The overarching messages from the papers in this journal issue are that: 1) adolescents and young people want and need sexual health information and health care, provided with a sex-positive approach to sex, sexuality, sexual identity and relationships; 2) those providing it need specialist training; and 3) adolescent and youth leadership and involvement in policy, activities and programmes are crucial. Adolescents and young people want to know about HIV, STIs, pregnancy, abortion, contraception, sexual and gender identity, communication in relationships, menstruation, sexual violence and coercion, stigma, bullying, discrimination. But above all, they want to know about sex and bodies. Remember surging hormones? Long before they ever have sex, they want to understand and be able to talk about these issues with family, friends, peers. If you read this journal issue from cover to cover, and I hope you do, you'll feel pummelled by these messages, as I did, by the time you reach the end, and you deserve to feel pummelled; we all do.
So it was a real boost for me to find the photograph for the cover of this edition of RHM, because the papers were really getting me down. I thought if I had to edit one more paper about the extent of sexual harassment, violence and abuse experienced by adolescent girls and young women, and the pressure on them to have sex whether they wanted it or not, I didn't know what I would do. The fact that the pressure on them was coming from fathers, relatives (including women at times), teachers, employers, sons of employers, neighbours, boys in the street, almost beggared belief. The silence and complicity of parents was the most upsetting of all. But why was I surprised? The article about eve-teasing in Bangladesh in this issue, for example, isn't just about the patriarchal culture of Bangladesh. It's happening here in London too (see Twitter @everydaysexism and #EndStreetHarassment). The rapes of young girls in India and South Africa, and the sexual abuse of boys and girls, including by gangs and priests, that have hit the news in recent years – these are global phenomena.
So this photo raised my spirits and I found many more like it that helped too. I wanted to put all of them into these pages, so much better than words, words, WORDS! We're drowning in oh-so-politically-correct words about adolescents and young people that always start with how important they are – in programmes of action, national policy documents, human rights conventions, conference resolutions, high-level task force recommendations, consultation briefs, research reports, police investigation findings, autopsies.
Unkept promises is what those words represent, as one paper here sets out thoroughly. Unkept promises – coming from adults who are afraid of challenging the systematic repression of young people, especially those who are not heterosexual, and who want to both protect and control them. Who want sex to be strictly controlled and don't trust young people with information because (and yes, it's true) they don't always act wisely when it comes to sex. As if most adults do. As if giving them information will make them act even more unwisely, when all the evidence says the opposite.
I love adolescents – the intensity, the exuberance, the screaming laughter, the sassiness, the stubborness, but also the shyness, the awkwardness, the anxiety, the self-doubt, the demands, the sulking, the expectation of fairness, the outrage at injustice and being denied. Late at night, young people seem to be everywhere in large numbers, in the streets, on public transport, shouting, pushing, laughing out loud, full of booze and testosterone, on their way from one set of late night clubs to others. And if you think I'm talking only about London, my friends, you'd better have a look at your own locale after midnight if you aren't aware already, because it's happening there too. Young people are on the move, including in these pages!
Here is what awaits you. First, something new for RHM – two papers about using visual and social media to raise issues around sex and relationships that affect young people, from their own perspective. One from South Africa, using video, DVD and a mobile clip, about using popular culture for social change and one from Ecuador about two videos, one with young people talking about sex and the other with three generations talking about what has changed. Links to these are provided in the papers so you can watch them as you read.
There are tons of such videos and they can be used in a myriad of innovative ways. Here is an example I found while scrolling one day – a short video on YouTube called Jamaica Anti-Rape Campaign (Please Share) by artistik.kreations. Its aim is “to heighten the awareness of every young man, to ‘MAN UP’ and end violence”. Go on, watch it and share it on social media yourself!Footnote* It's just over two minutes, and since it was made in October 2012, it's had more than 39,400 hits. www.youtube.com/watch?v=IS8uJ9dol5s&feature=player_embedded
And this one, called You Don't Own Me, by ProChoice Dublin, which was made in 2013 during a wave of activism for abortion rights. This video uses costume, song, music, acting out – fantastic! Its most telling message is: “If we can't be trusted with a choice… How can we be trusted with a child?” But it isn't just about abortion, it's also about girls owning their own lives. http://vimeo.com/55300483
In response to the many risks they face, young people's activism is the heartening subject of a number of papers, particularly one from Rwanda about work by the Rwandan Youth Action Movement on unsafe abortion. The group gathered data on the extent of unsafe abortion in Rwanda and testimonies of young women locked up in prison for many years for having abortions. They organised debates, values clarification exercises, interviews and a survey in four universities; launched a petition for law reform; produced awareness-raising materials; worked with the media; and met with representatives from government ministries, the national women's and youth councils, and parliamentarians. All of this played a significant role in the advocacy process for amendment of the law when the penal code came up for review in June 2012, making public a subject that had previously been taboo.
There is also a short report from public health students at the Johns Hopkins Bloomberg School of Public Health in the USA of their activities for Billion Women Rising in February 2013. They joined millions of people throughout the world to demand an end to violence against women and girls, inspired by Eve Ensler's play, The Vagina Monologues. Events took place in 207 countries. The Hopkins staff and students organised lectures and panel events, photo essays, information giveaways and a dance performance.
Children dance at a school AIDS club meeting. The club promotes AIDS prevention and supports children affected by HIV, Malawi, 2006
A paper from UNAIDS authors reports on the use of “crowdsourcing” both to formulate the problems and generate solutions to youth leadership and participation in the AIDS response, a process in which “problems are broadcast to an unknown group of solvers in the form of an open call for solutions. Users – also known as the crowd – submit solutions”. UNAIDS's youth policy this year has resulted from just such an exercise.
This paper gives much food for thought. For example, it says: “the introduction of social media has changed the relationship between the source of a message and the audience, where the audience no longer passively consumes media content, but actively engages in creating it. This marks a shift from a one-to-many to a many-to-many model of communication online, which has implications for how young people access information about sex and sexuality as well as the type of information available”.
There is a paper from Australia which reports on whether a wide range of adolescents thought that Facebook and other social media were appropriate sites for sharing messages about sexual health. The answer, in a word, was no, not really, because of the: “participatory culture of social network sites; the stigma of sexual health, especially sexually transmitted infections (STIs); young people's careful presentations of self; privacy concerns; fears of drama (bullying and gossip)”. A Bookshelf publication from Australia talks about how such messages should be communicated, with strong opinions about use of the Internet.
Adolescent and young peer researchers carried out and participated in analysing a lot of the studies reported here and young people (co-)authored quite a few of the articles too. Youth peer providers were the subject of another paper, about Ecuador and Nicaragua, in a programme begun in the 1990s in a number of Latin American countries. The model goes beyond peer education to train youth peer providers under the age of 20 to provide condoms, oral contraceptive pills, emergency contraception, injectable contraceptives, and sexual and reproductive health information to their peers.
A paper from Guatemala describes a different sort of peer-led programme, which involves clubs for adolescent Maya girls, led by girl leaders aged 15–24, in their own community. The goal is to increase the girls' personal and social resources, including a safe place to meet with peers, increased support networks, access to positive female role models, and a training programme to increase knowledge and skills, to build a base of critical life and leadership skills, which girls tend not to receive at home or in school.
Young people want and need sexual health information. One of the papers from Bangladesh shows the extent to which young people seek out information about sex and sexual health from a huge range of sources – and they find it, though it may be full of misconceptions. The paper provides a picture of adolescents' sexual feelings and concerns in relation to desire, pleasure, sexual power, masturbation, virginity, romantic love and dating, and arranged marriage – and how socio-sexual norms and taboos influence these. Curiosity of both boys and girls about sex was driven by a need and desire to know and understand, but also because it was exciting to read about and talk about sex. Young people were far from passive recipients of adult norms and messages around sexuality.
There are three papers here about sexuality education, one from the USA about the process over several years of developing an innovative programme for a tough, ethnically diverse urban area of Los Angeles. One from Brazil uses an innovative discourse analysis method to delve into what school teachers really thought about teaching sexuality education, which I would recommend to anyone teaching sexuality education. The third is on the successful use of a practical tool, created to help curriculum developers and educators integrate a gender perspective, a human rights focus, and critical-thinking teaching methods into their sexuality and HIV education curricula, called It's All One! (reviewed in RHM18(36)). NGOs working with young people report on how they used it for curricula in two school-based programmes (China, Nigeria), two programmes for extremely vulnerable youth (Guatemala, Haiti), and one for young people from a polygamous religious community (USA).
Then there is the vexed issue of adolescent pregnancy, a constant global reality that still elicits more judgemental attitudes than understanding, help and support, let alone access to alternative life choices. There is a paper from South Africa about the difficulties adolescent schoolgirls still have to stay in school during their pregnancies and after they have had their babies, despite national policy requiring schools to support them in doing both. Even so, the government policy is there and the young women are adamant they want to stay in school. Apropos of this subject, I accidentally stumbled across a summary of a publication in RHM6(12) from 1998, whose title was: “Pregnant schoolgirls no longer have to wear red overalls: Mexico”. So things do change for the better.
This paper raised issues about language… specifically: adolescent girls vs. young women. I had an exchange about this with several of the authors of papers here. None of them much liked using the words “adolescent girls” in their papers, even for 12–15 year olds, because many of these “girls” were having sexual relationships, and some had already been pregnant and had babies or abortions. Yet “adolescent women” didn't work either. As one paper rightly says: “adolescents have often been wrongly perceived as young adults or big children”. They are neither, and they deserve to be seen as a group all of their own, evolving over a short period of years away from childhood and towards adulthood, whether steadily or in fits and starts.
Sometimes, adolescents need far more protection and support than they may get. One paper here presents young pregnant adolescents in Kerala, India, who had no information, a fear of lack of support and of condemnation, and therefore delayed seeking abortions until the second trimester. Another, also from India, addresses young girls' lack of the means to practise menstrual hygiene and the need for community-based health education programmes and access to sanitary pads and washable cloths. These could lead to significant improvements in their quality of life and prevent them dropping out of school because of lack of privacy in sanitary facilities. Another in this vein is about adolescents in Tanzania who were born with HIV, who were uneasy about their sexuality, feared that sex and relationships were inappropriate and hazardous and worried about having to disclose their status and the risks of infecting others. With all these anxieties, many anticipated postponing or avoiding sex indefinitely. Caregivers and home-based care providers reinforced negative views of sexual activity, partly due to prevailing misconceptions about the harmful effects of sex with HIV. These adolescents had limited access to accurate information, appropriate guidance, or comprehensive reproductive health services.
Similarly, in another paper, young Tanzanian women faced major risks and risk-taking that undermined their ability to protect their own health and well-being: poverty that pushed them into having sex to meet basic needs; sexual expectations on the part of older men and boys their age; rape and coercive sex (including sexual abuse from an early age); and unintended pregnancy. Transactional sex with older men was one of the few available sources of income, making this a common choice for many girls, in spite of the risks. Yet parents and adult community members tended to blame the girls alone for putting themselves at risk. Men participated in the study as “community members” but they weren't challenged for their own sexual mores.
Yet another paper, on self-efficacy in HIV prevention from Zambia, takes up the issue of blame and focuses on the fact that even if educational programmes do address gender, they often reinforce a “male perpetrator, female victim” discourse. The findings here show that the realities young people face are much more complex than most HIV prevention strategies acknowledge or address. Adolescent boys and girls, for example, saw girls as having control (though a different kind) in intimate relationships too, not just boys. Many of the papers here reinforce this assessment and call for revised strategies.
Another paper from Zambia starts with recognising the evolving capacity of adolescents and young people to act to fulfil their own right to health and health care, as well as determine the trajectory of their lives, including in sexual relationships. This is another overarching message of this journal issue. The young people living with HIV interviewed for this paper embraced the concept of living positively and their right to enjoy a fulfilling sexual life, marry and have children. They were also articulate about the their needs for information, services, care and support – not all of which were being met. Yet this paper shows that positive-living messages about HIV can succeed, and it points to successful programmes in sub-Saharan Africa that aim to meet young people's needs.
A paper from the UK looks at how 20 young women who had discontinued use of the contraceptive implant experienced a conflict between contraception as bodily control and as fertility control. They had discontinued the method due to unacceptable side effects that they interpreted as a threat to their bodily control, which they decided they were not prepared to tolerate. These feelings were exacerbated if they then encountered delays after requesting removal. Although they remained concerned to avoid unintended pregnancy, they generally moved to a less reliable form of contraception following implant removal and felt discouraged from trying other long-acting contraception. The paper suggests that contraceptive choice should include facilitating the discontinuation of unsatisfactory methods and access to alternatives young women are willing to try.
The issue of adolescent capacity to consent to transgender-related health care in Colombia and the USA, is raised in a paper on the two countries' struggles with law and policy provisions to support and protect the rights of adolescents to make autonomous and confidential decisions and therefore limit the rights of their parents to take decisions for them, e.g. in the case of intersex decisions from infancy. Striking such a balance, of course, applies across sexual and reproductive health care services for adolescents. A paper from Mexico City looks at this issue from the point of view of conflicting regulations on adolescents' right to seek abortion information and services with or without adult accompaniment. While abortion clinic staff were generally positive about adolescents' ability to decide on abortion, more so at ages 15–17 than 12–14, they had different interpretations of the regulations about adult accompaniment and who that adult should be.
Adult control, in the absence of children's consent, is particularly problematic when it comes to child marriage. One paper here seeks to understand the factors affecting relationships, marriage and cohabitation among adolescents affected by conflict and displacement in two settlement camps in Uganda, among refugees from DR Congo and internally displaced Ugandans. It found that poverty, lack of access to schools and education, splintering of families and lack of communication between the generations, exacerbated by conflict, had resulted in changed marriage patterns, reduced formal marriage negotiation traditions and contributed to early, informal relationships.
Another paper outlines an expanded concept of risk by looking at how young people in Indonesia in their everyday lives are consuming a bewildering array of pharmaceutical, dietary and cosmetic products to self-manage their bodies, moods and sexuality, practices generally overlooked by sexual and reproductive health programmes. The young people interviewed turned to pharmaceuticals and cosmetics to feel clean and attractive, increase (sexual) stamina, feel good and sexually confident, and counter sexual risks. A group of transgender youths also used products to feminise their male bodies. Thus, another main message is the need for harm reduction programmes to provide youth with accurate information, taking into account broader concerns they have about body image and self-esteem which relate to their sexuality, and sexual and gender identity.
There are a number of web-based publications about young people summarised in Bookshelf pieces. There was no space for the Round Up sections, because there are so many good papers, so we've put them on the RHM website. Do go to the RHM website to read them; they are full of excellent information.
Lastly, I decided to start this journal issue off with a paper of my own about the death of Savita Halappanavar, Catholic health policy and termination of pregnancy as emergency obstetric care. Savita died in pregnancy in Ireland in October 2012 because of a lack of necessary treatment, including termination of pregnancy, for obstetric complications following a miscarriage. The paper argues that it is unethical to refuse to terminate a non-viable pregnancy when a woman's life is at risk. In practice in Catholic maternity services, this decision often intersects with health professionals' interpretation of Catholic health policy on miscarriage and abortion, as well as the law on abortion. This paper explores the consequences for pregnant women and maternity services worldwide.
With great sadness, we remember Erica Royston, the mother of all WHO's Safe Motherhood initiatives, mentor to many people connected to RHM, and one of RHM's first trustees, who died in February 2013.
Notes
* And link with RHM on Twitter and Facebook when you do!