In the Pursuit of Reproductive Justice in Lebanon

Reproductive justice, reproductive rights, and reproductive health are often used interchangeably. While these concepts do not intentionally contradict one another, they do however hold different commitments, approaches, and actions. More importantly, the contexts wherein they have emerged are significant to their different usages. The development of this paper takes the form of exposition; its methodology and format are atypical. While it may appear that there is a plethora of questions asked, there is but one question posed, albeit a large one: can a Reproductive Justice approach and analysis be a praxis befitting the multitude of our struggles in a Lebanese context? The process of asking this question, in and of itself, answers it, as it is an exercise in adopting a Reproductive Justice framework.

As we divulge the origin and history of this framework, then take a look at its distinction from reproductive health and rights, we extend it across over a dozen core economic and sociopolitical struggles and issues in Lebanon, in a semi-exhaustive methodology aimed at weaving movements together and tethering them to a matrix of justice. From environmental justice, to citizenship, borders, immigration, refuge, violence, access to sexual and reproductive health (SRH) services, sexual orientations, gender identities, and disability – we find that the possibilities of reproductive justice are as abundant as the reproductive oppressions faced by different communities, groups, and people. The value of proposing a different framing may serve as a lens capable of lifting conceptual blurs and giving fresher insight into long-standing structural problems. Reproductive Justice may prove to be the missing framework that is desperately needed in order to forge cross-movement solidarities and oppose state tactics of divisiveness.

The emergence of Reproductive Justice

In her keynote speech at a rally in Raleigh sponsored by the North Carolina Alliance Against Racism and Political Repression in 1974, Angela Davis denounced state racism and its practice of forced sterilizations against black and indigenous women, noting a then-active case brought to court by a black woman, who at 19 years of age, had discovered that she had been sterilized since she was 14[1]. Twenty years later, not long after the 1994 International Conference on Population and Development (ICPD) in Cairo had taken place, a number of women of color rejected the propagated illusion of “choice” in pro-choice, and put forth a more encompassing and truer narrative of their lived realities and histories under reproductive oppression. Together, at a pro-choice conference in Chicago, they held an impromptu Black Women’s Caucus where the term Reproductive Justice (RJ) was first coined – a framework evolving well before the 1980s [2]. Many women of color considered that the pro-choice movement was righteous in demanding more of the ICPD Programme of Action1 with regards to recognizing women’s right to make the decision to terminate a pregnancy. However, they criticized the limiting scope of the right to abort from a “choice” perspective whilst not accounting for systemic oppressions that restrict reproductive autonomy and prohibit the ability to make these “free choices.” Women of color knew that legality would be neither enough to ensure reproductive health access and availability, nor to gain justice for centuries of reproductive oppression.

Some members of the spontaneous Black Women’s caucus in the Chicago Pro-Choice conference founded the first collective to tackle Reproductive Justice in the United States, SisterSong Women of Color Reproductive Health Collective (currently SisterSong Women of Color Reproductive Justice Collective). Today, SisterSong is constituted of Indigenous, African American, Arab and Middle Eastern, Asian and Pacific Islander, and Latina women and LGBTQ people, who work “to improve the institutional policies and systems that impact the reproductive lives of marginalized communities” [3]. A member of SisterSong since 1989, the Asian Communities for Reproductive Justice (now named Forward Together) joins SisterSong in highlighting the need for safe and sustainable communities, as well as true bodily autonomy in reproductive choices. Forward Together believes that access to resources and sociopolitical and economic power enable healthy decisions regarding gender, bodies, sexualities, and families [4]. Meanwhile, SisterSong explains that the government is responsible for protecting all human rights including reproductive rights; to SisterSong, Reproductive Justice is more about ensuring access than choice, facilitating abortion provision, and most importantly securing access to contraception, comprehensive sex education, STI (sexually transmitted infection) prevention and care, alternative birthing options, adequate parental and pregnancy care, domestic violence assistance, adequate wages for family support, and safe homes [3]. Ultimately, both collectives’ definitions focus on addressing reproductive oppression – the notion that reproductive health issues affect people disproportionately according to social configurations and hierarchies of class, race, and gender [2]. Reproductive justice, therefore, encompasses a social, economic, environmental, and gender justice analysis of sexual and reproductive health and rights.

Where rights fall short, justice ensues

The process of normalizing the discourse and language of human rights in Lebanon has been at work for 70 years, ever since the signing of the United Nations Declaration of Human Rights (UDHR) in 1948. During the drafting of the UDHR, Lebanese representative Charles Malik stood alongside an Asian and Arab lobby against Western and Soviet powers, to ensure that individuals be able to petition human rights violations. Ironically, Edward Rizk, the Lebanese representative who replaced Malik in these debates, took the opposite stance: he considered that allowing individual petitions made states appear inherently tyrannical and that advocates of human rights may take advantage of such a mechanism [5]. The fact that representatives of the same state could take such fundamentally different positions underlines an early, ongoing dissonance on whom to trust: the people or the state. Similarly, the Arab Organization of Human Rights (AOHR)2 defined itself as a nonpartisan entity seeking reform, mediation, and no political power since its inception, so as to be perceived as non-threatening to states and therefore be allowed to practice in different countries. The organization did not posit a threat of rebellion or mass mobilizations because of its use of an elitist language of human rights resulting from formal education and AOHR members having closer connections to state politicians than grassroots groups. In fact, in their dialoguing with governments on human rights abuses, AOHR and similarly politically liberal organizations grant states a legitimacy they can display in international arenas [6].

As universal human rights language trickled down from an international political scene to questionable deliberations between human rights organizations and governments, it took time for people to incorporate it into their daily language. In Arabic, the word rights translates to hukook, and law translates to qanoun. However, university faculties offering a degree in law translate such degree to a degree in hukook, and define their sub-specialties as subspecialties of law (e.g. criminal law, business law, public law, etc.) [7, 8]. This colloquial and official conflation between the words rights and law may further contribute to why the term rights is not relatable. In their rigiditiy, laws often discriminate while rights do not. Lawmakers are citizens, and almost always cis-men of influence, status, and power. The Lebanese law has failed to protect and substantiate the basic human rights of women, refugees, migrants, queers, transgenders, working-class people, incarcerated people, people with disabilities, people living with HIV, and sex workers. More importantly, the language of human rights is exercised by human rights advocates and defenders, lawyers, politicians, judges, and non-governmental organizations’ workers. It is learned and acquired, and arguably not the language of the people who need it most. Justice [al aadalah], however, in its mere utterance, invokes a sense of right and the struggle for that right. Justice is imminent; it is demanded, brought, and achieved. Also, justice is a time traveler; it can be retroactive, present, and for the future. Human rights conventions and treaties can be, and often are, ratified, no matter how ideal their language is. Justice cannot be ratified. It can be sought by anyone – one does not need to be a justice advocate or defender. Unlike the rigidity of laws and rights, the process and conversation of attaining justice speaks truth to people’s lived realities. It is this malleability of justice – the fact that anyone can practice it – that gives it a sense of possibility. Many who face injustices are skeptical when learning from human rights defenders that rights are inalienable. They are not reassured by the notion that they have rights, yet cannot touch or feel them. How can one fight for something they already have? Ironically, the inalienability of rights is what often makes them feel alien.

Reproductive Justice addresses the abuses that take place in the wide gap between the language of reproductive rights, and actions taken locally to protect these rights. In 2003, long after the World Health Organization (WHO) had embraced the ICPD definition of reproductive health and rights [9], it supported its member states with a technical guideline on the management of complications arising from unsafe abortions and the provision of medical and surgical abortion. However, the guidelines recommended that these procedures be carried out to the full extent of national laws [10]. As a result, in most countries, including Lebanon, abortion is restricted to whether the pregnant woman’s life is in danger. It isn’t until two decades after the ICPD that the WHO published its second guidance on safe abortion, updating newest best practices, finally making a clear argumentation on the importance of integrating abortion services into health-systems, and stating that legal and policy changes towards decriminalization are in accordance with human and women’s rights framings [11]. Even in the utterance that it is a woman’s right to decide whether or not to terminate a pregnancy, many women will still be limited by national criminal laws, their “legal” status, marital status, employment, refugee status, economic condition, access to health, mobility restrictions, availability/accessibility of public transport, healthcare providers’ stigma, and last but not least, family members, spouses, religious figures, and other interpersonal interactions.

The fight for safe, legal, accessible, and free abortion is definitely a core-struggle in achieving Reproductive Justice, but as SisterSong and others have clearly stated for over twenty years, it extends to much further than that. At The A Project3, we adopt the vision of Reproductive Justice as SisterSong4 and Forward Together5 have described. The reproductive justice framework we are using aims to address the material conditions preventing the exercise of reproductive rights, labor rights, women’s rights, sexual rights, environmental rights, political rights, disability rights, and basic human rights. We extend this vision to encompass Lebanon’s historical and geopolitical significance. Our fight for Reproductive Justice, therefore, is based on a politics of decolonization and south-to-south solidarities. It perceives struggles as indivisible and interconnected in a political climate where issues are treated as operating in silos. It is part of our fight to call upon people, grassroots collectives, civil society groups, NGOs, and academics to adopt this framework. We embark on this exercise to crystalize the possibilities of seeing structural injustices through a Reproductive Justice lens, and begin by looking at the crux of the many struggles in Lebanon, citizenship.

A glimpse of the broad reach of Reproductive Justice

1. Citizenship

In Lebanon, citizenship laws are gendered and unequal, whereby Lebanese women’s citizenship is not as valuable as that of men. When Lebanese women acquired the right to vote, they gained political participation and representation, but not the social entitlements of citizenship [12]. This is clearly exhibited by their inability to pass their nationality to their non-citizen spouses and children, while Lebanese men can. Like many other countries in West Asia and North Africa region, Lebanon relies on nationality passed through parental bloodline (jus sanguinis), rather than from being naturalized, i.e. born in the country in question (jus soli). In Lebanon, the legally-blessed parental bloodline that transfers citizenship is paternal. As long as Lebanese women marry non-Lebanese men, their children, like any non-citizen in Lebanon, face state harassment in their legal residency, employability, property ownership or inheritance, education opportunities, and access to health [13]. Their politically-deviant desires and choice in spouse is punishable. This is proven in the legal exception that Lebanese women can only pass their nationality to their children when they are born out of wedlock, or when the father is unknown [14]. Aside from the social stigma of being an illegitimate child, these children, while considered Lebanese, are barred from holding positions in public office. The state gives preference to Lebanese women’s children born out of wedlock, than born of Palestinian or Syrian men. In his sexist-sectarian-racist statement to amend the Citizenship Law, leader of Free Patriotic Movement and Minister of Foreign Affairs and Emigrants, Gebran Bassil, stated that he supported women’s right to pass nationality as long as they don’t marry men from “neighboring countries” (read refugees of Muslim majority) [13]. Moreover, he incited hate towards unwed mothers, deeming it “strange and unacceptable” that legitimate children of Lebanese mothers married to foreigners are discriminated against in citizenship, whilst the “illegitimate” ones have rights [15]. Any and all population control efforts affect women. In Lebanon, the restriction on women to pass citizenship to Syrians and Palestinians is part of the larger plan of Christian political parties to decelerate the growth of Muslim populations whilst investing in the growth of Christian populations, going as far as inviting the long-lost Christian diaspora and their spouses to claim Lebanese citizenship [16].

Accusing mothers of purposefully disadvantaging their children by having them out of wedlock or with non-Lebanese men falls well within the culture of blame that ostracizes women for exercising their right to engage in non-marital sex, start a family, choose their own partner, and/or not desire men, specifically Lebanese men. The state-sanctioned desirability of a Lebanese husband ensures that members of the family will have better opportunities, won’t be harassed by state apparatuses, and would receive the full benefits of Lebanese citizenship – unless they have daughters, of course. The legal restrictions and consequences of the citizenship law hurdles women’s bodily autonomy; it directly affects her relationship with her children, her reproductive decisions, and her family’s safety and socioeconomic well-being.

2. Borders, immigration, and refuge

As the Lebanese state impugns the citizenship of its own female citizens, it is not difficult to predict its position towards outsiders. Syrians, Palestinians, Palestinians from Syria, Iraqis, migrant workers and migrant domestic workers (MDWs), and stateless people are estimated to make up a quarter of Lebanon’s residents. Refugees and migrants cross Lebanon’s borders to seek refuge from war or conflict, for political asylum, or employment. As non-citizens, women and trans* persons face multiple degrees of reproductive oppression due to their gender, residency status, race, economic class, nationality, and religion. Refugees who live in Lebanon have clear barriers and bureaucracies in their access to affordable and quality healthcare, reproductive and sexual health included. Being registered with United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) or United Nations High Commissioner for Refugees (UNHCR) does allow some degree of health accessibility, but that presupposes access to registration. Even then, refugees are dependent on whether their health needs are deemed truly necessary by these institutions.

a. Syrian women

A recent study reported that among refugees (n=20,642), migrants (n=3,395) and domestic inhabitants (n=11,634), the two formers were respectfully 2.6 and 1.89 times more likely than domestic inhabitants to be diagnosed with cancer. Refugee women were at a particularly higher risk than refugee men, as half the types of cancers identified targets their reproductive organs – cervical, vulvar, and breast cancer [17]. Syrians, and particularly Syrian women, seeking refuge in Jordan are estimated to have a high rate of untreated cancers due to a change in funding that withdrew monetary support for cancer treatment [18]. With the absence of preventative and early detection care, most women have a late diagnosis with poor prognosis. Humanitarian-aid-based reproductive healthcare is one of temporality and restricted to the “reproductive age.” For Syrian refugee women, it partially funds the costs of childbirth and antenatal care, and provides contraception, but cannot cater to the needs of women struggling with infertility, requesting tubal ligation (sterilization), suffering from reproductive cancers, or necessitating gynecological care for infections or menopause. Many Syrian women find it impossible to pay for the exuberant costs of Lebanese healthcare. Even with UNHCR covering three quarters of hospital bills for vaginal childbirth (cesarean section childbirths having much less coverage), many cannot afford the remaining quarter and are either forbidden from leaving the hospital until their bill is settled, or have their identification cards confiscated as ransom [19]. Syrian refugee women seeking to relocate with their family also fear that having more children would reduce their chances of resettlement through UNHCR, and decide to terminate sometimes wanted pregnancies in order not to hurt those chances for them and their family [19]. Through media and political actors, the dominant nationalist public discourse paints Syrian women as ignorant, backwards, and negligent mothers for, respectively, not knowing how to use contraception, engaging in sex in their cramped homes in front of their children, and birthing children into poverty. The influence of such a discourse makes Syrian women’s wombs a matter of public interest, and the pregnant woman herself a threat to public resources and security. The consequences of such propaganda affect their access to health, livelihoods, home, security, as well as the wellness of their families [19]. Not only are Syrian women at a heightened risk of reproductive morbidities and mortality, they are also blamed for it.

b. Palestinian women

The systemic impoverishment of Palestinians in Lebanon over the last 70 years has been detrimental to Palestinians and Palestinian women. Under the guise of “right to return,” the Lebanese state has effectively implemented discriminatory laws that have restricted Palestinians from improving their quality of living. By law, Palestinians are required to obtain work permits; are restricted from employment in at least 19 syndicated better-paying professions, owning property, and starting businesses; and are excluded in the National Social Security Fund (NSSF) from maternity, sickness, and family allowance benefits [20]. The selective discrimination against Palestinian women in the labor law shows clearly that the Lebanese state neither cares about Palestinian women’s reproductive wellbeing, nor about seeing them as women as they are not entitled to the same consideration as Lebanese working women: despite paying wages to the national fund for social support, this support only benefits citizens within the confines of the Lebanese state’s definition. Even outside their role as workers, Palestinian women are excluded from national programs and campaigns that grant free mammogram testing for the early detection of breast cancer [21]. One week before President Trump had initiated the global gag rule, the United States reduced 350 million USD from UNRWA’s budget, placing Palestinian women everywhere at a massive reproductive and sexual health risk [22]. With this most recent denial of reproductive healthcare and their pre-existing poor socioeconomic determinants of health placing them at a higher risk of reproductive cancers, Palestinian women are pushed to pay higher costs, out of family budgets, for their health. In the unfortunate case that a Palestinian woman does have cancer, of later detection and worse prognosis, the cost of treatment would be so high that she would not be given the fighting chance to survive her illness. The purposeful exclusion of women from primary care services that are affordable and bear better chances of recovery is but a slow and painful erasure; it constitutes the definition of reproductive oppression.

The only glimmer of hope that the Lebanese state presents Palestinian women with is naturalization by marrying a Lebanese man. One year after marrying, Palestinian or Syrian women are supposedly able to get the Lebanese nationality and all the benefits that come with it [13]. In practice, with General Security investigating the authenticity of this union, it is said to take up to three years or more, especially if the woman has not produced a Lebanese offspring. This unlawful practice, unashamedly corroborated by an officer of high ranking in General Security, sheds light on how state misogyny treats Palestinian, Syrian, and Lebanese women as incubators of Lebanese citizens, without ever being truly deserving of said citizenship themselves.

c. Migrant women

In comparison to citizens, migrant women are at an increased risk of cancer and reproductive cancers [17]. In pregnancy, they are less likely to have obstetrical interventions when needed, are more likely to experience stillbirths, early neonatal death, postpartum depression, and impaired communication with healthcare workers, and are themselves at an increased risk of maternal death [23]. In Lebanon, migrant women, and especially migrant domestic workers (MDWs) who come from many countries in South and Southeast Asia and Africa, suffer a wide array of human rights violations and reproductive oppressions. The job of domestic workers is unlike any other: under the sponsorship system (kafala), MDWs are paternalistically placed under the custody and are “the responsibility” of their employers. Living and working in close quarters with their employers-sponsors, a great majority of MDWs is forbidden from leaving their place of employment and residence, or from speaking to their families back home or to other MDWs via balconies. This isolation is not merely a verbal condition: many are locked in when the family is out, their passports are revoked, and their means of communicating with the outside world are monitored [24]. This “defamilialization” of the migrant worker occurs simultaneously with a “familialization” in the household where she works, as her job description often entails domestic work such as taking care of the children [25]. Accompanied by physical, verbal, emotional, and sexual violence on the one hand, and the normalization and inability to report these abuses on the other, the outcomes of such a forced isolation are detrimental to MDWs’ mental health. Many choose to escape their place of employment, and as many as two MDWs a week commit suicide in Lebanon [24].

The kafala system operates outside the labor law. Even though the employment of MDWs is highly regulated, monitored, and legitimized by General Security, MDWs are dehumanized by a racist, sexist, and classist system. They have no fixed working hours or days off, and despite making less than the minimum wage in Lebanon, they sometimes only receive their wages after years of work, if at all. The restriction on migrant women from having any personal relation, whether familial, sexual, or friendly, was substantiated in 2015 when a General Security memo proposed that sponsors of MDWs pledge that their employee will refrain from engaging in intimate relationships during her stay in Lebanon [26]. While this memo did not pass, it clarified General Security’s position regarding migrant women who breach contract, work and live outside their allotted place, and have children – an estimated 15,000 [23] – on Lebanese land. The demand for cheap and unpaid labor leads to the trafficking of women who are enslaved in domestic work or sex trade. Isolated under kafala, women would be denied access to healthcare and would face unwanted pregnancies, forced abortions, STIs, and separation from their children. Most recently, an Ethiopian worker, Lembibo, was recently found deceased in the private pool of her employer’s house, only two days after giving birth to her daughter, who had also died a couple of hours after delivery [27]. The death of a migrant woman and her “illegitimate” (as she is not permitted to have children on the job) daughter are glossed over without medical, forensic, or police explanation.

3. On violence

Freedom from violence is a cornerstone to achieving reproductive justice. The institutionalized violence of state and medical field on the bodies of those deemed “illegal” and of non-normative gender identities, as respectively described above and to be described below, constitutes a reproductive oppression. However, other forms of violence that appear more individual and interpersonal, such as domestic violence, intimate partner violence, street harassment, and rape, are also forms of institutionalized and state-sanctioned violence.

Freedom from violence is a cornerstone to achieving reproductive justice. The institutionalized violence of state and medical field on the bodies of those deemed “illegal” and of non-normative gender identities, as respectively described above and to be described below, constitutes a reproductive oppression. However, other forms of violence that appear more individual and interpersonal, such as domestic violence, intimate partner violence, street harassment, and rape, are also forms of institutionalized and state-sanctioned violence.

a. Domestic violence

Introducing laws to “protect” women from domestic violence often do not take into account the broader social context and structural conditions beneath these disputes [28]. In 2014, local Lebanese NGO Kafa (enough) stated receiving over 2,600 domestic violence cases annually on its hotline, and that over the three years prior, they had accounted for 25 women who had been murdered by their family [29]. Far from simply being a personal matter, domestic violence is implicitly sanctioned by Personal Status Laws. These laws govern matters related to marriage, divorce, inheritance, and custody, and are implemented differently depending on the sect of the couple or family. Personal status laws make it difficult for women seeking a divorce to be granted one in comparison to men seeking a divorce: they often exempt husbands from their monetary duties (spousal maintenance, alimony, quittance or khul, end of marriage pre-set payment or mu’akhar/muhr), and favor the father in child custody battles. Being forced to remain with an abusive husband, or being granted freedom on the condition of forfeiting alimony or the custody of their children are frequent pathways facing women in Lebanon [30]. Moreover, the fact that divorce is justified in cases where spouses are not fulfilling their “marital duties” (making themselves sexually available) affects women much more than men, and reinforces the idea that a wife’s duty is to have sex with her husband. Still, nothing reinforces the idea of marital rape more than its explicit non-criminalization in Article 503 of the Lebanese penal code, which defines rape as “forced sexual intercourse [against someone] who is not his wife by violence or threat” [31]. While the law to protect women and family members6 from domestic violence passed in 2014, it purposefully left out marital rape and inserted a clause agreeing that all legal provisions contrary to this protective law be annulled, with the exception of the Personal Status Law [29].

Guaranteeing that women have easier processes of divorcing their husbands or gaining quittance, muhr, or alimony are good, but still insufficient measures to protect women in the legally binding institution of marriage. In the pursuit of reproductive justice, the Lebanese government needs to recognize that it is its own failure that women are positioned as subsidiary to men, whereby women exist either under their father’s or husband’s Personal Status Records (sijilat el nufus). In addition to sexist upbringing, the institutionalization of women’s dependency on economic, social, religious, and legal grounds multiplies women’s vulnerabilities. The state must bear the responsibility of women’s deaths and the violence they have endured by providing women facing domestic violence and their children with rent-free homes, proper-waged employment, free healthcare, welfare, and child support in their time of need. Otherwise, women are doomed to request of their abusers financial support and permission to see their own children. Financial independence and safe homes for women, mothers, and children facing violence are cornerstones in the fight for reproductive justice.

b. Intimate partner violence

While domestic violence is institutionalized in Lebanon, it still has social and legal legitimacies that other forms of intimate partner violence (IPV) do not possess. The imbalance of power in intimate relationships grants a type of leverage which, if exploited, could lead to unhealthy dynamics and violence. Couples that are cohabiting, queer, or heterosexual do not benefit from a law that protects them from domestic violence. For the state, family and kinship strictly exist inside a heteronormative marital setup. Many heterosexual unmarried couples and queer couples confine their relationships to private spheres to avoid judgment; while queer intimacies are typically less accepted and considered more deviant than heterosexual ones, many communities and areas of Lebanon perceive heterosexual relationships outside of marriage as lacking in respectability and dishonorable for the woman. The myth that IPV exists less often among queer couples, and queer women in particular, than heterosexual couples has been discredited for some time [32]. In fact, the frequency of violence in queer relationships appears to be similar to that of heterosexual couples, if not more so in some studies [32]. Stigma, shame, homoantagonism, fear of not being believed, of making queerness look bad, of losing a community of friends, and the threat of being “outed” to family, employers, or friends by the abusive partner are but some of the reasons why queer people find it harder to leave abusive relationships than their heterosexual counterparts [32]. The institutionalization of heteropatriarchy makes IPV in non-marital and queer relationships irrelevant and non-existent. Hence, a practice of Reproductive Justice would disregard these legal structures in order to create ways wherein people in non-normative partnerships may also build families that are free from IPV.

c. Sexual harassment, sexual violence, and rape

Rape and other forms of sexual violence disproportionately target women, transgenders, and people with non-normative gender expressions. While sexual violence affects both citizens and non-citizens, it is much harder on non-citizens to get recourse to justice, to report, or to find medical, legal, or social support, because they are afraid of deportation or arbitrary detention. In Lebanon, priority is given to what the “legal” status of a person is, rather than their reporting of a crime. Unmarried (widowed, divorced, or single) Syrian refugee women report feeling vulnerable in Lebanon as they have experienced sexual harassment, solicitation for sexual favors, sexual violence, and rape from strangers who know of their non-marital status [19]. Many Syrian women are compelled to get into abusive marriages or polygamous setups, not because it would better their or their children’s living condition, but to ward off sexual violence [19]. Because of the restrictions on their mobility and communications, MDWs find difficulties contacting recruiting agencies, NGOs, or their embassies to report sexual harassment and violence faced at their place of employment. Migrant women who have broken contract are immediately propelled into irregular residency status, and any attempt to report rape would lead to their incarceration and deportation [24]. This makes migrant women easy targets of sexual violence, as rapists, of any nationality or residency status, know that state-supported and sustained patriarchy and racism make it an easy crime to commit. Trans* people are discouraged from reporting sexual violence because of their massive distrust in the local police who regularly harasses, arrests, and charges them with accusations of sex work, “masquerading” as women, disturbing public morality and decency, identity theft, and engaging in “sex that is contrary to nature” [33]. Gay men are also unlikely to report rape to patriarchal local authorities for fear of not being believed, being ridiculed, and facing emasculatory shame from a state body that legally and socially construes rape as a penetrative violation to a weaker feminine or effeminate sex. In fact, not too long ago, it was legal for the local police in Lebanon to conduct anal examinations in an attempt to identify homosexual men; in their view, only those who “penetrated” were “real” men, unlike homosexuals who received penetrative anal sex [34]. Within this sociolegal patriarchal understanding of rape as penile penetration, there should be no surprise as to why women who have been raped by other women do not come forward. In light of their disproportionate access to social support and care services, the bodily autonomy and mental, sexual, and reproductive health of people from different communities are threatened by state security’s purposeful disregard of the violence they face.

4. Access to sexual and reproductive health services

a. Maternal health & delivery

Maternal health in Lebanon is dominated by the medical profession, more specifically by obstetricians. Physicians outnumber midwives, whose scope of practice is legally restricted to the assistance of physicians. The privatization of maternal health, hospitals’ drive to make profit, and the introduction of costly new technological equipment and facilities force women to deliver in hospital settings and limit their participation in their deliveries. Forty percent of all deliveries in Lebanon are performed surgically via cesarean section, a much higher rate than the 15% recommended by the WHO [35]. Syrian refugee women in Lebanon have experienced negligence, poor pain management, isolation, and poor communication with healthcare providers. As obstetricians refuse to wait on refugee women’s normal vaginal deliveries, and are reassured that a majority of the bill would be paid by UNHCR, many Syrian women have complained of being forced into medically unsubstantiated cesarean section deliveries [19]. The sustainable development goals (SDGs) have placed a high value on the indicator of maternal mortality, and while Lebanon’s rate is low by global standards, it is regarded as high considering the rate of physician per capita and the proliferation of many private hospitals [35]. Many migrant and refugee women are hesitant about delivering in hospitals for fear of having to pay for unnecessary tests and unreasonably high hospital bill, or being asked about the legal status of their residency and their sponsor (in the case of MDWs). These factors may prompt poor and vulnerable women to deliver at home. As maternal mortality rates are assessed through hospital registrations of maternal deaths, it is possible that the national rate does not reflect the realities of poor and vulnerable women who are driven to home deliveries. Globally, the medicalization of childbearing and delivery, and unequal power dynamics between doctors and their patients have alienated women from their own pregnancies and trivialized their preferences and decision-making capacity.

b. Abortion and contraception

Reproductive Justice supports that women should be able to decide, through non-procreative sexual activity, contraception, or abortion, when and whether to have children. Contraceptive methods and medical advancements in this field are sexist in their focus on women’s fertility, as they shift the blame of unwanted pregnancies to women and exempt cis-men from any responsibility. Condoms and vasectomies, respectively singular or permanent, are the only effective modern methods offered to men, with vasectomies seen as emasculating under patriarchy. Once illegal under French colonial criminal law [36], contraceptive methods today are mostly uncontroversial. Unlike contraception, abortion in Lebanon criminalizes women and anyone assisting them or procuring the service, except when an abortion is needed to save the woman’s life [37]. While the stringent penal codes surrounding abortion are not implemented by the state, this does not mean that finding an abortionist is easy. Women pregnant out of wedlock are assumed to need an abortion to preserve their honor and not bring shame to their family. Many physicians exploit these women’s despair by placing a high price on surgical abortions and downgrading the efficacy and safety of medical abortion pills [38]. In 2013, the Order of Pharmacists of Lebanon distributed a circular to all pharmacies instructing them to demand, examine, and keep any prescription for Cytotec (an abortifacient) [39]. Before that, abortion medications were much more accessible. With the restrictions in access to abortion services impeding bodily autonomy, many women face compulsory motherhood.

c. STI testing and treatment

Despite being falsely associated with stigma rather than self-care, testing and treating STIs are major components of sexual health and rights. STIs are often seen as the consequences of reckless and immoral behavior such as adultery, promiscuity, and non-marital sexual activities. In Lebanon, a series of laboratory tests, including STI testing, is legally mandated to all couples before marrying. The value of these mandatory tests is so that both parties know what they are getting into, with the assumption that these test results could not vary after marriage. If diagnosed with an STI, a married woman could be accused by her husband of adultery, warranting state interference and her subsequent imprisonment [30]. Incarcerated women have severe disturbances in their reproductive and sexual healthcare due to the unavailability of gynecologists, the lack of sanitary pads [40], and the possibility of experiencing physical and sexual abuse [41].

The fear of stigma and of being treated negatively by intimate partners, friends, family, or healthcare providers hinders people’s care for their bodies. Some STIs are more likely to be asymptomatic in women, and routine testing helps with early detection, treatment, and prevention of complications (such as infertility or pelvic inflammatory disease) that arise from their being left untreated for too long. In Lebanon, health insurance schemes abide by patriarchal values; they punish unmarried sexually active women by refusing to cover the costs of their childbirth or sexual healthcare. As non-covered testing is expensive, unmarried people exhibiting STI symptoms often go to pharmacists for over-the-counter antibiotics.

Due to occupational risks, sex workers should be supported to the extent of the state’s possibility in their right to health and physical and emotional safety. Testing, vaccinations, treatment, contraception, and barrier methods must be made free for them so they can protect themselves from their clients. The public discourses of moral superiority and stigmatization of sex workers often justify their diminished health as a consequence of their own doing. In Lebanon, sex workers are also at a constant threat of arrest by state police for soliciting sex or sex work without officially having a work permit at a registered brothel [33] – permits that have not been issued since the Lebanese civil war [33]. Fearing imprisonment and even deportation, non-citizen sex workers face precarity as they cannot report clients who sexually assault them or refuse to wear condoms.

d. Adoption and assisted reproductive technology

The exclusion of poor and/or unmarried women from state-sponsored child care and welfare is one of many possible reasons for women to put their children up for adoption. Stern economic conditions contribute to reproductive oppression in that they force women to choose their survival over their own biological children. The reproductive oppression of pregnancies resulting from sexual violence and/or the inability to access safe abortion services in good time leads to further oppressions, as women are forced to carry pregnancies to term and abandon them after. Divorcing parenthood from biological reproduction is essential to provide children and parents with diverse possibilities of making and sustaining families [42]. The pathways of adopting in Lebanon, like most other matters relating to Personal Status Records, are under the jurisdiction of religion and not the state. While Islamic jurisprudence does not allow full adoption, Christianity’s does through a series of conditions set by the church.

Adoption and assisted reproductive technologies (ART) are important possibilities to consider, as they offer women uninterested in childbirth, past their reproductive age, infertile, with infertile partners, or with chronic illnesses contraindicating pregnancies, among others, the ability to override the biological prerequisites to becoming parents. Similar to sexual services and breastfeeding, surrogacy through ART has also made it possible for women to monetize typically uncompensated labors and place them in contexts of economic exchange. In countries where surrogacy is legally regulated, surrogates are entitled to having most aspects of their lives paid for, which appeals to women who are struggling financially [42]. On the other hand, ART also exacerbate inequalities because of the high cost of these technologies that favors access for the rich [43]. An informal discussion with a fertility specialist in Lebanon revealed that ART has been exploitatively used by wealthy Lebanese female patients, who have brought in the migrant domestic workers they sponsor as surrogates to their fertilized egg. The degree of consent on the part of MDWs in these transactions is unclear, but seeing as to how the kafala system enables abusive dynamics, this new level of transaction raises grave questions about the reproductive justice of MDWs. Reproductive Justice addresses the exploitation and socioeconomic inequalities of accessing ART, while simultaneously acknowledging the benefits of having technologies that assist in the right to form families without having to conform to traditional heterosexual marriages or biological reproduction [43].

5. Sexual orientation and gender identities

The rejection of non-normative sexual orientations is central to patriarchy’s practice. Capitalism and the institution of marriage rest on the unpaid domestic work of home-makers and wives. This institution supports men as heads of households, legally ensures they attain better pay, climb career ladders faster and farther, and inherit more than women, and sees that their family names and trees engulf and outlive women. The erasure of queer women’s desires and intimacies, and the cultural and legal propagation of heterosexual desire geared towards Lebanese men remind queer women that heterosexuality is the only accepted option of family formation. The right to family is thus rarely talked about when discussing queer and trans* issues; instead, the right to existing free from harm takes precedence in Lebanon. However, these issues are interrelated: when speaking of the right to live free from arrests, we must necessarily include discussions on the right to family and to reproductive and sexual health irrespective of the types of family setups. State law must not impose one type of partnership, desires, or intimacies. Marriage, as shaped by law and religion, must not be imposed on anyone, queers and non-queers, as the only institution of kinship.

Lebanese transgenders who aim to change their sex on their legal identification documents (ID) must undergo hormonal and surgical procedures, implicitly leading to sterilization, so that their physical appearances satisfy the courts to rule that their sex is as they claim. In the few cases that judges have ruled in favor of changing sex markers, they did so under the justification of “correcting” a clerical error in their original ID [44]. There is no recognition that the plaintiff is transgender, even though psychiatric records of a diagnosis of “gender identity disorder,” now gender dysphoria, are also mandated in their motion. Transgenders who have undergone gender affirming therapies struggle with state security and employability because of the incongruence in their IDs and presented selves [33]. The costs of legal, medical, psychiatric, and living fees for people already struggling financially is a major deterrent on their health and wellbeing. Living in precarity and facing transphobia, transgenders are unable to hold their physicians accountable for botched surgeries or for not offering to freeze their eggs or sperm before being rendered infertile. In comparison, doctors whose cis-patients are undergoing potentially sterilizing treatments are mandated to suggest reproductive technologies for egg/sperm preservation [45]. Meanwhile, transgenders face reproductive oppression in being made to choose between IDs offering sociolegal protection and their fertility. Even if they choose the former, transgenders who are already parents either get their legal cases rejected or are left in limbo [44]. Reproductive Justice approaches the issues of transgender and queers in their right to choose whether or not to have children, and be able to live free from harm and persecution with their families.

6. Disabled women

The marriageability of daughters is a major cause of concern for the patriarchal society. Mainstream beauty standards play an important role in the body shaming of young girls and women. Portraying fairer/white skinned, thin, cis-normative, feminine, heterosexual, and able-bodied women as the standard of beauty shapes the notions of acceptable desirability. In summer 2018, the President of Syndicate of Owners of Restaurants, Tony AlRamy chastised social media news outlets for divulging online the hygienic shortcomings of restaurants in Lebanon. In an elaborate metaphor, he compared the restaurant business with a hypothetically disabled daughter, saying: “if I want to marry my daughter, and my daughter limps, I would invite the potential groom to dinner and introduce him to her as she is sitting at the table. Perhaps they would hit it off. However, if I brought her up on stage, turned projector lights on her, and brought the family of this groom to come look at her, things would not work out” [46]. This sexist, ableist metaphor is not exceptional to AlRamy. While activists mostly criticized him for offending disabled people, little attention was cast on the sexism and insinuation that disabled women are not cut out to be married, loved, or desired. Disabled women may be deemed unable to assume their gendered roles, and instead of their feminized labor being exploited, they become a burden to the family as they are unlikely to be wed off. Many disabled women are forbidden from leaving their homes, which greatly restricts their ability to access reproductive and sexual health services. Furthermore, their right to privacy is also compromised: their visits to healthcare workers are usually accompanied by guardians who may take decisions for them, as they are often infantilized and told what is best for them.

7. Environmental justice

The Lebanese state’s deficiency in waste management was exposed in 2015, when people living near the Naameh landfill protested the renewal contract of a site that had already exceeded its capacity. Soon after the streets were filled with garbage, many people took to the streets in protest. Yet, no adequate waste management plan was set. The Lebanese state’s solutions posed a great risk to community health and wellbeing. They decided to open new landfills in other impoverished areas, such as the Bourj Hammoud landfill, and burn waste in open air, releasing dangerous inhalant particles such as dioxin and dioxin-like polychlorinated biphenyls (PCBs). People residing near the Bourj Hammoud landfill and other landfills have had to move houses to escape pollutants and the smoke emanating from burned garbage. Women also reported having to clean their houses much more often to be rid of the stench and trash burning residues. Many people have had to purchase air purifiers so their children won’t be exposed to such toxins [47]. Studies have shown that both landfills and the smoke and gas arising from incinerators contain carcinogens and other harmful chemicals that pose great health risks for people living near waste management sites, from respiratory illnesses, to heightened risk of cancers, to reproductive and developmental problems, in addition to disruptions in their immune systems. One of these carcinogens, dioxin, is a toxin linked to spontaneous abortions, preterm births, infertility, and birth defects [48]. Environmental concerns are framed by policy-makers as problems of over population, i.e. blaming poor and refugee women’s reproduction, when in reality the industrial and governmental mismanagement of wastes compromises water sources, soil, and eventually foods.

The inadequate infrastructure and housing conditions of crowded residential areas such as in Beirut’s suburbs, refugee camps, and informal settlements are in themselves a risk to the health of their residents. Sociolegal and economic discriminations and state security harassment ascertain that poor Lebanese, refugee, and migrant people are confined to environmentally compromised areas. As states target impoverished areas, low-income families unable to afford relocation and having restricted health coverage are placed at great risks of ill health. Aside from the physical stressors of their paid jobs, the demands on women’s domestic work multiply with attempts to keep their homes toxin-free and care work towards their sick children. The poisoning of women’s bodies, the first environment, also extends to their children through pregnancy and breastmilk. This is further confirmed in conflict zones, and even long after wars end, as the air, water, and soil of bombarded areas are contaminated with heavy metals or toxic gases that cause cancers, miscarriages, infertility, birth defects, and infant mortalities [49, 50]. In under 10 years, Iraq’s Al Basrah Maternity Hospital alone witnessed a 17-fold increase of congenital birth defects [50]. Environmental concerns should be traced back to their main culprits, including industries and states. Not only do they contribute to the largest amount of pollutants and gas emissions, but state policies also permit or neglect environmental dangers. The right of all women to have healthy pregnancies and to raise children in a healthy environment is a core principle that reproductive justice shares with environmental justice.

Movement building around Reproductive Justice

Calling it a glimpse of the broad reach of reproductive justice is precisely what this paper does. There are multitudes of reproductive oppressions omitted in the prior segment, and even more depths to delve into within the ones mentioned – from the undertested and underestimated population of women living with HIV, to public and private healthcare systems’ approach to SRH, to state-mandated STI tests for incarcerated homosexual men, couples prior to marriage, MDWs prior to employment, and exotic-dancers/artists upon their visa applications and every three months throughout their stay. As for environmental justice and MDWs’ relationship with reproductive justice, MDWs face environmental toxin exposures that affect their reproductive health in circumstances where their immunity is subdued due to constant allergic reactions triggered by pets they must tend to, or phthalates and other toxins that nail salon migrant workers from the Philippines commonly inhale. The market for adopted or sold children from Lebanon to different parts of the world poses a massive question of geo-economic and sectarian-based reproductive injustices. Reproductive oppression of refugees or migrant unmarried women of illegal residency are caused by their Lebanese male partners, who forbid them to leave by threatening them with disclosing their residency status to local authorities, which would result in their deportation or legal child-abduction through custody. Clearly, we do not aim to cover the depth and breadth of all these issues.

Reproductive Justice as a framework casts a wide net; imagine alone the extent of emotional violence and mental illness that befalls on refugee, migrant, Lebanese, queer, disabled, and poor women and transgenders from the daily attacks on their bodies and reproductive autonomy and agency in a system that impoverishes and physically sickens them and their families. Populations of people are systemically hindered from growth, health, family, intimacy, financial security, and safety, in the name of “sectarian balance,” “right to return,” nationalism, sponsorship, morality, war, and industrial development. The same politician that lobbied against Lebanese women’s right to pass citizenship [15] casually invited millions of non-citizens from the “right” religion to have full citizenship [16], and unashamedly stated that Lebanese women should desire differently if they want the right to pass citizenship to their children – a right that their unmarried counterparts “illegitimately” enjoy [15]. It is those same single mothers whom the healthcare industry coerces into delivering in a hospital under the care of an obstetrician, and who would have to pay for it out of pocket because health insurance punishes those who break the heteropatriarchal code of conduct.

The interconnectedness of these struggles is not coincidental. It is so because that is the definition of systemic. Oppressive structures are just as intersectional as our fight is against them. The divisiveness of working in silos and simplifying the issues is what partly impedes our progress and mobilization. There is nothing simple about the odds that we are up against; exhibiting just how complicated and connected they are shows the magnitude of what we are up against. Adopting the framework of Reproductive Justice in how we envision our collective struggles reconnects them as they are constantly being ripped apart, and gives us a better fighting chance.

SisterSong imagined that Reproductive Justice may not resonate outside of a US context, but this framework promises to realign our discourse and connect them with one another. We may not see oppressive structures brought to justice in our time, but at the very least building a movement around Reproductive Justice would allow us to alternatively and unapologetically practice our own vision of justice, one that needs no legitimacy or validity from the state. This is a call in pursuit of a Reproductive Justice movement locally, then regionally, in the hopes that we reach and exchange with the larger south-to-south solidarities.

• 1. The 1994 ICPD Programme of Action draws a clear relationship between maternal morbidity and mortality, and unsafe abortion; as a public health concern and not a women’s right issue. It advocates that abortions be reduced through expanding family planning services, education, and post-abortion counselling. It clearly conditions that where abortion is not against the law, reliable information, compassionate counselling and safe abortion services must be provided.
• 2. The Arab Organization for Human Rights is a Non-Governmental Organization that works on human rights issues in the Arab World. It was founded with a resolution agreed on in Hammamet, Tunisia, in 1983.
• 3. Grassroots group in Lebanon envisioning a society where sexuality and mental health are reclaimed by women and trans* people, cared for, respected, recognized in their diversities, and not utilized against us.
• 4. The human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.
• 5. All people having the social, political, and economic power and resources to make healthy decisions about their gender, bodies, sexuality, and families for themselves and their communities.
• 6. A clause bargained-for and won by the special parliamentary committee reviewing the draft law to dilute the basis that domestic violence is an issue of gender based violence.