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A nurse prepares surgical instruments in the abortion operating theatre at the Marie Stopes Center Chbar Ampov in June
A nurse prepares surgical instruments in the abortion operating theatre at the Marie Stopes Center Chbar Ampov in June. MSI uses USAID funding to provide women with information about where to access abortion as an option, but the Helms Amendment prohibits direct funding to the actual procedure. KARA FOX

Politics of sex reflected in funding

At this point we’re basically running on a shoestring,” said Dr Glenn Miles, a facilitator for anti-trafficking NGO Love146, about his research on Cambodian transgender sex workers.

Miles’s team of mostly self-funded researchers spends a bare minimum on travel expenses, small gifts for interviewees and other necessities. They are actively looking for donors to supplement the small budget Love146 offers, but so far it has been difficult.

“Generally, secular groups don’t want to touch it because they’re afraid of being seen as anti-gay, and faith-based groups don’t want to touch it because they’re afraid of being seen as pro-gay,” Miles said.

He acknowledged that some Cambodian groups working with LGBT issues – Men’s Health Cambodia and the Khmer HIV/AIDS NGO Alliance, among others – have attracted funding from major donors like the United States Agency for International Development (USAID) and the United Nations.

But Miles argued that these organisations have been more appealing to donors because their focus on health matters such as HIV/AIDS prevention diffuses the political sensitivity surrounding sex and sexuality.

Jarrett Davis, Miles’s fellow researcher of biologically male transgender (“ladyboy”) sex workers, agreed: “It’s quite difficult to find funding for research that addresses males as whole people, who have emotions and vulnerabilities beyond just sexual health.”

Homosexuality, prostitution and that other key target of American social conservatism, abortion, have long been divisive issues, not just in the United States but also when it comes to distributing US funds abroad – especially in a country like Cambodia that receives so much aid.

Since President Barack Obama took office, US executive and court decisions have opened up more channels of support for what many would term sexual and reproductive rights, in Cambodia and elsewhere. But activists in these areas say political sensitivity often still hampers funding.

Although Miles and Davis say the concerns of individual funders are the main sticking point, Cambodian organisations working in other sensitive areas face explicit US funding restrictions.
Until late last month, NGOs had to declare themselves opposed to prostitution in order to receive US funding for work against AIDS.

Between 2003, when former US president George W Bush initiated the policy, and June 20, when the United States Supreme Court ruled that it violated free speech, US-funded NGOs could still offer health services to sex workers but had to condemn sex work. Organisations including the World Health Organization and UNAIDS argued the requirement alienated sex workers and some NGOs, therefore seriously affecting the fight against AIDS.

While the overturn of the anti-prostitution pledge may now allow more organisations in Cambodia to access funding, the US government’s anti-abortion funding policy has had an even longer impact on the Kingdom – one that continues.

Abortion funding’s ‘grey area’
Since 1973, the Helms Amen-dment has banned the US government from funding abortions “as a method of family planning” anywhere in the world.

In 1984 President Ronald Reagan doubled down with the Mexico City Policy, which banned the US from providing money to any overseas NGOs that offered abortions as a method of family planning – even if they used other sources of funding for the abortion-related part of their services.

In the years since, the Mexico City Policy’s fate has varied depending on the party of the US president in office. Bill Clinton repealed the policy, George W. Bush re-instituted it and Barack Obama repealed it again – all within days of taking office.

“Fortunately, when the Obama administration came in, we started getting [US] funding,” said Melissa Cockroft, technical support manager for Marie Stopes International (MSI) Cambodia, an organisation that was denied US funding before 2009 because it offered abortions.

Since 2011, MSI has received USAID grants for a range of non-abortion services, including family counselling, intrauterine device implants, medical training sessions for health centre staff and community outreach through village health representatives.

MSI now also uses USAID funding to give women information about where to access abortion as an option. But with the Helms Amendment against funding abortion itself still in place, some ambiguities remain as to what sorts of abortion-related services NGOs can fund with US money, Cockroft said.

The Helms Amendment prohibits US funds from being “used to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practise abortion.”

According to Cockroft: “There’s a grey area around the interpretation of ‘motivating and coercing’.”

In an attempt at clarification, the 1994 Leahy Amendment stated: “The term ‘motivate’, as it relates to family planning assistance, shall not be construed to prohibit the provision, consistent with the local law, of information or counselling about all pregnancy options.”

In the case of Cambodia, local law since 1997 has allowed medical – or chemically induced – abortions for up to nine weeks of pregnancy, and surgical abortions for up to 12 weeks.

Nevertheless, and despite the amendment not blocking funding for abortions for pregnancies from rape or for other reasons unrelated to family planning, the whole hazily worded policy may have made some groups cautious of supporting anything to do with abortion, Cockroft said.

Now, receiving USAID “opens up a whole range of other donors who may have been reluctant to provide support” for MSI, she said.

If USAID supported abortion services, “there would be more funding available and the chance to provide more services to women,” she said. But she added that MSI has several other major sources of funding that do support abortion services, including the Australian Agency for International Development and the European Commission.

On the other hand, organisations more dependent on USAID funding still have little leeway to offer abortions, said Chan Theary, executive director of the Reproductive and Child Health Alliance (RACHA).

USAID has given RACHA $27.5 million in the past five years – about 80 per cent of the NGO’s total budget. So the reason RACHA provides no abortion services is simple, Theary said: “Because of USAID.”

RACHA has, however, offered post-abortion care and information on finding abortion services since 2004.

Meanwhile, the Reproductive Health Association of Cambodia (RHAC), another NGO that has long received USAID funding and therefore did not offer abortion services before 2009, began offering medical and surgical abortions in 2011 at its clinic in Kampot province, one of many RHAC locations across the country.

The majority of RHAC clinics are largely USAID-funded and do offer post-abortion counselling, but the Kampot clinic is the only one able to offer abortions because it is funded by the International Planned Parenthood Federation and not USAID, said Dr Noup Thear, the clinic’s manager.

Sexual stigma
It’s difficult to estimate the USAID abortion ban’s impact, because other factors like the stigma around pre-marital sex also put up barriers to women seeking safe abortions, and sometimes can push them toward more covert, less safe means, Cockroft said.

“I think that a big part of it is the lack of trained providers, lack of awareness that abortion’s legal, and still the stigma around abortion, both from the women and from providers, who can be reluctant to provide abortion services.”

Conservative attitudes about sexuality on the part of both funders and Cambodian society aren’t just an impediment to safe abortion access. They also interfere with effectively fighting HIV/AIDs among the populations most at risk, including sex workers and men who have sex with men, activists say.

Srun Srorn, facilitator for LGBT advocacy group Rainbow Community Kampuchea (RoCK), agreed with researchers Miles and Davis that organisations with an LGBT health focus have received much more funding from sources like USAID than groups with a broader LGBT rights focus – at least until quite recently. And the US’s stance has been particularly significant because it is the biggest funder of HIV programs in Cambodia for men who have sex with men, or MSM, he said.

According to Srorn, these programs so far have been “not really successful, even though lots of big donors give big funds, because we see still that the next generation of MSM are likely to be [infected with HIV] because they are targets of gender-based violence and broader LGBT discrimination”. Health researchers like Joanna Busza have made similar points about discrimination hampering health work with sex workers.

The US has only just started to address these concerns, they say.

Busza wrote in 2006 that before the Bush administration began its anti-prostitution policy, initiatives like the USAID-funded Lotus Club on the outskirts of Phnom Penh were having significant success giving sex workers health information through workshops that also addressed a range of social and economic concerns often suggested by sex workers themselves.

A review of the Lotus Club “highlighted sex workers’ appreciation of the non-judgmental approach and opportunities to socialise and to engage in activities unrelated to their work.”

But although studies clearly showed that working with sex workers reduced national HIV rates, Bush’s inauguration meant that under US policy “sex workers officially became ‘women in prostitution’ or ‘victims of trafficking’ requiring ‘rescue and rehabilitation’ instead of occupational safety.”

Members of LGBT advocacy group Rainbow Community Kampuchea (RoCK) at a Pride event in Phnom Penh in May.
Members of LGBT advocacy group Rainbow Community Kampuchea (RoCK) at a Pride event in Phnom Penh in May. Scott Howes

Bush’s 2003 Global AIDS Act committed an unprecedented $15 billion to fighting AIDS in poor countries over the next five years. But it declared that “no funds . . . may be used to provide assistance to any group or organisation that does not have a policy explicitly opposing prostitution and sex trafficking”.

In a more recent move that surprised some activists, Obama’s White House supported the act on the grounds that prostitution spreads infection – an argument that failed to convince the six US Supreme Court justices who voted against the policy in late June.

Though it’s not yet clear what the act’s overturn will mean for funding in Cambodia, activists say that while in place it significantly obstructed HIV work in the country.

As USAID implemented the policy, initiatives like the Lotus Club closed, and sex workers were “suddenly isolated . . . and excluded from this network of HIV and AIDS projects”, says a 2013 article in the Journal of the International AIDS Society.

The government said the pledge shouldn’t be “construed to preclude” organisations from offering health services for sex workers, such as condoms or STI testing. But like the Leahy Amendment aimed at softening the US stance on abortion funding, the clarification had little effect, according to a 2005 protest letter to president Bush signed by hundreds of organisations from around the world, including from Cambodia.

The letter noted that as a result of the policy, NGOs in Cambodia “discontinued plans to provide English language training classes for people working in the commercial sex sector for fear such programs would be interpreted as ‘promoting prostitution’.” Because English is “a means of accessing opportunities outside the sex sector”, the move actually hindered sex workers’ ability to find other work, it said.

US embassy spokesperson John Simmons said last week that USAID in Cambodia “is reviewing and revising its policies and practices so that they will be consistent with the Supreme Court’s ruling”.

He added, though, that “USAID in Cambodia does not believe the US Supreme Court’s decision will significantly alter the manner in which [aid] is delivered”, because the policy still prohibits recipients from using USAID funds “to promote or advocate the legalisation or practice of prostitution or sex trafficking”.

Activists worry that this ambiguous phrase could have effects similar to the Helms Amendment’s “grey area”, meaning that even without the pledge requirement some organisations will see working with sex workers and taking US money as incompatible.

Another reason the ruling may not significantly alter funding is that the US exempted several major donors from the pledge – UN agencies, the Global Fund, the World Health Organization and the International AIDS Vaccine Initiative – in 2004. But by that point, Busza argued, the damage already was done for many smaller Cambodian organisations.

“These political pressures appear to be spreading to work with other marginalised groups such as injecting drug users and men who have sex with men,” she added.

From health to human rights
Finding de-stigmatising ways to target these most at-risk groups is essential in fighting HIV/AIDS in Cambodia, said Dr Mean Chhivon, director of Cambodia’s National Center for HIV/AIDS, Dermatology and STDs (NCHADS).

A nurse practitioner explains family planning options
A nurse practitioner explains family planning options to a patient during a counselling session at the Marie Stopes Center Chbar Ampov in Phnom Penh last week. Kara fox

HIV rates in the general Cambodian population fell from two per cent in 1998 to 0.7 per cent in 2012, but HIV rates among men who have sex with men were estimated above two per cent in 2010, and rates for sex workers were at 14 per cent in 2010 and 10 per cent in 2012, Chh-ivon said.

The latter rate also shows a major decrease from 1998, when 42.6 per cent of sex workers were infected, and NCHADS is having success overcoming concerns about stigma by spreading health information through entertainment worker networks, he said. But he added that around 10 per cent of the MSM population still is very closed off.

“How many ladyboys are there in Phnom Penh, or in Cambodia? It’s hard to know,” researcher Glenn Miles said. “This is the hard part of doing research about sex – it’s all kind of covered up . . . These groups are vulnerable and they need our attention, but to be honest, many, many groups view only girls as vulnerable and boys as resilient.”

To make his point, Miles quoted a Cambodian proverb: “A girl is like a piece of cloth: if thrown in the dirt then she is soiled forever. A boy is like a piece of gold: he can be washed off again and be good as new.”

This attitude shows up not only in Cambodian society but also among international donors, he said.

“I have spoken to people who really can’t see why time and energy should be invested in work with boys,” Miles has written. “The impression is that ‘they can look after themselves’.”

According to Srorn of RoCK, however, the US government under Obama is starting to realise that to connect with marginalised groups like these, even for health purposes, it needs to consider their human rights as well as health.

In June 2011, the UN Human Rights Council passed an equal rights resolution co-sponsored by the Obama government – the first UN resolution to focus solely on LGBT issues. That December, the US State Department established the Global Equity Fund for LGBT rights, and Obama stated that consideration of LGBT rights was critical in USAID funding decisions.

In April 2013, USAID launched the LGBT Global Development Partnership, which “promotes foreign assistance to lesbian, gay, bisexual and transgender (LGBT) equality in emerging markets and developing countries.

US embassy spokesman Sean McIntosh said that, currently, USAID and the United Nations Development Program are conducting a joint analysis “together with grassroots LGBT organisations and community leaders throughout Asia to better understand the challenges faced by LGBT people across the continent.”

And last Wednesday, the US embassy in Phnom Penh held a roundtable discussion with both health and LGBT rights advocates on issues facing the Cambodian LGBT community and ways around them.

“When the US embassy talks about human rights,” Srorn said, “lots of US donors [and] lots of NGOs included into USAID can become more effective.”

Still, Srorn is cautious about his grassroots advocacy group, RoCK, taking on additional donors.

With the growing interest in promoting LGBT rights, several major donors have approached Srorn since RoCK began organising LGBT events in 2009. But RoCK is mostly run by volunteers – people who care passionately about promoting LGBT rights in Cambodia – and Srorn wants to keep it that way.

“We don’t want to use funds to buy activists, because many times when people are given too much to attend meetings, they come for the money and don’t know how to transfer the knowledge to support people,” he said.

Some large potential donors have told Srorn that to receive their funding, RoCK, which currently is mainly funded by the “very flexible” American Jewish World Service, would have to register as a non-profit – something Srorn doesn’t want to do. He wants his staff to focus on activism rather than on finances.

“The most important part is how we can build the staff’s abilities and network, because then funds can be used in the most sustainable way,” he said.

Sophal Ear, author of Aid Dependence in Cambodia: How Foreign Assistance Undermines Democracy, said that for organisations like RoCK, “I think the strategy is to keep that activist spirit alive and well while soliciting from partners who will support you in the long-term and whose policies won’t change.”

Finding such partners is more difficult when large donors like the US are subject to political swings, he suggested.

Although activists say that US funding for sexual and reproductive rights seems to be increasing, Sophal Ear warned: “We know that even in a democratic process, the rights of the minority can be trampled, as is constantly evidenced in Cambodia.”

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