Over the past 10 years, more than 1.5 million Colombians have been displaced within their country due to political and civil violence. The conflict in Colombia has continued for decades and many civilians in the rural areas -- caught between the armed forces, guerrillas and paramilitary groups -- have moved into urban areas, putting enormous pressure on an already overstretched health infrastructure. As a result, many internally displaced persons (IDPs) have no access to health-care of any kind.

Forced into hiding, the IDPs are unable to access services to which they are legally entitled for fear of drawing attention to themselves. IDPs frequently hesitate to apply for an identity card to avoid highlighting their displacement. Without an identity card, it is often not possible to obtain services such as schooling or access to health clinics. In some instances, IDPs have received special health-care cards, but these have not always been honoured when presented.

In Colombia, 58% of people forced to flee are women. Typically the decision to flee is taken when a husband, son, brother or father has been kidnapped or murdered. For rural women this trauma is compounded by the upheaval of migrating to an urban area, often as the head of the household, responsible for children and elderly relatives.

Sexual violence and reproductive health

Political violence has impacted directly on social and family structures, putting adolescent girls and women at greater risk of sexual violence and exploitation. For many women, the story is the same: left with no home, no income and continued threats against themselves and their families, they turn to menial jobs, sometimes turning to sex work to provide food for their families. Although the issue of sexual violence has not yet been officially documented, those who work with the displaced communities are aware of the high levels of sexual violence against women and girls. The struggle for food, health-care, shelter and the threat of violence also forces young girls into sexual relationships or marriage at early ages.

Violence and desolation among IDPs are undoubtedly leading to an increased number of unwanted pregnancies and abortions. In Colombia as a whole, every year there are an estimated 605,000 wanted pregnancies. In addition, some 275,000 pregnancies are unwanted because of ill-timing and approximately 230,000 are unwanted at all. The estimated number of abortions is around 350,000 per year; as abortions are illegal, more reliable data are not available.

Sexually transmitted infections (STIs) are a particular sexual and reproductive health problem among the displaced population. One of the main challenges for community instructors is to involve adult men in preventing pregnancies and HIV/STIs.

Offering an integrated reproductive health package

PROFAMILIA is working in collaboration with Marie Stopes International and the Reproductive Health for Refugees Consortium to provide an integrated package of services tailored to the needs of displaced communities. One component is the distribution of condoms, accompanied by information and educational talks about the role of correct use of condoms in preventing HIV/STIs. The talks stress safer sex, double protection (condoms as a contraceptive) and male participation. Participants in the talks receive two condoms and five brochures on STIs, HIV/AIDS, correct condom use, male participation and sexual and reproductive rights. Vaginal cytology consultations provide information and advice on the prevention of cervical cancer, STIs, HIV/AIDS and sexual rights. Considering the incidence of cervical cancer in the country, having regular pap-smears is encouraged. The services are offered at a low cost, usually within a community. Once test results are known, a community instructor explains the results to the individual. If an additional consultation is required, the community instructor organises a visit to the gynaecologist. Information is also given out on breast cancer and self-examinations. Prostate examinations for men over 40 years of age are included to detect and prevent prostate and testicular cancer. A third component comprises information, counselling and service delivery of a broad range of temporary and permanent family planning methods.

This integrated package helps to meet the needs for reproductive health-care of internally displaced women and men, young and old, living under difficult circumstances.