AGYW, sexual and reproductive health, human rights & gender equality
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Adolescent girls and young women are disproportionately affected by HIV and other sexual and reproductive health risks. Laws, policies and practices that perpetuate gender inequality, harmful gender norms and gender-based violence create barriers to access to sexual and reproductive health & rights.
Sexual and reproductive health and rights (SRHR) are essential to the well-being of each individual and to support the fulfilment of national responses to health risks, such as HIV. However, for many adolescent girls and young women (AGYW), this right remains unfulfilled; the GCHL 2018 Risks, Rights and Health Supplement recognises that, in global efforts to reach SDG targets, adolescent girls and young women are being left further behind. This leaves AGYW at risk of poor sexual and reproductive health. For instance:
- The Guttmacher Lancet Commission report Accelerate progress—sexual and reproductive health and rights for all found that “[c]ompared with young men, young women are more likely to acquire HIV, and the age of infection is 5–7 years earlier often coinciding with a sexual debut. Other STIs, including HPV, are also commonly acquired in the early reproductive years—ie, younger than 25 years.” The UNAIDS Global AIDS Update 2018 reports that in sub-Saharan Africa, adolescent girls and young women (aged 15–24 years) accounted for one in four HIV infections in 2017 despite being just 10% of the population. Women represented 59% of new infections among adults (aged 15 and older) in the region.
- According to the Guttmacher Institute 2016 report, Adding it up: costs and benefits of meeting the contraceptive needs of adolescents, about half of pregnancies among adolescent women aged 15–19 living in developing regions are unintended, and more than half of these end in abortion, often under unsafe conditions.
WHO defines adolescents as people between 10 and 19 years of age. The United Nations considers “youth” as those people between 15–24 years and “young people” as people between 10–24 years.
Here, we focus on adolescent girls aged 15 to 19 years and young adult women aged 20 to 24 years, in line with UNAIDS guidance. However, specific programmes should also include actions for adolescent girls aged 10 to 14 years and young adult women aged 25 to 29 years.
Adolescent girls and young women may also belong to one or more key populations or engage in activities associated with these key populations. Punitive laws, discrimination and violence combined with the vulnerability of youth, power imbalances in relationships and possible alienation from families and friends means that young key populations face increased marginalization, hindering their ability to access HIV-related and other health services.
Factors that heighten the risk of HIV and SRH risks amongst AGYW, as outlined in the GCHL and Guttmacher-Lancet Commission 2018 Report, include biological factors, as well as legal, social, economic and cultural factors relating to gender inequality, harmful gender norms, gender-based violence and other human rights barriers experienced by AGYW.
- The Guttmacher–Lancet Commission 2018 Report: Accelerate progress found that despite worldwide efforts to end child marriage, the practice remains common in developing regions, particularly in South Asia and sub-Saharan Africa: “[a]n estimated 7% of girls in developing regions marry before age 15 years, and 28% marry before age 18 years.” Child marriage increased sexual and reproductive health risks for adolescent girls for various reasons: ”they are often socially isolated, tend to begin childbearing early, are vulnerable to STIs, including HIV, and are often unable to negotiate safer sex with their husbands, who are typically much older”. Research found that girls who marry before 18 years are at greater risk of intimate partner violence and forced sexual intercourse than those who marry at adulthood. The report also found that adolescents who give birth at 15 years or younger have increased risks of pregnancy-related complications and death.
- The report also found reports that adolescents’ self-stigma and fear of health care workers was a barrier to access to sexual and reproductive health care services: “only a few of sexually active adolescent women who have an STI or who have symptoms seek care in a health facility. Many adolescents do not know where to seek STI services, and those who do might feel ashamed or afraid to get treatment from health-care providers.”
- The GCHL 2018 Risks, Rights and Health Supplement examined select legal, human rights and gender-related barriers to sexual and reproductive health for AGYW. It reported that criminalization, stigma, discrimination, violence and other legal and human rights barriers undermined women's and girl's ability to control their own bodies, choose their partners or to receive high-quality sexual and reproductive health care. For instance, it found that globally, laws and policies in more than 70 jurisdictions allow healthcare providers to refuse to provide health services to girls and young women based on claims of “conscience,” preventing AGYW from accessing critical services such as contraception or abortion.
Gender inequality limits access to education, resources and services for AGYW, preventing AGYW from being able to make decisions about, control and access health care services.
A wide range of laws, customs and practices – for instance laws and norms allowing young girls to be married below the age of 18 years, laws that fail to criminalise the rape of a wife by her husband, laws and practices that prohibit women from owning or inheriting property or to having autonomous decision-making power within their relationships, and laws, policies and practices limiting adolescent girls’ independent and confidential access to sexual and reproductive health services - perpetuate gender inequality. These laws, policies and practices limit the ability of women and young girls to control their lives, including their ability to protect themselves from HIV and other sexual and reproductive health risks.
Increased vulnerability to HIV infection has also been linked to intimate partner violence, which is more common among younger women and women who are economically dependent on their male partners. Violence or the fear of violence can make it very difficult for women to insist on safer sex and to use and benefit from HIV and sexual and reproductive health services. Women living with HIV who experienced intimate partner violence were significantly less likely to start or adhere to antiretroviral therapy, and they had worse clinical outcomes than other HIV-positive women.
Enabling legal environments need to prioritise laws, policies and programmes that address the human rights and gender-related factors that cause a heightened risk of HIV and other sexual and reproductive health risks amongst AGYW.
The GCHL Risks, Rights and Health Supplement recommends that governments must adopt and enforce laws that remove legal barriers to accessing the full range of sexual and reproductive health services and that protect and promote sexual and reproductive health and rights.
The Guttmacher-Lancet Commission report Accelerate progress—sexual and reproductive health and rights for all warns that a continuation of the status quo would mean that human rights violations, such as child marriage, female genital mutilation, intimate partner violence and sexual coercion and violence, will persist, along with major inequalities in health and access to healthcare. The report identifies high priority legal and policy reforms to support sexual and reproductive health and rights as outlawing child marriage, promoting gender equality and women’s autonomy, liberalising abortion laws and prohibiting discrimination against people with diverse sexual orientations and gender identities and expression.
Law reform to broaden the grounds under which abortion is permitted is crucial to improving the sexual and reproductive health and rights of adolescent girls and young women. Abortion law reform paves the way to training providers in safe abortion care, ensuring access to safe methods and destigmatising the practice.
In South Africa, where a liberal abortion law went into effect in 1997, the incidence of severe complications from unsafe abortions declined between two study periods, 1994 and 1999–2001, and the number of women who died due to abortion fell by 91%.
In Nepal, where a liberal abortion law was passed in 2004, the proportion of severe abortion complications dropped dramatically between 2001 and 2010.
In Mexico City, after first- trimester abortion became legal on demand in 2007, use of abortion methods recommended by the World Health Organisation increased, shifting away from more invasive procedures. In the public sector in Mexico City, medication abortion as a proportion of legal abortion procedures rose from 25% in 2007 to 83% in 2014.
In Peru, more than 10000 young people successfully challenged the constitutionality of the criminalisation of consensual sex among teens, which had the effect of prohibiting preventive reproductive health services for adolescents. In 2012, the court ruled in their favour referring to international human rights law and the country’s constitution (and the fact that many teens were already parents). It declared that young people aged 14–18 years had a right to personal autonomy and self- determination regarding their sexuality.