| | Access to sexual and reproductive health for young people: Bridging the disconnect between rights and reality published online 18 June 2009. Abstract Of the 1.5 billion young people globally, 78% live in Asia and Africa, the poorest regions of the world. The majority of young people infected with HIV are female and adolescent girls have a significant increased risk for maternal mortality and morbidity, such as fistula. Trends to delay marriage do not decrease the age of onset of sexual activity, but highlight the need for access to sexual and reproductive information, and skills and services to learn healthy sexuality and prevent unwanted pregnancy and sexually transmitted infections. Youth-friendly services require confidentiality, privacy, and non-judgmental attitudes, and rights of adolescents include the consideration of their evolving capacities to consent to services. Denial of young people's sexuality and rights by conservative and traditional forces has lethal consequences, especially for women and girls. Countries have committed to these rights through numerous international instruments and many are making progress, but challenges at the community level are significant. 1. Background  With 1.5 billion youth and adolescents—young people—between 10 and 25 years of age, the demographics of the world's population has caught the attention of many, although only recently has research begun to address their sexual and reproductive health needs. More than 78% of young people live in Asia and Africa, where they make up over 30% of the population and where two-thirds of the young women are married [1], [2], [3]. Furthermore, the continuing growth in the absolute numbers of young people as well as the lengthening period of years spent unmarried (and in many cases sexually active) ensure a rapid and continuing growth in young people's need for education, as well as for reproductive and other health services. Of the young women between 15 and 19 years, 14–15 million give birth every year [4]. Many die from pregnancy-related causes, including unsafe abortion. Those under 15 years are at greater risk. Young people aged 16–24 years are the age group most at risk of being diagnosed with a sexually transmitted infection, with young women being more vulnerable [5]. The sexual and reproductive health of young people is recognized as key to the development of nations, demographically, economically, socially, culturally, and politically. Meeting their needs is patently critical to achieving the Millennium Development Goals (MDGs). However, the inclusion of universal access to reproductive health as a target for MDG 5 occurred only in October 2006 after prolonged negotiations reflecting the reluctance, in circles of influence, to provide support where there are certain sociopolitical sensitivities. Denial of young people's sexuality and rights by conservative and traditional forces has lethal consequences, especially for those living in poverty. It is not, therefore, a surprise, but a tragedy, that HIV/AIDS is now the leading cause of death for women aged 15–29 years in Sub-Saharan Africa and one of the leading causes of death for men in the same age group [3]. 1.1. The determinants of sexual and reproductive health Determinants of health are primarily social; sexual and reproductive health (SRH) includes determinants such as education, gender, poverty, and mobility. The healthcare system can be considered a social determinant of health, since access to, experiences of, and benefits from healthcare are all closely linked to people's gender, education, occupation, income, ethnicity, and place of residence. Unlike other aspects of health, SRH is directly related to the survival of the human race and embroiled in complex community and societal taboos, often based on fear, misinformation, and a need to protect traditional norms without the recognition that they may be harmful. Sexual and reproductive behaviors are unique in being regulated by society, in part to protect the vulnerable, but legislation is often formulated or neglected without due consideration of the context of the lives impacted, the scientific evidence, or the potential consequences. These include marriage, sexual intercourse, and access to SRH services without parental consent. Sexual and reproductive health requires knowledge of normal physiology and development, healthy expressions of sexuality, an understanding of the consequences of sexual and reproductive behaviors, as well as communication skills that assist people in making informed and responsible decisions. Access to services that provide contraception, safe abortion, pregnancy care, and diagnosis and treatment of sexually transmitted infections is critical. Unmet contraceptive need in adolescents, many of whom are married, is twice as high as the general population [1] and it is staggering to note from Demographic and Health Surveys (DHS) data that unmet need for permanent contraception begins in Bangladesh under the age of 20 [6]. The importance of SRH services is essential to prevent unwanted pregnancies and unsafe abortion, and to reduce maternal and child mortality as well as reducing poverty and empowering women. The related available evidence has resulted in the articulation of multiple related human rights in several United Nations conferences since 1948. The landmark conference was the Fourth International Conference on Population and Development (ICPD), held in Cairo in 1994 [7]. The resulting Programme of Action was a clear road map for countries to follow, yet the available data suggest progress has been disappointingly slow. The United Nations General Assembly Special Session on Children in 2002 specified the need to improve care for pregnant adolescents [8]. The Lancet devoted one of its series to sexual and reproductive health in October 2006, noting that the inhomogeneous, multicultural, and religiously diverse nature of the world's population means that approaches to improving SRH must take into account the social context of planned interventions [9]. Importantly, as noted by WHO, behavioral patterns acquired during adolescence tend to last throughout adult life, with approximately 70% of premature deaths among adults due to behaviors that began during adolescence [10]. The ICPD was clear on the consequences of poverty and inequality for young women, as illustrated in Table 1.  | • Coerced unprotected sex | | | • Early marriage | | | • Teenage pregnancy | | | • Lack of access to contraception | | | • Unwanted pregnancy | | | • Unsafe abortion | | | • HIV/AIDS and other sexually transmitted infections | | | | |
2. Sexual and reproductive health, human rights, and youth It is important to consider the links between health and human rights broadly when relating to adolescents and youth because many of the social determinants are also articulated as rights—the rights to education, information, housing, and social security. Child or early marriage, defined as marriage carried out under the age of 18 years, violates numerous rights as outlined in Table 2, most of which are articulated in the Convention on the Rights of the Child (CRC) [11]. Although most countries have declared 18 years as the minimum legal age of marriage, more than 100 million girls are expected to marry in the next decade [12]. This is of critical importance since the percentage of adolescents giving birth in Western and Middle Africa under 18 years continues in excess of 30%, while in Southern Asia, Eastern and Southern Africa, and Central America and the Caribbean, rates of early childbearing remain over 20%. Maternal mortality rates from all causes are 5 times higher for girls under 15 years and are doubled for those aged 16–19 years, with unsafe abortion a significant contributor. Fistula is common in countries like Ethiopia where 50% of girls are married before the age of 15 [11]. | • | The right to education | | | | Article 28, CRC | | | • | The right to be protected from all forms of physical or mental abuse, including sexual abuse | | | | Article 19, CRC | | | • | The right to be protected from all forms of sexual exploitation | | | | Article 34, CRC | | | • | The right to enjoyment of the highest attainable standard of health, | | | | Article 12, ICESCR | | | • | The right to educational and vocational information and guidance | | | | Article 28, CRC | | | • | The right to seek, receive, and impart information and ideas | | | | Article 19, UDHR | | | • | The right to rest and leisure, and to participate freely in cultural life | | | | Article 31, CRC | | | • | The right not to be separated from their parents against their will | | | | Article 9, CRC | | | • | The right to protection against all forms of exploitation affecting any aspect of the child's welfare | | | | Article 36, CRC | | | | |
2.1. Right to health through education The right to education is enshrined in the CRC and a major focus of the MDGs, and while young women lag behind, they are at greater risk in terms of their sexual and reproductive health. Women with 7 or more years of schooling have between 2 and 3 fewer children than women with fewer than 3 years of education, are less likely to marry early, more likely to practice family planning, and their children have a higher survival rate (Africa, Asia, and Latin America) [10]. Students in school are less likely to have had sex than their non-enrolled peers [3]. Fortunately, school attendance globally is increasing, with substantial increases in grade attainment and closing of the gender gaps in enrollment. 2.2. Sexuality education Sexuality education is always a contentious topic, beset by vocal opinions from people in positions of influence in society who consider their personal or life experience justification to support their point of view [13]. The most commonly heard concern worldwide is that providing information to young people will encourage earlier sexual activity, despite evidence to the contrary. Withholding information is not simply a matter of morals, but a lack of acceptance of reality with potentially devastating consequences, particularly for girls. Misinformation and lack of knowledge about sexual and reproductive health is disturbingly common among young people, globally [13]. In a 2007 study in Malawi, while 90% of young people were aware of HIV, only 51% of females and 65% of males knew that abstinence, being faithful, and using a condom are 3 ways to avoid infection [14]. In Malawi, 40% of girls aged 12–19 years believed they could not get pregnant if they had sex while standing up, and in Kenya some believed that taking an aspirin would prevent pregnancy [15]. Abstinence only programs (AOP) are also controversial because of the reality of young lives. In a Centers for Disease Control and Prevention (CDC) study by Kohler et al. [16], it was noted that teenage pregnancy rates were significantly lower in those receiving comprehensive sex education (CSE) compared with those receiving no sex education (NSE). There was a 50% reduction in teenage pregnancies in CSE compared with the AOP, which showed no reduction in teen pregnancies compared with NSE. Related findings were that AOP participants reported no delay in onset of initiation of vaginal intercourse. In suburban Shanghai, a study of a youth-friendly intervention program providing information, skills, and services to promote safe sex behavior (contraception and condom use) compared with a control group, both unmarried females and males aged 15–24 years, showed that the intervention group was 14.59 times more likely to use contraceptives at onset of intercourse, if it occurred [17]. The rising age of marriage means an increased likelihood that sexual debut will occur before marriage, yet, in most countries, sex is not being initiated at an earlier age relative to the past. In fact, fewer young women report themselves to have been sexually active before 18 years [3]. Delayed marriage translates into a growing need for accessible information and reproductive health services so that young people can protect their health, avoid pregnancy, and delay childbearing until they are ready. What is required goes beyond the simple provision of services and includes acquisition of life skills such as being able to communicate, negotiate, and recognize and resist pressure from others—the right to decide. 2.3. Rights to sexual and reproductive health services While most are familiar with societal debate surrounding access to information and services for contraception and abortion for young people, the appearance of HIV has added greater weight to the discussion in support of the rights due to adolescents and youth. The right of young people to freely express their views and opinions and have them considered speaks to the need to develop an approach that allows meaningful participation opportunities at the policy level that respect young people's interests and needs in programming for HIV and reproductive health services. Table 3 illustrates many of the rights, and the human rights' instruments from which they are derived, related to sexual and reproductive health for adolescents and youth, with some examples of their practical relevance. According to the Convention on the Rights of the Child, the right to information should consider evolving capacities in the provision of services without parental consent [18]. | | | | Right | Examples | Source | |
|---|
| Right to health [Right to attain the highest standard of sexual and reproductive health] | Emergency obstetric care; prevention and early detection of cervical cancer; syphilis screening; access to essential medicines | CEDAW; ICESCR | | | Right to the benefits of scientific progress | HPV vaccine; emergency contraception; medical abortion; antivirals | ICESCR, Article 15(1)(b) | | | Right to non-discrimination | Requiring married women, not men to get spousal authorization for health services; adolescent access to health services | Political Covenant, Article 2(1); Children's Convention, Article 2 | | | Right of adolescents and youth to access information, counseling and youth friendly services | Comprehensive sexuality education, including life skills; HIV VCT | CRC; ICPD 1994 | | | Right to decide number, spacing, and timing of children | Access to information and services contraception and safe abortion | UNCHR 1968; ICPD | | | Right of all to make decisions concerning reproduction free of discrimination, coercion and violence | Informed choice; no coerced pregnancy or coerced abortion or sterilization | ICPD; Beijing 1995 | | | The right to life and survival | Maternal mortality; HIV/AIDS | ICCPR; CRPD; CRC | | | Right to bodily integrity and security of the person | Security from sexual violence, coercive sterilization or abortion | UDHR | | | Right to privacy | Sexuality; confidentiality for reproductive health services; HIV/AIDS; violence | ICCPR; CRC | | | Right to seek, receive and impart information | Informed decision making | UDHR, Article 19 | | | Right to equality in marriage and divorce | Right of woman to control and make decisions about her life, including reproductive health | CEDAW | | | Right to freedom of thought conscience and religion | Emergency contraception | Political Covenant, Article 18 | | | | |
2.4. The right to non-discrimination: Gender equality and the empowerment of women Most countries now recognize that investing in and empowering women and girls is one of the most cost-effective and efficient ways to advance the development agenda [1]. By supporting gender equity, governments, donors, international organizations, and civil society can improve the lives of millions of girls and women and their families, calling for interventions that affect all social classes with as much attention to boys' attitudes and behaviors as to girls [3]. Addressing gender biases in the structures of society, in laws and their enforcement, promotes gender equity and makes discrimination on the basis of sex illegal [10]. Well-designed incentive programs, such as free uniforms or monetary incentives, to keep girls in school have been shown to be effective interventions [3]. Gender inequality often involves societal norms that require women and girls to be ignorant and passive about sex, whereas men and boys should demonstrate manhood by risk-taking behaviors and having sex with multiple partners. In Sub-Saharan Africa the common issue of a significant age difference between young women and their partners aggravates the gender power imbalance and has been a major determinant of HIV spread in this region [4]. When, with whom, and how to have sex is largely determined by men. Poverty also introduces the element of sex as a commodity, often in desperate necessity, or through those in positions of power over children. To translate alternative gender messages and policy efforts into action they must be delivered in settings that exemplify stereotypical gender behavior. In the UK, predominantly male spaces such as football clubs and bars have been effective arenas in which to address not only men's needs from a gender perspective, but also to challenge male norms on violence against women (e.g. Coaching Boys into Men – Family Violence Prevention Fund). Similarly, adolescent health messages have more impact when extended to schools and popular “hang outs” rather than the clinic setting [19]. The Global Gender Gap annual report, initiated in 2006, provides tracking and ranking of countries by the World Economic Forum, identifying the gap between women and men in 4 key areas: economic participation and opportunity; political empowerment; educational attainment; and health and survival [20]. There has been recognition by policymakers and business leaders of an increasingly urgent need to close gender gaps and leverage the talents of both women and men owing to talent shortages. Table 4 illustrates selective data from the 2007 report where adolescent fertility rates, contraceptive prevalence, and maternal and infant mortality are key indicators, perhaps attracting a different audience than the MDGs. 2.5. Universal access to youth-friendly sexual and reproductive health care Equitable access to and utilization of health care has been articulated as a basic human right. Reproductive health services have a special role in attaining MDG 5 for the improvement of maternal health, including maternal and newborn health, family planning, prevention of unsafe abortion, control of sexually transmitted infections, and promotion of sexual health. HIV control and gender are crosscutting issues to be addressed, also captured in the MDGs. Strengthening sexual and reproductive health services for adolescents and young people should involve them in determining their needs as these vary between countries and regions. In particular, most family planning and reproductive health programs designed to serve young people have neglected the special needs of married adolescents, a particularly disadvantaged group. Lack of availability of services is commonly noted as the most important barrier, but lack of access to reproductive health knowledge was also associated with lack of self-confidence among adolescents to discuss such issues. In Sri Lanka, focus group sessions found that the most common problems for 17–19 year-olds were psychological distresses, masturbation, and menstrual cycle problems [21]. Young people rated expected factors as most important in youth-friendly services: confidentiality, privacy, short waiting time, low cost, and friendliness to both young men and young women [22], [23], [24]. Least important characteristics included youth-only service, youth involvement, and young staff. Studies of the attitudes of health professionals to adolescent SRH problems concerning provision of services in Kenya, Zambia [25], Swaziland [26], and Uganda [24] confirmed reported experiences of young people. There was disapproval of adolescent sexual activity, including masturbation, contraception, and abortion, although those with more education had more youth-friendly attitudes. Studies from the USA and UK have found similar needs to improve youth services and male-friendliness as well as integration of HIV services, learning from lessons integrating services for family planning and sexually transmitted diseases [27]. Health Sector reform in Mongolia has resulted in innovative youth-friendly services engaging urban youth. They reduced maternal mortality and increased contraceptive use, but sexually transmitted infections and rising rates of adolescent pregnancy remain a challenge [28]. Many countries are taking steps such as removing legal obstacles so that young people can access needed services, for example, under South African law, anyone 14 years or older has the right to receive contraception [1]. Cultural taboos present challenges to policy even when governments are progressive, for example in Nepal the practice, not the policy, is that government family planning services are provided to married couples only. The consequent reality is that almost 25% of girls become pregnant before 19 years, two-thirds of new cases of HIV occur among adolescents, and over half of all abortions carried out occur among women aged under 25 years [29]. Some taboos have been successfully addressed, such as improving traditional youth education to avoid pregnancy and prevent HIV/AIDS in Ghana. Work by the Planned Parenthood Association supported by the Department for International Development (DFID), reached almost 30 000 young people and the number of young people using contraception increased from 27% to 80%. In Zambia, DFID support to the AIDS Alliance has helped support sexual and reproductive health sessions with 80000 young people; a community member said, “More boys and girls recognize their rights to refuse sex, enjoy their feelings without intercourse or insist on using a condom” [29]. Reaching special vulnerable groups of young people, including sex workers and street children in urban areas, may require innovative pilot studies in service delivery formats, such as unconventional, non-clinical settings, and escorts or referrals using coupons or vouchers. In addition, studies should be undertaken to determine under which local epidemiological and health service conditions they would be cost-effective [5]. Integrating sexually transmitted infection (STI) prevention with reproductive health services instead of separate STI services can also help to ensure privacy and reduce stigma [19]. During the Pre-Congress Workshop at the 2006 FIGO Congress, the International Planned Parenthood Federation (IPPF), FIGO, and young people explored access issues for youth-friendly services. They noted that service providers needed greater understanding of the changing needs and evolving capacities of young people and that preservice curriculum was the optimal time to improve attitudes through education. Recommended comprehensive services for adolescents included emergency contraception, safe abortion, and care for survivors of sexual violence [30]. In follow-up, FIGO is beginning an initiative, with UNFPA support, to advance young people's SRH and rights through partnerships at global, regional, and national levels. The project will include dialogue between young people and health professionals in SRH, leading to the development and dissemination of a training curriculum and guidelines. 3. Conclusion There is significant unmet need for information, education, and services for sexual and reproductive health for married and unmarried young people. It is essential to create an environment conducive to keeping girls in school through the secondary level and to address gender inequalities for successful development of nations. The ideological resistance to comprehensive sexuality education programs and youth-friendly reproductive health services for males and females is not evidence based, leaves young people vulnerable, and perpetuates gender inequalities. Attitudes of health professionals often pose a barrier to access and must be addressed through leadership from health professionals using the evidence, to encourage broader social discussion of the issues, improve access to SRH services by young people, and access to male-friendly providers. No single program is likely to be able to serve the needs of all young people; what is required is that the particular reproductive health needs of adolescents are addressed and youth-friendly services provided are based on their input, broadly and in their communities in these decisions that affect their lives, their health, their future, and the future of their countries. This will require working with local political and religious leaders to increase public awareness of the reproductive and sexual health issues affecting adolescents and young people. 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