How rape myths cause miscarriages of justice (it’s not how you think)

Alexandra Fanghanel

Alexandra Fanghanel, author of Disrupting Rape Culture, discusses miscarriages of justice, unideal victims, and how rape myths still persist in contemporary society.

In the middle of 2017, a postgraduate student walked into my office to speak to my colleague, announcing that he was about to share some sensitive information. I made moves to leave the room to give him some privacy. ‘No’, he said, ‘I want you to hear this, too’, and informed me that he was going to go on trial accused of rape. He wanted everybody to know, so that he could be transparent. So that we would understand, if he was upset in class sometimes, why this was.

The previous week, another student had come to see me. She told me that she had been raped by her boyfriend. She was worried about doing badly in her assignment because she couldn’t bear to sleep in her bed anymore. She didn’t want me to tell anyone. She didn’t want anyone to know. She just wanted me to know. So that I would understand, if she was upset in class sometimes, why this was.

The two students did not know each other as far as I am aware, though they would go on to sit in the same lecture theatres that year, each dealing in their own way with their experiences of rape. His vocalism about being falsely accused matched only by her silence about accusing anybody.

As 2017 rolled on, a huge number of rape cases were being reviewed and dismissed before going to trial because crucial pieces of evidence had not been disclosed by the police to the defence. My student’s case was one of these 3,600 cases.

We all know the narratives based on rape myths which are patently untrue. The story about a woman’s thong being used as evidence against her, or women being told not to dress ‘like sluts’ in order not to be raped. We know that when people do use them to excuse rape, the public is rightly outraged.

But there are rape myths that persists despite the contemporary sensitivity to narratives like those above.

In the high-profile cases where non-disclosure of evidence led to the Crown Prosecution Service (CPS) changing its mind about pursuing a rape allegation, that evidence took the form of text messages between the plaintiff and the accused, in which she explained how much she loved having sex with him and how she also had rape fantasies. In other cases, pictures of the plaintiff and defendant cuddling in bed after the alleged rape took place were disclosed. Of course, maybe all of the 47 cases where rape charges were dropped as a result of the disclosure of new evidence are cases where women make false allegations of rape, though this would be unlikely. Maybe, it is rather is that the Criminal Justice System balks at cases where we are faced with unideal victims or unideal behaviour by victims.

It is a rape myth that a person who has rape fantasies cannot be raped. It is a rape myth that a woman would not cuddle with her rapist after he has raped her. Sure, these behaviours and desires are not easy to reconcile, but should only ideal victims have justice? The risk adverse approach of a CJS which will not prosecute apparently weak cases means that justice is not operating equally for all women and men, whether accused or accuser.

Instead, in the wake of these cases, we see a more troubling narrative emerging; one, like the case of my two students, that is dominated by the voices of the men accused and where the voice of the accuser is silent and absent. We see the phrase ‘miscarriage of justice’ used to describe what these men have suffered, without any consideration about what this miscarriage of justice might really mean for the women who accused them. This kind of linguistic slippage appears dangerously, almost absurdly, to turn what justice means upon its head.

Rape myths are what enable this. We are hoodwinking ourselves into thinking that we no longer believe them, yet they have never been more entrenched in the everyday grind of contemporary social life and how we understand justice more broadly.

Disrupting Rape Culture by Alexandra Fanghanel is available on the Bristol University Press website. Order here for £60.oo, or get the EPUB for £21.59.

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Image credit: Chase Carter, via Flickr (CC BY-ND 2.0)

What being happier together would actually look like

By Sam Wren-Lewis, author of The Happiness Problem: Rethinking Individual Success and Societal Progress.

You may not know it, but today is the International Day of Happiness. This celebration takes place on the 20^th March every year, to coincide with the Spring Equinox, and is a modern day tradition that’s been going since 2013, after its official ratification by the UN in 2012. Each year has a different theme, with this year’s theme being “Happier Together”, encouraging people to focus on “what we have in common, rather than what divides us.”

All of which seems fair enough. After all, everyone wants to be happy, right? Happiness researchers and policymakers like to point out that many of the things that make us happy are universal and don’t cost the world – simple things such as spending time with friends and loved ones, getting outside into nature and being physically active. If only we spent more time doing these kinds of ‘happifying’ activities, and less time pursuing financial success and material goods, the world would be a better, greener, healthier and happier place.

“There are a number of serious factors that prevent people from doing the things that make them happy.”

Of course, advocates of happiness also recognise that things are not this simple. There are a number of serious factors that prevent people from doing the things that make them happy. The pressures and demands of daily life are significant. We are lucky if we can find a spare 10 minutes to do some exercise or simply sit still for a while. Busyness and productivity has become the new norm. In fact, even the suggestion that we should focus more on being happier, when we have so many other things we need to do, can seem patronising or offensive.

These concerns point towards a deeper problem with the rhetoric of happiness. Predominantly, the idea of happiness centres around getting things ‘right’ – having the perfect job, relationship, family life, body and mind. Proponents of happiness may be suggesting that we have some of our priorities wrong in this respect – it matters less how much money we have and more how are relationships are going. But they are still emphasising an ideal that is not be so easy to achieve for everyone. For those who live in genuinely threatening environments, for example, how safe is it to get outside more?

“We may all want to be happy. But we do not all face the same conditions and challenges in life.”

We may all want to be happy. But we do not all face the same conditions and challenges in life. By ignoring this fact, the ‘happiness agenda’ risks either being something trivial or something that is only relevant to the privileged few who can take on its recommendations.

This needn’t be the case, however. Instead of downplaying the different conditions and challenges we face in life, we can employ a notion of happiness that takes suffering much more seriously. The idea of happiness does not have to centre around things being just right.

Thinking about happiness can help us realise that we all face numerous challenges and difficulties, and will continue to do so. This is, ultimately, what we have in common. Things are never just right. No matter how much progress we make, we will still be insecure: vulnerable to disappointment, loss and suffering.

“The first step towards being happier together is paying more attention to the different conditions and challenges faced by people across the world.”

Don’t get me wrong, I’m all for individual achievement and societal progress – these are good things. And there’s nothing wrong with trying to be a bit happier, on today of all days. But if we really want to be “Happier Together”, as this year’s International Day of Happiness theme encourages us to, then we must recognise that our common humanity rests on our common vulnerability. The first step towards being happier together is paying more attention to the different conditions and challenges faced by people across the world.

Interestingly, this, somewhat more depressing, way of looking at things has happiness research on its side. We are beginning to understand the psychological benefits of attitudes such as curiosity and compassion. Even if our lives are not perfect, we can pay more attention towards ourselves and our circumstances, including the things we already have. The same goes for the lives of others. Instead of trying to control people’s behaviour, or find quick fixes for all their problems, we can show them compassion and gain a deeper understanding of what they need. Although this is far from living happily ever after, I believe it is what being happier together would actually look like.

The Happiness Problem by Sam Wren-Lewis is available on the Policy Press website. Pre-order here for £10.39.

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Repealed! Now we look to Northern Ireland

Judith Orr

Originally published by the Abortion Rights blog on May 26th 2018.

An uprising of activists in every city, town and village across Ireland made history yesterday and sealed the end of an era that saw women denied basic human rights. The victory of the Repeal the Eighth campaign will ring out across the world to everyone who is fighting to win the right to safe and legal abortions, whether in Poland, Bolivia or even on the doorstep, in my own birthplace, Northern Ireland.

The grassroots campaign saw great teams of people knocking on doors night after night and taking stalls to local high streets all over the country. It was inspiring to witness thousands of people going out to talk to people face to face about why they should vote Yes.

Thousands came #HometoVote from all over the world, and numerous Twitter streams and new hashtags showed the reach and creativity of the movement. Dentists for Yes campaigned in tribute to Savita Halappanavar who died in 2012 after she was denied an abortion when she suffered a septic miscarriage. She was herself a dentist, and her parents spoke out from India in support of a yes vote. Farmers for Yes tweeted photos of themselves holding Yes signs alongside their livestock and tractors while Grandfathers for Yes defied the clichés that this was simply a generational divide.

“…while Grandfathers for Yes defied the clichés that this was simply a generational divide.”

But most of all the courage of all those who told their own personal stories, many for the first time, stands as a testament to the cruelty of a state ban of what is an essential part of women’s health care. Moving accounts, for example on In her Shoes Twitter account, recorded the anguish inflicted on women who had to travel to end an unwanted pregnancy, or who needed to end a wanted pregnancy for health reasons. Women spoke out about the past so no one would have to go through what they endured in the future.

The No side showed no humility in the face of this outpouring of moving experiences. In fact the anti abortion lobby rehearsed its well worn propaganda about being ‘pro-women’ and ‘pro-life’. These claims were exposed as being lies as the Yes campaign highlighted the impact that denying access to abortion services in Ireland had on every area of women’s health care.

Women described being denied cancer treatment, or medication for epilepsy, when they became pregnant. One doctor told of woman brought by ambulance to a maternity hospital rather than an A&E after being injured in a car accident because she was pregnant. Her own physical injuries were dealt with only after doctors successfully picked up the foetal heartbeat. In the most tragic cases surviving relatives bore witness to the consequences of the constitution treating a foetus and a pregnant women as equal under the law

So this is a momentous change that has been a long time coming. Many compare yesterday’s referendum to one that led Ireland to be the first country to legalise equal marriage after a poplar vote in a referendum. But although both show how attitudes to the Catholic Church’s orthodoxies are changing, today’s result is even more significant. Women’s lives, their bodies, their fertility and sexuality have always faced the greatest scrutiny by the church and the establishment.

“Abortion cannot be seen in isolation, rather as part of a regime of oppression that imposed severe restrictions on women’s lives, and on their sex lives in particular.”

Abortion cannot be seen in isolation, rather as part of a regime of oppression that imposed severe restrictions on women’s lives, and on their sex lives in particular. This is a system that saw women who did give birth, but who happened to be unmarried, forced into institutions, such as Mother and Baby homes and Magdalene laundries. Here their babies were forcibly taken from them to be adopted. Many babies were even sold, often to rich American couples, leaving a trail of personal devastation over generations.

The discovery, in 2017, of a mass grave of babies and children in the grounds of a former Bon Secours Mother and Baby home in Tuam, County Galway show that the full truth of these institutions has yet to come out.

This policing of women’s bodies meant that some women were shamed if they did give birth, but others were also shamed if they decided they did not want to continue a pregnancy. Yet, as so many Yes campaigners pointed out, keeping abortion illegal did not stop Irish women having abortions, it just stopped them having abortions in Ireland.

Yet the shame associated with abortion is not unique to Ireland. Abortion still carries a stigma in countries with access to legal abortion, such as Britain. Abortion is portrayed as the ultimate betrayal of what it is to be a woman, we are encouraged to see it as an aberration and a rejection of our natural biological selves. When anti abortion campaigners can’t win a bar on abortion they concentrate on maintaining these taboos.

Such stigma will not disappear overnight, but the impact of what has happened in Ireland cannot be overstated. It is a sea change that will not only affect the legal status of abortion. The result is both an expression of, and spur for, a transformation of social attitudes to abortion as well. This will be the backdrop for the debates still to come over what new abortion legislation will say, and then about how that is interpreted and implemented.

“But there is also other unfinished business that is thrust into the spotlight by the referendum result, and that is the ban on abortion rights in Northern Ireland. “

But there is also other unfinished business that is thrust into the spotlight by the referendum result, and that is the ban on abortion rights in Northern Ireland. The 1967 Abortion Act was never extended to Northern Ireland, last year least 700 women traveled to England for health care they should be able to access at home. Others risk prison sentences by buying abortion pills online. One woman, 19 years old when she bought online pills when she couldn’t afford to travel to England, received a three month suspended sentence in 2016.

Theresa May was forced to concede that women from Northern Ireland should have access to NHS funded abortions in England in 2017. Until then women from Northern Ireland, paying the same National Insurance and taxes as women in the rest of the UK, not only had to travel for abortion care, they also had to pay for it privately. The issue threatened May’s ability to form a government after a snap election in June left her without a Tory majority. Her subsequent deal with the DUP, a Northern Ireland party trenchantly opposed to abortion rights, led Labour MP Stella Creasy to put a widely-supported amendment that could have defeated May’s critical Queens Speech.

In a single afternoon 50 years of discriminatory practice was overturned. This was not a sudden change of heart by the Tory government wanting to put right half a century of injustice. Health Secretary Jeremy Hunt had only two weeks earlier fought a case in the Supreme Court to defend the right to deny NHS funded abortions to women from Northern Ireland.

This was a reform pushed through by a government to ensure its own survival, but it showed what was possible. It has made a real difference for hundreds of women. But they still have to travel, and many cannot take the trip even if it is funded, for many different reasons from ill health to child care or the fact they are living in an abusive relationship.

That’s why today while we are celebrating this tremendous referendum victory, the Abortion Rights campaign in the UK is saying let’s take this opportunity to demand reproductive rights for women in Northern Ireland too. It’s about time.

Abortion wars by Judith Orr is available with 20% discount on the Policy Press website. Order here for just £10.39.

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Social forms of care: Changing relationships of support

Mary Holmes

Mary Holmes, Co-Editor of Families, Relationships and Societies, discusses the new special issue of the journal which is now available on Ingenta.

It may seem obvious to most of us that we rely on other people for care and support, but how has that changed given the fragmenting tendencies of contemporary life? In the latest issue of Families, Relationships and Societies we look at some of the different ways in which people care and are cared for from Finland, to Sweden, the UK, to the Phillipines. Whether it is caring for children, grandchildren, teenagers, or the elderly, care calls upon our bonds with other human beings.

Whatever the kind of bonds or location, social forms of care include state provision and welfare services, as well as informal care arrangements. People use family, friends and other connections to get the support they need. It is not always easy and may require negotiation and involve conflict. Some informal arrangements may be ad hoc and fragile, but some may contribute to community building and be good alternatives to more institutionalised care provision.

“Childhood, sickness, frailty and old age mean receiving care at times of vulnerability, but even in these cases the cared for might offer some support to others”

A lot of care is mutual. Childhood, sickness, frailty and old age mean receiving care at times of vulnerability, but even in these cases the cared for might offer some support to others – be it financial or emotional. In everyday terms, we give and take care. A friend makes us dinner when we are busy, we look after their children when they have a meeting. A colleague offers to help with our marking and we take a class for them to return the favour. Older children may take a turn to cook, or listen to their parent’s small woes. Caring changes. Parents care for children together and then perhaps alone; help from grandparents disappears as they die; supportive friends move to another town or country. Alongside these ‘private’ forms of caring are changing public provisions and policies that impact on how people care.

The impact of the rolling back of the welfare state in many countries shifts care responsibilities back on to the private sphere.  For example, we see in one article how austerity has made lone mothers in Finland more reliant on informal support networks. In another, Swedish parents have to deal with pressures to control their teenagers’ alcohol consumption. These are changes in what care means and in ideas about who should care for whom and how.

“The articles reveal generational and cultural differences in expectations around care.”

What care means in different kinds of relationships also changes, and the articles look at parents and teenagers, children and child carers in institutions, social workers and clients, parents and parent-in-law, grandparents, children and grandchildren within multigenerational families. In one instance, we see Filipino daughters-in-law making efforts to create affinity with their mothers-in-law to help them balance a sense of autonomy with caring according to cultural norms around obligation to parents. The articles reveal generational and cultural differences in expectations around care. Women also still have to make sense of having the greater part of the burdens and satisfactions of care. Yet people work at caring for each other.

Different contexts of care affect how it is given and received. For example, one author argues that institutionalised care can give children a different sense of time to ‘private’ forms of care. Meanwhile, in social work practice, care becomes difficult if always concentrating on risk prevention, especially within child protection. The articles do not glorify informal or private care as innately superior, but point out the difficulties of caring in the current climate. The social pressures on ‘private’ forms of care can be acute as people try to look after each other around the demands of work, changing demographics and shifting social norms. Fear-oriented assessments of risk, emphasis on responsibility and self-reliance and the withdrawal of various public services have different impacts according to gender, age, disability, class and race/ethnicity. Limited availability and problems within publicly provided care forces people to find support within often already overstretched networks or communities.

Self-reliance is a fantasy, albeit a powerful one, and it is imperative to know how families, friends and public bodies navigate around it to provide support. Here we see them using a range of ways to maintain relationships of support at a time when vulnerability and care are often degraded. Care remains a social achievement.

 

Read the special issue “Social forms of care: changing relationships of support”.

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Shared Lives: a new health and care system

Alex Fox

Alex Fox is the author of A new health and care system – out today and launching at Nesta this evening.

Here he unpicks the dehumanising tendencies of our public services to introduce a new health care model where those living with long-term conditions can achieve wellbeing in a system that looks at people’s strengths and capabilities, and their potential, not just their needs.

“The NHS was designed in the 1940s for brief encounters: healing us or fixing us up. It often does that astonishingly well. But now 15 million of us (most of us at some point during our lives) live with long-term conditions; three million with multiple long-term conditions. We cannot be healed or fixed, we can only live well, drawing on state support relatively little, or live badly, drawing on state support heavily and falling repeatedly into crisis. That long term, increasing reliance on intensive support services is not only likely to feel miserable to us as individuals and families, it drives long term financial meltdown which will bankrupt our service economies, even if they survive the current period of austerity.

“…we remain locked into seeing people who need support as illnesses, impairments, problems, risks, not as people who can and must share at least some of the responsibility for their own wellbeing.”

So we need a different relationship between people with long term conditions, their families and the services they turn to for help. But health and care leaders continue to talk and plan as if the health and care system was fixable by streamlining what we currently do, integrating various kinds of organisation, or making better use of tech. This is because, whether we use public services, work in them, or lead them, we remain locked into seeing people who need support as illnesses, impairments, problems, risks, not as people who can and must share at least some of the responsibility for their own wellbeing. We do not recognise that people who live for years or decades can become more expert in what works for their wellbeing than many of the professionals who necessarily dip in and out of their lives. Family carers provide more care than the state, but even they are not recognised as vital members of a wider caring team, who might need knowledge, training, equipment and emergency back up just as much as their paid colleagues.

“…fit support around a good life instead of asking people to fit their lives around a good service.”

To unpick this, we need to trace the dehumanising tendencies of our public services from their first contact with people who may need their support and their families, through all of their interactions, to the ways in which they ultimately reject, or in some cases, cling on to, their inmates. With demand rising, services are putting more resources into assessment processes designed to keep away the less needy, but those processes are themselves a drain on resources, and they ensure that those who meet needs thresholds are least able to identify and build on their own capacity to self-care, and have already had their confidence and independence demeaned and undermined by bureaucracy.

The alternative is to take an ‘asset-based’ approach to every long-term support service offered: looking for people’s strengths and capabilities, and their potential, not just their needs. For nearly everyone, these ‘assets’ are partly their relationships with friends and families, so every support service must be delivered in ways which fit round and back up those informal networks, minimising disruption to them.

There is already at least one nationally scaled support model which does this: Shared Lives, now used by 14,000 people in almost every UK area.

Edward, Stephen and Christina’s story

Edward is 66 years old and lives with Shared Lives carers Stephen and Christina. Edward has a learning disability and has been blind since childhood, and when living with traditional methods of support his independence suffered. He didn’t have his own space and was restricted from carrying out many of the tasks and routines of daily life, as well as access to broader life experiences.

Stephen had had contact with Edward through his previous work as a social worker. He perceived that Edward had a lot of potential and believed he could do much more for himself. So when Stephen became a Shared Lives carer and developed his own personal care skills, he and Christina opened their home to Edward and made it their mission to develop his confidence.

The transformation has been profound, with Edward describing his increased independence: “I’ve got my own room and all the things I need. It’s been brilliant. I haven’t looked back since I’ve been with Stephen and Christine.”

Edward has gone from a situation in which he hardly ever experienced leisure activities or life outside home, to having an impressive list of holidays and trips under his belt. He has been to Las Vegas, and taken a helicopter ride over the Grand Canyon. Closer to home, with a bit of support from his Shared Lives carers, he has been to a Formula One Race at Silverstone: “I could feel the cars!” said Edward, describing the sensation of picking up the vibrations of the revving of engines through his feet.

Stephen has encouraged Edward’s enjoyment of the atmosphere at sporting events – and they go to the rugby almost every week. Through Shared Lives, Edward has been able to explore his pre-exiting interests in cars and sports to the full.

Shared Lives demonstrates that it is possible to combine people’s own capacity, with the strengths of positive family and community life, and the back-up and resources of a regulated care service. No one approach can be the magic bullet which will heal our ailing NHS, but Shared Lives offers lessons and challenges which could be taken up by any service: look for the person, not the condition; fit support around a good life instead of asking people to fit their lives around a good service; always connect.

A new health and care system, by Alex Fox is publishing on 28 February 2018 and is available with 20% discount on the Policy Press website. Order here for just £15.19.

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Repealing the 8th: how new legislation on abortion should be designed

Fiona de Londras

Mairead Enright

Fiona de Londras and Mairead Enright – authors of ‘Repealing the 8th: Reforming Irish abortion law‘ – respond to the announcement of the Irish Cabinet of its intention to hold a referendum to repeal Article 40.3.3 in May 2018. The book, now publishing on Thursday this week, looks beyond the referendum to what might come next, presenting detailed proposals for new legislation.

Chapter 4 from the book – Accessing abortion care: principles for legislative design – is now available to download free on our website. 

In 1983 the Irish Constitution was amended by the insertion of Article 40.3.3, now known as ‘the 8th Amendment’. This provides that “the State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right.”

At first glance, the 8th Amendment may seem innocuous or merely aspirational. However, over time, this provision has led to a near-absolute prohibition on abortion in Irish law and serious infringement of pregnant people’s rights. Under the current law, abortion is only lawfully available in Ireland when a woman will almost certainly die without it, and even then multiple doctors usually have to agree that this is the case.

“More than three decades of activism have come together in a large, vocal, visible and highly effective campaign for political and legal reform.”

Now, though, there are signs of change. More than three decades of activism have come together in a large, vocal, visible and highly effective campaign for political and legal reform; for the removal of the 8th Amendment and introduction of a law that will enable women to exercise agency in pregnancy and ensure that, for those who want to avail of it, abortion care is available at home in Ireland.

On Monday, the Irish Cabinet announced its intention to hold a referendum to repeal Article 40.3.3 in May 2018. The People will be asked to delete this Article and to insert a provision that expressly says that provision may be made by law for the termination of pregnancy. The Taoiseach said that the referendum will present the People with a choice to enable the Irish parliament to legislate for abortion care at home, or to continue to export abortion to other jurisdictions and to put the lives of women in Ireland at risk.

The Cabinet will publish indicative legislation for a GP-led abortion service ‘on request’ up to 12 weeks, and more limited access to abortion in later pregnancy.

After the referendum

In the book we look beyond the referendum, to what might come next once the 8th Amendment no longer absolves the Oireachtas of the responsibility to make law to provide for the needs of women in Ireland. We include detailed proposals for how new legislation on abortion might be designed, including draft legislation that gives effect to the proposals that appear to have received Cabinet support this week in a way that respects the rights of pregnant people in Ireland.

“…the rights of pregnant people can be developed in ways that truly respect and protect bodily integrity, privacy, and the right to be free from inhuman and degrading treatment.”

In doing this, we argue that repeal of the 8th Amendment would create opportunities for the progressive interpretation of the Constitution, so that the rights of pregnant people—for so long narrowed down to a bare right to life said to be equal in stature to that of an unborn foetus—can be developed in ways that truly respect and protect bodily integrity, privacy, and the right to be free from inhuman and degrading treatment. This, we argue, would compel the Irish state to provide for lawful abortion, but would allow it to pursue the socially valuable objective of preserving foetal life provided in doing so it respects the constitutional rights of pregnant people.

This can be done by introducing law that makes abortion available without restriction as to reason up to at least the twelfth week. After that such a law might make lawful abortion available on broadly drawn health grounds so that pregnant people can truly determine the course of their own reproductive lives, and so that victims of sexual violence or those who have received unexpected foetal diagnoses will be able to be supported through a decision to an end a pregnancy, rather than forced through a punitive ‘qualification’ processes. This is what we are calling for now that the Referendum has been announced.

Like the Citizens’ Assembly and Joint Oireachtas Committee on the 8th Amendment, we draw distinctions between the availability of abortion after 12 weeks and after 24 weeks, with later abortion (after 12 weeks) being truly exceptional in law, just as it is in life. Illustrating the feasibility of such an approach, we include in the book draft legislation that gives effect to this approach. This makes our book essential reading for anyone involved in the campaign.

Our objective in writing this book was threefold. First, we wanted to make the constitutional arguments about the 8th Amendment clear and accessible and, in so doing, to show that from a legal perspective there is nothing unusually difficult about legislating for abortion and no reason why, uniquely among medical procedures, it should be regulated within the text of the Constitution. Second, we wanted to show how the Constitution itself could develop after repeal to reinvigorate the personal rights of pregnant people and to strike a balance between protecting these legal rights and pursuing the social objective of preserving foetal life through voluntary, consensual, and well-supported pregnancy. Finally, we wanted to show that, by drawing on experience in other countries and on international human rights law, and by committing to ensuring that pregnant people have sufficient certainty and support to make decisions about their own reproductive lives, a workable, reasonable, and rights-based law on access to abortion can be imagined and designed for Ireland.

Now, with the announcement of the Referendum on the 36th Amendment to the Constitution, we are a step closer to achieving some of these goals, but there is still much work to do. Given this week’s developments, Policy Press has brought forward the publication of the book to 1 February: please circulate information about it to anyone who is involved in the debates around the referendum.

 

‘Repealing the 8th: Reforming Irish abortion law‘ by Fiona de Londras and Mairead Enright  is publishing on 1 February 2018 and is available with 20% discount on the Policy Press website. Pre-order here for just £10.39.

It will be available Open Access under CC-BY licence.

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The relationship between work & health in India

Martin Hyde, co-editor of  Work and health in India, discusses the relationship between work and health in a country with one of the fastest growing economies in the world and with a labour force of nearly half a billion people. 

Martin Hyde

Work stress and its effect on our health is something that we hear a lot about in the UK. Working longer and longer hours, having to do more and more in less and less time, increasing job insecurity are things that many of us experience. Newspapers and internet sites are full of stories about the damage that this can do to our overall sense of well-being as well as remedies to counter these negative effects. Many of these are supported by decades worth of academic research on the relationship between the working environment and health.

However, once we go beyond the high-income countries of Europe, North America and Japan we know very little about the nature of work and its impact on health in lower and middle-income countries. Given that these countries contain some of the world’s largest workforces and fastest growing economies this is a major oversight.

It was the desire to correct this oversight that motivated us to put together this book on the relationship between work and heath in India. Whilst there had been some research on this topic in India this book is one of the first to address the topic of work environment, stress and health in a rapidly developing country.

“The benefits of India’s tremendous economic growth have been unevenly distributed across society.”

India is one of the fastest growing economies in the world. The growth of the Indian economy has been matched by the steady increase in its labour force, which has risen from 330 million in 1990 to nearly half a billion people in 2014. This is roughly double the size of the labour force of the entire European Union.

Not only has the workforce grown but it has also changed from one dominated by agriculture to one with vibrant and growing service and manufacturing sectors. However, the benefits of India’s tremendous economic growth have been unevenly distributed across society.

The same is true of developments in the health of the Indian population. Life expectancy has risen steadily for both sexes and infectious diseases have declined over the past few decades. However, this fall in infectious diseases has been accompanied by a rise in non-communicable diseases (NCD), which now account for the top three causes of death in India.

“Chronic psychosocial stress at work is now becoming an important threat to the health of employees.”

So not only is the Indian economy and workforce beginning to more closely resemble those of the advanced industrial economies, so too are its disease and mortality profiles. As the labour market underwent a substantial transformation and while some traditional occupational hazards disappeared, chronic psychosocial stress at work is now becoming an important threat to the health of employees. For us, these twin developments called for more research to look at these issues.

To start to do so this book brings together a multidisciplinary and multinational authorship with researchers from all across India, from all careers stages, as well as researchers from the UK and Sweden. The range of topics covered, and methods and data used throughout the book reflect the diverse nature of the Indian economy.

Some chapters, such as those by Sanjay K. Mohanty and Anshul Kastor, and Harihar Sahoo, draw on large scale surveys to map the national picture of occupational inequalities in health. Other chapters focus on specific occupational groups such as tea pickers (Subrata K. Roy and Tanaya Kundu Chowdhury), police officers (Vaijayanthee Kumar and T.J. Kamalanabhan) and scavengers (Vimal Kumar).

What comes out in all of these chapters is a complex picture of the relationship between work and health. On the one hand we see many of the same issues in India that we see in other countries. Work stress is bad for your health wherever you live. On the other hand there are some findings that appear contradictory. For example, those in the highest occupations seem to have the highest rate of diagnosed illness. However, this is probably because only those in the top jobs can afford to go to a doctor. Finally, underlying all of this we see the intersections between gender, class and caste that impact on both work and health.

 

Work and health in India edited by Martin Hyde, Holendro Singh Chungkham and Laishram Ladusingh is available with 20% discount on the Policy Press website. Order here for just £60.00, or as an ebook for £21.59.

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Am I a patient?

Alan Cribb unravels the transition from an epidemiological approach to a philosophical approach to healthcare he discusses in his new book – Healthcare in transition – by examining how his identification, or not, as a patient impacts on his research.

Whilst working as an academic I tend not to identify myself as a patient. 

In the last few years one of the themes of my work has been patient-centred or person-centred healthcare, and I have just completed Healthcare in transition, a book in which I tried to tease out some of the elements of, and tensions within, this idea. But I have never self-identified as a patient in my writing and I only occasionally do so in my face to face encounters with trusted colleagues and in what feel like safe spaces to me.

In some ways this is odd. I am not simply a patient in a notional sense – like very many people, I have regular interactions with medical consultants and other health professionals, I follow a regime of treatment and I have health-related conditions that challenge my identity and frame the way I organise my life. So why not self-identify as a patient in my academic work?

“Why not self-identity as a patient in my academic work?”

Partly it is probably just about privacy or for reasons of self-protection – not to invite threatening line of enquiry from others. But it feels as if it is about something more than that. First and foremost it seems presumptuous. It feels like I have been invited to the meeting with one ticket – as a researcher – but now I am claiming to have a further ticket and am expecting to vote twice!

This sense of cheating applies however I think about what counts as a patient, and I have to confess that I am confused about this. In health services research, for example, it is now a methodological and ethical norm to worry about the inclusion of either patient perspectives or patients in some fuller sense. But there is a spectrum of attitudes and practices in response to this norm.

In some cases – and this is to exaggerate for effect – ‘patients’ is treated as a kind of self-fulfilling marginal category, such that if people happen to have any other source of relevant expertise – they are health professionals, or researchers, or activists or even heavily engaged in a peer led patient group then they will to some extent be disqualified as ‘patients’.

This attitude stems from an understandable concern that the identity of patients isn’t colonised and misrepresented by powerful voices but, at the same time – certainly in this exaggerated sense – it risks reproducing a deficit view of patients.

“I feel either disqualified or under qualified.”

At the other end of the spectrum there are strong patient voices and groups who will not only lobby for involvement in research but will themselves lead research and will challenge prevailing orthodoxies – for example, questioning not only the practices of patient involvement but also the ways in which research agendas are set and research is conducted and so on. These kinds of patient voices play an important role and can be inspirational. But there is also a danger here – again at the extreme – that the identity of patient itself becomes professionalised and owned by a few well-organised people.

The first account coincides with my worry about being presumptuous. I need to be cautious about saying I am speaking as a patient, especially with any implication that it is on behalf of other patients, when I already have a hearing as an academic.

But I am equally ruled out on the second account. I have not taken any special steps to become an expert patient; nor do I have any particular credentials to claim a quasi-professional status in this regard. For me to act as if I had would be to cheat.

In short, I feel either disqualified or under qualified. But the issue of my patient identity will not go away completely. It seems unavoidable because even not mentioning it feels like a significant choice. In some contexts there are temptations to mention it – because for certain audiences it may add a sense of authenticity and credibility. In other contexts there are temptations not to mention it – because, for example, some clinicians or others may worry about what axe I have to grind and see it as a source of ‘bias’.

How far this issue is seen to be of importance, and in what respects, is arguably a function of the kind of research we are talking about and also of disciplinary assumptions and conventions. But for anyone who thinks ‘reflexivity’ matters it does seem to be a question worth asking.

If I am being reflexive as an academic then I can treat my identity as a source of problems or limitations that need to be acknowledged, or as a source of legitimacy or authority, or sometimes as a combination of both. This seems as relevant to patient identity as to other aspects of identity. On this account there seems to be something seriously lacking in my approach to date.

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The struggle for abortion rights is far from over

Judith orr

Judith Orr, author of the hard-hitting Abortion wars, shows how there is no room for complacency in the fight for a woman’s right to choose.

 

“The historic 1967 Abortion Act is 50 years old this month, yet this fundamental part of women’s health care continues to be a fiercely contested issue. There are still politicians who want to turn back the clock and win support for complete opposition to all abortions in any circumstances. Tory MP Jacob Rees Mogg declared this as his view only last month, although his position was swiftly undermined by revelations that he profits from shares in a pharmaceutical company that produces abortion pills.

Rees Mogg’s desire to deny women any rights to legal abortion is a minority one in Britain. Here a clear majority, 70 percent in the most recent British Attitudes Survey, support a woman’s right to choose. But there is no room for complacency when women in one part of the UK, Northern Ireland, have no right to abortion unless they travel to Britain. The 1967 Act was never extended to Northern Ireland and thousands of women needing an abortion have had to cross the Irish Sea to access a legal termination. As an added injustice, until recently they also had to pay for it. This was only overturned in June after the snap general election when the Tories courted the anti abortion Democratic Unionist Party for support to win the Queens Speech. The ensuing outcry forced Theresa May to ditch the requirement for women from Northern Ireland to pay for terminations.

“This law against abortion doesn’t stop abortions happening, it simply exports them.”

Today the increasing vocal pro-choice side is highlighting the plight of women living in countries where abortion is banned, including on both sides of the Irish border. In the Republic of Ireland more than 40,000 people poured through the streets of Dublin on Saturday for the sixth annual March for Choice to demand a repeal of the eighth amendment to Ireland’s constitution. This amendment deems the rights of an embryo equal to those of the woman carrying it, at any stage of the pregnancy. This law against abortion doesn’t stop abortions happening, it simply exports them. Thousands of women are forced to travel to England to enable them to take control their own fertility. Over 200,000 women have travelled to Britain from Ireland to have an abortion since the 8th amendment was enacted in 1983.

After last year’s March for Choice, the Irish government handed the issue to a Citizens’ Assembly to examine and debate. The Assembly came out with a clear call for a change in the law, showing just how much attitudes are changing in Ireland. Last week the government finally announced it would hold a referendum on the question in 2018. This provides opportunity to overturn more than a century of anti-abortion legislation in the country, which up to 2013 included the 1861 Offences Against the Person act. This archaic law is still in place in Britain and it makes having or carrying out an abortion a criminal act punishable by life imprisonment. The 1967 Abortion Act did not replace this act, instead it created exceptions to allow legal abortions when certain conditions are fulfilled.

Even 50 years ago these conditions were restrictive, now when the majority of abortions are carried out by taking pills they are an oppressive anachronism. The website Women on Web reported that they receive requests from women living in Britain for abortion pills because access to abortion services is limited by the requirements of the law. The reasons women gave for contacting the website included the distance from a clinic providing abortion care, long waiting times, childcare responsibilities and the difficulty of getting time off work. But any woman in Britain who uses pills bought online potentially risks a prison sentence because of the strict controls over how abortion services are provided.

“…any woman in Britain who uses pills bought online potentially risks a prison sentence because of the strict controls over how abortion services are provided.”

This is a situation that cannot hold. The Royal College of Obstetricians and Gynaecologists joined the British Medical Association and the Royal College of Midwives last week in calling for abortion in Britain to finally be removed from criminal law and be treated as simply a medical issue.

Repressive laws and attitudes to women’s rights to control their own bodies are being challenged across the globe. While online access to sites such as Women on Web saves lives, millions have no access even to this service. The World Health Organisation estimates that 25 million abortions globally are unsafe, that’s almost a half of all terminations.

In Britain the fight is on to defend the rights won by past generations but to also extend those rights to allow genuine reproductive choices. Whatever the utterances of anti abortion campaigners such as Rees Mogg, pro-choice activists are on the march and determined to win the long-running abortion wars.

 

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TripAdvisor helps us choose hotels and restaurants – so why not where we end our days?

Originally published by The Conversation on August 1st 2017. 

Tony Walter

My 91-year-old mother was deeply unhappy at the geriatric hospital in which she found herself after breaking her ankle.

But we knew little of the alternatives. Official inspection ratings offer impersonal information. So how were we, her children, supposed to gauge the quality of other establishments offering care?

Our saviour turned out to be Alison – my mother’s hairdresser. As a specialist in older, housebound clients, she had continued to do her customers’ hair as they moved to various hospitals or care homes.

Alison gave us the names of three places nearby that our mother might prefer, and we arranged her transfer within 36 hours. It was a move which transformed the quality of her last few months of life.

Unlike formal inspectors, Alison was an unthreatening, secret observer of each of the institutions she visited. She proved to be a knowledgeable and reliable guide. Without her, my mother’s life could have ended very differently.

The trouble is, not every family is lucky enough to know an Alison.

In the UK, people are expected to make their own choices about their own care in the final months and years of life. But how can people become well informed about different care providers, especially when a crisis forces decisions to be made at short notice? Alison revealed the importance of informal contacts and social networks in allowing individuals and families to make good choices.

How could her role be made available to all families seeking similar information? Care settings for those nearing the end of life are, in terms of inspection, a bit like restaurants. Technical medical and nursing procedures, like a restaurant’s kitchen, need inspecting by technical inspectors. But most of the care provided at the end of a person’s life is not of the technical kind. It involves hard to measure factors like respect, a sense of belonging, and relationships with staff. It is in many ways like assessing a restaurant’s ambience. In the hospitality trade, this is something best considered by mystery customers who collectively author good food guides, or by informal online ratings like on TripAdvisor.

Such assessments rightly abandon the myth of objectivity embedded in formal inspections. Potential consumers perusing TripAdvisor ratings understand them as subjective experiences to be taken on balance.

So collective, honestly subjective, online ratings should be available for families to make informed choices about different care settings. For well-being over the course of life, we need to be able to read about customer experiences of health and care agencies just as much as we need to read about experiences of restaurants, hotels and holidays.

A great example of what is needed is carehome.co.uk, which gathers and publishes reviews of care homes, along with other information provided by the home. Many of the care homes listed, however, have no reviews. Care at home is reviewed by the online database homecare.co.uk, although the vast majority of organisations that look after people in their own homes have no reviews.

Those two websites are funded by industry subscriptions. Proposed reviews are authenticated and vetted before publication, and reviewers are advised not to publish complaints but send them direct to the agency. These safeguards should eradicate vexatious reviews, although they may also present an unrealistically positive overall view of user experience. The sites are, however, a step in the right direction.

Of course, TripAdvisor-style ratings for the “last journey” tend to come not from the actual service-user or patient. Most reviews are from family and friends, which could be an issue. Complex family dynamics – such as guilt at putting parents into care, or anxiety that care costs are eating up the inheritance – can mean families are rarely the baggage-free observers that Alison was.

Reviewing the situation

Of more concern is that even the most loving, attentive and observant family member may know little about the person’s experiences at the hands of their paid carers. This might only be achieved by CCTV cameras, but do we really want care homes, hospital wards and (in the case of home care) even the person’s own home to become zones of electronic surveillance?

No way of monitoring or collecting information will be perfect. And we should acknowledge that the trajectory of frail elderly dying is always uncertain. No one can predict how they will feel as bodies and minds fail, so all choices will entail a degree of guesswork.

Rigorous formal inspection – and public enquiries when things go dramatically wrong – are of course essential. But if people nearing the end of life (or their families) are to adopt the prescribed role of informed consumer, comprehensive collations of user experiences are vital.

End of life care is more important than booking a restaurant or the next holiday – so information needs to be just as good, or better.

What death means now by Tony Walter is available with 20% discount on the Policy Press website.  Order here for just £7.99.

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