. In 2010, Nattaya supported leaders at Health Ministry to begin a pilot program with the One Stop Crisis Center. They identified five pilot hospitals and all relevant staff – doctors, nurses, psychiatrists and social workers of nearby emergency shelters – and is now training them to offer options counseling, which provides choices and support for women with unplanned pregnancies, often the result of unprotected intercourse or rape. Most importantly, Nattaya is changing the way Crisis Center staff converse with their clients. Nurses now say they understand that these women are not “bad women.” Psychiatrists say they listen more and judge less. Social workers say they are more willing to provide comprehensive support for these women. Doctors are more willing to perform abortions, in cases where they are legal.

As a result of Nattaya’s efforts, 86 percent of women who enter the One Stop Crisis Center receive follow-up care and counseling. Of the women who choose to continue their unplanned pregnancy, 79 percent register for prenatal care and of the women who choose and qualify for abortion, as many as 38 percent have abortions at the same hospitals. This is a marked success, as most public hospitals are reluctant to perform legal abortions, even for women who are victims of rape. The remaining 62 percent of women who seek an abortion are referred by hospital staff to other services providing safe abortions by qualified health professionals. To prevent unsafe abortion, Nattaya has linked Crisis Center staff with other services and informal community networks, which helps identify women with unplanned pregnancies. She has helped to establish lines of communication between the gynecology, antenatal care, and psychiatry departments of these pilot hospitals with local emergency shelters, village health centers, pharmacies and guidance counselors at local schools. Even though Nattaya’s work with the Crisis Centers has had profound impact on the women who enter the Crisis Center (on average 37 every day), she sees room for incredible growth. In the near future, Nattaya plans to replicate this model of service improvement at all 253 Crisis Centers in every province in Thailand.

To accelerate the spread of her work, Nattaya has developed a facilitating environment on the national level. She is working with an advertisement agency to design national media campaigns. The first campaign, which began in 2011, encourages parents to talk to their children about sexual health and has appeared on national television as well as on banners in community markets. In addition, she has pushed for a new law on sexual and reproductive health, to guarantee basic rights and access to services such as allowing pregnant youth to attend school during pregnancy and after delivery, allowing unmarried pregnant women to remain in their jobs, providing birth control information for unmarried women, options counseling for women with unplanned pregnancy, and temporary shelters for women with unplanned pregnancy to carry to term without family and societal pressure. The Ministry of Health has offered to host the draft legislation, which is now being reviewed by the National Judicial Council. Nattaya is also collaborating with health professionals, academics, and legal experts to advocate changes to the existing law on abortion – namely to provide clearer criteria to distinguish legal and illegal abortion and to encourage all public hospitals to provide safe abortion services.




THE PERSON

Nattaya was brought up in an extended family, where she witnessed gender inequality spanning across three generations. Her grandmother dropped out of school in grade 4 in order to work and send her older brother through military school. Despite her grandmother’s complaints about the unequal value placed on sons over daughters, she continued to treat her own daughter differently from her sons. Nattaya’s mother perpetuated the cycle and applied the same unequal standards to Nattaya and her brother, by setting different expectations about proper manners, careers and overall definitions of success.

Nattaya resisted her mother’s urging to pursue a nursing career which her mother deemed a steady and reliable career path for women and instead studied anthropology and worked as a researcher on human trafficking of Thai women. Nattaya chose this path over nursing because she wanted to focus on solving structural social problems. She assisted women in preparing court testimony against their traffickers. Reading field notes and witnessing first-hand hundreds of cases in which women were continually abused, Nattaya was resolved to find a more systemic approach to addressing these problems. She believes that sexual violence is not rooted in individual cruelty, but stems from a society that permits such cruelty. In founding the Women’s Health Advocacy Foundation, Nattaya is determined to improve the health of all sexes, while instilling respect for humanity beyond the limitations of gender roles.




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