This writing is an exercise of reflection on the way policy issues and policy target groups are addressed during the policy design process. Some theoretical approaches, from the cognitive realms of the policy studies, suggest that issues and targets’ treatment of public policies depends on a series of cognitive and socially constructed aspects that interfere in the design as it is a process handled by actors.  The proposed written discusses sexual health and reproductive rights as a subfield of policies as well as on trans people as examples of a policy issue and target groups that depict the way in which social artifacts of making sense of the world and cognitive processes such as framing could affect the development of the policy and the benefits for a group of people.

Keywords: issues, framing, social construction, target groups

The policy design taken as an analytical framework helps to study the dynamics between actors and policy issues (or topics), as well as helps to understand how conflicts are played out in them, resulting in ways to address and comprehend these issues and groups.¹ Through the study of design, the policy analysis is carried out in its content and process, allowing the recognition of socio-constructed and historical contextual elements. These elements originated in the social contexts but take on relevance in the discussion at the level of politics and then are printed in the dynamics of design.²

There are some frameworks for design analysis that offer tools to understand these aspects. Some of them focus on policy tools, others on institutions or discourses. Thus, one of these models, is the Framework of Social Construction of Target Population or Framing (FSCTP or framing framework), from studies in public policies, by Schneider and Ingram (1997). This offers a discussion that highlights the role of those cognitive aspects such as framing and biases from social constructs or artifacts to make sense of reality, which are socially constructed, legitimized, and naturalized. According to the framing framework, these aspects steeps on the policies and can determine the possibilities to deal with certain groups and issues.

In sexual and reproductive health, several socio-constructed elements interfere in its treatment as an issue of public policy. As well, these elements affect the ways of constructing the target groups of these policies, consequently, affecting the way policies are formulated and the way target groups are addressed. Sometimes, the results produced improve the understanding of the issues or groups, while others affect the possibility of broadening the issue or meeting the needs of these groups efficiently. This article briefly reflects on how sexual and reproductive health has been understood as a matter, especially, addressing the treatment for certain target groups of this policy. For these purposes, a theoretical discussion is made with a historical perspective, and attention is placed on trans groups as recipients of these policies in relation to the identity affirmation process.

Basis for the discussion from the policy design

For Schneider and Ingram,² the analysis of policy design presents three instances of observation, the social context which is the macro level of analysis, the issue context or the middle level of analysis and the policy design as the micro level of analysis and which the results of designing are seen. All these instances are connected through dynamics of framing (from the social context to the issue context), design (from the issue context to the design), and translation (from the design to the social context). This is called the system of design according to their proposed.

Within what they call the instance of the issue context, a series of elements affect; such as institutions or institutional culture, political power, and the social constructions of groups and knowledge. All of these elements play a key role in the dynamics of policymakers, as well as for the actors that participate in defining the policy’s issue. This is because during the framing dynamics, all these elements, but especially the constructions, can resignify or frame the groups and topics through the actions that the actors involved do. Hence, under this comprehension actors present limited rationality as they do all act under cognitive processes such as frames or under social constructions that make sense by determining in the policy design a way of understanding sexual and reproductive health SRH and a way of approaching groups.²

The social constructions for these authors have a key role since they affect this framing, as they resulted from a process of creating reality and shaping the world, from the association of people and events with values, images, ideas (social, political, or historical) and stereotypes. In addition, the social constructions constitute intersubjective and interpretive practices, which allow forming meanings for action or creating truths and social understandings of the world, of groups, and of the phenomena in it.³

The social constructions are involved in the policies in two manners, the knowledge of the policy issue and the target groups.³ The knowledge of the policy is the set of scientific, social, or professional knowledge or certainties, influencing the way of approaching the matter, knowledge and discourses, and the way in which the targets are understood.^4,5 In relation to sexual and reproductive health SRH, the construction of knowledge will mark a way of understanding this issue, the technical and social approaches to address it from the public problem, as well as the groups that are addressed on it and their demands.

Social constructions affect groups, as actors associate groups with perceptions or stereotypes. This also determines a type of relationship or interaction between the populations of societies (identification, closeness, or segregation). The action of the social constructions in the groups of the policy affects the way in which the they are approached in policies, constructing them in a type of target groups.¹² Thus, trans groups are understood in policies under certain perceptions and stereotypes, impacting their approaches as groups and their demands. The relationship between knowledge and groups is that certainties or knowledge can influence the ways in which groups, their social constructions, and needs are resignified or understood. Hence, the way in which sexual and reproductive health is addressed impacts the way in which trans groups have the possibility to satisfy their need in a policy.

Brief historical account of the approach to sexual and reproductive health as public policy

Discussions about sexuality began at the beginning of the 19th century, from psychology, psychiatry, pedagogy and sexology. In these disciplines, sexuality was framed in aspects such as natural sexual impulse and traditional sexual behavior.⁶ In the 20th century, sexuality was approached from the medical view of the function of the body and the biological order, taking on a primordial character of the heterosexual reproductive issue.⁶ At the end of the 20th century, critical social theories nourished the knowledge of sexuality by adding elements of culture and societal demands, as well as the experience of the subject started to be taken into account.⁶ Feminist, sexual diversity, post-structuralist, sociological studies, etc helped to introduce other notions towards rights (planning and individual autonomy, etc.). Likewise, social phenomena influenced the appearance of scientific advances that would converge in medical discussions. Some of the were pushed by the demands for social care. For example, this is the case of the AIDS epidemic (the 80s), the sexually transmitted infections STI took importance as well as for women the fight for contraception started decades before.

In this discussion, it is important to identify that several actors,⁶ and in fact the historical study of sexuality, reveal that the ways of creating knowledge and approaching sexuality marked the way of making public policies. Thus, the first public policies on sexual and reproductive health were characterized by framing the issue in the reproductive perspective and Family planning.⁷ This was sustained by biology (concepts of what is nature) and from the need for the States to plan demography. For example, some countries, such as Argentina, opted for policies in the field of SRH as a mechanism to populate the nation through laws and other policy tools.⁸

Here it is important to recognize that, by focusing the approach to the matter on a biological issue and the function of the body, other notions were identified such as functional abnormality and proper behaviors, etc. As a result, women were identified as the main target groups for the approach of these policies, in their role as mothers and the role of government in birth control and reproduction.⁹ Also, because of this, other groups were presented in categories of groups with certain not usual behaviors. For example, Men who have sex with men, which was a boom in the 80's on the management of AIDS and HIV. Another important aspect to notice is that AIDS was not addressed from the PSSR approach, but from infectious disease management policies.³

These biological visions, of population control and planning, began a gradual process of modification thanks to the advance of societies; but, above all, by mobilization of thought, discussions and social action of certain groups.⁴ Since the 1960s, the action of feminist and LGBTI⁵ social movements have helped to change these visions towards a horizon of human rights, so that the government addresses other public problems and demands for rights. From now on, the struggle and organization of the groups allowed the inclusion of other notions based on rights in health and a dignified life.

Since this decade, important advances have been made in the knowledge of the policies for SRH. Some of this knowledge was introduced in forums, conferences, and global discussion platforms. For example, the Tehran Declaration of 1968 proclaimed the right of people to decide on reproduction and family life.⁹ Likewise, the 90's added new discussions, for example, through the Third International Conference on Population and Development (Cairo Platform for Action 1994) and the World Platform for Action of the Fourth World Conference on Women (of Beijing) The Conference defined “Reproductive Health as a state of complete physical, mental and social well-being, and not only the absence of ailments and diseases, in all matters related to the reproductive system and its functions and processes”. The Platform added the principle of gender equality and sexual diversity. All these understandings marked references for the countries to adopt guidelines on rights and dignified life for the treatment of health, sexuality, and reproduction.⁹

From this brief account it is important to indicate that at the beginning the treatment of this issue, sexuality was established in a binary (man woman-woman mother) vision. However, the attention of women goes from being an object of policies to a subject of rights in SRH, an aspect that occurs as the discussions of knowledge and its social constructions as women were modified. For the various sexual groups, a key guideline in their approach within SRH was introduced in the 21st century, from the Yogyakarta Declaration of Principles in 2006.

In the historical account of SRH as a policy issue, social constructions and artifacts of making sense have been immersed. These in the first instance were linked to the notion of abnormality vs. normality, functionality vs. non-functionality, morality, gender roles (motherhood and care). However, later the societal advances will be able to transform the notions by subjects or individuals of rights, decision, imposition, rebellion, among others. It should also be understood that the discussion on this matter is unfinished, since the changes in its certainties and in the social construction of knowledge and targets depend on the following discussions and social and medical advances, or on the possibilities that one leverages the other or vice versa. Therefore, the future aspects or notions could include other understanding as well as other stereotypes and perspectives about what is the health, sexual and reproductive policy and the target groups on it.

Brief historical account of the approach to trans groups

The term Trans refers to individuals whose expression and/or assumption of gender identity does not correspond to the social norms with which people are associated with their sex at birth.¹⁰ In this written, the term also applies for referring to transgender, transsexual or transvestite.⁶ At the end of 17th century and, later on, in the 19^th, diverse identities were understood from homosexuality. Plus, all the understanding of people with different sexual orientation was possible by studies from the clinical, philosophical and social realms part of psychiatry, psychology and psychoanalysis. However, all marked these people under conceptions of perversions or anomalies of bodies and behaviors.¹¹ The beginnings of trans studies were from transvestism or a pseudo hermaphrodism, and its approach was nourished by biomedical discourse and contributions from sexologists.¹² Some renowned figures and discussions about transvestism are synthesized at following.

1. Richard Von Krafft Ebing, Henry Havelock Ellis and Magnus Hirschfeld contributed important innovative knowledge of transvestism and homosexuality.
2. Krafft " Psychopathia sexualis " (1886), made a typology of the deviations of sexual behavior and psychic sexual anomaly, studying homoerotic attractions, feminizations or delocalized behavior. Other studies included sadism, masochism and sexual fetishism.
3. Havelock Elis, “Sexual Inversion” (1987), originated contributions such as “aesthetic sex inversion” (in 1913) and “eonism” (in 1920).¹³ The transvestite is beginning to be understood as a phenomenon and not as symptoms.
4. Magnus Hirschfeld, “Transvestites. The erotic drive to cross dress” (1910) raised the process of construction of subjectivity or identification and originated the term transsexual or transit to another body.
5. David O. Cauldwell (1949) added endocrinological knowledge and the practices of genital surgery.
6. Harold Benjamin (in 1948 and 1966 "The Transsexual Phenomenon") would rule out psychotherapeutic treatment and treatment of body adaptation to the person's identity.

This knowledge and discussions influenced the creation of mental health policies, especially giving guidelines and medical diagnoses to the professionals. Health reference dictionaries such as the International Classification of Diseases ICD and the Diagnostic and Statistical Manual of Mental Disorders DSM have collected a series of discussions and ways of approaching these people. The majority of them provided understandings but also stereotypes related to illness. Also, the directives from these dictionaries affected the understanding of the mental health policies as an issue addressed by states, as therapist use them as a source of diagnosis (forming a policy knowledge). The encounter with the SRH for these groups has been conditioned by the mental health policy. These dictionaries have been the guarantee for the access of these groups towards the affirmation of their identity through the detection of a category as a requirement of become candidates to change or intervene their bodies with medical procedures. However, these discussions that are collected in medical dictionaries have also been modified as it is accounted in the following table 1. The changes and modifications have been produced due to the advance of medical fundamentals, as well as with the advance of the comprehension of the behavior of the groups and the affectations that they suffer from been diverse. Also, the emerge of social and political movement introduced more acceptance to address diverse identities and sexual orientations.

On the first approaches of the trans group, an association of these groups with perceptions and stereotypes of deviations and perversions in sexual behavior is identified. This is possibly the reason why, to these days, these groups are associated with the disease or negative perceptions. This also has led to their delayed approach in public policies of sexual and reproductive rights as in first place they were treated more under the mental care field. However, in SRH it is noted that their access has been conditioned to the binary treatment of sexuality (mentioned above), as mainly this issue was addressed under the conceptions of planning and birth control making women the first target. Later, the demands of these group will open a field to new contributions to the policy. Also, the negative perceptions and stereotyped constructions about the conduct of trans people led to their discrimination, diminishing their possibilities of being addressed as policy targets which is an aspect that remains until now.  Consequently, much remains to be done to address the needs of these populations, as well as other sexual diversities such as gay, lesbian, intersex or bisexual.

Final reflection on the social construction of groups and sexual and reproductive health as a matter

Policy design is a purposeful and intentional process since actors involved act under some interests, understandings, and biases. Therefore, the way in which the policy issues and target groups are addressed in the policy design influences or guarantees two aspects, on the one hand, the meeting of public needs and public problems, and on the other hand, the policy performance. Consequently, the policy design process is key as it produces policies results in which it can be seen if the population demands are satisfied and/ or if the citizen participation increased, hence, interfering in democracy.²

In the policy design, interested actors and policymakers are influenced in their actions and decisions by a series of social constructions and cognitive processes. These are seen as perceptions about people, biases, and framing. All of these emerge in the social context but take an important role in the designing process at the issue context level. This is because, through them, the actors understand issues and target groups, and then create an approach to the public problems and locate the groups in types. 

In other words, the treatment of the sexual and reproductive health and of trans groups depends on the way in which social constructions and framing build the discussions and knowledge of the policy issue and target groups. These social constructions appeared in the time at the social level and then reached more specialized places of discussion; such as in the working tables or policy creation spaces.

The previous sections take up a brief historical perspective that makes visible how sexual and reproductive health has been addressed as a policy issue as well as trans groups have as policy targets. Also, the account showed that these approaches changed from the conceptions of the beginning and later on due to several reasons. In the case of sexuality and reproduction as a policy issue, its approach started under the influence of the medical scientific discourse of various disciplines (sexology, psychology, etc.). All of these located the approach under a limited scope of biology and functionality.  Likewise, the way it becomes a policy issue depended on the way in which the government puts the issue and the needs of the territory on the agenda, initially with demographic and control interests. This of course limited the scope of the policy by only addressing key target groups such as women and topics such as reproduction. Under these conceptions, the policy performance was framed under a binary vision of women-mother, also limiting the participation of other groups such as men and sexually diverse people.

However, it is the mobilization and social demand that gives a significant twist to this approach to sexual and reproductive health. Therefore, the processes of modification of the social construction of knowledge (the change in certainties and discourse) occurred gradually, as the social mobilization of chants and technical support started to take relevance. Therefore other sciences contribute to considering order aspects such as human rights perspectives and other targets apart from women as mothers. Here it is important to notice that policy issues and target groups depend on the way they are understood and portrayed in a social context and the issue context, hence, addressing them in a different way can take time as the mobilization of knowledge and social movements do not occur rapidly in societies.  As well, this can sometimes mean a late approach to certain aspects of the issue or certain groups. For example, moving from a broader perspective of rights and integrating more populations was a long process of discussion and resignification of the needs of the target group and of medical science. This led to a discussion in international venues to define what was sexual and reproductive health, as well as states had to broaden and address the issue under health policy instead that from demographic ones.

An aspect that should be highlighted is the great influence that the collectives and groups interested in addressing their demands can have in changing the way policy design occurs. This is because these are groups that can leverage big changes or the approach to new aspects of the themes. These social groups also initiate mobilization of certainties about the policy issued or demand the creation of technical and scientific elements so that they can be addressed in the issues. To this is added the demand of other actors immersed in the health sector such as researchers, academics, and professionals, who sometimes, through discussions of science, can leverage the social construction of knowledge. As a result, all of these groups can provoke a rethinking of an issue and can mobilize the government to set policy. In this respect, it is important to notice the contribution of the feminist groups and other international organizations for women's rights.

Regarding the approach of the target groups of the policies, the influence of social constructions is much more significant. The way in which the group is perceived socially (in the social contest) can open the way for it to be addressed in policies and in what way, marking the possibilities for their demands to be addressed. In simple words, if a social group is not perceived as positive, their possibilities to receive benefits in public policies are limited. Schneider and Ingram (1997)² gave a clear example of this when they referred to prisoners or people who infringed the law, who always receive more charges in policies and policies tools such as more years of dooms, or less political benefits.

In the brief discussion above, there were seen some associations with which trans groups have been approached and understood socially; for example, with notions of deviant behavior or abnormality. This not only has placed their approach in the field of mental health for several years, but from this, stereotypes play an important role in delaying their approach in sexual and reproductive health policies. Therefore, the way in which these groups are understood shape or condition their access to the benefits of the policies. In this case, it can be referred that these groups must be diagnosed within a mental symptom or category under the medical dictionaries in order to accede to their body affirmation procedure. This can clearly contravene their rights to free decision and personal autonomy which is why there are several discussions and considerations from these groups and other allied sectors.

However, their resignification as a group with other characteristics or perceptions outside of the abnormality has occurred thanks to their struggle to mobilize their recognition and their approach in the field of health. The sexual and reproductive health subsector is important because in it, the recognition of the trans groups as targets can affirm their identity and enjoyment of a series of guarantees (for example, body consolidation technologies, such as hormones, transplants, etc.). Consequently, it is important not only to consider the chants of these groups but also to produce more technical and social knowledge about them. This will contribute to creating more guidelines for professionals, as well as an approach to these groups from sexual and reproductive rights.

As mentioned before, activism is really important to change the ways to approach policy issues and target groups. Regarding trans activism, there are several examples of initiatives that have mobilized changes in health diagnoses. For example, it can be cited the movement "Stop Trans Pathologizing" of 2012. This sought to remove from medical dictionaries terms that can generate and perpetuate stereotypes of these people linked to mental illness. Likewise, other groups have advanced in their knowledge of these groups and changed the pathological discourses as a way to ensure their access to medical technologies and to their desired identity.

Here it is also worth mentioning that important advances have been made in the care and modernization of health models. Currently, there are debates about the need to change the traditional hegemonic models of health care to more horizontal models. The first models have a logic of a hierarchical relationship and care (doctor-knowledgeable-active and patient-ignorant-passive), whereas the second one believes in care there is shared knowledge, which combines the medical with the social, so patients have a more active role.^7,16 Likewise, there are specific institutions to understand trans health such as the Center of Excellence for Trans Health (CEST) or the World Association of Professionals for Trans Health (WPATH) that have helped to establish other categories of analysis in the diagnoses of trans people health, such as gender dysphoria,⁸ gender variability.⁹ All of these efforts seek to change the notions of pathological conditions.

The innovation in trans people's knowledge will lead to a broadened comprehension of their care and enjoyment of rights. In the public policy discussion, the comprehension of the target groups improves the policy efficiency. This is because policies act to generate or change behaviors in populations but also to satisfy populations' demands. Therefore, the comprehension of the groups' needs and characteristics is mandatory to have better policies. The policy can show more democratic social context when more people receive benefits in policy tools.

¹ 

²The authors provide a typology of targets (advantaged, dependent, deviant, and contending). This is formed according to the intersection of a variable positive/negative perception of the group and a variable of political power that the group exercises at the time of being taken into the design. As a result, these types of groups obtain privileged treatment or not, as well as advantages or disadvantages. This broad discussion is not part of this discussion but has been discussed by the author in Galarza, Shakira. The social construction of trans groups in sexual and reproductive health and rights policy. An analysis from the perspective of policy design. Thesis for the master's degree. FLACSO-Ecuador. 2022. 50

³See, for example, the discussion of the Argentina previously referred.

⁴The interested groups in promoting their demands and issues could be understood under the conception of issues activists or entrepreneurs, which is a well-studied category in policy studies.

⁵Amigo (2019) on account of trans organizations that emerged at this time Conversion Our Goal) in 1967, the following year it would form the National Transsexual Counseling Unit (NTCU), being the first organization constituted to support and defend these people and later, the Transsexual Orientation Service will appear in the United States. Amigo, Ana María. 2019. “Un recorrido por la historia trans: desde el ámbito biomédico al movimiento activista-social”. En Cuadernos Pagu. 2019;(5).1–26.

⁶There are important differences according to the term. Therefore, transexual is the individual that has done a biological change using methods to adequate his/her anatomy; travesty is an act of cross dressing, and transgender is for individual that self identifies with other gender but not necessarily made a biological change.

⁷Advances in knowledge can occur due to the social interest of clinical themes and the construction that have the same issues as positive or negative. The same goes for the treatment of groups.

⁸According to PAHO, self-identification is different from that of biological sex.

⁹According to PAHO, it is the assumption and expression of the diverse gender with respect to sex as a practice and socially assigned roles.

In conclusion, this work aimed to reflect on the ways in which sexual and reproductive health and trans people have been treated in policy design. The historical perspective allows identifying that both aspects have a long way to go in terms of broadening and scope. Especially in conservative localities and sectors, as well as where the influence of negative social constructions or even religious beliefs remains. Therefore, a key role of the policymakers and those dedicated to the design and policy analysis is to identify and question the constructions and biases behind policy issues and targets. This will lead to acknowledging the ways in which issues and groups are or have been treated. Besides, this will help to identify the policy performance and the way in which public problems have been addressed since biases and previous frames could interfere in the design process. The analysis of social constructions and cognitive processes in policy design is especially important in the cases of groups within conditions of vulnerability and in matters that compromise access to health or other rights.  This is because there are many gaps to overcome in order to address these groups' demands. Much research and awareness are also needed, especially in policy issues that act for the exercise of rights that are sometimes surrounded by taboos, such as the case of sexuality and reproduction.

None.

The author declares that there is no conflict of interest.

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