Book “REPRODUCTIVE RIGHTS AND HEALTH”

The book was published in Georgian language with the support of Women’s East-West Program and National Women’s Program, Open Society – Georgia Foundation.

The goal of the book is to give basic knowledge about reproductive health and rights (RHR), to increase understanding of linkages between health and reproductive rights.

The book consists of five chapters. The first chapter "Reproductive Rights and Health Problems" consists of translated materials from the publication "Sexual and Reproductive Rights and Health in Central and Eastern Europe" prepared by ASTRA.

It attracts the readers’ attention on the situation concerning reproductive health and rights problem in the region, the policies and strategies. In addition, it contains the situation analyses of RHR in Georgia.

The second chapter "Reproductive Health" contains basic knowledge on reproductive health and rights, sexual health and rights, sexually transmitted diseases as well as the situation analyses with respect to Reproductive Health in Georgia (STD: syphilis, chlamiydia, candida, herpes, hepatit A, B, C, gonorrhea, thrichomoniasis, HIV/AIDS, contraception, abortion) and the review of national legislative basis with respect to these problems. The materials of this chapter have been prepared in Women's Center by Ia Verulashvili, Lali Baratashvili, Nino Kartvelishvili, Maka Gabexadze, Lela Tevzadze, Tamta Komaxidze.

The third chapter -"Health and Human Rights Norms and Standards" discusses how human rights are enshrined in international law, links between health and human rights, international human rights instruments, integration of human rights in health, how human rights support work to strengthen health system, and also United Nations Human Rights Organizational Structure. The chapter is based on the translated materials "25 Questions & Answer on Health & Human Rights "publication series issues N1, 2002 WHO.

The forth chapter "International Legislative Bases of Reproductive Rights" contains Ten Human Rights Keys to Reproductive Rights translated from "Reproductive Rights are Human Rights " prepared by Center of Reproductive Rights.

The Fifth chapter "Protection of Human Rights System according to European Convention for the Protection of Human Rights" shows how the international system of human rights protection established under the European Convention on Protection of Human Rights can be used for protection of reproductive rights. The chapter has been prepared on the basis of translated materials from ASTRA publication "How to use European Convention for the Protection of Human Rights and Fundamental Freedoms in Matters of Reproductive Law”.

At the end of book the information on "Women's Center's" experience in the sphere of the issues in question is provided.

The book will be useful for health care providers, NGO representatives, policy makers and general public.

Sexual and reproductive health is a very personal and sensitive issue, yet it has far-reaching implications on the socio-economic development of a nation as well as on the quality of life of its citizens. It is essential for governments to ensure public awareness of the basic values of gender relations and to provide them with high-quality services of reproductive health.

The International Conference on Population and Development (ICPD) held in Cairo in 1994 marked a major paradigm shift in conceptualization of sexual and reproductive health and the issues related to population and development.

The right to the highest attainable standard of health was first reflected in the WHO Constitution (1946) and then reiterated in the 1978 Declaration of Alma-Ata and in the World Health Declaration adopted by World Health Assembly in 1998. It has been firmly endorsed in the wide range of international and regional human rights instruments.

The right to the highest attainable standard of health in international human rights law is a claim to set social arrangements –norms, institutions, laws and enabling environment –that can best secure the enjoyment of this right.

All persons have reproductive rights, which are founded upon principles of human dignity and equality. But women have a unique role to play in human reproduction and are uniquely affected by government policies. Women's reproductive rights under international human rights law are composite of a number of separate human rights. While a human rights perspective is not limited to legal principles, demands for reproductive self-determination should be based upon international law.

The 1990s was a key decade in articulating the links between the provision set out in exiting human right treaties and women's reproductive rights. Widespread recognition of the legal foundations for reproductive rights is a critical step toward achieving human rights for all women.

Women's reproductive rights were a major topic at two recent international conferences, the 1994 United Nations International Conference on Population and Development (ICPD) and the 1995 United Nations Fourth World Conference on Women (Beijing). The international women's community rallied to ensure that the consensus documents from these meetings affirmed the centrality of these rights to international human rights and described the panoply of rights that are included in the reproductive rights framework. As stated in Paragraph 7.3 of the ICPD Programme of Action:

Reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion violence, as expressed in human rights documents.

In this publication ten key international human rights have been set forth, each of which encompasses reproductive rights. With respect to each of these rights, we cite only to selected provisions from major international legal instruments. (www.reproductiverights.org).

1. The Right to Life, Liberty, and Security
2. The Right to Health, Reproductive Health, and Family Planning
3. The Right to Decide the Number and Spacing of Children
4. The Right to Consent to Marriage and Equality in Marriage
5. The Right to Privacy
6. The Right to be Free from Discrimination on Specified Grounds
7. The Right to be Free from Practices that Harm Women and Girls
8. The Right to not be Subjected to Torture or Other Cruel, Inhuman, or Degrading Treatment or Punishment
9. The Right to be Free from Sexual Violence
10. The right to Enjoy Scientific Progress and to Consent to Experimentation

The purpose of sexual health is the enhancement of life and personal relations and not merely counseling and care related to reproduction and sexually transmitted diseases." FWCW PFA Para 94

A definition of sexual health should include the following components:

• The ability to enjoy mutually fulfilling sexual relationships;
• Freedom from sexual abuse, coercion or harassment;
• Safety from sexually transmitted diseases;
• Success in achieving or in preventing pregnancy.

"The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence. Equal relationship between women and men in matters of sexual relations and reproduction, including full respect for the integrity of the person, require mutual respect, consent and shared responsibility for sexual behavior and its consequences." FWCW PFA Para 96

"Sexual Rights include the rights of all people to:

• decide freely and responsibly on all aspects of their sexuality, including protecting and promoting their sexual and reproductive health;
• be free of discrimination, coercion or violence in their sexual lives and in all sexual decisions;
• expect and demand equality, full consent, mutual respect, and shared responsibility in sexual relationship."

The elements of Reproductive Health, as identified in the ICPD Programme of Action, are the following:

• family-planning counseling, information, education, communication and services;
• education and services for prenatal care, safe delivery and post-natal care, especially breast-feeding and infant and women's health care;
• prevention and appropriate treatment of infertility;
• prevention of abortion and the management of the consequences of abortion;
• treatment of reproductive tract infections, sexually transmitted diseases and other reproductive health conditions;
• information, education and counseling on human sexuality, reproductive health and responsible parenthood.

The promotion of the responsible exercise of these rights for all people should be the fundamental basis for government and community-supported policies and programs in the area of reproductive health, including family planning.

There are complex linkages between health and human rights:

• Violations or lack of attention to human rights can have serious health consequences;
• Health polices and programs can promote or violate human rights in the ways they are designed or implemented
• Vulnerability and the impact of ill health can be reduced by taking steps to respect, protect and fulfil human rights.

The normative content of each right is fully articulated in human rights instruments.

Health legislation can be important vehicle towards ensuring the promotion and protection of the right to health. In the design and review of health legislation, human rights provide a useful tool to determine its effectiveness and appropriateness in the line with both human rights and public health goals.

The manual prepared by ASTRA - “How to use European Convention for Protection of Human Rights and Fundamental Freedom in matters of reproductive laws“ – shows in an easy and practical manner how the international system of human rights protection established under the European Convention on Protection of Human Rights and Fundamental Freedoms (“Convention“) can be used for protection of reproductive rights.

The manual provides basic knowledge about the convention adopted in 1950 guaranteeing the rights ( http://www.echr.cor.int/Converntion/webConvenENG.pdf).

The Convention not only guarantees these rights, but also provides a unique international mechanism allowing to control the compliance of State Parties with the human rights obligations under the Convention. The cornerstone of this mechanism lies in Article 34 of the Convention, which states that “the Court may receive application from any person, non-governmental organization or a group of individuals claiming to be the victim of violence by one of the High Contracting Parties of the rights set forth in the Convention or the protocol thereto.

This application can be brought to the European Court of Human Rights in Strasbourg.

The manual includes very important information about the role of the Convention in protection of human rights and how it can be used by NGOs, about the procedure to be followed to when bringing an individual case to the European Court of Human Rights in Strasbourg, and most important information about the substantive law aspects of the Convention that can be related to the issues of reproductive health.

According to the ASTRA publication sexual and reproductive health is of special concern in Central and Eastern Europe. Women of the region face many barriers in accessing satisfactory reproductive health services and exercising their reproductive rights.

The main problems in the field of sexual and reproductive health and rights in the region are:

• Lack of commitment of the governments to address issues of reproductive health and rights;
• Inadequate legislation and policy in the area of reproductive and sexual health;
• Inadequate access to family planning information and services;
• High rates of unmet contraception needs and the high reliance on abortion as a mean of controlling the fertility;
• Excessive reliance on unsafe abortion services and their poor quality of these service;
• Low priority to adolescents reproductive health and rights including the lack of adequate sexual education;
• Rapidly growing rates of STD’s including HIV/AIDS;
• Violence against women and domestic violence being a major and neglected problem in the region;
• Low awareness of reproductive and sexual rights and health issues of the society.

Reproductive Health Survey conducted in Georgia in 1999 revealed one of the lowest fertility rates in the world – a TFR of 1.7 births per woman in 1997-99 (falling to 1.1 by 2003) with the rate of natural increase below zero.

It should be noted that extremely low fertility in Georgia has been reached without the use of significant levels of modern contraceptives or marriage postponement.

In 1999, only 20 percent of currently married women 15-44 were using a modern method (mostly the IUD) with an additional 21 percent relying on traditional methods (withdrawal or rhythm). A major factor in the decline of fertility has been a very high rate of induced abortion – TAR of 3.7 abortions per woman (5.5 for married women) is probably the highest rate in the whole region if not in the world.

Only 16 per cent of abortions in the country are legal (Women reproductive health survey, Georgia 1999-2000, Tbilisi, 2001). More than three quarters of all abortions falls at women aged 20 to 34. Pregnancy related morbidity and mortality are higher than in most European countries (1999); 5945 cases of complications during pregnancy, delivery and postpartum were reported to MOH (112 per 1000 live birth). In the same year, maternal mortality was also high (70.8 death per 100,000 live births), but declined to 51.3 per 100.000 in 2002.

Mortality rates of the infants under one year increased since 1989 and reached the peak in 1994, since then it began to fall, though remained still high. The rate of stillbirths increased even more rapidly until 1999; since then it declined, though in 2002 was still above the level of that of 1989. Mortality rates of the infants under five as well as maternal mortality showed some improvement, though remained high compared to well-developed countries. Due to the general socio-economic instability in the country these trends are not stabile and may subject to further fluctuations. Abortion is again one the leading causes of maternal mortality.

The rate of post abortion complications is very high – 32% (even after legally performed procedures), which is related to poor hygienic conditions, untreated STDs, etc.

In Georgia medical abortion is not performed.

Due to the poor accessibility of contraceptive information and services, abortion remains the main method of fertility control. The low level of awareness of reproductive health issues and poor availability of family planning services continues to be a barrier to move from abortion to contraceptive culture.

Contraceptives coming to the country by donation of international organizations are often used by every woman without selection resulting in high rate of complications. Modern contraception is expensive. That’s why women prefer abortion.

The reason of the above-mentioned situation is the absence of up-to-date information, medical practitioners’ overestimated negative side effect of modern contraceptives, lack of information about the potential harmful effects of the repeated abortions on reproductive health and lack of implementation of safe abortion methods.

After regaining political independence in 1991, intensive work has been conducted in Georgia aiming at filling out the gray areas in the health legislation caused by the vast political and socio-economic changes.

At the very early stages of the above-mentioned period substantial time and consideration were devoted to the issues of human rights in the sphere of healthcare and biomedicine (i.e. patient's rights). Influence of international developments as well as national models of some European countries on the development of the Georgian health legislation is perceptible. Currently Georgian legislation covers all aspects of human rights related to the healthcare and biomedicine: issues of autonomy and security related to medical care, biomedical research, organ transplantation, genetics, etc. Some more detailed legal instruments are at different stages of discussions. It may be stated that today Georgian legislation is in harmony with the basic principles provided by the international instruments aiming at protection and, promotion of human rights in the sphere of biomedicine. The law about abortion is among them. In order to prepare this law, OSI Public Health Program issued grants to "Georgian Health Law and Bioethical Society", which in its turn together with the Ministry of Health has elaborated mentioned document. Georgian Parliament has not yet brought the draft for discussion and it has not been signed into Law yet. We hope it will happen very soon. Most of the excerpted materials have been translated into Georgian. The data and conclusions of international research/surveys and experience of various countries have also been taken into account.

As part of its health care reform, the government plans to generalize family planning services throughout the country, to reverse the increasing levels of STD and improve reproductive health care service. In November 1999 the Ministry of Health of Georgia ratified its new national program entitled „Development of Reproductive Services in Georgia“. The new program has several components: 1) family planning; 2) STD-AIDS/HIV prevention; 3) antenatal and prenatal surveillance; 4) sexual education; 5) training for health professionals.

In 1997 Georgian Parliament adopted the law about health protection. According to Article 140 advertisement of abortion is prohibited. Abortion after 12 weeks pregnancy is allowed only according to medical and social indications.

In 2000, Ministry of Health of Georgia elaborated draft law (2000, 13 march N30/0 Order) about changes and additions in this article. Additional social indications include: disability of husband, death of husband, imprisonment of woman or her husband, unemployment of woman or her husband, injunction about ceasing parents rights, unmarried woman, divorce during pregnancy, pregnancy after rape, homelessness or living in a hostel, woman with a status of refugee, having 3 or more children, child with disabilities in the family, income of one member of the family less than established minimum, woman's age below 15 or above 45.

The laws and regulations in the family planning arena are inconsistent. In some cases they permit a wide range of choice /abortion is permitted up to 12 weeks/while in others they are more restrictive /women must have 2 children and be over 35 to have sterilization/. Within the overall population, teens and youth sub-population of maternity care have emerged as a priority. With the exception of a new requirement for a girl under 17 to receive parents permission before getting an abortion, there are no be legislative or regulatory barriers to the provision of family planning services to youth. On the other hand, there are clearly attitudinal barriers that interfere with a client’s freedom to choose the right to high-quality care.

Women’s Center has implemented several projects relevant to the investigation and protection of women’s rights. According to our previous experiences our organization has been a pioneer working on the problems crucial to the country (breast cancer, life style education, prevention of STD,HIV/AIDS, education on trafficking and domestic violence, etc.).

Transitional period was very hard for Georgia because of the two ethnic conflicts and the civil war in early 1990s.

The conflicts of recent years coupled with the increased migration have led to the decline in population, which has come down from 5.4 million (1989) to 4.6 million (1999). Due to the ethnic conflicts 288,000 people have been forced to leave their houses in the Samachablo and Abkhazia territories and to live under IDP status. Besides, there are 188,000 registered refugees living in Russian Federation.

The 1990s heralded the advent of massive emigration from Georgia. This can be gauged by the fact of doubled migration rate from the annual figure of 300,000 in 1980s to 600,000 after 1991. Due to poor economic conditions a considerable part of population is studying and working abroad. Most emigrants live in Russia and Ukraine, the two countries with severe outbreak of HIV/AIDS epidemics in recent years. Therefore, migration has significantly increased the risk of HIV infection distribution. According to the epidemiological studies, in Georgia 45 percent of registered HIV positive persons have been infected in Ukraine and/or Russia, of which 78 percent are injecting drug-users.

The first evidence of HIV infection in Georgia was reported in 1989. Official estimates, which are undoubtedly low, indicate that there are 305 people infected with HIV/AIDS in the country. According to the data of May 2002, out of 305 HIV-infected persons 67 developed AIDS, of which 44 died. However, given the widespread underreporting, WHO and local experts estimate that more than 1500 individuals are infected with HIV. Currently, the primary mode of transmission of HIV/AIDS is injecting drug-users, who represent 71 percent of cases, followed by 22 percent of heterosexual contacts, 3.6 percent of homo-bisexual contacts, 1.4 percent of blood recipients, 1 percent of vertical transmission and 1 percent is undetermined.

HIV/AIDS is widespread in all regions of Georgia. Over 46% of all HIV infection cases are registered in Tbilisi, the capital of the country; 18 percent of cases are reported in Samegrelo, the region bordering Abkhazia, which has the highest density of Internally Displaced People; 16 percent of cases occur in Ajara, the region bordering Turkey, which is the major seaport.

HIV/AIDS is predominantly present in the age group of 21-35 years. In 2001, over 87 percent of all new AIDS cases were detected in the individuals of 26 - 35- year age group. As it is the most economically productive segment of population, death in this age causes great economic hardship to the family.

Children between the ages of 5 and 15 provide a special opportunity and window of hope. These children can be taught to protect themselves from HIV infection before they become sexually active, which may protect them from HIV for their entire lives. Both HIV and AIDS are predominantly prevalent in the male population. The male/female affliction ratio, in 2001, was 3.1, being almost the same for HIV and AIDS.

Antenatal screening on HIV is not a routine procedure and expenses are not covered by public sources.

Intravenous Drag Users

Drug abuse has become one of the most serious problems in Georgia. Since independence, marked escalation of drug abuse and drug dependence has been observed in the country. The official statistic shows a sharp increase in the number of drug users as well as drug addicts. This phenomenon is easily explained by the increase of drug inflow into the country for the last couple of years.

Beside the increasing number of drug-users and abusers, age range of such users has also broadened in recent years. The official statistics show that there are about 9,000 drug users, of whom 60-70 percent of injecting drug-users. In contrast to the age distribution of drug-users in the past years, the present day scenario shows notable change being characterized by proliferation of drug-users in the age bracket of 25-35 years.

The Institute of Narcology officials report from their experience that heroin is most common narcotic injected, accounting for 70 to 80 percent of patients that they have evaluated.

Sexually Transmitted Diseases

Today in Georgia a high percent of infertility is noted, the reason of which is untreated STD. By this reason Georgia is in the second place in the world with this problem.

STD patients are mainly young people, and sex distribution of STD shows male predominance, except for trichomoniasis, which is more common in women.

The above mentioned data confirms a higher sexual activity of men and highlights the specific character of sexual behavior in the country – whatever is allowed for men is prohibited for women.

Legislative regulation plays an important role in the process of STD control. Development and refinement of legislative basis for regulation and control of STD is essential.

The global experience confirms that STDs significantly increase the risk of HIV infection transmission. Similar to other developing countries in the region, a marked increase of STDs is observed in Georgia. The increase in the incidence of disease after 1996 is the result of overall deterioration of political and economic stability in the country, disruption of health care system and poor STD reporting. Experts estimate that STD morbidity has increased, at least, by 4-5 - fold in comparison to the levels of late 1980s.

STDs are mainly prevalent in young people. Individuals of 20-40-year age bracket have the highest rate of disease prevalence.

Youth

The available limited data suggests that the young generation in Georgia is engaged potentially high-risk behavior in the context of STD and HIV/AIDS. The data collected by non-governmental organizations working in the field shows that majority of adolescents begin their sexual life with street sex workers due to the inability to have a permanent partner. Such types of contacts are mostly unprotected and therefore put them at risk of STDs and HIV infection. The situation is aggravated by low awareness of young people regarding safe sex principles. The majority of the surveyed do not use condom at all during sexual intercourse or only on rare occasions.

The main reason is the absence of sex education in Georgian culture, lack of information, absent of sexual education and youth-friendly services, cultural taboos on abortion. Adolescence, who engage in sexual activities without realization of its implications, face the treat of unwanted pregnancies, abortions, abandoned babies, STD, HIV/AIDS, rape, trafficking.

Our project “Reproductive Health Education“, the goal of which was the education and consulting on: reproductive health, abortion and women's health, Herpes, STD (East-West Women) revealed necessity of creation of Reproductive Health, Rights and Youth Sexual Education Network in Georgia, which would work on the protection of young adults reproductive health and rights through the structure including comprehensive, gender-sensitive, sexuality and health education programs premised on gender equality in and outside schools, on the protection of adolescents sexual rights and health in Georgia. This would reduce awareness among preteens and young teens about STD, reproductive health and rights. Using the resources of lawyers the best legislation focusing on sexual and reproductive rights will be developed and the postponing sexual involvement education series for preteens and for teens will be implemented. Hotline and open door consultation services will be established.

It is necessary to establish a network of women’s reproductive health and rights in the regions of Georgia.

Georgia was one of those countries that immediately after detection of the first cases of HIV infection on March 21, 1995 drafted and adopted the “Law on HIV/AIDS prevention”.

The Government of Georgia and the President recognized the critical epidemiological situation on HIV/AIDS and based on the President Decree # 587 (article 5, Oct 8, 1998) on “Enforcement of the process of fight against AIDS and preventive activities” several amendments of the law on HIV/AIDS prevention were drafted. The new draft of the law was revised and adopted by the Parliament and was enforced in January 2001.

If we consider existing economic situation of the country, the current law on HIV/AIDS prevention ensures maximal possible financial assistance to HIV infected individuals.

The legislation basis on HIV/AIDS in Georgia does meet the international standards. For future active and effective anti-HIV/AIDS campaign it is necessary to follow the law in a strictly defined manner. Assuming economic and social reality of the country, the law does not include any specific articles limiting the disease control and prevention processes.

Draft law on "STD prevention" aiming to regulate the behavioral standards of HIV/AIDS high-risk commercial sex workers is awaiting the Parliament's approval.

Absence of the law on prostitution impedes implementation of effective preventive programs among the high-risk groups. For this reason it is necessary to strengthen existing legislative base and bring the legislative acts in compliance to each other.

Georgian health care system before 1991 was the part of Soviet system containing principal features of that system, which provided primary health care through a system of village clinics and ambulatory to all areas and sections of the population. Old system is destroyed and the Reform in Health System has just begun. By this reason Georgia has not been able to provide prophylactic examinations, free medical treatment, which was standard during the Communist era. Today there are no funds available for health education, prevention and examination. Therefore, morbidity caused by the disease, which could be avoided by prophylactic examinations (screening) and mass education (breast and cervical cancer, thyroid gland pathology), has highly increased.

Since 1998 all screening programs in the country have been stopped causing crucial situation concerning the breast and cervical cancer. Most of the patients apply to doctor, when they already have III-IV stage of pathology and surgical treatment is not effective.

Cervical cancer is a major health problem. It is a leading cause of cancer-related deaths in women in Georgia. Since 1997 screening examinations have not been practiced in the country, so we do not know the number of effected women, we only have information about how many women were operated in Oncological Center. During 1999-2003 years 1215 women were operated for cervical cancer. According to the Center for Medical Statistics and Information, during the recent 5 years 5,100 women died from cervical cancer in the country. There is an urgent need to find ways to reduce this coming burden.

The mortality and morbidity rate of the disease depends on early diagnosis. Before doctors started to use the Pap test in the 1950s, cervical cancer was the leading cause of death from cancer in women. In the United States the Pap test saves the lives of 70% of the women, who might have died from cervical cancer without this test.

Risk Factors for cervical cancer include a history of multiple sexual partners, early onset of intercourse, smoking, and infection with Human Immune Deficiency Virus and infection with a certain serotypes of the Human Papilloma Virus (HIV).

Women's Center health group understands that it is necessary to work in this direction according to the model of international standards and to implement their experience in their work.

By this reason in 2003 we became the member of European Cervical Cancer Association (http://www.ecca.fr). This organization aims to increase attendance for cervical cancer screening programs across Europe. We plan to use their experience and recommendations on Cervical Screening, their education programs and brochures in our work.

We acknowledge that in Georgia it is necessary to increase awareness of gynecologic screening procedures and to inform women about the risks of cervical cancer and its prevention.

Women’s Center has special program which in case of implementation can be used as a model in primary health reform.

According to the analyses of descriptive epidemiological data the following conclusions may be done. The women breast cancer is on the first place (ASR=10.6), skin cancer on the second (ASR=10.6), cervical cancer on the third (ASR=9.2. Most problematic is the fact that women apply to doctors, when they already have III-IV stage of breast cancer and surgical treatment is not effective.

The main reason of such situation is the absence of prophylactic examination and the lack of skills of breast self-examination among masses.

We are really very thankful to World Day Prayer German Committee, which has sponsored the project “Gift of Life” implementation of which saving the lives of thousand women.

Project Gift of Life gives possibility to organize a structure, which includes training of health care teams in 10 regions of Georgia including Adjara Autonomous Republic for conducting the medical examinations on cancer detection, to educate women about breast self-examination and to create a network of health care team-volunteers in each region. Informational brochures have been published not only in Georgian Language but in Azir, Armenian, Russian, and the necklaces showing the sizes of a tumor have been distributed.

Through publications in local newspapers we reach 80% of population of Georgia teaching them how to do breast self-examination.

For three-year period we have trained 600 medical staff and examined about 2030women.In the result of our campaign many cases of cancer were revealed in early stages.

Georgian National Breast Cancer Program covered 75% expenses for operation.

Georgia is a source and transit country for women and men trafficked for the purposes of sexual exploitation and forced labor. Victims are trafficked through Georgia from Ukraine, Russia, and other former Soviet republics to destinations such as Turkey, United Arab Emirates, Greece, Western Europe, and the United States.

Since 1998 we are working on the problems, which have not been studied and have been closed for open discussion. Women's Rights group of the Women's Center has been fighting against trafficking for 8 years. The survey conducted by the team revealed that trafficking as well as mass emigration of labor is closely linked to great hardships within the country. Although there are no official statistics and it is difficult to convince individual women to relate their experience, experiential data suggest that many women, who migrate abroad, particularly those who reside abroad illegally, are being exploited in the sex industry and other sectors. The team has prepared informational brochures for potential victims of trafficking and leaflets containing mail addresses and contact telephone numbers of the residences of the ambassador of Georgia in different States to be disseminated at the airports and other places, which are close to the State margins; they carried out social survey among the suppositional groups of heightened risk and provided the women from the group of heightened risk and general public of Georgia with the necessary information. The analysis show that the problem of trafficking is existing in Georgia in an obscured form (OSI, Mama-Cash)

They have also conducted meetings with many groups in the region and revealed that people have no information about trafficking and there are a lot of tourist agents, who visit villages and invite young girls to work abroad and take children for adoption. Nobody knows what happens with the girls who go abroad to find "beautiful" life and disappear (In the regions they can’t watch TV due to energy-crisis, have no communication by telephone as the lines are distorted).

Their analysis show the necessity to set up comprehensive network outside Tbilisi (capital of Georgia), which will work for protection of women’s rights, for increasing the awareness in women, especially young women, who are vulnerable to traffickers in women and prostitution and children for adoption.

In 1999- 2001 with the help of Global Fund for Women, Mama-Cash, Haella Foundation, the trafficking prevention network was created in 6 regions of Georgia through seminar-training and a local working group was established. Today local regional group delivers consultations and lectures about trafficking at schools and Institutes.

In 2002 as the representatives of the "mother country" we were invited to take part in international project "KIDSNET" - Stop Child Trafficking.

For our shame we don't have any information about this problem and we think that it doesn't exist. We try to get some information about it but the problem of child trafficking is most invisible in Georgia. Only in the report of Wold Bank, IMO we find information that street children in the age of 6-16 years are used for sexual exploitation and are taken to Turkey.

In the KIDSNET project we work together with international partners: KIDSNET FORUM (Austria), ECPAT (Germany), E.V.A. (Italy), RESEARCH and SUPPORT CENTER (Greece ), RADDA (Swish), GENDER RESEARCH FOUNDATION (Bulgaria), THE WORLD OF WOMEN (Ukraine). A transnational network was created to exchange information. As a complex qualitative effect, from international cooperation we achieved the increase of knowledge of the phenomenon, collection and diffusion of well documented information, adoption of appropriate interpretative outlines and conceptual tools.

Today many NGOs work in Georgia on the problem of awareness of trafficking and psychological consultations but no one organisation works on the medical problems of victims.

Unfortunately, there is no organization in Georgia, where sexually abused, harassed or otherwise victimized women can apply for medical help. There have never been carried out any training for medical and social workers.

Our experience shows that active involvement of medical authorities in prevention of trafficking and treatment of the victims is necessary. We want to fill this loophole by creating educational and health care consulting center to train health care professionals dealing with health problems of trafficked women and children.

Since 2002 we are working with American Bar Association on trafficking issues. We are the member of NGOs’ Roundtable dedicated to human trafficking matters and also a member of inter-agency working group, which has drafted Human Trafficking legislation for Georgia and submitted to the Parliament.

On January 17, 2003 the President of Georgia approved the Action Plan to Combat Trafficking (2003-2005).

On the basis of the Action Plan a Department for trafficking prevention was formed in the Ministry of Internal Affairs of Georgia. The Department will collaborate with INTERPOL and local NGOs working on this problem.

The government took steps to implement its several commitments. It established and adequately supported a new police anti-trafficking unit, replacing the previous administration’s disfunctional anti-trafficking unit under the Ministry of Interior Affairs. In addition, the government revised and publicly endorsed a comprehensive National Action Plan, appointed a primary point of contact for trafficking, and established an interagency commission. A few victims have been identified for protection and assistance. But government take proactive steps to fully implement its action plan, implement and formalize a victim referral mechanism with NGO assistance, ensure increased victim identification, and continue special law enforcement training programs. In addition, the government should ensure that up-to-date, comprehensive law enforcement statistics are collected and disseminated, perhaps via the interagency commission on trafficking.

Prosecution

In January 2005, the government established and adequately funded a new anti-trafficking unit with a staff of 49 people operating in Tbilisi and throughout Georgia. In its first few months the unit investigated 13 cases and arrested 30 traffickers. In one case, the unit arrested some members of an international ring operating in Georgia, Turkey, and Azerbaijan and shared information with law enforcement counterparts in Azerbaijan and Turkey to identify and arrest the Azeri and Turkish traffickers. In 2004, three traffickers were convicted and sentenced to 8 - 12 years’ imprisonment. The Ministry of Justice has also drafted a new law in collaboration with a legal NGO to address deficiencies in current legislation, particularly to release victims from criminal liability and assure the right to refuse to give evidence or testimony. Furthermore, the government increased its recognition of trafficking-related corruption and took some action against complicit officials. In August 2004 and February 2005, the government arrested and charged three passport officials facilitating trafficking.

Protection

The government established and successfully implemented a policy to protect the identity of trafficking victims. In one case, in early reporting period, police investigators verbally mistreated victims during initial interrogations. The Police Academy has since instituted formal trafficking awareness and sensitivity training for all new officers. Since January 2005, the new anti-trafficking unit successfully identified 15 victims and informally referred them to temporary shelter and other resources.

Prevention

In 2004, the government initiated some anti-trafficking public awareness efforts and continued to participate in prevention programs including the airing of public service announcements with NGOs and international organizations. Senior government officials spoke out about trafficking and the government’s new action plan. Although the government has not yet allocated specific funds to implement the new action plan, several ministries redirected funds from their budgets to underwrite anti-trafficking efforts. The government upgraded and enhanced the security features of Georgian passports to render passport fraud more difficult. After the discovery of four trafficking victims recruited from a specific area, the anti-trafficking unit proactively disseminated information in the neighborhood and in local colleges and schools to educate and prevent possible further victims.

(Released by the Office to Monitor and Combat Trafficking in Persons, US Department of State June 3, 2005)

Definition of human trafficking

In 2000, the states of the world have signed in Palermo the Protocol to Prevent, Suppress and Punish Trafficking in Person, Especially Women and Children, supplementing the United National Convention against Transnational Organized Crime which contains a legal definition of trafficking in human being.

The criminal Code of Georgia

Georgia doesn’t have a separate law on trafficking in human beings, Criminal Code of Georgia, as amended on 6 June 2003, includes article 143 (one and two) criminalizing trafficking in human being and trafficking in children.

Pursuant of Article 143-1

Trafficking in human being means the selling or buying a human being or making any other unlawful transaction in relation to him/her as well as recruitment, transfer, hiding or harboring a human being to means of coercion, blackmail or deception for the purpose of his or her exploitation.

Purpose of the crime, similar to that contained in the Palermo, protocol definition, is exploitation of human being.

Domestic violence is a global problem that occurs regardless the culture, ethnicity, orientation, or socioeconomic class. Georgia isn’t the exception. Domestic violence has been a tabooed topic in Georgia as deliberation on this issue was regarded as interference into the private life and, therefore, it was unacceptable.

Now Georgia is considered as young democratic country with political plurality where women have already been taken active social positions in each field of problems. The fact that domestic violence is not spoken openly does not mean that it doesn’t exist. Today this ice is broken and the non-stop work of many NGOs for several years has given the result.

In 2000, the president of Georgia approved “The Action Plan on Combating Violence against Women” which is extended up to 2005. Besides domestic violence the action plan embraces some other aspects of violence against women as well (trafficking, ecological and ethnical violence). In the implementation of action plan there are involved Ministry of Internal Affairs, The Prosecutor’s Office, the Statistic Department, the Office of Public Defender, Ministry of Health and Social Protection and NGOs.

With the help of OSCE-ODHIR and OSI – Georgia Foundation the NGO “Pioni” has set up an Anti-Violence Regional Network working on prevention of domestic violence and providing a shelter for the victims. Another NGO “Saxli“ works on psychological consultation of victims, also with the support of OSCE-ODIHR. “Caucasus Women Research and Consulting Center” works on the training of police, lawyers and governmental representatives., Women’s Center works with health care providers and in future plans to work with victims .

Women's Center has been working on the problem of domestic violence since 1998. From 1998 till 2001 we took part in training’s, conferences and share experience of other countries visiting their shelters, consulting and medical centers. The result of one-year work of hot-line revealed that domestic violence influences the health of women, who require not only psychological but also medical help (Mama-Cash-1999).

In 2002 our organization with the support of ODIRH and East-West Women translated and published the book "State Responses to Domestic Violence: Current Status and Needed Improvements”, which became the handbook for NGOs working in this direction.

In 2003 we implemented project "Psychology and Social Responsibility Facing Violence". The workshop was a part of a long-term strategic approach to prevention of domestic violence through education and enhancement of the problem awareness problem among regional coalition group, Women’s Leadership Coalition group, among the women at the decision-making level in Parliament, in government structures and in political parties. Training was led by the trainers from the School for International Training Dr. Paula Green., Dr Olivia Drier, USA (OSCE/ODIHR -Gender Unit - Karuna Center, USA).

Today, together with ABA we work on creation of comprehensive domestic violence legislation that specifically criminalizes and prohibits violence against women. This legislation will define the broadest range of domestic violence, including psychological and sexual violence and traditional practices condoning violence.

In 2004, we implemented the project "Building Bridges between Domestic Violence Advocates and Health Care Providers" (OSCE / ODIHR).

We are the first in Georgia to raise awareness of domestic violence among health care practitioners through training of 300 physicians from 20 medical institutions in Tbilisi. We have published the books, “Domestic Violence: The Health Sector Responds”, “Medical Aspects of Domestic Violence“, which have become the handbooks not only for doctors but for NGOs working on this problem. We’d like to express our gratitude to OSCE-ODIHR for support us in implementation this work.

Our experience shows that health care professionals are general obligatory persons with whom the women suffering from the effects of domestic violence may contact. These practitioners need guidance to develop a pragmatic and sensitive approach to recognition of violence and care for victims.

Education and campaigns are necessary to raise the health care professionals' awareness of violence against women but not as a one-time activity. It is necessary to establish the training center for doctors and nurses.

Criminal Code of Georgia

The Georgian legislation does not treat domestic violence as a separate crime, though the Georgian Criminal Code criminalized a number of actions, which are constituent components of domestic violence. Relevant articles of the Code are structures in way that they criminalize the acts contained therein without distinguishing on the basis of family membership. This is the positive side of the Code, as legislation of many countries does not recognize a series of criminal acts committed by family members as crimes.

This chapter discusses the Criminal Code articles by the types of violence: physical violence: beating, torture, deliberately inflicting serious bodily injury, deliberately inflecting less serious bodily injury, inflicting bodily injury with lethal result, deliberately inflicting minor bodily injury, murder, and murder committed in aggravating circumstances.

Physiological violence: physiological coercion, threatening, and driving a person to suicide.
Sexual violence: rape, coercive action of sexual character, compelling to sexual intercourse or to other action of sexual character.

Crime against personal liberty: unlawful deprivation of liberty.

Crimes against person security: infringement upon a personal family secret, interference with the secrecy of private conversation, interference with the secrecy of personal correspondence, telephone conversation, interference with the inviolability of dwelling or other premises.