I have been asked to talk with you today about cross cultural issues in the delivery of Natural Family Planning (NFP) services. As an anthropologist, I interpret this task as talking about '’culture'', and the relationship of NFP teaching to "culture change".

There are many definitions of culture. The one I will use today is commonly accepted in the science of anthropology: Culture is the knowledge that people use to interpret experience and generate social behavior.

Culture is what people know, what they think, and what they do. When we say that "my culture is different from yours", we are really saying that I have learned different things, I interpret experience differently, and, as a result, I behave differently.

Relevant to our topic today - people learn from a variety of sources about gender roles, about topics that are alright to talk about and topics that are not, the structure and function of families, the role and value of children...the list goes on.

People who live in the same community - whatever we identify as a community - tend to learn similar things. They interpret their experience similarly - or at least within a fairly restricted range, and they tend to behave similarly -- again, within the range of what is considered by others with whom they interact to be appropriate behavior.

But culture is not static.

Each culture is - to one degree or another - constantly changing. A culture changes when people learn new things, have different experiences, and consequently behave differently. Cultural factors, and culture change, are an integral part of our thinking about NFP services.

The Institute for Reproductive Health is part of the Department of Obstetrics and Gynecology at Georgetown University, and we are supported in our work by a grant from the United States Agency for International Development. The Agency for International Development is much like your ODA, in that its purpose is to work in developing countries.

Thus, our work focuses on the developing countries in Latin America, Africa, and Asia, involving us in a wide variety of different cultural settings - each with its own unique experiences, beliefs, and behaviors. Because of this, we need to be particularly sensitive to cultural differences and issues.

Given the fact, however, that my own country and yours are composed of people from very different backgrounds, many of the same issues we consider in working in developing countries need to be considered in our countries as well.

I have interpreted my task here from two perspectives.

One is the scientific, objective perspective of analyzing how cultural beliefs and culturally-defined gender roles are reflected in the way in which NFP services are, or should be, provided.

The second perspective is somewhat more subjective, although it too is based on science.

This second perspective considers what would need to happen -what we would need to do - given the fundamental role of culture - to expand acceptance and use of NFP and increase its impact.

We find from the anthropological literature that there are substantial differences among cultures regarding the appropriate roles of men and women in society and in the family, and regarding the appropriate interaction of men and women in both public and private spheres.

Women are variably regarded as nurturers who care for their families and essentially ‘make a house a home’, as keepers of tradition and virtue who must be protected so they will not be contaminated by outside influences, as weak but virtuous and subject to violation by men whose sexual drive is uncontrolled, as temptresses who endanger the morality of men, as the property of their husbands and his family, as partners with men, or as strong, competent people with the ability and the right to make decisions and act on their own.

Men, meanwhile, are regarded as protectors of and providers for their families, as powerful beings who can and should control women, as weak (at least morally) and unable to resist the temptation of women, as having strong sexual needs (although sometimes this characteristic is considered a sign of a man's weakness because he cannot control his desires and sometimes as an extension of this strength), as men responsible for protecting and leading women, etc.

While the roles of men and women are different in different cultures and at different times throughout their lives, and while there are individual examples of women in public leadership roles, in most cultures around the world the role of the man is to lead and dominate and the role of the woman is to follow and submit.

In some cultures, this is changing - and changing rapidly - but this remains the standard of the power relationship between the sexes in most cultures.

We also find differences in how people regard children - sometimes as a marker of the mother's adulthood or of the father's power, sometimes as future providers for their ageing parents, sometimes as a blessing, sometimes as burdens on a family trying to survive in a difficult political, economic, emotional, or physical situation.

From the literature on culture change, we find that cultures change at different rates, and individuals who are considered part of the same culture change in different directions. Certain elements of a culture may change, while others remain as they were. These differing rates, directions, and elements of change often result in discord, either overt conflict or underlying tensions.

The cultural contexts in which NFP services are provided reflect all these cultural differences. The challenge to NFP services is to address them.

Reviewing the activities of NFP organisations around the world has led to some interesting conclusions about the ways in which NFP services are being provided, the cultural factors that affect the acceptance, or non-acceptance, of NFP, and the larger context of which NFP is, or is not, a part.

I present two of these conclusions for your consideration.

One has to do with adapting NFP services to meet the needs of clients.

The second has to do with the potential role of NFP as an instrument for culture change.

First: There are two primary ways of providing family planning services - not NFP services, but family planning services.

Now we all know that any time someone says "there are two ways" - that in fact there are many ways in between and that what is being described is only the extremes. I admit that that is what I am doing, describing the extremes. AIso, when you hear that phrase, you know the speaker believes that one of the ways is right and the other way is wrong. That probably also applies to this case as well.

In any case -- one of the ways to provide family planning services is what I will call the ‘control’ approach. It often uses ‘terrorist’ tactics to frighten people and shape their behavior, making them afraid of the consequences of behaving otherwise. This control approach is based on concerns that if fertility rates are not dramatically reduced, over-population will result in environmental degradation, mass starvation, and social anarchy. Its vocabulary includes ‘population control’ and ‘birth control’.

Concerns about the environment, scarce resources, and the social distress and unrest that is fueled by crowding, lack of employment, and other factors are valid concerns, and they require the attention of all of us. But they may not be the best basis for a family planning program.

Few people make family planning decisions on this basis, and a program that sees its mission as reducing fertility rates to avoid disaster is unlikely to meet the real needs of the people it is intended to serve. Fortunately, this control approach - which was common in the '70s and '80s, is much less common today.

Instead, the second approach, which I will call the ‘empowerment’ approach, is the basis for most current family planning programs. The empowerment approach to providing family planning services involves helping people meet their fertility goals by providing them with accurate, appropriate information; by listening to their needs and addressing them in an unbiased, respectful manner; and helping people make their own decisions about fertility and family planning.

Many people involved in NFP would say at this point, ‘Well, thank goodness -- we don't fall into the control category. At least we don't behave like terrorists. We are part of that second approach, the empowerment one’. I would reply to them, based on many observations, listening to many clients, teachers, and program directors, and asking the opinions of many prominent people involved in the field, that quite often, NFP services are offered within their own context of control, that sometimes even involves the use of terrorist tactics.

It may not be the same form of control - but it is control nonetheless.

Let me explain

There are programs whose agenda appears to be to promote NFP at all cost, without true scientific integrity or a desire to empower.

They want to control people, and in their desire to do so, they sometimes resort to terrorist tactics, or attempts to convince people to behave in a certain way through fear of behaving otherwise.

Reviews of outreach messages used by NFP programs to attract clients indicates that - and remember, I'm describing the extreme - it is not unusual for NFP programs to generate, and then capitalize on, fears about other family planning methods.

Addressing very vulnerable people - their clients, and others in the community who are potential clients or could otherwise be supportive of NFP - these programs make incorrect and purposely frightening statements about other methods of family planning, statements that are not borne out by scientific investigation.

Some programs attempt to terrify people and thus control their behavior by threatening them with ostracism from their church or even damnation, with little sense of compassion and understanding of the real life circumstances of the people they are attempting to serve.

Some programs attempt to control people by offering them false hopes. For example, they make claims about the effectiveness of NFP without considering the circumstances of the people who will be using it.

In counseling clients or in promoting NFP, these programs cite extremely high effectiveness rates that can only be achieved under ideal circumstances and reflect perfect use rather than actual use. This alienates the scientific community and, more importantly, gives couples unrealistic expectations about NFP and about themselves, leading to disappointment with the method and a sense of personal failure.

Some programs make another claim - perhaps one of the most dangerous of all - that by using NFP, couples can select the sex of their child. This claim is dangerous for two reasons. First, there is virtually no scientific evidence that supports it, so people's hopes are raised falsely. Second, the fact is that the vast majority of couples who want to select the sex of their child want to have a boy.

Offering NFP to help them achieve this in a sense ratifies their desire for a boy and contributes to gender bias, or bias against girl children. The pervasive strength of gender bias and its negative consequences for women and for society as a whole are dramatic. For NFP to be associated with promoting gender bias - as it is when it is promoted, albeit falsely, as a tool for sex selection - for NFP to be associated with promoting gender bias does not achieve positive personal or social goals.

There is substantial evidence that the control approach to NFP is perceived positively by only a small number of people and that it diminishes the potential impact not only of the programs that engage in it, but of NFP in general.

Specifically, it alienates the scientific community, it drives away many people who could otherwise be supportive of natural methods, and data shows us that this approach attracts only a relatively small number of users.

On the other hand, there are many examples of NFP programs that work very hard to be the second kind, or empowering kind, of provider that I described earlier - to provide their clients and the community with accurate information, and to engage in a counseling approach that empowers people to make decisions and to gain confidence themselves and in their ability to use NFP.

These programs, first of all, are grounded in science - the physical and mathematical sciences such as biology, physiology, and statistics, and the behavioral sciences, such as psychology and anthropology.

They present NFP positively but realistically, basing their statements about efficacy, about appropriateness, about NFP relative to other methods, on the results of objective data, scientifically collected, analyzed, and interpreted. They also ground their work in the behavioral sciences, respecting their clients' ability to learn, to interpret experience, and to make decisions about their own behavior. They are not always successful. Their biases slip in. They are not always aware of how people perceive them.

They sometimes are insensitive to the needs of people who may be different in key respects from the people who they consider to be the primary target of their program. But by and large, they offer NFP in a positive light, not a frightening one. This leads me to the second conclusion I would like to present to you today. This is a bit of a paradigm shift, but I hope to tie these conclusion together in a moment.

The second conclusion: To develop NFP services that truly meet the needs of the millions of women and men around the world who could benefit from them, we must address the culture and the conditions in which these people live.

There are a number of NFP programs around the world that have adapted their outreach and their teaching to what they understand to be the culture of the people they serve. There are many examples of this.

Western European cultures are very driven by science, so programs offer ‘scientific’ evidence about NFP and stress physiology to their clients.

Programs that serve rural people who have a close relationship to nature use various nature-based or agricultural symbols to describe the fertile and infertile phases of the menstrual cycle.

Programs that serve low-literacy people devise unique ways to describe fertility with images rather than words.

Programs that serve people they often describe as ‘ecological’ -people who are interested in environmental issues, natural child birth, natural foods, etc. -promote NFP on the basis of its naturalness.

There is no text book approach to NFP teaching that meets with the same success in all settings, and many programs have wisely and creatively adapted to their circumstances. This kind of adaptation is both admirable and necessary, and it should be encouraged. However, it is not the same as actual cultural adaptation. It does not address the very real needs and concerns of the people it serves - of the people it could serve. What appears to be the case is that the people who use NFP are simply different from others in their society in general.

In some ways they differ so significantly that anthropologists would identify them as belonging to a sub-culture - a term that applies to a group of people within a larger culture whose ways of interpreting experience and the social behavior this interpretation generates are recognizably distinct from, often even in conflict with, the interpretations and behavior of others around them.

When we have asked people to direct NFP programs in countries around the world to characterize the kinds of people their program serves, we have gotten some very interesting information.

They typically responded at first in terms of whether they were from rural or urban areas, whether they were educated or illiterate, Christian or Moslem, etc.

We probed further, and asked, "But what are they really like as people," and then, "Are they just randomly drawn to your program from all the people in the region you serve, or is there something different about them that attracts them to NFP?".

People we have asked have found this to be quite thought-provoking, and it elicited some very interesting information that was astoundingly similar among programs, given that these reports were from more than 20 very different countries.

What they said was, "Our clients are not necessarily more religious than other people, but they're more spiritual.

They're not necessarily better educated, but they're more open to new ideas.

In general, they aren't really driven by material goals.

They aren't as frantic about their lives as many people are today.

They seem to have more patience in their relationship with each other and with their children.

They aren't so irritable with each other.

Their lives seem calmer.

Their lives are better organized.

They share more with each other - the man isn't so concerned about controlling his wife."

Let's consider these characteristics in comparison to the concerns that have emerged from a series of consultations with governments and non-governmental organizations around the world, specifically those consultations conducted by the Independent Commission on Population and the Quality of Life, and at United Nations-sponsored conferences in Cairo and Beijing.

One virtually universal concern is domestic violence, particularly violence against women and children.

Another is the increasing lack of involvement and responsibility on the part of the father -with men abandoning their families in rural areas or impoverished countries to seek work elsewhere, often without providing financial or emotional support to the families they leave behind.

Another wide-spread concern is the emphasis on consumption and the consequent stress on families to make enough money to buy the accoutrements of ‘the good life’.

Another is the bias against women, evident from the previously-noted preference for male children, that often manifests itself in such a broad range of areas as neglect of girl children to lack of laws to protect women against violence or discrimination to informal, but obvious, limitations on women's education or employment opportunities.

These conditions are hardly compatible with the characteristics of NFP users described by our informants. A woman who is physically afraid of her husband is unlikely to be in a spiritual or calm frame of mind, much less be able to abstain from intercourse.

A women whose husband may leave her - if not for work in another country, then at least for another woman - is likely to be rather frantic and to have little patience.

A woman whose status is low in society and in her family is unlikely to have a husband who wants to share decision-making with her.

Clearly, these are conditions we would like to change, and I am sure that each of us, in our own way, is working on it. But there are two rather different arguments we could make based on the evidence of incompatibility of the characteristics of NFP users and the characteristics of the larger society.

One argument is that NFP is a mechanism for change - it is a way to reduce domestic violence, increase male involvement, increase couple communication and empowerment of women through knowledge of and the ability to control their own fertility, an opportunity to feed the spirit and reduce reliance on products.

Viewed from this perspective, NFP is an instrument for positive culture change. It is one small but important way to create a better world.

But the other argument is that what we have in NFP is a method of family planning that is wonderful for a few people, but simply isn't applicable to the millions of women and men who are living in the real world of violence, stress, materialism, and gender-based discrimination.

In other words, it isn't an instrument for change - it is simply irrelevant for the vast majority of people. Both arguments have their point.

I submit that if we are to accept the argument that NFP is an instrument for culture change, we must provide services not in the ‘terrorist’ context that I described earlier, but in the ‘empowering’ context.

Further we must make extraordinary efforts to reach the people who are not like those described by our informants - the people whose lives are characterized by stress, violence and uncertainty.

That is our challenge - to seek ways to go beyond ourselves and our experience, to reach those who really need our help - using NFP as an instrument of culture change.

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