SRH Equity through a Gender Lens
One of the most important concepts to understand in advancing SRH for AYAs is “gender.”
In the 1970s, the term “gender” emerged in English language as a social construct
to make a distinction with the biological concept of “sex.”[18] While sexuality refers to “culture-bound conventions, roles, and behaviors involving
expressions of sexual desire, power, and diverse emotions, mediated by gender and
other aspects of social position (e.g., class, race/ethnicity),” gender refers to
the social construction of those conventions as well as “relations between and among
women and men and boys and girls.”[18] Importantly, within health, the construction of gender must be understood to differentially
interact with sex, which can subsequently have differential impact on a health or
disease exposure and/or its subsequent outcome.[18] Stated more simply, gender is complex; it must be understood through a societal
lens of power and privilege, is not necessarily synonymous with biological sex, and
has an impact through different pathways on a young person's health.
Gender, and ideas around gender, may shape and be shaped by both external and internal
forces. There is no time more transformative for how these forces shape an individual
than during adolescence and young adulthood. Extrinsically, gender norms are constructed
beliefs or expectations about how a “young man” or “boy” or “young woman” or “girl”
should act or present.[19] Gender norms ascribe societal value to what it means to be masculine, feminine,
or somewhere along the spectrum. This varies in different contexts and is externally
viewed through gender expression or self-presentation. Intrinsically, gender identity
is how a young person understands themselves based on cultural, normative gender ideas,
and their interpretation of their biology.[20] In the past, this construct has been described as binary (i.e., male or female).
However, there is increasing understanding on the fluidity of this spectrum, such
as explicitly recognizing genderqueer,[21] a term describing gender identity outside the binary limits. Killermann's Genderbread
model is a helpful tool to visualize how sex, gender, and identity relate and interact
in a young person's life.[22]
Once we recognize the intricacies of the idea of gender, we can better understand
why applying a gender lens is critical in AYA's health and beyond. Applying a gender
lens is necessary to untangle the gender bias inherent in all of our institutions,
including health and medicine.[23] Public health scholars such as Krieger and Fee describe the evolving understanding
of sex as well as race in biomedical literature, and further raise awareness of how
social class intersects with these ideas and subsequently health outcomes.[24]
Importantly, a gender lens calls us to recognize differential health risks according
to gender identity when providing services for AYAs. Our understanding of the socially
constructed nature of gender reminds us that, for example, AYAs SRH females and males
have different risks for violence, mental health, and other causes of morbidity and
mortality.
Within the AYA age group, a gender lens raises the importance and centrality of sexuality,
which is deeply connected to culture, relationships, development, and identity. Therefore,
SRH services and education must be explicit in positively centering the lived experiences
of young people.[11] Moreover, there is often a missed opportunity to ensure AYA's SRH services are gender
affirming in health care and science curricula.[25] Being mindful of gender allows for consideration of possible gender-related sexual
and reproductive vulnerabilities. One of these vulnerabilities is lack of consent
to sexual activity.
Consent for Sex: Central to SRH Rights and Justice
Consent for sex is an active agreement of both partners to engage in sexual activity
with the clear understanding of what the agreement includes. Partners must give and
obtain consent every time they engage in sexual activity and accept that either partner
can change their mind at any time.[26]
The legal age for an individual to consent to sexual contact defines the minimum age
at which one is deemed mentally capable of consenting to sexual activity. It aims
to protect adolescents from abuse and from consequences they may not be fully aware
of when engaging in early sexual activity. Sexual activity with a person under the
age of sexual consent is considered nonconsensual and constitutes statutory rape,
a criminal offense.[27] Statutory rape laws worldwide intend to discourage adults from pursuing sexual relationships
with developmentally immature minors.[27]
[28]
The rationale for a minimum age of sexual consent is to protect adolescents from situations
of dependency and power imbalance, which can lead to lack of resistance without genuine
and fully informed consent. These situations include adults exercising a form of authority
or offering other benefits to obtain sexual favors from underage children, older peers
blackmailing sexual activity for inclusion in a group, or other forms of recognition.[28] It also aims to protect adolescents from the multiple risks associated with early
sexual activity, such as sexually transmitted diseases and early pregnancy, which
have lifelong consequences on their health and development.
There is no international standard that indicates what the minimum age for sexual
consent should be. The Committee on the Rights of the Child has considered 13 years
to be very low.[28] However, this age aims to avoid the over-criminalization of adolescents' behaviors.
The age difference between the partners involved should be of greater determination
in terms of power imbalance. Any legislation making sexual activity illegal under
an age where most adolescents are already sexually active risks preventing them from
accessing critical sexual and reproductive healthcare and education. For this reason,
some countries have close-in-age exemption laws in addition to legally defined minimum
age for sexual consent.
There is wide variation on age of consent law both within and between countries. In
the United States, the age of consent differs between 16 and 18 years according to
individual state regulations. For example, the state of Ohio statutory rape law is
violated when a person has consensual sexual intercourse with an individual under
age 16 whom they are not married to. However, when marriage is used to legalize sex
with an underage child, the concern of power imbalance and inability to consent remains.
Ohio law also allows minors aged 13 and older to consent to a partner under age 18.
However, the state of Indiana has a broader regulation to the best interest of adolescents
depending on the situation. The Indiana close-in-age exemption may completely exempt
close-in-age couples from the age of consent law, or it may merely provide a legal
defense that can be used in the event of prosecution.[29] In Canada, the age of sexual consent is 16 years with two additional close-in-age
exemptions: sex with minors aged 14 to 15 is permitted if the partner is less than
5 years older, and sex with minors aged 12 to 13 is permitted if the partner is less
than 2 years older.[29]
[30]
In Europe, the lowest age of sexual consent is 14 years (14 countries), whereas the
highest age of consent is 18 years (Malta, Turkey, and Vatican City). Most of the
countries in Europe do not have a close-in-age exemption law, but when the age of
consent is as low as 14 years, close-in-age exemptions may not be as crucial as it
is in the countries having higher age limits.[29] In the countries where child marriages are still widespread, keeping the age of
consent at a higher age also aims to prevent child marriages, but the lack of a close-in-age
exemption in the law fails to differentiate between the forced marriage with an adult
and consensual sexual activity of older adolescents.[31] The advocacy for close-in-age exemption laws in such countries should be strengthened
to focus on the best interests of adolescents and mitigate health inequities in AYA's
SRH. Healthcare providers should be informed of the consent laws in their particular
localities.
Global Aspects of AYA's SRH Inequities
In this section, inequities in SRH for AYAs in a global context are examined, focusing
on sexual abuse/assault among AYAs; immigrant and refugee populations; child, early,
and forced marriage; human trafficking; and female genital mutilation. These topics
have been chosen due to the significant health inequities in SRH among AYAs, not only
in the United States but also worldwide.
Sexual Abuse and Assault among AYAs: Inequities in Reporting, in Identifying Those
at Risk, and in Access to Prevention and Treatment Programs
One important risk facing AYAs is sexual assault and abuse. The WHO defines child
sexual abuse as “the involvement of a child or an adolescent in sexual activity that
he or she does not fully comprehend and is unable to give informed consent to, or
for which the child or adolescent is not developmentally prepared and cannot give
consent, or that violates the laws or social taboos of society.”[32] The sexual abuse of children and AYAs, including rape and assault, is a global problem
that has devastating short- and long-term effects on individuals, their families,
and their communities. The prevalence of childhood and AYA sexual abuse around the
world is difficult to estimate due to a myriad of factors, including differing definitions
of “abuse” and “assault” in research, methodological differences among studies, discrepancies
between self-reporting and “officially reported” sexual abuse incidents, and underrepresentation
in research among some areas of the world[33]
[34]
[35]; it is likely that research vastly underestimates the true prevalence of childhood
and AYA sexual abuse worldwide. That said, the available research that includes studies
conducted globally estimates a worldwide prevalence of childhood sexual abuse at approximately
11.8%,[33] between 8 and 31% for girls and 3 and 17% for boys.[34] It is also noted that around the world, AYAs are reportedly four times more likely
to be victims of sexual assault than women in all other age groups.[36] Additionally, at least one in five women suffer rape or attempted rape in their
lifetime, often by an intimate partner.[37] Another population to consider is that of college and university students, as this
population is also at high risk. According to the American College Health Association:
“Sexual and relationship violence comprise a continuum of behaviors, including but
not limited to sexual/gender harassment, sexual coercion, sexual abuse, stalking,
sexual assault, rape, dating violence, and domestic violence.”[38] Sexual assaults, predominantly perpetrated against young women, are reported as
high as 20 to 28% in this population.[39]
[40] However, the totality of sexual violence among this young adult population is much
greater than reported in assault statistics.
Although sexual violence is known to affect people of all ages and backgrounds, women,
children, and adolescents are disproportionately affected worldwide.[32]
[33]
[34] In many countries, it has been noted that greater victimization is seen in children
and youth raised in families with lower socioeconomic status,[35]
[41] those with disabilities,[42]
[43]
[44] individuals who identify as racial or ethnic minorities[45] including African Americans and Indigenous populations,[46]
[47]
[48] and children and youth who identify with the LGBTQ2S+ community.[49] Moreover, children, adolescents, and young people living in locations with ongoing
war and conflict have been sexually abused as a weapon of war.[37] While it is essential that these special populations be highlighted in research
worldwide, there remains significant imbalances in identifying risks in certain populations
and locations. Without more data on the prevalence of sexual abuses in underrepresented
populations, there is a lack of information about who is at risk, making prevention
and treatment programs incredibly challenging to implement.
Several systematic reviews, meta-analyses, and original studies have linked childhood
and AYA sexual abuse with an increased risk of multiple negative medical, psychosocial/behavioral,
and psychiatric sequelae.[35]
[44]
[50]
[51]
[52]
[53]
[54]
[55]
[56] For example, a history of sexual abuse in childhood has been linked to higher rates
of unintended pregnancy and induced abortion,[40] functional gastrointestinal disorders,[53]
[57] as well as chronic pain,[53]
[54] most notably chronic pelvic pain.[53]
[57]
[58] There is also a noted increased incidence of engaging in risky sexual behaviors,[35]
[59] earlier onset of consensual sexual activity,[59] as well as increased rates of STIs, including HIV.[54] Moreover, a history of sexual abuse in childhood and/or adolescence is associated
with an increased risk of multiple psychiatric diagnoses, including anxiety disorders,
eating disorders, posttraumatic stress disorder, conversion disorder, borderline personality
disorder, and depression.[54]
[55] Substance misuse, nonsuicidal self-injury, and suicide attempts are notably high
in those with a history of sexual abuse,[54] as are the risks of involvement in sex trade work[60] and revictimization.[44] Importantly, there is also increased risk for the perpetration of childhood sexual
abuse in those with a history of sexual abuse themselves,[61] which underscores the intergenerational cycle of abuse.[56] Treatment for abuse depends on the symptoms and challenges that one experiences;
counseling, therapy, and support groups are often the cornerstone of individual treatment.[37] It is important to note that similar to research that explores the prevalence of
childhood and AYA at risk for sexual abuse, there is a paucity of research in some
locations regarding outcomes; and without information about outcomes in certain regions,
treatment and support programs are of course lacking. Even in countries where there
are more well-established support and treatment programs, inequities exist in access
especially for those living in rural areas and those who cannot afford to pay for
specialized services that may not be free.
Tackling the burden of childhood and AYA sexual abuse around the world requires more
equitable and inclusive representation in funding and research. Areas with the greatest
burden of health inequities should be prioritized and include epidemiology and surveillance,
and innovations in intervention development and treatment. Intervention development
must involve communities and those with lived experience, from conceptualization through
evaluation, to improve ecological validity and scientific rigor.[62]
Research needs to better explore the cultural nuances that affect the definition of
sexual abuse and assault around the globe and the alternate views as to what constitutes
sexual abuse in different regions (i.e., female genital mutilation, child marriage)
to build culturally educated treatment for survivors and their families. Community
members, policy-makers, government and law enforcement services, researchers, and
health care providers must recognize and combat the aforementioned health inequities,
to create effective sexual abuse primary prevention programs, trauma-informed screening
practices, and culturally competent and evidenced-based treatment.
SRH Inequities among Immigrants and Refugees
In the last two decades, international migration has become one of the emerging issues
challenging the health of youth around the globe. Today's world is inhabited by the
largest generation of 10 to 24 years old in human history.[63] The unique external forces surrounding this generation during their development
are also new and not well understood: population mobility, global communications,
and the most massively displaced movement of people in history due to natural disasters
or war. Around 70% of those on the move are women and those aged less than 18 years,
and it is estimated that 12% of the world's 15- to 24-year olds are migrating across
borders.[64]
[65] Development at this age is anchored in identity, which is a dynamic and nonlinear
process highly influenced by context.[13] Due to the recession in 2008, many countries' increased nationalism threatens to
undermine the ethnic and racial development of the most marginalized nondominant racial
groups of AYAs.[66]
This increase of “hate toward the other,” in this case xenophobia, has been translated
into migration policies and practices that trespassed on the human rights of AYAs,
who with their families or on their own were in search of survival, escaping abuse
and exploitation.[67] This significant context created the perfect antecedent for a myriad of preventable
vulnerabilities, such as xenophobic attacks (scapegoats) and discrimination, and increased
vulnerability, such as physical harm, psychological trauma, and sexual and economic
exploitation, limited access to basic needs, including reproductive preventive methods,
and, when at the World's borders, immigration raids and detention.[13]
[68]
More women are migrating alone and with others outside their families, usually for
work in domestic care, entertainment, and factories—where wages and working conditions
are lower than those for men, who are more likely to find highly skilled jobs. Women's
(including AYAs') migratory journey is a continuum of potential reproductive vulnerabilities
that can be divided into three main stages: pre-migration, during migration, and post-migration.
Pre-migration vulnerabilities include gender-based violence as the force propelling
migration, and being left behind in the migration journey, due to hostile conditions
of travels. Reproductive vulnerabilities during the migration journey include different
types of assault, including sexual assault, so well-known that most women coming from
Central America are started on Depo-Provera or a long-acting reversible contraception
(LARC) method, before the journey begins. Among those migrant AYAs who crossed borders,
there is another more violent challenge awaiting, detention and deportation, sending
some of them back to the vulnerable context that initiated their migration response.
In the United States, detention in the last years has constituted a repository of
human rights violations for both AYAs and their families. Post-migration reproductive
vulnerabilities go from health risks related to facing an unfamiliar and complex healthcare
system, mostly oriented to deliver care using the values and preferences of the mainstream
culture of the host country, to risks of human trafficking and sexual exploitation.[63]
These migration patterns have also created a series of challenges to the provision
of SRH services in the host countries. The increasing numbers of AYAs who have undocumented
status face challenges with access to healthcare, especially in countries where access
to healthcare is not a right.
Studies have explored the influence of transnational culture's impact on the construct
of SRH.[69] These studies show how parents and AYAs maintain cultural and religious values regarding
SRH, and therefore may encounter cultural barriers in seeking healthcare, adding to
the already existing (e.g., institutional, financial, legal) obstacles of how to access
those services.
Research had started to highlight the need to shift emphasis from a health belief
(knowledge–attitude–practice) model of reproductive health behavior toward an ecological
model of health for migrant and immigrant AYAs, which explores the influence of personal,
family, community, and societal (political/economic systems) factors on SRH.[70] One model for this is the U.S. nationally recognized Aqui Para Ti/Here for you Clinic
Model, caring for Latinx adolescents and their families, which uses a health equity
inclusive model of care to shift the focus from reproductive health to integrative
healing-oriented care that considers cultural identity and hope as determinants of
agency and reproductive health. The clinic has shown an increase in contraceptive
use, particularly LARCs, compared with all other health and patient care services
in the same hospital.[71] This provides evidence that favorable outcomes can be achieved utilizing comprehensive
approaches to SRH for this population.
Child Marriage
Child marriage, often synonymously referred to as early marriage, is a pervasive practice
globally. Defined by the United Nations as the formal marriage or union of an individual
before the age of 18, it is most discussed in reference to females (the girl child)
because of its prevalence.[72] Child marriage is also closely identified with forced marriage, a union without
free and full consent of both parties (regardless of age)[73]; these often-overlapping understandings of marriage may have different names in
different contexts (e.g., arranged, quasi-arranged). An estimated 650 million girls
and women alive today married before their 18th birthday; in fact, 1 in 5 girls and
women married before the age of 18 years.[72] In contrast, 115 million boys and men married early, before the age of 18 years.[74] Approximately 12 million girls marry early each year, and therefore violate the
human rights and Sustainable Development Goal (SDG) 5 Target 3, which calls for the
elimination of all harmful practices including child, early, and forced marriage.
Additionally, there is a growing evidence base supporting global consensus on the
negative consequences of girl child marriage. In this section, we describe statistics
of girl child marriage, provide evidence on why the practice persists, and share information
on how it can create inequities in AYA's SRH.
More than a decade ago, rates of girl child marriage were highest in South Asia, disproportionately
driven by high rates in India. Today, the percentage of young women who married as
children (before 18) is highest in West and Central Africa (41%), which has seen a
much slower decline, followed by Eastern and Southern Africa (35%), South Asia (30%),
Latin America and the Caribbean (25%), and the Middle East and Northern Africa region
(17%).[72] Rates of girl child marriage are much lower in Eastern Asia and Central Europe (11%)
and East Asia and Pacific (7%).[72] More recent data also indicate that child marriage exists in high-income countries;
for example, a recent study found that nearly 300,000 minors younger than 18 years
were legally married between 2000 and 2018 in the United States.[75]
Girl child marriage persists for several reasons with some differences across geographies
and cultures. Reasons commonly identified include poverty, or limited economic opportunities,
low education levels, lack of laws or their enforcement, cultural practices believed
to protect a female or her family's honor, and social norms.[76]
[77]
[78]
[79] In some contexts, religion may play a role in shaping norms that drive girl child
marriage,[80] and migration may also influence marital decision.[81] A forthcoming review particularly underscores the intersecting nature of social
norms, poverty, and economic factors.[82] More recent evidence has raised the strong role of gender and gender-discriminatory
norms, including control of adolescent females' sexuality, as a key reason the practice
continues.[83] Importantly, marriage at early ages is often not the choice of the young spouses;
there continues to be debate on AYA's ability to consent given the legal age of majority,
as well as norms, pressures, and economic realities within a young person's context.[73]
Child marriage has been associated with negative consequences for girls' and women's
health, particularly across SRH. It has been strongly associated with early age at
first birth, decreased modern contraceptive use, short birth spacing between pregnancies,
increased unintended pregnancies, and increased likelihood of stillbirth or miscarriage.[84]
[85] Girls who marry earlier will often have more children in their lifetime, and early
childbearing, through early marriage, may also negatively impact the health and developmental
outcomes of both the young mother and children born to those young women.[86]
[87] Girl child marriage has also been associated with poorer health-seeking behavior,
for example, among pregnant adolescents, reduced number of antenatal visits, and lower
likelihood of delivery by a skilled attendant.[84] Moreover, girl child marriage has been negatively associated with mental health
and psychosocial well-being,[88]
[89] and with broader non-health outcomes including reduced education and high cost for
countries,[86] which may further exacerbate inequities for AYA's SRH. Providers should also be
aware that girl child marriage may also increase risk for intimate partner violence.[90]
Because of its potentially harmful consequences, including both the health and rights
violations of girls and women, it is important to be aware of young peoples' rights
to determine if, when, and whom they marry. There are opportunities to further close
research gaps, particularly in understanding causal pathways toward impact. Providers
in low-, middle-, and high-income contexts should be aware of the potential consequences
associated with child, early, and forced marriage, particularly among female AYAs.
The WHO has guidelines on preventing early pregnancy and poor reproductive health
outcomes among adolescents in developing countries.[91] This resource continues to be updated with explicit reference to child marriage,
and can serve as a resource for healthcare providers.
Human Trafficking and Sexual Exploitation: Highlighting Inequities
Human trafficking is a global health concern. It is defined as “The act of recruitment,
transportation, transfer, harboring or receipt of persons … by means of threat or
use of force or other forms of coercion, of abduction, fraud, of deception, of the
abuse of power, or of a position of vulnerability or of the giving or receiving of
payments or benefits to achieve the consent of a person having control over another
person … for the purpose of exploitation.”[92]
[93] Examples of exploitation may include forms of sexual exploitation, forced labor,
slavery or servitude, and selling of organs.[92]
[93] The foundation of human trafficking is a predator taking advantage of a power differential
and preying on another individual's vulnerabilities. These vulnerabilities highlight
the inequalities and oppression created by society and social constructs as trafficking
victims and survivors are most often those who have been given less power by society.
Human trafficking for the purposes of sexual exploitation occurs globally regardless
of national economic development status and is the most common form of trafficking.[93] According to the United Nations, most sex trafficking occurs within a specific country,[93] although international trafficking is also an important concern.[94] In the United States, sex trafficking is a significant public health problem and
occurs in every region of the country.[95] The majority of victims have been seen by a health care provider while being trafficked,
and therefore there are opportunities for intervention.[96]
Sex traffickers around the world specifically target poor communities and individuals
who have been marginalized, knowing that people living in poverty are more vulnerable
in their need for financial resources. The vast majority of victims of human sex trafficking
are women and girls.[92]
[94]
[97] Many women are involved in human trafficking, not only as victims but also as traffickers.
Very often former victims have become perpetrators. Traffickers also lure women in
poor regions with false opportunities to improve their circumstances.[92]
[94]
[98]
[99] Immigrant AYAs in particular are vulnerable to sex trafficking.[100]
In addition to poverty, gender inequality plays a large role in human sex trafficking,
in particular in areas of the world and within countries, where women's rights are
not as well recognized. Similarly, racism is a notable factor in sex exploitation.
Systemic racism around the world has led to instances of discrimination and marginalization
(e.g., not being allowed access to schools, reduced employment opportunities due to
racism, reduced level of power in a community) that put individuals at high risk for
exploitation.[47]
[48]
[92]
[101]
Other examples of risk factors for sex trafficking include a history of childhood
sexual abuse, living within the foster care system or being homeless, identifying
with the LGTBQ2S+ community (includes Native American two spirit communities),[102] and/or having a substance abuse disorder.[103]
[104]
Victims and survivors of sex trafficking suffer a range of poor health consequences.[105]
[106] For example, sexually transmitted infections, unplanned pregnancies, and forced
abortions are common among young women forced into sex trafficking.[97]
[99] Moreover, trafficking victims are often exposed to physical violence which frequently
leads to multiple physical and mental health sequelae.[99] In recent years, the internet and digital technology have enabled the massive growth
in sex trafficking and sexual exploitation across the globe, and trafficking is a
lucrative enterprise.[100]
[101]
[107]
The international community has developed resources to combat trafficking. The UN
Office on Drugs and Crime (UNODC) publishes a global report on trafficking in persons,
as does the U.S. Department of State.[92] The Counter Trafficking Data Collaborative (CTDC) is one of a kind global data hub
on human trafficking with access to global map, demographic snap shots, and graphs
which highlights age, gender, and sectors in which people are exploited.
The UNODC document reports that only 125 of the 155 participating countries have passed
laws that mitigate the problem of human trafficking. National justice systems vary
in their capacity to address trafficking. The number of convictions is increasing,
but not in countries where trafficking is remarkably high. Patterns of traffic vary
across the world. Europe is the destination for victims from the widest range of origin
countries, while victims of Asia are trafficked to the widest range of destination
countries. The Americas are prominent for both origin and destination of victims.
Both the U.S. Department of Health and Human Services and the U.S. Department of State
offer resources for professionals who may encounter AYAs at risk (see [Table 1]).
Table 1
Practical recommendations for action to reduce SRH inequities
|
Section I: At the individual level: in everyday encounters
|
|
• Address each visit within a reproductive justice framework:
|
|
- Always use a holistic approach that centers the reproductive and sexual health
rights of adolescents and young adults (AYAs)
|
|
- Routinely assess AYAs' knowledge and attitudes toward “sexual consent” and provide
education and counseling
|
|
• Identify AYA-specific SRH risk factors:
|
|
- Consider possibilities of sexual abuse, child marriage, human trafficking, and
gender diverse/transgender equity concerns
|
|
- One-page decision tree from the national human trafficking center:[123]
|
|
- Use recommended screening tools
for older than 18 years/o https://www.acf.hhs.gov/otip/training-technical-assistance/resource/nhhtacadultscreening
validated 18–22 years/o (“youth friendly” as per authors)
https://vcrhyp.org/client_media/Trafficking%20and%20Exploitation%20Tools/QYIT%20-%20Covenant%20House%20NJ.pdf (reference is https://www.sciencedirect.com/science/article/pii/S0190740918307540?via%3Dihub)
|
|
• Follow guidelines and tools developed by World Health Organization (WHO) to prevent
early pregnancy and poor reproductive health outcomes (including child marriage) among
AYAs in developing countries
|
|
- WHO guidelines:
|
|
https://www.who.int/maternal_child_adolescent/documents/preventing_early_pregnancy/en/
|
|
• Approach individuals and their families with a trauma-informed lens that acknowledges
the role trauma may play in an individual's presentation/behaviors and relationships
|
|
- Clinical guidelines on responding to adolescent relationship abuse
https://www.futureswithoutviolence.org/userfiles/file/HealthCare/Adolescent%20Health%20Guide.pdf
|
|
- The integrated care “Toolkit” from the National Child Traumatic Stress Network's
Pediatric Integrated Care Collaborative includes a trauma-specific readiness assessment
and links to other tools related to providers' trauma-related stress and resilience.
http://web.jhu.edu/pedmentalhealth/PICC.html
|
|
- College age young people: The American College Health Association has resources
for adult allies and providers including an informative brochure on sexual violence
for young adults and a tool kit for the provision of services.
https://www.acha.org/ACHA/Resources/Topics/Violence.aspx
|
|
Knowledge areas to mitigate individual AYA risk during daily encounters
|
|
• Become familiar with local community-based resources to support SRH, in particular
community-based services geared for groups that have been marginalized
|
|
- Local health agencies often have resource directories for health education and
other services in communities that they serve, e.g., NGOs, nonprofit organizations
|
|
• Know the age-specific local consent laws for AYAs and child protection laws, e.g.,
sexual abuse, to identify risks for exploitation, e.g., early/child marriage, human
trafficking, relationship abuse
|
|
• Understand the legal reporting requirements in your area for healthcare providers
who suspect children and AYAs who are victimized and/or exploited
|
|
• Be informed of best practices for internet and social media safety tips and review
these with individuals and families; educate AYAs about protecting themselves from
on-line exploitation
|
|
- From the American Academy of Pediatrics Family/Teen Guidance:
https://www.healthychildren.org/English/family-life/Media/Pages/Points-to-Make-With-Your-Teen-About-Media.aspx
- From Media Smarts:
https://mediasmarts.ca/digital-media-literacy/digital-issues/sexual-exploitation
|
|
• Be cognizant of factors associated with inequities in access to sexual and reproductive
health (SRH) services and education, e.g., health and education policy, funding, population
poverty, racism, cultural hegemony, and populations living with social marginalization
|
|
• Utilize a culturally responsive, affirming model of care.
https://www.hennepinhealthcare.org/clinic/whittier-clinic-and-pharmacy/aqui-para-ti-here-for-you/
|
|
Section II: At an institutional/community and advocacy level
Collaborate with medical and public health institutions to address the following:
|
|
• Reaffirm commitment to preventing SRH inequities:
|
|
- Urge governments to sign, ratify, and implement policies and commit to recognizing
and eliminate all forms of SRH inequities
|
|
• Get involved with public health campaigns to promote equity:
|
|
- Engage in public health campaigns to promote health equity and protection of the
SRH rights of AYAs
|
|
• Advocate for close-in-age exemption laws
|
|
- To avoid over-criminalization of adolescents and to differentiate between the
unbalanced power by an adult and self-engaged sexual activity of adolescents
|
|
• Enact commitment to preventing FGM and other forms of SRH inequities by embedding
it in educational and training curricula
|
|
- Collaborate with school administrators and curricula designers to advocate for
positive, affirming, and inclusive approaches to teaching about human sexuality in
comprehensive school-based sexual health education
|
|
- Sexual Information and Education Council of the United States (SIECUS)
https://siecus.org/
|
|
• Advocate for increased research funding aimed at exploring the cultural nuances
of data collection of global childhood/adolescent sexual abuse to better inform prevention
strategies
|
|
• Advocate for more effective, affordable, culturally responsive, and accessible support
systems for survivors of sexual abuse and exploitation
|
|
- U.S. DHHS Administration for Children and Families
https://www.acf.hhs.gov/trauma-toolkit/victims-sexual-abuse
|
|
Section III—An SRH ethos/guiding values to approach all levels of efforts described
above
|
|
Reproductive Justice recognizes women's [and all AYAs] rights to reproduce as a foundational
human right
|
|
This includes the right to be recognized as a legitimate reproducer regardless of
race, religion, sexual orientation, economic status, age, immigrant status, citizenship
status, ability/disability status, and status as an incarcerated woman [AYA] and encompasses
the following:
|
|
A—Women's [and all AYAs] right to manage their reproductive capacity
|
|
1. The right to decide whether or not to become a mother and when
|
|
2. The right to primary culturally competent preventive health care
|
|
3. The right to accurate information about sexuality and reproduction
|
|
4. The right to accurate contraceptive information
|
|
5. The right and access to safe, respectful, and affordable contraceptive materials
and services; and
6. The right to abortion and access to full information about safe, respectful affordable
abortion services
|
|
7. The right to and equal access to the benefits of and information about the potential
risks of reproductive technology
|
|
B—Women's [and all AYAs] right to adequate information, resources, services, and personal
safety while pregnant include the following:
|
|
1. The right and access to safe, respectful, and affordable medical care during and
after pregnancy including treatment for HIV/AIDS, drug and alcohol addiction, and
other chronic conditions, including the right to seek medical care during pregnancy
without fear of criminal prosecution or medical interventions against the pregnant
woman's will
|
|
2. The right of incarcerated women [and all AYAs] to safe and respectful care during
and after pregnancy, including the right to give birth in a safe, respectful, medically
appropriate environment
|
|
3. The right and access to economic security, including the right to earn a living
wage
|
|
4. The right to physical safety, including the right to adequate housing and structural
protections against rape and sexual violence
|
|
5. The right to practice religion or not, freely and safely, so that authorities cannot
coerce women to undergo medical interventions that conflict with their religious convictions
|
|
6. The right to be pregnant in an environmentally safe context
|
|
7. The right to decide among birthing options and access to those services
|
|
C—A woman's [and all AYAs] right to be the parent of her child includes:
|
|
1. The right to economic resources sufficient to be a parent, including the right
to earn a living wage
|
|
2. The right to education and training in preparation for earning a living wage
|
|
3. The right to decide whether or not to be the parent of the child one gives birth
to
|
|
4. The right to parent in a physically and environmentally safe context
|
|
5. The right to leave from work to care for newborns or others in need of care
|
|
6. The right to affordable, high-quality child care
|
|
Adapted from: Conditions of Reproductive Justice
|
|
By Rickie Solinger[138]
|
Female Genital Mutilation
Female genital mutilation (FGM) is a violation of girls' and women's human rights
which refers to “all procedures involving partial or total removal of the female external
genitalia or other injury to the female genital organs for nonmedical reasons.”[108] The number of girls and women worldwide who have undergone FGM is estimated to be
over 200 million with the available prevalence data.[109] There has been an overall decline in the percentage of adolescent girls between
15 and 19 years of age who have undergone FGM worldwide over the last three decades
but not all countries have made progress.[110]
The large-scale representative surveys showed that FGM is highly concentrated in a
swath of countries from the Atlantic coast to the Horn of Africa, in areas of the
Middle East and in some countries in Asia. However, FGM is a global human rights issue
occurring in many other countries worldwide with large variations in terms of the
type performed, circumstances surrounding the practice. It is also found in some localities
of Europe, Australia, and North America which have been destinations for migrants
from countries where FGM is still prevalent.[110]
[111] Girls in immigrant communities could be at risk if their parents adhere to the beliefs
and practices from their home countries where FGM is common.
A 2016 study by the CDC estimated that 513,000 U.S. girls and women either had potentially
undergone the practice of FGM in the past or were at risk for undergoing it in the
future.[111] A U.S.-based study reported that half of the women's health providers did not receive
formal training about FGM and its complications, but a majority had cared for FGM-affected
women in their practice.[112] Thus, a knowledge and practice gap exists for managing infibulated patients, and
surgical defibulation procedures were not routinely offered. Authors have suggested
that FGM content needs to be embedded in educational and training curricula with an
ongoing clinical mentorship.
Despite the global recognition of FGM as a harmful practice of SRH and its illegal
status in most countries, the involvement of healthcare providers in the performance
of FGM still exists, which may create a wrong sense of legitimacy for the practice
and can lead to its perpetuation. WHO has developed a global strategy to stop medicalization
of FGM in collaboration with key stakeholders, including UN organizations and healthcare
professional bodies.[113]
Health Justice in SRH Services and Education
In this section, services and education in SRH for AYAs are examined, focusing on
access to contraception, abortion, and comprehensive sexual health education. These
topics have been chosen due to the significant health inequities in SRH among AYAs,
worldwide.
Health care and educational settings for AYAs can be a sanctuary for youth who have
experienced sexual exploitation and/or who have unmet needs for SRH services.
In this final section, inequities in contraception and abortion access and health
disparities in human papillomavirus (HPV) vaccination are discussed, as well as the
need for comprehensive sexual health education. In total, these services provide a
path to positive youth development, to health equity, and to empowering youth to make
SRH decisions in their best interest, while considering the dignity and rights of
others.
Contraceptive Access
Lack of access to sexual and reproductive healthcare, lack of opportunities and support
for reproductive autonomy, decision making, and the ability of individuals to make
the right sexual and reproductive choices for themselves and their families can lead
to unintended pregnancies and STIs and associated negative developmental and psychosocial
outcomes. Disparities in access to SRH services and education have had an important
impact in every aspect of life in communities struggling with marginalization.
Access to contraception can lead to decrease in teen pregnancy rates.[114]
[115] However, women in underrepresented and lower socioeconomic status groups have less
access to the most effective methods. Highlighting the ethnic and race inequities,
in the United States white women use contraception at a higher rate than Hispanics
and African Americans.[10]
In an analysis using the National Survey of Family Growth, the rates of no contraceptive
method used in the last month was almost 32% among 15 to 19 years old sexually active
women, followed by 19% in 20 to 29 years old. In terms of race differences, 16% of
white women used no contraception during the last month, compared with 19% of Hispanics
and 24% of African American women.[116]
In this same study, younger women, aged 15 to 19 years, used less effective methods
in 21% of cases, compared with 22% of the 20 to 29 years old. Marked differences were
noted for race across ages (15–24 years old): 14% white versus 18% of African American
and 18% Hispanics. It should be kept in mind that women in this study are more advantageous
than the population of women they represent, given the demands of responding to national
surveys; so, true population rates are likely greater. Less effective methods included
condoms, diaphragms/sponges, and spermicides.
Teenage pregnancy is mostly (75%) unintended and can lead to adverse health, educational,
and economic outcomes for both the mother and the child. There are multiple social
and health consequences of teen pregnancy including low birth weight, preterm delivery,
and severe neonatal conditions. The children of teenage mothers have higher rates
of school failure and incarceration, and are also more likely to give birth as a teenager,
perpetuating the cycle of poverty. Teen mothers usually attain lower education and
income with a lifelong impact of social and health inequities.[117]
[118]
Although teen pregnancy rates have declined in the United States over the last several
decades, rates continue to be high compared with other developed countries, and marked
disparities continue to persist: in 2018 (latest data available),[119] the birth rates of U.S. Hispanic 15- to 19-year-old girls (27/1,000) and non-Hispanic
black teens (26/1,000) were more than two times higher than the rate for non-Hispanic
white teens (12/1,000).[114]
At the same time, historical use of sterilization as a means to achieve fertility
control in communities that have been marginalized up until the very recent past calls
for a reproductive health justice framework and balance when approaching contraception
in populations that have been historically marginalized.[120]
[121]
Access to Abortion
The historical journey to legal access to abortion in the United States was long and
not without consequences. Abortion finally became legal in the United States in 1973
[Roe v. Wade].[122] Legal challenges to Roe v. Wade have failed to overturn it thus far, and in response
many states responded with laws and regulations restricting access to clinics. Strategies
employed by states included removing funding, publicizing overestimations of abortion
risks, imposing regulations on hospital admitting privileges, increasing waiting times,
and imposing unnecessary facility regulations. These actions not only made it more
difficult for patients to access abortion services, but they also promoted violence
aimed at patients, providers, and facilities, all the while being marketed as protecting
the health of the women.[123] This restrictive abortion movement gained political support through the 1990s, and
accelerated in the current political climate.
On the global scene, the United States used the expansion of the “global gag rule”
as part of “the weaponization of U.S. foreign assistance to systematically target
global sexual and reproductive health and rights programs.”[123] In countries where this funding was fundamental to provide access to abortion and
contraceptive services, it not only restricted access but also devastated health infrastructures,
taking an important emotional toll on the population.[124]
This policy action described earlier was recently rescinded by the current presidential
administration but could be restored by Congress at any time.[125]
Most abortion patients in 2014 (75%) were poor (income below the federal poverty level
of $15,730 for a family of two in 2014) or had low income (having an income of 100–199%
of the federal poverty level).[126] Insurance does not always cover abortion services and even when it does, most patients
pay out of pocket for many reasons including concerns about confidentiality. Current
barriers have led to more inequities in abortion access and hardship for AYA already
facing other obstacles to accessing healthcare in general.
HPV Vaccination Access
Disparities in HPV Vaccination
Implementation of publicly funded equitably delivered HPV vaccination programs offers
opportunities to reduce health inequalities associated with cervical cancer. Fisher
et al reviewed evidence of inequalities in HPV vaccine uptake in young women with
a systematic review and meta-analysis including 27 studies—majority originated from
the United States—that compared HPV vaccination initiation or completion by at least
one ethnicity or socioeconomic-related variable in AYA. Their analysis strongly suggested
that black AYA were less likely to initiate HPV vaccination compared with white peers.
They also reported that in the United States, AYA without healthcare insurance were
less likely to be vaccinated.[127]
There are also large disparities in HPV vaccination programs worldwide. Vaccination
for HPV varies according to the income level of countries. While the HPV immunization
programs in low- and middle-income countries are mostly nonexistent, the majority
of the new cervical cancer cases and deaths occur in these countries. It is estimated
that only 1% of women who had received at least one dose of the HPV vaccine through
the publicly funded HPV vaccination programs were from the low-income countries. Thus,
it is important to make HPV vaccination more affordable in all countries for narrowing
the global inequalities in cervical cancer burden.[128]
Access to Comprehensive Sexual Health Education
Comprehensive sexual health education goes beyond reproductive biological facts to
emphasize the relational, ethical, and developmental aspects of human sexuality with
grade-level/age-appropriate content delivered in schools. This concept is perhaps
best elaborated upon by the Sexuality Information and Education Council of the United
States (SIECUS).[129] The basic curricular components of the SIECUS program are the following: human development,
relationships, personal skills, sexual behavior, sexual health, and society and culture.
SIECUS essentially provides a life skills framework for empowering children and adolescents
to make responsible decisions about their sexual health and sexual behavior, within
the context of human rights and dignity. Young people learn about the life behaviors
of sexually healthy adults, where exploitation and manipulation are avoided and prevented.
Culture and values and respecting developing identities such as gender and sexual
orientation are part of the curriculum.[130]
Comprehensive sexual health education does not promote sexual activity, but rather
it supports positive youth development and socially responsible behavior.[11] The SIECUS guidelines are especially useful given the trend by governmental funding
and policy in many regions to exclusively support abstinence-only sexual health education,
which has been found to be ineffective and even harmful to children and adolescents.[131]
[132]
The provision of comprehensive sexual health education in schools varies widely by
region for many reasons, including funding, political influence, and cultural forces
related to education about sexuality. In many areas of the world, only more socially
advantaged adolescents have access to this resource, and in many cases the local educational
governing bodies have to approve it. In the United States, there is a stark difference
in availability of educational access to these curricula, which, when combined with
access to contraception, results in regional differences in teen pregnancy rates.[133] In the United States, for example, any sexual health education (not necessarily
comprehensive) is required in only 60% of the states; and among those states, most
do not require the content be based on evidence.[134]
[135]
There is increased momentum among the United Nations Educational, Scientific and Cultural
Organization (UNESCO) member organizations throughout the globe for comprehensive
sexual education. In 2008, the Latin America and Caribbean regions of UNESCO reported
that country-level leadership committed to delivering some form of SRH and sexual
health education. Likewise, in 2013, there was commitment across 20 countries in Eastern
and Southern Africa to improve both comprehensive SRH education and services for AYAs.
There is an emphasis in these latter countries on life skills for HIV prevention.[136]
Healthcare providers can learn about aspects of the SIECUS guidelines and tailor their
guidance to AYAs in clinical settings according to the needs of the youth. Furthermore,
they can learn about the availability of sexual health education in areas, schools,
and collaborate through their medical societies and with public health departments
to expand availability of services. If schools are not receptive, sexual health education
can and should also be provided within youth serving organizations. Such information
serves to empower youth to make responsible sexual health decisions and further to
protect their own health and safety and that of their peers.
