A Women's Health Leader On Why We Need To Talk About Sex

Photographed by David Brandon Geeting.
When women — including young and unmarried women — choose the number, timing, and spacing of their children, everyone wins.

That's the message from Ellen Starbird, director of the Office of Population and Reproductive Health of the U.S. Agency for International Development (USAID). Today, 222 million women in developing countries want to avoid pregnancy but aren't using a modern contraceptive method such as condoms, the pill, or the IUD. While the U.S. spends less than 1% of our $4 trillion federal budget on foreign aid — among the lowest percentages of any country — we're still the largest global donor by volume, giving $32.7 billion in 2014, and how we choose to spend that money impacts the health of countless people and communities.

USAID is at the core of that decision-making process, working in more than 100 countries and administering some $22.7 billion of aid. We spoke with Starbird, the woman who guides the agency's efforts to advance family planning, at the 2016 International Conference on Family Planning to get her take on the critical importance of women's reproductive health over the next 15 years and beyond.
Why did you decide to dedicate your career to women and girls?
"I feel like it was luck of the draw that I was born into a middle-class American family where I had opportunity and my parents believed that I deserved an education, where I could be who I wanted to be and make my own decisions. I think everybody deserves that. And I feel like having had that my whole life, my way of giving back is to do this work. It's what takes me to work every day and what makes the crazy bureaucracy worth struggling through."

You’ve been with USAID for 26 years now. What has changed in that time?
"[On the donor side,] there are a lot more players in the field than there used to be and I think that’s great. What’s also shifted is where countries are and where they see themselves. When I started there were still a lot of countries who, if you asked them whether their population growth rate was appropriate, too high, or too low, you'd get a lot of 'appropriate' or 'too low' and not so much 'too high.' I think most countries these days, if you ask them, those that still have high fertility would tell you that they think that their population growth is too high — so there's a really big shift in the policy environment for family planning in the developing world. Nobody was talking about youth, nobody was talking about unmarried women, nobody was talking about boys 26 years ago. Now, family planning is seen not just as part of women’s right to choose the number, timing, and spacing of their children, but a really important health intervention."

What is the role of young people in the family planning conversation?
"I think that it's funny in the family planning field we tend not to talk about sex, about why people engage in sex or don’t, what they find pleasurable, et cetera. If you're going to engage youth, you have to be able to be more open and find that comfort level to talk with them where they are and what they want to talk about... In the ’90s, talking about adolescents and sex [was subversive]. I think we're moving in a good direction. Now, continued population growth has been part of the recognition that the youth are the ones who are going to make decisions that will affect not only their lives, but what happens with their communities and our planet.

"And youth have been saying this to us for a while, that we have to figure out how we involve them from the beginning in the design of our programs and understand how they want to talk about issues. If we don’t pay attention to youth — and not just their reproductive health needs but their place in the world, the education they get, their ability to get jobs, et cetera — we are creating conditions that don’t lend themselves to the establishment of stable democracies, that lend themselves to alienation."

USAID is chasing an ambitious benchmark right now: that 75% of worldwide demand for family planning is met with modern contraceptive methods by 2030 — meaning that 334 million women need to be using a modern contraceptive method by 2030, as compared with the 226 million who were in 2014. How did you settle on this goal?
"We chose that 75% benchmark because it’s the average proportion of demand satisfied with modern contraception in developed countries. The idea that we could see a world in our lifetime where there is a convergence between the developed and the developing world in terms of access to health is really exciting. What I think is motivating about the indicator is that it is designed not to tell countries, 'You have to get to a particular contraceptive prevalence rate,' but to say, 'Look, you have this demand, think about how you want to meet it.'"
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You should have ambitious goals... Whether they are achievable is going to depend on how seriously people decide to take them.

What is the importance of expanding the menu of contraceptive methods available to women?
"It’s huge. Expanding method choices is a real priority for our office. We know that each option that’s newly available brings in new users. Nothing we've got is perfect, and nothing that anybody uses is likely to be the best method for them for their entire life. For example, it's one thing if you want to space your births to be taking a pill every day for a couple of years; it’s completely a different idea to have gotten to where you want with your family size and to be thinking about having pills as your only option for the next 20 years of your life [until menopause]."

Of course, we can’t forget the men and boys — how do they factor into this equation?
"Their reproductive health needs are generally neglected. We still mostly think about contraceptive use and family planning as something that girls and women need to be worried about, but boys need to understand their bodies as well. They need to know what they're getting into. STIs affect them. They want to be good partners. We do some work around male gender norms and encouraging boys to think about what it means to become a man, what kind of behaviors are expected of you, the way you want to be behaving towards your peers."

How will the 17 Sustainable Development Goals support women’s health?
"We've moved from a set of Millennium Development goals that were very focused on health to a broader set of goals that really are comprehensive around people, planet, peace, and prosperity... You should have ambitious goals... Whether they are achievable is going to depend on how seriously people decide to take them. Obviously 17 is a lot for any country, any community, to think about, and countries are going have to make decisions about the ones that they pursue and which ones are most important to them. Each SDG’s direct connection to family planning may not be obvious to everyone, but the connections to population are obvious — so how can we help people be more demographically literate, in a way? If you have a goal of reducing air pollution somehow, the fewer people there are driving cars, the better off you're going to be. And how does that fewer people doing something happen? Well, over time it happens by helping people have the kids they want when they want to have them. All the connections are there. We just have to build on them."
This reporting was made possible by a press fellowship to the 2016 International Conference on Family Planning granted to the author by the U.N. Foundation.
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