Content area
This article presents a preliminary view of perceptions of the sexual and reproductive health of indigenous migrant women in an agricultural valley in Northwestern Mexico. A qualitative design was implemented with individual interviews and participatory workshops. The objective was to learn about indigenous migrant women's experiences with health services and their understanding of their sexual and reproductive rights. It was found that family was not a sufficient source of sexual information or education; that for women participating in this study, talking about sexual and reproductive health meant talking about reproduction; that the education system participates little in this aspect and that the health sector fails to respond in a timely and sufficient manner to this segment of the population. It is necessary to develop a more comprehensive view of the sociocultural components of sexual and reproductive health in order to carry out a medical practice that considers the needs and perceptions of indigenous women. For women themselves, the challenge is to appropriate their body, to re-signify their sexual and reproductive rights and to exercise these rights.
ABSTRACT
This article presents a preliminary view of perceptions of the sexual and reproductive health of indigenous migrant women in an agricultural valley in Northwestern Mexico. A qualitative design was implemented with individual interviews and participatory workshops. The objective was to learn about indigenous migrant women's experiences with health services and their understanding of their sexual and reproductive rights. It was found that family was not a sufficient source of sexual information or education; that for women participating in this study, talking about sexual and reproductive health meant talking about reproduction; that the education system participates little in this aspect and that the health sector fails to respond in a timely and sufficient manner to this segment of the population. It is necessary to develop a more comprehensive view of the sociocultural components of sexual and reproductive health in order to carry out a medical practice that considers the needs and perceptions of indigenous women. For women themselves, the challenge is to appropriate their body, to re-signify their sexual and reproductive rights and to exercise these rights.
ARTICLE HISTORY
Received 14 June 2016
Accepted 12 June 2017
KEYWORDS
Sociology; sexual health and indigenous women; reproductive health and indigenous women; sexual and reproductive rights
Introduction
This article presents results of a broader investigation concerning the perceptions of sexual and reproductive health of indigenous migrant women living and working in the San Quintín valley, one of the two main agricultural valleys of northern Baja California, Mexico. This research aimed to learn about the perceptions that these women have regarding their own body, the stages of female growth and development, knowledge concerning family planning methods, traditional approaches to menstrual discomfort, care during pregnancy and puerperium, as well as their understanding of sexual and reproductive rights. Their experiences with the health services, as well as their understanding of some aspects of their sexual and reproductive health are discussed.
Over the past forty years the San Quintín Valley has become come to be an important agricultural exporter to the US market and a major centre of attraction for migrant jornaleros (day labourers). The intensification of commercial agriculture traditionally required a migrant workforce. The latter came from South-East Mexico, mainly from Oaxaca, Guerrero, and Veracruz, with mixteca, triqui, zapoteca and nahua ethnicities. Initially, the migration of agricultural workers was of a more temporary nature and gradually there has been a process of permanent settlement (Zlolniski, 2010). The proportion of women jornaleras in relation to men has increased in agricultural work because, as Lara-Flores (1995) points out, there has been a process of feminisation of agricultural labour, mainly because the female workforce is cheaper, and seen to be more docile and flexible.
Most of the studies carried out in the San Quintín area have documented that, in agricultural work, both men and women face a life of extreme poverty and working conditions below the minimum established by law, particularly if they are indigenous migrants (LaraFlores, 2003, 2008; Velasco, 2007; Velasco, Zlolniski, & Coubes, 2014). The migrant families of the San Quintín valley live under precarious economic circumstances, specifically regarding the conditions of their homes and access to medical care. Their houses are often unsafe since some are built with waste material, without concrete flooring, with little or no ventilation and do not have basic public services (PDH-BC, 2003). Over half (57%) of the total population lacks medical attention or health services, and nearly one-third (29%) of the population 15 years of age and over, have not completed primary school studies (PDR, 2011).
In this region, most of the female migrant population has at some point in their lives worked in the agricultural fields. Some of them engage in activities such as the sale of embroidery and food as an alternative source of income. Women of early-to-advanced ages join the agricultural work force. In the case of pregnant women, they often work until the last trimester of their pregnancy. Younger girls combine agricultural labour with employment in shops or with their high school studies. Their status as women imposes additional tasks on them such as getting home after work to perform household chores and childcare. Thus, they are subjected to a double shift of paid work outside the home in addition to unpaid labour within the home. The living and working conditions of indigenous women do not allow them to have greater opportunities for well-being, and this has affected, among other things, their health. Furthermore, they have little access to health services and social security benefits, and the medical care they receive can be discriminatory and fail to meet their needs.
In addition to the marginalised nature of their lives, indigenous women also face a monocultural health care system, particularly regarding sexual and reproductive health. This gives rise to a professional indifference and disinterest in recognising women's own knowledge about their health. Regarding this, Langer and Tolbert (1998) point out that both the community and individuals should be able to have the necessary information to guarantee their freedom of choice in accordance with their cultural beliefs and practices, and have access to health and education services that protect cultural integrity. Without these conditions, this segment of the population is deprived of being able to fully exercise their sexual and reproductive rights.
The field of sexual and reproductive health continues to change, and is subject to the various interpretations of different kinds of actors. In the 90s, sexual and reproductive health became an issue of importance in the agendas of international organisations concerned with development and population policies, such as the World Conferences organised by the United Nations, and in particular the conference on Population and Development (Cairo, 1994), the Fourth World Conference on Women (Beijing, 1995), and the World Conference on Social Development (Copenhagen, 1995).
The International Conference on Population and Development (CIPD), sponsored by the United Nations took place in Cairo in 1994, and represents an event of great relevance. In this conference, new demographic paradigms were set in place that focused attention on human rights and in covering the needs of men and women. The prevailing vision previous to these international conferences regarding women's health gravitated around maternal-child health (Frenk, Gómez-Dantés, & Langer, 2012; Galoviche, 2016). The latter was replaced at the headquarters of the CIPD for a broader vision that includes sexual and reproductive health. Importantly, reproductive rights were also recognised as human rights. Galoviche (2016) points out that this position emerges from feminist struggles and gender studies, and he goes on to cite Careaga and Sierra (2006), who argued that:
... concerned by population growth in Third World countries, the international organisations were influenced by the strength of the global feminist movement, since they had to acknowledge that people's sexual and reproductive behaviour occurs in the context of great inequalities, among others, those of gender. (p. 165)
There were advances at Cairo's International Summit regarding sexual and reproductive health as a population issue, but also as a matter of gender. The existing power asymmetries between men and women, as well as between these institutions were also acknowledged. Thus, the CIPD outlined as its main objectives:
... regarding the issue of equality, equity and potentiation of the role of women, we ask governments that they guarantee the promotion and protection of women's human rights; that they sign, ratify and apply the convention on the elimination of all forms of discrimination against women and that they integrate a gender perspective in all the processes of formulation, and application of policies in the delivery of services, especially those of sexual and reproductive health. (Galdos, 2013, p. 458)
The Fourth World Conference on Women (Beijing, 1995) introduced a gender perspective into public policy as an effective way of extending this vision towards women in all aspects of their lives, including family, work and as an obligation of the State. Visualising reproductive processes and sexuality from a gender perspective highlights the historical condition of women's subordination based on unequal power over the control of their bodies, thereby sustaining their condition of vulnerability and inequality, and as subjects of violence and injustice regarding their human rights (García, 2015).
In 1995 the UN defined reproductive health as 'a complete state of physical, mental and social well-being and not only the absence of disease or suffering, in all that is relevant to the reproductive system and its functions and processes' (United Nations, 1995). Discussions at international meetings focused mainly on how to articulate different understandings of the notion of reproductive health, taking into account the interests of different actors. As Correa points out:
On the one hand, the notion was developed in institutional apparatuses, sectors linked to the international system of family planning and, especially, the World Health Organization (WHO). On the other hand, similar efforts were made within women's movements; that is, the notion that reproductive health was also in the political agenda of civil societies. (2002, p. 130)
The WHO stressed the importance of both men and women exercising their sexuality autonomously and freely, as well as deciding about the number and spacing of pregnancies, complete information on contraception and access to timely care (Pedraza & Pedraza, 2014). This international health organisation conceptualised sexual and reproductive health as:
... a state of physical, mental and social well-being in relation with sexuality. It requires a positive and respectful approach to sexuality and of sexual relations, as well as the possibility of having pleasant and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be reached and maintained, the sexual rights of all people must be respected, protected and realized. (WHO, 2002)
As a result of these reinterpretations, basic documents were developed for the elaboration of recommendations and programs targeting women, thus opening one of the most fertile fields for the application of women's rights as a fundamental part of human rights. The debate on sexual and reproductive health requires consideration of a different set of concepts such as sexual and reproductive rights, which are intertwined with fundamental human rights (Correa, 2001; Salles & Tuiran, 2001). According to Ortiz, the proposal that sexual and reproductive rights be conceived as human rights, is based on the universal nature of human rights that each State is obligated to ensure on behalf of its citizens, thereby making their recognition less a sign of modernity than of the State's obligation to society. Therefore, it is individuals and their rights who are able to guide the rule of law and ensure compliance (Ortiz, 1999, p. 35).
Sexual and reproductive health needs must be based on human rights, which would make it possible to take autonomous decisions and assume responsibilities both individually and collectively. These rights must be guaranteed by the State through the exercise of public policies in addition to fostering the conditions for access to health services. According to Figueroa, the exercise of reproductive rights will be feasible when social, political, legal, economic, and cultural contexts favour access to these possibilities (1999).
Cervantes points out that, between the 1960s and 1990s in Mexico, reproductive decisions went from being a private issue to being a public and government concern (1999). Health services became more oriented toward family planning with the goal of population reduction. This macro vision of women's health impeded the view of women as subjects with rights. Additionally, the existence of strong religious influences and the exclusion of women's views in the formulation of population policies hindered the full exercising of reproductive rights (Ortiz, 1999). In the last 20 years, public administration has implemented programs to respond to the commitments made at these international conferences on development and population. One of these programs, called 'Even Start in Life', was implemented in 2001, with the aim of reducing maternal mortality and morbidity-mortality in children under five years of age. In the field of sexual and reproductive health, the policy of family planning was revised incorporating new methods of planning such as the morning-after pill, the female condom and the subdermal implant. At the same time, a gender perspective was adopted that was based on two main lines of action: combating female cancer and promoting initiatives aimed at a life without violence for women. Hence, in 2006, the Mexican government enacted the Ley General de Acceso de las Mujeres a una Vida Libre sin Violencia (General Law on Women?s Access to a Free Life Without Violence) and established the Centro Nacional para la Equidad de G?nero y la Salud Reproductiva (National Centre for Gender Equity and Reproductive Health), whose purpose is to suggest public policies related to sexual and reproductive health, and monitor and evaluate these policies, as well as the quality of health services (Frenk et al., 2012).
Mexican public policies on sexual and reproductive health have been gradually modified to better suit women. However, as Garc?a points out, these changes have occurred more in discourse than in action since ?in day-to-day life, women continue to be the main object of control, both in institutional implementation and in all [...] social relations based on the social imaginary of domesticity? (2015, p. 99). In line with this argument Salles and Tuir?n point out that ?sexuality and human reproduction are embedded in structures and networks of social relations, for example, class and gender asymmetries [and ethnicity] ... Reproductive, sexual, and health care behaviours can be understood as socially structured behaviours endowed with meaning? (Salles & Tuiran, 2001, p. 99). Sexual and reproductive practices of indigenous populations are influenced by socioeconomic, educational, health, and gender inequalities, as well as the cultural nuances related to ethnic difference. Sexual and reproductive health must be thought of as a fabric of several interlocking factors where subjectivity can also be incorporated, for example, in how women live their sexuality in their daily lives, in their relationship with their partners and in their interaction with other women. This article highlights how women in this study perceive their sexuality based on their own experiences and practices.
Methodological aspects
The research was based on a qualitative design, with the participation of a total of 60 indigenous women labourers who were migrants from the southern region of the country, mainly from the state of Oaxaca, and who lived in the four different localities of the San Quint?n Valley. Participants were recruited using the snowball technique. Their age range was between 17 and 60 years old in which three age groups were identified: 17-29, 30-44, and 45-60. The objective of this classification was to identify whether, in addition to intergenerational change, the migration process influenced their perceptions and practices in relation to sexual and reproductive health.
Most women over 40 years of age migrated from their place of origin at a younger age, many with their nuclear family. The younger women were born in the San Quint?n region. In the latter group, half spoke an indigenous language in addition to Spanish and half did not speak their native language. Of the women who spoke their indigenous language, roughly one-third spoke mixteco (indigenous language from the region of Oaxaca). Regarding education, over two-thirds had either no schooling (37%) or had primary schooling only (38%); 13% had a secondary education, 10% completed high school and 2% had a bachelor?s degree. Concerning current occupation, roughly half (55%) stayed at home, and the other half either worked as jornaleras (agricultural labourers) (23%), or were students (23%); 10% had regular employment.
Women who met the following criteria were invited to participate: identified as indigenous, spoke Spanish, had a minimum of one year residence in the locality and voluntarily consented to participate by signing a letter stating the purposes of the study and the confidentiality of the information. Two techniques were used in the field work conducted in each of the localities: participative workshops and individual interviews. Two workshops and ten interviews were carried out, which were recorded, transcribed and their content analysed. Individual interviews gathered in-depth information on the topics raised in the workshops.
The first workshop sought to obtain information on how women in the study perceived the different aspects of their sexual and reproductive health. The second explored their knowledge of the right to sexual and reproductive health, their perception of care in health services, doctor-patient interaction and how sexual health is a right for everybody. The attempt here was to determine whether these women perceived access to quality health care as their right, especially regarding sexual health.
Medical staff of the IV Health Jurisdiction of the Baja California Institute of Public Health Services, located in the San Quintín Valley, were also interviewed. It was deemed important to obtain the point of view of health services providers regarding the sexual and reproductive health and health-seeking behaviour of the indigenous female population settled in this Valley. The two nurses responsible for the Maternal Health and Female Cancer programs were interviewed, along with the doctor responsible for Family Planning and Sexual Health in Adolescents, as well as the psychologist in charge of the Violence and Gender Equity program.
Results
Sexual and reproductive health involves both biological and sociocultural processes such as the interaction of personal experiences, relationships between people, and interaction with health service providers. It also involves the broader structural context, including gender and other social and economic inequalities, sociocultural norms and practices, lack of access to education, limited employment opportunities, poor living conditions and ethnic origin, as well as political context. Results are organised under the following sub-themes: source of women's information about sexuality; onset of sexual activity and use of contraceptive methods; knowledge of sexually transmitted diseases; access to health services and doctor-patient interaction; and the exercise of sexual rights.
Source of women's information about sexuality
In the study group, women stated that their mothers did not provide sexual education such as information about the onset of menarche. Participants mentioned learning about such things from schoolmates or older sisters, information that tended to be more about personal hygiene and less about the physiological or anatomical basis of sexual development. As one interviewee commented:
... never spoke to us about sexuality nor the changes, I have another sister that, when I started menstruating, she was the one who taught me how to put the pad because I even did not know how to put it... my sister, the middle one, started to explain-because she was the one with me at the time-, she told me you will put the pad, this is going to happen, but don't be afraid. (Interviewee A: 30 years of age)
In addition, talking about the intimate parts of a woman's body is very uncomfortable for older women, as shown in the following quote:
No, we did not touch that subject because ... for them, it was like disrespecting us to ask those things ... did not teach me any of that, because, there, we could not talk about that, for example ... of our parts or so because, for them, it was rude ... (Interviewee B: 44 years of age)
Only women under the age of 40 reported having received information at school, although many felt that this information was insufficient. They commented that some teachers were reluctant or uncomfortable when teaching 'sex education'. Younger women acknowledged the importance of talking with their daughters about sexuality, although some admitted they dared not because they did not know how to approach the subject, or how to get close to their daughters. One of the youngest informants commented: 'I was told in primary school [about] what is menstruation and some parts of your body' (Interviewee C: 18 years old).
Beginning of sexual activity and contraceptive methods
In this group of women the first pregnancy often occurred between 15 and 20 years of age and the average number of pregnancies was between two and three. The following quote describes how the occurrence of pregnancies before the age of 15 years was seen as problematic: '. yes, it is very upsetting to have 13 years old girls who are already pregnant, [...] they already give all that information at school [...] but what is lacking is that their parents give them some direction' (Interviewee D: 41 years old). Another interviewee pointed out: 'I did not know how to give the right information to my daughter, I did not know how to guide her, she got pregnant at age 14' (Interviewee E: 35 years old).
Participants described two types of care in pregnancy and postpartum, those provided by the health sector and traditional home care and remedies. Births tend to be vaginal rather than by caesarean section. It was common for women to carry out their prenatal care at local clinics and most births took place in local health centres, although some elected to use midwives.
Regarding family planning, most women were familiar with contraceptive methods recommended by the health sector, such as hormonal approaches and intrauterine devices. Nevertheless, not all women used a contraceptive method, whether by their own or by their partner's decision. Among those who did use them, female contraception methods were the most common. In some cases, couples discussed family planning with each other, but sociocultural barriers prevented them from communicating about sexuality with their children.
The health sector is a major source of information about sexual and reproductive health although not about sexuality or gender. One of our participants described her experience regarding information received from the health sector as follows:
... When they tell you about sexual and reproductive health, they talk about the contraceptive methods, of when you have to go to a pap smear screening, or, for example, check your breasts for breast cancer. But the topics they do not touch, for example, are what it is to be a woman . gender difference, how do men develop . the woman . but they do not provide much information ... on gender. (Interviewee F: 36 years old)
Knowledge of sexually transmitted diseases
Women are aware of the importance of screening for cervical and breast cancers, as well as for the most common sexually transmitted diseases. Not only was screening commonly available, but women showed a greater willingness to take responsibility for their health care. One of the nurses in charge of the Women's Cancer Program said that '...I have seen advances in the indigenous population, that they are more empowered now to seek screening tests. They now make that decision'.
Access to health services and doctor-patient interaction
Concerning the use and access to health services, women often visited the health centre for general consultation, vaccine application and to carry out tests for early detection of cancer. However, basic medicines were often lacking or were insufficient. Moreover, there were no specialists available and medical equipment was often lacking. Regarding these issues, the doctor in charge of the Adolescent Reproductive Health Program mentioned:
If we compare ourselves with Canada, if we compare ourselves with other countries that have their attention focused on health and education, the percentage of Gross Domestic Product (GDP) [of Mexico] is minimal compared to those countries (...) that also leads to different material and human resources in the area of health. And that is not the fault of the worker, nor the citizens, these are matters of political approach to health (. ) the country focuses more on cure and has forgotten about the preventive side.
The health insurance program for workers provided by the Mexican National Social Security Institute provides clinics that are better equipped and where there is less rotation of medical staff. However, participants complained about the complexity of bureaucratic procedures required to access services at these clinics. Although a large proportion of women attended to their health in government-provided clinics, they also continued to use traditional medicine to treat certain diseases.
Study participants described two different types of experiences with doctors, one in which the doctor was attentive, responsible and respectful, and another where they felt discriminated against and mistreated due to their indigeneity. Figure 1 presents some of the ways participants exemplified the kinds of doctor-patient interactions they had experienced. For responsible and respectful treatment, there were phrases such as 'there are doctors who responsibly listen to people'; in contrast with discriminatory and unequal treatment, where participants said 'we wish that doctors (would) change their way of being' or 'there are doctors who make fun of their patients' health'.
Top set of notes from left to right (Figure 1):
"we would be happy if the doctors would change the way they treat us.", "there are doctors who don't want to treat indigenous people", "we need an indigenous doctor". Second row, from left to right: "we want a female doctor who treats all people equally", "there are doctors who are responsibly listen to people". Third row, left to right: "there are doctors who understand the situation of their patients and help them", "some doctors meet their professional responsibilities, while others do not". Fourth row, from left to right: "there are doctors who do not pay attention to their patients", "there are doctors who mock their patients when they know that they should not do that". Fifth row, from left to right: "there are doctors who discriminate against their patients", "there are irresponsible doctors who give you a wrong diagnosis". Sixth row: "there are doctors who ignore their patients and make us feel badly".
The training received by the health professional was often technical, and did not always provide the kinds of communication skills required for addressing issues of sexuality with adolescents, especially with indigenous populations. Relating to this issue, the doctor responsible for the Adolescent Reproductive Health and Family Planning programs mentioned that:
I did not come out [of training] sensitized [to] do Pap smears and breast cancer detections nor, much less [to] talk about family planning. I was not sensitized to that and then it is difficult for me as the head of adolescent reproductive health and family planning to sensitize medical staff (...) there is no academic training where they tell us and insist that it is very important because [in this way] violence is prevented, cancer, unplanned pregnancies, and many other things are prevented, with the simple fact of addressing sexuality at the right moment (...) we are shy talking about everything that is related to sexuality when it is necessary. Thus, as health personnel it is difficult for us to address issues of sexuality with the patients.
These omissions and deficiencies in the health sector make it more difficult for women to go to health centres and receive not only information on sexual and reproductive issues but comprehensive health care. Regarding this matter, Castro (2011) points out that when women go to health centres seeking attention on matters regarding reproductive health, the interaction with medical staff is often depersonalising, reducing the ability of women to claim their own reproductive rights. From a human rights perspective, these deficiencies constitute violations of sexual and reproductive rights.
Exercise of sexual rights
In both workshops and interviews, scarce information was obtained on how women perceive their own sexuality and whether they see themselves and their sexual partners as active agents in terms of sexual pleasure and satisfaction. Participants revealed even less about their understandings of their rights to reciprocity in their sexual relationships, that would allow them to address their own sexual needs and desires and to exercise greater control over their intimate life. One of the few interviewees who discussed her sexual rights was 24 years of age and with more schooling than most; she stated:
... sometimes I tell him I do not want [to engage in sexual relations], and no, I want to rest, I feel tired, and sometimes, truly, he gets upset, but I tell him that I don't want to, and he has to respect me . (Interviewee G).
In one of the exercises during the workshops, some women said: 'I have the right to take care of my body and no one can force me', 'I have the right to be accepted as I am' (Figures 2 and 3). In Figure 2 the central circles says:
'I have the right to:' Around it, there are eight circles with notes in them. Moving clockwise: 'I have the right to have children to educate them, look after them and dress them', 'I decide if I work or take a break [from working]'; 'I have the right to be free and to develop myself more every day', 'I have the right to consent to sexual relations with my partner, or not'; 'I have the right to be respected by other people', 'I have the right to be respected physically and mentally'; 'I have the right to learn what rights I have', 'I have the right to decide what I want and do not want in my future'; 'I have the right to express my opinion about a topic or something important' . ; 'I have the right to insist on my rights as a person', 'I have the right to receive good treatment at work and be respected'; 'As a mother, I have the right to be respected by my children', 'I have the right to study and to express myself, 'I have the right to be respected the way I am'; 'I have the right to go out, be free, and behave myself, 'I have the right to take care of my body and no one can force me', 'I have the right to plan how many children I have or want'.
Discussion and conclusions
The impact that the education and health sectors have had in this population regarding the prevention of pregnancy is scant. This study has found that women have their first pregnancy in adolescence, some even as young as 13 years old. This coincides with the results published in the 2014 Encuesta Nacional de la Dinámica Demográfica-ENADID (National Demographic Dynamics Survey-NDDS), which shows that the average age of the first coupling of indigenous women of fertile age is within the 15-49 years of age range, almost two years younger than women who do not speak an indigenous language (INEGI, 2016).
The discourse of this group of women focuses more on reproduction than on sexuality. This makes sense when placed in the context of the health services providers' discourse, which emphasises family planning, sexually transmitted diseases and the timely detection of cervical and breast cancer, while omitting issues associated with sexuality. To talk about sexuality is, for many women, a taboo (Marston, 2004), unless it is associated with motherhood.
For a small group of these women, sexual and reproductive health implies respecting and caring for one's own body as well as being able to express emotions and to value oneself. They consider that people should be free to sustain a sexual relationship under conditions of their own choice, as well as to control their own fertility and protect themselves from sexual violence. However, they do not have a specific notion of their sexual rights, since they barely recognise as such the right to bodily integrity and privacy.
For the participants of this study, the meaning of being a woman has undergone changes that can be explained by the migratory experience from rural to urban centres, and the interaction with other women. Aizenberg (2014) points out that it is the interaction between members of a community that allows the construction of social-capital bonds within the community. Migration processes expose women to a new life environment that reshapes their practices and knowledge about their sexuality. The indigenous women participating in this study who had migrated, had reconstructed their identity in constant interaction with other indigenous and non-indigenous people in this region, in daily life, in community ties, and in new jobs where they had transformed and re-signified their beliefs and perceptions.
These changes are more noticeable among younger women than older women for whom cultural norms are strongly internalised and inhibit changes in how they perceive their sexuality. Changes in life conditions are reflected in how they wish to live their sexuality and also in the way they conceive their ethnic and gender identity as subjects of law. Changes in the perception of indigenous women have meant that they not only perceive themselves as caretakers of others and are placed last among the family, but now recognise themselves as sexual beings and, therefore, begin to appropriate their body and themselves. However, the desire to live their sexuality where they can control their own fertility and protect themselves from sexual violence is not reflected in the relationships of most of the women. According to Beasley (2008), the way to increase women's ability to negotiate with their partners their intimate relationship is through sexual education, which can play an important role in preventing domestic violence.
According to the cultural beliefs of these participants, 'respectable' women do not discuss sexuality. This coincides with the findings of Karver, Sorhaindo, Wilson, and Contreras (2016), who point out in their study on indigenous women in Oaxaca, that feelings of shame and fear influence the expression of these women's sexuality. They also found that the key attribute of being a woman is linked to motherhood. Women's knowledge about their right to express their sexual desire (i.e. sexual pleasure and corporal sensuality) did not arise at the workshops reported in the Karver et al. research. Nevertheless, the current study found that for some women, the inability or unwillingness to discuss sexuality can become modified after leaving their places of origin and settling in a different environment. Interaction with indigenous and non-indigenous women about these matters can change their perceptions.
Women's perception of the quality of health care may be, among other things, an obstacle to the use of health services. Health services are focused on the medical aspects of reproduction and sexuality, as opposed to the full expression of sexuality and the promotion of the exercise of sexual and reproductive rights. Health care provided women by institutional services is not only deficient, but conforms to a unilateral institutional view that leaves aside women's needs and voices. Furthermore, indigenous women are often not treated with respect, are guaranteed neither privacy nor confidentiality and do not always receive full explanations about available services. This situation inhibits the exchange of information and encourages authoritarian treatment of doctors and other health agents towards women. It also deepens inequality in access to health services, accentuates differences and generates discrimination and social injustice.
From a social perspective, health care must focus on reducing inequalities, which in turn depends largely on the distribution of power between political actors and the role of the state, which must guarantee the exercise of health as a human right. It is therefore necessary and desirable for the health sector to have a more comprehensive view of the sociocultural components of sexual and reproductive health, so as to be able to carry out medical care in ways that takes account of the needs of indigenous women (Rodriguez-Vargas & Molina-Berrio, 2015). For this reason, it would be good to institute a series of training strategies with the goal of sensitising institutional staff on the subject of gender perspective, to aid in the promotion of access to information and guidance on sexual and reproductive health, especially for indigenous women and girls.
The full exercise of sexual and reproductive rights requires that women's partners recognise their female partner's right to decide about their own body. Here men must assume responsibility towards women's sexual and reproductive rights, which runs contrary to the traditional cultural role of men where they are permitted satisfaction of their sexual needs but have no responsibility in terms of reproduction.
The findings of the present study show that the challenge faced by health care and other institutions is to bring about changes in sexual and reproductive health care that account for the voices and needs of indigenous women. This includes not only the health sector, but also the education sector, since its role is key in sexual education, especially in the basic and higher education of the adolescent indigenous population. For women themselves the challenge is to re-establish their sexual and reproductive rights and exercise them.
More than 20 years after the International Conference on Population and Development in 1994, the need to adopt a rights perspective to approach sexual and reproductive health is still evident. This requires more than a biomedical approach to sexual and reproductive health. It is important to take into account the complex political, economic, cultural and social contexts that disadvantage broad sectors of the population such as indigenous women. To conceive and implement sexual and reproductive health from a technical standpoint is to leave aside issues of social justice.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This project was funded by the Comision Nacional para el Desarrollo de los Pueblos Indigenas; Comisi?n para el Desarrollo de los Pueblos Ind?genas en M?xico (Commission for the Development of Indigenous People in Mexico).
References
Aizenberg, L. (2014). Facilitating indigenous women's community participation in healthcare: A critical review from the social capital theory. Health Sociology Review, 23(2), 91-101.
Beasley, C. (2008). The challenge of pleasure: Re-imagining sexuality and sexual health. Health Sociology Review, 17(2), 151-163.
Castro, R. (2011). Teoría social y salud. In Salud Colectiva. Lugar Editorial, S.A., Buenos Aires.
Careaga, G., & Sierra, S. C. (2006). Debates sobre masculinidades: poder, desarrollo, políticas públicas y ciudadanía. México: UNAM.
Cervantes, A. (1999). Políticas de población, control de la fecundidad y derechos reproductivos: Una propuesta analítica. In B. García (Coord.), Mujer, género y población en México (pp. 363-429). México: COLMEX. SOMEDE.
Corrêa, S. (2001). Salud reproductiva, género y sexualidad: Legitimación y nuevas interrogantes. In C. Stern y G. Figueroa (Eds.), Sexualidad y salud reproductiva. Avances y retos para la investigación (pp. 127-153). México: COLMEX.
Figueroa, J. (1999). Derechos reproductivos y el espacio de las instituciones de salud: algunos apuntes sobre la experiencia mexicana. In A. Ortiz-Ortega (Comp.), Derechos reproductivos de las mujeres: Un debate sobre justicia social en México (pp. 147-190). México: EDAMEX.
Frenk, J., Gómez-Dantés, O., & Langer, A. (2012). A comprehensive approach to women's health: Lessons from the Mexican health reform. BMC Women's Health, 12(42), 1-7.
Galdos, S. (2013). La conferencia de El Cairo y la afirmación de los derechos sexuales y reproductivos, como base para la salud sexual y reproductiva. Revista Peruana de Medicina Experimental y Salud Pública [online], July 30. Retrieved December 6, 2016, from http://www.redalyc.org/ articulo.oa?id=36329476014
Galoviche, V. (2016). Conferencia sobre población y desarrollo de El Cairo (1994). RevIISE, 8(8), 89-97.
García, M. I. (2015). El control del crecimiento de la población y las mujeres en México: organismos internacionales, sociedad civil y políticas públicas. Revista Colombiana de Sociología, 38(2), 93- 111.
INEGI "ESTADÍSTICAS A PROPÓSITO DEL...DÍA DE LA MADRE (10 DE MAYO)" DATOS NACIONALES. 06 DE MAYO DE 2016. Retrieved November 2, 2016, from http://www.inegi. org.mx/saladeprensa/aproposito/2016/madre2016_0.pdf
Karver, T. S., Sorhaindo, A., Wilson, K. S., & Contreras, X. (2016). Exploring intergenerational changes in perceptions of gender roles and sexuality among indigenous women in Oaxaca. Culture, Health & Sexuality, 18(8), 845-859.
Langer, A. y Tolbert, K. (Eds.). (1998). Mujer: sexualidad y salud reproductiva en México. México: EDAMEX, The Population Council.
Lara-Flores, S. (2003). Violencia y contrapoder: una ventana al mundo de las mujeres indígenas migrantes, en México. Revista Estudios Feministas, 11(2), 381-397.
Lara-Flores, S. (2008). ¿Es posible hablar de un trabajo decente en la agricultura moderna-empresarial en México? El Cotidiano, 23(147), 25-33.
Lara-Flores, S. (1995). Las empacadoras de hortalizas en Sinaloa: historia de una calificación escatimada. In A. González, & V. Salles (Coord.), Relaciones de género y transformaciones agrarias (pp. 165-186). México: PIEM-COLMEX.
Marston, C. (2004). Gendered communication among young people in Mexico: Implications for sexual health interventions. Social Science & Medicine, 59(3), 445-456. doi:10.1016/j. socscimed.2003.11.007
Ortiz, A. (Comp.). (1999). Los derechos reproductivos de las mujeres. Un debate sobre justicia social en México. México: EDAMEX.
PDH-BC (Procuraduría de Derechos Humanos del estado de Baja California). (2003). Recomendación 6/2003. Mexico: Procuraduría de Derechos Humanos del estado de Baja California.
PDR (Programa de Desarrollo Regional: San Quintín). (2011). http://imipens.org/IMIP_files/PDRSanQuintin.pdf (Consulted July 19, 2012).
Pedraza, V. y Pedraza, I. (2014). Derecho a la salud sexual y reproductiva desde un enfoque de derechos humanos. EN LETRA, número extraordinario Derecho de la Salud, pp. 28-56.
Rodríguez-Vargas, F., & Molina-Berrio, D. (2015). Elementos del contexto que intervienen en el desarrollo de las políticas públicas de salud sexual y salud reproductiva elaboradas entre el 2003 y el 2013. Revista Gerencia y Políticas de Salud, 14(28), 10-30.
Salles, V. y Tuiran, R. (2001). Sexualidad y salud reproductiva. Avances y retos para la investigación. In C. Stern y G. Figueroa (Eds.), Sexualidad y salud reproductiva. Avances y retos para la investigación (pp. 93-113). México: COLMEX.
United Nations. (1995). International conference on population and development, Cairo 5-13 September, 1994. Programme of action, New York: United Nations, Department for Economic and Social Information and Policy Analysis.
Velasco, L. (2007). Diferenciación étnica en el Valle de San Quintín: Cambios recientes en el proceso de asentamiento y trabajo agrícola. (Un primer acercamiento a los resultados de investigación). In M. Ortega, P. Castañeda, & J. Sariego (Eds.), Los jornaleros agrícolas, invisibles productores de riqueza (pp. 57-78). México: Plaza y Valdés.
Velasco, L., Zlolniski, C. y Coubes, M.-L. (2014). De Jornaleros a Colonos: Residencia, trabajo e identidad en el Valle de San Quintín. México: COLEF.
World Health Organisation (WHO). (2002). Sexual health. Retrieved June 10, 2016, from www. who.int/reproductive-health/gender/sexualhealth.html#2
Zlolniski, C. (2010). Economic globalization and changing capital-labor relations in baja California's fresh-produce industry. In The Anthropology of Labor Unions (pp. 157-188). University Press of Colorado.
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