Aligning human rights and social norms for adolescent sexual and reproductive health and rights

Introduction

The 10th of December 2018 marks the 70th anniversary of the adoption of the Universal Declaration of Human Rights by the United Nations (UN) General Assembly. On the 20th November, the United Nations Convention on the Rights of the Child (CRC) reached its 29th anniversary. In September, 24 years had passed since the International Conference on Population and Development in Cairo introduced the term sexual and reproductive health and rights (SRHR) and declared SRHR as a fundamental human right, including for adolescents. Only three years ago, all UN Member States adopted the 2030 Agenda for Sustainable Development that included a specific target for achieving universal access to SRHR (Gender Equality Goal 5). Despite these important efforts to create consensus around human rights frameworks and steps to secure universal access to SRHR, the promise of child rights and adolescent girls’ and boys’ evolving capacities¹ to claim SRH rights remains unrealised. For instance, a recent review of evidence on the SRHR of adolescent girls highlighted that many low- and middle-income countries have not yet made significant progress in delaying marriage and childbearing, reducing unwanted childbearing, or narrowing socioeconomic, health and gender gaps that could reduce girls’ risks of adverse adolescent sexual and reproductive health and rights (ASRHR) outcomes and related health effects over the life course.²

Multiple converging factors contribute to an ongoing lack of prioritisation of SRHR, which is defined, following the recent Guttmacher-Lancet report (see Panel 1), as a “ … state of physical, emotional, mental, and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction, or infirmity”.³ However, ASRHR is seemingly often relegated to a lower priority or is entirely absent from discussions on SRHR. Barriers to international and local prioritisation of (A)SRHR range from global political and economic trends, such as the shift towards far-right and populist politics in high-income countries and in regions that push international health policy and aid investment toward the bottom of foreign policy agendas,⁴ to local inequitable social norms that define social expectations for adolescents boys’ and girls’ behaviours according to restrictive, binary gender roles and identities.

Panel 1: Definition of SRHR

The 2018 Guttmacher-Lancet report, “Accelerate progress – SRHR for all: Report of the Guttmacher-Lancet Commission”, provides an integrated definition of SRHR highlighting aspects fundamental to all people’s – including adolescents’ – rights to: freely define their own sexuality, including sexual orientation and gender identity and expression; decide whether and when to be sexually active; choose their sexual partners; have safe and pleasurable sexual experiences; decide whether, when, and whom to marry; decide whether, when, and by what means to have a child or children, and how many children to have.

Source: Starrs et al³

The same overarching “meta-norms” – norms prevalent across communities, nations and regions – underpin both the widespread lack of political will for investment in ASRHR, and local inequitable norms that confound ASRHR processes and outcomes. Meta-norms of hierarchy, adultism, patriarchy and heteronormativity bundle together to reproduce conceptions of childhood and adolescence with differing gender role and identity expectations, producing gender disparities in the distribution of resources and opportunities, disadvantaging girls while reinforcing boys’ higher perceived value in society. Social hierarchy norms define who decision-makers identify as valuable and worthy of investment based on intersectional identity markers of age, gender, race, religion, sexual orientation, class or other local identifiers of social status. Hence, inequitable meta-norms become mechanisms of control, maintaining and perpetuating socioeconomic inequality.⁵ At the same time, norms around adultism include expectations for obedience to adult authority, affecting children’s and adolescents’ right to have a say – according to their evolving capacities – in decisions that affect their health and life options. Finally, patriarchy as a meta-norm engenders processes of social hierarchy and obedience to male authority. To survive, patriarchy requires girls’ inequitable socialisation into becoming women who lack equal access to and control over resources, and overall decision-making power. Large gains in ASRHR progress require displacing these powerful meta-norms and creating positive new norms at community, national and regional levels that can in turn catalyse acceptance of, and resource mobilisation for, ASRHR.

How do social norms relate to ASRH rights?

Large divides persist between international human rights treaties and conventions, and local norms affecting ASRHR. Layers of complexity emerge when ASRHR interventions based on a human rights approach define a “child” as a person as under 18 years of age, whereas adolescent girls may see themselves, and community members may see them, as “women” from menarche, or when they develop “womanly” body features. Even international definitions of childhood and adolescence at times lead to some confusion around whether the CRC applies to 18- and 19-year-olds, who are defined as adolescents, when the convention technically applies only to children under age 18. As children’s rights are human rights though, and because SRHR apply to all, regardless of age, the perspectives in this commentary remain relevant when considering the SRHR of adolescents up to 19 years of age.

The concept of “adolescence” as a distinct, critical life stage with unique neuro-cognitive potential and strengths,⁶ and developmental health, education and economic skill-building needs,⁷ may not yet exist within the local norms and practices in some contexts. Where the concept of “adolescence” does exist, it is often regarded as a static moment rather than a dynamic period rich in behavioural and developmental variation.⁸ Furthermore, the concept of “evolving capacities” – a CRC principle that as children develop enhanced competencies, they have greater capacity to take responsibility for decisions affecting their lives, and that guidance and direction should match these evolving capacities¹ – also often remains absent in policies and programmes with child and adolescent health and development aims in low- and middle-income countries.

Children’s rights to participate in decisions that affect them directly, to freedom of expression and access to information, often collide with local norms and worldviews, conscribing what is socially acceptable for a girl or boy to say or do in the presence of an adult woman or man in a family or healthcare context. Where rights-based interventions may seek to promote universal access to SRH services explicitly, local norms may raise barriers to adolescent girls’ and boys’ access to those services. While implementation of a rights-based SRH intervention forwards the concept of “equal rights” for women, men, boys and girls, programmes that do not proactively take into account inequitable gender norms imposed on adolescent girls and boys, can trigger unintended stigma, discrimination and exclusion. Girls or boys can then be seen as transgressing normative community and family expectations.

Inequitable gender normative socialisation processes intensify for girls and boys during and after puberty, as parents and peers strongly influence and regulate girls’ and boys’ conformity or resistance to gender normative behaviour during this period.⁹ Norms to control and regulate adolescent girls’ sexuality often combine with conservative ideologies against girls being sexually active before marriage. This can result in barriers of exclusion when, for example, unmarried adolescent girls seek to access contraceptives or SRH services, only to be met with discriminatory, dismissive attitudes. Both unmarried and married adolescent girls face barriers in accessing ASRHR information and services. For example, child brides in some contexts report discrimination in accessing ASRHR information and services. A recent UNICEF child marriage report describes how only 30% of women (20–24 years) in Nepal and 48% in Vietnam, who married before the age of 15 years, had received medical care during pregnancy. They were less likely to receive care compared to women who had married at 18 years or older.¹⁰

While the burden of ASRHR gender disparities falls disproportionately on girls, adolescent boys also suffer from poor ASRHR access and outcomes. Norms of masculinities, such as sexual risk-taking, having multiple partners, avoiding healthcare, and discriminatory provider attitudes, become barriers to boys’ ASRHR decision-making and access to services. Boys and men face intense pressures to live up to expectations of heteronormative masculinities. They also find it difficult to report and seek medical, legal and psychosocial assistance, for instance, as recognised survivors of sexual exploitation and abuse.^11,12

Obstacles to ASRHR beyond reproductive health include gender norms that do not acknowledge or value equal sexual rights – including adolescent girls’ rights to explore consensual, safe and pleasurable sexual experiences – as integral to their healthy development and to reducing gender disparities in ASRHR outcomes.¹³

Bridging the divide between ASRH rights and social norms

Bearing the above in mind, we strongly believe that if the UN Member States are to realise commitments to child rights – in particular, those entailed in universal access to ASRHR – then inequitable, discriminatory meta- and local social norms that serve as obstacles to ASRHR need to be brought into alignment with human and child rights. There is evidence to show that gaps between ASRHR and norms can be bridged through interventions that facilitate community-level reflection and deliberation on norms, combined with community-led mobilisation and collective action to transform inequitable local norms and meta-norms.^14,15 Most of this evidence has emerged from evaluations of interventions designed to prevent and respond to harmful gender practices, such as female genital cutting,¹⁶ early and forced marriage,¹⁷ and violence against women and girls,^18,19 all of which connect with the expanded definition of ASRHR.³

Intervention approaches that bridge gaps between ASRHR and social norms are rooted in small group-based discussions about local norms, power and gender equality, comparing and contrasting locally accepted behaviours with human rights. This approach emphasises reflection and critical thinking from within communities, attending to the specific, lived realities of community members and incentivising community mobilisation and collective action around positive alternative norms grounded in human rights. It is through this inclusive, grounded, reflective deliberation on norms and rights that the field of ASRHR could start to align international human rights agreements with local realities, and spark change from within, in a sustainable way.

In addition to reflection on gender equality and human rights and based on existing evidence that adolescence is not clearly recognised in many societies as a distinct developmental phase,²⁰ we propose that this critical thinking process should include the re-conceptualisation of the end of childhood. Creating a new norm of “adolescence” as a critical biological, cognitive and psychosocial developmental stage between childhood and adulthood – one that involves increased autonomy and capacities, but also heightened vulnerabilities – offers a clear first step towards shifting local attitudes, beliefs, practices and norms in which all family and community members can play a role in upholding ASRHR. In the process of introducing adolescence as a concept, researchers and practitioners need to explore and take into account local understandings of the end of childhood in order to compare and align these with the more conventional definitions. The recognition that adolescents acquire enhanced capacities as they mature from early to later adolescence should translate into their increasing involvement in discussion and decision-making regarding SRHR beliefs, behaviours and service access.²¹ In doing so, researchers and practitioners should keep in mind that children’s rights extend to all children irrespective of capacity. What they need to consider carefully, therefore, is the degree of support a specific child or adolescent needs to cultivate increasing independence in the exercise of his or her rights. Adopting “adolescence” as a normative concept and unique life cycle stage foundational to lifelong health and well-being also stands to catalyse government implementation of child rights commitments and advance population health and development gains. Introducing adolescence as a new positive norm for advancing ASRHR must include adolescents’ rights of access to life stage-appropriate SRHR information, self-expression and decision-making power concerning SRHR – as core to healthy development and well-being, and as a universal right for all, regardless of age or perceived social status.

Reflecting on how meta- and local norms affect adolescent girls’ healthy transition to adulthood opens up opportunities to interrogate beliefs that a young girl’s first menses, or breast and hip development, automatically signify her readiness for sex. Creating new normative beliefs that young adolescent girls are not necessarily biologically, cognitively, socially or economically ready for sex and its potential consequences, could reduce risks and negative outcomes of early and coerced sexual debut, early pregnancy, sexually transmitted infections, (STIs) human immunodeficiency virus (HIV), school dropout and subsequent inter-generational transmission of poverty. Furthermore, ASRHR interventions engaging adolescent boys to dismantle inequitable norms and prevent health and developmental gender disparities are also needed. Despite evidence showing that boys are more likely to endorse inequitable gender norms than girls,²² considerably fewer interventions targeting boys exist to date. Finally, interventions aiming to introduce complementary, new positive peer group as well as parenting norms and behaviours that support ASRHR while valuing girls equally to boys, could contribute to reductions in the prevalence of early and coerced first sexual experiences for girls and related SRH risks²³ and all forms of sexual, physical and emotional violence against girls²⁴ based on girls’ perceived inferior status.

Key strategies to align social norms with ASRHR

It is clear that the focus over the past two decades on increasing access to SRH services has not by itself led to improved ASRHR outcomes. Indeed, norms mediating community acceptance of SRH and healthy adolescent sexual development have persistently acted as obstacles to uptake of available ASRHR information and services. Shifts in norms concerning social approval of ASRHR and adolescent sexual development are required first to obtain gatekeepers’ acceptance and increase adolescent girls’ and boys’ agency, which can increase service demand and improve ASRHR outcomes.²⁵ Working at different levels of society through multiple strategies requires a complex, potentially difficult to evaluate intervention. As a result, the state of evidence on impact and learning on interventions to align social norms with rights is in its early stages. Poised for further investment, and in some cases scale-up, promising programme examples demonstrate how a community-based social norms approach can contribute to aligning norms with human rights for advancing ASRHR. While community-based interventions are not the only or primary way to advance ASRHR outcomes, it is focused, community-based work fostering reflection, dialogue and collective action for ASRHR that can help bring local norms into alignment with ASRH rights.

Insights from interventions to date point out that social norms can either confound or catalyse programme and policy outcomes for advancing ASRHR. Several examples of social norm change interventions aligning with child rights can be found in Save the Children’s ASRHR programme portfolio of work with partners across 23 countries.²⁶ This portfolio covers younger to older adolescent age ranges with interventions designed to foster supportive, equitable gender norms before, during and after puberty, and provide access to information about sexuality and SRH services, explicitly grounded within the framework of child rights. Additionally, ASRHR programmes such as the Gender Roles, Equality and Transformation (GREAT) project²⁷ work purposefully to shift gender inequitable attitudes, beliefs, norms and behaviours that intensify in early adolescence, and build positive, alternative norms and behaviours to support ASRHR outcomes in the transition to adulthood. An endline evaluation of the GREAT project found significant improvements in attitudes and behaviours concerning beliefs about gender equality, healthy intimate partner communication, use of modern family planning methods, and rejection of sexual and gender-based violence.²⁷ In a review of the evidence of intervention effectiveness for addressing intimate partner violence (IPV) and sexual violence (SV) against adolescents, community-based prevention interventions were found to cultivate gender equitable beliefs among adolescent girls and boys with reductions in risk factors for adolescents' exposure to IPV and SV.²⁸

When looking at the development of ASRHR interventions to date, we can see that the field has moved from interventions focused on building individual knowledge and risk awareness, to skills development and group action that allow adolescents to generate and steer change. Grounded in child rights to participation, expression and information on ASRHR and its effects over the life course, a paradigm of “positive youth development” calls also for balancing individual capacity development with addressing wider societal norms and structural inequalities beyond adolescents’ direct control – peer and family influence, the environment where adolescents live, and access to education and economic opportunities.²⁹ The Global Early Adolescent Study (GEAS)³⁰ identified the role of primary caregiver and service provider attitudes and beliefs in socialising children into unequal traditional gender roles and related harmful norms acknowledged as significant limitations to the achievement of ASRHR.²² This insight reveals some of the pathways through which norms produce and maintain social inequalities, as parents and service providers seek to maintain a gender status quo and known social order. Human rights may be perceived as threatening some local norms for how an adolescent girl or boy should behave, hence the gap between them.

Interventions emphasising analyses of gender and human rights have demonstrated improved ASRHR outcomes, particularly as egalitarian attitudes toward gender roles in intimate partnerships have been shown to be associated with young peoples’ increased odds of delaying sexual debut, using condoms, and practicing other forms of contraception.^31,32 Among other factors, promising SRHR programme strategies commonly include the promotion of principles of positive youth development;²⁹ the use of an ecological framework to situate different interventions and provide critical analyses for their design and evaluation;³³ linking the provision of sexuality education and SRH services; building awareness, acceptance and support for adolescent-friendly SRH education and services; addressing gender inequality in terms of beliefs; attitudes and norms; and targeting the early adolescent period of 10–14 years of age³⁶ (see Panel 2 for more detail).

Panel 2: Promising practices for developing and evaluating interventions to align social norms and ASRHR

Design
Use an ecological framework to analyse and address different intersecting factors affecting norms and rights for ASRHR.	Develop a theory of change incorporating evolving capacities, norms, gender and rights, and map intervention components to theory of change stages.
Conduct gender and age-analytical formative research to understand local norms and practices concerning gender, human rights and ‘adolescence’ that affect ASRHR.	Design components for the evolving capacities of the intervention age group, rather than adapt material previously for adults.
Incorporate formative research into the design and implementation of multi-level, multi-component interventions and evaluation.	Budget for and develop child protection protocols for implementation and evaluation, including for external evaluation teams.
Implementation
Consider engaging adolescents aged 10-14 years, capitalising on early adolescence for intervening on beliefs about gender roles, responsibilities and norms before they intensify later.	Work with men and boys, and with teachers, parents and community leaders to transform gender norms underpinning poor ASRHR decision-making and outcomes.
Use an empowerment approach with adolescents, taking into account rights to participation, self-expression, information and ASRHR decision-making.	Tap into local media and technology for diffusion of new positive ASRHR norms.
Incorporate participatory activities for community deliberation, mobilisation and collective action that unpack gender, norms, power, human and child rights affecting ASRHR and create new norms for ASRHR.	Monitor ethics and child protection protocols to prevent, monitor and respond to the potential retaliation for resisting strong norms and promoting new ones.
Evaluation
Develop quantitative and qualitative evaluation methods and instruments to diagnose and measure change in ASRHR-relevant norms at community level, and understand pathways where norms affect ASRHR.	Ensure that evaluation of interventions assesses shifts in power dynamics, gender roles and responsibilities, and social norms.
Explore vignettes in focus group discussions and surveys to identify and measure harmful and helpful norms that affect ASRHR.	Select and train evaluation data collection teams on ethical protocols on responding to child protection disclosures.

Sources: Adapted in part from^9,21,33–36

Looking ahead for ASRHR progress

As the Lancet Commission on Adolescent Health and Well-being identified, adolescence is an opportune time to influence health and life course altering beliefs and behaviours.⁷ Investing in adolescent health will allow us to capitalise on the potential “triple dividend” of demographic, epidemiological and economic gains.⁷ Low- and middle-income countries facing a “youth bulge” may be poised to capitalise on a “demographic dividend”, meaning that, as a majority young population transitions to adulthood and bears fewer children than their parents' and grandparents’ generations, an increase in working-age adults and improved socioeconomic and health outcomes could result.³ SRHR, including, vitally, those of adolescents, require significantly greater political will and investment to fulfil human and child rights, and achieve large population gains in health and development in the decades to come. Reviews of programmes and evidence over the past two decades have explicitly recognised not only the need to improve comprehensive sexuality education and SRH services, or the need to build an enabling environment for SRH services to promote SRHR. They have identified also that in going forward, families, communities and nations must address inequities in gender beliefs, attitudes and norms, beginning at least in early adolescence when gender norms consolidate and intensify. Bridging the gap between nation-state commitments to human and child rights and achieving outcomes for ASRHR and healthy development requires shifting inequitable social norms that confound rather than catalyse ASRHR through aligning norms with rights.³

Improving access to, and outcomes for ASRHR requires careful community-level reflection, mobilisation and collective action to align social norms with human and child rights, and to catalyse positive new norms that support ASRHR.

Diffusing new positive norms across peer groups, families, communities and nations must include adolescent girls’ and boys’ equal rights to explore safe, healthy and pleasurable sexual lives and intimate relationships, and to develop socially and economically in the transition to adulthood. Media and technology may play a catalytic role for organised diffusion of positive ASRHR norms, yet the use of online and mobile platforms will require further research into the risks of such technologies and safe, healthy use among young adolescents.

In summary, we have highlighted common factors in existing approaches for intervention and the available evidence that show promise in improving ASRHR through aligning social norms with rights, contributing to positive change in ASRH outcomes. Aligning ASRH rights and social norms through norm change interventions offers a promising, critical strategy to fulfil the 2030 Sustainable Development target of “universal access to SRHR.”

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Ana Maria Buller http://orcid.org/0000-0002-3007-9747

Marie Celine Schulte http://orcid.org/0000-0002-8344-3493