Sexual and Reproductive Health and Rights F.A.Q.

love yourselfSexual and Reproductive Health and Rights is an area where, unfortunately, there is a lot of misunderstanding and misinformation floating around. In this section we have tried to provide objective information about this subject, including links to reference material. Some of the information is specific to Malta, such as where laws are concerned, some is more universal.

Since this topic is closely linked with personal ethical values, we do not try to say what is right or wrong, but rather what are the facts, so that every individual can form an opinion based on reliable information.

This section of our website is by no means exhaustive, since we did not try to duplicate information already found elsewhere, such as the government's Sexual Health website which contains useful information on many aspects of sexual health. The site is more concerned with information which, for political or other reasons, might not be available on official sites.

Always consult a medical professional before using any medical products


Sexual & Reproductive Health

What are Sexual & Reproductive Health & Rights?

Sexual Health

A state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.
Reference: WHO 

Reproductive Rights

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 the right to make decisions concerning reproduction, free of discrimination, coercion and violence, as expressed in human rights documents. Reference: UNFPA

Reproductive Health

Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition is the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility. Reference: UNFPA 

Sexual Rights

Sexual health cannot be achieved and maintained without respect for, and protection of, certain human rights. The application of existing human rights to sexuality and sexual health constitutes sexual rights.
Rights critical to the realization of sexual health include:

  • The right to privacy
  • The right to equality and non-discrimination
  • The right to information, as well as education
  • The right to the highest attainable standard of health (including sexual health) and social security
  • The right to marry and to found a family and enter into marriage with the free and full consent of the intending spouses, and to equality in and at the dissolution of marriage
  • The right to decide the number and spacing of one’s children
  • The rights to freedom of opinion and expression
  • The right to an effective remedy for violations of fundamental rights.

The responsible exercise of human rights requires that all persons respect the rights of others. Sexual rights protect all people’s rights to fulfil and express their sexuality and to enjoy sexual health, with due regard for the rights of others and within a framework of protection against discrimination. Reference: WHO

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Contraceptives in Malta

Most contraceptives, except emergency contraceptives, are available in Malta.

Condoms are easily available from most pharmacies and supermarkets, and have the important added advantage of offering protection against sexually transmitted infections, apart from being effective contraceptives.

Some medical contraceptives may require a prescription. Consult the doctor or pharmacist before using a medical contraceptive for the first time.

Long-term contraceptives such as the copper IUD and coil are available. Consult your gynaecologist about this option.

Information about other methods is available on this website: http://sexualhealth.gov.mt/content/contraception/

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Can a woman get emergency contraceptives (“morning-after pill”) in Malta?

Note: A judicial protest has been filed by the organisation Foundation for Women's Rights to make the emergency contraceptive available in Malta, so the situation described here could change rapidly.

Although there is no law explicitly declaring emergency contraceptives to be illegal, all medicines must be authorised by the Medicines Authority before they can be imported, and so far they have refused to authorise any emergency contraceptive pills. The National Commission for the Promotion of Equality has stated that the lack of access to the ECP is discriminatory against women.

Note: The term "morning after pill" is being phased out in favour of "emergency contraceptives" because modern ECs function up to 5 days after.

WARNING: Taking excess doses of regular medications is not recommended.

There are actually medicines legally available in Malta that have the same active ingredient as the emergency contraceptive pill. For instance, Esyma which is prescribed for uterine fibroids contains 5mg of ulipristal, the same active ingredient used in the emergency contraceptive EllaOne, though the latter contains 30mg.

More information about emergency contraception is available on a number of sites including this one from Princeton University.

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Are the Morning-After Pill and the Abortion Pill the same?

No, they are very different products.

Emergency Contraception ("morning-after") Pill

The morning-after pill works by preventing an egg from being released by the ovaries. In short, it prevents fertilisation from taking place.

Contrary to claims made by certain groups, a study on the effects of the emergency contraceptive shows no indication that the emergency contraceptive can prevent implantation of an egg once it is fertilised.

Once a fertilised egg implants in the uterus wall, the morning-after pill is ineffective. This is why it is categorised as an emergency contraceptive. The most common emergency contraceptive pill is effective up to 5 days after having unprotected sex - so the term "morning after" is being phased out since it's rather misleading.

Here is a video giving a short description of emergency contraception and how it works.

Abortion Pill

The abortion pill is something else entirely. These are two pills - mifepristone and misoprostol - that are taken up to 70 days after a woman's last period. Unlike the emergency contraceptive which prevents pregnancy, the abortion pill terminates the pregnancy. This type of abortion is often called a "medical abortion" as opposed to surgical abortion, since it involves no surgery or similar interventions.

The abortion pill is illegal in Malta, while emergency contraceptive pills have not yet been authorised.

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Can the Morning-After Pill cause an abortion or prevent egg implantation?

No.

Some groups expressed concerns that the emergency contraceptive pill could prevent a fertilised egg from implanting in the uterus, or even cause an abortion, however this was found not to be the case.

So why do some ECP labels say that it might?

On the 28th July 1999, the American medicines authority, the FDA, approved the packaging, labelling and information leaflet for "Plan B", an emergency contraceptive pill. Since, in 1999, nobody was sure about the mechanism of action of these pill, the FDA required that all conceivable possibilities be listed - including the possibility that the pill somehow prevented the fertilised egg from being implanted. In fact, the wording used was that the pill might act in these ways. The FDA's Medical Review even notes the fact that "the primary difficulty with the label is that this is the first product to be approved by the FDA that is a progestin-only for contraception", so they took warnings from several other contraceptives and medicines, preferring to be extra cautious and include more warnings than less.

Since then, many studies have been performed to determine the precise mechanisms, and the prevention of implantation was excluded. In fact, the US' National Library of Medicine website has already corrected the description of the emergency contraceptive pill to remove the misleading statements.

Other statements from recent scientific studies include:

"Recent evidence suggests that UPA modulates human sperm functions while it has no effect on established pregnancy. To date the majority of the evidence concurs in excluding a post-fertilization effect of UPA"
Mechanisms of action of oral emergency contraception, Gynecological Endocrinology, 30:10, 685-687 (2015)

"Neither LNG nor UPA impairs endometrial receptivity or embryo implantation. Correct knowledge on the mechanism of action of ECPs is important to avoid overestimating their effectiveness and to advise women on correct use."
Kristina Gemzell-Danielsson, Cecilia Berger & P. G. Lalitkumar (2014)Mechanisms of action of oral emergency contraception, Gynecological Endocrinology, 30:10, 685-687 (2014)

"Some studies have shown histologic or biochemical alterations in the endometrium after treatm ent with the regimen, leading to the conclusion that combined ECPs may act by impairing endometrial receptivity to subsequent implantation of a fertilized egg. However, other more recent studies have found no such effects on the endometrium."

"Inhibition or delay of ovulation is LNG ECPs principal and possibly only mechanism of action; Review of the evidence suggests that LNG ECPs cannot prevent implantation of a fertilized egg. Language on implantation should not be included in LNG ECP product labeling"
Mechanism of action. How do levonorgestrel-only emergency contraceptive pills (LNG ECPs) prevent pregnancy?
International Federation of Gynecology & Obstetrics (2011)

Notes

The Copper IUD, which is legal in Malta, as well as the regular contraceptive pill, could prevent the implantation of the fertilised egg.

Note that under normal circumstances and without any human intervention, it is estimated that around half of all fertilised eggs fail to implant and are discarded by the body when the woman next has her period, and go unnoticed.

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Gamete? Embryo? Fetus?

Discussions about pregnancy often involve biological terms that some might not be familiar with. Here's a summary of the most common ones.

The sperm and egg are called gametes. They are haploid cells - that is, cells with half the normal amount of DNA.

Once they join and the DNA merges (and thus becomes a diploid cell) it’s referred to as a zygote.This is the "fertilised egg".

When this cell starts dividing it is referred to as an embryo, right up to the 8th week, after which it is referred to as a fetus. A blastocyst is an embryo plus its placenta and umbilical cord, all of which come from the same fertilised egg.

The embryo will embed into the uterus walls typically around 7 - 10 days after fertilisation. This is considered to be the start of pregnancy.

 

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When does science say that life begins?

The short version: It doesn’t.

Science can tell when fertilisation occurs, when implantation occurs, when there’s a beating heart, when a fetus becomes viable, when there’s a functioning higher brain, when the quickening occurs, and of course when birth occurs, but it does not state which of these milestones constitutes “the beginning of life”.

Individual scientists may of course have their own opinions on this matter, as well as personal religious views.

This question is not really a scientific question but more of a philosophical one. Opinions may and do vary, not only among scientists but among philosophers, religious people and so on.

Some points to consider

  • From a biological perspective, the fertilised egg is alive - but then so are the unfertilised egg and the sperms.
  • The fertilised egg has different DNA than either parent, however identical twins have the same DNA and they’re still distinct individuals.
  • An embryo can divide into two and form identical twins up to 15 days after fertilisation. If life begins at conception, where did the second life come from?
  • It is estimated that, under normal circumstances, around half of all fertilised eggs don’t implant in the uterus and are flushed from the body when the woman next has her period.

Articles

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Pro-choice? Pro-abortion? Pro-life?

The term pro-choice refers to the position that the owner of the womb chooses how and when it is used. This means that if the woman does not want an abortion she should not be forced to have one, and if she does want it she should not be prevented from doing so. Many pro-choice people do not subscribe to the belief that life begins at conception.

It is possible to be pro-abortion, and some people believe that there’s an overpopulation problem and are literally in favour of abortion to keep the population down, but this is a very different position from pro-choice, and rather uncommon.

Pro-life typically means that the individual believes that life begins at conception, and that once life has begun, the fetus has a right to life, which places an obligation on the woman to at least reach viability and give birth. Some opponents object to the title “pro-life” since they consider both sides to be equally pro-life (they just disagree on when that life begins). Others point out an apparent inconsistency since many who use the title pro-life are also in favour of the death penalty and tend to be war supporters.

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Is abortion legal in Malta?

No.

In legal terms, the criminal code allows no exception whatsoever - not if the woman’s life is in danger, not if the fetus cannot survive after birth, nothing. In fact, in the English version of the law, the term used is “miscarriage” - anything that causes a miscarriage is a crime. There are prison terms for the woman as well as any medic involved - the latter could also be permanently banned from practising medicine.

In practical terms, doctors will do what is necessary to save a woman’s life if need be, and then nobody says anything to anyone. There have even been cases where the police were told about someone having a life-saving abortion and they refused to prosecute.

However doctors are operating in a legal limbo and have no guarantee that the police will not one day launch an investigation and press charges.

Medics who believe that someone got an abortion or attempted one do report the woman to the police. There was a suggestion in parliament (which was subsequently shot down) to prevent pregnant women from leaving the country if it’s suspected that they might get an abortion abroad, and there was indeed a case when this happened. This happened before Malta joined the EU and Maltese women were guaranteed freedom of movement.

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What does the law actually say?

Articles 241-244 of the Criminal Code say the following:

241. (1) Whosoever, by any food, drink, medicine, or by violence, or by any other means whatsoever, shall cause the miscarriage of any woman with child, whether the woman be consenting or not, shall, on conviction, be liable to imprisonment for a term from eighteen months to three years.

(2) The same punishment shall be awarded against any woman who shall procure her own miscarriage, or who shall have consented to the use of the means by which the miscarriage is procured.

242. If the means used shall cause the death of the woman, or shall cause a serious injury to her person, whether the miscarriage has taken place or not, the offender shall, on conviction, be liable to the punishment applicable to wilful homicide or wilful bodily harm, diminished by one to three degrees.

243. Any physician, surgeon, obstetrician, or apothecary, who shall have knowingly prescribed or administered the means whereby the miscarriage is procured, shall, on conviction, be liable to imprisonment for a term from eighteen months to four years, and to perpetual interdiction from the exercise of his profession.

243A. Whosoever, through imprudence, carelessness, unskilfulness in his art or profession, or non-observance of regulations, causes the miscarriage of a woman with child, shall, on conviction, be liable to imprisonment for a term not exceeding six months or to a fine (multa) not exceeding two thousand and three hundred and twenty-nine euro and thirty-seven cents (2,329.37).

In Maltese

241. (1) Kull min b’ikel, b’xorb, b’mediċini, jew bi vjolenza, jew b’kull mezz ieħor, jikkaġuna l-abort ta’ mara tqila, sew bil-kunsens kemm ukoll mingħajr il-kunsens tagħha, jeħel, meta jinsab ħati, il-piena ta’ priġunerija minn tmintax-il xahar sa tliet snin.
(2) L-istess piena tingħata kontra l-mara li tikkaġuna l-abort fuqha nfisha, jew li tkun qagħdet għall-użu tal-mezzi li bihom l-abort ġie ikkaġunat.
242. Kemm-il darba l-mezzi li jsir użu minnhom jikkaġunaw il-mewt tal-mara jew ħsara kbira fuq il-persuna tagħha, sew jekk l-abort isir kemm jekk ma jsirx, l-akkużat, meta jinsab ħati, jeħel il-piena stabbilita għall-omiċidju volontarju jew għall-offiżi volontarji fuq il-persuna, imnaqqsa minn grad sa tliet gradi.
243. Kull tabib, kirurgu, ostetriku jew spiżjar illi xjentement ikun wera jew ta l-mezzi li jkunu ikkaġunaw l-abort, jeħel, meta jinsab ħati, il-piena ta’ priġunerija minn tmintax-il xahar sa erba’ snin u l-piena tal-interdizzjoni perpetwa mill-eżerċizzju tal-professjoni tiegħu.
243A. Kull min, b’nuqqas ta’ ħsieb, bi traskuraġni, b’nuqqas ta’ ħila fl-arti jew professjoni tiegħu, jew b’nuqqas ta’ tħaris ta’ regolamenti, jikkaġuna l-abort ta’ mara tqila jeħel, meta jinsab ħati, il-piena ta’ priġunerija għal żmien ta’ mhux iżjed minn sitt xhur jew multa ta’ mhux iżjed minn elfejn tliet mija u disgħa u għoxrin euro u sebgħa u tletin ċenteżmu (2,329.37).

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Is Abortion a Right?

While you will not find an explicit mention of abortion as a human right in any treaties and documents that confer these rights, just as you will not find a mention of eating and drinking as a human right, it has been confirmed by many bodies that restricting access to abortion is a breach of a woman's rights.

  • On the 9th June 2016, the United Nations' Human Rights Committee found that Ireland's restrictive abortion laws are a breach of human rights, subjecting women to "suffering and discrimination". Read more here.
  • In November 2015, Northern Ireland's High Court ruled that N.Ireland's abortion law breaches Article 8 of the European Convention on Human Rights. Read more here and here.
  • See also: Safe and Legal Abortion is a Woman's Human Right (PDF)

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Can a woman get an abortion pill in Malta?

The abortion pill is not legal to buy or use anywhere in Malta, although a number of international organisations including Women on Web and Women Help Women are known to send abortion pills to all countries by post.

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Can a woman get an abortion abroad?

It is legal to have an abortion in a country where abortion is legal. Freedom of movement laws mean that a woman cannot be prevented from leaving the country.

Most Maltese women who need an abortion get it done in the UK or Italy. The only country providing statistics is the UK, which shows that the number of women from Malta having abortions there is in the vicinity of 50 per year, peaking at 78 in 2009.

Costs of abortions vary, but generally become more expensive the later it is in the pregnancy.

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Are abortions safe?

Both abortions and childbirth carry some risks. Abortions are actually safer than childbirth (when done in a proper hospital or clinic). Abortions are safer the earlier they occur. Obviously, clandestine abortions carry very serious risks, whether “home made” or backalley abortions.

There is serious concern that the requirement in Malta for medical practitioners to report women who attempt abortions to the police will discourage them from seeking medical help should they need any, which places increased risk on women's lives.

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Does a woman suffer emotional problems after an abortion?

The most widely-reported emotion felt by women after having an abortion is relief. In a study by the University of California, 95% of all women felt it was the right decision. Even among women who reported negative feelings, 89% still felt it was the right decision to make. By comparison, women who were denied an abortion due to legal restrictions reported anger and regret.

A 2010 study of women in Ireland found that 87% of women who had an abortion felt it was the right outcome for them.

The emotions felt by women vary greatly from one person to another, and are likely to be influenced by one’s religious or cultural background, as well as the circumstances leading to the abortion. An unintended miscarriage tends to produce more negative feelings than an abortion. A late abortion or miscarriage can also cause symptoms similar to post-natal depression, and for the same reasons. This is usually short term but, like post-natal depression, can also persist.

Other factors influencing women’s emotions are, whether they receive support from others, whether they receive judgemental treatment, whether the abortion was due to an unwanted pregnancy or a severe deformity in the fetus, etc.

No comparable information exists for Malta.

More reading:

 

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What is the MHA’s position on the ECP, abortion, etc?

MHA is in favour of the introduction of Emergency Contraceptive Pills.

See our press release supporting the Women's Rights Foundation.

MHA has not taken a position on abortion, in part due to different opinions among our members. However we have supported a call for a mature discussion on the subject.

See our press release.

MHA has expressed its support for IVF, including the use of embryo freezing.

See our press release.

Note: The Malta Humanist Association is non-dogmatic, and our members can have and express positions different to these.

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