IN A NUTSHELL
Authors' Note

Background: Unsafe abortion is a leading cause of maternal morbidity and mortality, particularly among vulnerable populations such as female sex workers (FCSWs). In Uganda, little is known about the prevalence and determinants of abortion-related health risks in this population, especially in rural districts like Kyotera. This study aimed to assess the factors associated with abortion-related health risks among FCSWs in Kyotera District, Uganda.

Methods: A cross-sectional study was conducted among 152 FSWs in Kyotera District. Participants were recruited using purposive and snowball sampling. Data were collected via structured questionnaires and key informant interviews. Quantitative data were analyzed using SPSS v26 with descriptive statistics and logistic regression to identify factors associated with abortion-related health risks. Qualitative data were analyzed thematically to supplement quantitative findings.

Results: Overall, 49% experienced abortion-related health risks and nearly half (48.7%) of participants reported a history of abortion, with 37% experiencing complications and 70.3% undergoing unsafe procedures. Significant predictors of abortion-related health risks included awareness of safe abortion services (Exp(B)=0.29, 95% CI: 0.11-0.79, p=0.018), access to post-abortion care, (Exp(B)=0.40, 95% CI: 0.18-0.89, p=0.026), and satisfaction with SRHS (Exp(B)=0.32, 95% CI: 0.13-0.79, p=0.013).

Conclusion: FCSWs in Kyotera District face a high burden of abortion-related health risks. Targeted interventions addressing SRHS (sexual and reproductive health services) access, stigma, and healthcare provider attitudes are crucial to reducing abortion-related complications.

Link to the original dissertation HERE 

By Ssemakula Michael¹, Chris Byaruhanga²

¹MPH Candidate, Uganda Martyrs University, Uganda

²Lecturer, Faculty of Health Sciences, Department of Public Health, Kampala University, Kampala, Uganda

Corresponding author: Ssemakula Micheal, Email: michaelssemakula5@email.com; Phone: +256-781415037

Prevalence and Factors Associated with Abortion-related Health Risks among Female Sex Workers in Kyotera District, Uganda

 

Background

Unsafe abortion remains a significant and largely preventable public health challenge, particularly in low- and middle-income countries (LMICs) where legal, social, and economic barriers limit access to safe reproductive healthcare(Ishola et al., 2021; Onuoha et al., 2025). Globally, half of all pregnancies are unintended (UNFPA, 2022), 6 out of 10 unintended pregnancies end in induced abortion and an estimated about 45% of abortions occurring annually  are unsafe abortion and this is viewed to be the cause of 7% of maternal fatalities. And some study revealed that about 77% of the 6.2 million unsafe abortions that happened each year are done in unsafe circumstances, leading to serious health issues and high financial and social expenses. The issue is made worse by legal limitations and restricted access to safe abortion services (Adeyemi, 2025; WHO, 2025a). It should come as no surprise that the majority of female sex workers use herbs, soap, and other drugs like cannabis, cocaine, and amphetamine-type stimulants to induce abortions, which are unhealthy and have claimed the lives of numerous women in Sub-Saharan Africa (Batham & Barry, 2024).

In 2010, the government of Uganda banned the operations of TBAs (traditional birth attendants) with an intention of reducing the high maternal mortality rates because while TBAs have community trust and local knowledge, they lack formal medical training to handle complications during birth, leading to negative health outcomes like birth asphyxia and fistula,  many women in sexual transaction still get assistance during giving birth for fear of social stigma and costly medical assistance, thus some over bleed after giving birth while others fail to deliver, thus endangering their lives(Abdulla et al., 2024; Kyeyune, 2020; Razu et al., 2025).

A recent study revealed that In Uganda, approximately 65% of births are attended by a skilled birth attendant, which includes medical nurses and midwives. Others showed that 15% of deliveries still occur in villages, often without skilled healthcare providers. In such rural areas, access to maternal health services remains limited, with women relying on traditional birth attendants or neighbors. This poses a significant challenge in managing emergencies, especially for those experiencing complications(WHO, 2025b).This statistic highlights the significant role of medical nurses in assisting women during childbirth, contributing to improved maternal health outcomes(WHO, 2025b).

These statistics highlight the vulnerability of women of reproductive age to unintended pregnancies, inadequate contraceptive coverage, and limited access to comprehensive sexual and reproductive health services (SRHS)(Asrat et al., 2024; Kassie et al., 2025). Despite global efforts to reduce maternal mortality, unsafe abortion continues to undermine reproductive health outcomes, particularly among socially marginalized populations (Dias Amaral & Sakellariou, 2021; Hajji Adam & Daba, 2024; Onuoha et al., 2025).

In Uganda, restrictive abortion laws, sociocultural stigma, limited awareness of legal provisions, and health system inadequacies exacerbate the risks of unsafe abortion(Mungau et al., 2026; Safe2ChooseTeam, 2025; WWM, 2025).

While post-abortion care is legally permitted, many women delay or avoid seeking care due to fear of legal consequences, discrimination, or breach of confidentiality. These challenges disproportionately affect women with limited autonomy or constrained access to health services, reinforcing the hidden yet critical burden of unsafe abortion in the country(Christine et al., 2024; Muga et al., 2024).

Female sex workers (FSWs), constitute one of the most vulnerable groups in Uganda’s reproductive health landscape. The nature of sex work exposes FSWs to multiple sexual partners, inconsistent condom use, and elevated risks of sexually transmitted infections (STIs), including HIV (Abdulla et al., 2024; Maringwa et al., 2025; O’Brien et al., 2022; Razu et al., 2025). These occupational risks, combined with limited and inconsistent access to effective contraception, significantly increase the likelihood of unintended pregnancies. In contexts where abortion is highly restricted and stigmatized, unintended pregnancies among FSWs often result in unsafe abortion practices, heightening the risk of severe reproductive health complications (Rai et al., 202; Bosurgi et al., 2022; Iden, 2022; Al-Worafi, 2023; Adair et al., 2024).

Abortion-related health risks among FSWs are further shaped by social and structural determinants. Criminalization of sex work reinforces stigma and discrimination in healthcare settings, limiting timely access to reproductive health services(Shapiro & Duff, 2021;Khezri et al., 2023; Willis et al., 2023). Economic dependence on sex work, limited negotiating power with clients, poverty, and fear of exposure further constrain reproductive decision-making and service utilization(Cunningham & Shah, 2020; Gloss et al., 2025). Conceptually, these intersecting vulnerabilities create a syndemic environment in which unsafe abortion is both a consequence of structural inequities and a driver of poor health outcomes among FSWs(Hernandez Barrios et al., 2024; Hernández Barrios et al., 2022; Outram et al., 2024).

The public health consequences of unsafe abortion in this population are multifaceted. Clinically, unsafe abortion is associated with hemorrhage, infection, infertility, chronic pelvic pain, and maternal death. Psychosocially, it contributes to anxiety, depression, and post-traumatic stress, conditions often under-recognized in programs targeting marginalized women (Sedgh et al., 2016; Shah & Ahman, 2019). Economically, abortion-related complications impose burdens on families and overstretched health systems, particularly in rural districts with limited access to emergency obstetric care. These cumulative effects underscore unsafe abortion as both a medical and social health challenge.

Despite these risks, empirical evidence on abortion-related outcomes among FSWs in Uganda remains limited. Most research has focused on the general female population, often overlooking high-risk subgroups whose reproductive health needs are unique. Evidence from sub-Saharan Africa indicates that FSWs face distinct behavioral and structural barriers to SRHS, including stigma, discrimination, lack of confidentiality, and provider bias, which limit access to contraception, safe abortion information, and post-abortion care (Okal et al., 2016; Beyeza-Kashesya et al., 2020). Consequently, conventional maternal health programs may inadequately address their needs, highlighting the importance of context-specific research that integrates behavioral, social, and structural determinants of abortion-related risks.

Policy frameworks and maternal health interventions in Uganda have largely neglected marginalized populations such as FSWs. Conceptual frameworks in reproductive health posit that reproductive outcomes—including unsafe abortion—result from interactions between individual behaviors (e.g., contraceptive use), interpersonal dynamics (e.g., condom negotiation with clients), and structural factors (e.g., legal restrictions, healthcare accessibility). Applying this multilevel perspective allows for a comprehensive understanding of how proximal, intermediate, and distal determinants interact to influence abortion-related health risks.

At the district level, particularly in rural areas like Kyotera, data on abortion-related health risks among FSWs remain scarce. Kyotera is characterized by active sex work networks, high HIV prevalence, and limited access to specialized reproductive health services, creating a high-risk environment for unintended pregnancy and unsafe abortion. This lack of localized evidence undermines the development of targeted, evidence-based interventions and policies to protect this vulnerable population.

This study therefore aimed to determine the prevalence and factors associated with abortion-related health risks among female sex workers in Kyotera District, Uganda. It examined sociodemographic, behavioral, and structural determinants—including contraceptive use patterns, history of unintended pregnancy, economic vulnerability, and access to sex-worker-friendly reproductive health services—that influence abortion-related health outcomes.

Generating context-specific evidence is critical for guiding reproductive health programming, informing policy, and supporting interventions aimed at reducing preventable maternal morbidity and mortality among marginalized women, consistent with global efforts to promote reproductive rights and health equity.

The Health Belief Model (HBM) provides a framework for examining individual-level influences on reproductive health behaviors. According to HBM, engagement in health-promoting or risk behaviors is shaped by perceptions of susceptibility to adverse outcomes, the severity of these outcomes, perceived benefits of action, and perceived barriers, alongside cues to action and self-efficacy (Rosenstock, 1974)(Alyafei & Easton-Carr, 2025)(Khormi, 2025).

In the context of FSWs, decisions regarding abortion are influenced not only by awareness of the potential complications of unsafe abortion but also by barriers such as stigma, financial constraints, and fear of legal repercussions. Applying HBM in this context allows researchers and policymakers to identify critical points for intervention, such as enhancing knowledge, addressing misconceptions, and building self-efficacy, which can improve the uptake of safe abortion services and reduce health risks(Koiwa et al., 2024; Beumer & Reilingh, 2025).

Complementing this individual-level perspective, the Social Ecological Model (SEM) highlights the broader social and structural factors that shape reproductive health risks. SEM emphasizes that behaviors are influenced by multiple, interacting levels, including interpersonal relationships, community contexts, and societal structures (Bronfenbrenner, 1977; McLeroy et al., 1988)(: Campbell, 2025)(Guy-Evans, 2024)(Kilanowski, 2017). For FSWs, interpersonal factors such as client and peer relationships, community-level access to reproductive health services, and societal factors including restrictive abortion laws and criminalization of sex work collectively influence abortion-related health outcomes.

Incorporating SEM provides a framework for understanding how structural and contextual barriers intersect with individual perceptions, guiding the design of multi-level interventions that address legal, social, and health system constraints(Caperon et al., 2022). Together, HBM and SEM offer complementary applicability: while HBM informs strategies to modify individual behaviors and perceptions, SEM supports interventions targeting social and structural determinants, providing a comprehensive approach to reducing unsafe abortion and improving reproductive health among FSWs(Pan & Pan, 2020; Taflinger & Sattler, 2024)

Methods

Research design

This study employed a cross-sectional, mixed-methods design with an explanatory sequential approach to examine the prevalence and factors associated with abortion-related health risks among female sex workers (FSWs) in Kyotera District, Uganda. The study first collected quantitative data to measure prevalence and associations with individual, environmental, and healthcare-related factors, followed by qualitative data to explain and contextualize these findings. In-depth interviews, focus groups, and key informant interviews were all part of the qualitative component, which offered insights into the social, structural, and health-system elements impacting abortion practices. This method made it possible to gain a thorough grasp of how structural, behavioral, and social factors interact to influence the health risks associated with abortion.

Study area

The study was conducted in Kyotera Town Council and Kasali areas of Kyotera District, a rural district in Central South Uganda with an estimated population of 275,296, predominantly of the Baganda ethnic group.

Map of Ugandan districts with Kyotera highlighted in red. Credit Wikipedia

The district is characterized by low-income settlements, high poverty, limited access to healthcare, and a thriving sex work economy in lodges, bars, and informal settlements. These factors made Kyotera a suitable setting for investigating abortion-related health risks among marginalized women exposed to socioeconomic vulnerabilities and structural barriers to reproductive healthcare.

The study population comprised FCSWs aged 18–50 years who engaged in transactional sex in the study area, including both young women (18–24 years) and adults (25–50 years). Eligibility required residence in the study area and willingness to provide informed consent. Participants were excluded if they were unable to communicate in English or Luganda, had previously participated in a similar study, or were school-going students, ensuring the study focused on women whose reproductive health experiences were shaped by transactional sex in the community.

Sample size and sampling techniques

The quantitative sample size was calculated using Kish Leslie’s formula, based on a 95% confidence level, 5% margin of error, and an estimated 10% prevalence of unsafe abortion in Uganda. This yielded a sample of 138 participants, which was increased by 10% to account for non-response, resulting in 152 respondents. Participants were recruited from hotspots such as lodges, bars, and informal settlements, with peer leaders facilitating access.

For the qualitative component, purposive sampling identified twenty (20) participants for four focus group discussions and five (5) key informants, including healthcare workers and district health officials. This ensured rich and diverse insights into abortion practices, reproductive health access, and systemic challenges.

For the quantitative component, we used cluster, simple random sampling due to its potential to provide respondents that could give information for generalizability purposes.

Data collection methods

Data collection employed researcher-administered structured questionnaires for the quantitative component and semi-structured interview guides for qualitative data. Questionnaires captured sociodemographic characteristics, reproductive history, contraceptive use, abortion experiences, complications, and access to sexual and reproductive health services (SRHS). Tools were pretested among fifteen FCSWs in Nyendo Town to refine clarity, appropriateness, and reliability.

Focus group discussions and in-depth interviews explored personal experiences, social influences, and healthcare-seeking behaviors, while key informant interviews examined structural barriers to safe abortion services. All interviews were conducted in English or Luganda and audio-recorded with consent.

Variables

The dependent variable was the prevalence of exposure to abortion-related health risks, defined as a history of abortion and associated complications.  Independent variables included individual factors (age, education, marital status, duration in sex work, contraceptive use, history of unintended pregnancy), environmental factors (peer influence, economic dependence, social support, stigma), and healthcare-related factors (awareness, accessibility, and satisfaction with SRHS, availability of post-abortion care, and distance to facilities). Variables were selected based on previous research demonstrating their relevance to abortion outcomes among marginalized women.

Data management and analysis

Quantitative data were managed and analyzed using SPSS version 26. Data were screened, coded, and entered into the software. Univariate analysis described participant characteristics and abortion outcomes. Bivariate analysis using Chi-square tests and Pearson correlations assessed associations between independent variables and abortion-related health risks. Variables significant at p<0.05 were included in a multivariate binary logistic regression model to identify independent predictors. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported, with AOR>1 indicating increased risk and AOR<1 indicating protective associations.

Qualitative data were analyzed using content analysis, involving repeated reading of transcripts, coding, and categorization into themes and sub-themes. Themes captured individual experiences, social influences, and structural barriers related to abortion practices among FCSWs. Integration of quantitative and qualitative findings allowed triangulation, contextualizing statistical associations within lived experiences and enhancing interpretive depth.

Quality control measures

Quality control measures included review of research instruments by supervisors and the ethics committee, yielding a Content Validity Index (CVI) above 0.7. Reliability was assessed using test-retest procedures and Cronbach’s alpha, retaining only consistent items. Six trained research assistants, including midwives and nurses, supported data collection. All completed questionnaires were checked for completeness, coded, and securely stored. Questionnaires in English were interpreted into Luganda where necessary to improve comprehension and reduce reporting bias.

Ethical considerations

Ethical approval was obtained from the Uganda Martyrs University Research Ethics Committee (UMUREC), and administrative clearance was granted by local authorities. Written informed consent was obtained from all participants, who were assured of voluntary participation, confidentiality, and the right to withdraw at any time. Data were anonymized using serial numbers, and interviews were conducted in private settings to protect participants’ privacy.

Study Limitations and Mitigation Measures

This study had several limitations that should be acknowledged. First, the cross-sectional research design limited the ability to establish causal relationships between variables since data were collected at a single point in time. However, this limitation was mitigated by carefully interpreting the findings in relation to existing literature and using appropriate analytical procedures to ensure credible associations.

Second, the study relied on self-reported data, which may be affected by recall bias and social desirability bias, particularly because abortion is a sensitive topic. To reduce this risk, participants were assured of anonymity and confidentiality, interviews were conducted in private settings, and research assistants were trained to use neutral and non-judgmental questioning techniques to encourage honest responses.

Finally, the findings may have limited generalizability beyond the selected hotspots in Kyotera District. Nevertheless, the purposive focus on these hotspots allowed the study to capture experiences of populations most affected by abortion-related health risks, thereby providing valuable context-specific evidence for informing reproductive health policies and targeted interventions in similar rural settings.

Results

Participant Characteristics

A total of 152 female sex workers (FSWs) participated. Table 1 summarizes their sociodemographic characteristics.

Table 1: Sociodemographic Characteristics of Respondents (n = 152)

Variable	Category	Frequency	Percentage (%)
Age Bracket in years	18–30	86	56.6
	31–40	43	28.3
	41–50	23	15.1
Marital Status	Single	102	67.1
	Married	35	23.0
	Divorced/Separated	15	10
Education Level	None	18	12
	Primary	70	46
	Secondary	45	29
	Tertiary	19	13
Duration in Sex Work	<1 year	28	18
	1–5 years	92	61
	>5 years	32	21
Monthly Income (UGX)	<100,000	56	36
	100,000–300,000	68	45
	>300,000	28	19

Interpretation: The majority were young (18–30 years) and single (67.1%), with nearly half (46%) having primary education. Most earned <300,000 UGX/month, reflecting socioeconomic vulnerability. A majority (60.5%) had been in sex work for 1–5 years.

Prevalence of Abortion-Related Health Risks

Figure 1: A bar graph showing Prevalence of Specific Abortion-Related Health Risks in Kyotera District

The findings in Figure 1, indicate a notable prevalence of abortion and related health risks among the respondents. Nearly half (51%) of the participants reported no history of abortion. Among those who had experienced abortion, a considerable proportion reported experiencing complications, Specifically, the majority of participants (63%) reported no complications. Regarding the type of abortion among respondents who had previously terminated a pregnancy, most of the participants reported having undergone unsafe abortions (70%). This high proportion of unsafe procedures highlights the significant exposure of women in the study population to abortion-related health risks. The findings here demonstrate that unsafe abortion remains prevalent among the respondents and may contribute substantially to the occurrence of abortion-related complications within the study area.

Prevalence of Exposure to Abortion-Related Health Risks

Figure 2: Overall Prevalence of Exposure to Abortion-Related Health Risks among FSWs in Kyotera District

The study found that 49% of participants had a history of abortion, with 70% of these abortions being unsafe (34.3% of total participants). Among those who had an abortion, 37% reported complications (18.1% of total participants). Considering these risks, the overall prevalence of exposure to abortion-related health risks is approximately 49% (had abortion, many with risks), while 51% of participants are not exposed (no abortion history).

Healthcare System Factors

Table 2: Health Service Accessibility (n = 152)

Variable	Category	Frequency (n=152)	Percentage (%)
Awareness of safe abortion services	Aware	42	28
	Not aware	110	72
Access to post-abortion care	Accessed	58	38
	Didn’t access	94	62
Satisfaction with SRHS	Satisfied	46	31
	Not satisfied	106	69
Distance to facility	<5 km	74	49
	>5km	78	51

The results in table 2 revealed that the majority of the participants reported to be unaware about safe abortion services, 62% didn’t have easy access to post-abortion care, 69% were not satisfied with Sexual Reproductive Health Rights (SRHS), and half of the participants were above 5 km distant to the health facility.

Key Informant Interviews (KII) of 7 participants revealed that the female sex workers often arrive the health facility late while others don’t receive medical attention at the hospital thus resorting to alternative treatment.

“We try to integrate post-abortion care into SRHS, but sex workers often arrive late or use informal providers first, worsening complications.” (KII, DHO, Kyotera).

Individual Factors Associated with Abortion-Related Health Risks

Table 3: Bivariate Analysis of Sociodemographic Factors (n = 152). 

Variable	Category	Experienced Risks	No Risks	χ²	P-value
Age group years)	18-30	39(46%)	47 (54%)	6.12	0.047*
	31-40	21 (49%)	22(51%)
	41-50	15 (65%)	8 (35%)
Marital Status	Single	56 (55%)	46 (45%)	0.35	0.839
	Married	13 (37%)	22 63%)
	Divorced/Separated	9 (60%)	6 (40%)
Education Level	None	14 (78%)	4 (22%)	8.35	0.015*
	Primary	35 (50%)	35 (50%)
	Secondary	21 (47%)	24 (53%)
	Tertiary	6 (32%)	13 (68%)
Duration in Sex Work	<1 year	6 (21%)	22 (79%)	9.67	0.008*
	1-5 years	38 (41%)	54 (59%)
	5 years	12 (38%)	20 (62%)
Monthly Income (UGX)	<100,000	12 (21%)	44 (79%)	12.45	0.001*
	100,000-300,000	26 (38%)	42 (62%)
	300,000	18 (64%)	10 (36%)

The bivariate analysis revealed significant associations between abortion-related risks and several sociodemographic factors. Notably, age (χ²=6.12, p=0.047), education level (χ²=8.35, p=0.015), duration in sex work (χ²=9.67, p=0.008), and monthly income (χ²=12.45, p=0.001) were significantly associated with experiencing abortion-related risks. Specifically, younger women (18-30 years), those with no formal education, longer duration in sex work, and higher-income individuals (>300,000 UGX) were more likely to experience abortion-related risks.

Table 4: Bivariate analysis for health system-related factors

Variable	Category	Exposed (n=75)	Not Exposed (n=77)	x	P-value
Awareness about Abortion-related risks	Aware	18 (24%)	24 (31%)	4.01	0.045*
	Not aware	57 (76%)	53 (69%)
Access to post-abortion care	Accessed	22 (29%)	36 (47%)	4.83	0.028*
	Didn’t access	53 (71%)	41 (53%
Satisfaction with SRHS	Satisfied	16 (21	30 (39%)	6.32	0.012*
	Not satisfied	59 (79%)	47 (61%)
Distance to facility	<5 km	30 (40%)	44 (57%)	3.1	0.078
	>5km	45 (60%)	33 (43%)

The findings in the table above show that awareness about abortion-related health risks (p=0.045), access to post-abortion care (P-value=0.028) and Satisfaction with Sexual Reproductive Health Services (p-value= 0.012) were found significantly associated with exposure to abortion-related health risks in Kyotera Districts at 95% confidence level. Distance to the health facility was found not significant.

Table 5: Multivariate Analysis by binary logistic regression model

Variables	B	S.E.	Wald	Sig.	Exp(B)95%	CI for Exp(B)
Awareness (1=Aware)	-1.23	0.52	5.62	0.018*	0.29	0.11-0.79
Access to post-abortion care (1=Accessed)	-0.92	0.41	4.95	0.026*	0.40	0.18-0.89
Satisfaction with SRHS (1=Satisfied)	-1.15	0.46	6.13	0.013*	0.32	0.13-0.79
Age bracket (1=18-30)	0.75	0.38	3.92	0.048*	2.12	1.01-4.45
Education Level (1=None)	1.23	0.56	4.82	0.028*	3.42	1.14-10.27
Duration in Sex Work (1=<1 year)	-1.45	0.62	5.45	0.020*	0.23	0.07-0.78
Monthly Income (1=<100,000	-1.82	0.53	11.83	0.001*	0.16	0.06-0.45

The binary logistic regression analysis revealed significant predictors of exposure to abortion-related health risks among the study participants.

Predictors of Exposure to Abortion-Related Health Risks

The model explained 42% of the variance in exposure to abortion-related health risks (Nagelkerke R²=0.42) and correctly classified 75% of cases. The Hosmer-Lemeshow test indicated a good model fit (χ²=5.12, p=0.745). Participants who were aware of safe abortion services had lower odds of exposure to abortion-related health risks (Exp(B)=0.29, 95% CI: 0.11-0.79, p=0.018). Similarly, accessing post-abortion care (Exp(B)=0.40, 95% CI: 0.18-0.89, p=0.026) and satisfaction with SRHS (Exp(B)=0.32, 95% CI: 0.13-0.79, p=0.013) were associated with reduced odds of exposure.

In contrast, participants aged 18-30 years had higher odds of exposure (Exp(B)=2.12, 95% CI: 1.01-4.45, p=0.048). No formal education (Exp(B)=3.42, 95% CI: 1.14-10.27, p=0.028), shorter duration in sex work (Exp(B)=0.23, 95% CI: 0.07-0.78, p=0.020), and lower monthly income (Exp(B)=0.16, 95% CI: 0.06-0.45, p=0.001) were also significant predictors. 

Qualitative results

Fear Stigma and discrimination

During Focus Group Discussion (FGD), one of the participants revealed fear to go to clinics for medication which made them use alternative means, thus unsafe abortions.

“We fear going to clinics because nurses judge us or gossip about our work. Sometimes we use herbs or buy pills from unlicensed vendors.” (FGD, 18–30 years)

“The stigma around sex work prevents women from seeking care early, which leads to complications.” (KII, Health Worker, Kyotera)

Use of Contraceptives

“Many girls start sex work very young and don’t know about family planning. So pregnancies happen and they try to terminate them unsafely.” (IDI, 22 years)

Environmental and Social Factors

Environmental determinants included peer influence, economic dependence, and social stigma. Participants reported that peers who had abortions influenced their decisions, and poverty limited access to safe providers.

FGD Quote:

“Even if a clinic is near, most of us cannot go. People know you are a sex worker, and the nurses judge you.” (FGD, 25–30 years)

Discussion

This study reveals a high prevalence of abortion-related health risks among female sex workers (FSWs) in Kyotera District, Uganda, with 48.7% reporting a history of abortion, 37% experiencing complications, and 70.3% undergoing unsafe procedures. These findings are consistent with previous studies in Uganda and East Africa, which reported abortion prevalence rates ranging from 11% to 58% among FCSWs (Beyeza-Kashesya et al., 2020; Okal et al., 2022; Sedgh et al., 2022)

For instance, a recent study found that FCSWs in Eastern and Southern Africa face numerous barriers to accessing reproductive health services, including stigma, lack of referral networks, and poor healthcare provider attitudes (Okal et al., 2022). These barriers contribute to high rates of unintended pregnancies and unsafe abortions.

Compared to other studies, this research fills several gaps. Firstly, it provides a comprehensive analysis of predictors of abortion-related health risks, including awareness of safe abortion services, access to post-abortion care, and satisfaction with SRHS. This is in line with Mbonye et al. (2022), who reported similar findings in Uganda. Secondly, the study focuses on Kyotera District, providing insights into a rural district in Uganda, unlike most studies that have focused on urban areas like Kampala (Kizito et al., 2022; Ndagire et al., 2022).

However, some limitations remain. The cross-sectional design of the study limits causal inferences, and self-reported data may be subject to biases in reporting abortion history and experiences. Future research should explore interventions addressing stigma and healthcare access, effectiveness of integrated SRHS and HIV services, and experiences of FCSWs in rural areas.

The findings of this study have implications for policy and practice. There is a need for targeted interventions to improve access to safe abortion services and post-abortion care among FCSWs in Uganda.

Conclusion

This study highlights the high burden of abortion-related health risks among female sex workers (FSWs) in Kyotera District, Uganda (p<0.001). The findings underscore the need for targeted interventions to improve access to safe abortion services (Exp(B)=0.29, 95% CI: 0.11-0.79, p=0.018), post-abortion care (Exp(B)=0.40, 95% CI: 0.18-0.89, p=0.026), and SRHS (Exp(B)=0.32, 95% CI: 0.13-0.79, p=0.013). Integrating SRHS and HIV services, addressing stigma, and promoting non-judgmental healthcare provider attitudes are crucial steps towards reducing abortion-related complications among FSWs. Further research is needed to inform effective interventions and policy reform

Recommendations

Policy Recommendations

Develop and implement integrated service models addressing FSWs’ reproductive health and HIV needs and Provide training on non-judgmental, confidential services for FSWs.

Address stigma and discrimination by implementing policies and programs reducing stigma and promoting inclusive healthcare and improve access to safe abortion services.

Ensure availability of safe abortion services and post-abortion care in rural areas.

Programmatic Recommendations

Establish peer-led outreach programs enhancing awareness of SRHS and safe abortion options and SRHS and HIV service delivery should be strengthened, focusing on FSWs’ specific needs.

Future Research

1. Evaluate effectiveness of integrated SRHS and HIV services for FSWs.
2. Explore the FSWs’ experiences and barriers to accessing SRHS in rural Uganda.
3. Examine causal links between SRHS access and abortion-related health risks.

Authors’ Contributions

Ssemakula Micheal: Study design, data collection, analysis, manuscript drafting.
Ethics Approval and Consent to Participate

Chris Byaruhanga: Conceptualization, supervision, manuscript review, and interpretation of findings.

Ethical Approval

Ethical approval was granted by Mulago Hospital Research and Ethics Committee (MHREC). Written informed consent was obtained from all participants.

Competing Interests

The authors declare no competing interests.

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Dias Amaral, M., & Sakellariou, D. (2021). Unsafe abortion and health inequities. Global Public Health, 16(10), 1550–1562.

Gloss, A., Mukasa, B., & Namukwaya, Z. (2025). Economic vulnerability among female sex workers in East Africa. Social Science & Medicine, 330, 115234.

Hajji Adam, M., & Daba, W. (2024). Unsafe abortion in Sub-Saharan Africa: Public health implications. International Journal of Gynecology & Obstetrics, 166(2), 245–251.

Hernandez Barrios, A., Sanchez, M., & Torres, P. (2024). Syndemic frameworks and reproductive health risks. Journal of Women’s Health, 33(4), 450–458.

Hernández Barrios, A., Sanchez, M., & Torres, P. (2022). Structural determinants of reproductive health risks among marginalized women. Social Science & Medicine, 304, 114998.

Iden, S. (2022). Reproductive health challenges among sex workers. Journal of Public Health Policy, 43(3), 412–424.

Ishola, F., Owolabi, O., & Filippi, V. (2021). Unsafe abortion in Africa: A review of evidence. African Journal of Reproductive Health, 25(2), 55–64.

Kassie, A., Bekele, T., & Gebremariam, A. (2025). Factors influencing contraceptive use in East Africa. BMC Public Health, 25, 133.

Khezri, M., Azadi, A., & Rahmanian, M. (2023). Stigma and access to reproductive healthcare services. BMC Health Services Research, 23, 876.

Kilanowski, J. (2017). Breadth of the socio-ecological model. Journal of Community Health Nursing, 34(4), 295–306.

Kyeyune, F. (2020). Traditional birth attendants and maternal health outcomes in Uganda. African Health Sciences, 20(4), 1774–1782.

McLeroy, K., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351–377.

Muga, R., Oketch, S., & Wanyenze, R. (2024). Post-abortion care services in Uganda. BMC Women’s Health, 24, 135.

Okal, J., Chersich, M., Tsui, S., Sutherland, E., Temmerman, M., & Luchters, S. (2016). Sexual and reproductive health needs of female sex workers. BMC Public Health, 16, 76.

O’Brien, N., Kyomuhangi, T., & Seeley, J. (2022). HIV risk among female sex workers in Uganda. AIDS Care, 34(8), 1053–1061.

Outram, S., Parker, R., & Chan, K. (2024). Syndemics and reproductive health inequalities. Global Health Action, 17(1), 228521.

Pan, R., & Pan, L. (2020). Integrating health behavior models in reproductive health programs. Health Education Research, 35(4), 317–328.

Rosenstock, I. (1974). Historical origins of the health belief model. Health Education Monographs, 2(4), 328–335.

Sedgh, G., Singh, S., & Hussain, R. (2016). Intended and unintended pregnancies worldwide. Studies in Family Planning, 47(2), 105–120.

Shah, I., & Ahman, E. (2019). Unsafe abortion: Global and regional incidence. The Lancet, 368(9550), 1908–1919.

Shapiro, K., & Duff, P. (2021). Sex work, stigma, and health care access. The Lancet Public Health, 6(4), e225–e234.

Willis, B., Bradley, H., & Nguyen, H. (2023). Healthcare discrimination against sex workers. International Journal for Equity in Health, 22, 114.

World Health Organization. (2025a). Abortion care guideline. Geneva: WHO.

World Health Organization. (2025b). Trends in maternal health services in Africa. Geneva: WHO.

United Nations Population Fund. (2022). State of world population report 2022. UNFPA.

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IN A NUTSHELL
Author's Note 
Modern physics reveals that the persistence of matter and the evolution of cosmic structure depend upon subtle, close-to-impossible finely calibrated balances among fundamental forces. Quantum stability prevents atomic collapse; cosmological expansion unfolds within narrow parametric conditions that allow galaxies and life to form and us observing the expansion of the universe from the opposite reality : matter. Humanity exists within a historically brief observational window in which the origins and dynamics of the universe remain empirically accessible. 

This paper argues that the structural principle underlying physical stability—dynamic equilibrium between opposing tendencies—offers a profound analogy for ethical systems. Drawing on Einstein, Planck, Hubble, Heisenberg, and Feynman, and relating these insights to the Sustainable Health Equity Movement (SHEM), we propose that sustainable equity represents the ethical analogue of physical balance. The convergence of physics and ethics around the principle of equilibrium suggests a unifying framework for planetary sustainability

By Juan Garay

Co-Chair of the Sustainable Health Equity Movement (SHEM)

Professor/Researcher of Health Equity, Ethics and Metrics (Spain, Mexico, Cuba, Brazil)

Founder of Valyter Ecovillage (valyter.es)

By the same Author on PEAH: see HERE

Physics and Ethics Converge in the Principle of Balance

From Quantum Stability to Sustainable Equity

 

Introduction: A Universe Balanced on Thresholds

The 20th century transformed humanity’s understanding of reality. Through the work of Albert Einstein, spacetime became dynamic rather than static. Edwin Hubble demonstrated that galaxies recede from one another, revealing cosmic expansion. Max Planck introduced quantization, and Werner Heisenberg formalized the uncertainty principle. Richard Feynman later emphasized the astonishing fact that humans exist during a relatively small (considering the age of the universe from the big bang theory) narrow historical interval in which the universe is both structured and still observable in its origin signals.

These developments reveal a consistent pattern: physical existence depends not on excess, but on balance.

Quantum Stability: Why Matter Exists

Classical electrodynamics predicted atomic instability: an orbiting electron should radiate energy and collapse into the nucleus. The resolution emerged through quantum mechanics.

Planck’s quantization and Heisenberg’s uncertainty principle established that confinement of a particle within an arbitrarily small region implies increasing momentum and energy. Total collapse is therefore prohibited by quantum structure.

Atomic stability is not static equilibrium but quantized dynamic balance:

Excess localization → energy divergence.

Excess dispersion → absence of structure.

Matter persists within constrained freedom.

Cosmological Balance: Expansion, Gravity, and the Window of Observability

Einstein’s field equations describe gravity as curvature of spacetime. Hubble’s redshift observations revealed that space itself expands. Later detection of the cosmic microwave background confirmed an early hot dense phase.

Cosmic structure formation requires calibrated conditions:

If gravitational coupling were significantly stronger → premature recollapse.

If expansion were too rapid → no galaxy formation.

If dark energy dominated too early → no large-scale structure.

We inhabit a cosmological epoch uniquely suited for observational cosmology:

The cosmic microwave background remains detectable.

Galaxies beyond the Local Group are still observable.

Expansion history can be reconstructed.

In the far future, accelerated expansion will isolate gravitationally bound systems. Observers may perceive an apparently static local universe, lacking evidence of cosmic origin. Thus, humanity exists within a narrow epistemic window.

Feynman emphasized the extraordinary nature of this circumstance: we are conscious beings in a universe that is, for a limited time, intelligible.

Ethical Analogue: Sustainable Equity

The Sustainable Health Equity Movement (SHEM) advances a framework of sustainable equity grounded in planetary boundaries, distributive justice, and intergenerational responsibility.

At the societal level, analogous tensions exist:

Economic growth vs. ecological limits

Individual autonomy vs. collective welfare

Resource accumulation vs. equitable distribution

Excess consumption destabilizes ecological systems.

Excess concentration of wealth destabilizes social cohesion.

Excess restriction suppresses innovation and vitality.

Equity, in this framework, is not uniformity but dynamic balance within biophysical constraints.

Just as atomic stability requires constrained freedom, sustainable societies require bounded expansion.

From Physical Equilibrium to Ethical Responsibility

Physics does not prescribe morality. However, it reveals a structural truth: complex systems endure only within thresholds.

Human civilization now confronts planetary-scale instabilities—climate change, biodiversity loss, health inequities—that reflect departures from balance.

If physical systems collapse when parameters exceed stability domains, social systems are unlikely to behave differently.

The convergence of physics and ethics occurs at the recognition that sustainability requires calibrated equilibrium.

Love as Conscious Equilibrium

In physics, balance is automatic; in human systems, it is voluntary.

Love may be redefined—not sentimentally, but structurally—as the conscious maintenance of conditions that allow mutual flourishing.

Where physics enforces equilibrium through law, humanity must choose it through ethics.

Sustainable equity thus represents the ethical translation of a cosmological principle.

Conclusion

The microcosm persists through quantum balance.

The macrocosm evolves through gravitational and expansionary balance.

Human societies endure through ethical balance.

We live in a rare cosmological and civilizational window in which the consequences of imbalance are scientifically visible.

Physics and ethics converge in the principle of balance.

To ignore this convergence is to risk collapse.

To embrace it is to align human development with the structural logic of the universe itself.

 

References

Einstein, A. (1915). Die Feldgleichungen der Gravitation.

Hubble, E. (1929). A relation between distance and radial velocity among extra-galactic nebulae.

Planck, M. (1901). On the law of distribution of energy in the normal spectrum.

Heisenberg, W. (1927). Über den anschaulichen Inhalt der quantentheoretischen Kinematik und Mechanik.

Feynman, R. P. (1965). The Character of Physical Law.

Sustainable Health Equity Movement (SHEM). Sustainable Equity Framework.

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IN A NUTSHELL
Author's Note 
As a follow up to my reflections on the Munich security conference, find an article here assessing the opportunity cost in human life/health inequity of the growing military spending. The article examines the moral implications of allocating a substantial share of global economic capacity to systems of violence while massive deficits in life‑assuring goods persist.

“Not in my name” becomes not only a moral protest against direct violence, but also a demand for fiscal priorities that safeguard life. Ethical selective tax objection emerges as a civic mechanism to articulate this demand

By Juan Garay

Co-Chair of the Sustainable Health Equity Movement (SHEM)

Professor/Researcher of Health Equity, Ethics and Metrics (Spain, Mexico, Cuba, Brazil)

Founder of Valyter Ecovillage (valyter.es)

By the same Author on PEAH: see HERE

Not in My Name

Military Spending as Toxic GDP, Health Inequity, and the Case for Ethical Selective Tax Objection

 

Introduction

Global military expenditure in 2024 reached approximately USD 2.7 trillion, marking the largest annual allocation to organized capacity for violence in history.¹ Against a backdrop of persistent and profound structural deprivation, international security fora such as the Munich Security Conference 2026 have become platforms where Western powers articulate a worldview of escalating geopolitical tension and Western self-claimed supremacy and privilege. Recent analyses note that leading delegates at the Munich Security Conference framed the global order as undergoing “wrecking‑ball politics,” urging investment in hard power and asserting Western strategic supremacy amid rising multipolar tensions.⁶

This rhetoric of urgency, deterrence, and confrontation buttresses arguments for ever‑increasing military expenditure, even as fundamental questions about global justice and the allocation of scarce resources remain unresolved.

While direct conflict fatalities in 2024 are estimated at approximately 239,000 deaths,¹ a much larger and more persistent hazard to human life arises from structural inequity. In 2023, the net burden of health inequity (nBHiE) in deficit countries was estimated at 12.6 million avoidable deaths, out of 15.6 million globally.² These deaths occur in settings where basic conditions of health and dignity are chronically unmet due to resource distribution failures.

At the same time, the global deficit required to ensure a universal minimum dignity threshold is estimated at USD 7.563 trillion annually.² The present article examines the moral implications of allocating a substantial share of global economic capacity to systems of violence while massive deficits in life‑assuring goods persist.

Toxic GDP and Opportunity Cost

The concept of toxic GDP — portions of economic output that are used in ways that degrade human well‑being — provides an analytical lens for interpreting large‑scale military spending. As recent commentary on restoring the broken human deal argues, certain sectors of economic activity transform human work and wealth into social toxins when they sustain capacities for destruction rather than life support.³ Military expenditure exemplifies such toxic allocation.

When military spending of USD 2.7 trillion is compared to the USD 7.563 trillion required to close the global dignity deficit, the share of toxic GDP devoted to militarization is approximately:

2.7/7.563≈35.7%2.7 / 7.563 ≈ 35.7\%2.7/7.563≈35.7%

Applying this proportion to the 12.6 million excess deaths in deficit countries yields:

0.357×12,600,000≈4,498,2000.357 × 12,600,000 ≈ 4,498,2000.357×12,600,000≈4,498,200

Thus, ≈ 4.5 million preventable deaths annually can be ethically attributed to the opportunity cost of military expenditure. This estimate is not an epidemiological causation claim, but a proportional ethical attribution that highlights the moral significance of resource allocation choices.

Reframing Security as Health Justice

Security rhetoric at forums like Munich 2026, where Western leaders not only emphasize military readiness but also implicitly appeal to cultural and civilizational privilege to justify augmentation of defense budgets, necessitates reframing. The pursuit of deterrence and geopolitical advantage must be juxtaposed with the persistent neglect of structural deprivation that kills millions each year.

Public health and global justice frameworks argue that the prevention of avoidable death from inequity should be at least as central to national and global security policy as militarization.

Ethical Selective Tax Objection

From an ethical standpoint, citizens confronted with the moral asymmetry between militarization and life‑preserving investment may consider the legitimacy of ethical selective tax objection — a claim that taxpayers should not be compelled to finance expenditures that perpetuate structural harm when alternatives exist that directly save lives.

This idea is built upon traditions of conscientious objection to war taxation advocated by international civil society organizations such as Conscience and Peace Tax International and the National War Tax Resistance Coordinating Committee.⁵,⁶ An ethically informed model would allow taxpayers to redirect the proportion of their taxes corresponding to military expenditure toward funds dedicated to health equity, social protection, and basic dignity provision.

Such frameworks strengthen democratic accountability and foreground the moral agency of citizens in shaping public goods. They also align with broader movements in tax justice and human rights that seek to democratize fiscal policy and enhance transparency in how public revenues are deployed.

Conclusion

In 2024–2025, global military rhetoric—including that articulated at conferences such as Munich Security Conference 2026—is increasingly framed around Western strategic primacy, escalating geopolitical competition, and the necessity of higher defense spending.⁶ Despite this, proportional ethical analysis reveals that a large fraction of preventable mortality correlates with the opportunity cost of existing military expenditure relative to unmet basic human needs.

The projection that ≈ 4.5 million avoidable deaths per year can be proportionately attributed to these toxic allocations should give pause to policymakers and public health scholars alike. In an ethical world, defense (in US terms boldly called war) spending should shift to the protection of life through health equity and economic justice.

“Not in my name” becomes not only a moral protest against direct violence, but also a demand for fiscal priorities that safeguard life. Ethical selective tax objection emerges as a civic mechanism to articulate this demand.

References

1. Stockholm International Peace Research Institute (SIPRI). SIPRI Yearbook 2025: Armaments, Disarmament and International Security. Stockholm: SIPRI; 2025.
2. Garay J. Enough is Enough, and More is Too Much: Between Basic Dignity and Excess/Hoarding Thresholds. Policies for Equitable Access to Health (PEAH); 2024.
3. Garay J. Restoring the Broken Human Deal: Reframing Toxic GDP and Harmful Economic Allocation. Policies for Equitable Access to Health (PEAH); 2024 Apr 13.
4. Sustainable Health Equity Movement (SHEM). Webinar Series: Ethics and Metrics; Tax Justice as Step Toward Health Equity. Geneva: SHEM; 2023–2025.
5. Conscience and Peace Tax International. Advocacy for Peace Tax Funds and Conscientious Taxpayer Rights. International Civil Society Organization.
6. From Potsdam 1945 to Munich 2026: Technological Leap and Backward Trends in Global Governance, Inequality, and Planetary Health. Policies for Equitable Access to Health (PEAH); 2026 Feb.

 

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Female Genital Cutting in the Nigeria Context  by Hadiza Magaji Mahmoud

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IN A NUTSHELL
Author's note
…In this paper, details of female genital cutting-FGC (or female genital mutilation-FGM as interchangeable terms) will be discussed within the context of Nigeria…

…Even though cultural norms and values are integral elements in shaping views and behavioral patterns of the community, FGC is one of the harmful cultural beliefs and practices that have no scientific proven medical basis and therefore must be abolished…

…The WHO has advised that neither FGM must be institutionalized nor should any form of FGM be performed by any health professional in any setting, including hospitals or in the home setting…

By Dr. Hadiza Magaji Mahmoud, MBBS

Masters in Reproductive Health, MSc Public Health (LSHTM), AMRSPH

By the same Author on PEAH: HERE

Female Genital Cutting in the Nigeria Context

 

‘’INTERVENTIONS TO MODIFY SEXUAL PLEASURE AND PERFORMANCE ARE NEVER SOLELY ABOUT ANATOMY AND PHYSIOLOGY BUT ARE HEAVILY INFLUENCED BY SOCIAL, CULTURAL, AND POLITICAL CONTEXT AND NORMS.”

 

The statement above highlights the idea that sexual experiences are shaped by a variety of factors beyond just biological processes. These factors include social norms, cultural values, political ideologies, and personal beliefs, all of which can impact sexual behaviors, attitudes, and expectations.

In the settings of Female Genital Cutting (FGC), modification of the normal external female anatomy does not only change the anatomy or physiologic function but also have implications on sexuality and general wellbeing. In addition, factors like social, cultural, and political context and norm do contributes in larger proportions towards causing harm to one’s sexuality.

In this paper, details of female genital cutting will be discussed within the context of Nigeria giving into account how such practice influenced by social norms, cultural values, political ideologies and personal beliefs will have impact on sexuality.

Female genital mutilation is also known as female circumcision or female genital cutting. The terms will be used interchangeable in this paper.

Female genital mutilation (FGM) is defined by the World Health Organization (WHO) as all procedures which involve partial or total removal of the external female genitalia and/or injury to the female genital organs, whether for cultural or any other non-therapeutic reasons.¹

An estimated 140 million women have undergone Female genital cutting.² In Africa alone, an estimated 101 million girls above the age of 10 years have undergone the procedure with an estimated 3 million being at risk of undergoing FGC each year.²

Though FGC is practiced in more than 28 countries in Africa and a few scattered communities worldwide, its burden is seen in Nigeria, Egypt, Mali, Eritrea, Sudan, Central African Republic, and northern part of Ghana where it has been an old traditional and cultural practice of various ethnic groups.^3,4

Nigeria has the highest absolute number of cases of FGC in the world, accounting for about one-quarter of the estimated 115–130 million circumcised women worldwide.³ The national prevalence rate of FGC is 41% among adult women. Prevalence rates progressively decline in the young age groups and 37% of circumcised women do not want FGC to continue.³ FGC has the highest prevalence in the south south (77%) (among adult women), followed by the south east (68%) and south west (65%), but practiced on a smaller scale in the north, paradoxically tending to a more extreme form.^3,5

The practice is widespread among different tribes and religions. FGC practice was deeply entrenched in the culture in all geopolitical zones of the country.⁶

In Nigeria, the practice is performed on neonates, infants, pubertal, antepartum, or post-partum women.^7,8 In most part of the country, it is carried out at a very young age (minors) and there is no possibility of the individual’s consent.⁹

FGC practiced in Nigeria is classified into four types¹⁰ as follows: Type I or Clitoridectomy (the least severe form of the practice): It involves the removal of the prepuce or the hood of the clitoris and all or part of the clitoris. In Nigeria, this usually involves excision of only a part of the clitoris. Type II or “sunna” is a more severe practice that involves the removal of the clitoris along with partial or total excision of the labia minora. Type I and Type II are more widespread in Southern Nigeria but less harmful compared to Type III which is commoner in Northern Nigeria. Type III (infibulation) is the most severe form of FGC. It involves the removal of the clitoris, the labia minora and adjacent medial part of the labia majora and the stitching of the vaginal orifice, leaving an opening of the size of a pin head to allow for menstrual flow or urine. Type IV or other unclassified types recognized by include introcision and gishiri cuts, pricking, piercing, or incision of the clitoris and/or labia, scraping and/or cutting of the vagina (angurya cuts), stretching the clitoris and/or labia, cauterization, the introduction of corrosive substances and herbs in the vagina, and other forms.⁷

FGC procedure is usually performed by traditional barbers, traditional healers, traditional birth attendants, and to some extents trained midwives and community health workers.

Various reasons have been given for performing FGC in Nigeria. In some communities, the procedure is observed as a religious rite, even though the role of religion in propagating the practice is extremely controversial. Interestingly, this practice is carried out among Muslims, Christians and others in the communities where it is seen. There is no clear evidence in the Bible or Qur’an supporting female circumcision.¹¹

Female circumcision is sometimes performed as an initiation rite into womanhood or into the tribe. An important reason forwarded by others for this practice is to safeguard the virginity of girls until marriage, or as a means of attenuating sexual desires of the girls thus rendering them less vulnerable to sexual temptation .¹²

Among the Yorubas of Ekiti and Atakumasi in Osun State, clitoridectomy is performed so that the head of the new born does not come in contact with the clitoris during delivery. If it does, these people believe it will result in the death of the newborn infant.¹³

In case of hypertrophy of the labia minora, circumcision is done for aesthetic reasons. Sometimes it is done for hygienic reasons.¹¹

FGC is recognized worldwide as a fundamental violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes and constitutes an extreme form of discrimination against women. It involves violation of rights of the children and violation of a person’s right to health, security, and physical integrity, the right to be free from torture and cruel, inhuman, or degrading treatment, and the right to life when the procedure results in death. Furthermore, girls usually undergo the practice without their informed consent, depriving them of the opportunity to make independent decision about their bodies.⁷ Another implication of FGC at early childhood age is that the female themselves grow into adulthood without the awareness of having had genital mutilation.

The complications of female genital cutting depend on the type and extent of the procedure. The most severe form, infibulation, which is usually carried out by untrained personnel in rural settings, carry the greatest health hazard been increased morbidity, psychological problems, and even death.¹¹

FGC has been associated with various sexual and reproductive health challenges in literatures, including sexual dysfunction, painful intercourse, infertility, clitoral cyst, reduced sexual desire and satisfaction, and recurrent urinary tract infection ^14,15

Difficulty of sexual intercourse and sexual dysfunction with resultant sexual dissatisfaction, especially in the female, could result in marital disharmony, reactive depression and in some cases psychosis.¹⁶

However, recent work on the sexual experiences of women with FGC is relatively lacking in FGC burden countries including Nigeria. The latest study on this issue utilized 2008 NDHS data to investigate the relationship between FGC and sexual behavior assessed using age at sexual initiation and number of lifetime partner.¹⁷

The results of a study conducted in Edo State, Nigeria indicate that genital cutting does not reduce the level of sexual activity in women. By contrast, the study suggest that genital cutting may predispose women to adverse sexuality outcomes including early pregnancy and reproductive tract infections.¹⁸

The study which utilizes the NDHS data, talks about female genital cutting and sexual behavior by marital status among a nationally representative sample of Nigerian women, it shows there is no evidence to support the claim that FGC prevents premarital sex and ensures marital fidelity in Nigeria ¹⁹  and is in consonance with another study that found no relationship between female genital circumcision and age at first intercourse in Nigeria and Kenya ²⁰, and disproves the assertion that circumcised women were more likely to initiate first sexual experience compared to uncircumcised women.²¹ This study also revealed that ever married women who were mutilated were at lower risk of having multiple sexual partners in contrast to a study in Sierra Leone that showed an increased risk of multiple sexual partners among circumcised women.²²

The study disproves one of the cultural beliefs deeply held to which also forms a basis for the practice of FGC, which is supposedly aimed at reducing promiscuity and ensuring acceptable sexual behavior including virginity and fidelity ^23,24. Therefore, there is need to understand the underlying complexities of this cultural belief in order to design successful, culturally acceptable, and correctly targeted FGM eradication campaigns ^{24, 25}. However, there are some potential limitations to this particular study, causal relationship was not established as national data was used for interpretation and FGC was self-reported by participants. Therefore, some questions assessing sexual behavior characteristics may be under reported (example, under reporting of age at first sexual initiation or virginity status due to societal and cultural expectations). To address such limitations, studies that test true causal relationship should be used and good methodological approach towards data collection should be encouraged. Generally, emphasis should be made to encourage more research on FGC especially in the Northern Nigeria where only few studies are available and such practices are still carried out.

Many initiatives, approaches and efforts that have been initiated to eradicate the practice of FGM including increasing legislation ^{15, 24} and messaging that inform on the adverse health effects are without much success ^26,27,28. Exposure of negative health consequences or criminalization of the practice often time results in the medicalization of FGC and introduction of various methods to continue the practice secretly ²⁹. Nigeria ratified the Child Rights Charter in 2001 ³⁰ and outlawed FGC in 2015 by enacting the Violence Against Persons (Prohibition) Act ³¹. Many state governments have also domesticated the Child Rights Act and criminalized FGC in their respective states, but with little to show for it, as the trend for FGC continues with minimal decline.³²

In Nigeria, FGM is being tackled by WHO, United Nations International Children Emergency Fund (UNICEF), Federation of International Obstetrics and Gynecology (FIGO), African Union, the Economic Commission for Africa (ECA), and many women organizations. Intensification of education of the general public at all levels has been done with emphasis on the dangers and undesirability of FGM.⁷

Even though cultural norms and values are integral elements in shaping views and behavioral patterns of the community, FGC is one of the harmful cultural beliefs and practices that have no scientific proven medical basis and therefore must be abolished.

A multidisciplinary approach is needed to tackle this deep rooted legendary practice of FGM. There is a need for legislation in Nigeria with health education and female emancipation in the society. The process of social change in the community with a collective, coordinated agreement to abandon the practice “community-led action” is therefore essential.³⁴ With improvement in education and social status of women and increased awareness of complications of FGM, most women who underwent FGM disapprove of the practice and only very few are prepared to subject their daughters to such harmful procedures.⁴ The more educated, more informed, and more active socially and economically a woman is, the more she is able to appreciate and understand the hazards of harmful practices like FGM and sees it as unnecessary procedure and refuses to accept such harmful practice and refuses to subject her daughter to such an operation.⁷

Medicalization of FGC involving trained health workers might reduce harm especially in communities resistant to change. Though, the WHO is strongly against this medicalization and has advised that neither FGM must be institutionalized nor should any form of FGM be performed by any health professional in any setting, including hospitals or in the home setting.³³Stakeholders should support families and communities to strengthen their efforts toward abandoning the practice and to improve care for those who have undergone FGC. A culturally acceptable approach respecting individual’s values and beliefs regarding FGC should be encouraged to help improve sexual and overall wellbeing across population groups.

 

REFERENCES

1. World Health Organization: Female Genital Mutilation: An overview. Geneva: World Health Organization; 1998.
2. WHO. 2013. Female Genital Mutilation. World Health Organization. http://who.int/mediacentre/factsheets/fs241/en (accessed September 18, 2015).
3. UNICEF. Children’s and Women’s right in Nigeria: A wake up call. Situation Assessment and Analysis. Harmful Traditional Practice (FGM) Abuja NPC and UNICEF Nigeria; 2001. p. 195-200.
4. Odoi A T. Female genital mutilation: In Kwawukume EY, Emuveyan EE (eds) Comprehensive Gynecology in the Tropics. 1st ed. Accra: Graphic Packaging Ltd; 2005. p. 268-78.
5. Adegoke P. Ibadan University Humanist Society. Female Genital Mutilation: An African Humanist view. November, 2005
6. Kolawole, A. O. D., and K. Anke. 2010. A review of determinants of female genital mutilation in Nigeria. Journal of Medicine and Medical Sciences1 (11):510–15
7. Okeke, T. C., U. S. B. Anyaehie, and C. C. K. Ezenyeaku. An overview of female genital mutilation in Nigeria. Annals of Medical and Health Sciences Research. 2012; 2 (1):70–73. doi: https://doi.org/10.4103%2F2141-9248.96942
8. Okhiai, O. I., O. B. Donije, and E. C. Asika. Awareness of health risks of female genital mutilation among women of childbearing age in two rural communities of Nigeria. Asian Journal of Medical Sciences. 2011; 3 (6):223–27.
9. Hathout HM. Some aspects of female circumcision. J Obstet Gynaecol Brit Emp 1963; 70:505-7.
10. World Health Organization. Female genital mutilation. A joint WHO/UNICEF/UNFPA statement. Geneva: World Health Organization; 1997.
11. Mandara. M.U. et al. Female genital mutilation in Nigeria. International Journal of Gynecology and Obstetrics 84 (2004) 291–298 doi: 10.1016/j.ijgo.2003.06.001
12. WHO. Female genital mutilation: information kit. WHO/FRH/WHD/.26. 1996. p. 96.
13. Oguntuyi A. History of Ekiti. Ibadan: Bisi Books, 1979. p. 28 –29.
14. Alsibiani SA, Rouzi AA. Sexual function in women with female genital mutilation. 64th annual meeting of the American Society for Reproductive Medicine. San Francisco, California., Elsevier Inc 2008.
15. Berg RC, Denison E, Fretheim A. Psychological, social and sexual consequences of female genital mutilation/cutting (FGM/CFGM/C): a systematic review of quantitative studies. Report from Norwegian Knowledge Centre for the Health Services. 2010:13.
16. Mustafa AZ. Female circumcision and infibulation in the Sudan. J Obstet Gynaecol Br Cwlth 1966; 73:302 –306.
17. World Bank’s total population and age/sex distributions of the United Nations Population Division’s World Population Prospects: 2019 https://data. world bank. org/ indicator/ SP. POP. 1564. TO. ZS.
18. Okonofua. F.E. et al.  The association between female genital cutting and correlates of sexual and gynecological morbidity in Edo State, Nigeria. An International Journal of Obstetrics and Gynecology October 2002, Vol. 109, pp. 1089–1096
19. Adelekan et al. Female genital mutilation and sexual behavior by marital status among a nationally representative sample of Nigerian women. Reproductive Health. (2022) 19:91 https://doi.org/10.1186/s12978-022-01379
20. Mpofu S, Odimegwu C, De Wet N, Adedini S, Akinyemi J. The relation of female circumcision to sexual behavior in Kenya and Nigeria. Women Health. 2017;57(7):757–74. https:// doi. org/ 10. 1080/ 03630 242. 2016. 1206054 (Epub 2016 Jun 29 PMID: 27355616).
21. Wagner N. Why female genital cutting persists, International Institute of Social Studies at Erasmus University Rotterdam, Kortenaerkade 2012. https:// www. Research gate. net/ profi le/ Natascha_ Wagne r2/ publi cation/ 22882 9687_ Why_ female_ genit al_ cutti ng_ persi sts/ links/ 00b49 5236cb68a3 90e00 0000.pdf.
22. Ahinkorah B, Hagan J, Seidu A, Budu E, Armah-Ansah E, Adu C, Yaya SE, et al. Empirical linkages between female genital mutilation and multiple sexual partnership: evidence from the 2018 Mali and 2013 Sierra Leone Demographic and Health Surveys. J Biosoc Sci. 2018; 2021:1–16. https://doi. org/ 10. 1017/ S0021 93202 10001 09.
23. Ojo TO, Ijadunola MO. Socio-demographic factors associated with female genital cutting among women of reproductive age in Nigeria. Eur Soc Contracep Reprod Health. 2017. https:// doi. org/ 10. 1080/ 13625 187. 2017.13280 48.
24. Working with Women and Girls Who Have Experienced Female Genital Cutting http:// www. serc. mb. ca/ site/ default/ files/ resources/ WrkwithWomen% 26Gir ls2015. pdf. 2015.
25. Ismail EA. Female genital mutilation survey In: Somaliland. Hargeisa, Somaliland: The Edna Adan Maternity and Teaching Hospital; 2009.
26. Population Council. Using Operation Research to Strengthen Programs for Encouraging abandonment of Female Genital Cutting. Report of the Consultative Meeting on Methodological Issues for FGC Research Nairobi http:// www. popco uncil. org/ pdfs/ front iers/ nairo bi_ fgcmtg. pdf.
27. Behrendt A. Listening to African voices female genital mutilation/cutting among immigrants in Hamburg: Knowledge, Attitudes and Practice. Hamburg: Plan; 2012.
28. Yirga WS, Kassa NA, Gegremicheal MW, Aro AR. Female genital mutilation: prevalence, perceptions and effect on women’s health in Kersa district of Ethiopia. Int J Women’s Health. 2012; 4:45–54.
29. Feldman-Jacobs C, Ryniak S, Wilcher R, Shears K, Ellsberg M. Fua I, et al. abandoning female genital mutilation/cutting: an in-depth look at promising practices. Population Reference Bureau; 2006.
30. Yerima TF, Atidoga DF. Eradicating the practice of female circumcision/female genital mutilation in Nigeria within the context of human rights. J Law Policy Global. 2014; 28:129–140.
31. Muthumbi J, Svanemyr J, Scolaro E, et al. Female genital mutilation: a literature review of the current status of legislation and policies in 27 African countries and Yemen. Afr J Reprod Health. 2015; 19:32–40.
32. T. O. Ojo & M. Y. Ijadunola (2017) Sociodemographic factors associated with female genital cutting among women of reproductive age in Nigeria. The European Journal of Contraception & Reproductive Health Care. 22:4, 274-279, DOI:10.1080/13625187.2017.1328048
33. WHO Elimination of FGM in Nigeria Plot 617/618 Diplomatic drive, Central District Abuja. Family Health Department, Federal Ministry of Health Phase II Federal Secretariat Abuja Dec 2007.
34. UNICEF. Changing a harmful social convention: Female genital mutilation/cutting. Innocent Digest. Florence: UNICEF; 2005.

IN A NUTSHELL
Author's Note 
...From Potsdam to Munich, humanity has achieved extraordinary technological progress and dramatic improvements in life expectancy and knowledge. Yet governance, equity, and ecological stewardship lag. Institutional legitimacy erodes, health inequities persist, and planetary systems degrade.

The way forward is clear: humanity must align technology, governance, and justice...

By Juan Garay

Co-Chair of the Sustainable Health Equity Movement (SHEM)

Professor/Researcher of Health Equity, Ethics and Metrics (Spain, Mexico, Cuba, Brazil)

Founder of Valyter Ecovillage (valyter.es)

 

By the same Author on PEAH: see HERE

From Potsdam 1945 to Munich 2026

Technological Leap and Backward Trends in Global Governance, Inequality, and Planetary Health

 

Eighty-one years ago, the world gathered at Potsdam, emerging from the devastation of a global war, with a shared vision: rebuild societies, prevent future conflicts, and create institutions to safeguard human rights, peace, and cooperation. At that time, humanity numbered 2.3 billion, global life expectancy was 46 years, and scientific and technological advances were still in their infancy. The moral and institutional ambitions of Potsdam were bold: create a rules-based order where diplomacy, multilateralism, and human dignity could guide global action.

Today, in 2026, the contrast is stark. The Munich Security Conference unfolds in a world of more than 8 billion people, twenty more years of average life expectancy, and unprecedented technological capabilities—artificial intelligence, quantum computing, biotechnology, advanced medicine, renewable energy, and space exploration. And yet, the institutions that once promised global solidarity, equitable governance, and environmental stewardship have not kept pace. Where Potsdam embodied reconstruction and normative leadership, Munich emphasizes deterrence, military-industrial expansion, and long-term confrontation. Humanity has the tools to solve planetary crises, yet governance, wealth distribution, and moral leadership lag dangerously behind.

Western institutions, long seen as defenders of peace, human rights, and multilateralism, now increasingly prioritize security and strategic influence. Munich 2026 demonstrates that support and attention are selective: strong for Ukraine, limited for crises outside Europe, and sometimes contingent on strategic interests rather than universal rights. Partnerships with authoritarian regimes continue under the guise of energy security, migration control, or industrial competition. For much of the Global South, this selective advocacy signals that moral authority is instrumental rather than universal, eroding trust in Western leadership.

Technological acceleration compounds economic inequality. Automation, AI, and digital platforms concentrate wealth and information power in fewer hands. Today, the top decile holds over 50% of global wealth, and less than 10% of the population controls the dominant financial and media flows that shape trade, consumption, and politics. These inequalities are not abstract—they directly shape health outcomes. SHEM analyses emphasize that inequality is a causal determinant of morbidity and mortality, determining exposure to hazards, access to nutrition, healthcare, and social resilience. Without structural change, widening inequities will deepen health disparities and accelerate intergenerational decline.

Environmental degradation intensifies these challenges. Climate change, biodiversity loss, deforestation, and ecosystem disruption increasingly drive human health risks. Heat-related mortality rises, vector-borne diseases expand, food insecurity worsens, and pandemics become more likely. Vulnerable populations suffer the most, amplifying inequities. Technology alone cannot offset these ecological-social interactions; governance, justice, and equitable resource distribution are decisive.

SHEM data estimate that roughly 16 million deaths annually are avoidable if inequity were addressed. Counterfactual equity comparisons suggest that life outcomes could match those of the most advantaged populations under sustainable conditions. Distribution-sensitive metrics reveal how averages hide disparities, while universal dignity thresholds—ensuring access to income, nutrition, housing, healthcare, and education—offer a measurable path toward equity. Further details and resources are available at https://www.sustainablehealthequity.org/webnair.

Looking toward the second half of the 21st century, risks compound: widening health disparities, climate-driven displacement, increased epidemic potential, food-system collapse from biodiversity loss, and declining intergenerational wellbeing. Technological capacity is not enough without equitable governance and ecological stewardship.

Global governance structures must adapt. The UN’s legitimacy depends on neutrality and geographic balance, yet its headquarters and Security Council remain concentrated in the West. The veto system allows a handful of states to block action even in mass-atrocity situations, limiting coordinated responses to crises that threaten health, dignity, and planetary stability. Reform is urgently needed: limit veto power in humanitarian emergencies, expand representative membership, introduce supermajority voting, and ultimately end privileges of structural supremacy that allow any single country to dominate global security decisions.

Economic redistribution is equally critical. SHEM modelling suggests that 5–7% of global GDP redirected toward universal dignity thresholds—providing roughly 10 USD PPP per person per day for income, nutrition, housing, healthcare, and education—could secure minimum living standards worldwide. This is modest compared to wealth concentrated above the “hoarding threshold” (~70 USD PPP per person per day) held by less than 10% of the population. Munich 2026 illustrates how security-focused politics continue to protect elite privilege at the expense of universal social protection.

From Potsdam to Munich, humanity has achieved extraordinary technological progress and dramatic improvements in life expectancy and knowledge. Yet governance, equity, and ecological stewardship lag. Institutional legitimacy erodes, health inequities persist, and planetary systems degrade.

The way forward is clear: humanity must align technology, governance, and justice. This requires democratized and geographically balanced governance, economic redistribution sufficient to guarantee universal dignity, and a normative shift from privilege-preserving competition toward cooperative planetary stewardship. Only by integrating these three dimensions can we secure the health and dignity of current and future generations, turning our technological potential into a force for equitable and sustainable global wellbeing.

 

References

United Nations. Charter of the United Nations. https://www.un.org/en/about-us/un-charter

World Health Organization. Social determinants of health. https://www.who.int/health-topics/social-determinants-of-health

Intergovernmental Panel on Climate Change. Assessment Reports. https://www.ipcc.ch/reports/

United Nations Environment Programme. Global Environment Outlook. https://www.unep.org/resources/global-environment-outlook

World Bank. World Development Indicators. https://databank.worldbank.org/source/world-development-indicators

International Monetary Fund. Technology and inequality analyses. https://www.imf.org/en/Topics/Inequality

International Labour Organization. World Employment and Social Outlook. https://www.ilo.org/global/research/global-reports/weso

Sustainable Health Equity Movement (SHEM). Webinar materials on health equity and avoidable burden of inequity. https://www.sustainablehealthequity.org/webnair

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Bluespotted cornetfish (Fistularia commersonii)

News Flash 652

Weekly Snapshot of Public Health Challenges

 

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