I 113th CONGRESS 1st Session H. R. 3206 IN THE HOUSE OF REPRESENTATIVES September 27, 2013 Ms. Clarke (for herself, Ms. Bass , Ms. Brown of Florida , Mr. Clay , Mr. Conyers , Mrs. Davis of California , Mr. Ellison , Mr. Enyart , Mr. Grijalva , Ms. Norton , Mr. Honda , Mr. Huffman , Ms. Jackson Lee , Mr. Jeffries , Ms. Lee of California , Mrs. Carolyn B. Maloney of New York , Mr. McGovern , Ms. Moore , Mr. Moran , Mr. Quigley , Mr. Rangel , Mr. Rush , Ms. Schakowsky , Ms. Slaughter , Ms. Wasserman Schultz , Ms. Waters , and Mr. Bera of California ) introduced the following bill; which was referred to the Committee on Foreign Affairs A BILL To promote the sexual and reproductive health of individuals and couples in developing countries, and for other purposes.

1. Short title This Act may be cited as the Global Sexual and Reproductive Health Act of 2013 . 2. Findings and purposes (a) Findings Congress makes the following findings: (1) The advancement of sexual and reproductive health is central to the global development agenda and necessary to meeting most of the eight United Nations Millennium Development Goals (MDGs), the current international development framework developed by 189 countries, including the United States. Target 5B, which is found under MDG 5 on improving maternal health and which requires achieving universal access to reproductive health, is an essential element in attaining MDGs related to eradicating poverty (MDG 1), achieving universal education (MDG 2), promoting gender equality (MDG 3), reducing child mortality (MDG 4), improving maternal health (MDG 5), combating HIV/AIDS (MDG 6), and ensuring environmental sustainability (MDG 7). Furthermore, advancement of sexual and reproductive health and rights will be critical in building on the achievements of the MDGs when they expire in 2015 and realizing the core goals of poverty reduction and sustainable development in the post-2015 development agenda. (2) The resolution of the 2013 United Nations Commission on Population and Development recognize[es] that . . . sexual and reproductive health and reproductive rights … as well as … population and development, education and gender equality, are integrally linked to global efforts to eradicate poverty and achieve sustainable development … . . (3) Throughout much of the world, the lack of access of women, particularly poor women, to basic reproductive health services and information contributes to death and suffering among women and their families, undermines women’s struggle for self-determination, and vitiates the efforts of families to lift themselves out of the poverty in which over a billion of the world’s people live. By allowing individuals and couples to choose the number and timing of their children, reproductive health care gives families and individuals greater control over their economic resources. (4) Aspects of sexual and reproductive health, including maternal mortality and morbidity, reproductive cancers, and sexually transmitted infections (STIs), including HIV, account for nearly 20 percent of the global burden of ill-health for women and some 14 percent for men, according to the World Health Organization (WHO). (5) According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), HIV/AIDS is the leading cause of death among women of childbearing age. (6) School-based education and family planning play an interrelated role in lifting the status of women. Delaying sexual debut, along with contraceptive use among young women already sexually active, lowers the likelihood that young women will leave their schooling due to pregnancy, and education increases the chances that young women will delay the age at which they marry and give birth. (7) Sexual and reproductive health programs can empower women to make informed decisions and better control their lives, and by engaging men and boys in taking responsibility for the sexual and reproductive health of their partners, can contribute to greater gender equality. (8) Access to sexual and reproductive health services, including family planning, has a direct and important impact on infant and child mortality. By allowing women to choose the timing, number, and spacing of their pregnancies, high-risk births are averted, and the children that are born have a greater chance of surviving to adulthood. Over 3,000,000 newborns die in the first 4 weeks of life, which accounts for nearly 40 percent of all deaths of children under the age of 5. By providing women family planning services to space their births 3 years apart, rates for under-5 mortality would drop by 25 percent, averting 1,800,000 children’s deaths each year. (9) Increasing access to sexual and reproductive health could significantly decrease pregnancy-related mortality and morbidity by reducing the number of pregnancies that place women at increased risk of experiencing such complications. (10) An estimated 222,000,000 women in developing countries have an unmet need for effective, modern contraceptives and would like to postpone childbearing, space births, or want no more children but are not using a modern method of contraception. Providing modern contraceptives to fill this unmet need would avert an estimated additional 54,000,000 unintended pregnancies each year, including 21,000,000 unplanned births and 26,000,000 abortions, 16,000,000 of which would be unsafe. In turn, this would prevent 79,000 maternal deaths and 1,100,000 infant deaths. (11) Complications due to pregnancy and childbirth are a leading cause of death among adolescent females ages 15 to 19 in low- and middle-income countries. Each year, an estimated 287,000 women worldwide die from complications related to pregnancy, childbirth, or unsafe abortion. (12) Unsafe abortion accounts for 13 percent of maternal deaths worldwide. More than half of abortions (56 percent) in the developing world are unsafe. Of the 22,000,000 unsafe abortions that take place each year, nearly all occur in the developing world. Around 47,000 women die and millions more suffer serious injuries from the complications of unsafely performed abortions. Abortion rates are similar in countries whether abortion is illegal or legal, with evidence suggesting abortion rates may in fact be higher in countries where it is illegal. Regardless, death and injury from unsafe abortion is greatly reduced where abortion is legal for a broad range of indications and where safe abortion is accessible. (13) Meeting the need for family planning services and pregnancy-related care, by doubling the current global investment for both, would prevent millions of needless cases of maternal and newborn deaths and disabilities. (14) Worldwide, women of childbearing age account for more than half of people living with HIV/AIDS. Integrating reproductive health services, including family planning, with HIV prevention programs, such as those for voluntary counseling and testing and prevention of mother-to-child transmission, is essential to effectively combating HIV/AIDS and other STIs. (15) The world is witnessing the largest generation of young people in history—almost half of the world’s population, approximately 3,000,000,000 people, are under the age of 25. Unmet need for sexual and reproductive health services is highest among this age cohort. Fewer than 5 percent of the poorest sexually active youth use modern contraception. (16) The WHO has identified unsafe sex as the second most important risk factor for disability and death among young people in the world’s poorest communities. Forty percent of all new adult HIV infections occur among young people ages 15–24. (17) Sixty percent of unsafe abortions in Africa, 42 percent in Latin America and the Caribbean, and 30 percent in Asia are undergone by women under the age of 25. (18) The WHO has identified a 4-pronged approach to preventing HIV infection in infants, which includes prevention of unintended pregnancy among HIV-infected women as a key strategy to prevent mother-to-child transmission of HIV. (19) According to the World Health Organization, enabling HIV-positive women who want to avoid a pregnancy access to contraceptive services can prevent as many as 160,000 additional HIV-positive births each year in high HIV prevalence countries. (20) Demographic factors exacerbate problems related to environmental sustainability. The past century of population growth has put increasing pressure on natural resources as the scale of human needs and activities expands. At the same time, actual family size in most developing countries remains greater than the desired family size. Access to family planning services helps couples to determine their own family size, hence mitigating the depletion of natural resources like clean water, air, and land. (21) Practices like early and forced marriage, female genital mutilation/cutting, and early sexual debut adversely impact the sexual and reproductive health of young people in many developing countries, and strong barriers exist to providing the information, services, and other forms of support that young people need to lead healthy sexual and reproductive lives. (22) Comprehensive sexuality education seeks to help young people develop the interpersonal skills necessary for the formation of caring, supportive, and noncoercive relationships and the ability to exercise responsibility regarding sexual relationships by addressing such issues as abstinence and the use of condoms, contraceptives, and other protective sexual health measures. (23) The United Nations has estimated that the minimum financial requirements for sexual and reproductive health, including family planning and maternal health, are roughly $32,700,000,000 in 2013 and increase to approximately $33,000,000,000 in 2015. The minimum financial requirement for HIV/AIDS is estimated at $34,700,000,000 in 2013, and increases to $36,200,000,000 in 2015. As agreed in the International Conference on Population and Development’s Programme of Action, which the United States committed to, developed-country donors are responsible for one-third of the total cost needed per year. Developing countries are responsible for the remaining two-thirds, on average, with low income countries requiring a larger share of external funding. (24) The United States has had a history of supporting and recognizing the fundamental health and human rights of all people through the signing or ratifying of various international agreements. Those agreements include the Universal Declaration of Human Rights (1948), the International Covenant on Civil and Political Rights (1966), the International Covenant on Economic, Social, and Cultural Rights (1966), the Convention on the Elimination of All Forms of Discrimination Against Women (1979), the Convention on the Rights of the Child (1989), the International Conference on Population and Development Programme of Action (1994), the United Nations Millennium Development Goals (2000), and the Convention on the Rights of Persons with Disabilities (2009). (25) The United States has been the largest donor to international family planning and reproductive health efforts over the last 40 years and has been an unparalleled source of leadership and innovation in the field. Nonetheless, it has not met its fair share of financial assistance to global sexual and reproductive health programs. Now is the time to shore up the United States political and financial commitment in order to satisfy the large unmet need for these services, thereby helping to improve women’s and young people’s sexual and reproductive health worldwide. (b) Purposes The purposes of this Act are to— (1) authorize assistance to improve the sexual and reproductive health of individuals and couples in developing countries; and (2) implement comprehensive sexual and reproductive health programs offering a continuum of care that are responsive to the sexual and reproductive health needs of young people and adults. 3. Statement of policy The following shall be the policy of the United States Government: (1) All individuals and couples shall have the basic reproductive right to decide freely and responsibly the number, spacing, and timing of their children and shall have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. (2) All individuals and couples also shall have the right to make decisions concerning reproduction free of discrimination, coercion, and violence, as expressed in human rights documents. (3) The promotion of the responsible exercise of these reproductive rights for all people shall be the fundamental basis for sexual and reproductive health programs supported by United States Government assistance. (4) The principle of free and informed consent must underlie all sexual and reproductive health programs and services. This principle applies to individuals whether they choose to continue or terminate their pregnancies—thus, forced pregnancies as well as forced abortions or sterilizations are prohibited. Decisions relating to contraceptive use should be made on an informed and voluntary basis after adequate information, counseling, and services are provided on a range of methods. (5) Incentives and disincentives should not be used in family planning programs in order to meet numerical population targets or quotas for fertility goals. Instead, governments should use other indicators, such as unmet needs, to define family planning goals. (6) In sexual and reproductive health programs funded by the United States Government, special attention should be paid to serving the needs of young people. 4. Assistance to support the achievement of universal access to sexual and reproductive health (a) Assistance authorized The President is authorized to provide assistance in order to support the achievement of universal access to sexual and reproductive health in developing countries and to ensure individuals and couples in developing countries can freely and responsibly determine the number, timing, and spacing of their children and have the means to do so. (b) Activities supported Assistance provided under subsection (a) may be used to— (1) expand access to and use of voluntary family planning information and services, to enable individuals and couples to avoid unintended pregnancies and other risks to sexual and reproductive health, including those associated with pregnancy, reproductive tract infections, and sexually transmitted infections (STIs), including HIV; (2) improve public knowledge of contraceptives, including where methods may be obtained, and risk-reduction strategies, and to promote the benefits of family planning and other sexual and reproductive health care to individuals, families, and communities, including through the use of education and awareness programs, mass media, and community mobilization and outreach; (3) increase the responsiveness of sexual and reproductive health programs to the needs of the intended beneficiaries during the entirety of their sexual and reproductive lives, including young people and older adults; (4) reduce the incidence of unsafe abortion, including research on the health consequences of unsafe abortion, and provide for the equipment and training necessary for medical treatment of the consequences of unsafe abortions; (5) notwithstanding any other provision of law, provide safe abortion, to the extent permitted by the laws of the recipient country; (6) promote the integration of family planning services in HIV and other STI prevention, treatment, care, and support; (7) integrate family planning services with maternal and newborn health care, especially in antenatal, post-partum, and post-abortion care settings; (8) ensure the consistent availability and affordability of high-quality sexual and reproductive health supplies and services, including male and female condoms, for the prevention of HIV and other STIs; (9) encourage the abandonment of female genital mutilation, early marriage, early childbearing, and other harmful traditional practices that have negative reproductive health consequences; (10) prevent and repair obstetric fistula; (11) promote the constructive engagement of men and boys, the empowerment of women and girls, and more equitable gender norms in order to improve health outcomes and support the adoption of healthy reproductive behaviors; (12) prevent and mitigate gender-based violence; (13) provide comprehensive sexuality education for young people; (14) prevent, diagnose, and treat, where appropriate, infertility and cancers of the reproductive system and refer as appropriate; (15) develop improved methods of safe and effective contraception and related disease control through investments in biomedical research, with particular emphasis on methods which— (A) are likely to be safer, easier to use, more efficient to make available in developing country settings, and less expensive than current methods; (B) are controlled by women, including barrier methods and microbicides; (C) are likely to prevent the spread of STIs; and (D) encourage and enable men to take greater responsibility for their own fertility and the protection of their partner; (16) support an enabling environment for women to access sexual and reproductive health care services by working with communities to identify and lower or remove barriers to access, including financial, gender, sociocultural, and transportation barriers; (17) train health care professionals on educating individuals, including young people, about their sexual and reproductive health care options, including family planning options; and (18) foster conditions to create favorable policy environments, improve quality, strengthen systems, and contribute to the sustainability of family planning and other reproductive health programs. 5. Assistance to reduce the incidence of unsafe abortion and its consequences (a) Assistance authorized The President is authorized to provide assistance to reduce the incidence of unsafe abortion in developing countries and provide care for women experiencing injury or illness from complications of unsafe abortion in developing countries. (b) Activities supported Assistance provided under subsection (a) shall be used to— (1) ensure access to family planning services to prevent unintended pregnancies; (2) ensure that women who experience an unintended pregnancy have access to reliable information and compassionate counseling on all of their options, including access to antenatal care and safe abortion when permitted by the laws of the recipient country; (3) where local laws permit abortion, support safe abortion services, including referrals, and support the training of abortion providers and the necessary equipment and commodities for surgical and medical abortion; and (4) support emergency treatment for complications of induced or spontaneous abortion, including provision of services and training and equipping of providers. (c) Eligibility for assistance Notwithstanding any other provision of law, regulation, or policy, in determining eligibility for assistance authorized under this section, sections 104, 104A, 104B, and 104C of the Foreign Assistance Act of 1961 ( 22 U.S.C. 2151b , 2151b–2, 2151b–3, and 2151b–4), foreign nongovernmental organizations— (1) shall not be ineligible for such assistance solely on the basis of health or medical services, including counseling and referral services, provided by such organizations with non-United States Government funds if such services are permitted in the country in which they are being provided and would not violate United States Federal law if provided in the United States; and (2) shall not be subject to requirements relating to the use of non-United States Government funds for advocacy and lobbying activities other than those that apply to United States nongovernmental organizations receiving assistance under part I of the Foreign Assistance Act of 1961. 6. Assistance to provide sexual and reproductive health services during emergency situations (a) Assistance authorized The President is authorized to provide assistance, including through international organizations, national governments, and international and local nongovernmental organizations, to ensure that sexual and reproductive health services are provided in developing countries at every phase of a humanitarian emergency, including early recovery. (b) Priority In providing assistance authorized under subsection (a), the President shall give priority to— (1) those reproductive health services that are essential in emergencies, whether they are conflict or natural disaster settings, to save lives and help survivors fulfill their potential even under the most difficult circumstances; and (2) building local capacity and improving national systems whenever possible during displacement and early recovery. (c) Activities supported Assistance provided under subsection (a) shall be used to— (1) direct the Secretary of State and the Administrator of the United States Agency for International Development to implement the Minimum Initial Services Package (MISP), a set of life-saving priority activities that must be put in place in the earliest days of an emergency and that is set out in the Sphere Project’s Humanitarian Charter and Minimum Standards in Disaster Response; (2) among other activities, establish critical reproductive health coordination mechanisms, prevent sexual violence and assist survivors by providing essential medical care including psychosocial services, prevent transmission of HIV and other sexually transmitted infections (STIs), ensure access to emergency obstetric and newborn care, to contraceptive methods, and to treatment of STIs, continue antiretroviral treatment, and lay the groundwork for comprehensive reproductive health care; and (3) as soon as conditions permit, ensure that comprehensive reproductive health care programs, including comprehensive family planning, are put in place for the duration of displacement and are maintained as the relief phase ends and communities transition to early recovery. (d) Coordination Assistance authorized under subsection (a) shall be coordinated in terms of policy, practice, and funding across and within relevant United States Government departments and agencies involved in emergency situations. 7. Assistance to promote sexual and reproductive health care for young people (a) Assistance authorized The President is authorized to provide assistance to ensure access to sexual and reproductive health care for young people in developing countries. (b) Priority In providing assistance authorized under subsection (a), the President shall prioritize a plan to increase comprehensive knowledge about sexuality among young people and improve sexual and reproductive health outcomes among young people, while improving coordination and implementation of host country and United States Government activities focused on adolescent and youth sexual and reproductive health. (c) Activities supported Assistance provided under subsection (a) shall be used, among other things, to— (1) provide universal and affordable access to— (A) evidence-based comprehensive sexuality education and reproductive health education, in consultation with local communities, in and outside schools to ensure young people can delay sexual debut and make informed decisions about their sexual and reproductive health; and (B) youth-friendly comprehensive sexual and reproductive health care, including activities described in section 4(b), as appropriate; (2) coordinate the achievement of the goals of sexual and reproductive health programming for young people in United States Government-funded programs; (3) educate implementers on best practices in adolescent and youth programming and delivery and for effective dissemination of policy guidelines regarding adolescent and youth programming; and (4) incorporate the recommendations of young people in program design and service delivery oriented for young people. 8. Strategy to integrate and link sexual and reproductive health services (a) Strategy required (1) In general The President shall develop and implement a strategy to improve and create linkages among the various components of sexual and reproductive health with each other and with other global health care services, delivery, and policies in order to meet the goal described in paragraph (2). (2) Goal described The goal of better linkages and integration referred to in paragraph (1) is to ensure that individual men and women are provided with a continuum of sexual and reproductive health services that meet their needs. Integration does not require that all of these services should be provided by the same clinician or even in the same setting; rather, there should be a mechanism in place, so that every person has access to the sexual and reproductive health services he or she needs, either directly or by referral. (b) Elements The strategy required by subsection (a) shall include the following: (1) In general, at the program level, supporting health systems to link the various components of sexual and reproductive health services both in terms of health system management, such as integrating commodity and supply systems, training, supervision, data collection and analysis, and service provision, to ensure that people have access to a full range of services in their community. (2) In general, such services should include prevention of ill-health, provision of information and counseling, screening, diagnosis and curative care and referral for a full range of sexual and reproductive health and other health and social services. (3) With respect to linkages and program integration of sexual and reproductive health services, such services shall include activities described in section 4(b). (4) With respect to linkages of sexual and reproductive health services with other global health services, such services shall include— (A) counseling about and referrals to other related health services such as addressing newborn, infant, and child health (including educating families about proper antenatal and delivery care, breastfeeding, hygiene, and interventions for neonatal infections and life-threatening childhood illnesses), malaria, tuberculosis, neglected tropical diseases, and proper nutrition for all ages; and (B) referrals to nearby quality services that cannot be provided by the primary provider and other social services. 9. Coordination; research, monitoring, and evaluation (a) Coordination Assistance authorized under this Act shall promote coordination between and among donors, the private sector, nongovernmental and civil society organizations, and governments in order to support comprehensive and responsive sexual and reproductive health programs in developing countries. (b) Research, monitoring, and evaluation (1) In general Assistance authorized under this Act shall be used for the conduct of formative research and to monitor and evaluate the effectiveness and efficiency of programs. (2) Requirements In carrying out paragraph (1), the President shall ensure that there is— (A) support for formative research on the determinants of accessing sexual and reproductive health products and services, and adopting healthy behaviors related to sexuality and reproduction, to inform program design; (B) support for the ongoing, regular, and systematic collection of information to serve as the basis for monitoring change in population-based outcomes; (C) support for evaluations of programmatic effectiveness by measuring the extent to which change in population-based outcomes can be attributed to program interventions or environmental factors; (D) support for operations research that uses appropriate scientific methods to compare different interventions with the objective of increasing the efficiency, effectiveness, and quality of programs; (E) support for field research on the characteristics of programs most likely to result in sustained use of effective family planning in meeting each individual’s lifetime reproductive goals, with particular emphasis on the perspectives of family planning users, including support for relevant social and behavioral research focusing on such factors as the use, nonuse, and unsafe or ineffective use of various contraceptive and related-disease control methods; and (F) support for the development of new evaluation techniques and performance criteria for sexual and reproductive health programs, emphasizing the user’s perspective and reproductive goals. 10. Definitions In this Act: (1) Adolescent The term adolescent means an individual who has attained the age of 10 years but not 20 years. (2) Comprehensive sexuality education The term comprehensive sexuality education means helping young people develop the interpersonal skills necessary for the formation of caring, supportive, and non-coercive relationships and the ability to exercise responsibility regarding sexual relationships by addressing such issues as sexual diversity, abstinence, and the use of condoms, contraceptives, and other protective sexual health measures. (3) Integration The term integration means joining together different kinds of services or operational programs, either directly or by referral, to ensure more comprehensive services, promote a continuum of care, and to maximize health outcomes. (4) Linkages The term linkages means— (A) the bi-directional synergies in policy, programs, services, and advocacy related to sexual and reproductive health, including HIV/AIDS; and (B) refers to a broader human rights based approach, of which service integration is a subset. (5) Reproductive health The term reproductive health — (A) means a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes; and (B) implies that an individual is able to have a satisfying and safe sex life and that such individual has the capability to reproduce and the freedom to decide if, when, and how often to do so, including the right of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. (6) Reproductive rights The term reproductive rights — (A) means those rights that embrace certain human rights that are already recognized in national laws, international human rights documents, and other consensus documents; (B) includes the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing, and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health; and (C) further includes the right of all couples and individuals to make decisions concerning reproduction free of discrimination, coercion, and violence, as expressed in human rights documents. (7) Sexual health The term sexual health — (A) means a state of physical, emotional, mental, and social well-being in relation to sexuality and not merely the absence of disease, dysfunction, or infirmity; (B) includes a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence; and (C) further includes the sexual rights of all persons to be respected, protected, and fulfilled. (8) Unmet need The term unmet need refers to nonuse of a modern contraceptive method by an individual who is married or unmarried and sexually active, is able to become pregnant, and wants to stop childbearing or to wait at least 2 years before having a child. (9) Young people The term young people means those individuals who have attained the age of 10 years but not 25 years. (10) Youth The term youth means an individual who has attained the age of 15 years but not 25 years.