Adolescent sexual and reproductive health: Harmful gender norms as invisible barriers to service access

Summary

Adolescents have the right to access sexual and reproductive health services that protect them against pregnancy and infections, and provide a safe space to report abuse or obtain counselling and information about their sexual development. But harmful gender norms may hinder this access.

Adolescents who identify as lesbian, gay,
bisexual, transgender and intersex are
sometimes subjected to discrimination and
ridicule in health-care settings.
Photo: Baylee Gramling, Unsplash

Sexual and reproductive health (SRH) is increasingly considered a policy priority area in ensuring the overall health and wellbeing of adolescents across Southern Africa. Yet, many adolescents (persons aged between 10 and 19 years) do not have access to age-appropriate services in this region. Such services include counselling; dysmenorrhoea (painful menstruation) screening and treatment; contraceptives; medical male circumcision; pregnancy testing; safe termination of pregnancy; treatment for sexual violence; and counselling, testing and treatment for HIV and other sexually transmitted infections.

The objectives of international agreements and national policies to ensure that all adolescents have full access to SRH services are vastly under-achieved. This is partly due to health-system failures such as those caused by a shortage of skilled health professionals and the unavailability of medicines and supplies. Deeply rooted gender norms also obstruct adolescents from accessing SRH services.

Clash between rights and harmful gender norms
The African Union’s African Charter on the Rights and Welfare of the Child provides an overarching framework for the protection of children and their rights and wellbeing. In addition, the African Youth Charter stipulates that governments should ensure the involvement of young people in identifying their reproductive and health needs and provide them with access to youth-friendly services, including contraceptives and antenatal and postnatal care.

This encourages adolescents to exercise their rights and practise healthy choices. However, a focus on rights sometimes exists in tension with local beliefs and gender norms that shape youth sexualities. Researchers recognise this in the Guttmacher–Lancet Commission’s 2018 report, Accelerate progress—sexual and reproductive health and rights for all, emphasising that unequal and harmful gender norms may hinder access to SRH services.

Fearing moral scrutiny
Adolescents’ evolving capacities to decide about their sexual health are under-recognised by health-service providers and other significant adults in their lives. In this regard, gender norms intersect with age to prescribe to adolescents how they are supposed to conduct themselves at home, in their communities, at school or in health-care settings. It also limits the types of questions they can ask about sex and sexuality, and the types of services they can and cannot request. Health-care professionals are often considered custodians of cultural and moral guidelines on sex and relationships and may act according to these prevailing norms. Therefore, when adolescents seek SRH services, they are perceived as breaking the “rules” of what is acceptable behaviour, which are often different for boys and girls.

Social expectations
For example, unmarried adolescent girls wanting to access contraceptives or other SRH services often encounter blaming and shaming responses from service providers – due to the belief that they should not be sexually active. Thus, in some cultures only married women are encouraged to access such services. Adolescent boys, on the other hand, may also suffer poor SRH outcomes due to norms about socially valued forms of masculinity, which encourage sexual risk taking such as not using condoms or having multiple and concurrent partners. There are also social expectations of boys not to show vulnerability. This could result in them not reporting sexual exploitation or abuse or avoiding seeking health care.

Also, heteronormative beliefs – the assumption that everyone is or should be heterosexual – lead to stigma and exclusion of adolescents who identify as lesbian, gay, bisexual, transgender and intersex (LGBTI), and subject them to discrimination and even ridicule in health-care settings.

Harmful gender norms

According to Ana Maria Buller and Marie-Celine Schulte from the London School of Hygiene and Tropical Medicine in the UK, there is a need for more research that makes harmful gender norms about adolescent sexuality in Southern Africa visible. Gender norms and associated inequalities can either hinder the uptake or act as a catalyst for programme and policy outcomes that protect adolescent sexual and reproductive health rights (SRHR), they wrote in an article titled, “Aligning human rights and social norms for adolescent sexual and reproductive health and rights”, published in the journal Reproductive Health Matters in 2018. Research that delves into how harmful gender norms are transmitted and challenged can help remove barriers to SRH services. Harmful gender norms are tenacious, precisely because they are seen as “normal” and “natural” and therefore difficult to name.

A participatory approach
Research that allows adolescents and the adults in their lives to articulate and challenge these norms, for example through a participatory action research approach, can assist efforts to develop new norms that do not limit adolescent SRH. These would include norms that see young people’s sexualities in a positive manner instead of only focusing on messages about sexual risk, danger and disease. For girls, this would mean not attaching blame and shame to their sexuality. For boys, it would mean creating spaces in which they can recognise their own vulnerability and take responsibility for their sexuality in ways that show self-care and care for others.

Welcoming diversity
Overall, such healthy and gender-equitable norms would also welcome diversity, so that LGBTI youth are not stigmatised. A team at the HSRC, led by Prof Finn Reygan, is currently conducting research across Eastern and Southern Africa exploring ways to improve young people’s sexual and reproductive health and rights. This project, funded by Amplify Change*, is particularly interested in how different resources in communities - from sexuality education in schools to the role of civil-society organisations - can help create more equitable gender norms for girls and LGBTI youth.

Talking about sex     
Research should focus on health-care providers, families and the broader community, including religious and cultural organisations that influence gender norms within society. For adults to talk to young people about sex remains taboo in many African societies. Research should provide guidance on how health-care providers and other adults can talk to adolescents about their sexual health in empowering ways. A recent HSRC study - funded by the Aids Foundation South Africa and led by Dr Ingrid Lynch, Dr Benita Moolman and Dr Tracy Morison - is in the process of developing materials that provide adults with accessible language with which to have such conversations.

Aligning human-rights frameworks
Finally, research that offers ways to better align regional human-rights frameworks with local gender norms that shape the lived realities of adolescents can assist in improving the implementation of such frameworks. Addressing invisible access barriers essentially means chipping away at gendered perceptions that limit adolescents’ rights to make decisions about their bodies and their sexual health. Shifting harmful gender norms will require time and complex interventions that address various domains of adolescent SRH, including physiological, sexual, emotional and relational aspects, as well as factors related to the widespread violence in society.

Authors:
Dr Lorenza Fluks (postdoctoral fellow), Dr Ingrid Lynch (senior research specialist), Nazeema Isaacs (master research trainee), Dr Benita Moolman (senior research specialist), Roshin Essop (researcher), Tsidiso Tolla (PhD researcher), Dr Mokhantšo Makoae (chief research specialist) and Prof Finn Reygan (chief research specialist) from the HSRC’s Human and Social Development (HSD) research programme

*This article is based on peer-reviewed literature studied by the HSD researchers as part of the project that was funded by Amplify Change.
Contact: Prof Finn Reygan
freygan@hsrc.ac.za