At present, these adolescent girls – who are at greatest risk and have the greatest needs – are often ‘falling through the net,’ and not accessing SRHR information and services at all. This failure is due to a range of different factors at different levels in different contexts. These include the stigmatising attitudes of health workers to the cultural norms of local communities, inappropriate service delivery methods, punitive legislation and unsupportive policies of donors. Combined, these represent powerful barriers to marginalised and vulnerable adolescent girls aiming to fulfil their SRHR.
The following are examples of the barriers:
Gender and associated norms: adolescent girls who are child brides; unmarried sexually active females; survivors of gender-based violence; or females in conservative or patriarchal religious communities. In addition, adolescent boys and young men can also be under immense pressure to conform to cultural and gender norms, which can also negatively affect their SRHR.
Socio-cultural status: adolescent girls who are from ethnic minority, indigenous or ‘closed’ religious/cultural communities; unmarried mothers; out-of-school; orphans; in/released from prison or remand homes; or those who use drugs.
Socio-economic status: adolescent girls who live in poverty; have low literacy/have dropped out of school; have been trafficked; are migrants; are child labourers; are heads of households; are engaged in transactional sex; live or work on the streets; or work in informal labour.
Geographic location: adolescent girls who are living in rural areas; in urban slums; in nomadic communities; or are displaced.
Health status: adolescent girls who are pregnant; have physical or mental health disabilities; are living with HIV; or are survivors of sexual abuse or violence.
Sexual orientation: adolescent girls who identify as lesbian, bisexual or transgender; intersex or are unsure of their sexual orientation.
Political context: adolescent girls who live in conflict situations or refugee communities.
Legal context: adolescent girls whose status/behaviour is criminalised (e.g. same sex couples, people who use drugs, sex workers).
Adolescent girls’ status, including family and community roles, profoundly influences their ability to make decisions about their own bodies, health and childbearing, which, in turn, increases their vulnerability to poor sexual and reproductive health. Early marriage, female genital mutilation (FGM) and domestic violence are entrenched forms of gender-based discrimination that are internalised and enshrined within communities’ social fabrics, traditions and customs. Often the rights of girls to make decisions over their own bodies, sexuality and fertility are not recognised.
Furthermore, it is often argued that young people, particularly those who are not yet married, should not receive detailed information about SRHR. This may be due to the false belief that providing information will result in young people having sex earlier and with many partners. In many contexts this is referred to as encouraging “free sex” or promiscuity. In fact, some literature shows that young people who are well-informed about SRHR will make their sexual debut (first sexual intercourse) later, and when they do have sex, they will do it more safely because they already know how to protect themselves. Therefore, the denial of adolescents and young people’s rights to quality information and services actually increases their vulnerability to risky behaviours and negative health consequences.
Adolescent girls, in particular, require:
• accurate information about risks and choices, offered in a safe and non-judgemental context;
• peer, family and other social support to make healthy choices;
• access to services that are “youth-friendly”27 – appropriate, affordable and safe – these may be separate services or separate spaces staffed by adequately trained providers within general services; and
• a range of tools to help them deal with health risks.28
Challenges and opposition to SRHR for adolescent girls can often be overcome through the active engagement of key community stakeholders in order to provide these services. This includes placing adolescent girls at the centre of change and working with parents, traditional and religious leaders, and government decision makers.
Many other challenges, such as those learning to negotiate sexual interactions and combating GBV, require programmatic approaches within communities and in educational settings. These investments include comprehensive education on adolescent life-skills, sexuality, gender, reproductive and human rights; the creation of safe spaces and mentoring for out-of-school girls with limited mobility and life choices; the provision of services that are accessible to young people; and social mobilization to prevent harmful customary practices such as early marriage and FGM.
The roles played by men and women in a society, the rights of adolescent girls to make decisions and act independently, and their treatment by the males around them all have an immediate influence on the quality of sexual and reproductive health care available to them. Demand for SRHR must come from the adolescent girls themselves, but resources are "only as good as women’s rights to use them".29 Because many adolescent girls have limited control over their sexual lives and contraceptive use, integrating gender issues into reproductive health and HIV/AIDS programme interventions becomes critical.30 Furthermore, active male involvement in reproductive and family care-giving enhances responsible parenthood and reduces GBV that affects women’s reproductive health and rights.