MY BODY IS MY OWN

CLAIMING THE RIGHT TO AUTONOMY AND SELF-DETERMINATION

State of World Population 2021 ACKNOWLEDGEMENTS
Illustrations were based on original photography by Joel Koko (page 65);
This report was developed under the auspices George Koranteng (page 108); Bushra Noor (page 16); Kingsley Osei-
of the UNFPA Division for Communications Abrah on Unsplash (page 9); Mikey Struik on Unsplash (page 114).
and Strategic Partnerships.
UNFPA thanks the following people for sharing glimpses of their
EDITOR-IN-CHIEF lives and work for this report: Anonymous “virginity inspector,”
Arthur Erken South Africa; Ayim, Kyrgyzstan; Dr. Mozhgan Azami, Afghanistan;
Enkhjargal Banzragch, Mongolia; Dr. Wafaa Benjamin Basta, Egypt;
EDITORIAL TEAM Víctor Cazorla, Peru; Daniyar, Kyrgyzstan; Dr. Mouna Farhoud,
Editor: Richard Kollodge Syria; Isabel Fulda, Mexico; Dr. Caitríona Henchion, Ireland; Josefina
Features editor: Rebecca Zerzan (not a real name), Mexico; Liana, Indonesia; Lizzie Kiama, Kenya;
Creative direction: Katie Madonia Olga Lourenço, Angola; José Manuel Ramírez Navas, El Salvador;
Digital edition managers: Katie Madonia, Monika, North Macedonia; Leidy Londono, USA; Dr. Ahmed Ben
Rebecca Zerzan Nasr, Tunisia; Chief Msingaphansi, South Africa; Sarojini Nadimpally,
Digital edition adviser: Hanno Ranck India; Dr. Nuriye Ortayli, Turkey; Dipika Paul, Bangladesh; Dr. Sima
Samar, Afghanistan; Jay Silverman, USA; Dr. Suraya Sobhrang,
RESEARCH ADVISER Afghanistan; Maeve Taylor, Ireland; Alexander Armando Morales
Nahid Toubia Tecún, Guatemala; Romeo Alejandro Méndez Zúñiga, Guatemala.

UNFPA TECHNICAL ADVISERS Chief of the UNFPA Media and Communications Branch, Selinde
Satvika Chalasani Dulckeit, provided invaluable insights to the draft, and Gunilla Backman
Nafissatou Diop and Jo Sauvarin from the UNFPA Asia and the Pacific Regional Office
Emilie Filmer-Wilson supported research and commented on drafts.
Mengjia Liang
Leyla Sharafi UNFPA colleagues and others around the world supported the
development of feature stories and other content or provided
RESEARCHERS AND WRITERS technical guidance: Samir Aldarabi, Iliza Azyei, Lindsay Barnes,
Daniel Baker Dr. Shinetugs Bayanbileg, Esther Bayliss, Shobhana Boyle, Warren Bright,
Alice Behrendt Ikena Carreira, Cholpona Egeshova, Jens-Hagen Eschenbaecher,
Stephanie Baric Usenabasi Esiet, Rose Marie Gad, Irene Hofstetter, Matt Jackson,
Marieke Devillé Kinda Katranji, Daisy Leoncio, Guadalupe Natareno, Ziyanda Ngoma,
Laura Ferguson Claudia Martínez, Subhadra Menon, Rebecca Moudio, Rachel Moynihan,
Gretchen Luchsinger Jasmine Uysal, Dalia Rabie, Zaeem Abdul Rahman, Patrick Rose,
Mindy Roseman Mindy Roseman, Alvaro Serrano, Ramz Shalbak, Avani Singh, Irena
Spirkovska, Walter Sotomayor, Sabrina Morales Tezagüic, Nahid Toubia,
COVER ARTWORK Sujata Tuladhar, Roy Wadia, Irene Wangui, Asti Setiawati Widihastuti,
Rebeka Artim Renato Zeballos.

COMMISSIONED ORIGINAL ARTWORK The editors are grateful to the Population and Development Branch of
Rebeka Artim UNFPA for aggregated regional data in the indicators section of this report
Kaisei Nanke and for overall data guidance. Source data for the report’s indicators were
Hülya Özdemir provided by the Population Division of the United Nations Department of
Tyler Spangler Economic and Social Affairs, the United Nations Educational, Scientific and
Naomi Vona Cultural Organization and the World Health Organization.

Publication and web interactive design and production: Prographics, Inc.

MAPS AND DESIGNATIONS

The designations employed and the presentation of material in
maps do not imply the expression of any opinion whatsoever on the
part of UNFPA concerning the legal status of any country, territory,
city or area or its authorities, or concerning the delimitation of its
frontiers or boundaries.

© UNFPA 2021

Ensuring rights and choices for all since 1969

 MY
BODY
IS MY
OWN
CLAIMING THE RIGHT
TO AUTONOMY AND
SELF-DETERMINATION
 CONTENTS

OUR AUTONOMY, OUR LIVES

A woman’s power to control her own body is linked to how much
control she has in other spheres of her life  7

THREE DIMENSIONS OF AUTONOMY

Measuring the power to make decisions about health care,
contraception and sex  17

WHEN DECISIONS
ARE MADE BY OTHERS
The denial of bodily autonomy and integrity
takes many forms  33

MY BODY, MY RIGHTS
International treaties and declarations provide
foundations for the right to bodily autonomy
and integrity  55

LAWS THAT EMPOWER

LAWS THAT CONTROL
A look at how laws and regulations
impact bodily autonomy  85

THE POWER TO SAY YES

THE RIGHT TO SAY NO
Achieving bodily autonomy depends on gender
equality and expanding choices and opportunities
for women, girls and excluded groups  109

Artwork by Rebeka Artim

 FOREWORD
My body is my own. International Conference on Population
and Development Programme of Action,
How many women and girls can which made the empowerment and
freely make that claim? autonomy of women a basis for global
action for sustainable economic and
Each of us has a right to bodily social progress. UNFPA also stands
autonomy and should therefore have with countless others who are often
the power to make our own choices excluded from making autonomous
about our bodies, and to have those decisions about their bodies: people of
choices supported by everyone around diverse sexual orientations and gender
us, and by our societies at large. identities, persons with disabilities,
and ethnic and racial minorities.
Yet, millions of people are denied their
right to say no to sex. Or yes to the The family planning programmes we
choice of a partner in marriage or to support both increase the availability of
the right moment to have a child. Many contraceptives and dismantle barriers
are denied this right because of race, to services, thus empowering women
sex, sexual orientation, age or ability. to govern their own bodies. In 2019,
for example, UNFPA procured more
Their bodies do not belong to them. than 128 million cycles of the pill
and doses of emergency and long-
Depriving women and girls of bodily acting reversible contraception.
autonomy is wrong. It causes and
reinforces inequalities and violence, all of We support programmes that promote
which arise from gender discrimination. men’s equitable involvement in parenting
and encourage them to be better
By contrast, when women and girls can communicators with their spouses in
make the most fundamental choices about matters of sexual and reproductive
their bodies, they not only gain in terms of health, helping to clear the way for
autonomy, but also through advances in women to make decisions about their
health and education, income and safety. own sexual and reproductive health.
These add up to a world of greater justice
and human well-being, which benefits us all. The UNFPA Maternal Health Thematic
Fund is helping make life-saving services
At UNFPA, we stand with women and more accessible and affordable by
girls in claiming their rights and choices, training midwives and deploying them
throughout their lives. Since 1994, our to underserved areas, and our joint
programmes have been guided by the programmes with UNICEF are helping

Artwork by Naomi Vona

4
end child marriage, a practice that than a disconnected series of projects
denies girls’ autonomy, and eliminating or services, as important as these may
the harmful practice of female genital be. Real, sustained progress largely
mutilation, a violation of bodily integrity. depends on uprooting gender inequality
and all forms of discrimination, and
In 2019, at the Nairobi Summit transforming the social and economic
on ICPD25, nations, civil society, structures that maintain them.
development institutions and others
called for the protection of the right In this, men must become allies. Many
to bodily autonomy and integrity, more must commit to stepping away
building on international commitments from patterns of privilege and dominance
in the 2030 Agenda for Sustainable that profoundly undercut bodily
Development. Further momentum has autonomy, and move towards ways of
come in 2021 from the Generation living that are more fair and harmonious,
Equality Forum, which is building on benefiting us all. And all of us must
the singular achievements of the 1995 take action to challenge discrimination
Fourth World Conference on Women wherever and whenever we encounter
to reach gender equality by 2030. it. Complacency equals complicity.

Through our leadership in the new Our communities and countries can
Generation Equality Action Coalition flourish only when every individual has
on Bodily Autonomy and Sexual and the power to make decisions about their
Reproductive Health and Rights, and bodies and to chart their own futures.
through this edition of the State of World
Population, UNFPA is highlighting why Let us therefore claim the right for each
bodily autonomy is a universal right that individual to make decisions about
must be upheld. The report reveals how their body and enjoy the freedom
serious many of the shortfalls in bodily of informed choices. All of us want
autonomy are; many have worsened this. All of us should have it. It is at
under the pressures of the COVID-19 the core of our humanity, and we
pandemic. Right now, for instance, record should never lose sight of just how
numbers of women and girls are at risk much depends on it—for everyone. 
of gender-based violence and harmful
practices such as early marriage. Dr. Natalia Kanem
United Nations Under-Secretary-General
The report also outlines solutions that and Executive Director of UNFPA,
are already at hand, while making the the United Nations sexual and
point that success requires much more reproductive health agency

STAT E OF WOR L D POPUL AT I ON 2 02 1 5

Artwork by Rebeka Artim
OUR AUTONOMY
OUR LIVES
A woman’s power to control her own body
is linked to how much control she has in other
spheres of her life

We have the inherent right to choose who we are, fully. We do not have to shrink to fit
what we do with our body, to ensure its choices that are not ours, to be in any way “less
protection and care, to pursue its expression. than”. Further, since claiming bodily autonomy
The quality of our lives depends on it. is fundamental to the enjoyment of all other
In fact, our lives themselves depend on it. human rights, such as the right to health or
the right to live free from violence, institutions
The right to the autonomy of our bodies in our societies are obligated to extend all the
means that we have the power and agency support and resources required for us to carry out
to make choices, without fear of violence or our choices in a meaningful way (PWN, n.d.).
having someone else decide for us. It means
being able to decide whether, when or with Intertwined with bodily autonomy is the
whom to have sex. It means making your own right to bodily integrity, where people can
decisions about when or whether you want live free from physical acts to which they do
to become pregnant. It means the freedom not consent. While many women and girls
to go to a doctor whenever you need one. in the world today have the power to make
autonomous decisions about their own bodies,
Saying no, saying yes, saying this is my choice many more still face constraints, some with
for my body—this is the foundation of an devastating consequences to their health,
empowered and dignified life. We can realize well-being and potential in life.

STAT E OF WOR L D POPUL AT I ON 2 02 1 7

 My body, but not my choice There are many dimensions to the forces that
prevent women and adolescent girls from
For many people, but especially women
enjoying bodily autonomy and integrity.
and girls, life is fraught with losses to
But a root cause is gender discrimination,
bodily integrity and autonomy linked
which reflects and sustains patriarchal systems
to a lack of agency in making their own
of power and spawns gender inequality and
decisions. These losses manifest when a lack
disempowerment.
of contraceptive choices leads to unplanned
pregnancy. They result from terrible
Where there are gender-discriminatory social
bargains where unwanted sex is exchanged
norms, women’s and girls’ bodies can be subject
for a home and food. They run through
to choices made not by them, but by others,
violations such as female genital mutilation
from intimate partners to legislatures. When
and child marriage. They arise when
control rests elsewhere, autonomy remains
people with diverse sexual orientations and
perpetually out of reach. While gender-
gender identities cannot walk down a street
discriminatory norms are by themselves harmful,
without fearing assault or humiliation.
they become even more so when they are
They leave people with disabilities stripped
compounded by other forms of discrimination,
of their rights to self-determination, to be
based on race, sexual orientation, age or
free from violence and to enjoy a safe and
disability, among other issues.
satisfying sexual life.

Discriminatory norms are perpetuated by the

community and can be reinforced by political,
economic, legal and social institutions, such

WOMEN as schools and the media, and even by health

services, including those that provide sexual and

ENJOY JUST
reproductive health care. These services may, for
example, undermine autonomy by being poor

75%
in quality and constrained in meeting all of the
needs of women and adolescent girls.

Despite constitutional guarantees of gender

equality in many countries, worldwide, on
average, women enjoy just 75 per cent of

of the the legal rights of men (United Nations

Secretary-General, 2020). Women and girls

legal rights
in many instances lack the power to contest
these disparities because of still low levels of
participation in political and other forms of

OF MEN
decision-making. Economic marginalization
can detract from a woman’s financial

8 Our autonomy, our lives

independence, which in turn can weaken when or how many children to have, or
her authority to make autonomous decisions choose to stay in school instead of marrying
about sex, health care and contraception. at a young age, or who accepts domestic
The hardships brought on by the COVID-19 violence as her fate, stands little chance of
pandemic have only made matters worse. gaining empowerment in the workforce or
community decision-making or anywhere else.
For some women and girls, the impact of She essentially loses rights not just in one part
gender inequality is amplified by multiple of her life, but in many or even every part.
sources of discrimination based on age,
race, ethnicity, sexual orientation, disability Interests in sustaining patterns like these can
or even geography. When diverse types of be deeply entrenched in how societies and
discrimination intersect, they leave women economies function. In some parts of the world,
and girls even more at risk of not realizing
bodily autonomy, not enjoying their rights,
and even further away from gender equality.

No country in the world today can claim to

have achieved gender equality in its totality. If it
had, there would be no violence against women
and girls, no pay gaps, no leadership gaps, no
unfair burden of unpaid care work, no lack of
quality and comprehensive reproductive health
services, and no lack of bodily autonomy.

Voice, choice and agency

Sexual and reproductive health and rights
have direct bearing on bodily autonomy
and integrity for women and girls, with the
body the locus of all sexual and reproductive
functions and choices. These choices
are subject to powerful, discriminatory
subjugations of the rights of women and
girls. It is here where their bodies are all too
often bartered, bought and sold.

From a perspective of patriarchy, control of

sexual and reproductive choices effectively
becomes control in many other areas of
life. A woman who cannot define whether,

Artwork by Rebeka Artim

 for instance, bride price, where a man offers the ICPD, the most comprehensive global
money, property or other assets to essentially endorsement of reproductive rights. The
“purchase” a wife, is a critically important Programme of Action set forth a series of
economic mechanism for exchanging power measures to achieve universal sexual and
and wealth (Shetty, 2007). reproductive health and drew attention to
women’s and girls’ limited power to make their
When women and adolescent girls have more own decisions not just about their bodies, but
choice in sexual and reproductive health in all aspects of their lives.
care, multiple positive health outcomes
result, including greater understanding Further, in 2015, most countries endorsed the
of how to prevent HIV, and a greater 2030 Agenda for Sustainable Development,
likelihood of having the number of prenatal where gender equality is the fifth of 17
visits recommended by the World Health Sustainable Development Goals. The
Organization as well as giving birth with the gender equality goal contains a series of
help of a doctor, nurse or midwife. targets, including one affirming the ICPD
Programme of Action, by calling for universal
Failures to uphold bodily autonomy thus access to sexual and reproductive health and
result first and foremost in profound reproductive rights. But the 2030 Agenda also
losses for individual women and girls. takes a critical step further. For the first time
But they also add up to broader deficits, in an international framework, it requires
potentially depressing economic productivity, measuring progress towards universal access
undercutting valuable skills, and imposing through two indicators: one that looks beyond
extra costs for health-care and judicial services, the provision of services and focuses on
including for responding to violence against whether girls and women can actually make
women and girls (UN Women, 2013). their own decisions in terms of having sex,
using contraception and seeking reproductive
A mixture of low levels of bodily autonomy health care, and one that tracks laws and
and the losses in human capacity associated regulations that enable or impede full and
with it can undermine social stability and equal access to care and information.
resilience, leaving societies less equipped
to confront and recover from crises and Information so far from 57 countries shows
challenges, such as the COVID-19 pandemic. that only about half of adolescent girls and
women can make their own decisions that
In recent years, countries around the world underpin bodily autonomy and integrity
have started prioritizing access to sexual and as measured by these two indicators. The
reproductive health care as an important means share drops as low as about one in 10 in
to advance gender equality (UN ECOSOC, some countries. Strikingly, once the choices
2019). Gains align with the 1994 Programme are broken down, more women can make
of Action of the landmark International decisions around contraceptive use, which
Conference on Population and Development, could be seen as offering benefits to men, but

10 Our autonomy, our lives

fewer can say no to sex, where male privilege New alliances stand
works in the opposite direction.
behind bodily autonomy
These indicators, which are the focus of this In 2019, the Nairobi Summit marked the
report, capture only a few dimensions of twenty-fifth anniversary of the ICPD. It was
autonomous decision-making in sexual and a moment to reflect on how much more
reproductive health and only for women and girls needs to be done to realize women’s bodily
aged 15 to 49 years who are married or partnered. autonomy and integrity. While the use of
The issue of bodily autonomy, however, also modern contraception has more than doubled
relates to a range of other issues, including since 1994, 217 million women worldwide
abortion, age of consent, surrogacy, sex work still have unmet contraceptive needs, for
and more, and is a concern for other groups too, instance. Rates of female genital mutilation
such as women and girls who are not married, have declined among girls in countries where
LGBTI communities, persons with disabilities the practice is common. The share of girls
and any other community marginalized or who are child brides has dropped (Pantuliano,
discriminated against because of race, ethnicity, 2020). Yet as many as 4 million girls were still
wealth, disability or place of residence. subjected to female genital mutilation and
an estimated 12 million were still married as
Because bodily autonomy and integrity children in 2020, and that number is likely
influence so many aspects of health as undercounted.
well as a decent, dignified life, progress
in realizing them will lead not just to At the Nairobi Summit, governments and
achieving sexual and reproductive health others committed to accelerating action in
and the fifth Sustainable Development closing gaps, striving for three zeros by 2030:
Goal on gender equality, but many of the zero maternal mortality, zero unmet need for
other Sustainable Development Goals contraception and zero sexual and gender-
too, including those related to promoting based violence and harmful practices. Implicit
health, reducing inequalities and ending in all three is the full realization of bodily
poverty. For example, if the discriminatory autonomy for all women and girls.
gender gap in lifetime earned income were
closed, it would generate an astounding In 2020, another milestone was the twenty-
$172 trillion in human capital wealth and fifth anniversary of the 1995 United Nations
help lift millions of people out of poverty Fourth World Conference on Women. The
(United Nations Secretary-General, 2020). conference agreed on the Beijing Declaration
and Platform for Action, which refers to the
Rapid progress must be made now, however, empowerment and autonomy of women as
given there is just one “Decade of Action” before essential to sustainable development. For the
the 2030 endpoint of the global goals, when all anniversary, a United Nations “Generation
women and girls should have full power to make Equality” campaign has brought together
choices in their lives. young and seasoned advocates to celebrate

STAT E OF WOR L D POPUL AT I ON 2 02 1 11

 Your body:
an owner’s manual
Few parents or community supported programme show it may actually help
leaders object when a student providing life skills and delay adolescents’ sexual
brings home a chemistry or comprehensive sexuality debut (UNESCO, 2016).
calculus textbook. Yet lessons education to youth in Angola.
in comprehensive sexuality “Almost nothing is said about Lourenço explained that,
education—accurate, age- comprehensive sexual and because she lacked accurate
appropriate information about reproductive health because information at a young age,
one’s own body, sexual and of our taboos and prejudices.” she actually felt pressured to
reproductive health, and human engage in sexual relationships
rights—are widely considered Opponents of comprehensive before she was ready, at
taboo. Many schools do not sexuality education often age 15. “My friends already
teach the subject, or provide contend that it promotes had their boyfriends. They
only incomplete information. sexual activity, yet studies already had sexually active
This leaves students both show that this is incorrect. lives. They made fun of me
ill-prepared for the changes Rather, evidence indicates that for being the ‘virgin of the
their bodies are undergoing this education, when provided group’,” she said. “In a way,
and ill-equipped to protect to international standards, this psychologically affected
themselves from harm. improves young people’s me... I think that, in a way, it
knowledge and constitutes violated my bodily autonomy.”
“We are in a constant struggle a crucial and cost-effective
to include this topic in the strategy for preventing Dipika Paul, a longtime
school curriculum,” said unintended pregnancy and sexual and reproductive
Olga Lourenço, a coordinator sexually transmitted infections, health researcher and an
for Project CAJ, a UNFPA- including HIV. Some studies adviser at Ipas in Dhaka,
Bangladesh, has seen the
consequences of poor access

“They need to
to sexuality education in her
own community. “When I

know how their

was a student, I was in class
seven, and there was just one
chapter—on menstruation,”
bodies work.” she recalled. “The teacher

12 Our autonomy, our lives

Olga Lourenço is used to facing resistance when providing comprehensive sexuality education, but she is undeterred.
Original artwork by Naomi Vona; photo © UNFPA/C. Cesar.

also did not feel comfortable and misinformation. Boys using contraception because
teaching that section to us.” and men, in particular, “have of the belief that “an IUD
knowledge gaps, they have travels anywhere around
Without comprehensive misconceptions,” Paul said, in the body… they think
sexuality education, young explaining that she has seen they can feel pain from an
people are vulnerable to myths men forbid their wives from IUD. This is not true.”

STAT E OF WOR L D POPUL AT I ON 2 02 1 13

 Students who receive locked herself up and couldn’t are increasingly calling for this
comprehensive sexuality speak with anyone for fear information to frame violence
education are not only of being expelled from the prevention as the responsibility
empowered to make healthier home and ending up on the of potential perpetrators,
sexual choices, but they street,” Lourenço described. rather than the responsibility
are also better equipped Mentors were able to secure of victims and survivors
to seek help when needed. services for both girls, but (Schneider and Hirsch, 2020).
“The information I share Lourenço is haunted by what
can significantly change a might have been: “If we did “They need to know what
person’s life,” said Lourenço. not intervene, what would their rights and duties are in
become of these girls?” a society first,” Lourenço said,
She recalled one girl who, while explaining that this is the
receiving sexuality education Comprehensive sexuality foundation of comprehensive
through a mentorship education can also play a role sexuality education as she
programme, revealed she had a in preventing gender-based teaches it. “Then they need
chronic wound on her breast— violence. When taught to to know how their bodies
something she regarded as international standards, the work so that they can make
an embarrassment but not an lessons include messages decisions for themselves
emergency. Another young about human rights, gender and not let others make
woman disclosed that she was equality and respectful decisions for them.”
living with an uncle who had relationships (UNESCO and
sexually abused her. “The girl others, 2018). And experts

achievements to date and to demand that the Ramped-up activism offers inspiration, but
next generation be the one where promises it is unfolding against a worrying backdrop,
to realize gender equality are finally kept. Six with the COVID-19 pandemic convulsing
action coalitions have formed, including one the world, and current economic growth
co-led by UNFPA on bodily autonomy and models leading to extreme and destabilizing
sexual and reproductive health, which is taking inequalities. Pushback against gender equality
up issues such as how health-care and other has grown, leading to new restrictions on
services can more closely support the choices sexual and reproductive health and rights
that women themselves say they want. and thus threatening progress towards bodily

14 Our autonomy, our lives

autonomy for women and girls worldwide. and reproductive rights are among the most
For example, there have been attempts to important entry points. Progress here can,
remove comprehensive sexuality education in turn, build on and support other efforts
from school curricula (UN ECOSOC, 2019). to empower women in the economy and
And there is mounting evidence that critical decision-making, and to guarantee access to
sexual and reproductive health services have justice. Much depends on overturning gender
been deemed “less essential” and have suffered and other discriminatory norms to prevent
a diversion of capacity and funding during the bias from operating in the first place.
response to COVID-19 (Pantuliano, 2020).
Diverse constituencies are collectively
Surmounting these issues will not be easy. Yet, galvanizing momentum for change. The
to some extent, bodily autonomy and integrity Generation Equality campaign, for example,
can unify action for gender equality, just as is forging new alliances among gender
they often unify the opposition to it. Now is equality activists, between disabilities, gender
the moment for making a powerful, potentially and health advocates, and with LGBTI groups
transformative case for asserting what bodily and organizations of persons with disabilities.
autonomy and integrity really mean in practice,
and what is really required to achieve them. To look at bodily autonomy and imagine
what it could and should mean is to see a
In broad terms, we already know that achieving vastly different future for human beings.
bodily autonomy and integrity for women and A different path starts with rights and leads
girls depends on realizing gender equality on all to choices, allowing people to care for and
fronts, and that sexual and reproductive health love their bodies and their lives as they see fit.

Artwork by Kaisei Nanke

STAT E OF WOR L D POPUL AT I ON 2 02 1 15

Artwork by Hülya Özdemir
THREE DIMENSIONS
OF AUTONOMY
Measuring the power to make decisions about
health care, contraception and sex

The power to make decisions about sexuality of Action, which acknowledged that “the goal
and reproduction is fundamental to women’s of the empowerment and autonomy of women
empowerment overall. and the improvement of their political, social,
economic and health status is a highly important
A woman who has control over her body is more end in itself and is essential for the achievement
likely to be empowered in other spheres of her of sustainable development”.
life. A woman—or adolescent girl—with little
bodily autonomy is less likely to have control Since then, the word “bodily” has been joined
over her home life, her health and her future, with “autonomy” to create a term with a broad
and less likely to enjoy her rights. and sometimes ambiguous meaning. It is used
today by advocates, activists and human rights
But what exactly is bodily autonomy? And how experts surrounding issues related to sexuality,
does one determine whether one has it? Is it health, reproductive rights, sexual orientation,
something that can be measured? gender identity, transactional sex, surrogacy,
disability status, abortion and more.
The notion of autonomy in the context of
women’s empowerment emerged in the 1970s The term gained further prominence in 2019,
and was later taken up by the sexual and when governments, civil society organizations,
reproductive health and rights movement. academics and members of the private sector
In 1994, at the International Conference on came together for the Nairobi Summit on
Population and Development or ICPD, the ICPD25, where they pledged to finally achieve
term appeared in the pathbreaking Programme all the goals set out in the ICPD Programme

STAT E OF WOR L D POPUL AT I ON 2 02 1 17

 of Action. Many of the delegates adopted the • Who usually makes decisions about health
voluntary Nairobi Statement, which cited the care for yourself?
need “to protect and ensure all individuals’
right to bodily integrity, autonomy and • Who usually makes the decision on whether
reproductive rights, and to provide access to or not you should use contraception?
essential services in support of these rights”.
• Can you say no to your husband or
While the term has become part of the partner if you do not want to have sexual
vernacular of the feminist and sexual and intercourse?
reproductive health and rights movements,
it continues to elude simple definition and Only women who say they make their
easy measurement. However, when the own decisions in all three of these areas are
United Nations adopted its transformative considered to have autonomy in reproductive
2030 Agenda for Sustainable Development health decision-making and to be empowered
and the accompanying 17 Sustainable to exercise their reproductive rights.
Development Goals, it established indicators
to help governments track progress towards DHS surveys rely on standard questionnaires
achieving the goals and their related targets, that yield nationally representative data
such as target 5.6, the achievement of sexual on marriage, fertility, mortality, family
and reproductive health and reproductive planning, reproductive health, child
rights for all. Two indicators have been health, nutrition and HIV/AIDS. The
identified to measure progress in this area. DHS programme is implemented by ICF
The first, indicator 5.6.1, aims to measure International and funded by the United
the proportion of women aged 15 to 49 years States Agency for International Development
who make their own informed decisions with contributions from international
regarding sexual relations, contraceptive organizations such as UNFPA.
use and reproductive health care. The
second indicator, 5.6.2, tracks the number The formulation of indicator 5.6.1 marks the
of countries with laws and regulations that first time that an international framework
guarantee full and equal access to women and measures sexual and reproductive health—and
men aged 15 years and older to sexual and bodily autonomy—in ways that look beyond
reproductive health care, information and access to services and explores the extent to
education. which girls and women are able to make their
own choices. UNFPA, the United Nations
Indicator 5.6.1 is based on responses to sexual and reproductive health agency, is
questions posed to women aged 15 to 49 years responsible for managing the data included
in Demographic and Health Surveys, or DHS, in this indicator, as well as indicator 5.6.2,
in 57 countries: covered in chapter 5 of this report.

18 Three dimensions of autonomy

A look at the numbers picture of the state of bodily autonomy for millions
of women and girls: only 55 per cent of girls and
Complete data on all three dimensions of women are able to make their own decisions in all
indicator 5.6.1 are available only for 57 three dimensions of bodily autonomy.
countries, most of which are in sub-Saharan
Africa. However, future international surveys, That means that little more than one in two
such as UNICEF’s Multiple Indicator Cluster women and girls has the power to decide whether
Surveys, as well as regional survey programmes and when to seek health care, including sexual
such as the Generations and Gender Survey, are and reproductive health services, whether to use
expected to yield data for more countries over contraception and whether and when to have sex
the next few years. with their partner or husband (Figure 1).

While data currently cover only about one in four Percentages vary across regions. For example, while
of the world’s countries, they paint an alarming 76 per cent of adolescent girls and women in

FIGURE 1 

Proportion of women aged 15 to 49 years who make their own decisions

regarding sexual and reproductive health and rights (including deciding
on their own health care; deciding on the use of contraception; and can
say no to sex), by SDG region, most recent data 2007–2018
All three dimensions Power to say no Power to decide Power to decide
of indicator 5.6.1 to sex on contraception on health care

100
94 92 94
91 91 91 92 91
90 89 88
86 87 86
80
79 79
75 75 76 74 75
70 70 71 71
60 64 64
59 59
55 53
51
48
40 43
38 36

20

0
World (57) Eastern Asia Latin America Central Asia Sub-Saharan Southern Africa Eastern Africa Western Africa Middle Africa
and and Caribbean and Southern Africa (36) (4) (12) (13) (7)
South-eastern (7) Asia (5)
Asia (5)

Notes: The number of countries with comparable survey data included in the regional aggregations is presented in parentheses.

Source: United Nations Population Fund, global databases, 2020. Based on the Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys
(MICS) and other national surveys conducted in the 2007–2018 period.

STAT E OF WOR L D POPUL AT I ON 2 02 1 19

Eastern and South-eastern Asia and Latin America to 87 per cent in Latin America and the
and the Caribbean make autonomous decisions in Caribbean.
all three dimensions of indicator 5.6.1, this figure
is less than 50 per cent in sub-Saharan Africa and The data also show inconsistencies across the
Central and Southern Asia. three dimensions: a high percentage in one
dimension does not automatically mean high
Regional aggregates mask substantial differences percentages in others. In Mali, for example,
across countries (Figure 2). In sub-Saharan Africa, 77 per cent of women take independent or
for example, where about 50 per cent of women joint decisions on contraceptive use, but only
make autonomous decisions, there are three 22 per cent are able to do the same in seeking
countries, Mali, Niger and Senegal, where less health care. In Ethiopia, 53 per cent of women
than 10 per cent do. are able to say no to sex, but 94 per cent can
independently or jointly make decisions about
In other regions, differences between countries are contraception. Such discrepancies help explain
less pronounced but are nevertheless noteworthy. lower overall composite indicators in some
For example, the percentages of women who countries: a woman is counted only when
make autonomous decisions across she reports autonomous choices in all
all three dimensions of indicator three dimensions. A woman who
5.6.1 range from 33 per cent decides autonomously to use
to 77 per cent in Central and contraception but is unable to
Southern Asia, from 40 per say no to sex to her husband,
cent to 81 per cent in Eastern for example, would not be
and South-eastern Asia, included in the 5.6.1 overall
and from 59 per cent composite indicator.

Artwork by Rebeka Artim

FIGURE 2

Proportion of women aged 15 to 49 years who make their own decisions

regarding health care, contraception and sex with their husbands or
partners, most recent data by country, 2007–2018
All three dimensions Power to say no Power to decide Power to decide
of indicator 5.6.1 to sex on contraception on health care
Albania 69 84 84 93
Angola 62 85 90 77
Armenia 66 75 89 97
Benin 36 62 90 55
Burkina Faso 20 62 91 32
Burundi 44 63 94 72
Cambodia 76 93 89 91
Cameroon, Republic of 38 89 89 48
Chad 27 63 81 47
Comoros 21 47 71 47
Congo, Democratic Republic of the 31 74 85 47
Congo, Republic of the 27 71 87 41
Côte d'Ivoire 25 67 82 43
Dominican Republic 77 93 92 88
Ecuador 87 95 92 100
Eswatini 49 74 89 72
Ethiopia 45 53 94 85
Gabon 48 86 90 60
Gambia 41 64 84 71
Ghana 52 72 90 82
Guatemala 65 89 91 77
Guinea 29 55 85 61
Guyana 71 83 90 92
Haiti 59 80 93 78
Honduras 70 94 88 84
Jordan 61 69 93 94
Kenya 56 77 89 81
Kyrgyzstan 77 85 95 94
Lesotho 61 71 93 91
Liberia 67 92 89 83
Madagascar 74 88 93 90
Malawi 47 70 93 70
Maldives 58 71 93 88
Mali 8 31 77 22
Mongolia 63 80 84 85
Mozambique 49 67 85 77
Myanmar 68 81 98 85
Namibia 71 94 83 91
Nepal 48 91 85 59
Niger 7 35 77 21
Nigeria 46 70 90 68
Pakistan 40 64 94 58
Panama 79 95 89 94
Philippines 81 88 94 97
Rwanda 70 83 98 84
São Tomé and Príncipe 46 79 78 69
Senegal 7 19 85 31
Sierra Leone 40 79 82 60
South Africa 65 75 89 95
Tajikistan 33 60 83 54
Tanzania, United Republic of 47 76 89 66
Timor-Leste 40 44 94 94
Togo 30 75 84 47
Uganda 62 87 93 75
Ukraine 81 86 95 98
Zambia 47 71 83 76
Zimbabwe 60 72 93 87

0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100

Source: United Nations Population Fund, global databases, 2020. Based on the Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS)
and other national surveys conducted in the 2007–2018 period.

STAT E OF WOR L D POPUL AT I ON 2 02 1 21

 What are the trends? legal and policy environment (including
the abolition of user fees for maternal and
An analysis of trends in 22 low- and middle- under-5 child health services) combined
income countries that have had at least two with community-outreach approaches
consecutive DHS surveys that asked women aiming at tackling gender inequality norms
about the three dimensions of bodily autonomy (UNFPA, 2019).
shows that investments in programmes or
services in one dimension do not necessarily Figure 3 shows that overall indicator
lead to positive changes in the others. In fact, percentages can mask simultaneous negative
the trends in responses to the three standard and positive trends within a country. Positive
questions for indicator 5.6.1 often move in trends are more common in responses to the
different directions (Figure 3). question about autonomous decisions on
seeking health care. Negative trends, however,
In Ghana, for example, massive investments have are more common in responses to the question
been made to improve maternal health through about having the power to say no to sex. In
increased affordability, quality and reach of fact, women in more than half the countries
services, combined with community-outreach with at least two data points lost ground
programmes to promote these services. As a between 2005 and 2018 in their power to say
result, the percentage of women able to make no to sex. It is difficult to pinpoint the exact
their own decisions regarding their own health cause of this negative trend or the apparent
care has risen continuously. At the same time, lack of progress. However, one study suggests
the percentage of women who make their own that a combination of factors may be at play
decisions about contraception has levelled off, (UNFPA, 2019):
and the percentage of women who are able to
say no to sex has seen a considerable decrease. • Persistent taboos about sex and sexuality that
A similar situation has occurred in Benin, where are reinforced by social norms and attitudes,
the percentage of women who are able to make leaving women and adolescent girls little
autonomous decisions about contraception and opportunity to negotiate openly about sex
health care has shown little change in the past with their partners or husbands.
10 years. Women’s power to say no to sex, on
the other hand, has decreased by 20 per cent • Patriarchal systems that perpetuate unequal
over that same period (UNFPA, 2019). power dynamics in relationships, where male
sexual demands are placed above those of
Among the 22 countries, only Uganda and women. Studies show that in Azerbaijan,
Rwanda have shown consistent positive Rwanda and Mexico, some women agree to
trends in the percentage of women who make forfeit their right to say no to sex in exchange
autonomous decisions in all three dimensions for greater autonomy in other spheres of
of indicator 5.6.1. Data show that Uganda had their lives, such as in making decisions for
the largest increase: 12.3 per cent. The positive the household or deciding whether or when
change can be attributed to a conducive to venture outside the home.

22 Three dimensions of autonomy

FIGURE 3
Change in the percentage of women who report making autonomous
decisions in the three components of indicator 5.6.1 in West Africa

All three dimensions Power to say no Power to decide Power to decide

of indicator 5.6.1 to sex on contraception on health care

BENIN GHANA MALI

100 100 100

50 50 50

2006 2017 2008 2014 2006 2012

NIGER NIGERIA SENEGAL

100 100 100

50 50 50

2006 2012 2008 2013 2010 2017

• Qualitative research indicates that women may only reflect women who were married or in
also comply with men’s sexual demands as a cohabiting unions and who were actually
trade-off to achieve more independence in their using contraception at the time survey data
economic and personal endeavours. Such trade- were collected. Also, the question used to elicit
offs have been reported in countries as diverse responses about decisions to access health care
as Azerbaijan, Mexico, Niger and Nigeria does not specifically refer to reproductive health
(UNFPA, 2019). care. And all three questions are asked only of
girls and women aged 15 to 49, thus leaving out
younger adolescents and women aged 50 or older.
The indicator’s limitations
Indicator 5.6.1 is a picture of women’s bodily Another limitation is that the data related to
autonomy painted with a broad brush and contraception and health care reflect both joint
thus reveals few subtleties about the forces and individual choices. A woman may say, for
behind positive or negative trends. Data on example, that the decision to use contraception
women’s use of contraception, for example, was made jointly with her husband or partner.

STAT E OF WOR L D POPUL AT I ON 2 02 1 23

But there are likely instances where a “joint” covert contraceptive use is an individual choice,
decision was actually an individual one, made women generally describe the experience as
by the woman but overruled by her husband. negative and disempowering (UNFPA, 2019).
Furthermore, women whose husbands forbid
them from using contraception may still use it
covertly, but this type of situation is not reflected An ecological model
in the indicator on making autonomous decisions
about contraception. Quantitative surveys suggest
of bodily autonomy
that between 4 per cent and 29 per cent of A range of social and economic factors influence
women who use contraception do so without a woman’s decision-making in the three
their husbands’ or partners’ knowledge. While dimensions of indicator 5.6.1 (Figure 4).

FIGURE 4

Determinants of women’s decision-making power

COMMUNITY
INDIVIDUAL GENDER NORMS,
STIGMA, BELIEFS

POWER
HEALTH SYSTEMS
KNOWLEDGE ON SEXUAL AND
REPRODUCTIVE HEALTH AND PROXIMITY, COST,
RIGHTS, HEALTH EXPERIENCE QUALITY OF CARE,
PROVIDER BIAS
AND AGENCY

INTERPERSONAL
POSITION OF PARTNER,
COMMUNICATION,
EXTENDED FAMILY

SOCIOECONOMIC
EDUCATION, WEALTH,
MEDIA ACCESS, RURAL/URBAN

Artwork by Hülya Özdemir

Socioeconomic circumstances contraception and health care. A woman
A woman’s level of educational attainment who has less education than her husband
is a key factor in determining how much or partner is more likely to be subjected
power she has to say no to sex but it to sexual violence than a woman whose
also correlates with her power to make education level is more or less equal to
her own decisions about contraception that of her husband (UNFPA, 2019).
and health care (Figures 5a and 5b). Meanwhile, girls and women in the two
The education level of her partner lower wealth quintiles are also more likely
is also positively associated with to have experienced unwanted sexual
her participation in decisions about relations (Figure 6).

FIGURE 5A

More decision-making power linked to higher levels of education

Decision-making on women’s own health care, by women’s level of education, select countries, per cent

No education   Primary   Secondary   Higher  

Tajikistan 2017
Gabon 2012
Burkina Faso 2010
Côte d'Ivoire 2012
Zambia 2014
Burundi 2017
Cameroon, Republic of 2011
Mali 2018
Tanzania, United Republic of 2010
Guatemala 2015
Mozambique 2011
Nigeria 2013
Congo, Democratic Republic of the 2014
Malawi 2016
Honduras 2012
Eswatini 2007
Maldives 2017
Gambia 2013
Angola 2016
Chad 2015
Togo 2014
Kenya 2014
Pakistan 2018
Uganda 2016
Nepal 2016
Senegal 2017
Namibia 2013
Rwanda 2015
Ghana 2014
Zimbabwe 2015
Liberia 2013
0 20 40 60 80 100

STAT E OF WOR L D POPUL AT I ON 2 02 1 25

 Interpersonal relations responsibility for reproductive health but at the
Relationships and communication with same time deny them decision-making power.
husbands or partners as well as with extended
family members influence a woman’s ability to Communication is a positive predictor for
make autonomous decisions. joint or autonomous decision-making. Couples
who regularly communicate about matters of
Men, as heads of households, often hold all sexual and reproductive health are more likely
the power and make many of the decisions, to make decisions jointly about contraception
including those related to sexual and and reproductive health care. The opinions of
reproductive health issues, even though these extended family members, particularly mothers-
issues are often perceived as “women’s matters”. in-law, also play an important role in these
Gender norms typically assign women the sole decisions (UNFPA, 2019).

FIGURE 5B

More decision-making power linked to higher levels of education

Say no to sex, by women’s level of education, select countries, per cent

No education   Primary   Secondary   Higher  

Tajikistan 2017
Mozambique 2011
Guinea 2018
Burkina Faso 2010
Pakistan 2018
Ethiopia 2016
Jordan 2018
Mali 2018
Gambia 2013
Côte d'Ivoire 2012
Guatemala 2015
Malawi 2016
Myanmar 2016
Comoros 2012
Timor-Leste, Democratic Republic of 2016
Eswatini 2007
Cameroon, Republic of 2011
Nigeria 2013
Ghana 2014
Burundi 2017
Togo 2014
Angola 2016
Zimbabwe 2015
Sierra Leone 2013
Kenya 2014
Tanzania, United Republic of 2010
Congo, Democratic Republic of the 2014
Guyana 2009
Armenia 2016
Lesotho 2014
Albania 2018
Kyrgyzstan 2012
0 20 40 60 80 100

26 Three dimensions of autonomy

The role of the community and reproductive health care. Studies in nine
In certain communities, the notion of bodily countries have shown that some men report
autonomy may be seen as incompatible with beliefs of entitlement to dominate women, with
local norms and values. Communities may clear expressions of unequal power relations
pressure women to bear children and may (e.g., Habibov and others, 2017; Fahmida and
generally perpetuate views that women should Doneys, 2013; Hattori and DeRose, 2008).
be submissive and passive in sexual relations.
At the same time, community norms can Adolescent girls face further barriers to
often dissuade women from discussing matters information and services because of norms
of sexual and reproductive health with men, that discourage sexual activity out of
making it difficult, if not impossible, for women wedlock. At the same time, norms in some
to negotiate sexual relations, contraceptive use communities may permit or even encourage

FIGURE 6

Greater power to say no to sex in higher wealth quintiles

Say no to sex, by household wealth, select countries, per cent

Poorest   Poorer   Middle   Richer   Richest  

Guatemala 2015
Albania 2018
Angola 2016
Armenia 2016
Jordan 2018
Eswatini 2007
Togo 2014
Mozambique 2011
Lesotho 2014
Pakistan 2018
Maldives 2017
Gambia 2013
Tajikistan 2017
Burkina Faso 2010
Chad 2015
Benin 2018
Congo, Republic of the 2012
Guinea 2018
Ethiopia 2016
Timor-Leste, Democratic Republic of 2016
Comoros 2012
Mali 2018
0 20 40 60 80 100

STAT E OF WOR L D POPUL AT I ON 2 02 1 27

 Healing bodies,
minds, spirits
Health-care providers have production, and production is make their own decisions
a unique responsibility in synonymous with quantity,” about when to have sex
affirming and safeguarding he said. “We’re forgetting with their partner… Male
the bodily autonomy of their about quality in the care we chauvinism prevails,” he said.
patients. “My advice for any give to our patients.” There Women patients often feel
health worker would be to have are also cultural barriers, he unable to speak candidly
empathy,” said Víctor Cazorla, added. “Many colleagues, about issues pertaining to
a male midwife working in many people, have gone to their sexual health, and they
the Andes mountains of rural areas without knowing can be shy about expressing
Peru. He has spent more Quechua, the mother tongue their discomfort about
than two decades working of the communities there,” gynaecological procedures,
with indigenous communities leading to misunderstandings particularly with male
in Ayacucho Region, and and even discrimination. health providers, he noted.
he knows all too well the
challenges that threaten the At the same time, many These factors, together, are
well-being and autonomy of patients are not sensitized to a dangerous combination:
the most vulnerable patients. their sexual and reproductive doctors are left struggling
rights. “Among the general to understand the needs
“The work system for health population, maybe 80 to and boundaries of their
workers often revolves around 90 per cent, I dare say, cannot patients, and patients are

“Do they consent?... If they are

not prepared psychologically,
we must respect their choice.”

28 Three dimensions of autonomy

Medical personnel at a health centre in the Ayacucho Region of Peru. Midwife Victor Cazorla is fifth from the left. Original artwork by Naomi Vona;
photo © UNFPA/A. Castañeda.

left without the words or tools women are ignorant of their consider that talking about
to advocate for themselves. sexual, physical and general these topics harms their
rights,” said Mouna Farhoud, dignity and their reputation.”
Such concerns are all the more a gynaecologist in Damascus
harrowing when health workers who specializes in treating Dr. Farhoud says even health
tend to survivors of sexual survivors. “Even the educated professionals hold views that
and gender-based violence. women are exposed to violence undermine the health and rights
“In Syria, more than half of and unable to address it. They of their patients. She recalled

STAT E OF WOR L D POPUL AT I ON 2 02 1 29

 teaching a course to health “I make it clear that this is healthy relationships are also
providers on treating sexual a medical procedure to find discussed during individual
assault survivors: “There were out if there are infections, and family counselling
many objections from the wounds, bleeding, bruises or sessions. These efforts are
participants... There was a things that help document the making a difference, he said,
denial and lack of recognition case. Do they consent? Even especially among younger
about the existence of when people realize that the people. But the burden of
sexual assault cases.” goal is for documentation, providing this information falls
if they are not prepared heavily on health providers.
Doctors must communicate psychologically, we must “I am the only midwife, for
non-judgmentally with their respect their choice. Maybe example, working on a shift
patients, and recognize this time we are not able to at the health centre and I
when their patients are examine her, but next time we have to stay there to attend
uncomfortable or when they will be able to do so after she to patients who arrive with
may have experienced feels respected and valued.” emergencies.” He says there
abuse. Sometimes, this is a need for more health
means being a detective, Cazorla added that showing resources, including staff,
Dr. Farhoud explained. “Maybe respect for one’s culture so that they can do more
the patient’s symptoms are is paramount. But what is community education, such
not commensurate with most important, he says, as targeted programmes
her complaint. Her way is empowering patients for men and boys.
of walking, her look, her themselves to become
words, her companion, the defenders of their own bodies Dr. Farhoud echoes the
physical examination—all and autonomy. “We teach call for support. Her
these come together to flag them to expect respect, organization also holds
that there is a problem.” that nobody has a right to awareness sessions for the
touch their bodies: not me, community. But she wants
And health workers must not their aunts, not their to see more education
know when to back away. fathers, not their mothers, not and accountability among
“It is your right to refuse. staff, not police, nobody.” health staff, as well. They
When I examine the patient, have a special duty of care,
such as a gynaecological He and his colleagues as sexual and reproductive
exam, I explain its importance, conduct education sessions health service providers, to
especially for people who for the community, and respect and empower their
have been subjected to sexual issues such as rights, self- patients. “We have sworn a
assault,” Dr. Farhoud said. esteem, sexual health and professional oath,” she said.

30 Three dimensions of autonomy

adolescent girls to engage in transactional friendly environment, also has a positive
sex as a way to support their households or impact. Studies have shown that family
to cover the costs of their own education. planning services that are provided through
As these girls typically come from poorer community health workers lead to increased
households, they have little power to say no use of contraception, especially when services
to sex. Whether married or unmarried, they include family planning information and
may have limited power to negotiate the use education for men (UNFPA, 2019).
of condoms (November and Sandall, 2018;
Moore and others, 2007). Married girls,
however, may also face family and communal Bodily autonomy still only
pressure to demonstrate their fertility, and
experience coerced sex and opposition to their
a distant possibility for many
using contraception (Woog and Kågesten, 2017). That only 55 per cent of women have the
power to make their own decisions about
Barriers in the health system their bodies should be a wake-up call to
Decisions about contraception and governments, policymakers and development
reproductive health care are sometimes institutions. In Mali, Niger and Senegal,
impeded by the distance to clinics more than 90 per cent of women are deprived
and facilities, especially in rural areas. of their bodily autonomy.
Other impediments include the absence
of adolescent- and youth-responsive The data for indicator 5.6.1 provide insights
services, shortages of preferred methods into the challenges women face in claiming
of contraception, poor-quality or poorly their right to bodily autonomy. But a deeper
managed services, services that are staffed analysis of the data is needed to understand
by judgmental providers and lack of privacy. the scope and nature of the obstacles faced by
In contrast, services that have convenient groups such as women who are not married
opening hours and employ health workers or in a union, persons with disabilities or
who have positive attitudes towards their ethnic and racial minorities.
clients and respect their privacy help
empower women and adolescent girls to make What is clear from the data is that in
autonomous decisions. Readily available and 57 countries—and likely every other country
accurate contraceptive information, especially in the world—women are not fully in control
when provided in a respectful, private and of their bodies.

STAT E OF WOR L D POPUL AT I ON 2 02 1 31

Artwork by Rebeka Artim
WHEN DECISIONS ARE
MADE BY OTHERS
The denial of bodily autonomy and integrity
takes many forms

The feminist slogan “the personal is political” has Despite international agreements and
been rallying women around the cause of bodily declarations about the importance of autonomy
autonomy since the 1960s. Activists before and in women’s health and overall empowerment,
since have argued that if women and girls lack untold millions of women and girls around the
the power—or agency—to realize their rights to world today still lack the power to make their
self-determination and autonomy, they are also own decisions about health care, contraception
unable to control other aspects of their lives. and sex with their husbands or partners.

Agency means having the power to make choices Often these decisions are made or influenced by
and decisions on one’s own behalf. In matters of others, whether partners, families, societies or
sex, sexuality and reproduction, agency can mean even the government, and that means women
having the power to decide freely whether, when and girls are denied their bodily autonomy.
or with whom to have sex and whether, when or
how often to become pregnant. Without agency, Although there are many impediments to bodily
a person can never have autonomy. autonomy, gender inequality is perhaps the most
insidious and pervasive one. More than 160 years
According to the Positive Women’s Network, ago, American suffragist Lucy Stone wrote, “It is
when women have full bodily autonomy, not very little to me to have the right to vote, to own
only are they empowered to make decisions property, etc., if I may not keep my body, and
about their health and future—without coercion its uses, in my absolute right. Not one wife in
or control by others—they also have the support a thousand can do that now, and so long as she
and resources needed to meaningfully carry out suffers this bondage, all other rights will not help
these decisions. her to her true position” (Hasday, 2000).

STAT E OF WOR L D POPUL AT I ON 2 02 1 33

 that newly married women were less likely
Gender inequality to refer to their first sex as forced or “against
deters autonomous their will” because sex was expected within
decision-making marriage. The notion of consent was irrelevant
because sex, even if it was forced, was thought
Gender-unequal norms and attitudes lead to to be a marital duty and therefore not a matter
power imbalances in relationships that restrict of consent (UNFPA, 2019).
women’s decisions, particularly when it comes
to saying no to sex. Patriarchal beliefs often Gender-unequal norms and attitudes can
translate into expectations that women defer to undermine a woman’s power to make her own
their husbands or partners in all aspects of their decisions about contraception. For example,
lives, including their sex lives. These expectations in a number of countries included in indicator
may not only mean that a woman should always 5.6.1, husbands, especially in rural areas,
engage in sex whenever her husband wants want more children than their wives do and
it, but also that she should not initiate sex or consider it their right to make the decision
openly express her desires. At the same time, about family size and about whether or when
women may be expected to avoid conflict, thus contraception should be used. Unequal power
reinforcing unequal power dynamics. Women dynamics in relationships constitute yet
may also refrain from saying no to sex out of fear another barrier for women who want to have
of verbal abuse, withdrawal of financial support, conversations with their husbands or partners
divorce, or even beatings and rape. about contraception. Furthermore, even raising
the topic of contraception may be perceived
Research has shown that girls and women are by men as an admission to extramarital
often unaware that they have the right to say relationships and can lead to conflicts
no. One study in India, for example, showed resulting in violence, separation or divorce
(UNFPA, 2019). The nexus between gender
inequality and denial of bodily autonomy has
a real impact on the lives of women and girls

Research has
everywhere, every day. Attitudes and norms
that subordinate a woman’s or girl’s well-

shown that girls

being, needs and rights to those of a man or
boy take away her power—her agency—and

and women are

research has verified that this can have negative
consequences that can last a lifetime and

often unaware
carry from one generation to the next (van
Eerdewijk and others, 2017; O’Neil and others,

that they have the

2014). This dynamic can play out in many
ways, some more egregious than others, but

right to say no
it is particularly evident in marital laws and
practices that subordinate women to men.

34 When decisions are made by others

Persons with disabilities at greater risk
of rape and coerced sex
Girls and young women with disabilities Research on levels of sexual assault against
are more likely to experience violence than persons with disabilities shows elevated levels
either their male peers with disabilities or when compared to people without disabilities. In
girls and young women without disabilities the United States, for example, the U.S. Department
(UNFPA and others, 2018). Girls and boys of Justice found that girls and women with
with disabilities are nearly three times disabilities suffer violent crime, including sexual
more likely to be subjected to sexual assault and rape, at a rate of 32.8 women per 1,000
violence, with girls at the greatest risk. each year, compared to 11.4 women per 1,000 for
women who do not have disabilities (Harrell, 2017).
Consent is crucial when any person
engages in sexual activity, but it plays In the United States, an advocacy group, Disabled
an even bigger and potentially more World, reported that an estimated 80 per cent of
complicated role when someone has a women and 30 per cent of men with intellectual
disability, according to RAINN (the Rape, disabilities are forced at some point into some
Abuse and Incest National Network), form of non-consensual sex but only 3 per cent
an anti-sexual violence organization in of such sexual abuses involving people with
the United States (RAINN, 2020). developmental disabilities are ever reported.
Women with a disability were far more likely to
have a history of undesired sex with, or marital
rape by, an intimate partner. One study found
that 54 per cent of boys who are deaf have been
sexually abused in comparison to 10 per cent of
boys who are hearing (Disabled World, 2012).

Insofar as societies do not equip persons

with disabilities with the means to control
whether, when or with whom to have sex
and whether, when or how often to become
pregnant, they are denying large numbers of
people of their right to bodily autonomy.

Artwork by Kaisei Nanke

STAT E OF WOR L D POPUL AT I ON 2 02 1 35

 lifelong subordinate relationships before they
achieve the legal capacity to make decisions
that affect their entire lives. The most recent
estimates indicate that there are 650 million
women alive today who were married before
the age of 18, and every year another 12 million
girls are married before they become adults
(UNFPA, 2020; UNICEF, 2020).

Even though all but one of the world’s countries

has ratified the Convention on the Rights of
the Child, many countries still allow marriage
Artwork by Tyler Spangler under the age of 18, sometimes with the
consent of a parent, guardian, judge or other
governmental official.

Forced and child marriage But even where child marriage is prohibited
The most obvious marital practices that deny a by law, it continues in practice. Many such
woman agency are marriages where she cannot marriages take place through traditional or
make a free and informed choice about her religious ceremonies and are never registered
own partner: forced and child marriage. Forced with civil authorities. In some parts of the world,
marriage is any marriage in which one or both of cohabitation where one or both partners are
the partners enter into it “without full, free and minors is also common. With continued high
informed consent”. Child marriage, a subset of rates of child marriage in South Asia and sub-
forced marriage, is any marriage where at least Saharan Africa and parts of Latin America and
one of the parties is under the age of 18 and the Caribbean, it is projected that by 2030, in
has therefore not reached the age when she or the absence of high-impact interventions, there
he can express full, free and informed consent could be as many as an additional 120 million
(OHCHR, 2020). Both forms of marriage women and girls who will have been married by
violate an individual’s rights, including rights the age of 18 (UNFPA, 2020; UNICEF, 2020).
associated with bodily autonomy and integrity.
Forced marriages are driven by institutionalized
These marriages are rooted in patriarchal patriarchal practices, including payment
attitudes and deny women and girls autonomy in of dowry or bride price, bride kidnapping,
general, and their power to make decisions about marriage of widows to in-laws, or “widow
health care, contraception and sex in particular. inheritance”, and marriage of rape survivors
to their assaulters. Through these practices,
Child marriage is a form of gender-based brides become a commodity, or property,
violence. It is also a powerful constraint on the to be owned, bought, sold or traded, with
agency of women and girls, forcing them into no regard for their rights or autonomy.

36 When decisions are made by others

Through dowries, the bride’s family pays, in compliance” (Turner, 2009). The tradition of
cash or in kind, the groom’s family to “take her refunding the bride price is especially problematic
off their hands”. Dowries ostensibly provide because it means that if a woman or her family
for the welfare of the bride but a closer look cannot afford to repay it, then she can be trapped
reveals a system that is “as ugly and corrosive to in an abusive relationship with no recourse. Bride
women’s rights as child marriage, female genital price also takes place in other parts of the world,
mutilation, and systems of male guardianship” including some Pacific Island countries.
(McCarthy, 2017).
There are other, less common, traditional
In almost all cases, the dowry practice directly patriarchal marriage customs that take away
or indirectly oppresses women, often leading to female autonomy. In some parts of the world, for
abuse and violence and maintaining a system of example, there is a tradition of bride kidnapping:
gender inequality. It encourages child marriage physically removing a girl or woman to take her
because families pay smaller dowries for younger to the home of a man who wants to marry her.
brides. It also results in violence: about 8,000 According to a 2016 UNFPA study in Kyrgyzstan,
dowry deaths, where women are killed because the tradition of bride kidnapping persists,
families are not paid the expected dowry, are despite being illegal. Under the custom, a man
recorded each year in India alone, according to may abduct a woman or girl from her home or
that country’s National Crimes Statistics Bureau school or work and take her to his family’s home,
(Dhillon, 2018). where she is usually forced to write a letter asking
consent from her family. The letter is accompanied
Bride price is the opposite of dowry: a girl or by a bride price payment from the groom’s family.
woman is “bought” by the groom’s family to Fewer than one in 10 such “proposals” is turned
become a wife for their son. The practice is down by the woman’s or girl’s family. The UNFPA
common in some parts of Africa where “a bride study found that almost one fifth of marriages
price is the conditional exchange of property, in Kyrgyzstan follow the traditional practice of
usually cows or money, from the groom to the “kidnapping”, and an estimated one quarter of
parents of the bride in return for marriage” those are without the bride’s “consent” (UNFPA
(Turner, 2009). It relegates the woman to the in the Kyrgyz Republic, 2016).
status of property and supports the notion that
a man has purchased his wife’s reproductive and Another still-practised tradition is that of widow
productive capacity as well as, most importantly, inheritance, whereby a woman whose husband
her obedience. The payment of a price can give has died is forced to marry a relative of the
the man licence to use violence against his wife deceased, usually a brother. Traditionally, this
to make her obey (Thiara, 2011). was seen as a means of providing protection for
the woman and her children and of keeping
Moreover, the bride price must be refunded if the woman in her husband’s family, especially
a man decides to divorce or separate from his after dowry had been paid. But the widow does
wife: “this practice hangs like a threat over her not give her consent and often ends up in a
head and that of her parents, ensuring the wife’s relationship she did not want or ask for.

STAT E OF WOR L D POPUL AT I ON 2 02 1 37

 Marital practices that Girls and women who are subjected to child
and forced marriage are often denied their
subordinate women and right to make decisions about, or lack accurate
undermine health information about, their sexual and reproductive
health. A large-scale study in India, for example,
The more pernicious of the female-subordinating documented negative reproductive health
marital practices, which violate a woman’s right to consequences of child marriages: young women
bodily autonomy, have also been shown to have who had married at the age of 18 or older were
negative consequences for sexual and reproductive more likely than those who had married before
health. Widow inheritance, for example, requires a the age of 18 to have been involved in planning
woman to engage in sexual relations with the man their marriage, to refuse to tolerate domestic
who “inherits” her, regardless of how many sexual violence, to have used contraceptives to delay
partners he may have had in the past, increasing their first pregnancy and to have had their first
the risk of HIV transmission (Mabumba and birth in a health facility. They were less likely
others, 2007). A study in the Bondo district of than women who had married early to have
Kenya found that 56.3 per cent of widows had experienced physical violence or sexual violence
been “inherited” through a traditional ceremony. in their marriage or to have had a miscarriage or
Among those women, the ones who had taken stillbirth (Santhya and others, 2010).
part in a sexual ritual known as “widow cleansing”
were found to be more likely to be infected with Another study in Nepal found that a
HIV (Agot and others, 2010). Widow cleansing combination of pressure to give birth soon
is a ritualized dissolution of the bond of the after marriage, limited autonomy, and little
spirit of a dead man with his wife, through her knowledge about reproductive health issues
submission to sexual intercourse with one of his make young married girls vulnerable to high-risk
living relatives. pregnancies (Maharjan and others, 2019).

Child marriage has countless deleterious effects Besides the violation to bodily autonomy, child
on a girl’s sexual and reproductive health and marriage impinges on other human rights, such as
bodily autonomy. Forced sex and early and the right to education. Differential education rates
frequent pregnancies are closely linked to high between genders is one of the major impediments
maternal and infant morbidity and mortality to full gender equality and the empowerment of
rates, as well as poor mental health. In low- and women and girls, and child marriage and early
middle-income countries, complications from childbearing are significant obstacles to ensuring
pregnancy and childbirth are the leading cause educational, employment and other economic
of death among girls aged 15 to 19 years, and opportunities for girls and young women.
adolescent mothers face much higher rates of
complications during pregnancy and childbirth, An extensive World Bank study undertook
with higher rates of stillbirths and newborn to test whether women worldwide who had
deaths, than mothers just a few years older, 20 to married as children had less decision-making
24 years (WHO, 2020). power in the marriage, with specific questions

38 When decisions are made by others

Slavery: the ultimate violation
of the right to autonomy
People who are enslaved have no power to Although modern slavery is not defined
make any decisions about their bodies or lives. in law, it is an umbrella term covering
practices such as forced labour, debt
An estimated 40 million people are in some bondage, forced marriage and human
form of modern slavery (United Nations, n.d.). trafficking. It refers to situations of
exploitation that a person cannot refuse
or leave because of threats, violence,
coercion, deception or abuse of power.

There are more than five victims of modern

slavery for every 1,000 people in the
world. One in four victims is a child. More
than seven in 10 victims are female.

Embedded in Sustainable Development

Goal 8—to achieve inclusive economic
growth and decent work by 2030—is a
target to eradicate forced labour and end
modern slavery and human trafficking.

Victims are often the most vulnerable in

our societies: those suffering multiple
forms of discrimination—women, children,
indigenous peoples, people of African
descent and persons with disabilities, United
Nations Deputy Secretary-General Amina J.
Mohammed said in 2020. “Modern slavery is
a blight in our world that we must eradicate,”
she added, calling modern slavery and
human trafficking “international crimes with
significant costs to society and economy”.

Artwork by Kaisei Nanke

STAT E OF WOR L D POPUL AT I ON 2 02 1 39

 Able to choose
In 1999, Lizzie Kiama was redefining what it means, she And then there are the
commuting to work in explained. Kiama went on horror stories.
Mombasa, Kenya, when her to found This Ability Trust,
minibus collided, head-on, into a social enterprise focusing “I have heard stories of women
another vehicle. “I was seated on the rights of persons who would rather give birth
in the front,” she remembered. with disabilities, through at home than face nurses or
“The accident resulted in me which she has observed midwives who question why,
becoming disabled.” But it the many ways people in their disabled condition,
would be 11 years before she with disabilities are denied they would be having children
fully accepted this new reality. agency, particularly when it or getting pregnant,” Kiama
comes to their sexual and said. “Society, in general,
“I did not identify as a reproductive health and rights. has associated persons
person with a disability for with disabilities, women in
a long time,” Kiama said. Those with visual or hearing particular, as being asexual...
“That’s because there was disabilities seldom have Simple things like legal
always a very negative access to interpreters or Braille capacity, bodily autonomy, the
connotation that surrounded when seeking health services, right to decision-making are
the word ‘disabled’.” she said, and persons with not considered the norm.”
caregivers face reduced privacy
The turning point was and confidentiality. Many Women and girls with
becoming a mother and persons with disabilities lack disabilities face high rates
deciding she would improve accessible transport options, of gender-based violence
the world for her children. For and many health facilities lack in Kenya (Salome and
her, that meant identifying as the infrastructure, equipment others, 2013). But too often,
a person with a disability—and and trained staff to serve them. in response, their bodily
autonomy is further violated,
Kiama said. “You find in some
cases girls with disabilities

“Families collude with

whose families collude with
medical professionals to
sterilize them as a means of

medical professionals ‘protecting them’, because

they are constant victims

to sterilize them.”
of sexual violence,” she
explained. “Nothing happens
to the perpetrators.”

40 When decisions are made by others

Lizzie Kiama is a champion for the rights of persons with disabilities. Original artwork by Naomi Vona; image courtesy of Lizzie Kiama.

But these issues are in no way In Mongolia, for example, consent from the women’s
unique to Kenya alone. People there have been reports of guardians, according to
with disabilities confront health workers performing Enkhjargal Banzragch, a social
serious obstacles to sexual and abortions on women with worker at the Mongolian
reproductive health decision- disabilities without consulting National Wheelchair Users
making almost everywhere. them. Instead, the doctors seek Association. One study by the

STAT E OF WOR L D POPUL AT I ON 2 02 1 41

 Association found 22 per cent was happening. “She said, “But how do we deal with
of persons with disabilities ‘No, I trust my doctor.’” the actual practices?”
have been forced by family
members or health-care Still, there are reasons For that, experts agree,
providers to use contraception. for hope. attitudes must also change.
“Women with disabilities have
Refusing contraception “Looking at policies and a right to fall in love, have a
can have consequences. the legal framework from baby, get services and have
Women with intellectual an advocacy point of view, a life,” Azyei emphasized.
disabilities are often there has been progress,”
denied their allowances or Kiama said, citing Kenya’s Persons with disabilities
extension of their disability 2003 disability act, the must be protected from
status if they have not country’s constitution, the sexual abuse, but these
received required doses of ratification of international protections must support—
injectable contraceptives, conventions on disability rather than undermine—
Banzragch explained. rights, and increasingly their bodily autonomy. And
accessible building standards. they must be empowered
Individuals with disabilities to claim their rights.
and their caregivers may be Mongolia, too, has seen
given little to no explanation, progress. During a 2015 “As persons with disabilities,
says UNFPA Assistant review of Mongolia’s human we imagine that we need
Representative in Mongolia rights records, reproductive to have our hands held
Iliza Azyei, who worked health violations against and to ask for permission,”
with activists and the health persons with disabilities Kiama said. But she sees
ministry to raise these issues. were brought to light. The change in the younger
Government “made immediate generation of persons with
She recalled the story of one revisions in the health disabilities. “We’re seeing
girl: “As soon as she turned ministerial order to provide more young women taking
16, the public health doctor sexual and reproductive health up space and using social
came to her house and they services to women, including media for advocacy. They
started providing quarterly disabled women,” Azyei said. are advocating for sexual
injectable contraceptives.” and reproductive rights
Azyei asked the girl’s mother Policy-level change is in different ways, and
if they had questioned what just one step, she added. that’s incredible to see.”

42 When decisions are made by others

about seeking reproductive health services vulnerable. Niger, for example, has the highest
and use of contraception. The study found child marriage prevalence rate in the world
that, in the case of both contraceptive use and (76 per cent of girls are married before 18),
decision-making power, the variable with the but the rates in regions with large numbers of
most impact was years of education. What persons receiving humanitarian assistance are
the study validated was that child marriage even higher—up to 89 per cent in Maradi. In
did have an effect on reproductive health and another example, an Oxfam report found 70 per
decision-making power mostly through its cent of girls in a northern town in Sudan were
indirect impact on educational attainment married before the age of 18 after an outbreak
(Wodon and others, 2017). The shortening of of fighting in the region, much higher than
formal education for girl brides has economic the national average (UN HRC, 2019).
implications for them and society, but it
also has a real impact on their sexual and Conflict and post-conflict settings are
reproductive health and their ability to exercise particularly conducive to gender-based violence,
their agency and make autonomous decisions. including forced and child marriage, because of
such factors as the breakdown of the rule of law
and security, changes in traditional gender roles
Humanitarian crises and constraints on the freedom of women and
negatively impact women’s girls, cultures of impunity, loss of economic and
bodily autonomy social capital, and even extremist ideologies that
encourage the abduction of women and girls into
Evidence from humanitarian crises around armed groups (Swaine and others, 2019).
the world shows that a breakdown of family,
social and legal networks increases the risk of In the case of these extreme ideologies, in
sexual violence as well as fuelling widespread recent years armed non-state actors have
perceptions that the “honour” of girls and enforced a social order that perceives women
women, and therefore their families, is in danger. and girls as either tools of their movements
This fear of “damage” to family honour may or as threats. In some cases, girls and women
underpin families’ decisions to marry girls at an have been forced to marry members of these
early age, resulting in higher numbers of forced groups to serve as sex slaves. For example,
and child marriages. Fear of sexual violence beginning in 2014, Yazidi girls and women
against women and girls has been found to be in Iraq were forced to marry members of
a leading cause for families to flee their homes Islamic State in Iraq and the Levant (ISIL).
in emergencies—and an incentive to marry off
their daughters at a young age in the belief that ISIL in the Syrian Arab Republic, Boko Haram
marriage will protect them (UN HRC, 2019). in Nigeria and Cameroon and Al-Shabaab in
Somalia abducted girls and women to be raped,
Within countries with high prevalence rates sold and forced into marriage. The ideological
of child marriage, girls who are displaced exploitation of child and forced marriage has
or impacted by crisis are some of the most been reported in the Central African Republic,

STAT E OF WOR L D POPUL AT I ON 2 02 1 43

 Libya, Mali and Somalia, while armed and Programmes to end or prevent female
organized crime groups in Malaysia and Nigeria genital mutilation are often left out of
have been reported to use child and forced humanitarian response plans. During the
marriage as a cover for sexual exploitation and initial phases of the COVID-19 pandemic,
human trafficking (UN HRC, 2019). for example, most countries where female
genital mutilation is prevalent did not
While there is ample evidence that gender-based prioritize the elimination of the practice in
violence increases in conflict and displacement their national humanitarian response plans
settings, there is less evidence about how crises (UNFPA and UNICEF, 2020). Yet, several
impact women’s decision-making capacity in assessments indicated an increased risk of
sexual relations. Although crises often lead to girls undergoing the practice: a UNFPA
a deterioration of public services, there is also assessment in Somalia showed that 31 per
evidence to suggest that women’s agency in cent of community members who were
accessing health care and using contraception can interviewed said they believed there had
actually be enhanced in such times. One reason been an increase in this harmful practice
for this is the diminished influence of gender- since the pandemic began (UNFPA,
unequal community norms in crisis-affected 2020a). A survey by Save the Children in
settings, which allow greater latitude in making September 2020 in the Dadaab refugee
autonomous decisions. camp in Kenya explored the impact of
COVID-19 and found that 75 per cent of
In crisis-affected countries such as Eritrea and child-protection workers reported a 20 per
Liberia, the progressive dissolution of community cent increase in female genital mutilation
norms enabled some women to have not only (Save the Children, 2020).
more autonomy, but also greater freedom of
speech and decision-making authority at the In countries such as Ethiopia, Kenya,
household level. This phenomenon has also Nigeria and Sudan, girls are also reportedly
been seen in places affected by natural disasters, at an increased risk of undergoing female
such as droughts, where more women chose to genital mutilation as a precursor to marriage,
use contraception. Another reason why some suggesting a negative coping strategy
women have more power to make decisions about associated with economic fallout and school
health care is that contraceptive information closures (UNFPA and UNICEF, 2020).
and services are often readily available in refugee
camps (UNFPA, 2019). However, during and According to estimates by UNFPA, the
after crises, gender inequality and discrimination pandemic may result in 2 million cases
can also compound the challenges women and of female genital mutilation that would
girls face in securing their bodily autonomy and otherwise have been averted, or a one
integrity. As a result, many endure increased third reduction in progress towards
insecurity, restricted mobility, gender-based Sustainable Development Goal target 5.3
violence and harmful practices, including to eliminate female genital mutilation by
female genital mutilation (ICRC, 2020). 2030 (UNFPA, 2020b).

44 When decisions are made by others

“Honour killings”:
an extreme denial of
bodily autonomy
Honour killings occur in communities where
the “honour” of the family is considered
to be more important than the life of the
person, usually a woman, who violates
certain so-called norms or codes (Gibbs and
others, 2019).

Rationalizations for honour killings have

included separation from a spouse who
paid a bride price, refusing to enter into
an arranged marriage, entering into a
relationship with a person from a different
religion, ethnic group or caste, engaging
in premarital or extramarital sex, being the
victim of rape or assault, or being identified
as gay (Selby, 2016).

Although both men and women can commit

or be victims of honour killings, the “code
of honour” has different standards for men
and women, including stricter standards of
chastity for women and a perceived duty for
men to commit violent acts to secure their
honour or that of their family. In all cases,
the honour code is part of the patriarchal
social system that subjugates women to
men. The result is that honour killings are Artwork by Tyler Spangler
disproportionately violence against women.
Although it is not possible to know the true
number of these killings, it is estimated that of murder were killed by an intimate partner or
there are approximately 5,000 such murders member of their own family, amounting to 137
every year, of which most take place in the women every day (WHO, 2013). This has been
Middle East and South Asia (Gibbs and exacerbated by the COVID-19 pandemic—and
others, 2019). It is important to note that violence against women has been deemed the
an estimated 58 per cent of female victims “shadow pandemic”.

STAT E OF WOR L D POPUL AT I ON 2 02 1 45

 Threatened by a
woman’s sexuality
Culture, tradition and religion caused by the practice, which obstetrician and gynaecologist
are among the most commonly can include haemorrhage, in Egypt, convince parents to
cited motivations for performing sepsis, future childbirth reject the practice. Clearly
female genital mutilation. Yet complications and even death. articulating harms, like inability
curtailed sexual desire is almost Emphasis on the physical to experience orgasm, pain
universally understood to be consequences is more easily during intercourse, and aversion
an outcome of the practice received in conservative to sex due to post-traumatic
and, in fact, it is also a key communities, where discussing stress disorder, has been an
motivator. Many proponents of female sexuality is often effective deterrent, especially
female genital mutilation have taboo. But a sole focus on “if the mother had a very bad
argued that unbridled female physical harms may risk experience while undergoing
sexuality is somehow a threat inadvertently leading to the female genital mutilation when
to chastity, honour and virtue medicalization of the practice, she was young or had troubles
(Berg and Denison, 2013). or the practice of alternative in her marital life because of the
types of cutting, rather than circumcision,” Dr. Basta said.
Frank conversations about its abandonment altogether
female sexuality, bodily integrity (Powell and Yussuf, 2021). She speaks with ease about
and bodily autonomy may the social and psychological
offer an unexpected antidote Broadening these repercussions women can
to the practice, experts say. conversations to include an experience. “This may affect her
honest accounting of the mental health, social well-being
Efforts to end female genital sexual harms caused by female and her relation with her partner,
mutilation have historically genital mutilation has helped which may affect deeply the
underscored the physical harms Wafaa Benjamin Basta, an concept of the family itself.”

One reason Dr. Basta is able to

“Minds are changing,

have these forthright discussions
is her role as a physician. “There
is this bond between the patient

especially for the and the doctor,” she said. But

even more critical is the growing

new generations.”
acceptance of women’s rights
and empowerment in Egypt.

46 When decisions are made by others

Female genital mutilation is not simply a health issue. It is a sexuality issue. Original artwork by Naomi Vona; photo by Hana Lopez on Unsplash.

“Minds are changing, especially to rethink the practice of community and practitioner.
for the new generations.” female genital mutilation. Still, she has seen great
progress in recent years, and
As fears of female sexuality Dr. Basta says her is hopeful about the future,
diminish, and sexual observations are limited to both for ending female genital
well-being is increasingly the confidential conversations mutilation and for promoting
considered within the frame she is able to have with her women’s sexual health and
of psychological and social patients, and that comfort well-being. “There’s no shame
health, it becomes easier with these topics will vary by to talk about that,” she said.

STAT E OF WOR L D POPUL AT I ON 2 02 1 47

 Marital rape and (Jewkes and others, 2011). Women
experiencing abuse in marriage are one-
“marry-your-rapist” laws and-a-half to three times more likely to test
It is clear that the data points chosen for positive for HIV and two to four times more
indicator 5.6.1 are inexact measures for all the likely to report another sexually transmitted
ways that the agency of women is attenuated infection (WHO, 2015).
by patriarchal marital structures, but there is a
direct relation in the case of one component: The various practices that enforce male
can a woman say no to her husband or partner control and violate the bodily autonomy
if she does not want sexual intercourse? rights of women are interrelated. Studies
Whatever the interpersonal dynamics inside a have found a strong correlation, for example,
marriage, it is the case that in some countries between marital rape and child marriage: a
the law permits the husband to have sexual 2011 study found that most cases of marital
intercourse whether the wife wants it or not, rape in Uganda were committed against 15-
and there are countries where a man who rapes to 19-year-old girls whose older husbands
a woman can escape penalties if he marries her had paid a bride price to obtain their wives
against her will. (Hague and others, 2011).

Whether a woman has been forced into a Forty-three countries do not have any
marriage or entered into it freely, traditional legislation that addresses the issue of marital
patriarchal norms have held that once a rape. Even in countries that recognize the
marriage has taken place a man “owns” his concept, the penalties for non-consensual sex
wife’s body and can use it for sex whenever he within marriage may be significantly lower
wants. It is only within the last few decades than in other cases. Likening marriage to
that “marital rape” has been recognized as a “get-out-of-jail-free card”, a 2020 study
a concept and as constituting an egregious found that among the 54 Commonwealth
human rights violation. The victims of marital countries 35 still apply some form of marital
rape are subject to the manifold harms suffered exemption to criminal sexual offences
by all rape survivors: psychological damage (Richardson, 2020).
as well as the physical injuries associated
with forced sex, unintended pregnancies, In some countries and territories,
miscarriages and sexually transmitted marriage may be considered a legal
infections (Yllö and Torres, 2016). “cure” for rape by allowing perpetrators
to marry their victims and thereby avoid
This human rights violation has important any penalties for their crime. Laws
reproductive health consequences. The allow men convicted of rape to have
risk of HIV and other sexually transmitted the verdict overturned if they marry the
infections is increased because of forced women they have assaulted in Algeria,
vaginal penetration and abrasion, which Angola, Bahrain, Bolivia, Cameroon,
facilitates entry of the virus into the body Dominican Republic, Equatorial

48 When decisions are made by others

Guinea, Eritrea, Gaza, Iraq, Kuwait, Libya, Female genital mutilation
Philippines, the Russian Federation, Serbia,
Syria, Tajikistan, Thailand, Tonga and Female genital mutilation comprises all
Venezuela (Equality Now, 2020). procedures that involve partial or total removal
of the external female genitalia, or other injury
In 2017, the NGO Equality Now to the female genital organs for non-medical
undertook an extensive review of “marry- reasons (WHO, 2020a).
your-rapist” laws. It found, for example,
that in Iraq, if the perpetrator marries Female genital mutilation is a violation of
the victim, any legal action against women’s and girls’ human rights and an extreme
him becomes void, and any ongoing form of discrimination and violence directed
investigation or legal case is discontinued. exclusively at girls and women. It is also a part
If a sentence has already been handed down, of wider patriarchal practices, rooted in gender
it is reversed and not carried out, but it can inequality and aimed at controlling women’s and
be reinstated if there is divorce within three girls’ sexuality, their bodies and their sexual and
years. In Kuwait, if the perpetrator legally reproductive rights.
marries his victim with the permission of
her guardian and the guardian requests The practice denies women and girls their rights
that he not be punished, the perpetrator to: physical and mental integrity; freedom from
is set free. In Russia, if the perpetrator has violence; the highest attainable standard of
reached 18 years of age and has committed health; freedom from gender discrimination; and
statutory rape with a minor below 16, he freedom from torture and cruel, inhuman and
is exempt from punishment if he marries degrading treatment, among others. Yet, more
the victim. In Serbia, “cohabiting with than 200 million girls and women live with the
a minor” is prohibited; however, “if a consequences of female genital mutilation, and
marriage is concluded, prosecution shall not at least 4 million girls are at risk of undergoing
be undertaken and if undertaken it shall be the practice each year (UNFPA, 2020c;
discontinued”. In Thailand, marriage can be UNICEF, 2020a).
considered as a settlement for statutory rape
if the offender is over 18 and the victim is Female genital mutilation deprives women
over 15 years old, if she “consented” to the and girls of their right to make autonomous
offence and if the court grants permission decisions about an intervention that has a lasting
for marriage (Equality Now, 2017). effect on their bodies and infringes on their
autonomy and control over their lives. Female
Marriage laws and practices that subordinate genital mutilation is a deprivation of capabilities,
women and deny them agency are widespread affecting the ability of women and girls to
and difficult to root out. However, they are achieve full functioning in the world because of
far from the only ways in which patriarchal the physical, sexual and emotional consequences
structures reinforce male dominance and of the practice. These consequences, in turn,
circumscribe female sexuality. may adversely affect their individual well-being,

STAT E OF WOR L D POPUL AT I ON 2 02 1 49

 Putting the unity
in community
Daniyar realized he was unique. In fact, advocates advocacy groups that are a
transgender at age 7, but and researchers have long driving force for change.
believed for years that he was observed the creative and
alone. “When I was 15 or 16, collective ways people come That is happening in
I was very depressed. I was together to reclaim their Kyrgyzstan, said Ayim, a
not accepting myself… I didn’t bodily autonomy when it is 24-year-old transgender
know that there were LGBTI threatened. LGBTI people woman. She, too, felt isolated
communities or organizations have created safe spaces for for years before finding
in Kyrgyzstan.” It was not each other in even the most acceptance and solidarity
until someone tipped him off restrictive settings around in the LGBTI community. “I
about a local LGBTI group the world. And there are would wear my mom’s skirts.
that he felt equipped to take other examples. Sex workers My mom would make fun
control over his body and life. come together to share of me and scold me at the
“I understood that this is my information about violent same time… When I started
environment,” he said. “Before clients. Women help each my studies at a university,
that, I felt I was not living in other conceal contraceptives, I understood that I needed
my own body. But I learned escape abusive partners, to disclose who I am. If I
about transgender people, and or terminate unwanted disguised it all my life, I
started reading about it, and pregnancies in countries would be trapped. In 2016,
then I started my transition.” where abortion is hard to I started actively getting
access or illegal. When and acquainted with people from
Daniyar, now 23, knows where possible, these informal the LGBTI community.”
this experience is far from networks tend to formalize into

“We have common problems

and we know how to
support each other.”

50 When decisions are made by others

Ayim says she felt isolated before finding the LGBTI community. Original artwork by Naomi Vona; image courtesy of Ayim.

Today, both Daniyar and Ayim housing assistance and people are especially vulnerable,
are LGBTI activists. They work access to health information they say, with high rates of
with a local non-governmental and care. This support is unemployment in part because
organization, Kyrgyz Indigo, critical in a country where they cannot update their
to provide services to LGBTI LGBTI people face frequent identification documents to
people in need, including discrimination. Transgender reflect their gender identity.

STAT E OF WOR L D POPUL AT I ON 2 02 1 51

 “The latest amendments we know how to support the pandemic to meet
in the law prohibit people each other,” explained the increased need for
from changing their Ayim. “We stick with each emergency housing.
passports to correct their other.” And expressing
gender,” said Daniyar. one’s authentic gender Their experiences
There are also very identity is non-negotiable, hold lessons for
few medical specialists they say. It is a matter of other marginalized
helping transgender life or death. If transgender communities working to
people transition, making people were forced to advocate for their rights
the process extremely hide completely, “I think and bodily autonomy,
costly. “Many sacrifice there would be many they say. Firstly, “there
their nutrition or do not suicides,” said Daniyar. is a need to empower
sleep [to work around Or they would “leave the community and to
the clock], so they can Kyrgyzstan and become increase visibility,” Ayim
save money for surgery a refugee, because living noted. Acceptance of
to correct their bodies.” in a body that is not yours LGBTI issues within
is terrible,” added Ayim. the country is greatest
There is always a threat in Bishkek, the capital,
of violence looming Circumstances for thanks to the presence of
over them. Both Daniyar the community have activist groups and efforts
and Ayim have been worsened under the there, she explained.
threatened, and they COVID-19 pandemic,
have friends who have with job losses leaving But advocates must
been assaulted. “There many homeless, also be prepared for
are many stories like hungry or unable to opposition, and they
this,” Daniyar said. “They afford medication. must protect themselves:
beat up or take the Kyrgyz Indigo has “You need to be ready for
person somewhere, to been delivering food any reactions and move
the mountains, outside and essential supplies, with no fear,” Ayim said.
of the city… beat them including soap, toilet “When you fully devote
almost to death or maybe paper and sanitary yourself to activism, to
to death and leave napkins, to those in such work, you burn out.”
them in a wasteland.” need. It is helping ensure And most important, she
continued access to said, is trust: “The main
Despite these risks, they hormone therapy for thing is to trust yourself,
are motivated by an transgender people and trust your power… Do
intimate understanding antiretrovirals for people not be afraid of anyone.
of the struggles in their living with HIV. And it Because there is you,
community. “We have has been operating three there is us, and together
common problems and shelters throughout we can all go further.”

52 When decisions are made by others

including opportunities for sexual satisfaction No gender equality without
and for choice in matters of reproduction
(Nussbaum, 2000).
control over one’s own body
Forced and child marriage, marital rape and
While families and communities cite cultural, female genital mutilation are some of the more
religious and social reasons for practising female stark examples of the relationship between
genital mutilation, justifications centre on the gender-unequal norms and the erosion of a
need to reduce women’s sexual desire (Gamal woman’s or girl’s power to make autonomous
and others, 2018). Female genital mutilation is decisions in life. Assaults on this power come
directly linked to gendered power relations and from many other directions as well, ranging
social control over women’s bodies and sexuality, from legal and economic systems that deny
and to the status of women and girls in a given women financial independence, to patrilineal
society and their level of empowerment or inheritance traditions and education systems
agency (Toubia and Sharief, 2003). that fail to impart knowledge to girls about
their bodies and rights.
Women living in communities that practise
female genital mutilation are subject to a strong Breaking through the many economic,
patriarchal social and economic regime with social and institutional barriers to full gender
very few options for choices in livelihood, which equity and equality is complex and difficult,
leaves them little opportunity for negotiating a but any achievements that are made are
limited amount of power (Toubia and Sharief, of little consequence unless they provide
2003). The lack of choice over their own lives the most fundamental right: the right to
means that having their daughters undergo control one’s own body. This has become
female genital mutilation, and complying with globally recognized through the Sustainable
other social norms, especially those linked to Development Goals, which acknowledge
sexuality and the economics of reproduction, that Goal 5 to achieve gender equality and
is an essential requirement for “silent power the empowerment of all women and girls
negotiations” (Toubia and Sharief, 2003). has to include universal access to sexual and
reproductive health and reproductive rights.
Women may protect and practise female genital And one of the measurements of achievement
mutilation because they use it as a power-gaining is the proportion of women who make
tool (MIGS, 2015). Women may even forego their own informed decisions about sexual
autonomy over their body in exchange for and reproductive choices—in other words,
social inclusion, economic survival (marriage) the extent to which women control their
and other freedoms (MIGS, 2015; Toubia and own bodies.
Sharief, 2003).

STAT E OF WOR L D POPUL AT I ON 2 02 1 53

Artwork by Hülya Özdemir
MY BODY
MY RIGHTS
International treaties and declarations
provide foundations for the right to bodily
autonomy and integrity

Do people have rights to make decisions about Bodily autonomy in the context of sexual and
their own health care, including reproductive reproductive matters encompasses rights that
health care? Do these rights include making enable individuals to make informed choices
choices about contraception? Does a woman and decisions regarding their sexual and
have a right to say no—or yes—to sex, when she reproductive health needs, and to do so free from
wants and with whom she wants? discrimination, coercion and violence. These
rights were first articulated in the Programme of
According to international human rights law, the Action of the 1994 International Conference on
answer to these questions is an emphatic “yes”. Population and Development (ICPD), and the
Platform for Action of the 1995 Fourth World
Even though bodily autonomy is a foundation Conference on Women (United Nations, 1995;
upon which human rights are built, it is rarely UNFPA, 1994).
articulated as a right in and of itself (UN
General Assembly, 2007). Rather, bodily Depending on the treaty or agreement,
autonomy underpins or is subsumed in a “autonomy” in matters related to sexuality and
number of rights that are spelled out in treaties reproductive health and decision-making may
and international agreements. encompass access to comprehensive sexuality

STAT E OF WOR L D POPUL AT I ON 2 02 1 55

 education, contraceptive information and cruel, inhuman and degrading treatment,
services, maternal health care, infertility or as a right to dignity and privacy, or in
treatment, gender-affirming interventions, the right to health as expressed in many
such as hormonal and surgical treatment, and national constitutions (Viens, 2020).
comprehensive abortion care. Autonomy also
touches on matters of civil status, ranging from
marriage and divorce to the legal capacity to Bodily autonomy
make decisions about one’s own body and the and reproductive
power to express one’s gender identity. decision-making
Rights to bodily autonomy are aligned with Human rights law robustly affirms
rights to bodily integrity, which are tied the right to information and means
physically to liberty and security of the person, to make decisions about childbearing.
and to freedom from torture and cruel, Article 16.1(e) of the Convention on the
inhuman or degrading treatment, as well as Elimination of All Forms of Discrimination
the inviolability of one’s self: body and mind. against Women, commonly known as
In the context of reproduction and sexuality, the Women’s Convention, requires States
violations of bodily integrity include practices Parties to uphold women’s rights “to decide
such as female genital mutilation, virginity freely and responsibly on the number and
testing and punitive anal examinations, as well spacing of their children and to have access
as rape, including rape by a spouse or partner, to the information, education and means to
and other forms of gender-based violence. enable them to exercise these rights” (UN
General Assembly, 1979).
Rights related to bodily autonomy and
integrity enable individuals to make their own The Convention on the Rights of Persons
decisions in the realms of reproduction and with Disabilities, known as the Disabilities
sexuality. States affirm and regulate these rights Convention, specifies that the right to
through policies and laws that define “legal make decisions about the number and
capacity” or determine the age of consent spacing of children applies to persons
for sex, marriage or accessing services such with disabilities (UN General Assembly,
as contraception. 2007). The right to decide on the number
and spacing of children is mirrored in the
Autonomy rights are interdependent and African Charter on Human and Peoples’
mutually supporting, regardless of how they Rights, in its Protocol on the Rights of
are expressed, whether as a “right to respect Women in Africa, the “Maputo Protocol”
for… physical and mental integrity” (European (African Union, 2003). Similar language
Union, 2012, Article 3(1)), as “rights to life, is also found in the ICPD Programme
physical and mental integrity, liberty and of Action and the Beijing Declaration
security of the person” (UN General Assembly, and Platform for Action of the Fourth
2007a, Article 7(1)), as freedom from torture, World Conference on Women.

56 My body, my rights
Human rights and the United Nations treaty system
Human rights are basic guarantees, which the Observations, which suggest certain actions
international community recognizes and promises countries should take to better meet their
to uphold. These rights cover civil, political, social, human rights obligations. They may also issue
economic and cultural matters and establish what General Comments or Recommendations to help
governments can and cannot do, as well as what governments understand their treaty obligations
they should do for all of us without discrimination. and provide authoritative interpretation as to
Everyone, regardless of sex, gender, race, ethnic the meaning of treaties. In certain cases, treaty
origin, religion, nationality, language, disability, place bodies can act like courts and issue opinions that
of residence or any other status, has these rights. are meant to settle disputes and points of law.

Human rights are often expressed and guaranteed Another important source of human rights norms
by law, in the forms of treaties, customary comes from political consensus agreements,
international law, general principles and other such as the ICPD Programme of Action and the
sources of international law (OHCHR, n.d.). Platform for Action of the 1995 Fourth World
Conference on Women. These agreements,
Human rights treaties are overseen by the United together with the United Nations Sustainable
Nations through treaty-monitoring committees, Development Goals, establish global policies
known as treaty bodies, which ensure that States and targets for the realization of rights,
Parties honour their commitments under each including sexual and reproductive rights.
treaty. For example, the United Nations Committee
on the Elimination of Discrimination against
Women monitors progress for women made in
countries that are States Parties to the 1979
Convention on the Elimination of All Forms
of Discrimination against Women. The
Committee also makes recommendations
on issues to which it believes the States
Parties should devote more attention.

Similar bodies have been established

to monitor progress in meeting
obligations to other treaties, such as the
Convention on the Rights of the Child.

Treaty bodies may issue non-binding

recommendations, or Concluding

Artwork by Kaisei Nanke

STAT E OF WOR L D POPUL AT I ON 2 02 1 57

 First, do no harm
Virginity testing violates and García-Moreno, 2017). virginity tests but also forced
individuals’ human rights and And yet many of its defenders anal exams, which involve
dignity, the United Nations invoke feminist language to the insertion of fingers or
has resoundingly asserted. argue for its continuation. objects into the anus of a man
When performed without or transgender woman with
consent, it constitutes torture A virginity test, also known the purported objective of
and a form of sexual violence. as a hymen exam or “two- finding “proof” of homosexual
It is also scientifically useless, finger” test, typically involves conduct. Forced anal tests
and a violation of medical an examination of the have been reported throughout
ethics (WHO and others, hymen, a thin tissue often, the Arab States and East and
2018). Yet it persists in but not always, present in Southern Africa regions, yet
every region of the world; the vagina. The test relies they are “medically worthless”
its continued practice has on the assumption that and “amount to torture or
recently made headlines in the physical characteristics of ill-treatment”, said the 2018
United Kingdom, for instance, the hymen or vagina can report of an independent expert
where a bill is under review demonstrate whether a to the United Nations Human
to ban the practice. Virginity woman or girl has engaged in Rights Council (UN HRC, 2018).
tests are used to enforce vaginal intercourse—a belief
or encourage abstinence overwhelmingly discredited by Virginity tests, as well as
among unmarried women medical studies. Unscientific forced anal exams, are
and girls, with justifications examinations to “prove” or physically invasive, painful
ranging from the preservation “disprove” intercourse only and stigmatizing. Suraya
of their “purity” and family reinforce harmful social norms Sobhrang, a medical doctor
“honour” to the prevention and must be banned, medical and former human rights
of HIV transmission and and human rights experts commissioner in Afghanistan,
adolescent pregnancy (Olson assert. These include not only says the tests used to be

“This is a violation of
human rights and it’s
against human dignity”

58 My body, my rights
Suraya Sobhrang describes how medical and legal personnel perpetuated nonconsensual virginity testing in Afghanistan. Original artwork by Naomi Vona;
photo © UNFPA/A. Mohaqqeq.

ordered punitively after any Examination conditions were women… One woman told
perceived transgression, such often neither sanitary nor me, ‘I feel that the second
as sitting next to a member private, and women could time, somebody raped me.’”
of the opposite sex. “All be forced to undergo the
this was a ‘moral crime’,” test repeatedly, she said. Women could be imprisoned
Dr. Sobhrang described. “This was traumatizing these for failing a virginity test.

STAT E OF WOR L D POPUL AT I ON 2 02 1 59

 “Some women did self- and realities: in places without into having sexual relations
immolation after this testing,” scientifically sound medical and abuse by ‘iintsizwa’
Dr. Sobhrang recalled. Others procedures, such as DNA [older men], especially girls
were killed by their families. testing, virginity testing offers in grades 10, 11 and 12,”
one of the few ways survivors said Chief Msingaphansi of
Dr. Sobhrang and her can submit evidence to support Umzimkhulu in KwaZulu-
colleagues helped to ban an allegation of rape. “For Natal. He suggests the tests,
nonconsensual virginity tests the victim, the hymen test largely performed by women
in Afghanistan in 2018. Today, is a tool through which to elders, emphasize the cultural
virginity tests can only be seek justice and fight back value on abstinence, thereby
performed in Afghanistan against social and traditional encouraging girls to reject
when there is a court order blame,” Dr. Azami said. peer pressure and delay sexual
and consent of the patient— activity. Chief Msingaphansi
though enforcement of this The test, if its results are couches the ritual in the
rule remains a concern, favourable, can also help language of empowerment:
especially in rural areas. And women avoid violence in “Following the tests, the girls
both doctors and patients can places where a perceived loss are made aware of their rights,”
still face consequences if they of virginity can be a death he said, adding that they
decline the test. Mozhgan sentence. “On a marriage learn to identify exploitative
Azami, a forensic medicine night, a white cloth or paper relationships. Yet these tests
specialist in Kabul, recalled is given to the couple that are often nonconsensual,
one girl who refused twice, should be coloured red by the making them illegal. “The
despite a court order: “The blood of the hymen after the parents decide,” acknowledged
third time, the court sent her marriage is consummated,” a “virginity inspector”
back to us saying that if the Dr. Azami added. If “the from uMgungundlovu
doctors do not perform the man doesn’t see the signs of and uThukela districts.
test this time, they will be virginity, the virginity test will
placed under investigation. be performed... based on the Despite these justifications,
Therefore, after two hours request of the girl,” typically in the test contributes to the
of talking to the girl, we the hope that her hymen will erroneous belief that a
convinced her to do the test.” show an indication of tearing. woman’s virtue is dependent
on her sexual history, and
Dr. Azami agrees that virginity In some communities, such it perpetuates a flawed
tests, particularly when as in South Africa’s KwaZulu- understanding of human
performed under duress, can Natal Province, virginity anatomy. Lending credibility
“hurt them psychologically”. testing is also seen by some to the test will inevitably
Yet she defends the test in as protection from adolescent lead to harm, Dr. Sobhrang
some instances, if performed pregnancy, HIV and other stressed. “The hymen,
confidentially, with dignity and harms (UN HRC, 2016). “It is some women don’t have
full informed consent. Those believed that virginity testing one. And sometimes the
views are shaped by real fears will prevent girls being coerced structure is very elastic.

60 My body, my rights
I saw one woman who had her
Bodily autonomy
first baby and at the delivery, and health
she still had a hymen. So it
Deciding for oneself, seeking and receiving
does not assure that a girl
information, and accessing services for
has not had intercourse.”
reproductive and sexual matters are
Someone who reports a rape understood and included in the right to
could be found to still have a health, according to the United Nations
hymen, and the complainant Committee on Economic, Social and
could be being jailed for Cultural Rights (UN CESCR, 2016).
making false accusations At the same time, enjoying sexual and
while the perpetrator goes reproductive health is “indispensable to
free, the doctor explained. [women’s] autonomy” and “intimately
And virginity tests are not a linked to civil and political rights
substitute for post-rape medical underpinning the physical and mental
examinations, which assess
integrity of individuals and their
and treat physical trauma
autonomy” (UN CESCR, 2016, para. 34).
without requiring the insertion
of anything into the vagina
The rights “to make free and responsible
(WHO and others, 2018).
decisions and choices, free of violence,
“This is a violation of human coercion and discrimination regarding
rights and it’s against human matters concerning one’s body and sexual
dignity,” said Sima Samar, a and reproductive health”, and to have
medical doctor and former “unhindered access to a whole range
state minister for human of health facilities, goods, services and
rights in Afghanistan, who information” are therefore two sides of the
also championed the ban on same coin (UN CESCR, 2016, para. 5).
nonconsensual virginity tests.
“It requires education in the According to the United Nations
public, to everyone, particularly
Committee on the Elimination of
to the youth. Secondly, I think
Discrimination against Women,
it is required to educate police,
health services must create an enabling
to educate the prosecutor, to
environment where people can exercise
educate the medical doctors.”
their autonomous choices and States
Most importantly, individuals should “[r]equire all health services to
must be emboldened to know be consistent with the human rights of
and claim their bodily autonomy, women, including the rights to autonomy,
Dr. Samar added. “How many privacy, confidentiality, informed consent
of them know their rights?” and choice” (UN CEDAW, 1999).

STAT E OF WOR L D POPUL AT I ON 2 02 1 61

 Bodily autonomy
Rights and and privacy
infertility Being able to make decisions about private
and family life are additional aspects of
treatment rights to bodily autonomy. For example, the
Political Rights Covenant provides that “No
Access to infertility treatment is part of one shall be subjected to arbitrary or unlawful
reproductive health care and includes interference with his privacy, family, home or
techniques such as in vitro fertilization (Zegers- correspondence, nor to unlawful attacks on his
Hochschild and others, 2009). International honour and reputation” (UN General Assembly,
human rights require all reproductive and 1966, Article 17(1)).
sexual health-care services to be available and
accessible on the basis of non-discrimination
Similar formulations of the right to privacy
and equality. Various treaty bodies have
are also included in other international and
concluded that where in vitro fertilization
regional human rights treaties, notably the
is available within a State, it must not be
unduly restricted, or offered in such a way Children’s Convention (UN General Assembly,
as to violate other human rights (UN CESCR 1989, Article 16), the American Convention
2019; UN CCPR, 2016; UN CEDAW, 2015). on Human Rights (OAS, 1969, Article 11),
the European Convention on Human Rights
(Council of Europe, 1950, Article 8), the African
Charter on the Rights and Welfare of the Child
(African Union, 1990, Article 10) and the
ASEAN Human Rights Declaration (ASEAN,
2012, Article 21).

The European Court of Human Rights and

Inter-American Court of Human Rights have
interpreted their treaties in a similar way,
emphasizing that “the notion of personal
autonomy is an important principle underlying
the interpretation of its [Article 8 privacy]
guarantees” (ECtHR, 2002).

In the United States more than a century ago,

Samuel Warren and Louis Brandeis articulated
a right to privacy as the “right to be left alone”
(Warren and Brandeis, 1890). Since then,
privacy has gained a much broader definition
in the United States and elsewhere and applies

Artwork by Kaisei Nanke

62 My body, my rights
Abortion and bodily integrity and autonomy
United Nations treaty bodies, the committees The ICPD Programme of Action is a foundational
that monitor governments’ application of their document that has guided the work of UNFPA
human rights obligations, have called on States since 1994. It stresses that measures or changes
to reform abortion laws to protect women’s related to abortion within the health system are
bodily integrity and autonomy. According matters left to national legislative process. The
to the United Nations Committee on Civil Programme of Action also affirms that where
and Political Rights, for example, laws must abortion is legal, it should always be safe; and,
permit women the choice to end pregnancies in all cases, women should be provided quality
that endanger their lives (UN CCPR, 2019). care for the consequences of abortion.

Laws that compel women against their wishes to Meanwhile, international, regional and national
continue non-viable pregnancies, or impel them human rights bodies and courts increasingly
to travel outside their countries to terminate recommend ensuring that even where access is
such pregnancies, or those which endanger restrictive, women’s health and lives should be
their lives, violate a range of recognized human promoted and protected. Moreover, they direct
rights (UN CCPR, 2017). States must also ensure States to decriminalize abortion—both for the
that where their laws permit women to elect an women who seek services and the health-care
abortion, no barriers are erected to impede them practitioners who provide services—thereby reducing
in exercising their choice (UN CCPR, 2011, 2005). the stigma and discrimination that they might face.

Artwork by Kaisei Nanke

STAT E OF WOR L D POPUL AT I ON 2 02 1 63

 to decisions about sexual and reproductive prohibit governmental interference with private,
health, including contraceptive information consensual sexual and reproductive behaviour
and services, access to abortion, infertility between adults (UN CCPR, 1994). The United
treatments, sexual relations, sexual orientation States Supreme Court based its decision in
and gender identity. International, regional and Roe v. Wade on such a right to privacy.
national courts have found that rights to privacy

Legalized same-sex relationships mean greater

autonomy for previously excluded groups
Mirroring laws that discriminate against people, allow individuals to love whom they choose and to
particularly women, within marriage or coerce them enjoy the same rights as others (OHCHR, 2017).
into unwanted marriage, there are widespread legal
restrictions on sexual relations between consenting In this statement the High Commissioner was
adults of the same sex, as well as restrictions on acknowledging that such a change in laws and
same-sex partners contracting a legal marriage. attitudes concerning our understanding of bodily
autonomy would have a liberating effect on the
In recent years, the Office of the High Commissioner estimated 300 million people worldwide who
for Human Rights of the United Nations and identify as LGBTI (Patterson and D’Augelli, 2012).
other international organizations concerned with
human rights have recognized that LGBTI persons’ However, the High Commissioner acknowledged
autonomy rights are violated through discriminatory that not only was progress slow, it was regressing
laws and actions. The 2015 report of the High due to political agendas that cater to prejudice
Commissioner for Human Rights stated forthrightly: and bigotry. In fact, there are 69 countries in
“States that criminalize consensual homosexual acts the world today where consensual same-sex
are in breach of international human rights law since sexual relations are illegal (ILGA World, 2020).
these laws, by their mere existence, violate the rights
to privacy and non-discrimination” (OHCHR, 2015). Along with the human rights implications of such
laws, discrimination against LGBTI people has
In a groundbreaking address at a ministerial important implications in many other spheres, such
meeting of the United Nations General Assembly as health. The Independent Expert on protection
in 2017, the High Commissioner for Human against violence and discrimination based on
Rights said: “But the premise for dialogue must sexual orientation and gender identity of the United
be clear: not whether to end these abuses, but Nations Office of the High Commissioner for
how. LGBTI people are full members of the human Human Rights has found that such laws “hinder
family. They are not lesser than the rest of us; the ability of relevant government departments and
they are equal—and, as such, they are entitled other actors involved in health responses”, in, for
to enjoy the same rights as everyone else.” The example, the response to HIV and AIDS. A recent
High Commissioner called on all governments to report pointed out that punitive legal environments,

64 My body, my rights
 Artwork by Kaisei Nanke

combined with stigma, discrimination and high determine the form of recognition, but whatever
levels of violence, placed gay men and other men form is chosen, there should be no difference in
who have sex with men at high risk of HIV infection treatment between same-sex and different-sex
because they are driven underground out of fear couples” (United Nations, 2016). This recognition
of prosecution or other negative consequences. is far from being achieved throughout the world.
As a result, they do not receive appropriate health
education, and are reluctant to seek health-care But things are changing. In 1989, same-sex registered
services, testing and treatment (UN HRC, 2018). partnerships became a reality in Denmark. Two
years later, the Netherlands legalized same-sex
An important part of achieving full equality under marriage. Since then, the legal right of same-sex
the law is the ability of LGBTI individuals to form partners to marry and establish families has also
unions with the same legal standing as that of been recognized in Argentina, Austria, Belgium,
opposite sex unions: “The United Nations and Brazil, Canada, Colombia, Ecuador, Finland, France,
regional human rights bodies… have urged States Germany, Greenland, Iceland, Ireland, Luxembourg,
to provide legal recognition of same-sex couples Malta, New Zealand, Norway, Portugal, South
and their children and ensure that same-sex Africa, Spain, Sweden, Taiwan Province of China,
couples are not discriminated against compared the United Kingdom, the United States of America
to different-sex couples… It is up to the State to and Uruguay (World Population Review, 2020).

STAT E OF WOR L D POPUL AT I ON 2 02 1 65

 Going to labour:
the job of a surrogate
Josefina remembers making the not had any children before. She still had her mobile phone
choice to become a surrogate. I remember thinking ‘where and was able to surreptitiously
“Part of it was for the money, am I?’” A few months into her contact the intended parents
but what really moved me was pregnancy, she, along with two of the baby, something she
having the power to make real or three other surrogates and had been expressly forbidden
the dream of many women some of their children, were to do. “I found the parents
of having a baby,” she said. taken to a dilapidated house through Facebook,” she
What she did not anticipate with no water, electricity or said. “They were very nice
was how poorly run—and food—and then locked inside. to me and supportive.” They
abusive—the surrogacy moved to another surrogacy
agency would turn out to be. The situation was only agency, bringing Josefina
temporary. But Josefina (not with them. “I continued the
“I thought there would be other her real name), who lives in process in a safer place,
women like me: confident in Mexico, said she suddenly where I felt more confident.”
their decision, with a minimum started worrying that the
of one child, just like the pregnancy wasn’t actually Yet even after that perilous
requirements established. for the purpose of being a experience, Josefina says she
But the place where I arrived surrogate. “A lot of ideas came never doubted her decision.
wasn’t like that. There were a to my mind such as child “I was sure that I wanted to
lot of young women who had trafficking or organ trafficking.” have the baby. I don’t regret it.

“I saw this opportunity of helping

others get something they really
desired: a baby.”

66 My body, my rights
Policymakers seldom consider the perspectives of surrogates when crafting surrogacy laws, experts say. Original artwork by Naomi Vona;
photo by Alexander Krivitskiyz on Unsplash.

It was an adventure,” she said. The issue of surrogacy has questions about the rights and
“Once I met the parents, I was long been considered ethically responsibilities of surrogates
pleased with the process.” and legally fraught. Highly and intended parents, as
publicized lawsuits and custody well as the rights of the baby
She would even consider battles in the United States, produced by the surrogacy
doing it again. India and elsewhere have raised arrangement (Nadimpally

STAT E OF WOR L D POPUL AT I ON 2 02 1 67

 and others, 2016). Laws vary intense cultural pressure prohibitions, “the practice
widely across and within to become mothers while still goes on, but now in an
countries. Some ban surrogacy; same-sex couples or single underground and unsafe way.”
some ban commercial, parents are often barred from
also called compensated, commissioning surrogates Josefina bore many of these
surrogacy but allow so-called because they fail to meet consequences. “When I was
altruistic surrogacy; some accepted norms of parenthood. with the first agency, we
permit both; and others And surrogates may be didn’t even have a contract.
have no specific surrogacy criticized for betraying the A contract would have given
laws at all (UCLS, 2019). perceived sacred bond between me safety that everything
a woman and the fetus she would be okay.” She believes
Where compensated carries. Josefina kept her the restrictions are only
surrogacy is permitted, a surrogacy arrangement quiet pushing surrogacy further into
lucrative industry often for just this reason. “It’s a the shadows, where unethical
emerges, comprising assisted taboo. A lot of people get agencies can thrive without
reproductive technology clinics, scared when they hear about regulation and surrogates
medical tour operators, law it, so I decided not to tell themselves are penalized.
firms, recruiters and others. that many people. Actually, “If it was legal, people
Countries with lower costs a lot of people from my own would feel safer,” she said.
can become sought-after family don’t know,” she said.
destinations for commissioning Rather than bans, there must
parents. Yet, in such places, “Stigma has grown a lot in the be more nuanced policies
surrogacy is often one of the last 10 years,” said Isabel Fulda, that account for the input and
few well-paying opportunities Deputy Director of Grupo de perspectives of those affected,
available to economically Información en Reproducción said Sarojini Nadimpally, a
marginalized women, creating Elegida, a reproductive justice founding member of the Sama
the potential for exploitation. organization in Mexico, Resource Group for Women
Brokers and agencies may which has advocated on and Health in India and expert
control the exchange of behalf of both surrogates on the social and legal issues
money and information as and commissioning parents. surrounding surrogacy. “Have
well as the provision of health Surrogacy laws vary across the surrogates and infertile
care. Surrogates may be left Mexico, but have generally couples been involved in the
underpaid, underinformed grown more restrictive in policy formulations? Were
and medically underserved recent years. “Even if the they asked what they want in
(Nadimpally and others, 2016). initial intentions of reform are the policy or in the legislation?
good, and intended for better How accessible will these legal
The highly gendered nature protection of every party, it provisions be for surrogates?”
of surrogacy and motherhood has unfortunate consequences,
also creates vulnerabilities on especially for surrogate Not only are surrogates’
both sides of the agreement. women,” she said. In places experiences neglected in the
Infertile women may face that have implemented strict crafting of legislation, but

68 My body, my rights
stigmas and punitive rules have Even in cases of alleged harmful sexual
made it harder for them to raise behaviour, the European Court of Human Rights
their voices. “The more political directs governments to carefully balance the
the issue becomes, the more State’s interests against an individual’s autonomy
they are silenced,” Fulda said. In interests and right to engage in private,
place of surrogates’ real stories,
consensual sexual activity (ECtHR, 1997).
a caricature has emerged, in
which compensated surrogates
Privacy, especially as it relates to family life, is
are depicted as victims while
capacious enough to encompass all manners
altruistic surrogates “are often
portrayed as angels who are
of decision-making related to sexuality and
willing to breed for nine months, reproduction, embracing “the right to respect for
and expose themselves to both the decisions to become and not to become
possible risks just for the love a parent” (ECtHR, 2010, 2007). The privacy
their hearts carry. It becomes jurisprudence of the European Court of Human
unbelievable to think they would Rights is most developed; abortion as well as
want money for it,” Fulda said. medically assisted reproduction for heterosexual
and same-sex couples and individuals (including
The distinction between surrogacy, both compensated and altruistic) have
compensated and altruistic been interpreted under the private and family
surrogacy doesn’t make sense
life protections of Article 8 of the European
to Josefina. For her, being a
Convention for the Protection of Human Rights
surrogate was both a job and
and Fundamental Freedoms (Roseman, 2020).
a gift. She did not resort to
it because of poverty: “My
economic situation at that time
was not really that bad. My Non-discrimination
choice was made because I and gender equality
wanted to do something different
with my life and to do something Enjoying autonomy and having the capacity
positive for someone else... I am to make decisions free from discrimination are
a mother as well, and I know the central to human rights.
happiness a child can bring.”
Being free from discrimination and enjoying
equal treatment means that States may not
make any distinction in law or policy on
the basis of characteristics such as sex, age,
race, ethnicity, gender expression, religion,
nationality, marital status, health or disabilities
(UN CESCR, 2009). Discrimination based on
sex, for example, would include distinctions
made “not only on physiological characteristics

STAT E OF WOR L D POPUL AT I ON 2 02 1 69

but also the social construction of gender (UN Working Group on Discrimination Against
stereotypes, prejudices and expected roles” (UN Women in Law and Practice, 2017).
CESCR, 2009, para. 20). Unequal access by
adolescents to sexual and reproductive health Women and girls have often been denied rights
information and services is an example of age- to make their own decisions because of social
based discrimination (UN CESCR, 2009). and cultural stereotyped beliefs or attitudes
that assign more value to the opinion of men
States must respect individuals’ bodily autonomy and parents. International human rights law
and integrity irrespective of social context. views these beliefs and attitudes as gender-based
According to a human rights working group on stereotypes associated with harmful practices,
the issue of discrimination against women in law including female genital mutilation, marital
and in practice, “The right of a woman or girl to and “curative” rape (against individuals based
make autonomous decisions about her own body on their sexual orientation or gender identity),
and reproductive functions is at the very core of child marriage, forced marriage and forced
her fundamental right to equality and privacy” childbearing.

These beliefs and attitudes have also resulted

in exclusion from comprehensive sexuality
education, denial of contraceptive information
and services, and forced abortion, as well
as violence against people of diverse sexual
orientation and gender identities (UN CEDAW
and UN CRC, 2014). These coercive and violent

Unequal access
by adolescents
... is an example
of age-based
discrimination

Artwork by Hülya Özdemir

practices are all predicated on social beliefs all other practices which are based on the idea
that privilege heteronormativity and seek to of the inferiority or the superiority of either of
control and subordinate women’s sexual and the sexes or on stereotyped roles for men and
reproductive capacities. women” (OAS, 1994, Article 8(b); UN General
Assembly, 1979, Article 5(a)).
States have a duty “to modify the social
and cultural patterns of conduct of men Governments can, and sometimes must,
and women, with a view to achieving the treat people differently; however, there must
elimination of prejudices and customary and be a legitimate justification for the disparate

Transactional sex and surrogacy

What are the limits for exercising bodily autonomy in sexuality
and reproduction? According to human rights principles, personal
choices that do no harm to others should be permitted. But does
the exchange of money do no harm? Should an individual be able
to be financially compensated for sexual acts or reproductive
services? There is great variability in national laws and
regulations regarding sex work, prostitution, gamete provision and
gestational surrogacy. Some governments see these exchanges
as inherently exploitative and criminalize them. Others view
sex work and gestational surrogacy as legitimate livelihoods or
forms of labour (UN HRC, 2018a; UN General Assembly, 2010).

Human rights law does not provide definitive answers,

although rights-based arguments have been invoked
to support both prohibition and legalization.

For example, the UNAIDS Global Commission on HIV/AIDS

and the Law has recommended decriminalizing sex work,
while the Human Rights Council has recommended that
in cases of compensated surrogacy the human rights of
all parties involved must be considered and respected
appropriately in law (UN HRC, 2019a; UNDP, 2012).

Artwork by Kaisei Nanke

STAT E OF WOR L D POPUL AT I ON 2 02 1 71

 Legal capacity and age of consent
The Office of the High Commissioner for Human A legacy of deeming women, children and
Rights defines legal capacity as “the capacity persons living with disabilities “incompetent”
and power to exercise rights and undertake to make decisions for themselves or in need of
obligations by way of one’s own conduct, protection from exploitation is what international
i.e., without assistance or representation by human rights redress. For example, the Women’s
a third party” (OHCHR, 2005). Recognition in Convention directs that “States Parties shall
law of having “capacity” means a person can accord to women, in civil matters, a legal capacity
give or withhold consent to sexual activity, identical to that of men” and they shall have “the
health services, marriage and more. same opportunities to exercise that capacity”
(UN General Assembly, 1979, Article 15(2)).

Given the history of discrimination faced by

women with disabilities, the Convention on the
Rights of Persons with Disabilities emphasized
the importance of legal capacity for autonomous
decision-making by women with disabilities: “All
women with disabilities must be able to exercise
their legal capacity by taking their own decisions,
with support when desired, with regard to medical
and/or therapeutic treatment, including by taking
their own decisions on retaining their fertility and
reproductive autonomy… Restricting or removing
legal capacity can facilitate forced interventions,
such as sterilization, abortion, contraception, female
genital mutilation, surgery or treatment performed on
intersex children without their informed consent and
forced detention in institutions” (UN CRPD, 2016).

Another way of understanding legal capacity

is “age of consent”. Minimum ages of consent
vary among and sometimes within nations by
activity and sometimes by sex (although this
is considered incompatible with human rights
standards). The Children’s Convention directs
States to recognize the evolving capacities of
children, specifically adolescents, with regard
to consent to sexual activity as well as access
to sexual and reproductive health services and

Artwork by Kaisei Nanke

72 My body, my rights
information. The Committee on the Rights of treatment, balancing all the respective rights
the Child urges governments to put supportive (Clapham, 2015). The general principle of
laws and policies in place so that “children, “best interests” in the Children’s Convention
parents and health workers have adequate is an illustration of this approach. While
rights-based guidance on consent, assent and parents and guardians make decisions on
confidentiality” (UN CRC, 2013). These policies behalf of their children, children have a right
include providing confidential counselling
to participate meaningfully in decisions that
to children, without the need for parental
affect them, with no clear line delimiting
or guardian consent, as well as conferring
an appropriate age (Coyne and Harder,
presumptive legal competency for adolescents
to seek and obtain sexual and reproductive
2011). As children’s capacities evolve, the
health services, commodities and information Children’s Convention expects parents to
(UN CRC, 2016). According to the Committee include them and eventually cede final
on the Rights of the Child, governments control over such decisions to them when
should avoid criminalizing consensual, they are mature. One example of respecting
non-exploitative sexual activity among children’s evolving capacities is in the shift
adolescents of similar ages (UN CRC, 2016). in thinking about intersex infants. In the
past, it was widely accepted that surgery
The right to marry and found a family is should be performed immediately to assign
recognized in both the Universal Declaration of the genitalia to one sex or the other. That
Human Rights, Article 16 (UN General Assembly,
attitude has largely been replaced by one of
1948), and the Political Covenant, Article 23,
waiting for the children to make their own
specifying that “no marriage shall be entered
choice about surgery (Reis, 2019; Zillén and
into without the free and full consent of the
intending spouses” (UN General Assembly,
others, 2017). Without intersex children’s
1966). Any marriage entered into without meaningful consent, such surgeries have
such consent is forced and is always a human been labelled violations of bodily integrity,
rights violation. The Women’s Convention tantamount to torture (UN HRC, 2016a).
clearly states that child betrothal and marriage
is legally null and void and directs States Similarly, the categorical denial of the
to establish minimum ages for consent sexual and reproductive desires and
to marriage (UN General Assembly, 1979, choices of persons living with physical
Article 16(2)). In keeping with the principle of or developmental disabilities evidenced
evolving capacities, most nations, following the by giving authority to parents, guardians
Children’s Convention, establish a minimum age and institutions, or “substituted decision-
of consent to marriage at 18, although in some
making”, has been transformed into the
settings the minimum age varies, depending
standard of “supported decision-making”,
on the sex of the individual (Pew Research
where every effort is made to educate and
Center, 2016). In over half of the world’s
nations, parental consent can override any
ascertain the person’s will and enable them
age-related minimum (Arthur and others, 2018). to execute it (UN CRPD, 2018, 2014).

STAT E OF WOR L D POPUL AT I ON 2 02 1 73

 Bodily integrity Convention, Article 37(a) (UN General
Assembly, 1989); and the Convention
As a general principle, rights related to bodily
against Torture and Other Cruel, Inhuman
integrity prevent the State or third parties from
or Degrading Treatment or Punishment
intruding on someone’s physical body without
(UN General Assembly, 1984).
obtaining free and informed consent.

Bodily integrity has been interpreted by the

The foundation for the notion of informed
Human Rights Committee as protected by the
consent in relation to bodily integrity flows
right to liberty and security of the person in
from Article 7 of the Political Convention: “No
the Political Convention (UN HRC, 2014)
one shall be subjected to torture or to cruel,
and by Article 7 of the Political Convention,
inhuman or degrading treatment or punishment.
which protects all individuals from cruel,
In particular, no one shall be subjected without
inhuman or degrading treatment.
his free consent to medical or scientific
experimentation” (UN General Assembly, 1966).
Rights to bodily integrity are formally
This idea has been echoed in international
recognized in human rights instruments. The
and regional human rights treaties, including
Disabilities Rights Convention, for example,
the Disability Rights Convention, Article 15
notes that “Every person with disabilities has
(UN General Assembly, 2007); the Children’s
a right to respect for his or her physical and
mental integrity on an equal basis with others”
(UN General Assembly, 2007, Article 17).
A number of regional human rights treaties
recognize bodily integrity outright or as part
of the right to humane treatment, for example,
the African Union Banjul Charter (African
Union, 1981, Article 4); the African Union
Rights to Maputo Protocol (African Union, 2003,
Article 4(1)); and the American Convention
bodily autonomy on Human Rights (OAS, 1969, Article 5(1)).

and integrity An array of sexual and reproductive health

and rights matters have been adjudicated by

are formally regional human rights courts. For example,

the Inter-American Court of Human Rights

recognized under has found violations of the right to bodily

integrity in cases of forced nudity and vaginal

international
inspections (IACtHR, 2006), threats of rape
and sexually transmissible infection (IACtHR,

human rights law

2014) and a wide range of other forms of
sexual violence (IACtHR, 2013, 2010).

74 My body, my rights
Obligations of States Parties According to the United Nations Committee
on Civil and Political Rights, criminal laws
Rights to bodily autonomy and integrity related to contraception, comprehensive
are formally recognized under international sexuality education, abortion and accessing
human rights laws and address a range of information about sexual and reproductive
reproductive and sexual health and rights health violate rights to bodily autonomy and
matters. But how do these rights translate integrity (UN CCPR, 2019; UN CESCR,
into what governments can, cannot or must 2016). Laws that require third-party
do for the people and populations they serve? authorization or consent (taking account of
the evolving capacities of children) also violate
Governments primarily observe their rights (UN CEDAW, 1999).
human rights duties through legislation,
policy and budgetary appropriation; some Human rights treaty bodies have criticized
actions can be taken immediately and States that have permitted third parties,
others may be taken progressively over time whether parents, spouses or others, to
so that rights are respected, protected and obstruct individuals from making decisions
fulfilled (UN CESCR, 2016; Gruskin and about their own bodies and reproductive
Tarantola, 2002). and sexual lives (UN CCPR, 2005).

Remove barriers to individual Human rights treaties and agreements direct

decision-making governments not to interfere with “adult
Respecting the rights to bodily autonomy consensual sexual activity in private” or to
and integrity requires governments to ensure enact criminal laws against same-sex sexual
that their laws, policies and programmes activity among adults in “private” (UN CCPR,
do not infringe on individuals’ ability to 1994, para. 8.2). Furthermore, laws that
make decisions about their reproductive “criminalize” abortion, non-disclosure of HIV
and sexual lives. This means removing status and transgender identity or expression
barriers that interfere with access to run afoul of bodily autonomy and integrity
comprehensive sexual and reproductive rights (UN CESCR, 2016, para. 40).
health services, goods, education and
information (UN CESCR, 2016). The United Nations Committee on
Economic, Social and Cultural Rights states
Laws, policies and programming must that laws and policies can fulfil a government’s
take into account the differing needs and human rights obligations provided they are
vulnerabilities of women, children, LGBTI enabling and guarantee all individuals access
communities, migrants, racial and ethnic to affordable, safe and effective contraceptives
minorities and people in rural areas, and and comprehensive sexuality education,
ensure that measures to protect one group liberalize restrictive abortion laws, guarantee
do not infringe on others along the way women and girls access to safe abortion
(UN CESCR, 2000). services and quality post-abortion care, and

STAT E OF WOR L D POPUL AT I ON 2 02 1 75

 “Conversion therapy”
“Conversion therapy” aims to change sexual para. 59). He detailed the psychological and
orientation and gender identities that do not physical pain and suffering conversion therapy
conform to heteronormative social and cultural causes and noted that treaty bodies have
expectations. It employs methods such as “corrective found these practices to violate the rights to
rape”, aversion therapy, chemical castration and equality and non-discrimination, health and
hormonal treatments, and even exorcism. freedom from torture and ill-treatment.

In 2020, the Independent Expert on protection The Independent Expert recommended

against violence and discrimination based on sexual that States ban the practice of conversion
orientation and gender identity published a report therapy and take affirmative measures
on practices of so-called conversion therapy. to protect bodily autonomy and integrity
In it, he observed that all such practices share through interventions including eliminating
“the specific aim of interfering in [an individual’s] prejudice and discrimination against
personal integrity and autonomy” (UN HRC, 2020, LGBTI communities (UN HRC, 2020).

Artwork by Kaisei Nanke

76 My body, my rights
respect women’s right to make autonomous
decisions about their sexual and reproductive accurate
health (UN CESCR, 2016).
information about
one’s own body
Uphold adolescents’ rights
Having accurate information about one’s own

and health... is
body and health and understanding what it
means is indispensable to exercising bodily
autonomy (UN CESCR, 2016). This means
ensuring that adolescents have such access
“regardless of their marital status and whether
indispensable to
their parents or guardians consent, with
respect for their privacy and confidentiality”
exercising bodily
(UN CESCR, 2016, para. 44).
autonomy
Some States have criminalized child marriage
and sex under the age of 18, in the interest
of protecting vulnerable populations from
exploitation or harm (Khosla and others,
2017). But human rights advocates are
generally sceptical about criminal prohibitions, “prevent, address and remediate violations
despite their symbolic importance, because of the right of all individuals to autonomous
they disproportionately affect communities decision-making on matters regarding their
that are already marginalized and comparatively sexual and reproductive health, free from
disempowered, and have few alternatives. violence, coercion and discrimination”
Advocates instead recommend redressing the (UN CESCR, 2016).
conditions that render such individuals and
communities vulnerable to exploitation in In addition to removing requirements for
the first place, such as providing economic third-party authorization to access services and
opportunities for young women (Miller and information, the Committee called for ending
Roseman, 2019). health-care professionals’ “conscientious
objection” to the provision of services and for
Establish systems to redress requiring referrals to providers “capable of and
rights violations willing to provide the services being sought”
Protecting rights to bodily autonomy and (UN CESCR, 2016, para. 43).
integrity requires a functioning system to
redress rights violations. The United Nations Laws that are aligned with human rights
Committee on Economic, Social and Cultural guarantee equal protection for all individuals
Rights in 2016 called on governments to put aiming to exercise their rights to bodily
into place laws, policies and programmes that autonomy and integrity. But all around the

STAT E OF WOR L D POPUL AT I ON 2 02 1 77

 The language
of violation
In her years as a survivors’ survivors to hospitals and health, whether or not
advocate in the United States, provided hotline counselling. they consented to a sexual
Leidy Londono has grown She now works as an educator encounter. Without the words
accustomed to the language and programme manager to identify this experience,
of shock, fear and shame that at Planned Parenthood in they often express confusion
people use when grappling Washington, DC. “It can and self-recrimination.
with the aftermath of sexual take a lot of different forms. Londono recalled one young
assault. And she has listened There are explicit attempts to person who discovered that
to people struggle to put into impregnate a partner against their partner had secretly
words one particular form of their own wishes. It could be removed a condom during
sexual violation, a phenomenon about controlling the outcomes consensual sex—a practice
that is pervasive yet poorly of a pregnancy, coercing a known as stealthing. “At
understood, even by those partner to have unprotected first they were like, ‘Am I
who experience or perpetrate sex, interfering either explicitly just exaggerating this?’”
it: reproductive coercion. or implicitly with birth control
methods, or lying or deceit The concept of reproductive
“It involves behaviours that a around birth control methods.” coercion is relatively new,
partner or someone uses to with most studies on the
maintain power and control Survivors lack a common topic taking place in the last
in a relationship that are language to describe the 20 years, often in the United
connected to reproductive specific violation felt when States, where the prevalence
health,” explained Londono, they are denied ownership of reproductive coercion is
who has accompanied of their fertility or sexual estimated at 15 to 25 per

“There’s a universal involved here,

and it is male entitlement to
control female partners.”

78 My body, my rights
Leidy Londono has worked in person, over the phone and via online chat to provide support and information to survivors of sexual assault.
Original artwork by Naomi Vona; photo © UNFPA/R. Zerzan.

cent (Park and others, 2016). require husbands’ permission with the term reproductive
But recent inquiries show before a woman can use coercion. Rather, she and
that it is widespread globally, family planning, for example. health workers and advocates
perpetrated not only by spoke more generally about
partners but even by families Dipika Paul has worked for “barriers in family planning”.
and community members decades as a researcher in
(Grace and Fleming, 2016). It sexual and reproductive health Today, Paul is an expert in the
may even be abetted by health in Bangladesh, yet even she topic. As an adviser at Ipas in
systems, via policies that says she was not familiar Dhaka, she sees many forms of

STAT E OF WOR L D POPUL AT I ON 2 02 1 79

 reproductive coercion. “With Jay Silverman, a professor at Silverman explained, “I also
husbands... it can start with the University of California, believe human beings innately
telling them, ‘do not use any San Diego School of Medicine, resist against being controlled…
contraception’, then women began his career working There are many different
will follow their husband’s with men and boys who had coping strategies that women
opinion. And it also ranges to perpetrated intimate partner in communities around the
severe violence. Sometimes violence. He has since studied world have developed to cope
husbands withhold food or reproductive coercion in with reproductive coercion,
money if she wants to continue Bangladesh, India, Kenya, Niger including women supporting
using contraception,” Paul said. and the United States. Even women. That is something that
Often this pressure is related though reproductive coercion is just happening organically,
to “husbands’ or other family may sometimes be carried out everywhere. It always has,
members’ desire for more by female family members, the whether it be a neighbour or
children or desire for sons”. violation is rooted in gender female family member hiding
Forced use of contraception inequality, Silverman said. your pills for you or helping
and forced abortion are you get to a clinic.” Where
also seen, she added. “There’s a universal involved clinics give out pamphlets
here,” he explained, “and it is about reproductive coercion,
These coercive acts are not male entitlement to control partner violence and how to
widely regarded as forms of female partners… On some seek help, women often “take
violence because reproduction level, that sense that men handfuls” so they can share the
may be seen as a family do have, that entitlement to information with other women.
decision. “In-laws, they play that control, is something
a big role,” Paul said. This is that’s ubiquitous in, I think, Much of the burden of
particularly true for younger most of our societies.” addressing reproductive
and underage wives; the coercion falls to service
median age of marriage is 16, Silverman and his colleagues, providers, who often face a
according to a Demographic including Ipas in Bangladesh, double bind: they must strike a
and Health Survey from 2018. are piloting tools to help health balance between engaging men
“It is difficult for young women workers identify reproductive in reproductive health matters
to take decisions alone.” coercion, such as questions without ceding full decision-
about partner attitudes and making power to them. “The
And yet there is a clear link behaviour. Once coercion is ideal of male engagement
between reproductive coercion acknowledged, women can in sexual and reproductive
and violence. Paul estimates reassert bodily autonomy by, health and maternal and child
that, in a study she is currently for example, selecting family health internationally has
conducting, about three in planning methods that are become a priority,” Silverman
five women who said they undetectable by a partner. said. Male involvement
had experienced reproductive has been associated with
coercion also experienced Even as women lack the increased family planning
sexual or physical violence language to describe and contraceptive use and
from their husbands. reproductive coercion, improved maternal and child

80 My body, my rights
health outcomes (Kriel and world, there are examples where protections
others, 2019; Assaf and Davis, are anything but equal. Violence and
2018). But when men wish to discrimination against people of diverse sexual
control the reproductive choices orientation or gender identities, for example, is
of their partner, “involving men well-documented and has been perpetrated by
is obviously detrimental”.
State and non-State actors (UN HRC, 2016b).

And men—indeed, people

Similarly, women and girls, especially those
of all genders and sexual
facing intersectional discrimination, such
orientations—can also be victims
of reproductive coercion. “Anyone
as those with disabilities or those who are
can experience reproductive members of ethnic or religious minorities,
coercion,” said Londono. face higher rates of gender-based violence
“Women in marginalized and disparities in access to justice and fair
communities experience levels policing (UN CEDAW, 2015a). Impunity for
of violence at disproportionate sexual and gender-based violence, marital rape
rates, and that includes and “curative rape” targeted at gender-non-
reproductive coercion… but that conforming individuals are other egregious
doesn’t negate the fact that I examples of unequal protection under the law
have talked to young boys and (UN CESCR, 2016).
young men—men in general—
who are trying to identify their
own experiences and put it into Enabling everyone to
words and contextualize it.”
exercise the rights to bodily
Fluency in the language of autonomy and integrity
reproductive coercion is needed,
particularly among policymakers. Fulfilling rights to bodily autonomy and
“When our laws and our policies integrity requires that governments make
are vague and our language is quality sexual and reproductive health
ambiguous, it doesn’t provide information, services and methods available
for survivors,” Londono said. and accessible (UN CESCR, 2016, 2000).
According to United Nations treaty bodies,
And learning about bodily this would entail services and information
autonomy is also crucial. In one that support decisions about family formation
recent project, Paul said, “we
(contraception, infertility treatment, maternal
talked to women, and they chose
health care, safe abortion) and about sexual
this terminology: ‘my body,
health (prevention of sexually transmitted
my rights.’... They all agreed
infections, including HIV, comprehensive
that we need to disseminate
this among the population—
sexuality education, treatment for sexual
that my body is mine.” dysfunction, prevention of sexual violence
and care for survivors), and gender-affirmative

STAT E OF WOR L D POPUL AT I ON 2 02 1 81

 The right to
reproductive health
and rights in the
Programme of Action
“Reproductive health is a state of complete
physical, mental and social well-being and not
merely the absence of disease or infirmity, in
all matters relating to the reproductive system
and to its functions and processes. Reproductive
health therefore implies that people are able to
have a satisfying and safe sex life and that they
have the capability to reproduce and the freedom
to decide if, when and how often to do so. Implicit
in this last condition are the rights of men and
women to be informed and to have access to safe,
effective, affordable and acceptable methods of
family planning of their choice, as well as other
methods of their choice for regulation of fertility
which are not against the law, and the right of access
to appropriate health-care services that will enable
women to go safely through pregnancy and childbirth
and provide couples with the best chance of having
a healthy infant. In line with the above definition
of reproductive health, reproductive health care is the recognition of the basic right of all couples
defined as the constellation of methods, techniques and individuals to decide freely and responsibly
and services that contribute to reproductive health the number, spacing and timing of their children
and well-being by preventing and solving reproductive and to have the information and means to do
health problems. It also includes sexual health, the so, and the right to attain the highest standard
purpose of which is the enhancement of life and of sexual and reproductive health. It also
personal relations, and not merely counselling and includes their right to make decisions concerning
care related to reproduction and sexually transmitted reproduction free of discrimination, coercion
diseases.… Reproductive rights embrace certain and violence, as expressed in human rights
human rights that are already recognized in national documents” (UNFPA, 1994). —Excerpts from
laws, international human rights documents and the Programme of Action of the International
other consensus documents. These rights rest on Conference on Population and Development

Artwork by Kaisei Nanke

82 My body, my rights
health care (World Professional Association for and actively in all matters concerning them,
Transgender Health, 2011). to make their own choices about their health,
including sexual and reproductive health, and
Services and information, as detailed by the their treatment, with appropriate support where
United Nations Committee on Economic, needed” (UN HRC, 2017, para. 43).
Social and Cultural Rights, must be:
International human rights to bodily autonomy
• Available—in sufficient quantities; and integrity ensure that every person can
make decisions that affect their sexual and
• Accessible—reachable and affordable by all; reproductive lives and have the means to do so.
This requires States to provide comprehensive,
• Acceptable—sensitive to gender, culture, age- and culturally appropriate information
age and medically ethical; about sexuality and reproduction, as well as the
quality goods and services to effectuate those
• Quality—meeting scientific and medical decisions, free from discrimination, coercion
standards of care and delivered with respect and violence.
for rights.
Human rights provide the common ground
Having the means to exercise the rights related upon which States build their national legal and
to bodily autonomy and integrity through policy standards to promote and protect bodily
reproductive and sexual health services is autonomy and integrity in the context of sexual
inseparable from the recognition of those rights and reproductive health. But many States still
in the first place. According to the United have a long way to go to ensure all people have
Nations Human Rights Council, “Health the power to make their own decisions about
settings must empower users as rights holders to health care, contraception and sex—and about
exercise autonomy and participate meaningfully many other dimensions of bodily autonomy.

STAT E OF WOR L D POPUL AT I ON 2 02 1 83

Artwork by Tyler Spangler
LAWS THAT
EMPOWER
LAWS THAT
CONTROL
A look at how laws and regulations
impact bodily autonomy

Every country has laws that protect or deny same-sex relationships. Laws that are not
bodily autonomy. well formulated or are unclear can also be
detrimental to bodily autonomy, even if
Laws can help support bodily autonomy by, they were not intended to have that effect.
for example, guaranteeing everyone’s access
to sexual and reproductive health services, Laws in some countries still require
mandating schools to provide comprehensive married women to obey their husbands,
sexuality education and requiring informed still fall short of making domestic violence
consent in the provision of health care. a criminal offence, still treat divorce in
ways giving more rights to men, and
Governments can also use laws to control still do not criminalize rape in marriage.
people’s bodies by, for example, limiting More than 30 countries restrict women’s
adolescents’ access to sexual and reproductive right to move around outside the home
health services and information, or forbidding (World Bank, 2020).

STAT E OF WOR L D POPUL AT I ON 2 02 1 85

 National laws can also be the primary from other countries. The law changed in 2019
instruments used by governments to fulfil their to expand access to all prisoners, regardless of
obligations under international human rights nationality (UNAIDS, 2019).
law. But to make these rights meaningful in
people’s lives, governments must go beyond
enacting laws and take action to effect change. Conflicting laws
No single law or policy can be considered in
The World Health Organization has called on isolation from a country’s entire legal and policy
governments to establish supportive legislative framework. Many countries, for example, have
and regulatory frameworks that improve access age-of-consent laws in relation to sexual activity
to sexual and reproductive health services and that are inconsistent with minimum-age laws
remove unnecessary restrictions that have the for accessing sexual and reproductive health
effect of preventing women from enjoying their information and services (Figure 7). This means
right to bodily autonomy (WHO, 2004). that adolescents may legally have sex before they
can legally access any information or services
Understanding how national legal frameworks relating to safer sex practices or contraception
affect bodily autonomy—where they might be (Sexual Rights Initiative, 2020; Committee on
supportive and where legal reform might be Adolescence, 2017; Dennis and others, 2009).
needed—is a critical starting point for action.
Sometimes the law changes to reflect evolution Where conflicting laws exist, there may be
in public opinion; at other times, legal change confusion about which law takes precedence.
precedes changes in societal attitudes, in The confusion can sometimes affect not
which case substantial social and behavioural only individuals but also the people who are
communication-change efforts may be required responsible for enforcing it.
for the law to become widely accepted and to
ease implementation. Once a law is enacted, its Even in the absence of conflicting legislation,
intended impact may not be realized for years, lack of clarity can remain a problem. What are
depending on political will or the commitment health workers required to do in cases where
to implement or enforce it. Policies may need to they are unsure of their legal obligations or
be formulated to add operational detail to the potential criminal liabilities arising from any
law, a budget may need to be allocated, or an given action? For example, where abortion is
accountability system may need to be created. legal under certain circumstances, providers
may still be reluctant to provide this service for
Even when a law is broadly supportive, it may fear of being accused of breaking the law, and
not benefit everyone equally. For example, many health systems’ guidelines and policies may be
countries have laws that guarantee access to free based on a more conservative interpretation
antiretroviral therapy to treat HIV, but access to of the law. Post-abortion care, which 179
it may not be universal. In Botswana, treatment governments agreed at the International
was available to citizens only, including those Conference on Population and Development
in prison, but that excluded prisoners who were (ICPD) in 1994 should be available irrespective

86 Laws that empower, laws that control

FIGURE 7

Age of consent for sex and age at which parental consent is not
required for selected services in selected countries
North
Belize Croatia Italy Jamaica Macedonia Malaysia Palau Poland
Legal age of marriage 18 18 18 18 18 18 No minimum 18
age for
citizens; 18
for others

Legal age of marriage with parental, 16 16 16 16 16 16 None needed 16

judicial or other consent for citizens;
16 for others

Age of consent for sex 16* 15 14 16 14 16* 15 15

Access to abortion without 18 16 18 18 18 18 18 18

parental consent

Access to emergency contraception 18 16 14 16 18 18 18 18

without parental consent

Access to oral contraception 18 18 14 16 18 18 18 18

without parental consent

* Applies to girls only

Source: Sexual Rights Initiative, 2020

Artwork by Tyler Spangler

 When sex is work
“Knowing that I have a say “I visited one of the Monika, in North Macedonia,
and that I’m in control of established venues for sex became a sex worker after
my own body, I really only work and applied to work she lost her job and got
learned those things after there,” she said, emphasizing divorced. She, too, is firm
becoming a sex worker,” that this was her choice. when she says this was her
Liana explained through a “I did it independently decision. “I was 19 or 20
translator in Indonesia. and without force.” years old. I was sufficiently
aware and mature to think
By now, Liana is used to These days, Liana is the about what I did and what I
shattering expectations; as national coordinator of OPSI, didn’t want.” Today—as the
a middle-class university a network that supports sex regional coordinator of STAR,
graduate and former workers with services including the first sex workers collective
accountant, she does not health care. OPSI is supported in the Balkans, also a UNFPA
fit the stereotype of a sex by UNFPA. “Sex workers are partner—she says she has
worker. “When my baby was actually quite diverse,” she observed that this is the norm:
four months old, my husband explained. “There are male “I am most often surrounded
passed away,” she recalled. sex workers, transgender by sex workers who voluntarily
Her income did not stretch sex workers, and the reasons engage in sex work.”
far enough and, at the same people choose to engage in
time, her family’s business sex work vary from person Still, both Liana and Monika
was struggling and her sister to person. The majority are acknowledge that sex
was facing financial hardship. seeking a source of income.” trafficking—sexual exploitation
through force, coercion, fraud
or deception—is a serious
concern within the industry.
Their respective organizations
work closely with victims

“I learned that actually, and survivors, helping them

to secure services and exit
sex work if they choose.
hey, I can control
The prevalence of exploitation

my own body. My and abuse has driven much of

the conversation around the

body is my own.”
legal status of sex work. Both
proponents and opponents of

88 Laws that empower, laws that control

Liana advocates for the rights of sex workers in Indonesia. Original artwork by Naomi Vona; image courtesy of Liana.

decriminalization cite the need sex industry is inherently history of childhood poverty,
to protect people from abuses. fraught. Indeed, studies abuse and family instability,
show that many entrants as well as barriers to the
But for opponents of into sex work have formal economy, including
decriminalization, the experienced heightened lack of education (McCarthy
notion of consent within the vulnerablities, such as a and others, 2014). These

STAT E OF WOR L D POPUL AT I ON 2 02 1 89

 conditions are seen as even while earning decent not legal and thinking that
undermining their free incomes outside the sex trade. we cannot report it and that
and informed consent. there is nothing we can do”.
Additionally, a significant “Please don’t assume that all
proportion of sex workers— sex workers are victims of They want to see the
estimated at between 20 trafficking. There are people criminalization—and
and 40 per cent—report like me who choose this work prosecution—of sexual
entering sex work as intentionally. We’re not being violence and exploitation
children (Parcesepe and tricked,” Liana said. “When we rather than sex work. “Violence
others, 2016), a clear ask OPSI members whether is not just an issue among
human rights violation. they would want to stop sex sex workers. It’s an issue
work if they could find other for all women and minority
Human rights instruments jobs, most of the time the groups,” Liana emphasized.
have responded to these answer is no.” Other jobs
vulnerabilities. The Convention available to sex workers are The movement to decriminalize
on the Elimination of all often low wage, she explained, sex work has gained ground
Forms of Discrimination and sex work offers flexibility in recent years at the United
against Women calls for “all that many find desirable. Nations, with many agencies
appropriate measures, including “They can manage their own and programmes, such as the
legislation, to suppress all time. They can fulfil their World Health Organization
forms of traffic in women and obligations in society, and they and UNAIDS, embracing
exploitation of prostitution of can feel closer to their kids.” it as an effective means to
women”. And the Protocols of prevent HIV transmission and
the United Nations Convention Sex work, or aspects of it end discrimination against
against Transnational (such as facilitation), is illegal vulnerable populations (WHO,
Organized Crime include “the in the majority of countries, 2014; UNAIDS, 2012).
giving or receiving of payments according to the Global
or benefits to achieve the Network of Sex Work Projects. At the same time, the United
consent of a person having Liana and Monika say such Nations is stepping up efforts
control over another person for laws only drive the profession to eliminate sexual exploitation
the purpose of exploitation” underground, where sex and abuse. Concerns over
within the definition of workers have a harder time peacekeepers and humanitarian
trafficking in persons. screening out violent clients. workers entering exploitative
Criminalization also leaves relationships with sex
But many sex worker advocates sex workers vulnerable to workers and vulnerable and
say the focus on vulnerability arrest and fearful of reporting marginalized individuals have
actually strips away their safety abusers, they assert. Some prompted the institution to
and autonomy. Both Liana police also harass and abuse strengthen the enforcement of
and Monika say they freely sex workers, Monika said, rules that prohibit staff from
chose to continue sex work “knowing that sex work is exchanging money, goods or

90 Laws that empower, laws that control

services for sex, even in countries of the legal status of abortion, is still lacking in
where sex work is legal. These many places and is sometimes denied by health
positions—that decriminalization workers who fear prosecution or stigmatization
will help safeguard the health for providing services to someone who has had
and rights of sex workers, and an illegal abortion.
also that staff members must
not purchase sex, even where
legal—are not contradictory, Structural obstacles
say United Nations officials.
At the structural level, adequate budgets are
“UN personnel must not
critical to ensuring a law’s effectiveness. Mexico,
participate in any activity that for example, enacted a law requiring that
could even potentially result in contraceptives be available to all, regardless of
sexual exploitation. This is not a age or marital status. Nevertheless, fertility rates
judgment on voluntary sex work remained high among adolescents, especially
by consenting, informed adults, those from the poorest households. A number
but we must acknowledge the of civil society organizations looked at budgets
reality that legality alone does for, and spending on, sexual and reproductive
not ensure that participation health services at federal and state levels and
in sex work is voluntary,” said identified bottlenecks and inefficiencies in
Eva Bolkart, who coordinates
making funds available to local programmes. The
UNFPA’s efforts to prevent
analysis led to better earmarking of funds so they
sexual exploitation and abuse.
reached poorer communities, where the need
for contraceptive information and services for
Monika and Liana agree that
legality alone is not enough. For
adolescents had not been fully met (Rajan, n.d.).
them, decriminalization must
come alongside destigmatization. Ensuring that health systems have the capacity
Until sex workers are afforded to fully implement a law may require actions
the respect and dignity of normal ranging from creating medical guidelines
citizens, they will continue to on the provision of services, to training
be forced to operate in the health workers on the law’s content and its
shadows, where abuses can be implications for their work, strengthening
hidden. “We are parents. We logistics and procurement systems to ensure
are someone’s children. We uninterrupted access to appropriate drugs
have families,” Monika said.
and equipment, ensuring that information
“There is no need for anyone to
systems can capture data on service uptake,
treat us differently from others
quality and impact, adjusting health financing
because of the choice of our
mechanisms to promote the affordability of
profession. Sex work is work.”
services and monitoring the acceptability and
quality of services being provided.

STAT E OF WOR L D POPUL AT I ON 2 02 1 91

 Societal factors, including religion and gender important role in ensuring accountability,
norms, can influence the extent to which laws including in health care for diverse populations,
are implemented or enforced. For example, in by guaranteeing access to justice, redress and
societies where sex before marriage is considered reparation mechanisms for people whose human
unacceptable, laws allowing adolescents to rights are violated (WHO, 2015).
access contraception may not translate into use
of contraception if the stigma associated with
teenage sex is too great. Indicator 5.6.2 tracks
supportive laws and
Even where supportive laws exist, other legal barriers
concerns may impact people’s ability to protect
their bodily autonomy or access appropriate To help governments track progress towards
health services. People may face immediate target 5.6 of the Sustainable Development
challenges such as hunger, poverty or difficult Goals—to ensure universal sexual and
living situations. Services may be unaffordable, reproductive health and reproductive rights
childcare may be unavailable, or a husband or in line with the ICPD Programme of Action
relative may interfere with decisions about health and the Beijing Platform for Action—the
care or contraception. United Nations developed indicator 5.6.2.
This indicator is an assessment of “the extent
Structural factors that perpetuate or exacerbate to which countries have laws and regulations
poverty, impede access to education or that guarantee full and equal access to women
employment, and lead to discrimination based and men aged 15 years and older to sexual
on race, ethnicity, sexual orientation or gender and reproductive health care, information and
identity must be understood and addressed by education” (UNFPA, 2020d).
policymakers because they can interfere with
the intended benefits of supportive laws for Guided by international human rights law,
certain groups. For example, even in countries international consensus documents and
where sexual and reproductive health services human rights standards, this composite
are available to all under the law, health-care indicator seeks to assess the legal environment
providers may nevertheless deny access to related to sexual and reproductive health and
people living with HIV, sex workers, men rights. It covers four broad topics: maternity
who have sex with men or transgender people care, contraception and family planning,
(UNAIDS, 2017). comprehensive sexuality education and
information, and sexual health and well-
Furthermore, individuals may not be aware of being (Figure 8). Each of the 13 components
a law or may find it an abstraction far removed within these four topics addresses areas that
from their daily lives. are susceptible to regulation by law. For each
of the components, data are collected on the
Laws and policies can empower women to existence of legal enablers (supportive laws and
make their own decisions and can play an regulations) and legal barriers. Such barriers

92 Laws that empower, laws that control

encompass restrictions to supportive laws All aspects of this indicator are relevant to
and regulations—for example, requirements bodily autonomy.
for third-party authorization that compel
individuals to obtain consent from a parent, Within each of these components, the
spouse, judge or medical committee to access indicator assesses whether a supportive
certain health service. law exists and whether there are potential

FIGURE 8

The four topics and 13 components tracked by indicator 5.6.2

MATERNITY CARE CONTRACEPTIONAND

• Maternity care FAMILY PLANNING
• Life‐saving commodities • Contraception
• Abortion • Consent for contraceptive
• Post‐abortion care services
• Emergency contraception
INDICATOR
5.6.2
The existence of laws,
regulations or policies that
guarantee full and equal access
to women and men aged
15 years and older to sexual
and reproductive health care,
information and education

COMPREHENSIVE SEXUAL HEALTH

SEXUALITY ANDWELL-BEING
EDUCATION • HIV testing and counselling
• HIV treatment and care
• Comprehensive sexuality
education law • Confidentiality of health
status formen and women
• Comprehensive sexuality living with HIV
education curriculum
• HPV vaccine

STAT E OF WOR L D POPUL AT I ON 2 02 1 93

 restrictions, such as limitations according Guaranteeing sexual
to age or a requirement for spousal
permission. It also assesses whether there
and reproductive
are plural legal systems—those that are health and rights
traditional, customary or determined by
religion—that exist alongside national Data for indicator 5.6.2 and its individual
law and that can restrict the applicability components are reported by 107 national
of national law for certain population governments, including national statistics
groups (UNDESA, 2018). authorities and line ministries. There are,
however, only 75 countries with complete
Thus indicator 5.6.2 captures data for the overall indicator.
information on the existence of a
supportive law and also on some Within the overall indicator, each of the four
additional factors that might impede sections has a different number of reporting
that law’s positive impact. Data on all countries: 79 countries for maternity care,
of these aspects are used to calculate a 104 countries for contraception and family
value for each country for each of the 13 planning, 98 countries for comprehensive
components, which are then aggregated sexuality education and 101 countries for sexual
up to the four broad topics and then to health and well-being.
an overall value (Figures 9 and 10).
In the 75 countries reporting complete data, on
The indicator is a percentage scale up average, 73 per cent of the laws and regulations
to 100, indicating a country’s status and needed to guarantee full and equal access to
progress in the existence of national laws sexual and reproductive health and rights were
and regulations to guarantee full and reported to be in place. However, 20 per cent of
equal sexual and reproductive health and the countries that have enabling laws also have
rights. Indicator 5.6.2 measures only the plural legal systems, which suggests that not
existence of laws and regulations; it does everyone in those countries benefits from the
not measure their implementation. enabling laws.

Among all countries that reported data About 80 per cent of the countries with data
for this indicator, the five countries with report having laws to protect or support sexual
the highest overall value for indicator health and well-being. About 75 per cent
5.6.2 are Sweden (100), Uruguay (99), report having laws and regulations needed to
Cambodia (98), Finland (98) and the guarantee full and equal access to contraception.
Netherlands (98). The five countries with About 71 per cent have laws guaranteeing
the lowest values are South Sudan (16), access to overall “maternity care”, which could
Trinidad and Tobago (32), Libya (33), include maternal health services and supplies,
Iraq (39) and Belize (42). abortion or post-abortion care, and 56 per cent

94 Laws that empower, laws that control

FIGURE 9

Indicator 5.6.2 combined value (per cent) for 13 sexual and reproductive
health components, by country

Afghanistan 54 Malawi 76
Albania 82 Malaysia 81
Angola 66 Maldives 45
Armenia 87 Mali 79
Barbados 44 Malta 90
Belarus 87 Mauritania 62
Belize 42 Mauritius 73
Benin 91 Montenegro 52
Burkina Faso 72 Mozambique 94
Burundi 64
Myanmar 82
Cambodia 98
Namibia 96
Central African Republic 77
Nepal 48
Chad 75
Netherlands 98
Colombia 97
New Zealand 94
Congo, Republic of the 53
Pakistan 65
Costa Rica 62
Palestine* 60
Côte d'Ivoire 63
Philippines 75
Czechia 70
Saint Vincent and the Grenadines 81
Denmark 90
São Tomé and Príncipe 54
Egypt 44
Serbia 86
El Salvador 83
Sierra Leone 65
Finland 98
South Africa 95
Gabon 58
South Sudan 16
Gambia 83
Sri Lanka 89
Georgia 93
Sudan 57
Greece 54
Suriname 45
Guinea-Bissau 70
Sweden 100
Guyana 75
Switzerland 92
Haiti 65

Iraq 39 Syrian Arab Republic 77

Japan 83 Togo 73

Kazakhstan 63 Trinidad and Tobago 32

Korea, Democratic People's Republic of 83 Ukraine 88

Kyrgyzstan 73 United Kingdom 92

Lao People's Democratic Republic 96 Uruguay 99

Latvia 70 Viet Nam 54

Libya 33 Yemen 63

Lithuania 88 Zambia 91

0 20 40 60 80 100 0 20 40 60 80 100

*On 29 November 2012, the United Nations General Assembly passed Resolution 67/19, which accorded Palestine “non-member observer State status in the United Nations...”

STAT E OF WOR L D POPUL AT I ON 2 02 1 95

FIGURE 10

Extent to which countries have laws and regulations that guarantee full and equal
access to women and men aged 15 years and older to sexual and reproductive health
care, information and education (values expressed as percentages)

Maternity Care Contraceptive Services Sexuality Education HIV and HPV Overall
value
for all
Sexuality Sexuality HIV HIV categories,
Life Saving Post– Contra- Contra- Emergency Education Education Counselling Treatment HIV SDG
Maternity Commod- Abortion Category ceptive ceptive Contra- Category Curriculum Curriculum Category and Test and Care Confiden- HPV Category indicator
Care ities Abortion Care Average Services Consent ception Average Laws Topics Average Services Services tiality Vaccine Average 5.6.2

Afghanistan 100 92 0 100 73 60 0 50 37 0 0 0 100 100 100 0 75 54

Albania 100 77 50 100 82 80 100 75 85 100 100 100 80 100 100 0 70 82

Angola 100 62 0 100 65 100 100 100 100 0 0 0 100 100 100 0 75 66

Antigua and
– 85 0 100 – 0 100 0 33 0 0 0 100 100 100 0 75 –
Barbuda

Armenia 75 100 100 100 94 80 100 100 93 100 100 100 80 100 100 0 70 87

Australia 100 – 0 100 – 80 100 100 93 0 0 0 100 100 100 0 75 –

Bangladesh 0 85 – 100 – 0 0 0 0 100 88 94 40 40 75 0 39 –

Barbados 100 77 75 0 63 60 0 0 20 0 0 0 80 80 100 0 65 44

Belarus 100 85 75 100 90 100 100 100 100 100 100 100 100 100 75 0 69 87

Belgium – – 100 0 – 100 100 100 100 100 100 100 100 100 100 100 100 –

Belize 0 100 0 100 50 0 0 0 0 0 100 50 60 80 100 0 60 42

Benin 100 100 50 100 88 80 100 50 77 100 100 100 100 100 100 100 100 91

Botswana 100 92 – 0 – 80 100 100 93 100 88 94 40 80 100 100 80 –

Burkina Faso 75 100 0 100 69 80 0 75 52 100 50 75 60 100 100 100 90 72

Burundi 75 92 50 100 79 40 0 75 38 0 100 50 100 100 100 0 75 64

Cambodia 100 100 75 100 94 100 100 100 100 100 100 100 100 100 100 100 100 98

Cameroon, Rep of 100 92 25 100 79 100 100 100 100 0 0 0 – – – 0 – –

Central African
100 100 0 100 75 60 100 50 70 100 88 94 100 100 100 0 75 77
Republic

Chad 100 100 75 100 94 100 100 100 100 0 0 0 100 100 100 0 75 75

China 100 62 – 100 – 100 100 100 100 – – – 100 100 100 0 75 –

Colombia 100 92 75 100 92 100 100 100 100 100 100 100 100 100 100 100 100 97

Congo, Democratic
100 92 – 100 – 80 100 75 85 – – – 100 100 100 0 75 –
Republic of the

Congo, Rep of 100 100 -25 0 44 100 100 75 92 0 0 0 60 80 100 0 60 53

Costa Rica 100 77 25 0 50 100 100 0 67 0 0 0 100 100 100 100 100 62

Côte d'Ivoire 100 100 25 0 56 100 100 100 100 0 0 0 100 100 100 0 75 63

Czechia 100 15 100 100 79 0 0 0 0 100 100 100 100 100 100 100 100 70

Denmark 100 100 50 100 88 80 100 75 85 100 100 100 80 80 100 100 90 90

Egypt 100 54 -50 100 51 60 0 50 37 0 0 0 80 80 100 0 65 44

96 Laws that empower, laws that control

 Maternity Care Contraceptive Services Sexuality Education HIV and HPV Overall
value
for all
Sexuality Sexuality HIV HIV categories,
Life Saving Post– Contra- Contra- Emergency Education Education Counselling Treatment HIV SDG
Maternity Commod- Abortion Category ceptive ceptive Contra- Category Curriculum Curriculum Category and Test and Care Confiden- HPV Category indicator
Care ities Abortion Care Average Services Consent ception Average Laws Topics Average Services Services tiality Vaccine Average 5.6.2

El Salvador 100 100 -25 100 69 100 100 100 100 100 100 100 100 100 100 0 75 83

Equatorial Guinea – 100 – – – – – – – 0 0 0 100 100 100 0 75 –

Finland 100 100 75 100 94 100 100 100 100 100 100 100 100 100 100 100 100 98

Gabon 100 100 0 100 75 40 0 25 22 100 100 100 40 100 50 0 48 58

Gambia 100 100 25 100 81 100 100 100 100 100 100 100 40 20 100 100 65 83

Georgia 100 85 75 100 90 100 100 100 100 100 88 94 80 80 100 100 90 93

Germany 100 46 50 75 68 80 100 75 85 – – – 100 100 100 100 100 –

Greece 100 62 75 0 59 100 0 0 33 0 0 0 80 80 100 100 90 54

Guatemala 100 85 – 0 – 80 100 75 85 100 100 100 80 80 100 0 65 –

Guinea 100 100 – 100 – 100 100 100 100 – 100 – 100 100 100 0 75 –

Guinea-Bissau 100 100 100 0 75 80 100 75 85 0 100 50 80 80 100 0 65 70

Guyana 100 92 75 100 92 60 100 50 70 100 100 100 60 60 75 0 49 75

Haiti 100 92 0 100 73 80 100 75 85 0 0 0 100 100 100 0 75 65

Honduras 50 – -25 0 – 80 100 0 60 0 0 0 100 100 100 0 75 –

India – 85 75 – – 100 100 100 100 0 0 0 60 100 100 – – –

Iran, Islamic Rep of 100 100 0 – – 100 100 100 100 0 0 0 100 100 100 0 75 –

Iraq 75 77 0 0 38 80 0 0 27 0 0 0 80 100 100 0 70 39

Japan 100 85 0 0 46 100 100 100 100 100 100 100 100 100 100 100 100 83

Kazakhstan 75 69 75 100 80 100 100 0 67 0 0 0 100 100 100 0 75 63

Korea, Democratic
75 77 100 100 88 100 100 100 100 100 25 63 100 100 100 0 75 83
People’s Republic of

Kyrgyzstan 100 92 50 50 73 60 100 50 70 100 88 94 60 100 100 0 65 73

Lao People's
Democratic 100 100 50 100 88 100 100 100 100 100 100 100 100 100 100 100 100 96
Republic

Latvia 100 31 75 0 51 0 100 0 33 100 100 100 100 100 100 100 100 70

Liberia 100 92 – 100 – 80 100 75 85 0 0 0 100 100 100 0 75 –

Libya 75 77 -25 0 32 0 0 0 0 0 0 0 100 100 100 0 75 33

Lithuania 100 92 75 100 92 80 100 75 85 100 100 100 60 60 100 100 80 88

Malawi 25 100 -50 75 38 80 100 100 93 100 100 100 80 80 100 100 90 76

Malaysia 75 77 -25 75 50 80 100 75 85 100 100 100 100 100 100 100 100 81

Maldives 0 92 25 0 29 0 0 0 0 100 63 81 100 100 100 0 75 45

Mali 100 100 50 100 88 80 100 100 93 0 0 0 100 100 100 100 100 79

Malta 100 100 -25 100 69 100 100 100 100 100 100 100 100 100 100 100 100 90

Mauritania 50 85 -25 0 27 100 100 100 100 0 0 0 100 100 100 100 100 62

Mauritius 100 85 50 100 84 60 100 50 70 0 0 0 100 100 100 100 100 73

STAT E OF WOR L D POPUL AT I ON 2 02 1 97

 Maternity Care Contraceptive Services Sexuality Education HIV and HPV Overall
value
for all
Sexuality Sexuality HIV HIV categories,
Life Saving Post– Contra- Contra- Emergency Education Education Counselling Treatment HIV SDG
Maternity Commod- Abortion Category ceptive ceptive Contra- Category Curriculum Curriculum Category and Test and Care Confiden- HPV Category indicator
Care ities Abortion Care Average Services Consent ception Average Laws Topics Average Services Services tiality Vaccine Average 5.6.2

Mexico 100 – – 0 – 100 100 100 100 100 88 94 – – – 100 – –

Moldova,
75 100 75 100 88 100 100 0 67 100 – – 80 80 75 100 84 –
Republic of

Montenegro 75 100 75 75 81 60 0 50 37 0 0 0 80 80 75 0 59 52

Mozambique 100 92 25 100 79 100 100 100 100 100 100 100 100 100 100 100 100 94

Myanmar 100 92 -25 100 67 100 100 100 100 100 100 100 100 100 100 0 75 82

Namibia 100 100 50 100 88 100 100 100 100 100 100 100 100 100 100 100 100 96

Nepal 100 77 50 100 82 100 100 0 67 0 0 0 0 0 100 0 25 48

Netherlands 100 100 75 100 94 100 100 100 100 100 100 100 100 100 100 100 100 98

New Zealand 100 100 25 100 81 100 100 100 100 100 100 100 100 100 100 100 100 94

Niger 100 100 – 100 – 100 100 100 100 100 100 100 80 100 100 100 95 –

Nigeria – 100 75 0 – 100 100 100 100 100 100 100 100 100 100 100 100 –

Pakistan 100 92 -50 100 61 100 100 100 100 0 0 0 100 100 100 0 75 65

Palestine* 100 77 -50 100 57 80 100 75 85 0 0 0 100 100 100 0 75 60

Peru 100 – – 100 – 80 100 100 93 100 100 100 100 100 100 100 100 –

Philippines 100 77 -25 100 63 60 100 0 53 100 100 100 80 80 100 100 90 75

Romania – – – – – – – – – 0 0 0 – – – – – –

Russian Federation 100 77 – 100 – 100 100 100 100 0 0 0 100 100 100 0 75 –

Saint Lucia 100 92 – 100 – 60 100 50 70 100 100 100 80 80 75 100 84 –

Saint Vincent and

100 62 25 100 72 80 100 100 93 100 100 100 80 100 100 0 70 81
the Grenadines

São Tomé and

0 100 0 100 50 0 0 0 0 100 0 50 100 100 100 100 100 54
Príncipe

Saudi Arabia 75 – – – – 100 100 100 100 – – – 100 100 100 0 75 –

Senegal 25 92 – 100 – 40 0 25 22 0 0 0 40 80 75 – – –

Serbia 100 92 25 100 79 100 100 100 100 100 0 50 100 100 100 100 100 86

Sierra Leone 100 100 50 0 63 100 100 100 100 0 0 0 100 100 100 0 75 65

Slovenia 100 54 – 100 – 100 100 100 100 – – – 100 100 100 100 100 –

Somalia 0 85 – 100 – 0 0 0 0 0 0 0 100 100 100 0 75 –

South Africa 100 100 75 100 94 80 100 75 85 100 100 100 100 100 100 100 100 95

South Sudan 0 100 0 0 25 20 0 0 7 0 88 44 0 0 0 0 0 16

Sri Lanka 100 77 -25 100 63 100 100 100 100 100 100 100 100 100 100 100 100 89

Sudan 100 85 25 100 77 60 0 75 45 0 0 0 100 100 100 0 75 57

Suriname 100 62 0 0 40 60 0 0 20 0 0 0 80 80 100 100 90 45

Sweden 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

Switzerland 100 100 0 100 75 100 100 100 100 100 100 100 100 100 100 100 100 92

Syrian Arab
100 85 -50 100 59 80 100 100 93 100 88 94 100 100 100 0 75 77
Republic

98 Laws that empower, laws that control

 Maternity Care Contraceptive Services Sexuality Education HIV and HPV Overall
value
for all
Sexuality Sexuality HIV HIV categories,
Life Saving Post– Contra- Contra- Emergency Education Education Counselling Treatment HIV SDG
Maternity Commod- Abortion Category ceptive ceptive Contra- Category Curriculum Curriculum Category and Test and Care Confiden- HPV Category indicator
Care ities Abortion Care Average Services Consent ception Average Laws Topics Average Services Services tiality Vaccine Average 5.6.2

Tanzania, United
100 100 – 100 – 100 100 100 100 100 100 100 100 100 100 100 100 –
Republic of

Togo 100 100 50 100 88 100 100 100 100 0 0 0 100 100 100 0 75 73

Trinidad and
25 85 0 25 34 0 0 0 0 100 100 100 40 40 0 0 20 32
Tobago

Tunisia 100 100 – 100 – 100 – – – 0 0 0 0 0 75 0 19 –

Turkey 100 100 0 100 75 80 100 75 85 – – – 80 100 100 0 70 –

Ukraine 100 69 75 100 86 100 100 100 100 100 100 100 100 100 100 0 75 88

United Kingdom 100 100 0 100 75 100 100 100 100 100 100 100 100 100 100 100 100 92

Uruguay 100 85 100 100 96 100 100 100 100 100 100 100 100 100 100 100 100 99

Uzbekistan 100 69 75 – – 100 100 0 67 – – – – – – 0 – –

Viet Nam 50 77 25 0 38 80 0 75 52 0 100 50 100 100 100 0 75 54

Yemen 25 100 0 100 56 100 100 100 100 0 0 0 100 100 100 0 75 63

Zambia 100 100 50 100 88 60 100 75 78 100 100 100 100 100 100 100 100 91

Source: UNFPA, global databases, 2020. Based on official responses to the United Nations 12th Inquiry among Governments on Population and Development.
Negative values reflect the existence of more legal restrictions than supportive laws. This may mean, for example, that a country or territory has restrictions on abortion,
such as requiring a husband’s consent for a married woman to access abortion, and that it criminalizes obtaining an abortion.
“–” signifies missing data
*On 29 November 2012, the United Nations General Assembly passed Resolution 67/19, which accorded Palestine “non-member observer State status in the United Nations...”

say they have laws supporting comprehensive privacy. But in some of these countries, plural
sexuality education. legal systems may impede access, and some have
age restrictions or require third-party consent.
Analysis of the overall values for indicator 5.6.2
reveals that countries of any income level can A little more than 50 per cent of the reporting
perform either well or poorly. Countries of any countries have laws or regulations in place
income level can create a supportive legal and to guarantee adolescent girls’ access to the
regulatory environment (Figure 11). HPV vaccine. A recent review of experience
introducing HPV vaccines in 45 low- and
Sexual health and well-being middle-income countries showed that success
In the context of HIV, almost all countries depended above all on securing political will
reported laws and regulations that guarantee and financing, but also required solid planning,
access to voluntary HIV counselling and testing social mobilization and clear communications
services, treatment and care, and protection of (Howard and others, 2017).

STAT E OF WOR L D POPUL AT I ON 2 02 1 99

Contraception and family planning and informed consent of individuals before
Ninety-one per cent of 104 countries reported receiving contraceptive services, including
having laws and regulations that guarantee access sterilization, 9 per cent of these countries
to contraceptive services, but in a number of reported plural legal systems that contradict
these countries access depends on a minimum these laws.
age, third-party authorization or marital status.
Maternity care
In 12 per cent of 104 countries where laws The maternity care dimension of indicator 5.6.2
protect access to contraceptive services, plural covers four components: laws that guarantee
legal systems contradict the enabling laws access to maternity care services, life-saving
and regulations. Although 87 per cent of medicines and supplies, or “commodities”,
reporting countries reported having laws abortion and post-abortion care. Data on each
and regulations that ensure full, free of these are explored below.

Ninety-five per cent of 79 countries reported

having laws and regulations to guarantee access
to maternity care. However, access to services
in some of these countries depends on marital
status, age or authorization by a third party,
such as a parent or spouse.

Only 44 per cent of these countries

reported that their national essential
medicines list included all 13 of
the commodities deemed by the
United Nations Commission
on Life-Saving Commodities
for Women and Children
to be “life-saving” across
reproductive, maternal,
newborn and child health.

Artwork by Tyler Spangler

FIGURE 11

Overall values for indicator 5.6.2 showing that the existence of supportive
sexual and reproductive health laws and regulations does not depend on a
country’s income level (values expressed as percentages)

HIGH-INCOME COUNTRIES UPPER-MIDDLE-INCOME COUNTRIES

Sweden 100 Colombia 97

Uruguay 99 Namibia 96
South Africa 95
Finland 98
Georgia 93
Netherlands 98
Armenia 87
New Zealand 94 Belarus 87
Switzerland 92 Serbia 86
United Kingdom 92 Albania 82
Malta 90 Malaysia 81
Saint Vincent and the Grenadines 81
Denmark 90
Guyana 75
Lithuania 88 Kazakhstan 63
Japan 83 Costa Rica 62
Mauritius 73 Gabon 58
Czechia 70 Montenegro 52
Suriname 45
Latvia 70
Maldives 45
Greece 54
Belize 42
Barbados 44 Iraq 39
Trinidad and Tobago 32 Libya 33

0 20 40 60 80 100 0 20 40 60 80 100

LOWER-MIDDLE-INCOME COUNTRIES LOW-INCOME COUNTRIES

Cambodia 98 Mozambique 94
Lao People’s Democratic Republic 96 Korea, Democratic People's Republic of 83
Zambia 91 Gambia 83
Benin 91 Mali 79
Sri Lanka 89 Syrian Arab Republic 77
Ukraine 88 Central African Republic 77
El Salvador 83
Malawi 76
Myanmar 82
Chad 75
Philippines 75
Togo 73
Kyrgyzstan 73
Burkina Faso 72
Angola 66
Guinea-Bissau 70
Pakistan 65
Sierra Leone 65
Côte d'Ivoire 63
Mauritania 62 Haiti 65
Viet Nam 54 Burundi 64
São Tomé and Príncipe 54 Yemen 63
Congo, Republic of the 53 Sudan 57
Nepal 48 Afghanistan 54
Egypt 44 South Sudan 16

0 20 40 60 80 100 0 20 40 60 80 100

STAT E OF WOR L D POPUL AT I ON 2 02 1 101

 Laws aside: the
reality of unequal
abortion access
“One woman, she was had been able to come to whether a woman will be able
brought from a remote village the hospital… you could do to access a safe abortion.
and she was in very severe it under local anaesthesia,”
condition… She’d tried to she said. Instead, her story is Dr. Ortayli saw this
induce an abortion by herself,” about a reality facing women phenomenon play out both as
recalled Nuriye Ortayli, who and health providers around a physician in Turkey and as
worked as an obstetrician the world: abortions happen, a programme manager and
and gynaecologist in Turkey frequently, even in places reproductive health adviser for
in the 1980s and 1990s. where the procedure is highly health organizations, including
“Everybody, younger residents, restricted or illegal (Bearak UNFPA, in Eastern Europe,
more senior people, tried for and others, 2020), and women the Middle East, West Africa
more than 12 hours, close to are regularly denied access to and the Americas. “We see it
24 hours. We tried everything safe abortion even in places again and again. Independent
we could. But she died.” where it is legally permitted of the legal status of abortion
(Gerdts and others, 2015). in a country, women make
Yet Dr. Ortayli’s story is No matter the law, then, it those decisions and they find
not about an illegal, back- is often other factors—such a way,” she said. “Those who
alley abortion. Safe abortion as economic resources, are affluent, somehow they
services were legally available distance from services or manage to have better health
in Turkey at the time. “If she social norms—that determine than others, because they

“Independent of the legal status of

abortion in a country, women make
those decisions and they find a way.”

102 Laws that empower, laws that control

No matter the legal status of abortion, women with means tend to find a way to access the procedure while women without resources face heightened risks.
Original artwork by Naomi Vona; photo by JESHOOTS on Unsplash.

have opportunities, they have all circumstances in Ireland, said Caitríona Henchion, the
money, they have networks. large numbers of women who medical director at the Irish
Those who are disadvantaged wanted the procedure were Family Planning Association.
economically or socially or able to travel overseas to obtain
culturally, they suffer more.” it. “In an awful lot of cases, if For many—even most—
women were determined to women, the law did not
By contrast, even when abortion have an abortion, they would prevent abortion, but it “often
was strictly banned in almost eventually manage to do it,” might result in a long delay in

STAT E OF WOR L D POPUL AT I ON 2 02 1 103

 actually being able to get it,” explained. Still, it was “regular do not speak English also
Dr. Henchion said. “All of the enough” to receive patients continue to face challenges.
time that they were waiting with heavy or prolonged
is a period of great stress and bleeding and “women who Dr. Ortayli described a similar
anxiety… [and] there would maybe took abortion pills at frustration. “I had a private
have obviously been the higher home at a more advanced practice for seven or eight
risk attached to the procedure gestation than either they years in Istanbul, and I had
that they were then having.” thought they were, or than they many clients coming from
should have been if they were the Gulf, where [abortion] is
Those who were unable going to use that method.” more restricted. Of course,
to obtain an abortion by these women were women
travelling internationally were These circumstances were who could afford it.” At the
“a, relatively speaking, small challenging for doctors, Dr. same time, she knew that
group,” she said, “particularly Henchion recalled. Sometimes, vulnerable women in her
women who had either poor patients literally begged own country were struggling
English or who didn’t have full for abortion information or to receive the same level of
citizenship and those rights referrals she legally could care, whether because of
that would go with it”—such not provide. In the end, the distance to services or spousal
as the ability to easily leave the rules seemed to create one permission rules. “I have seen
country and return—“teenagers outcome for people with money men sometimes use this as a
who might’ve required and resources, and another weapon towards women. For
parental consent, people outcome for those without. example, if a woman wants a
who didn’t have the money ”That’s how I always felt,” divorce, but she gets pregnant,
to travel at all… or people she said. She was a leading and he doesn’t let her have an
who did not have anybody proponent for the legalization abortion in order to tie her up.”
that they could disclose [the of abortion in Ireland, a change
pregnancy] to or nobody that that took place following Still, she was glad the option
could have helped them.” a referendum in 2018. to terminate a pregnancy
was available in Turkey, even
Though Dr. Henchion could But even today, those who are if access was uneven. She
not provide abortions at the most disadvantaged continue remembers being bereft when
time, she could and did perform to experience higher barriers her patient died following the
post-abortion care, typically and greater risks. “There are unsafe abortion. A more senior
after women illegally obtained some parts of the country physician told her it used to
pills to induce a medical that really have almost no be worse. “He said, before the
abortion. “In most cases, it is access in terms of providers,” liberalization of the [abortion]
safe and straightforward and Dr. Henchion said. Some law, in the same ward, we lost
people won’t have problems women still have to travel to women like her, maybe two or
or complications,” so only a access safe abortion, incurring three of them every week.”
fraction of abortions performed all the associated delays
this way came to the attention and costs. Undocumented And paradoxically, Dr. Henchion
of the health system, she immigrants and people who says, the legalization of

104 Laws that empower, laws that control

abortion in Ireland has given Of the 13 commodities on this list, three
many women one more option: are contraceptives—female condoms,
the choice to change their contraceptive implants and emergency
minds. Before, when women contraception—and their inclusion on
had to travel internationally national essential medicines lists was lower
for an abortion, they might
than any of the other 10 commodities.
feel compelled to undergo the
procedure after spending the
Ninety-three per cent of the 79 countries
time and resources to arrange it.
reported that abortion is legal on some or
“The pressure on them to actually
make the decision was huge…
all grounds, with about 90 per cent of them
This is your only chance either allowing abortion to save a woman’s life,
to have it, or don’t.” But today, about 80 per cent allowing it to preserve a
she says, “you can actually give woman’s physical health or in cases of fetal
people all of the information and impairment, and a little more than 60 per
give them space and time.” cent allowing it in cases of rape.

She says these changes make The most frequently cited restriction on
an even bigger difference now abortion in these countries is a requirement
during the COVID-19 pandemic. for authorization by a medical professional.
“When you think about the
This restriction may be construed as
[pandemic-related] limitations
discrimination against people who face
on travel, we would be looking at
barriers accessing health services in general
a really, really serious situation
or whose health-care providers refuse
if we hadn’t legalized when
we did… There have been a lot
to provide abortion because of personal
of crisis pregnancies because or prevailing societal beliefs against this
of COVID, people who maybe procedure. Medical abortion is one safe
have lost jobs or their situations option that does not necessarily require
have totally changed, and they the direct involvement a doctor. With
can still access this care.” this type of abortion, counselling may be
provided by a lay person at pharmacies
where pills are dispensed, by other health
professionals, or through telemedicine and
safe-abortion hotlines.

Countries where women can legally access

abortion services and are provided with
access to information and to all methods of
contraception, have the lowest abortion rates
(UN Working Group on Discrimination
Against Women in Law and Practice, 2017).

STAT E OF WOR L D POPUL AT I ON 2 02 1 105

 One study drawing on data from 61 Indicator limitations
countries found that in countries where
abortion is completely banned or allowed No single indicator can ever capture the whole
only to save a woman’s life or her physical story with regard to legal and regulatory
health, only 25 per cent of abortions environments. The complexity of these
were safe. In countries where abortion is frameworks on paper, with multiple laws and
legal on broader grounds nearly 90 per regulations impacting health outcomes and
cent of abortions were safe (Ganatra and a long pathway from the existence of laws to
others, 2017). Abortions are considered their full implementation, makes it impossible.
safe when they are carried out by a As a result, there are few clear associations
method recommended by the World between a country’s performance on indicator
Health Organization that is appropriate 5.6.2 and relevant sexual and reproductive
to the pregnancy duration, and when the health outcomes in that country. The data
person carrying out the abortion has the from indicator 5.6.2 provide an entry point
necessary skills. Such abortions can be for deeper investigation into the strengths and
done using tablets (medical abortions) or weaknesses of laws and regulations as they exist
through outpatient procedures. on paper, and into their implementation.

International declarations such as the All of the laws and regulations assessed under
ICPD Programme of Action say that indicator 5.6.2 relate only to the supply side
post-abortion care should be universally of health services, which paints a critical but
available irrespective of the legal status incomplete picture. What is also needed is a
of abortion. However, only about deeper understanding of the laws and many
80 per cent of the 79 countries with other forces that support or diminish women’s
data have laws or regulations that ensure autonomy and empowerment in general and
access to post-abortion care irrespective how those forces more directly affect the
of the legal status of abortion. This decision-making power of the individual in
inconsistency between international legal matters of sexual and reproductive health.
frameworks and national laws in some
countries creates gaps in services that Also, indicator 5.6.2 encompasses only
can contribute to maternal mortality a selection of the areas of health that are
and morbidity. associated with bodily autonomy. The
indicator does not cover laws governing
Comprehensive sexuality other important matters, such as rape within
education and information marriage, self-determination in gender
Only 62 per cent of reporting countries identity, genital surgeries in the case of
have laws, regulations or national policies intersex infants and same-sex sexual activity.
that make comprehensive sexuality
education a mandatory component of Other laws governing health-care service
national school curricula. delivery are also relevant to bodily

106 Laws that empower, laws that control

autonomy but are not included in indicator allowed rapists to escape punishment if they
5.6.2. These laws include provisions for married the woman (or girl) they had raped
non-discrimination, privacy and access to (McCormick-Cavanagh, 2017).
justice. For example, where people’s identities
or professions might be criminalized, such In Malta, the 2015 Gender Identity, Gender
as transgender people or sex workers, stigma Expression and Sex Characteristics Act
and discrimination in health facilities is often recognized a right to “bodily integrity and
known to be high, acting as a barrier to access physical autonomy” as part of the right to
to services that can play a role in protecting gender identity. The law prohibits “any
bodily autonomy (Global Commission on sex assignment treatment and/or surgical
HIV and the Law, 2012). intervention on the sex characteristics of a
minor which treatment and/or intervention
can be deferred until the person to be
Recent legal reforms treated can provide informed consent”
paving way to change (Cabral, 2015).

Countries around the globe are enacting In Ireland in 2015, a law was passed allowing
laws and regulations with the intention transgender people over the age of 18 to self-
of guaranteeing full and equal sexual and declare their gender without the need for a
reproductive health and rights. While the medical certificate or other interventions by
impact of these positive changes is yet to be state authorities (Transgender Europe, 2015).
assessed, they are important first steps towards Ireland was the fourth country in the world,
ensuring bodily autonomy. after Denmark, Malta and Argentina, to
introduce such a law (Heidari, 2015).
In Tunisia, for example, marital rape was once
not considered a crime. However, in 2017, the And Botswana, in 2019, became the latest
Parliament passed a comprehensive gender- country in Africa to decriminalize same-sex
based violence law that included the explicit sexual conduct or acts among consenting
criminalization of marital rape. The new law adults, citing rights to privacy, dignity and
also eliminated a pre-existing loophole that non-discrimination (Esterhuizen, 2019).

STAT E OF WOR L D POPUL AT I ON 2 02 1 107

Artwork by Rebeka Artim
THE POWER
TO SAY YES
THE RIGHT
TO SAY NO
Achieving bodily autonomy depends on gender
equality and expanding choices and opportunities
for women, girls and excluded groups

Women and women’s movements have always The centuries since then have echoed with the
known, at the core, that choice is power. And voices of women insisting on autonomy and
that there are no more fundamental choices than choice, all the way to the women’s movements
those related to one’s own body. of recent decades that have claimed “our bodies,
our choice” as a rallying cry.
Claiming the right to make choices seems like
a modern concept, but it was in 400 BC that Bodily autonomy involves many issues, but they
the Greek gynaecologist Agnodice refused to all come back to the power to make one’s own
acknowledge a law banning women physicians decisions. Tracking bodily autonomy under the
and depriving women of the power of choice. Sustainable Development Goals emphasizes
Taken to court for treating patients anyway, three critical dimensions: the ability to make
she won her case, and the law was revoked. your own decisions on health care, contraception

STAT E OF WOR L D POPUL AT I ON 2 02 1 109

 and sex. But many other issues influence There is no question that today women
these decisions. Little progress will be made and girls are starting to face less gender
without demolishing an underlying barrier discrimination. Gains in gender equality
to making choices: gender discrimination, and the choices available to women and girls
which is woven throughout the fabric are evident everywhere. And yet, the goal of
of our societies, economies and political equality and the power to make decisions
arrangements, sustained by privilege and are far from realized. Women and girls face
power still mostly held by men. continued, blatant violations of their rights,
even more so if they are also experiencing
The power to make choices is so important discrimination because of their race, age,
because it underpins many other rights, and sexual orientation, income or disability status.
because the benefits run in many directions.
A woman who can make her own decisions Being able to make meaningful decisions
about sex, contraception and reproductive depends on both empowered individuals,
health is also likely to enjoy better health who have information and agency, and on an
overall, own property, be gainfully employed, environment, from families to legal systems,
have more time for leisure and avoid gender- that fully upholds and respects individual
based violence. If she chooses to have choices. These twin notions sit at the core of
children, they are more likely to be healthy the Programme of Action of the International
(UNFPA, 2020e). Conference on Population and Development
(ICPD) and the Beijing Declaration and
Platform for Action. These notions are
reflected as well in the 2030 Agenda for
Sustainable Development and the 2019

The power to
Nairobi Statement on ICPD25, which called
for protecting and ensuring “all individuals’

make choices is so
right to bodily integrity, autonomy and
reproductive rights, and to provide access to

important because
essential services in support of these rights”.

it underpins many
Such commitments now serve as touchstones
for a new global Generation Equality campaign

other rights, and

mobilizing around the Beijing Platform’s
twenty-fifth anniversary and committed to

because the benefits

achieving gender equality by 2030. Linking
people of all ages and backgrounds, who are

run in many
outspoken and passionate in calls for change,
Generation Equality has a chance to see choice

directions
and autonomy finally, irrevocably, reaching
everyone. What is still required to get there?

110 The power to say yes, the right to say no

Autonomy depends while around three quarters of countries claim
that gender equality is central to their national
on gender equality strategy for implementing the Sustainable
Achieving bodily autonomy for women and Development Goals, only half involve national
girls depends above all on achieving gender institutions for gender equality in formulating
equality. While a bold goal, gender equality is these strategies (UN ECOSOC, 2019).
also an internationally agreed one, as the fifth
Sustainable Development Goal, and as the An increasing number of governments, starting
purpose of the Beijing Declaration and Platform with Sweden in 2014, have adopted a “feminist
for Action. All countries can do more to achieve foreign policy”. Such a policy, according to
gender equality, since none is yet there. the Centre for Feminist Foreign Policy, is a
“multidimensional policy framework that
Governments have a lead role to play in reaching aims to elevate women’s and marginalized
that goal. By fulfilling their obligations under groups’ experiences and agency….” While an
human rights treaties, such as the Convention on encouraging development, feminist foreign
the Elimination of All Forms of Discrimination policy will only make a difference if it goes
against Women and the Convention on the beyond “fem-washing”, where rhetoric does
Rights of the Child, governments can alter the not meet reality.
social, political, institutional and economic
structures that reinforce and thrive on gender- One place to start might be with official
unequal norms. international development and humanitarian
aid. In 2018, only about 4 per cent of the total
One foundational advance comes from ending aid provided by the 30 largest donors supported
inequalities in civil services, legislatures and programmes with gender equality and women’s
leadership positions, so that women’s perspectives empowerment as the primary objective.
inform and guide policies and regulations
that affect women’s rights and choices. Some Looking ahead, an urgent issue will likely
countries have made strides in bringing more revolve around record levels of public debt.
women into elected positions, including through Many countries are on the cusp of a new wave of
the use of quotas and other special measures. fiscal austerity, affecting, by one pre-pandemic
But such shifts can have a greater impact when estimate, almost three quarters of women
they are accompanied by stronger and adequately and girls globally. Decisions on such austerity
financed systems, institutions or “machineries”, measures rarely reflect alignment with gender
as they are referred to in the Beijing Platform for equality. They tend to reduce public services,
Action, for promoting gender equality. wages and the overall quality of employment,
hitting poor women with particular force. Even
As it stands now, many national machineries for amid major challenges, governments can shape
gender equality are poorly funded, or are funded monetary and fiscal policies so they protect
by donor countries, whose priorities may not services essential to equality and autonomy, and
align with those of developing countries. And promote full employment and the creation of

STAT E OF WOR L D POPUL AT I ON 2 02 1 111

 At UNFPA, realizing bodily autonomy
is everything we do
For over 50 years, UNFPA has been the leading Since early pregnancy is often a consequence
global champion of the right to bodily autonomy. of little or no access to school, information or
As the United Nations sexual and reproductive health care, UNFPA helps protect and fulfil the
health agency, our mission is to deliver a world rights and choices of adolescent girls through
where every pregnancy is wanted, every childbirth comprehensive sexuality education and by
is safe and every young person’s potential is advocating for girls to complete their schooling.
fulfilled. Our programmes operate in more than
150 countries and territories with 80 per cent Collaboration with UNICEF sustains the world’s
of the world’s population, and all programmes largest global programme to accelerate the
in one way or another further the realization of abandonment of female genital mutilation
the rights and choices that define autonomy. in 17 countries where the practice is most
prevalent. Among other achievements, the
For women, girls and young people all over programme has pioneered strategies to shift
the world, UNFPA provides accessible and social norms towards ending a practice that
quality health care, a variety of modern undermines bodily integrity early in life.
contraceptives, accurate and empowering
information, and protection from harmful Collaboration with UNICEF also sustains
practices such as early marriage and all programmes to eliminate child marriage by 2030.
other forms of gender-based violence. Every year, as many as 12 million girls are subjected
to this practice, which can undermine their power
We are the world’s single-largest provider to make decisions not only about health care,
of donated contraceptives to developing contraception and sex, but also about schooling,
countries. In 2019, these contraceptives livelihoods and participation in community affairs.
empowered women to make decisions that
helped avert an estimated 14 million unintended As one of the lead entities in the United Nations
pregnancies and 3.9 million unsafe abortions. committed to furthering gender equality and women’s
empowerment, UNFPA acts to protect survivors of
Our support for women’s maternal health gender-based violence, providing a combination of
options worldwide is especially significant in essential services, including in humanitarian crises.
the 32 countries in five regions with the highest
rates of maternal mortality and morbidity. The realization of bodily autonomy is in some
In 2019, 29,000 midwives received education sense the measure of the role of UNFPA in
and training while 2,700 midwifery tutors the world: it is our purpose. And only when
upgraded their skills, expanding affordable, every woman and girl realizes it, without
quality health-care choices for women. exception, will our mission be complete.

112 The power to say yes, the right to say no

 decent work (UN ECOSOC, 2019), but this
would in part require latitude in international
debt servicing, something that could be
advocated under a feminist foreign policy.

Autonomy demands
seeing the connections
This report focuses on choices and bodily
autonomy related to sexual and reproductive
health and rights, in line with some of the gender
equality targets defined under the Sustainable
Development Goals. This is an important
starting point, since the power to decide in
these areas can determine decisions in many
other parts of life. Women’s choice and bodily
autonomy are compromised on many fronts,
however, and these are highly interconnected
and mutually reinforcing. Industries and entire
sectors of economies, for instance, thrive because
women do tedious, poorly paid jobs in marginal
working conditions that may undermine their
health and longevity. Women in many societies
suffer the indignities, if not worse, of sexual
harassment, which can define decisions about
choices to move in or even go to public spaces.

Impetus to consider the diverse elements of

autonomy and the numerous ways they intersect
comes from the new United Nations Action
Coalition on Bodily Autonomy and Sexual and
Reproductive Health and Rights. An integral
part of preparations for the Generation Equality
Forum to mark the twenty-fifth anniversary
of the Beijing Declaration, the coalition is
charged with putting ambitious actions on
the table to boost improvements in women’s
rights within the next five years. UNFPA is the

Artwork by Kaisei Nanke

STAT E OF WOR L D POPUL AT I ON 2 02 1 113

 that entrench gender discrimination. Women’s
entrepreneurship programmes, for example,
while popular in many quarters and with the
potential to improve women’s economic well-
being and ability to make choices, can only go so
far without eliminating multiple biases at work
and in social protection systems, health care,
pension schemes, access to assets and financial
services, access to markets and labour protections
(UN ESCAP and UN Women, 2020).

Autonomy requires
changing norms and
opening opportunities
Important advances have been in made
in understanding how to alter the social
norms that keep gender and other forms of
discrimination intact. These include advocacy
and communications campaigns, and work
within communities to raise awareness about
how everyone—women, men, boys and girls—
can benefit from gender-equal societies.

The UNFPA-supported MenCare programme

in Georgia may be a model that other countries
Artwork by Kaisei Nanke
could adapt to local circumstances. It promotes
men’s involvement as equitable fathers and
caregivers in order to achieve better health and
United Nations agency designated as one of the family well-being, and encourage men to support
coalition’s leaders. gender equality. It also contributes to better
couples’ communication, consent and decision-
Overall, women and adolescents need more making, which in turn can foster better bodily
options that support their choices in immediate autonomy for women and girls.
and practical terms, such as through equal
opportunities for high-quality education and Steps like these must be combined with broader,
decent work. But even well-intentioned measures more systemic ones that support and even
can fall short if they do not make links and incentivize new ways of thinking. Rebalancing
actively contribute to transforming systems the unfair burden of unpaid care work placed on

114 The power to say yes, the right to say no

women and girls, for instance, requires not just were in decisions related to family law or the
that men step up and do their fair share, but family, followed by cases of gender-based
that families enjoy affordable access to essential violence. This may demonstrate the challenges
services that lighten the load of this kind of courts face in advancing women’s equality in
labour, from quality child- and eldercare to relation to customs that are widely supported
reliable water and electricity supplies. and practised (UN Women and IDEA, 2017).

Reviewing laws for gender responsiveness

Autonomy depends on laws and alignment with human rights standards
that enable, not constrain can be a step towards removing vestiges
of discrimination and inequality. In some
Laws may not be a panacea for correcting countries, a national human rights institution
deficits in choice and autonomy, but they do can comprehensively advise on legal reform,
set standards and ensure accountability by looking at discrimination in all its forms,
guaranteeing recourse for when those standards and across civil, political, economic, social
are broken. They can have the greatest impact and cultural rights (UNFPA, 2020c). Such
when they align with globally agreed human a process could encourage adopting laws
rights principles and commitments that that guarantee universal access to sexual
countries have made to women’s rights, gender and reproductive health services without
equality and sexual and reproductive health. discrimination of any kind, if these do not
already exist. It could help in removing
In most countries, having explicit contradictions such as requirements for
constitutional commitments to women’s third-party consent and constraints related to
rights and gender equality opens the door marital status. Misalignment between the age
to correcting discrimination in law and of consent for sexual activity and for accessing
legal practice. Yet, while 191 constitutions sexual and reproductive health information and
now include some provisions on equality services should be resolved, so that as soon as
and non-discrimination, only 24 have adolescents can legally have sex, they can access
stand-alone provisions on women’s rights information and services.
(UN ECOSOC, 2019).

Explicit constitutional provisions for Making choices must be

applying international treaties, such as the upheld in legal practice
Convention on the Elimination of All Forms
of Discrimination against Women, have Since discriminatory social norms infiltrate
been successful in advancing women’s rights, justice systems just as efficiently as other
providing an extra source of law to resolve institutions in a society, they can lead to
contradictions domestically. A recent review of discriminatory outcomes, even if the letter of
62 court decisions in 30 countries found the the law is correctly aligned with human rights
most frequent references to the Convention and gender equality. The social backdrop can

STAT E OF WOR L D POPUL AT I ON 2 02 1 115

 in fact be as much of a determinant of justice as own assumptions and biases, and how these
the law itself. may operate as they adjudicate or report cases.
With this knowledge, judicial officials can be
Nepal, for example, has a highly patriarchal encouraged to apply innovative interpretative
society and acute gender disparities. To techniques, such as analysis that factors in
counteract these patterns and ensure that social context, and routine gender assessments
substantial recent legal reforms supporting of whether groups of women or girls would
gender equality would actually be implemented, be negatively affected by a judgment.
it has proactively established strong mechanisms
for enforcement and accountability. These have Women and girls also need to be aware of rights
included a National Women’s Commission guaranteed by the law and where they can find
mandated by the Constitution to regularly recourse if these are violated. Since many issues
investigate issues related to women and the around bodily autonomy operate in deeply
law. Steps to increase the number of women personal realms, behind barriers reinforced by
police officers have encompassed establishing notions of public and private spaces as well as
units of women officers in all 77 districts of the gender discrimination, it can be important to
country. Since doing so, reporting of domestic support women’s rights organizations as the
violence cases has increased more than eight-fold vanguard for this outreach. With often better
(Akhmetova and others, 2020). access to women in families and communities,
they can help provide a bridge between women
There are some indications of growing judicial and their legal rights. They can also detect
recognition that patriarchal rules and practices, patterns of discrimination among marginalized
whatever their source, cannot be sustained groups that could potentially be rectified through
in conflict with changing societal attitudes public interest legislation.
and constitutional values. A number of
gender-based violence cases have seen courts
defining discrimination based on religious Choices in health care
or cultural grounds as unconstitutional, as
was the case with female genital mutilation
centre on the patient
in Uganda. In Pakistan, the Lahore High Women and girls cannot realize bodily autonomy
Court not only rejected an argument based on without access to health care, including essential
religion, but referred to Islamic principles to sexual and reproductive health services. Twenty-
maintain the sentence passed for the murder six years ago, the Beijing Declaration, the
of the perpetrator’s daughter, son-in-law and political statement accompanying the Platform
grandchild (UN Women and IDEA, 2017). for Action, recognized that “the right of all
women to control all aspects of their health, in
Moving in such directions requires members particular their own fertility, is basic to their
of the judiciary and police not only to be fully empowerment”. More recently, the Sustainable
aware of laws designed to uphold women’s rights Development Goals set the first global goal for
and autonomy, but to be able to examine their achieving universal health coverage, defined as

116 The power to say yes, the right to say no

Artwork by Hülya Özdemir

all people accessing the essential health services and using sound data to adapt services and social
they need, without being exposed to financial protection to different population groups as well
hardship (Hogan and others, 2017).  as needs across the life cycle.

Universal health coverage depends on prioritizing But given the ways in which gender
care in national development planning, discrimination operates, including in health
developing effective health systems, providing systems, universal health coverage that supports
adequate budgetary allocations, and generating bodily autonomy must go beyond the notion

STAT E OF WOR L D POPUL AT I ON 2 02 1 117

 that it is enough to provide services based solely understand, probe and respond to the barriers
on narrow definitions of medical needs, without to choice faced by some patients. Regular
attention to gender dynamics that influence monitoring for compliance with principles of
those needs as well as health-seeking behaviour. non-discrimination and quality of care could
As the Beijing Platform for Action noted, include patient monitoring, such as through
“Women’s health is also affected by gender bias simple text message surveys.
in the health system and by the provision of
inadequate and inappropriate medical services Services that support choice and autonomy
to women.” Similar issues apply to people offer multiple options for contraception, ensure
with disabilities and those with diverse sexual that if women prefer a female doctor they will
orientations and gender identities, and others. be able to find one, and provide channels to
communicate with health-care providers in a
While much attention has been paid to variety of languages. Posting a patient bill of
whether health services are technically sound rights emphasizing dignity, rights and choices
and affordable, there is often less emphasis on in hospitals and health-care service centres, with
acceptability, safety and empowerment from provisions to communicate this information to
the perspective of women and girls as users. women who are illiterate or have a disability,
Tolerance or acceptance of discriminatory sets a tone that services are grounded in what
norms can quickly lead health-care providers patients want and decide. Service relevance
to put aside the notions of informed consent is also key, underscoring the importance of
and patient autonomy, which require them prioritizing health-care interventions that
to support and educate patients to make respond to demand from patients, starting with
choices, without making decisions for them a strong focus on groups with the highest unmet
(Bernstein, 2018). Outcomes may include the need for sexual and reproductive health care or
denial of services, such as a refusal to provide low service use. Also needed is an environment
contraceptives or safe abortion or post-abortion that enables sexual and reproductive health
care to unmarried girls and women, even where workers, the majority of whom are women,
that is not against the formal law, as well as to do their jobs with professionalism and
obstetric violence, defined as experiencing, in compassion.
pregnancy or childbirth, mistreatment or being
forced into procedures against one’s will, at the Encouraging service use and the exercise of
hands of medical personnel. choice also depends on basic elements of quality
health care, such as proximity, convenient
A number of options can help correct biases in operating hours and affordability. Services must
health care. Medical guidelines can stipulate how guarantee privacy and employ health workers
services should be provided in line with the law; with positive attitudes and full respect for their
training can make health-care workers aware of clients. Providing family planning services
legal statutes so they can work in line with them. through community health workers who share
Specific gender-sensitivity training for health- correct information and help educate men has
care providers could include developing skills to been shown to increase uptake of contraceptives

118 The power to say yes, the right to say no

(UNFPA, 2019). Community-level advocacy of delivery. Midwifery also requires continued
the health benefits of sexual and reproductive and scaled-up investment in cultivating,
health information and services for unmarried deploying and retaining skilled practitioners.
adolescents can diminish stigma and foster use.
All health-care systems need to respond to the
Uganda’s “SASA!” programme, backed by ways in which gender discrimination intersects
UNFPA, uses multiple forums to catalyse with other forms of exclusion to undermine
community-led changes in norms and autonomy and choice. If left unrecognized,
behaviours that perpetuate gender inequality, this can result in services that are inappropriate
violence and increased HIV vulnerability among or not available or are even based on blatant
women. Health workers, local authorities and rights violations. This danger has been realized,
activists start with a critical analysis of power and for instance, by many indigenous women and
inequalities, and then introduce concepts learned women with disabilities, who have been subject
through community conversations, door-to-door to practices such as forced sterilization. To
discussions, film shows, soap opera groups and rectify disempowerment and discrimination, the
other events. The programme has significantly United Nations Inter-Agency Support Group
decreased social acceptance of intimate partner on Indigenous Issues has emphasized several
violence, and increased agreement that a woman measures to ensure indigenous peoples fully
can refuse sex. Rates of physical intimate partner realize their sexual and reproductive health
violence among women in communities with and rights, including through their active
the programme have fallen by up to 52 per cent engagement in designing culturally appropriate
(Starmann and others, 2017; Kyegombe and health policies and programmes. This has
others, 2014).  increased access among indigenous women,
girls and youth to critical services for sexual
Midwives offer potentially unique opportunities and reproductive health, HIV prevention and
as primary caregivers for pregnant women gender-based violence, especially in rural and
all over the world. They also provide a host underserved areas (UN IASG, 2014).
of other services essential to realizing sexual
and reproductive health and rights, from
counselling on family planning to screening for Autonomy requires
nutrition and cervical cancer. In their practices,
midwives, almost all of whom are women, can
information
model and shift norms around what choice Realizing bodily autonomy depends on the
and bodily autonomy can mean, especially if ability not just to make choices, but to make
they themselves are skilled and empowered. informed choices, grounded in a careful
Since they may have a clearer sense of the weighing of facts and options. Women with
issues that other women face around bodily more education are more likely to make
autonomy, health-care systems should encourage their own decisions about contraception
channels where they can share knowledge and health care, and to be able to say no to
that supports more gender-responsive service sex. With less education than her husband

STAT E OF WOR L D POPUL AT I ON 2 02 1 119

 or partner, a woman is more likely to face that circulate and undermine the ability to
sexual violence. Further, a correlation exists make informed choices. One novel approach
between women and girls with more access being pursued by UNFPA in Colombia and the
to mass media and using contraception Philippines is to “scrape” Twitter conversations
and seeking health care (UNFPA, 2019). to identify common myths about issues from
contraception to sexually transmitted infections.
Among 75 countries with data on laws This information can then be used to shape
and regulations supporting sexual and sexuality education and health-care programmes.
reproductive health, fewer than two
thirds have statutes or policies making Reinforcing empowering messages around choice
comprehensive sexuality education mandatory could operate in education more broadly by
in national school curricula. Such education encouraging girls to pursue diverse fields of study,
is age-appropriate, based on a clearly defined unfettered by gender norms around what “girls
curriculum, aligned with human rights and should do”. Making such a choice is empowering
gender equality, and culturally relevant. in and of itself, and could lead to further
It is ideally available in and out of school empowerment and autonomy as girls cross into
(UNESCO and others, 2018). potentially more lucrative and rewarding jobs.
Much of the current gender pay gap is explained
The United Nations Educational, Scientific by labour market segregation that shunts women
and Cultural Organization stresses that into lower-paying jobs. A mere 3 per cent of
evidence-based comprehensive sexuality students joining information and communication
education from early childhood encourages technology courses across the globe are women,
greater autonomy and safety during young for instance (United Nations, n.d.a).
adulthood without leading to earlier sexual
activity (UNESCO, 2009). Comprehensive
courses can support more respectful Autonomy demands
relationships and more autonomous decisions
about sexuality late in life (Marí-Ytarte and
defending the defenders
others, 2020). of women’s empowerment
and rights
Since much information on sex and
reproduction can come from health-care Women’s movements have long advocated
providers, they need to be attuned to offering and defended the right to choice and bodily
it respectfully and without judgment, and autonomy, often with minimal resources.
accounting for different needs based on age, The same is true for organizations of LGBTI
ability or socioeconomic standing. This is people, indigenous peoples, youth and people
particularly necessary for adolescents and other with disabilities. Today, however, space for
groups who have been traditionally overlooked them to operate is increasingly under pressure,
or marginalized in access to sexuality education. and there is evidence of backtracking on
Providers should be prepared to counter myths hard-won gains. More vocal and organized

120 The power to say yes, the right to say no

opposition to gender equality and women’s Political parties should be encouraged
rights activism has emerged around the to recognize women’s political value and
world, including by religious and conservative rights, and move beyond lip service and
groups, populist and nationalist groups, tokenism (O’Neil and Domingo, 2016).
men’s rights groups and anti-gender ideology
movements (Roggeband and Krizsán, 2020). Women’s groups and movements are
highly diverse, with enormous stores of
Women politicians, journalists, activists knowledge about the issues women face in
and human rights defenders have been realizing autonomy and rights. But from
increasingly subject to harassment, violence grass-roots service providers to women’s
and cyberbullying. Between 2014 and 2018, professional associations, they are not
the Special Rapporteur on Human Rights always well connected. Sustained support
Defenders issued 181 communications to and resources to systematically bring them
60 States on women human rights defenders. together could advance organizing around
Documented attacks have included defamation common problems (O’Neil and Domingo,
campaigns; physical or sexual violence, 2016) and presenting a more unified,
torture, killings and forced disappearances; powerful response to regressive forces.
threats to and attacks on family members,
or by family members, because of their
activities; and attacks against their collectives
and movements (UN ECOSOC, 2019).

Decisive action should counter and prevent

such violations. Some countries have passed Women politicians,
specific laws criminalizing violence against
women in politics and public life, often journalists,
under pressure from women’s activists, as in
Costa Rica, Ecuador, Mexico and Peru. The activists and
Organization of American States in 2017
issued its Inter-American Model Law on the human rights
Prevention, Punishment and Eradication of
Violence against Women in Political Life. defenders have been
Since the fear of violence is a major deterrent
to women taking more public roles in many increasingly subject
places, adopting and implementing measures
like these could reshape the conditions under to harassment,
which women can participate, lead and make
choices. Complementary actions might include violence and
advocacy campaigns and work with media
and schools to eliminate gender stereotypes. cyberbullying

STAT E OF WOR L D POPUL AT I ON 2 02 1 121

Similarly, bodily autonomy presents a Autonomy requires shifts
unifying concern for diverse groups of
activists, including around disability,
in men’s attitudes
LGBTI rights and the rights of indigenous Women can claim their rights. States can
communities. Linking different issues and uphold them. Yet progress fundamentally
the intersections among them could shape depends on men, individually and collectively,
a collective, influential agenda and activism being willing to step away from dominating
for realizing fundamental human rights roles that privilege their power and choices at
in all economic priorities, justice systems, the expense of women’s power and choices.
health and social services and safety nets. This is now happening, with a shift in attitudes
towards gender equality among younger men in
particular, but still has far to go.

Part of the way forward may be more

men understanding the downside of male
dominance, such as risks to their own health
and that of their wives or partners, and
interpersonal conflicts. A regional survey of
Europe by the World Health Organization
found that gender equality benefits men’s
health, including through lower mortality
rates, half the chance of being depressed and
a 40 per cent reduced risk of violent death
(WHO Regional Office for Europe, 2018).
Adolescent boys in particular need exposure
to positive notions of masculinity, especially
at a time of life when harmful gender
norms start to crystallize, causing long-term
harm to themselves and girls (UNFPA and
Promundo, 2016).

The #MeToo movement as well as survey data

show that one of the areas where women are
most behind in terms of choice and autonomy
is in the power to say no to sex. Notions of
respectful, non-violent relationships are ideally
modelled to children in households from
the beginning, but regardless, they should be
integral to comprehensive sexuality education
in school. They can feature more prominently

Artwork by Rebeka Artim

in the media and entertainment, in the ways
religion is taught, and even in workplaces in
Gender equality
terms of clear and enforced policies on sexual
harassment. Ending impunity for sexual
benefits men’s
violence in all its forms, from single violations
to the mass crimes that occur when rape is
health, including
used as a weapon of war, is also essential. In
2000, the United Nations Security Council
through lower
issued Resolution 1325, which called on parties
to armed conflict to take special measures to
mortality rates,
protect women and girls from gender-based
violence, particularly rape and other forms of
half the chance
sexual abuse, and all other forms of violence
in situations of armed conflict. Since then,
of being depressed
the Security Council has issued seven other
resolutions condemning this form of violence.
and a 40 per cent
Improving women’s opportunities for
reduced risk of
livelihoods and leadership roles in their
community and beyond can increase their
violent death
power to make decisions within households
and about their bodies. Such support may
need to build in explicit work with men and do more to encourage men to break
communities, however, to ease a transition to stereotypes and enter female-dominated
more progressive gender norms and limit the care professions such as child- and eldercare
risk of backlash from some men who may feel (UN ECOSOC, 2019).
threatened by women’s gains.
Other opportunities exist to promote gender-
Another important element is to engage men equitable attitudes among men and adolescent
in transforming patterns of unpaid care, so boys through sexual and reproductive health
that it is not performed primarily by women, services, where providers can share knowledge
and household dynamics in power and choice about equitable relationships, parenting and
to achieve greater equilibrium. Paternity and communications (IPPF and UNFPA, 2017).
parental leave policies can encourage men to Community mobilization programmes can
participate in caregiving, especially if leave also challenge unequal power relations and
cannot be transferred to the other parent. discriminatory social norms, building on a strong
These provisions are becoming more common, grounding in theories of gender and power.
but still reach a limited number of families Initiatives involving women, men, girls and boys
in developing countries, particularly in the together have proven more effective than those
informal workforce. Public policies could also for men and boys alone (UN ECOSOC, 2019).

STAT E OF WOR L D POPUL AT I ON 2 02 1 123

 The masculinit y trap
The lush beauty of Guatemala’s according to Georgetown in the United States, national
central highlands hides University’s 2019 Women, media reported that she was
a dark reality for women Peace and Security Index. In known to dress inappropriately
and girls, says Alexander fact, victims around the world for her age. In Afghanistan, rape
Armando Morales Tecún, an are routinely blamed for inviting survivors may be imprisoned
indigenous youth educator gender-based violence by being for “morality crimes”.
and gender equality advocate in the wrong place, wearing
in the rural department of the wrong clothing, behaving The blaming and shaming of
Quiché. “In many places, the wrong way or simply being victims rather than perpetrators
women are blamed if they physically developed at an can be traced back to norms
are attacked, said to have early age. And such factors are that encourage men to take
tempted or seduced their often considered mitigating or control—not only of women’s
aggressors or rapists, because exculpatory for perpetrators. bodies but also of their families.
of the way they are dressed, Tecún recalled asking a group
for example, or because In 1998, for instance, Italy’s of young men why they wanted
of their way of acting.” Supreme Court overturned the to get married. One of them
rape conviction of a man whose answered, “I want to rule my
These attitudes are not unique accuser was wearing tight blue family. Because I want someone
to Guatemala, which ranks in jeans at the time of the attack. to cook for me, someone to
the bottom third of countries In 2010, when an 11-year-old wash my clothes, someone
and territories on measures of girl was gang-raped by more to give me children and
women’s safety and welfare, than a dozen boys and men someone to keep my house.”

Jay Silverman, a professor

“Women are blamed

at the University of
California, San Diego School
of Medicine who studies
if they are attacked, reproductive coercion, says
these attitudes are universal.

said to have tempted “Male entitlement to control

female partners often also

or seduced their extends to children. The

perception of that right is
maintained by all sorts of
aggressors or rapists.” different structures and

124 The power to say yes, the right to say no

Alexander Armando Morales Tecún educates young people about gender equality. Original artwork by Naomi Vona; photo © UNFPA/J. Serrano.

norms in communities and gender norms—which he are not in a relationship,

nations across the globe.” calls “a hegemonic model you are not a man.”
of masculinity”—can leave
But the result is not a simple men feeling trapped, as And women play a role in
male-versus-female dynamic, well. “If you are not married, perpetuating these beliefs
Tecún cautioned. These you are not a man. If you as well, he added. “Many

STAT E OF WOR L D POPUL AT I ON 2 02 1 125

 women also reaffirm that it is is born, a good creole chicken negative ideas because it
acceptable to beat a woman broth is made. When a girl affects the patriarchal male
when she has not fulfilled her is born, it is totally silent, as chauvinist system,” he said.
duties, because she did not if the event were a wake.”
wash her husband’s clothes, Zúñiga wants men and boys
because her husband’s food Anything that undermines to embrace new norms
was burned… It is said that these norms—including that liberate both men and
it is good that they beat you the very concept of bodily women from traditional
because you did not comply autonomy—can be regarded masculine ideals. “What our
with satisfying your husband.” as a threat, according to society deserves… are new
Romeo Alejandro Méndez masculinities, new ways of
These ideas are instilled early Zúñiga, another indigenous seeing manhood, ways that
and reinforced “from music, youth educator and activist strengthen and promote
games, images, advertising,” in Quiché. “The few people equality of opportunity for
Tecún said. “In the locality who have heard of bodily development, that enable all
where I am from, when a boy autonomy associate it with of us to live with dignity.”

Autonomy requires education services could address the multiple

risks and vulnerabilities that women and
investment girls face throughout their lives, and build in
Gender discrimination poses multiple empowerment and autonomy by putting a
steep barriers to women’s empowerment central emphasis on sexual and reproductive
and autonomy. Taking these down requires health and rights (UN ECOSOC, 2019). Such
substantial and sustained investment, in line approaches have never been more important
with principles of fairness and equity, and with than in COVID-19 recovery plans, with poor
particular attention to intersecting inequalities. and increasingly desperate families struggling
Yet financing typically falls far short of what it to cope with the economic downturn by, for
should be, for reasons that start with economies example, marrying off their daughters.
structured to concentrate resources in a few
privileged hands, mostly belonging to men. National gender equality action plans and
institutions for gender equality need adequate
Substantial and sustained investments in resources, as many remain chronically
integrated social protection, health and underfunded and unable to fulfil their

126 The power to say yes, the right to say no

mandates (UN ECOSOC, 2019). So do about their bodies. Yet gaps in data broken
women’s civil society organizations, which down by gender remain large. Gender data
are often on the front lines of protecting may not be collected, or if they are, may
women’s autonomy and rights. They provide not be used or shared. Inconsistencies in
many of the services to assist survivors of collection prevent essential analysis of how
gender-based violence, for instance, yet trends move over time.
were significantly underfunded even before
the COVID-19 pandemic. While the need This lack of information on what is actually
for such services rose dramatically during taking place in the lives of women and girls
the crisis, funding in many cases did not. automatically diminishes the possibility of
In the Asia and the Pacific region, 12 per developing services and policies that most
cent of civil society organizations working effectively support gender equality and
on eliminating violence against women autonomy. It can be a driver of discrimination
completely suspended their services as a where issues like gender-based violence and
result, and 71 per cent are only partially unpaid care work remain invisible, uncounted
operational (UN ESCAP and UN Women, and unaddressed.
2020). Smaller groups doing pioneering work
and with a dedicated women’s rights agenda Only an estimated 13 per cent of countries
tend to be among those most often missed by have a dedicated budget to collect and analyse
international aid and other donors. gender statistics. For the 54 gender-specific
indicators in the Sustainable Development
The price tag for ending preventable maternal Goals, regular data are produced for only
deaths, covering all unmet needs for family 22 per cent worldwide (UN Women, 2018).
planning and stopping gender-based violence Major shortfalls exist in data on women over
worldwide by 2030 will total $264 billion, reproductive age; digital literacy among girls;
according to a joint study by UNFPA and and gender and the environment, among
Johns Hopkins University, in collaboration others (Data2x, 2020).
with Victoria University, the University of
Washington and Avenir Health. Achieving Women’s informed decision-making is
these goals would contribute to women’s poorly measured, and data are missing or not
bodily autonomy (UNFPA, 2020f ). regularly produced on women’s use of health
services as well as on laws guaranteeing full
and equal access to sexual and reproductive
Autonomy means health care. Also missed are intersectional
needs, especially for women and adolescent
measurement girls in humanitarian crises, LGBTI
The Sustainable Development Goals represent individuals and women with disabilities.
an advance in calling for the measurement of Health data for adolescents are not always sex-
progress on gender equality, including whether disaggregated, and data on socially excluded
women and adolescent girls can make choices girls are particularly scarce (Data2x, 2020a).

STAT E OF WOR L D POPUL AT I ON 2 02 1 127

 Data systems need to be strategically designed A world of rights,
to capture the common experiences of
women and girls, while being nuanced
choices, autonomy
enough to reflect their diversity (Data2x, Many justifications, rationalizations and theories
2020). Such systems need to be systematic have been put forward to justify depriving
and comprehensive, and should apply human women and girls of their rights and choices and
rights principles to prevent marginalization for making their bodies subject to the whims
and discrimination, a direction that should of others. But if these excuses are allowed to
be set through national policy. continue, virtually none of the United Nations
Sustainable Development Goals will be
Another priority is to avoid compartmentalizing achieved by 2030. And that means the potential
gender within certain issues or areas of work, for human, social and economic progress
which is happening even now under the envisioned by the international community in
Sustainable Development Goals, where six of the 2030 Agenda for Sustainable Development
17 goals are dubbed “gender-blind”, meaning would go unrealized, to everyone’s detriment.
that they make no mention of gender even
though achievement of the goal will require Gender equality is a critical variable in the
addressing some aspects of gender inequality equation for success. So is realizing the rights
(UN Women, 2018). More questions of people who identify as LGBTI, people
reflecting broader dimensions of choice with disabilities, and anyone else who is
and bodily autonomy could be included discriminated against or denied autonomy
in national surveys. Measurement also falls because of their race, ethnicity or economic
short in capturing links across the global status. Everyone should have the power to
goals (Data2x, 2020), a problem reflected make their own decisions about health care,
as well in the “sectoral” divisions of many contraception and sex.
national statistical systems.
Governments, all social and economic
Bolstering investment in gender data requires institutions, communities, families and men
a fully funded national gender action plan have roles in upholding women’s rights and
covering all sources of data and statistics, and ending discrimination more broadly. All
guided by measurable milestones. Work with must do a better job. The new “Generation
national statistics offices could start by clearly Equality” is here, and it won’t wait for change.
demonstrating the value of collecting gender Nor should it.
data and addressing sex differentials within
important administrative data such as civil Individuals alone have the right to decide
registration and vital statistics, building on and make choices about their bodies and
some momentum now evident on the issue lives. They alone have the right to say yes
(Pryor, 2020). or no. We together can make it happen.

128 The power to say yes, the right to say no

Artwork by Rebeka Artim
Tracking Progress Towards ICPD Goals

Sexual and Reproductive Health

Maternal Range Range Births Number of Contraceptive Unmet need Proportion Laws and regulations
mortality of MMR of MMR attended new HIV prevalence rate, women for family of demand that guarantee
ratio (MMR) uncertainty uncertainty by skilled infections, aged 15–49, per cent planning, satisfied access to sexual and
(deaths per (UI 80%), (UI 80%), health all ages, ANY MODERN women aged with modern reproductive health
100,000 live lower upper personnel, per 1,000 METHOD METHOD 15–49, per cent methods, all care, information and
births)a estimatea estimatea per cent uninfected All Married All Married All Married women aged education, per cent
population or in or in or in 15–49
union union union

Countries,
World and territories, other areas
regional areas 2017 2017 2017 2014–2019 2018 2021 2021 2021 2021 2019
World 211 199 243 81 0.24 49 63 45 57 9 11 77 73
More developed regions 12 11 13 99 – 59 71 53 62 7 9 80 84
Less developed regions 232 219 268 79 – 47 62 43 56 9 12 76 69
Least developed countries 415 396 477 61 0.58 32 42 28 37 16 20 59 71

UNFPA regions
Arab States 151 121 208 90 – 34 53 29 45 10 16 65 53
Asia and the Pacific 120 108 140 85 – 52 67 48 62 7 9 80 72
Eastern Europe and Central Asia 20 18 22 99 – 46 64 36 49 8 12 66 82
Latin America and the Caribbean 74 70 80 94 – 59 75 56 70 8 10 83 66
East and Southern Africa 391 361 463 64 – 34 43 31 39 16 21 62 75
West and Central Africa 717 606 917 55 – 20 22 17 18 17 22 46 70

Countries, territories, other areas 2017 2017 2017 2014 –2019 2018 2021 2021 2021 2021 2019
Afghanistan 638 427 1010 59 0.02 19 26 17 23 17 24 47 54
Albania 15 8 26 – – 31 44 4 5 12 17 10 82
Algeria 112 64 206 – 0.03 35 64 31 57 6 9 76 –
Angola 241 167 346 47 1.01 16 17 15 15 27 36 35 66
Antigua and Barbuda 42 24 69 100 – 45 64 43 61 10 13 78 –
Argentina 39 35 43 94 0.15 60 71 57 67 9 11 84 –
Armenia 26 21 32 100 0.06 39 59 21 31 8 12 44 87
Aruba – – – – – – – – – – – – –
Australia 6 5 8 97 0.04 59 67 57 64 8 11 85 –
Austria 5 4 7 98 – 65 70 62 68 6 8 88 –
Azerbaijan 26 21 32 99 – 37 57 15 22 9 14 32 –
Bahamas 70 48 110 99 0.55 45 67 43 65 9 12 80 –
Bahrain 14 10 21 100 – 31 67 21 46 5 10 59 –
Bangladesh 173 131 234 53 0.01 55 66 48 57 9 11 75 –
Barbados 27 17 39 99 0.58 50 63 47 61 12 14 76 44
Belarus 2 1 4 100 0.22 61 70 52 58 6 8 78 87
Belgium 5 4 7 – – 59 67 58 66 6 8 90 –
Belize 36 26 48 94 0.81 44 57 42 53 14 18 71 42
Benin 397 291 570 78 0.34 17 18 14 14 25 31 33 91
Bhutan 183 127 292 96 0.11 39 60 38 58 8 13 80 –
Bolivia (Plurinational State of) 155 113 213 72 0.13 48 67 35 49 12 16 59 –
Bosnia and Herzegovina 10 5 16 100 0.01 38 49 19 21 11 14 38 –
Botswana 144 124 170 100 4.36 57 69 56 68 8 10 86 –
Brazil 60 58 61 99 – 65 80 63 77 6 7 89 –
Brunei Darussalam 31 21 45 100 – – – – – – – – –
Bulgaria 10 6 14 100 0.05 65 79 50 57 5 7 71 –
Burkina Faso 320 220 454 80 0.12 30 34 29 33 20 24 58 72
Burundi 548 413 728 85 0.16 19 31 17 28 17 28 47 64
Cambodia 160 116 221 89 0.05 43 63 32 46 7 11 63 98
Cameroon, Republic of 529 376 790 69 1.02 27 23 22 17 16 23 51 –
Canada 10 8 14 98 – 74 82 70 77 3 5 91 –
Cape Verde 58 45 75 92 0.19 49 68 47 65 11 11 79 –
Central African Republic 829 463 1470 – 1.20 23 26 17 20 18 22 42 77

130 Indicators
 Tracking Progress Towards ICPD Goals

Sexual and Reproductive Health

Maternal Range Range Births Number of Contraceptive Unmet need Proportion Laws and regulations
mortality of MMR of MMR attended new HIV prevalence rate, women for family of demand that guarantee
ratio (MMR) uncertainty uncertainty by skilled infections, aged 15–49, per cent planning, satisfied access to sexual and
(deaths per (UI 80%), (UI 80%), health all ages, ANY MODERN women aged with modern reproductive health
100,000 live lower upper personnel, per 1,000 METHOD METHOD 15–49, per cent methods, all care, information and
births)a estimatea estimatea per cent uninfected All Married All Married All Married women aged education, per cent
population or in or in or in 15–49
union union union

Countries, territories, other areas 2017 2017 2017 2014–2019 2018 2021 2021 2021 2021 2019
Chad 1140 847 1590 24 0.44 7 8 6 7 18 24 25 75
Chile 13 11 14 100 0.27 63 77 59 71 6 8 85 –
China 29 22 35 100 – 69 85 67 83 4 3 91 –
China, Hong Kong SAR – – – – – 48 70 45 67 8 9 81 –
China, Macao SAR – – – – – – – – – – – – –
Colombia 83 71 98 99 0.14 64 82 60 77 6 7 87 97
Comoros 273 167 435 – 0.00 20 27 16 22 19 29 41 –
Congo, Democratic Republic of the 473 341 693 80 0.21 23 25 12 12 21 26 28 –
Congo, Republic of the 378 271 523 91 1.03 42 43 28 27 15 19 50 53
Costa Rica 27 24 31 99 0.21 55 73 53 71 9 11 84 62
Côte d'Ivoire 617 426 896 74 0.70 26 26 23 22 21 27 49 63
Croatia 8 6 11 100 0.02 51 71 36 47 7 8 63 –
Cuba 36 33 40 100 0.15 70 75 69 74 7 8 89 –
Curaçao – – – – – – – – – – – – –
Cyprus 6 4 10 98 – – – – – – – – –
Czechia 3 2 5 100 0.05 63 85 56 76 3 4 85 70
Denmark 4 3 5 95 0.02 65 78 61 74 5 7 88 90
Djibouti 248 116 527 – 0.57 16 29 16 28 15 27 50 –
Dominica – – – 100 – – – – – – – – –
Dominican Republic 95 88 102 100 0.26 57 72 55 70 9 10 84 –
Ecuador 59 53 65 96 0.13 60 81 54 73 6 6 82 –
Egypt 37 27 47 92 0.04 44 61 43 59 9 12 81 44
El Salvador 46 36 57 100 0.11 52 73 49 69 8 10 81 83
Equatorial Guinea 301 181 504 – 4.21 17 17 15 14 23 31 37 –
Eritrea 480 327 718 – 0.15 9 14 9 13 18 29 32 –
Estonia 9 5 13 99 0.23 57 65 52 58 7 11 81 –
Eswatini 437 255 792 – 8.62 54 68 53 66 10 13 83 –
Ethiopia 401 298 573 28 0.24 29 42 29 41 15 21 66 –
Fiji 34 27 43 100 – 35 51 30 44 12 16 65 –
Finland 3 2 4 100 0.04 79 82 74 78 3 5 91 98
France 8 6 9 98 0.09 65 78 63 75 4 4 91 –
French Guiana – – – – – – – – – – – – –
French Polynesia – – – – – – – – – – – – –
Gabon 252 165 407 – 1.01 38 37 30 27 18 24 53 58
Gambia 597 440 808 – 1.06 11 15 11 15 17 25 39 83
Georgia 25 21 29 99 0.18 32 47 24 34 13 19 52 93
Germany 7 5 9 99 0.03 61 78 60 78 5 5 91 –
Ghana 308 223 420 78 0.70 27 36 23 31 19 26 51 –
Greece 3 2 4 100 – 54 74 39 50 6 7 64 54
Grenada 25 15 39 100 – 45 64 42 59 10 13 76 –
Guadeloupe – – – – – 46 60 41 53 11 15 73 –
Guam – – – – – 42 66 36 56 7 10 75 –
Guatemala 95 86 104 70 0.14 42 64 36 53 9 13 70 –
Guinea 576 437 779 55 0.52 12 10 10 9 20 25 33 –
Guinea-Bissau 667 457 995 45 1.43 29 20 27 19 16 20 60 70
Guyana 169 132 215 96 0.51 34 46 32 44 17 25 63 75

STAT E OF WOR L D POPUL AT I ON 2 02 1 131

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Sexual and Reproductive Health

Maternal Range Range Births Number of Contraceptive Unmet need Proportion Laws and regulations
mortality of MMR of MMR attended new HIV prevalence rate, women for family of demand that guarantee
ratio (MMR) uncertainty uncertainty by skilled infections, aged 15–49, per cent planning, satisfied access to sexual and
(deaths per (UI 80%), (UI 80%), health all ages, ANY MODERN women aged with modern reproductive health
100,000 live lower upper personnel, per 1,000 METHOD METHOD 15–49, per cent methods, all care, information and
births)a estimatea estimatea per cent uninfected All Married All Married All Married women aged education, per cent
population or in or in or in 15–49
union union union

Countries, territories, other areas 2017 2017 2017 2014–2019 2018 2021 2021 2021 2021 2019
Haiti 480 346 680 42 0.69 28 38 26 35 23 34 50 65
Honduras 65 55 76 74 0.09 52 76 47 67 7 9 78 –
Hungary 12 9 16 100 0.02 49 70 45 63 6 9 81 –
Iceland 4 2 6 98 0.05 – – – – – – – –
India 145 117 177 81 – 43 57 39 51 9 12 74 –
Indonesia 177 127 254 95 0.17 44 62 42 59 8 11 81 –
Iran (Islamic Republic of) 16 13 20 99 0.05 58 81 46 65 4 5 75 –
Iraq 79 53 113 96 – 37 56 26 39 9 13 57 39
Ireland 5 3 7 100 0.08 66 71 63 66 6 9 88 –
Israel 3 2 4 – 0.05 39 74 30 56 5 8 68 –
Italy 2 1 2 100 0.05 59 67 48 51 7 9 73 –
Jamaica 80 67 98 100 – 42 68 40 64 9 11 78 –
Japan 5 3 6 100 0.01 48 56 41 44 12 16 68 83
Jordan 46 31 65 100 0.00 30 54 22 38 8 14 56 –
Kazakhstan 10 8 12 100 0.14 43 53 40 51 11 15 75 63
Kenya 342 253 476 62 1.02 46 64 45 62 12 14 77 –
Kiribati 92 49 158 – – 20 26 16 21 18 26 44 –
Korea, Democratic People's Republic of 89 38 203 100 – 58 74 55 71 8 9 84 83
Korea, Republic of 11 9 13 100 – 56 81 51 73 6 5 82 –
Kuwait 12 8 17 100 0.04 41 60 34 49 9 14 67 –
Kyrgyzstan 60 50 76 100 0.09 29 41 27 39 13 18 66 73
Lao People's Democratic Republic 185 139 253 64 0.08 39 61 34 54 8 11 74 96
Latvia 19 15 26 100 0.19 61 72 54 62 6 9 81 70
Lebanon 29 22 40 – 0.02 29 62 21 46 6 12 61 –
Lesotho 544 391 788 87 7.80 53 66 52 65 11 15 81 –
Liberia 661 481 943 – 0.39 28 30 27 29 25 28 51 –
Libya 72 30 164 – 0.07 25 39 16 25 17 26 38 33
Lithuania 8 5 12 100 – 46 66 38 53 8 11 70 88
Luxembourg 5 3 8 – 0.09 – – – – – – – –
Madagascar 335 229 484 46 0.24 41 50 36 44 15 16 65 –
Malawi 349 244 507 90 2.28 48 64 48 63 13 15 77 76
Malaysia 29 24 36 100 0.18 35 57 25 41 9 14 57 81
Maldives 53 35 84 100 – 15 22 12 17 22 30 33 45
Mali 562 419 784 67 0.78 18 19 17 19 21 24 45 79
Malta 6 4 11 100 – 64 85 50 66 4 3 74 90
Martinique – – – – – 47 62 43 56 11 14 74 –
Mauritania 766 528 1140 69 0.03 12 18 11 16 18 29 35 62
Mauritius 61 46 85 100 0.70 43 67 28 43 8 10 56 73
Mexico 33 32 35 96 0.08 56 73 53 70 9 10 82 –
Micronesia (Federated States of) 88 40 193 – – – – – – – – – –
Moldova, Republic of 19 15 24 100 0.25 53 64 42 50 9 12 67 –
Mongolia 45 36 56 99 0.01 41 56 37 51 13 15 70 –
Montenegro 6 3 10 99 0.08 26 26 18 15 17 22 43 52
Morocco 70 54 91 87 0.03 43 71 37 61 7 11 74 –
Mozambique 289 206 418 73 5.25 26 28 25 27 19 22 56 94
Myanmar 250 182 351 60 0.20 33 58 33 56 8 14 78 82

132 Indicators
 Tracking Progress Towards ICPD Goals

Sexual and Reproductive Health

Maternal Range Range Births Number of Contraceptive Unmet need Proportion Laws and regulations
mortality of MMR of MMR attended new HIV prevalence rate, women for family of demand that guarantee
ratio (MMR) uncertainty uncertainty by skilled infections, aged 15–49, per cent planning, satisfied access to sexual and
(deaths per (UI 80%), (UI 80%), health all ages, ANY MODERN women aged with modern reproductive health
100,000 live lower upper personnel, per 1,000 METHOD METHOD 15–49, per cent methods, all care, information and
births)a estimatea estimatea per cent uninfected All Married All Married All Married women aged education, per cent
population or in or in or in 15–49
union union union

Countries, territories, other areas 2017 2017 2017 2014–2019 2018 2021 2021 2021 2021 2019
Namibia 195 144 281 – 2.82 52 61 52 60 10 15 83 96
Nepal 186 135 267 58 0.03 43 55 38 48 17 21 63 48
Netherlands 5 4 7 – 0.03 63 73 61 71 6 7 89 98
New Caledonia – – – – – – – – – – – – –
New Zealand 9 7 11 97 0.03 65 80 61 75 5 5 88 94
Nicaragua 98 77 127 96 0.07 53 82 51 79 5 6 88 –
Niger 509 368 724 39 0.08 16 19 16 18 16 18 49 –
Nigeria 917 658 1320 43 0.65 17 20 13 15 15 19 41 –
North Macedonia 7 5 10 100 0.02 40 48 21 21 13 17 40 –
Norway 2 2 3 99 0.02 67 86 63 80 4 4 89 –
Oman 19 16 22 99 0.07 21 35 14 24 15 26 40 –
Pakistan 140 85 229 69 0.11 25 37 19 28 12 17 52 65
Palestine1 – – – 100 – 41 62 31 47 7 11 65 60
Panama 52 45 59 93 0.32 48 60 45 56 14 17 73 –
Papua New Guinea 145 67 318 56 0.26 28 38 23 32 18 25 51 –
Paraguay 84 72 96 98 0.16 58 72 54 67 8 9 82 –
Peru 88 69 110 92 0.10 55 77 42 57 5 7 70 –
Philippines 121 91 168 84 0.13 36 57 27 43 10 16 58 75
Poland 2 2 3 100 – 53 73 43 57 6 8 72 –
Portugal 8 6 11 99 0.07 61 75 52 65 7 7 78 –
Puerto Rico 21 16 29 – – 57 82 52 74 6 5 82 –
Qatar 9 6 14 100 – 30 48 26 40 10 16 64 –
Réunion – – – – – 49 72 48 71 9 9 83 –
Romania 19 14 25 97 0.04 55 72 45 58 5 8 75 –
Russian Federation 17 13 23 100 – 49 68 41 57 6 10 75 –
Rwanda 248 184 347 91 0.29 34 58 31 53 12 17 69 –
Saint Kitts and Nevis – – – 100 – – – – – – – – –
Saint Lucia 117 71 197 100 – 49 61 46 57 12 15 76 –
Saint Vincent and the Grenadines 68 44 100 99 – 50 67 48 64 10 12 80 81
Samoa 43 20 97 83 – 17 29 16 27 24 41 39 –
San Marino – – – – – – – – – – – – –
São Tomé and Príncipe 130 73 217 93 – 36 46 33 43 21 27 59 54
Saudi Arabia 17 10 30 99 – 19 30 15 24 15 25 44 –
Senegal 315 237 434 74 0.08 22 31 21 29 16 22 56 –
Serbia 12 9 17 98 0.02 49 56 33 30 10 13 56 86
Seychelles 53 26 109 – – – – – – – – – –
Sierra Leone 1120 808 1620 87 0.55 28 25 27 25 20 24 57 65
Singapore 8 5 13 100 0.04 40 69 36 61 6 10 77 –
Sint Maarten – – – – – – – – – – – – –
Slovakia 5 4 7 98 0.02 56 79 48 66 4 6 79 –
Slovenia 7 5 9 – – 54 80 45 67 6 5 76 –
Solomon Islands 104 70 157 86 – 24 33 20 27 13 17 54 –
Somalia 829 385 1590 – 0.03 16 27 7 12 16 27 23 –
South Africa 119 96 153 97 4.94 50 58 50 57 11 14 82 95
South Sudan 1150 789 1710 – 1.56 6 8 5 7 20 30 21 16
Spain 4 3 5 – 0.07 60 63 58 62 9 13 84 –

STAT E OF WOR L D POPUL AT I ON 2 02 1 133

Tracking Progress Towards ICPD Goals

Sexual and Reproductive Health

Maternal Range Range Births Number of Contraceptive Unmet need Proportion Laws and regulations
mortality of MMR of MMR attended new HIV prevalence rate, women for family of demand that guarantee
ratio (MMR) uncertainty uncertainty by skilled infections, aged 15–49, per cent planning, satisfied access to sexual and
(deaths per (UI 80%), (UI 80%), health all ages, ANY MODERN women aged with modern reproductive health
100,000 live lower upper personnel, per 1,000 METHOD METHOD 15–49, per cent methods, all care, information and
births)a estimatea estimatea per cent uninfected All Married All Married All Married women aged education, per cent
population or in or in or in 15–49
union union union

Countries, territories, other areas 2017 2017 2017 2014–2019 2018 2021 2021 2021 2021 2019
Sri Lanka 36 31 41 100 0.01 45 67 37 55 5 7 74 89
Sudan 295 207 408 78 0.13 11 16 10 14 18 28 34 57
Suriname 120 96 144 98 0.49 33 46 33 45 15 23 68 45
Sweden 4 3 6 – – 62 73 57 66 6 8 84 100
Switzerland 5 3 7 – – 72 73 68 69 4 7 89 92
Syrian Arab Republic 31 20 50 – 0.00 37 62 28 46 8 13 62 77
Tajikistan 17 10 26 95 0.09 24 32 22 29 16 22 55 –
Tanzania, United Republic of 524 399 712 64 1.41 36 44 32 39 16 20 61 –
Thailand 37 32 44 99 0.09 56 80 54 78 4 5 91 –
Timor-Leste, Democratic Republic of 142 102 192 57 – 19 32 17 29 14 24 52 –
Togo 396 270 557 69 0.70 24 26 22 24 22 31 48 73
Tonga 52 24 116 – – 20 37 17 32 13 25 52 –
Trinidad and Tobago 67 50 90 100 – 40 49 36 45 14 20 66 32
Tunisia 43 33 54 100 0.02 30 58 26 50 7 13 69 –
Turkey 17 14 20 98 – 48 71 33 49 7 10 61 –
Turkmenistan 7 5 10 100 – 37 55 34 51 10 14 74 –
Turks and Caicos Islands – – – – – – – – – – – – –
Tuvalu – – – – – – – – – – – – –
Uganda 375 278 523 74 1.40 35 45 32 41 19 25 59 –
Ukraine 19 14 26 100 0.28 53 68 44 55 6 9 74 88
United Arab Emirates 3 2 5 100 – 36 51 29 41 12 17 60 –
United Kingdom 7 6 8 – – 73 82 67 74 4 5 87 92
United States of America 19 17 21 99 – 64 76 57 67 5 6 83 –
United States Virgin Islands – – – – – 52 75 49 70 8 8 81 –
Uruguay 17 14 21 100 0.26 57 79 55 77 6 7 87 99
Uzbekistan 29 23 37 100 0.16 49 69 46 65 6 9 83 –
Vanuatu – – – – – 36 48 31 41 15 20 61 –
Venezuela (Bolivarian Republic of) 125 97 170 99 – 56 76 52 71 8 10 82 –
Viet Nam 43 32 61 94 0.06 59 80 50 67 4 5 79 54
Western Sahara – – – – – – – – – – – – –
Yemen 164 109 235 – 0.04 27 43 20 31 15 24 48 63
Zambia 213 159 289 63 2.97 37 53 35 50 15 18 68 91
Zimbabwe 458 360 577 86 2.79 49 69 49 68 8 10 85 –

134 Indicators
 Tracking Progress Towards ICPD Goals

Sexual and Reproductive Health

NOTES MAIN DATA SOURCES
− Data not available. Maternal mortality ratio: United Nations Maternal Mortality Estimation Inter-
a The MMR has been rounded according to the following scheme: <100, rounded to agency Group (WHO, UNICEF, UNFPA, The World Bank and the United Nations
nearest 1; 100–999, rounded to nearest 1; and ≥1,000, rounded to nearest 10. Population Division).
1 On 29 November 2012, the United Nations General Assembly passed Resolution
Births attended by skilled health personnel: Joint global database on skilled
67/19, which accorded Palestine “non-member observer State status in the
attendance at birth, 2020, United Nations Children’s Fund (UNICEF) and World Health
United Nations...”
Organization (WHO). Regional aggregates calculated by UNFPA based on data from
the joint global database.
DEFINITIONS OF THE INDICATORS
Maternal mortality ratio: Number of maternal deaths during a given time period per Number of new HIV infections, all ages, per 1,000 uninfected population: UNAIDS.
100,000 live births during the same time period. (SDG indicator 3.1.1)
Contraceptive prevalence rate: United Nations Population Division.
Births attended by skilled health personnel: Percentage of births attended by skilled
heath personnel (doctor, nurse or midwife). (SDG indicator 3.1.2) Contraceptive prevalence rate, modern method: United Nations Population Division.

Number of new HIV infections, all ages, per 1,000 uninfected population: Number of Unmet need for family planning: United Nations Population Division.
new HIV infections per 1,000 person-years among the uninfected population. (SDG Proportion of demand satisfied with modern methods: United Nations Population
indicator 3.3.1) Division.
Contraceptive prevalence rate: Percentage of women aged 15 to 49 who are Laws and regulations that guarantee access to sexual and reproductive health
currently using any method of contraception. care, information and education: UNFPA.
Contraceptive prevalence rate, modern method: Percentage of women aged 15 to 49
who are currently using any modern method of contraception.
Unmet need for family planning: Percentage of women aged 15 to 49 who want to
stop or delay childbearing but are not using a method of contraception.
Proportion of demand satisfied with modern methods: Percentage of total demand
for family planning among women aged 15 to 49 that is satisfied by the use of modern
contraception. (SDG indicator 3.7.1)
Laws and regulations that guarantee access to sexual and reproductive health
care, information and education: The extent to which countries have national laws
and regulations that guarantee full and equal access to women and men aged 15
years and older to sexual and reproductive health care, information and education.
(SDG indicator 5.6.2)

STAT E OF WOR L D POPUL AT I ON 2 02 1 135

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Gender, Rights and Human Capital

Adolescent Child Female Intimate Decision- Total net Gender Total net Gender Total net Gender
birth rate per marriage genital partner making on enrolment parity index, enrolment parity index, enrolment parity index,
1,000 girls by age 18, mutilation violence, sexual and rate, primary total net rate, lower total net rate, upper total net
aged 15–19 per cent prevalence past 12 reproductive education, enrolment secondary enrolment secondary enrolment
among girls months, health and per cent rate, primary education, rate, lower education, rate, upper
aged 15–19, per cent reproductive education per cent secondary per cent secondary
per cent rights, education education
per cent
World and territories,
Countries, regional areas
other areas 2020
2003–2018 2019
2005–2019 2019
2004–2018 2018
2000–2019 2020
2007–2018 2019
2010–2020 2019
2010–2020 2019
2010–2019 2019
2010–2019 2019
2009–2019 2019
2009–2019
World 41 20 – 13 55 – – 85 1.00 65 0.99
More developed regions 12 – – – – – – 98 1.00 93 1.01
Less developed regions 45 27 – – 54 – – 83 1.00 62 0.99
Least developed countries 91 38 – 22 50 – – 66 0.97 44 0.89

UNFPA regions
Arab States 48 20 55 – – – – 81 0.94 60 0.91
Asia and the Pacific 23 26 – – 59 – – 87 1.02 63 1.03
Eastern Europe and Central Asia 27 12 – – 75 – – 96 0.99 85 1.00
Latin America and the Caribbean 61 25 – – 74 – – 93 1.00 79 1.03
East and Southern Africa 95 32 24 – 53 – – 66 0.96 44 0.84
West and Central Africa 108 39 23 – 37 – – 62 0.96 43 0.86

Countries, territories, other areas 2003–2018 2005–2019 2004–2018 2000–2019 2007–2018 2010–2020 2010–2020 2010–2019 2010–2019 2009–2019 2009–2019
Afghanistan 62 28 – 46 – – – – – 44 0.56
Albania 16 12 – – 69 98 1.04 96 1.05 82 1.07
Algeria 10 3 – – – 100 0.99 – – – –
Angola 163 30 – 26 62 82 0.78 76 0.76 18 0.71
Antigua and Barbuda 28 – – – – 99 1.01 99 0.99 87 1.02
Argentina 54 – – – – 100 0.99 100 1.00 90 1.10
Armenia 21 5 – 4 66 91 1.00 90 1.02 89 1.15
Aruba 26 – – – – 100 1.00 – – – –
Australia 10 – – 2b – 100 1.00 98 1.00 92 1.04
Austria 7 – – 4c – 100 1.00 100 1.00 90 1.01
Azerbaijan 45 11 – 10 – 92 1.03 100 1.00 100 1.00
Bahamas 29 – – – – 76 1.02 71 1.02 67 1.06
Bahrain 14 – – – – 98 0.99 96 1.07 87 1.14
Bangladesh 74 59 – 29 – 95 1.11 74 1.10 62 1.08
Barbados 50 29 – – – 99 0.98 95 1.04 95 1.05
Belarus 14 5 – – – 99 0.98 99 1.00 99 1.02
Belgium 6 – – 8c – 99 1.00 99 0.99 99 1.00
Belize 64 34 – – – 100 1.01 90 0.98 64 1.04
Benin 108 31 2 14 36 94 0.94 66 0.78 44 0.63
Bhutan 28 26 – 7 – 96 1.03 88 1.15 72 1.16
Bolivia (Plurinational State of) 71 20 – 27 – 93 1.00 87 0.99 79 1.00
Bosnia and Herzegovina 11 4 – – – – – – – 79 1.04
Botswana 50 – – – – 89 1.01 – – – –
Brazil 53 26 – – – 96 0.99 97 1.00 85 1.07
Brunei Darussalam 10 – – – – 99 1.01 97 1.00 82 1.04
Bulgaria 38 – – 9c – 87 1.00 87 0.99 88 0.95
Burkina Faso 132 52 58 9 20 78 0.99 54 1.08 34 1.04
Burundi 58 19 – 28 44 92 1.04 66 1.08 35 1.15
Cambodia 57 19 – 9 76 91 1.00 87 0.98 – –
Cameroon, Republic of 119 31 0.4 22 38 92 0.91 63 0.89 46 0.83

136 Indicators
 Tracking Progress Towards ICPD Goals

Gender, Rights and Human Capital

Adolescent Child Female Intimate Decision- Total net Gender Total net Gender Total net Gender
birth rate per marriage genital partner making on enrolment parity index, enrolment parity index, enrolment parity index,
1,000 girls by age 18, mutilation violence, sexual and rate, primary total net rate, lower total net rate, upper total net
aged 15–19 per cent prevalence past 12 reproductive education, enrolment secondary enrolment secondary enrolment
among girls months, health and per cent rate, primary education, rate, lower education, rate, upper
aged 15–19, per cent reproductive education per cent secondary per cent secondary
per cent rights, education education
per cent
Countries, territories, other areas 2003–2018 2005–2019 2004–2018 2000–2019 2007–2018 2010–2020 2010–2020 2010–2019 2010–2019 2009–2019 2009–2019
Canada 8 – – – – 100 1.00 100 1.00 94 0.99
Cape Verde 80 18 – 8 – 94 0.98 87 1.01 73 1.08
Central African Republic 229 68 18 26 – 67 0.80 44 0.61 16 0.48
Chad 179 67 32 18 27 74 0.79 38 0.68 22 0.51
Chile 26 – – – – 99 0.99 95 0.99 95 1.00
China 9 – – – – – – – – – –
China, Hong Kong SAR 2 – – – – 97 1.05 99 1.00 99 1.00
China, Macao SAR 3 – – – – 99 0.99 98 1.02 87 1.06
Colombia 61 23 – 18 – 98 1.01 94 1.01 79 1.03
Comoros 70 32 – 5 21 82 1.00 81 1.02 50 1.07
Congo, Democratic Republic of the 138 37 – 37 31 – – – – – –
Congo, Republic of the 111 27 – – 27 89 1.09 – – – –
Costa Rica 50 21 – – – 100 1.00 98 1.01 94 1.03
Côte d'Ivoire 123 27 27 22 25 95 0.93 56 0.87 42 0.74
Croatia 9 – – 4c – 98 1.03 99 1.02 86 1.05
Cuba 52 26 – – – 99 1.00 90 1.00 82 1.07
Curaçao 23 – – – – – – – – – –
Cyprus 4 – – 3c – 99 1.00 100 1.00 93 0.98
Czechia 12 – – 6c – 100 1.01 99 1.00 97 1.00
Denmark 3 – – 7c – 99 1.01 99 0.99 90 1.02
Djibouti 21 5 80 – – 67 0.96 52 1.00 34 0.95
Dominica 48 – – – – 96 1.01 99 1.02 82 1.03
Dominican Republic 51 36 – 16 77 96 1.01 94 1.00 78 1.02
Ecuador 71 20 – 11 87 99 1.03 95 1.03 80 1.01
Egypt 52 17 70 14 – 99 1.01 98 1.02 77 0.98
El Salvador 74 26 – 7 – 86 1.01 83 0.99 66 0.97
Equatorial Guinea 176 30 – 44 – 45 1.02 – – – –
Eritrea 76 41 69 – – 53 0.91 64 0.88 51 0.86
Estonia 11 – – 4c – 98 1.00 99 1.02 99 0.99
Eswatini 87 5 – – 49 84 0.98 97 1.00 84 0.96
Ethiopia 80 40 47 20 45 86 0.93 53 0.92 26 0.91
Fiji 23 – – 30c – 99 0.97 96 – 74 1.09
Finland 5 – – 8c – 99 1.00 100 1.00 96 0.98
France 9 – – 7c – 100 1.00 99 1.00 95 1.01
French Guiana 76 – – – – – – – – – –
French Polynesia 42 – – – – – – – – – –
Gabon 91 22 – 32 48 – – – – – –
Gambia 86 26 75 7 40 85 1.12 69 1.03 – –
Georgia 32 14 – 1d – 99 1.01 100 1.00 94 1.04
Germany 6 – – 5c – 99 1.01 95 1.02 86 0.96
Ghana 75 21 2 19 52 99 1.01 89 1.05 72 1.00
Greece 9 – – 8c – 99 1.00 96 0.99 95 0.98
Grenada 36 – – – – 99 1.02 97 – 97 1.00

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Gender, Rights and Human Capital

Adolescent Child Female Intimate Decision- Total net Gender Total net Gender Total net Gender
birth rate per marriage genital partner making on enrolment parity index, enrolment parity index, enrolment parity index,
1,000 girls by age 18, mutilation violence, sexual and rate, primary total net rate, lower total net rate, upper total net
aged 15–19 per cent prevalence past 12 reproductive education, enrolment secondary enrolment secondary enrolment
among girls months, health and per cent rate, primary education, rate, lower education, rate, upper
aged 15–19, per cent reproductive education per cent secondary per cent secondary
per cent rights, education education
per cent
Countries, territories, other areas 2003–2018 2005–2019 2004–2018 2000–2019 2007–2018 2010–2020 2010–2020 2010–2019 2010–2019 2009–2019 2009–2019
Guadeloupe 16 – – – – – – – – – –
Guam 35 – – – – – – – – – –
Guatemala 79 30 – 9 65 89 1.01 67 0.93 41 0.90
Guinea 120 47 92 – 29 78 0.83 49 0.70 33 0.59
Guinea-Bissau 106 24 42 – – 73 0.95 – – – –
Guyana 74 30 – – 71 98 0.96 93 1.02 70 1.11
Haiti 55 15 – 14 59 – – – – – –
Honduras 89 34 – 11 70 87 0.97 62 1.23 44 1.11
Hungary 23 – – 8c – 96 1.00 97 1.00 88 1.01
Iceland 6 – – – – 100 1.00 100 1.00 87 1.04
India 11 27 – 22 – 98 1.02 85 1.07 52 0.98
Indonesia 36 16 – 5d – 94 0.95 84 1.07 77 1.01
Iran (Islamic Republic of) 33 17 – – – 100 1.00 95 0.97 74 0.97
Iraq 82 28 4 – – – – – – – –
Ireland 7 – – 4c – 100 1.00 99 – 99 1.01
Israel 10 – – – – 100 1.01 100 – 98 –
Italy 4 – – 7c – 97 1.00 98 1.00 95 1.01
Jamaica 52 8 – 9 – 83 1.00 82 1.02 76 1.04
Japan 3 – – – – – – – – – –
Jordan 27 10 – 14 61 81 0.98 70 1.00 54 1.09
Kazakhstan 26 7 – 6c – 99 1.02 100 – 99 –
Kenya 96 23 11 26 56 81 1.04 – – – –
Kiribati 49 20 – 43 – 96 1.08 – – – –
Korea, Democratic People's Republic 1 – – – – – – – – – –
of
Korea, Republic of 1 – – – – 99 1.00 97 1.00 96 0.99
Kuwait 6 – – – – 83 1.22 94 1.05 82 1.03
Kyrgyzstan 34 13 – 17 77 100 0.99 98 0.99 72 1.05
Lao People's Democratic Republic 83 33 – 6 – 92 0.98 72 1.00 56 0.92
Latvia 16 – – 7c – 99 1.01 99 1.01 96 1.01
Lebanon 13 6 – 35 – – – – – – –
Lesotho 94 16 – – 61 98 1.01 83 1.11 66 1.15
Liberia 150 36 26a 35 67 79 1.01 79 0.90 74 0.86
Libya 11 – – – – – – – – – –
Lithuania 13 – – 6c – 100 1.00 100 1.00 97 1.02
Luxembourg 4 – – 3c – 99 0.98 96 0.98 81 1.06
Madagascar 152 40 – – 74 98 1.05 70 1.03 36 0.97
Malawi 138 42 – 24 47 98 1.04 81 1.01 31 0.64
Malaysia 9 – – – – 100 1.01 87 1.03 63 1.16
Maldives 9 2 1 6 58 98 1.03 91 – – –
Mali 164 54 86 21 8 59 0.90 47 0.86 25 0.74
Malta 13 – – 5c – 100 1.01 99 1.01 90 1.05
Martinique 17 – – – – – – – – – –
Mauritania 84 37 63 – – 77 1.05 72 1.08 39 1.12

138 Indicators
 Tracking Progress Towards ICPD Goals

Gender, Rights and Human Capital

Adolescent Child Female Intimate Decision- Total net Gender Total net Gender Total net Gender
birth rate per marriage genital partner making on enrolment parity index, enrolment parity index, enrolment parity index,
1,000 girls by age 18, mutilation violence, sexual and rate, primary total net rate, lower total net rate, upper total net
aged 15–19 per cent prevalence past 12 reproductive education, enrolment secondary enrolment secondary enrolment
among girls months, health and per cent rate, primary education, rate, lower education, rate, upper
aged 15–19, per cent reproductive education per cent secondary per cent secondary
per cent rights, education education
per cent
Countries, territories, other areas 2003–2018 2005–2019 2004–2018 2000–2019 2007–2018 2010–2020 2010–2020 2010–2019 2010–2019 2009–2019 2009–2019
Mauritius 24 – – – – 99 1.03 95 1.02 79 1.10
Mexico 71 26 – 10 – 99 1.01 92 1.02 74 1.05
Micronesia (Federated States of) 44 – – 26 – 90 0.98 87 1.06 – –
Moldova, Republic of 21 12 – 15 – 90 0.98 84 0.98 65 1.02
Mongolia 33 12 – 15 63 99 0.99 – – – –
Montenegro 10 6 – – – 100 1.00 92 1.01 89 1.02
Morocco 19 14 – – – 100 1.01 91 0.96 72 0.94
Mozambique 180 53 – 16 49 98 0.97 57 0.87 31 0.76
Myanmar 28 16 – 11 67 98 0.96 79 1.03 57 1.16
Namibia 64 7 – 20 71 98 1.03 – – – –
Nepal 88 40 – 11 48 96 0.93 97 1.03 81 1.18
Netherlands 3 – – 7c – 100 1.01 97 1.01 100 1.00
New Caledonia 15 – – – – – – – – – –
New Zealand 14 – – – – 100 1.01 99 1.00 98 1.03
Nicaragua 92 35 – 8 – 96 1.03 88 1.03 64 1.08
Niger 154 76 1 – 7 59 0.88 35 0.79 14 0.67
Nigeria 106 43 14 14 46 66 0.84 – – – –
North Macedonia 15 7 – – – 99 1.00 – – – –
Norway 3 – – – – 100 1.00 99 0.99 92 1.01
Oman 12 4 – – – 97 1.06 98 1.02 90 0.90
Pakistan 46 18 – 15 40 – – – – – –
Palestine1 48 15 – – – 97 1.00 97 1.04 75 1.21
Panama 76 26 – 10 79 87 0.99 88 1.01 56 1.08
Papua New Guinea 68 27 – 48 – 93 0.94 86 0.89 54 0.82
Paraguay 72 22 – 8e – 89 1.00 90 0.90 68 1.05
Peru 44 17 – 11 – 98 0.96 98 1.00 92 0.94
Philippines 39 17 – 6 81 96 0.99 89 1.07 79 1.09
Poland 11 – – 3c – 98 1.01 98 0.98 96 1.00
Portugal 8 – – 6f – 100 0.99 100 1.00 99 0.99
Puerto Rico 22 – – – – 78 1.03 80 1.10 83 1.07
Qatar 9 4 – – – 98 1.03 95 0.92 91 0.97
Réunion 30 – – – – – – – – – –
Romania 38 – – 7c – 87 1.00 91 1.00 80 1.03
Russian Federation 22 – – – – 100 1.00 100 1.01 97 1.00
Rwanda 41 7 – 21 70 94 1.00 96 1.04 50 1.02
Saint Kitts and Nevis 46 – – – – 99 0.98 87 0.95 96 0.99
Saint Lucia 36 24 – – – 98 1.03 90 0.98 79 0.99
Saint Vincent and the Grenadines 52 – – – – 97 1.06 98 0.99 85 1.02
Samoa 39 11 – 22 – 99 1.02 100 – 90 1.11
San Marino 1 – – – – 95 1.10 99 – 46 0.89
São Tomé and Príncipe 92 35 – 26 46 94 1.00 90 1.06 83 1.03
Saudi Arabia 9 – – – – 98 0.98 99 0.98 96 0.94
Senegal 78 29 21 8 7 74 1.14 – – – –
Serbia 15 3 – – – 98 1.00 98 1.00 88 1.03

STAT E OF WOR L D POPUL AT I ON 2 02 1 139

Tracking Progress Towards ICPD Goals

Gender, Rights and Human Capital

Adolescent Child Female Intimate Decision- Total net Gender Total net Gender Total net Gender
birth rate per marriage genital partner making on enrolment parity index, enrolment parity index, enrolment parity index,
1,000 girls by age 18, mutilation violence, sexual and rate, primary total net rate, lower total net rate, upper total net
aged 15–19 per cent prevalence past 12 reproductive education, enrolment secondary enrolment secondary enrolment
among girls months, health and per cent rate, primary education, rate, lower education, rate, upper
aged 15–19, per cent reproductive education per cent secondary per cent secondary
per cent rights, education education
per cent
Countries, territories, other areas 2003–2018 2005–2019 2004–2018 2000–2019 2007–2018 2010–2020 2010–2020 2010–2019 2010–2019 2009–2019 2009–2019
Seychelles 68 – – – – 98 1.05 99 – 82 1.16
Sierra Leone 101 30 64 29 40 99 1.03 51 0.99 35 0.93
Singapore 3 – – – – 100 1.00 99 0.99 100 –
Sint Maarten – – – – – 97 1.07 – – – –
Slovakia 27 – – 8c – 96 1.00 95 1.00 89 1.00
Slovenia 4 – – 2c – 100 1.00 98 1.01 98 1.01
Solomon Islands 78 21 – 42 – 96 1.01 – – – –
Somalia 123 45 97 – – – – – – – –
South Africa 41 4 – 11 65 89 1.02 86 1.03 79 1.02
South Sudan 158 52 – – – 38 0.77 44 0.72 36 0.65
Spain 7 – – 2c – 97 1.00 100 1.00 98 1.01
Sri Lanka 21 10 – 6g – 99 0.99 100 1.00 84 1.06
Sudan 87 34 82 – – 62 0.98 45 0.88 43 0.96
Suriname 57 36 – – – 88 1.04 85 1.09 62 1.15
Sweden 5 – – 6c – 100 1.00 100 1.01 99 0.99
Switzerland 2 – – – – 100 1.00 99 0.99 82 0.96
Syrian Arab Republic 54 13 – – – 72 0.98 62 0.97 34 1.00
Tajikistan 54 9 – 19 33 99 0.99 94 0.94 61 0.74
Tanzania, United Republic of 139 31 5 30 47 87 1.04 – – 14 0.76
Thailand 38 23 – – – – – – – 79 1.00
Timor-Leste, Democratic Republic of 42 15 – 35 40 95 1.04 90 1.04 76 1.07
Togo 89 25 1 13 30 97 0.98 79 0.85 43 0.64
Tonga 30 6 – 19 – 99 1.02 95 1.02 62 1.17
Trinidad and Tobago 38 11 – 7 – 99 0.99 – – – –
Tunisia 4 2 – – – 99 1.02 – – – –
Turkey 21 15 – 11 – 95 0.99 94 0.99 83 0.99
Turkmenistan 28 6 – – – – – 92 0.98 83 0.99
Turks and Caicos Islands 15 – – – – 99 1.03 80 1.06 68 0.90
Tuvalu 27 10 – 25 – 85 0.96 71 0.92 50 1.57
Uganda 132 34 0.1 30 62 96 1.03 – – – –
Ukraine 19 9 – 10 81 92 1.02 96 1.01 94 1.03
United Arab Emirates 5 – – – – 99 0.97 99 0.99 88 0.86
United Kingdom 12 – – 6c – 99 1.00 100 1.00 96 1.01
United States of America 19 – – – – 99 1.00 100 1.02 96 1.00
United States Virgin Islands 25 – – – – – – – – – –
Uruguay 36 25 – 3 – 100 1.00 100 1.01 88 1.08
Uzbekistan 19 7 – – – 99 0.99 99 0.98 86 0.99
Vanuatu 51 21 – 44 – – – – – – –
Venezuela (Bolivarian Republic of) 95 – – – – 90 1.00 86 1.02 77 1.12
Viet Nam 30 11 – 10 – 99 1.03 – – – –
Western Sahara – – – – – – – – – – –
Yemen 67 32 16 – – 84 0.88 72 0.85 44 0.59
Zambia 135 29 – 25 47 85 1.05 – – – –
Zimbabwe 78 34 – 20 60 100 1.01 98 0.95 52 0.90

140 Indicators
 Tracking Progress Towards ICPD Goals

Gender, Rights and Human Capital

NOTES Total net enrolment rate, lower secondary education: Total number of students of
− Data not available. the official age group for lower secondary education who are enrolled in any level of
education, expressed as a percentage of the corresponding population.
a 
 Percentage of girls aged 15 to 19 years who are members of the Sande society.
Membership in Sande society is a proxy for female genital mutilation. Gender parity index, total net enrolment rate, lower secondary education: Ratio of
female to male values of total net enrolment rate for lower secondary education.
b For ever-partnered women aged 18+.
Total net enrolment rate, upper secondary education: Total number of students of
c For ever-partnered women aged 18 to 49.
the official age group for upper secondary education who are enrolled in any level
d For ever-partnered women aged 15 to 64. of education, expressed as a percentage of the corresponding population.
e For ever-partnered women aged 15 to 44. Gender parity index, total net enrolment rate, upper secondary education: Ratio of
f For ever-partnered women aged 18 to 50. female to male values of total net enrolment rate for upper secondary education.
g For ever-partnered women aged 15+.
1 O
 n 29 November 2012, the United Nations General Assembly passed Resolution MAIN DATA SOURCES
67/19, which accorded Palestine “non-member observer State status in the Adolescent birth rate: United Nations Population Division.
United Nations...” Child marriage by age 18: UNICEF. Regional aggregates calculated by UNFPA based
on data from UNICEF.
DEFINITIONS OF THE INDICATORS Female genital mutilation: prevalence among girls aged 15 to 19: UNFPA.
Adolescent birth rate: Number of births per 1,000 adolescent girls aged 15 to 19. Intimate partner violence, past 12 months: UNFPA. Regional estimates generated
(SDG indicator 3.7.2) by Violence Against Women Inter-Agency Group on Estimation and Data (WHO, UN
Child marriage by age 18: Proportion of women aged 20 to 24 years who were Women, UNICEF, UNSD, UNODC, and UNFPA).
married or in a union before age 18. (SDG indicator 5.3.1) Decision-making on sexual and reproductive health and reproductive rights:
Female genital mutilation prevalence among girls aged 15–19: Proportion of UNFPA. As this report went to press, updated data for this SDG indicator became
girls aged 15 to 19 years who have undergone female genital mutilation. (SDG available. The updated figures are available at https://unstats.un.org/sdgs/
indicator 5.3.2) indicators/database/.
Intimate partner violence, past 12 months: Percentage of ever-partnered women Total net enrolment rate, primary education: UNESCO Institute for Statistics (UIS).
and girls aged 15 to 49 who have experienced physical and/or sexual partner Gender parity index, total net enrolment rate, primary education: UNESCO Institute
violence in the previous 12 months. (SDG indicator 5.2.1) for Statistics (UIS).
Decision-making on sexual and reproductive health and reproductive rights: Total net enrolment rate, lower secondary education: UNESCO Institute for
Percentage of women aged 15-49 years who are married (or in union), who make Statistics (UIS).
their own decisions in three areas—their health care, use of contraception, and
Gender parity index, total net enrolment rate, lower secondary education:
sexual intercourse with their partners. (SDG indicator 5.6.1) As this report went to
UNESCO Institute for Statistics (UIS).
press, updated data for this SDG indicator became available. The updated figures
are available at https://unstats.un.org/sdgs/indicators/database/. Total net enrolment rate, upper secondary education: UNESCO Institute
for Statistics (UIS).
Total net enrolment rate, primary education: Total number of students of the
official age group for primary education who are enrolled in any level of education, Gender parity index, total net enrolment rate, upper secondary education:
expressed as a percentage of the corresponding population. UNESCO Institute for Statistics (UIS).

Gender parity index, total net enrolment rate, primary education: Ratio of female to
male values of total net enrolment rate for primary education.

STAT E OF WOR L D POPUL AT I ON 2 02 1 141

Demographic Indicators
POPULATION POPULATION POPULATION COMPOSITION FERTILITY LIFE EXPECTANCY
CHANGE
Total population Average annual Population Population Population Population Population Total Life expectancy at birth,
in millions rate of population aged 0–14, aged 10–19, aged 10–24, aged 15–64, aged 65 fertility rate, years, 2021
change, per cent per cent per cent per cent per cent and older, per woman
per cent

Countries,
World and territories, other areas
regional areas 2021 2015–2020 2021 2021 2021 2021 2021 2021 male female

World 7,875 1.1 25.3 16.0 23.6 65.1 9.6 2.4 71 75

More developed regions 1,276 0.3 16.3 11.0 16.6 64.0 19.7 1.6 77 83
Less developed regions 6,599 1.3 27.0 17.0 25.0 65.4 7.6 2.5 69 74
Least developed countries 1,082 2.3 38.5 22.3 31.7 57.8 3.6 3.8 64 68

UNFPA regions
Arab States 385 1.9 33.8 19.2 27.6 61.0 5.1 3.2 70 74
Asia and the Pacific 4,116 0.9 23.4 15.6 23.3 67.9 8.6 2.1 71 75
Eastern Europe and Central Asia 251 0.9 23.4 14.4 21.2 66.2 10.5 2.1 71 78
Latin America and the Caribbean 656 1.0 23.7 16.0 24.2 67.2 9.2 2.0 73 79
East and Southern Africa 633 2.6 40.9 23.0 32.3 55.9 3.2 4.2 62 67
West and Central Africa 471 2.7 42.9 23.3 32.3 54.3 2.8 4.9 57 60

Countries, territories, other areas 2021 2015–2020 2021 2021 2021 2021 2021 2021 male female

Afghanistan 39.8 2.5 41.2 25.0 35.2 56.1 2.7 4.0 64 67

Albania 2.9 -0.1 17.1 12.2 19.8 67.7 15.2 1.6 77 80
Algeria 44.6 2.0 30.9 15.8 22.3 62.2 6.9 2.9 76 79
Angola 33.9 3.3 46.2 24.1 32.9 51.6 2.2 5.3 59 65
Antigua and Barbuda 0.1 0.9 21.7 14.0 21.6 68.6 9.7 2.0 76 78
Argentina 45.6 1.0 24.3 15.7 23.3 64.2 11.5 2.2 74 80
Armenia 3.0 0.3 20.8 12.7 18.4 66.9 12.3 1.8 72 79
Aruba1 0.1 0.5 17.3 12.8 19.8 67.5 15.1 1.9 74 79
Australia2 25.8 1.3 19.3 12.4 18.5 64.2 16.5 1.8 82 86
Austria 9.0 0.7 14.5 9.6 15.1 66.1 19.5 1.6 80 84
Azerbaijan3 10.2 1.0 23.4 13.4 20.2 69.5 7.1 2.0 71 76
Bahamas 0.4 1.0 21.3 15.9 24.3 70.7 8.0 1.7 72 76
Bahrain 1.7 4.3 18.0 11.1 17.0 79.1 2.9 1.9 77 79
Bangladesh 166.3 1.1 26.3 18.3 27.5 68.4 5.3 2.0 71 75
Barbados 0.3 0.1 16.6 12.5 19.0 66.3 17.2 1.6 78 81
Belarus 9.4 0.0 17.3 10.2 14.5 66.6 16.1 1.7 70 80
Belgium 11.6 0.5 17.0 11.4 17.0 63.5 19.6 1.7 80 84
Belize 0.4 1.9 28.8 19.2 29.0 66.1 5.2 2.2 72 78
Benin 12.5 2.7 41.7 22.9 32.1 55.0 3.3 4.6 61 64
Bhutan 0.8 1.2 24.6 17.2 26.6 69.1 6.3 1.9 72 73
Bolivia (Plurinational State of) 11.8 1.4 29.8 19.5 28.6 62.6 7.6 2.6 69 75
Bosnia and Herzegovina 3.3 -0.9 14.3 10.5 17.0 67.2 18.5 1.2 75 80
Botswana 2.4 2.1 33.0 20.1 28.7 62.3 4.7 2.8 67 73
Brazil 214.0 0.8 20.5 14.4 22.3 69.6 9.9 1.7 73 80
Brunei Darussalam 0.4 1.1 21.9 14.7 22.7 72.1 6.0 1.8 75 77
Bulgaria 6.9 -0.7 14.7 10.1 14.3 63.6 21.7 1.6 72 79
Burkina Faso 21.5 2.9 44.1 24.1 33.3 53.5 2.4 5.0 62 63
Burundi 12.3 3.1 45.1 23.1 31.8 52.5 2.5 5.2 60 64
Cambodia 16.9 1.5 30.7 18.5 27.4 64.3 5.0 2.4 68 72
Cameroon, Republic of 27.2 2.6 41.8 23.3 32.4 55.5 2.7 4.4 59 61
Canada 38.1 0.9 15.8 10.5 16.6 65.7 18.6 1.5 81 85
Cape Verde 0.6 1.2 27.7 17.7 25.8 67.4 4.9 2.2 70 77
Central African Republic 4.9 1.4 43.0 26.1 36.3 54.1 2.8 4.5 52 56
Chad 16.9 3.0 46.2 24.6 33.9 51.3 2.5 5.5 53 56
Chile 19.2 1.2 19.0 13.0 20.1 68.3 12.7 1.6 78 83

142 Indicators
 Demographic Indicators
POPULATION POPULATION POPULATION COMPOSITION FERTILITY LIFE EXPECTANCY
CHANGE
Total population Average annual Population Population Population Population Population Total Life expectancy at birth,
in millions rate of population aged 0–14, aged 10–19, aged 10–24, aged 15–64, aged 65 fertility rate, years, 2021
change, per cent per cent per cent per cent per cent and older, per woman
per cent

Countries, territories, other areas 2021 2015–2020 2021 2021 2021 2021 2021 2021 male female

China4 1,444.2 0.5 17.6 7.4 17.5 70.0 12.4 1.7 75 80

China, Hong Kong SAR5 7.6 0.8 13.0 11.6 12.1 68.1 18.9 1.4 82 88
China, Macao SAR6 0.7 1.5 14.6 7.4 12.5 72.6 12.7 1.3 82 87
Colombia 51.3 1.4 21.9 15.6 24.1 68.7 9.4 1.8 75 80
Comoros 0.9 2.2 38.7 22.0 31.1 58.1 3.2 4.0 63 67
Congo, Democratic Republic of the 92.4 3.2 45.6 23.6 32.2 51.4 3.0 5.6 60 63
Congo, Republic of the 5.7 2.6 41.0 23.0 31.7 56.2 2.8 4.3 63 67
Costa Rica 5.1 1.0 20.6 13.9 21.6 68.8 10.6 1.7 78 83
Côte d'Ivoire 27.1 2.5 41.4 23.0 32.6 55.7 2.9 4.5 57 60
Croatia 4.1 -0.6 14.5 10.0 15.6 63.9 21.7 1.4 76 82
Cuba 11.3 0.0 15.7 10.9 17.0 68.1 16.2 1.6 77 81
Curaçao1 0.2 0.5 17.8 13.0 19.0 64.0 18.2 1.7 76 82
Cyprus7 1.2 0.8 16.5 11.7 19.1 68.8 14.7 1.3 79 83
Czechia 10.7 0.2 15.8 10.1 14.4 63.8 20.4 1.7 77 82
Denmark8 5.8 0.4 16.3 11.6 17.9 63.4 20.3 1.8 79 83
Djibouti 1.0 1.6 28.6 18.0 27.0 66.6 4.8 2.6 66 70
Dominica 0.1 0.2 – – – – – – – –
Dominican Republic 11.0 1.1 27.2 17.7 26.2 65.1 7.8 2.3 71 78
Ecuador 17.9 1.7 27.2 17.4 26.2 65.0 7.8 2.4 75 80
Egypt 104.3 2.0 33.8 18.2 26.3 60.7 5.4 3.2 70 75
El Salvador 6.5 0.5 26.3 17.6 27.1 64.9 8.8 2.0 69 78
Equatorial Guinea 1.4 3.7 36.8 19.4 29.2 60.8 2.4 4.3 58 61
Eritrea 3.6 1.2 40.7 24.5 32.6 54.8 4.5 3.9 65 69
Estonia 1.3 0.2 16.5 10.7 14.9 62.8 20.8 1.6 75 83
Eswatini 1.2 1.0 37.0 23.7 33.4 59.0 4.0 2.9 57 66
Ethiopia 117.9 2.6 39.6 23.1 33.3 56.9 3.6 4.0 65 69
Fiji 0.9 0.6 28.9 17.7 25.6 65.1 6.0 2.7 66 70
Finland9 5.5 0.2 15.6 11.0 16.6 61.4 23.0 1.4 80 85
France10 65.4 0.3 17.5 12.1 17.8 61.4 21.1 1.8 80 86
French Guiana11 0.3 2.7 31.7 19.0 27.6 62.5 5.8 3.2 77 83
French Polynesia11 0.3 0.6 22.0 15.5 23.1 68.6 9.4 1.9 76 80
Gabon 2.3 2.7 37.4 19.2 27.1 59.1 3.5 3.8 65 69
Gambia 2.5 2.9 43.8 23.1 32.4 53.7 2.5 5.0 61 64
Georgia12 4.0 -0.2 20.3 12.1 17.8 64.2 15.6 2.0 70 78
Germany 83.9 0.5 14.0 9.4 14.8 64.0 22.0 1.6 79 84
Ghana 31.7 2.2 36.9 21.3 30.4 59.9 3.2 3.7 63 66
Greece 10.4 -0.4 13.4 10.2 15.3 63.9 22.6 1.3 80 85
Grenada 0.1 0.5 23.8 14.4 21.8 66.2 10.0 2.0 70 75
Guadeloupe11 0.4 0.0 18.2 14.2 21.5 61.9 19.9 2.1 79 86
Guam13 0.2 0.8 23.6 15.8 24.0 65.5 10.9 2.3 77 84
Guatemala 18.2 1.9 32.9 21.2 31.3 62.0 5.1 2.7 72 78
Guinea 13.5 2.8 42.7 24.2 34.1 54.3 3.0 4.5 61 63
Guinea-Bissau 2.0 2.5 41.7 22.9 32.1 55.4 2.9 4.3 57 61
Guyana 0.8 0.5 27.5 18.1 27.8 65.2 7.3 2.4 67 73
Haiti 11.5 1.3 32.1 20.4 29.7 62.6 5.3 2.8 62 67
Honduras 10.1 1.7 30.1 20.4 30.6 64.8 5.1 2.4 73 78
Hungary 9.6 -0.2 14.5 10.0 15.2 65.0 20.6 1.5 74 81
Iceland 0.3 0.7 19.2 13.2 19.5 64.8 16.1 1.7 82 85

STAT E OF WOR L D POPUL AT I ON 2 02 1 143

Demographic Indicators
POPULATION POPULATION POPULATION COMPOSITION FERTILITY LIFE EXPECTANCY
CHANGE
Total population Average annual Population Population Population Population Population Total Life expectancy at birth,
in millions rate of population aged 0–14, aged 10–19, aged 10–24, aged 15–64, aged 65 fertility rate, years, 2021
change, per cent per cent per cent per cent per cent and older, per woman
per cent

Countries, territories, other areas 2021 2015–2020 2021 2021 2021 2021 2021 2021 male female

India 1,393.4 1.0 25.8 18.0 26.9 67.4 6.8 2.2 69 71

Indonesia 276.4 1.1 25.6 16.8 25.1 67.9 6.5 2.2 70 74
Iran (Islamic Republic of) 85.0 1.4 24.8 14.1 20.5 68.4 6.8 2.1 76 78
Iraq 41.2 2.5 37.3 21.6 31.1 59.2 3.5 3.5 69 73
Ireland 5.0 1.2 20.5 13.8 19.7 64.6 14.9 1.8 81 84
Israel 8.8 1.6 27.7 16.3 23.6 59.7 12.6 3.0 82 85
Italy 60.4 0.0 12.8 9.5 14.4 63.6 23.6 1.3 82 86
Jamaica 3.0 0.5 23.1 15.5 24.1 67.6 9.3 1.9 73 76
Japan 126.1 -0.2 12.3 8.9 13.6 59.0 28.7 1.4 82 88
Jordan 10.3 1.9 32.1 21.3 30.5 63.9 4.0 2.6 73 77
Kazakhstan 19.0 1.3 29.2 15.2 20.8 62.7 8.2 2.7 70 78
Kenya 55.0 2.3 38.0 23.6 33.4 59.4 2.6 3.3 65 70
Kiribati 0.1 1.5 35.8 20.0 28.8 59.8 4.3 3.5 65 73
Korea, Democratic People's
25.9 0.5 19.8 13.6 21.0 70.6 9.6 1.9 69 76
Republic of
Korea, Republic of 51.3 0.2 12.3 9.1 15.1 71.2 16.6 1.1 80 86
Kuwait 4.3 2.1 21.1 13.1 18.5 75.5 3.4 2.1 75 77
Kyrgyzstan 6.6 1.8 32.6 17.3 24.9 62.5 4.9 2.9 68 76
Lao People's Democratic Republic 7.4 1.5 31.6 20.0 29.3 64.0 4.4 2.5 67 70
Latvia 1.9 -1.1 16.8 10.2 13.7 62.2 21.0 1.7 71 80
Lebanon 6.8 0.9 24.5 16.3 24.8 67.6 7.9 2.0 77 81
Lesotho 2.2 0.8 32.1 19.7 29.1 62.8 5.0 3.0 52 59
Liberia 5.2 2.5 40.0 23.2 32.4 56.6 3.4 4.1 63 66
Libya 7.0 1.4 27.4 17.4 25.2 68.0 4.6 2.1 70 76
Lithuania 2.7 -1.5 15.6 9.0 13.7 63.3 21.1 1.7 71 82
Luxembourg 0.6 2.0 15.6 10.5 16.8 69.8 14.6 1.4 81 85
Madagascar 28.4 2.7 39.8 22.7 32.4 57.0 3.2 3.9 66 69
Malawi 19.6 2.7 42.5 24.7 34.4 54.8 2.7 4.0 62 68
Malaysia14 32.8 1.3 23.3 15.5 24.1 69.3 7.4 1.9 75 79
Maldives 0.5 3.4 19.8 11.3 19.3 76.4 3.8 1.8 78 81
Mali 20.9 3.0 46.7 24.8 33.7 50.8 2.5 5.6 59 61
Malta 0.4 0.4 14.4 9.3 14.7 63.8 21.8 1.5 81 85
Martinique11 0.4 -0.2 15.5 12.2 18.8 62.2 22.3 1.8 80 86
Mauritania 4.8 2.8 39.5 21.7 30.6 57.3 3.2 4.4 64 67
Mauritius15 1.3 0.2 16.4 13.4 20.7 70.6 13.0 1.4 72 79
Mexico 130.3 1.1 25.5 17.2 25.6 66.7 7.8 2.1 72 78
Micronesia (Federated States of) 0.1 1.1 31.0 19.9 29.8 64.4 4.6 2.9 66 70
Moldova, Republic of16 4.0 -0.2 15.8 10.5 16.2 71.2 13.0 1.3 68 76
Mongolia 3.3 1.8 31.2 15.8 22.4 64.3 4.5 2.8 66 75
Montenegro 0.6 0.0 18.0 12.4 18.9 65.9 16.2 1.7 75 80
Morocco 37.3 1.3 26.5 16.5 24.2 65.6 7.9 2.3 76 78
Mozambique 32.2 2.9 43.8 24.2 33.6 53.3 2.9 4.6 59 65
Myanmar 54.8 0.6 25.1 17.9 26.7 68.4 6.5 2.1 64 71
Namibia 2.6 1.9 36.7 20.8 30.2 59.7 3.6 3.2 61 67
Nepal 29.7 1.5 28.1 20.3 31.2 66.0 5.9 1.8 70 73
Netherlands17 17.2 0.2 15.5 11.3 17.2 64.0 20.5 1.7 81 84
New Caledonia11 0.3 1.0 21.7 15.0 23.2 68.3 10.0 1.9 75 81
New Zealand18 4.9 0.9 19.3 13.0 19.5 64.0 16.7 1.9 81 84

144 Indicators
 Demographic Indicators
POPULATION POPULATION POPULATION COMPOSITION FERTILITY LIFE EXPECTANCY
CHANGE
Total population Average annual Population Population Population Population Population Total Life expectancy at birth,
in millions rate of population aged 0–14, aged 10–19, aged 10–24, aged 15–64, aged 65 fertility rate, years, 2021
change, per cent per cent per cent per cent per cent and older, per woman
per cent

Countries, territories, other areas 2021 2015–2020 2021 2021 2021 2021 2021 2021 male female

Nicaragua 6.7 1.3 29.1 18.6 27.3 65.0 5.9 2.3 71 78

Niger 25.1 3.8 49.5 24.4 33.1 47.9 2.6 6.6 62 64
Nigeria 211.4 2.6 43.3 23.2 32.0 53.9 2.8 5.2 54 56
North Macedonia 2.1 0.0 16.2 11.1 17.2 68.9 14.9 1.5 74 78
Norway19 5.5 0.8 17.1 11.9 18.3 65.1 17.8 1.7 81 85
Oman 5.2 3.6 22.9 11.1 17.1 74.5 2.6 2.7 77 81
Pakistan 225.2 2.0 34.6 20.4 29.7 61.0 4.4 3.3 67 69
Palestine20 5.2 2.4 38.0 21.8 31.4 58.8 3.3 3.4 73 76
Panama 4.4 1.7 26.2 16.7 24.8 65.0 8.8 2.4 76 82
Papua New Guinea 9.1 2.0 34.8 21.3 30.7 61.5 3.7 3.4 64 66
Paraguay 7.2 1.3 28.6 18.5 27.8 64.4 7.0 2.4 72 77
Peru 33.4 1.6 24.7 15.5 23.1 66.4 9.0 2.2 75 80
Philippines 111.0 1.4 29.5 19.4 28.6 64.7 5.7 2.5 68 76
Poland 37.8 -0.1 15.2 9.9 14.9 65.4 19.4 1.5 75 83
Portugal 10.2 -0.3 12.9 9.9 15.2 64.0 23.1 1.3 79 85
Puerto Rico13 2.8 -3.3 14.9 14.1 19.4 63.9 21.3 1.2 77 84
Qatar 2.9 2.3 13.7 8.4 16.5 84.5 1.9 1.8 79 82
Réunion11 0.9 0.7 22.0 15.3 22.6 64.8 13.2 2.2 78 84
Romania 19.1 -0.7 15.5 10.8 16.1 64.9 19.7 1.6 73 80
Russian Federation 145.9 0.1 18.5 10.8 15.3 65.5 16.0 1.8 67 78
Rwanda 13.3 2.6 39.2 22.3 31.5 57.5 3.2 3.9 67 72
Saint Kitts and Nevis 0.1 0.8 – – – – – – – –
Saint Lucia 0.2 0.5 17.7 12.8 21.2 71.7 10.6 1.4 75 78
Saint Vincent and the Grenadines 0.1 0.3 21.6 15.4 23.8 68.3 10.2 1.8 71 75
Samoa 0.2 0.5 37.1 21.2 29.5 57.7 5.2 3.7 72 76
San Marino 0.0 0.4 – – – – – – – –
São Tomé and Príncipe 0.2 1.9 41.3 24.7 33.5 55.6 3.1 4.2 68 73
Saudi Arabia 35.3 1.9 24.5 14.2 20.8 71.8 3.6 2.2 74 77
Senegal 17.2 2.8 42.3 23.2 32.3 54.6 3.1 4.4 66 70
Serbia21 8.7 -0.3 15.2 11.3 17.3 65.4 19.4 1.4 74 79
Seychelles 0.1 0.7 23.7 14.3 20.6 67.9 8.4 2.4 70 78
Sierra Leone 8.1 2.1 40.0 23.4 32.8 57.1 2.9 4.0 55 56
Singapore 5.9 0.9 12.4 8.4 14.8 73.3 14.3 1.2 82 86
Sint Maarten1 0.0 1.4 – – – – – – – –
Slovakia 5.5 0.1 15.6 10.1 15.2 67.2 17.2 1.5 74 81
Slovenia 2.1 0.1 15.1 9.6 14.2 63.6 21.3 1.6 79 84
Solomon Islands 0.7 2.6 39.9 21.7 30.6 56.4 3.7 4.3 72 75
Somalia 16.4 2.8 46.0 24.6 34.3 51.1 2.9 5.8 56 60
South Africa 60.0 1.4 28.6 17.7 25.8 65.8 5.6 2.3 61 68
South Sudan 11.4 0.9 41.1 23.0 32.5 55.6 3.4 4.5 57 60
Spain22 46.7 0.0 14.2 10.2 15.0 65.5 20.3 1.4 81 86
Sri Lanka 21.5 0.5 23.4 15.8 22.7 64.9 11.6 2.2 74 81
Sudan 44.9 2.4 39.5 23.0 32.5 56.8 3.7 4.2 64 68
Suriname 0.6 1.0 26.4 17.3 25.6 66.3 7.3 2.3 69 75
Sweden 10.2 0.7 17.7 11.3 16.5 61.9 20.5 1.8 81 85
Switzerland 8.7 0.8 15.0 9.7 15.1 65.6 19.4 1.6 82 86
Syrian Arab Republic 18.3 -0.6 30.7 18.3 27.1 64.4 4.9 2.7 71 79
Tajikistan 9.7 2.4 37.4 19.0 27.4 59.3 3.3 3.5 69 74

STAT E OF WOR L D POPUL AT I ON 2 02 1 145

Demographic Indicators
POPULATION POPULATION POPULATION COMPOSITION FERTILITY LIFE EXPECTANCY
CHANGE
Total population Average annual Population Population Population Population Population Total Life expectancy at birth,
in millions rate of population aged 0–14, aged 10–19, aged 10–24, aged 15–64, aged 65 fertility rate, years, 2021
change, per cent per cent per cent per cent per cent and older, per woman
per cent

Countries, territories, other areas 2021 2015–2020 2021 2021 2021 2021 2021 2021 male female

Tanzania, United Republic of23 61.5 3.0 43.3 23.6 32.5 54.0 2.7 4.7 64 68
Thailand 70.0 0.3 16.3 12.0 18.7 70.2 13.5 1.5 74 81
Timor-Leste, Democratic Republic of 1.3 1.9 36.6 22.8 32.7 59.1 4.3 3.8 68 72
Togo 8.5 2.5 40.3 23.1 32.2 56.8 2.9 4.1 61 63
Tonga 0.1 1.0 34.4 22.1 31.5 59.7 6.0 3.4 69 73
Trinidad and Tobago 1.4 0.4 19.8 13.4 19.4 68.3 11.9 1.7 71 76
Tunisia 11.9 1.1 24.2 14.0 20.8 66.6 9.2 2.1 75 79
Turkey 85.0 1.4 23.6 15.9 23.9 67.1 9.3 2.0 75 81
Turkmenistan 6.1 1.6 30.6 17.0 24.5 64.4 5.0 2.7 65 72
Turks and Caicos Islands 0.0 1.5 – – – – – – – –
Tuvalu 0.0 1.2 – – – – – – – –
Uganda 47.1 3.6 45.5 25.0 34.6 52.4 2.0 4.6 62 66
Ukraine24 43.5 -0.5 15.9 10.3 15.1 66.8 17.3 1.4 67 77
United Arab Emirates 10.0 1.3 14.9 9.1 16.5 83.7 1.4 1.4 78 80
United Kingdom25 68.2 0.6 17.6 11.4 17.3 63.5 18.8 1.7 80 83
United States of America26 332.9 0.6 18.2 12.7 19.4 64.7 17.0 1.8 76 82
United States Virgin Islands13 0.1 -0.1 18.9 13.4 19.6 59.9 21.1 2.0 78 83
Uruguay 3.5 0.4 20.2 13.6 20.9 64.5 15.3 1.9 74 82
Uzbekistan 33.9 1.6 28.7 16.4 24.4 66.2 5.0 2.4 70 74
Vanuatu 0.3 2.5 38.2 21.9 30.3 58.2 3.6 3.7 69 72
Venezuela (Bolivarian Republic of) 28.7 -1.1 26.5 18.2 25.9 65.3 8.2 2.2 68 76
Viet Nam 98.2 1.0 23.2 14.0 20.7 68.6 8.2 2.0 72 80
Western Sahara 0.6 2.5 26.9 16.5 24.8 69.5 3.6 2.3 69 73
Yemen 30.5 2.4 38.4 22.6 32.2 58.6 3.0 3.5 65 68
Zambia 18.9 2.9 43.6 24.7 34.3 54.3 2.2 4.4 61 68
Zimbabwe 15.1 1.5 41.3 24.2 33.6 55.6 3.1 3.4 60 63

146 Indicators
 Demographic Indicators

NOTES DEFINITIONS OF THE INDICATORS

− Data not available. Total population: Estimated size of national populations at mid-year.
1 For statistical purposes, the data for Netherlands do not include this area. Average annual rate of population change: Average exponential rate of growth
2 Including Christmas Island, Cocos (Keeling) Islands and Norfolk Island. of the population over a given period, based on a medium variant projection.
3 Including Nagorno-Karabakh. Population aged 0–14, per cent: Proportion of the population between age 0 and
age 14.
4 For statistical purposes, the data for China do not include Hong Kong and
Macao, Special Administrative Regions (SAR) of China, or Taiwan Province Population aged 10–19, per cent: Proportion of the population between age 10
of China. and age 19.
5 As of 1 July 1997, Hong Kong became a Special Administrative Region (SAR) of Population aged 10–24, per cent: Proportion of the population between age 10
China. For statistical purposes, the data for China do not include this area. and age 24.
6 As of 20 December 1999, Macao became a Special Administrative Region (SAR) Population aged 15–64, per cent: Proportion of the population between age 15
of China. For statistical purposes, the data for China do not include this area. and age 64.
7 Refers to the whole country. Population aged 65 and older, per cent: Proportion of the population aged 65
and older.
8 For statistical purposes, the data for Denmark do not include Faroe Islands
or Greenland. Total fertility rate: Number of children who would be born per woman if she
lived to the end of her childbearing years and bore children at each age in
9 Including Åland Islands.
accordance with prevailing age-specific fertility rates.
10 For statistical purposes, the data for France do not include French Guiana,
Life expectancy at birth: Number of years newborn children would live if subject
French Polynesia, Guadeloupe, Martinique, Mayotte, New Caledonia, Réunion,
to the mortality risks prevailing for the cross section of population at the time of
Saint Pierre and Miquelon, Saint Barthélemy, Saint Martin (French part) or
their birth.
Wallis and Futuna Islands.
11 For statistical purposes, the data for France do not include this area.
MAIN DATA SOURCES
12 Including Abkhazia and South Ossetia.
Total population: United Nations Population Division.
13 For statistical purposes, the data for United States of America do not include
Average annual rate of population change: United Nations Population Division.
this area.
Population aged 0–14, per cent: UNFPA calculation based on data from
14 Including Sabah and Sarawak.
United Nations Population Division.
15 Including Agalega, Rodrigues and Saint Brandon.
Population aged 10–19, per cent: UNFPA calculation based on data from
16 Including Transnistria. United Nations Population Division.
17 For statistical purposes, the data for Netherlands do not include Aruba, Population aged 10–24, per cent: UNFPA calculation based on data from
Bonaire, Sint Eustatius and Saba, Curaçao or Sint Maarten (Dutch part). United Nations Population Division.
18 For statistical purposes, the data for New Zealand do not include Cook Islands, Population aged 15–64, per cent: UNFPA calculation based on data from
Niue or Tokelau. United Nations Population Division.
19 Including Svalbard and Jan Mayen Islands. Population aged 65 and older, per cent: UNFPA calculation based on data from
20 Including East Jerusalem. United Nations Population Division.
21 Including Kosovo. Total fertility rate: United Nations Population Division.
22 Including Canary Islands, Ceuta and Melilla. Life expectancy at birth: United Nations Population Division.
23 Including Zanzibar.
24 Refers to the territory of the country at the time of the 2001 census.
25 Refers to the United Kingdom of Great Britain and Northern Ireland.
For statistical purposes, the data for United Kingdom do not include
Anguilla, Bermuda, British Virgin Islands, Cayman Islands, Channel
Islands, Falkland Islands (Malvinas), Gibraltar, Isle of Man, Montserrat,
Saint Helena or Turks and Caicos Islands.
26 For statistical purposes, the data for United States of America do not include
American Samoa, Guam, Northern Mariana Islands, Puerto Rico or United
States Virgin Islands.

STAT E OF WOR L D POPUL AT I ON 2 02 1 147

Technical notes
The statistical tables in the State of World Population 2021 include indicators that track progress toward the goals of the Framework of Actions for the
follow-up to the Programme of Action of the International Conference on Population and Development (ICPD) and the Sustainable Development Goals
(SDGs) in the areas of maternal health, access to education and reproductive and sexual health. In addition, these tables include a variety of demographic
indicators. The statistical tables support UNFPA’s focus on progress and results towards delivering a world where every pregnancy is wanted, every birth is
safe and every young person’s potential is fulfilled.

Different national authorities and international organizations may employ different methodologies in gathering, extrapolating or analyzing data. To
facilitate the international comparability of data, UNFPA relies on the standard methodologies employed by the main sources of data. In some instances,
therefore, the data in these tables differ from those generated by national authorities. Data presented in the tables are not comparable to the data in
previous State of World Population reports due to regional classifications updates, methodological updates and revisions of time series data.

The statistical tables draw on nationally representative household surveys such as Demographic and Health Surveys (DHS) and Multiple Indicator Cluster
Surveys (MICS), United Nations organizations estimates and inter-agency estimates. They also include the latest population estimates and projections
from World Population Prospects: The 2019 Revision, and Estimates and Projections of Family Planning Indicators 2020 (United Nations Department of Economic
and Social Affairs, Population Division). Data are accompanied by definitions, sources and notes. The statistical tables in the State of World Population 2021
generally reflect information available as of January 2021.

Tracking Progress Towards ICPD Goals

Sexual and Reproductive Health

Maternal mortality ratio (MMR), (deaths per 100,000 live births) Contraceptive prevalence rate, women aged 15–49, any method
and range of MMR uncertainty (UI 80%), lower and upper estimates (2021).
(2017). Source: United Nations Population Division. Percentage of women aged 15
Source: United Nations Maternal Mortality Estimation Inter-agency Group to 49 who are currently using any method of contraception. Model-based
(MMEIG). This indicator presents the number of maternal deaths during estimates are based on data that are derived from sample survey reports.
a given time period per 100,000 live births during the same time period Survey data estimate the proportion of all women of reproductive age, and
(SDG indicator 3.1.1). The estimates are produced by the MMEIG using married women (including women in consensual unions), currently using
data from vital registration systems, household surveys and population any method of contraception.
censuses. UNFPA, WHO, the World Bank, UNICEF and the United
Nations Population Division are members of the MMEIG. Estimates and Contraceptive prevalence rate, women aged 15–49, modern methods
methodologies are reviewed regularly by the MMEIG and other agencies (2021).
and academic institutions and are revised where necessary, as part of the Source: United Nations Population Division. Percentage of women aged
ongoing process of improving maternal mortality data. Estimates should 15 to 49 who are currently using any modern method of contraception.
not be compared with previous inter-agency estimates. Model-based estimates are based on data that are derived from sample
survey reports. Survey data estimate the proportion of all women of
Births attended by skilled health personnel, per cent (2014–2019). reproductive age, and married women (including women in consensual
Source: Joint global database on skilled attendance at birth, 2020, UNICEF unions), currently using any modern methods of contraception. Modern or
and WHO. Regional aggregates calculated by UNFPA based on data from clinic and supply methods include male and female sterilization, IUD, the
the joint global database. Percentage of births attended by skilled health pill, injectables, hormonal implants, condoms and female barrier methods.
personnel (doctors, nurses or midwives) is the percentage of deliveries
attended by health personnel trained in providing life-saving obstetric Unmet need for family planning, women aged 15–49 (2021).
care, including giving the necessary supervision, care and advice to Source: United Nations Population Division. Percentage of women aged 15
women during pregnancy, labour and the post-partum period; conducting to 49 who want to stop or delay childbearing but are not using a method of
deliveries on their own; and caring for newborns (SDG indicator 3.1.2). contraception. Model-based estimates are based on data that are derived
Traditional birth attendants, even if they receive a short training course, are from sample survey reports. Women who are using a traditional method
not included. of contraception are not considered as having an unmet need for family
planning. All women or all married and in-union women are assumed to
Number of new HIV infections per 1,000 uninfected population (2018). be sexually active and at risk of pregnancy. The assumption of universal
Source: UNAIDS. Number of new HIV infections per 1,000 person-years exposure among all women or all married or in-union women may lead to
among the uninfected population (SDG indicator 3.3.1). lower estimates compared to the actual risks among the exposed. It might
be possible, in particular at low levels of contraceptive prevalence, that
when contraceptive prevalence increases, unmet need for family planning
also increases. Both indicators, therefore, need to be interpreted together.

148 Indicators, Technical notes

Proportion of demand for family planning satisfied by any modern Total net enrolment rate, primary education, per cent (2010–2020).
methods, women aged 15–49 (2021). Source: UNESCO Institute for Statistics (UIS). Total number of students of
Source: United Nations Population Division. Percentage of total demand the official age group for primary education who are enrolled in any level of
for family planning among women aged 15 to 49 that is satisfied by the education, expressed as a percentage of the corresponding population.
use of modern contraception (SDG indicator 3.7.1). Modern contraceptive
prevalence divided by total demand for family planning. Total demand for Gender parity index, total net enrolment rate, primary education
family planning is the sum of contraceptive prevalence and unmet need for (2010–2020).
family planning. Source: UNESCO Institute for Statistics (UIS). Ratio of female to male
values of total net enrolment rate for primary education.
Laws and regulations that guarantee access to sexual and reproductive
health care, information and education (2019). Total net enrolment rate, lower secondary education, per cent
Source: UNFPA. The extent to which countries have national laws and (2010–2019).
regulations that guarantee full and equal access to women and men aged Source: UNESCO Institute for Statistics (UIS). Total number of students
15 years and older to sexual and reproductive health care, information and of the official age group for lower secondary education who are
education (SDG indicator 5.6.2). enrolled in any level of education, expressed as a percentage of the
corresponding population.

Gender, Rights and Human Capital Gender parity index, total net enrolment rate, lower secondary
education (2010–2019).
Adolescent birth rate per 1,000 girls aged 15–19 (2003–2018). Source: UNESCO Institute for Statistics (UIS). Ratio of female to male
Source: United Nations Population Division. Number of births per 1,000 values of total net enrolment rate for lower secondary education.
adolescent girls aged 15 to 19 years (SDG indicator 3.7.2). The adolescent
birth rate represents the risk of childbearing among adolescent women Total net enrolment rate, upper secondary education, per cent
aged 15 to 19 years. For civil registration, rates are subject to limitations (2009–2019).
which depend on the completeness of birth registration, the treatment Source: UNESCO Institute for Statistics (UIS). Total number of students
of infants born alive but which die before registration or within the first of the official age group for upper secondary education who are
24 hours of life, the quality of the reported information relating to the enrolled in any level of education, expressed as a percentage of the
age of the mother and the inclusion of births from previous periods. corresponding population.
The population estimates may suffer from limitations connected to
Gender parity index, total net enrolment rate, upper secondary
age misreporting and coverage. For survey and census data, both the
education (2009–2019).
numerator and denominator come from the same population. The main
Source: UNESCO Institute for Statistics (UIS). Ratio of female to male
limitations concern age misreporting, birth omissions, misreporting the
values of total net enrolment rate for upper secondary education.
date of birth of the child and sampling variability in the case of surveys.

Child marriage by age 18, per cent (2005–2019).

Source: UNICEF. Regional aggregates calculated by UNFPA based on data
Demographic indicators
from UNICEF. Proportion of women aged 20 to 24 years who were married
Population
or in a union before the age of 18 (SDG indicator 5.3.1). Total population in millions (2021).
Source: United Nations Population Division. Estimated size of national
Female genital mutilation prevalence among girls aged 15–19, per cent
populations at mid-year.
(2004–2018).
Source: UNFPA. Proportion of girls aged 15 to 19 years who have
Population change
undergone female genital mutilation (SDG indicator 5.3.2).
Average annual rate of population change, per cent (2015–2020).
Source: United Nations Population Division. Average exponential rate
Intimate partner violence, past 12 months, per cent (2000–2019).
of growth of the population over a given period, based on a medium
Source: UNFPA. Regional and global estimates generated by Violence
variant projection.
Against Women Inter-Agency Group on Estimation and Data (WHO,
UN Women, UNICEF, UNSD, UNODC and UNFPA). Percentage of
Population composition
ever-partnered women and girls aged 15 to 49 who have experienced Population aged 0–14, per cent (2021).
physical and/or sexual partner violence in the previous 12 months (SDG Source: UNFPA calculation based on data from the United Nations
indicator 5.2.1). Population Division. Proportion of the population between
age 0 and age 14.
Decision-making on sexual and reproductive health and reproductive
rights, per cent (2007–2018).
Source: UNFPA. Percentage of women aged 15 to 49 years who are
married (or in union), who make their own decisions on three areas—their
health care, use of contraception, and sexual intercourse with their partners
(SDG indicator 5.6.1). As this report went to press, updated data for this
SDG indicator became available. The updated figures are available at
https://unstats.un.org/sdgs/indicators/database/.

STAT E OF WOR L D POPUL AT I ON 2 02 1 149

Population aged 10–19, per cent (2021). Population aged 65 and older, per cent (2021).
Source: UNFPA calculation based on data from the United Nations Source: UNFPA calculation based on data from the United Nations
Population Division. Proportion of the population between age 10 Population Division. Proportion of the population aged 65 and older.
and age 19.
Fertility
Population aged 10–24, per cent (2021).
Total fertility rate, per woman (2021).
Source: UNFPA calculation based on data from the United Nations
Source: United Nations Population Division. Number of children who
Population Division. Proportion of the population between age 
would be born per woman if she lived to the end of her childbearing
10 and age 24.
years and bore children at each age in accordance with prevailing age-
specific fertility rates.
Population aged 15–64, per cent (2021).
Source: UNFPA calculation based on data from the United Nations
Life expectancy
Population Division. Proportion of the population between age 15
Life expectancy at birth, years (2021).
and age 64.
Source: United Nations Population Division. Number of years newborn
children would live if subject to the mortality risks prevailing for the cross
section of population at the time of their birth.

Regional classifications
UNFPA aggregates presented at the end of the statistical tables are West and Central Africa Region
calculated using data from countries and areas as classified below. Benin; Burkina Faso; Cameroon, Republic of; Cape Verde; Central African
Republic; Chad; Congo, Republic of the; Côte d’Ivoire; Equatorial Guinea;
Arab States Region Gabon; Gambia; Ghana; Guinea; Guinea-Bissau; Liberia; Mali; Mauritania;
Algeria; Djibouti; Egypt; Iraq; Jordan; Lebanon; Libya; Morocco; Oman; Niger; Nigeria; São Tomé and Príncipe; Senegal; Sierra Leone; Togo
Palestine; Somalia; Sudan; Syrian Arab Republic; Tunisia; Yemen
More developed regions are intended for statistical purposes and do
Asia and the Pacific Region not express a judgment about the stage reached by a particular country
Afghanistan; Bangladesh; Bhutan; Cambodia; China; Cook Islands; Fiji; or area in the development process, comprising UNPD regions Europe,
India; Indonesia; Iran (Islamic Republic of); Kiribati; Korea, Democratic Northern America, Australia/New Zealand and Japan.
People’s Republic of; Lao People’s Democratic Republic; Malaysia;
Maldives; Marshall Islands; Micronesia (Federated States of); Mongolia; Less developed regions are intended for statistical purposes and do not
Myanmar; Nauru; Nepal; Niue; Pakistan; Palau; Papua New Guinea; express a judgment about the stage reached by a particular country or
Philippines; Samoa; Solomon Islands; Sri Lanka; Thailand; Timor-Leste, area in the development process, comprising all UNPD regions of Africa,
Democratic Republic of; Tokelau; Tonga; Tuvalu; Vanuatu; Viet Nam Asia (except Japan), Latin America and the Caribbean plus Melanesia,
Micronesia and Polynesia.
Eastern Europe and Central Asia Region
Albania; Armenia; Azerbaijan; Belarus; Bosnia and Herzegovina; Georgia; The least developed countries, as defined by the United Nations
Kazakhstan; Kyrgyzstan; Moldova, Republic of; North Macedonia; Serbia; General Assembly in its resolutions (59/209, 59/210, 60/33, 62/97,
Tajikistan; Turkey; Turkmenistan; Ukraine; Uzbekistan 64/L.55, 67/L.43, 64/295 and 68/18) included 47 countries (as of
December 2018): 33 in Africa, 9 in Asia, 4 in Oceania and 1 in Latin
East and Southern Africa Region America and the Caribbean­­—Afghanistan; Angola; Bangladesh; Benin;
Angola; Botswana; Burundi; Comoros; Congo, Democratic Republic of Bhutan; Burkina Faso; Burundi; Cambodia; Central African Republic;
the; Eritrea; Eswatini; Ethiopia; Kenya; Lesotho; Madagascar; Malawi; Chad; Comoros; Congo, Democratic Republic of the; Djibouti; Eritrea;
Mauritius; Mozambique; Namibia; Rwanda; South Africa; South Sudan; Ethiopia; Gambia; Guinea; Guinea-Bissau; Haiti; Kiribati; Lao People’s
Tanzania, United Republic of; Uganda; Zambia; Zimbabwe Democratic Republic; Lesotho; Liberia; Madagascar; Malawi; Mali;
Mauritania; Mozambique; Myanmar; Nepal; Niger; Rwanda; São Tomé
Latin America and the Caribbean Region
and Príncipe; Senegal; Sierra Leone; Solomon Islands; Somalia; South
Anguilla; Antigua and Barbuda; Argentina; Aruba; Bahamas; Barbados;
Sudan; Sudan; Tanzania, United Republic of; Timor-Leste, Democratic
Belize; Bermuda; Bolivia (Plurinational State of); Brazil; British Virgin
Republic of; Togo; Tuvalu; Uganda; Vanuatu; Yemen; Zambia. These
Islands; Cayman Islands; Chile; Colombia; Costa Rica; Cuba; Curaçao;
countries are also included in the less developed regions. Further
Dominica; Dominican Republic; Ecuador; El Salvador; Grenada;
information is available at http://unohrlls.org/about-ldcs/.
Guatemala; Guyana; Haiti; Honduras; Jamaica; Mexico; Montserrat;
Nicaragua; Panama; Paraguay; Peru; Saint Kitts and Nevis; Saint Lucia;
Saint Vincent and the Grenadines; Sint Maarten; Suriname; Trinidad
and Tobago; Turks and Caicos Islands; Uruguay; Venezuela (Bolivarian
Republic of)

150 Indicators, Technical notes

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