When the Means Become the Ends: The Sexual and Reproductive Health of Minority Women in Amsterdam
Flipping through a sex education booklet in the Netherlands school system today you find pictures and motifs much different from those of the 1990’s. Now the pages are filled with photographs of students from many ethnic backgrounds mingling around the bike racks or walking through the park. Dennis and Remco, a young white gay couple, are depicted next to a portrait of Nouzha, a teenage Muslim girl wearing the traditional hijab. Cindy and Roy, an interracial couple, debate the value of safe sex while lying in bed.
The change in the curriculum of sex education classes is one of the best examples of the efforts the Netherlands has taken to better address the health of its growing ethnic minority community. However, even with these changes, residents (including second and even third generation residents) of non-Dutch origin face poorer health outcomes across the board, including infant mortality, abortion, sexually transmitted diseases, diabetes, cancer, and self-reported quality of health.
Among these health related issues, the sexual and reproductive health of immigrant women may be the most important as it gives insight to the overall health of a population, its place in society, and the promise of future generations. In all cultures, women are at the center of society and represent the historical foundation for economic, political, and social strength.
When considering the sexual and reproductive health of women, there are many items to keep in mind. This report will overview the services and relatively recent adaptations within the Dutch healthcare system in Amsterdam specifically designed to address and protect the sexual and reproductive health of minority women (defined as women of non-Dutch origin) and evaluate the effect of these changes. The sexual and reproductive health of women includes topics such as sexuality, sexually transmitted diseases (STD’s), abortion and teen pregnancy, sexual abuse, and pregnancy and childbirth.
Over the last few decades the Netherlands has witnessed the immigration of over one million people from other nations, leading to a more diverse society with a greater range of healthcare demands and perspectives than ever before. Although recent restrictions on immigration have helped to slow the influx of foreign-born residents, the Netherlands, and especially Amsterdam, is still seeing its ethnic minority population grow. As shown in Table I, the ethnic minority population in Amsterdam is a heterogeneous mix of nationalities and cultures that now constitutes 47.3% of the city (compared to 33% in 1997). Although ethnic minorities may be becoming more integrated in Dutch life in some ways, new residents of Amsterdam still face barriers in accessing health services and resources and frequently suffer poorer health for it.
Table I: Ethnic Composition of Amsterdam, January 1, 2002
Origin Population % of tot. pop.
Suriname 71,979 9.8
Antilles 12,299 1.7
Turkey 36,035 4.9
Other S. Euro 17,414 2.4
Non- Industrialized 79,785 10.9
Industrialized 70,944 9.6
Dutch 387,694 52.7
Total 735,528 100
In 1982 the municipal health service (GG&GD) established the Voorlichting Eigen Taal en Cultuur (VETC) program nationwide as a corner stone in its attempts to aid foreign-born residents. The VETC uses trained healthcare workers of non-Dutch origin for educational outreach, translation services, and community-based efforts among minority populations.
Starting with a handful of Turkish and Moroccan female educators, the VETC began training men as well in 1985, and added other ethnic groups in 1995. Until 1999 the minority men and women were trained in translation services, and most importantly, in educational outreach and public speaking. After 1999 the VETC workers started to work with general practitioners and counsel foreign-born Dutch residents one on one. Starting just one year ago, the VETC workers began giving lectures out of community centers in addition to mosques. There are now 40 VETC workers in Amsterdam alone.
The VETC offers a wide array of services, including 39 different courses on themes ranging from drug use to childcare. Although no specific course focuses on sexual health and protection, these topics are woven into all of the courses offered by the VETC. As the VETC program has expanded and become more comprehensive for ethnic minorities, the educators have noticed changes among their communities.
In particular, they have noticed a shift in the discussions about sex in the homes of minorities. In the early 1990’s sex was a much more taboo subject for the immigrant families than it is now. According to Filiz Yildirim, a Turkish female VETC worker, “these days when children get sex education in the schools they become motivated to ask their parents questions at home. The parents do not always know the answers and so they turn to the VETC; this way they can still be involved in the sexual education of their children. We give them information about sexually transmitted diseases, sexuality, and other important issues. Now it seems that the families are more willing to discuss these things. It is like we are reaching the parents through their children.”
Looking to the future however, some VETC workers are worried that their effectiveness may be tarnished if the current government has its way. As of right now, the VETC workers see their educational programs as having a ripple effect. Said Haovam, a male Moroccan worker says “the people we educate talk to their friends who then also pass the information along so that the education extends farther than just us.” However, currently there are rumors that officials will force the VETC to only provide services in Dutch so as to supposedly expedite the integration process of new residents. The workers worry this will only push minorities out of the system even more and hurt their ability to effectively reach the immigrant populations.
One of the biggest challenges in terms of bridging multicultural gaps in any healthcare system is overcoming language barriers. When doctors and patients cannot communicate, a patient’s health is immediately jeopardized. Luckily in Amsterdam this problem has to a large extent solved itself. Most hospitals and emergency rooms are stocked with multilingual health professionals that cover the basic languages needed to communicate with most patients that come through the door. Patients also frequently bring relatives and friends with them to assist with translation. Although this can sometimes be problematic if a younger child is translating for more graphic situations, overall many doctors feel the translation is accurate and efficient.
In the case that doctors do reach a disjunction with patients to the extent that they cannot communicate effectively, the Dutch government created the TVCN phone translation service. Operators collectively speak scores of languages and are trained in specialties such as medicine or law. Doctors can call this free service on the spot or arrange appointments in advance. In the case that a doctor knows he or she will be working with multiple patients who speak the same language at a given time TVCN will send an actual translator to the location at the specified time. Although this system appears to function smoothly, most hospital workers and general practitioners avoid using the service as much as possible as it is often very slow and difficult to arrange. Even though it is more tedious, the TVCN service offers greater objectivity than acquaintance translators who are more likely to add subjective cultural nuances to a doctor’s orders and diagnosis, which may mislead a patient about their health.
Many doctors have noticed that female patients of non-Dutch origin (especially those of non-Dutch and non-Industrialized origins) prefer or request female doctors as well, especially for gynecological services. Some religions demand that women are not examined by men unless for urgent medical reasons, especially in the days around religious holidays. Some doctors also comment that translation in such cases is more successful with a female friend of the patient than a husband or son, as it sidesteps cultural taboos of some patients and also helps women to talk more openly about topics relevant to their sexual health. Even so, research shows that there is still cultural pressure on lay translators to have socially desirable answers, which may alter the communication between a doctor and his or her patient.
Most discourse surrounding immigrants in Holland focuses on Turks, Moroccans, Surinamers and Dutch Antilleans. However, there are also significant enclaves of residents from Somalia, Indonesia, Egypt, and other countries around the world that are facing a similar crisis- female genital mutilation (FGM). Although FGM is often perceived as a religious issue (even by those who practice it), it is actually a cultural habit that is frequently tied to religious practices.
Unfortunately, the Netherlands has been unable to obtain any hard figures as to the depth and severity of FGM within its borders. FGM is practiced almost universally in Somalia, and immigrants (from Somalia, Egypt, Sudan and Eritrea) to the Netherlands frequently bring this practice with them. However, Indonesian residents are quite resolute that they do not continue with such a tradition once in Holland. Regardless of how often FGM is practiced among particular ethnic groups, it is very private and quietly discussed. Because the procedures are never performed by Dutch healthcare professionals, (leading Dutch experts are not even sure if the practice is performed in the Netherlands or in the girl’s country of origin) it is impossible to know how many Dutch residents undergo the procedure each year. Anke Kwaak, a researcher on gender identity at Medical Center of Amsterdam, estimates that fewer than 100 girls are mutilated in a given year. In fact, she is adamant that although FGM remains a problem, it pales next to the much greater issue of sexual violence and abuse of young girls.
Ambiguity also surrounds the legality of FGM. Because there is no law specifically prohibiting the practice, ethnic minorities have used this wiggle room to continue the tradition. There are statutes within the Dutch criminal code that protect children from abuse, however the interpretation of such laws can be difficult, especially in terms of identifying the intent of the involved parents. Overall, none of the public health, medical, or governmental agencies in the Netherlands have been able to adequately address this issue. However, public health officials suggest that educational outreach about the practice and the harmful physical effects of FGM can help families choose to leave the tradition in the past.
Women’s history in any culture includes prostitution and this industry continues to affect their sexual and reproductive health worldwide today. Amsterdam hosts over 300,000 tourists a year, and a significant percentage are looking for sex. The advent of prostitution in Amsterdam coincided with the construction of the first port, and liberal Dutch social policy has sheltered the industry from prosecution, leading to global attention- and bigger business. According to the Mr. A. de Graaf Foundation, approximately 50% to 60% of all female prostitutes in Amsterdam are of non-Dutch origin, mostly from Eastern European, Latin American, and African nations.
The Netherlands does appear to excel in programs and social services available for female (and male) prostitutes. The STD Foundation of the Netherlands, the Mr. A. de Graaf Foundation, the GG&GD, and other agencies provide health, educational, and outreach services to prostitutes. Services are available in myriad languages and include free vaccinations, health literature, condoms (and other protective devices) and counseling (often by ex-prostitutes of non-Dutch origin). These programs have helped to support and educate prostitutes so that there is near 100% condom use.
According to the Prostitute Information Center (PIC), many agencies go out of their way to pre-test resources with immigrant women themselves. The STD Foundation has explicitly tried to involve minority women in designing pamphlets about sexual health. For instance, they found that Latina women prefer comic strip formats and Eastern European women prefer larger text panels and tailored their publications to each ethnic group’s preferences. By designing more effective pamphlets, agencies have guaranteed easier access to all female sex workers regardless of their nation of origin.
Although prostitution as a profession is perfectly legal in the Netherlands, many restrictions are placed on business establishments and the women themselves. All legal prostitutes must be at least 18 years of age and have a European passport. Anyone who does not meet these criteria is kept from participating in the system. Although this may superficially appear to protect young women, some advocates are concerned that the restrictions alienate younger and non-European sex workers from much needed social services, which are harder to access outside of the legal network.
In addition to legal prostitution, Amsterdam is affected by the illegal sex trafficking of young women, resulting in the creation of strict policies designed to facilitate the trials of offenders and often to expel the young women themselves from the Netherlands. After seeking assistance from the law, women are given three months to decide whether or not to press charges. If they decide not to press charges they are forced to leave the country in less than one month’s time. However, if they do wish to go to trial they are granted temporary resident status for the duration of the proceedings. After a verdict (of any kind) the women then must leave the Netherlands unless they wish to apply for asylum status through the standard process or are granted an exception and allowed to stay. Compared to other European nations, the Netherlands has the harshest record of granting exceptions, thus forcing most women to either leave the country or stay illegally.
Worldwide, forced prostitution most frequently involves foreign women, directly jeopardizing their sexual and reproductive health. Although illegal residents still receive services in the Dutch healthcare system, it is possible that young women who remain in the Netherlands illegally after being freed from sex trafficking networks may face greater difficulty in accessing the specialized care relevant to their particular needs.
Young women typically represent one of the healthier populations within society, however they have considerable exposure to the healthcare system during pregnancy and childbirth. Despite its comprehensive and universal healthcare system, the Netherlands persists in experiencing a high infant mortality rate (IMR) among its residents of non-Dutch origin.
One common explanation for a high IMR is the underutilization of pre and post-natal services. However many Dutch healthcare workers feel that minorities do benefit from these services as much as the traditional Dutch population. According to Filiz Yildirim, a VETC Educator, immigrant women utilize post-natal services as much as the typical Dutch population. W. Schilthuis at the GG&GD that although immigrants may start using pre-natal services later than the average Dutchman, they still receive the necessary resources in a timely fashion and do not receive substandard care overall. Even so, women of non-Dutch origin and their babies face greater rates of morbidity and mortality.
In Dutch society post-natal care usually includes 15 hours of in-home services known as “kraamzorg,” or “maternity care.” Amsterdam healthcare professionals visit the homes of newborns and assist families with household chores and baby care. They also give instruction and guidance on breastfeeding, childcare and maternal health. Minority women are the least likely to utilize this service. In part, this is because of greater participation by the extended family. However, some families may also feel tension with (strongly Dutch-oriented and seemingly inflexible) kraamzorg workers due to cultural differences in home maintenance and childcare. Whatever the reason, the result is that new mothers of non-Dutch origin may receive less education about baby and maternal care resulting in greater morbidity.
The lack of participation in kraamzorg services by minority families may be a glimpse of a greater problem of inflexibility by the Dutch healthcare system. An example involves an American-Canadian couple’s struggle with the Dutch healthcare system after having a baby. At home three hours after childbirth, the new mother still felt deep pain and experienced continuous heavy bleeding. Concerned, the couple contacted the hospital only to be told that “of course it hurts down there, you just had a baby.” The mother says that because she is American, the doctors assumed she was weak and there was not really a problem. After six hours they were finally allowed in the hospital whereupon doctors discovered a life-threatening hematoma.
The multicultural needs and differences of Western and European immigrants are often overlooked in the face of more “noticeable” differences between the Dutch and immigrants from Turkey or Morocco for example. However, similar complaints about cultural bias in the healthcare system are voiced by immigrants from every origin. If Americans and immigrants from other developed nations have difficulty accessing the system, concern should arise as to the level of difficulty faced by less empowered immigrants. When Dutch doctors allow cultural stereotypes to guide their diagnosis more than physiological symptoms, a patient’s health is always threatened.
Part of the Pacemaker in Global Health (a multicultural health advocacy foundation) lobbyist strategy is forcing the government to realize that the “healthcare system works extremely well, but only for those people in it.” Health advocates observe that the Dutch system may be too rigid to allow the flexibility necessary to truly serve all Dutch residents. Some minority patients complain about Dutch doctors approaching them with preconceptions about their culture that predispose the doctors to undermine the severity of a condition or objectively identify certain presented symptoms.
According to Karima Belhaj, a Pacemaker board member, “the Dutch system is looking at discrepancies in health from an anthropological standpoint, not an epidemiological one,” suggesting that the healthcare establishment is relying too much on cultural stereotypes and excuses as explanations for health discrepancies.
In 1999 Minister Borst of the Department of Health tried to establish the first master plan regarding multicultural health in the Netherlands. However, the main objective was not equalizing health among all populations in the Netherlands; it was “inter-culturalizing health care.” “The Netherlands has yet to establish goals. It is focusing on the means and not the ends,” says Karima Belhaj. The committee established in 1999 has still not taken any action. According to top sexologist, Dr. H.W. van Lunsen, “the Dutch system waited too long to change- not only in the field of sexual health, but all fields.”
Although the Netherlands has overcome many obstacles in the last decade, these efforts are being quickly undercut by the direction of recent administrations that have been following a trend of cutting social services. The current administration has directed cutbacks for both health programs and immigrant services. In this regard, new Dutch residents are facing a steeper uphill climb in either direction.
A. van Enk, “Perinatal Death in Ethnic Minorities in The Netherlands.” Journal of Epidemiology and Community Health, Vol. 52, 735-39.
Aika van der Kleij, “Provisions for Victims of Trafficking in Bonded Sexual Labour.” BLinN, 2002.
Drs. Anke van der Kwaak, Researcher of Gender Identity, Medical Center of Amsterdam
Annet van der Berg, Media Director, World Population Foundation
Drs. Caro Koning, Radiation Oncologist
Filiz Yildirim, Turkish VETC Worker
Dr. H.W. van Lunsen, Sexologist and Physician, Medical Center of Amsterdam
Handbook of Intercultural Care, Elsevier, 2003
J.C.M. van Beek, Emergency Room Head Nurse, Medical Center of Amsterdam
Jacqueline, information services, Prostitute Information Center
John Mollenkompf, “Assimilating Immigrants in Amsterdam.” Amsterdam Study Center for the Metropolitan Environment, June 1998.
Karima Belhaj, Board Member, Pacemaker in Global Health
Kraamzorg Online Information Website, http://www.zorgmaat.nl/frames
Long Live Love workbook and video. GG&GD, 2002.
Drs. Nordin Dahhan, Director, Pacemaker in Global Health
Operator, Counseling Hotline for Sexual Abuse
Dr. Rob Hermanus, General Practitioner
Said Haovam, Moroccan VETC Worker
Drs. W. Deville, NIVEL Utrecht
Drs. W. Schilthuis, Department of Epidemiology and Health Promotion, GG&GD
Drs. M. van der Wal, Head of Youth Department, GG&GD
We would also like to acknowledge the input and advice of health professionals and patients that did not wish to be named.