We Can't Forget about the Reproductive Health Needs of Adolescent Girls in Humanitarian Settings


Humanitarian settings refer to a place where there has been a man-made or natural disaster. When these disasters strike, populations are often forced to leave their communities or country, and are forced to resettle. While people indeed need food, shelter, and water in humanitarian settings, there are also special reproductive health needs that women and adolescent girls face. Julianne Deitch with the Women’s Refugee Commission (WRC) sits down with us to talk about these specific reproductive health needs for adolescent girls in humanitarian settings.

Basic reproductive health needs for girls in refugee settings should be dispensed immediately along with food, water, and shelter. Since adolescent girls in humanitarian settings often face separation from their families, dropping out of school, and losing their friends and community, there exists a heightened danger. This puts them at risk of sexual and gender-based violence, and also places adult roles on girls to contribute (collecting firewood, doing work around the home, etc.). Unfortunately, this means more room for girls to experience transactional sex, early marriage, and gender-based violence.

WRC garners active engagement with girls in adolescent settings which allows them to speak openly and honestly about their reproductive health needs. Insight gained from research (which includes art therapy and group discussion) allows WRC to translate that evidence into real action. WRC’s current work in Iraq, Lebanon, and Bangladesh has shown that safe spaces for women and girls are vital for program delivery and linking girls to sexual and reproductive health services.

WRC has found that girls in Lebanon and Iraq, like any teenagers, are tied to their cellphones. They are accessing the internet to find information on sexual and reproductive health, anatomy, puberty, contraception, menstruation, and marriage. Parents and guardians have voiced concern that girls might stumble upon inappropriate content when doing so, which is why WRC is introducing an online platform that provides safe, accurate, and reliable SRH information for girls in humanitarian settings to access.

Photo by United Nations on Flickr


Jennie: Welcome to rePROs Fight Back a podcast on all things repro. I'm your host Jennie Wetter. In each episode, I'll be taking you to the front lines of the escalating fight over our sexual and reproductive health and rights at home and abroad. Each episode, I will be speaking with leaders who are fighting to protect our reproductive health and rights to ensure that no one's reproductive health depends on where they live. It's time for repros to fight back.

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Jennie: Hi everybody and welcome to a special bonus episode of rePROs Fight Back. I'm your host, Jennie Wetter and today we're going to be continuing our ongoing series of interviews that I did while I was at Women Deliver, a global maternal and reproductive health conference. In today's episode, you're going to hear an interview I did there with Julianne Deitch with the Women's Refugee Commission. We talk about the SRHR needs of adolescents in humanitarian settings. I hope you enjoy the interview.

Jennie: Hi Julianne, thank you for being here!

Julianne: Thank you so much for having me.

Jennie: Um, so before we get to that, maybe we should just touch real quick on what do we mean when we say humanitarian settings?

Julianne: Generally we mean humanitarian settings to be, um, a place in which there is either a man-made or natural disaster. So, um, that could be due to war or earthquake, flood. Um, any place where I guess normal life is disrupted due to a man-made or natural disaster. Um, we usually work with refugee populations, so populations that have been forced to leave their country for one of those reasons and had to resettle somewhere else as well as internally displaced populations, which, um, are similarly forced to leave their home, but they stay in their native country.

Jennie: Great. And know a lot of people when they think of humanitarian settings, they think of food, shelter, water are being the things that people need and uh, don't necessarily think of that there's a lot more that people need when they are in a humanitarian setting. So what special needs do adolescent girls have?

Julianne: Of course, those needs are the basic needs that should be covered immediately upon, you know, when refugees arrive at, um, the new location. Um, those are the basics, food, water and shelter. But we know also that there are, um, a lot of other risk factors, um, that populations face and that's especially the case for adolescent girls. Um, when adolescent girls are, uh, away from their home, away from their normal social structure, um, they don't have those normal protective mechanisms that they would have at home. So they might be separated from their families. They might have to drop out or they likely have to drop out of school. Um, they might not be with their friend group, their community groups. So, um, all of those that normally protect girls in a time of peace or, um, when they're in their home setting, uh, might not exist. Uh, also there are additional protection or safety concerns. Uh, girls are very at risk of sexual and gender based violence. They also, um, might have to take on more adult responsibilities in the home. So they might be expected to stay at home and take care of the children, um, to go and collect water and firewood or to be an economic, uh, contributor to the household. And these adult roles sort of push them forward, um, into adulthood quicker than they might have, um, done so at home. And this might also expose them more to, let's say transactional sex, um, being married earlier because a, their family expects them to sort of have their own household. Um, and these sorts, sorry, these sorts of things. All of these safety concerns, results can result in some negative sexual and reproductive health outcomes.

Jennie: Yeah, no, I think that's so important. I think people don't necessarily think that, uh, about all the needs that people have and that they continue when they go into humanitarian settings. And, and don't think of that a humanitarian setting that often people are there for a long time in a refugee camp or something.

Julianne: I think they say. Now the average length of displacement is, um, over 10 years. So we usually, we used to think of, you know, these acute emergency settings where, um, there's just a need for food distributions, shelter and it's kind of in and out. But now we're seeing these really protracted conflicts and displacement. And so that also gets us to think about, um, what additional services are needed and more long-term for adolescents to sort of transition into adulthood, um, safely and in a healthy way.

Jennie: And one way to figure that out is to talk to the adolescents and see what they need, but it's not quite as simple as that, is it?

Julianne: Think about when you first went through puberty and if someone were to just ask you a question about, you know, all the embarrassing changes you're going through or you know, if you are not yet married and someone's asking you about pregnancy and childbirth, you can imagine that it would be, um, perhaps not the most comfortable thing to discuss. And in humanitarian settings, as I mentioned, all these normal protective systems aren't there. So girls might have, you know, less trust in someone who's asking them those questions. They might not know what it's for or why they're being asked that. Um, so in order to really understand what it is that girls need in terms of sexual and reproductive health services, we have to really ask them and listen to them in a way that's comfortable for them and that they can really express what it is that they need and want.

Jennie: Yeah, I think that's really important because a lot of this stuff is often done with surveys. So you're just going up and asking people and like you said, the social systems are really broken down and you might not have trust with the person conducting the survey.

Julianne: Another typical way of conducting research is often focus group discussions where you get a group of, you know, 10 to 12 people and you just ask open ended questions with a guided questionnaire and you let them sort of talk amongst themselves. And this can be really great um, if you have a very skilled facilitator with adults on various topics, but generally with adolescents, it can be really hard to have them in a group setting and open up, especially if the researcher is kind of a stranger to them um, and talk about more sensitive issues.

Jennie: Or if you don't know the things you need , if you've, you're just getting your first period, right, you don't know what you need.

Julianne: Or if you know you haven't yet had sex, um, and you might not know that there's ways of protecting yourself from STDs or HIV or to protect yourself from getting pregnant too early.

Jennie: Or if you have experienced gender based violence or have been raped, knowing that you would need services for that. Those are things they just might not know.

Julianne: Exactly.

Jennie: So I know another thing you work on is how do you meet the needs once you have the needs. So, um, what does WRC do in that? Okay, so now we talked about what doesn't work for a research and with adolescents. So what, what does work, what do we need to do?

Julianne: So, um, WRC has been trying to, um, create different research methodologies, um, that generally we refer to as participatory research methods. Um, and that means that the adolescent girls are more, it's a more active engagement with the girls, um, and sort of getting, building that trust in a short amount of time for them to discuss more sensitive issues. Um, one example of that is, um, an exercise called body mapping where the girls are asked to draw three pictures, one of which a girl asked to draw three pictures, one of a young girl, age seven or eight, uh, one of an adolescent girl that's their age and one of an adult woman. And, uh, a local researcher. We'll sit with them in small groups and have them draw those pictures. And while they're drawing, the researcher will sort of guide the discussion to, uh, ask them about the different changes they go through, what are the main challenges that they experienced as adolescents? Um, and this we found kind of helps the girl to feel more comfortable. You know, if they're in smaller groups, they're, you know, sitting on the ground with a researcher and they're drawing. We know that, you know, art therapy and while drawing can be very therapeutic. Um, so we've found that this kind of helps to facilitate discussions.

Julianne: Um, another thing we've found is as you mentioned, or as we just discussed, um, how can you articulate needs that you don't know you necessarily have or how can you ask for services that you have no idea exist? Um, so what we've done to sort of try to overcome that challenge is after the body mapping activity, then we, um, ask the girls further, you know, we kind of summarize what they've said in terms of their challenges and what are really the most difficult parts for them of being an adolescent. And then based on those challenges we ask them, um, what kind of things would help you to not experience those challenges? And through that we, um, do something called participatory ranking, which is an, a methodology that was created at Columbia University and it can be used with children. Um, and it's really great for populations who might have low literacy and it works by girls listing what their challenges are and then they assign objects, um, to those challenges. And then they put them in order, they rank them, and then you can do the same thing to ask them what services or um, programming they would need to overcome the challenges. And again, they can list all of the services, um, in a free listing manner. And then they assign, um, a physical object, a pen or a water bottle or a notebook or scrap of paper, um, to that service or program. And then they work in a group to rank them from most important to less important.

Jennie: Oh, that's great. It's nice to see creative ways to make sure you're getting, uh, what is the most important to these adolescent girls. So once you've figured out the challenges, um, what do you work on to meet their needs?

Julianne: Equally important, of course, is responding to whatever we find from our research. Um, there's no point in conducting research if you don't also try to translate that evidence into real action. Um, and what we're doing is trying to, um, engage adolescent girls more in designing programs that really respond to their needs. So we're currently working, um, to expand programming in, um, women and girls safe spaces. Uh, right now we're working in three countries, Lebanon, Iraq and Bangladesh. And we are trying to build the capacity of the program staff in those safe spaces to um, engage girls in the entire process of program design and implementation. And then also to monitor and evaluate the results of the program to make sure that it's continuously responding to their needs. Um, so in practice, this might, um, start with these research methods that really give girls more of a voice and have them feel more confident in expressing what it is that they want to learn or what services they need access to. Um, and then ideally, um, several girls would be a part of a task force that would work with the program staff at the safe space to sort of select perhaps modules from a curriculum, um, on SRH or think of ways in which they could maybe anonymously ask questions to a safe space staff member or they might be able to um, sorry, do a service mapping to see what services in their immediate surroundings are adolescent friendly. And so this small group of girls will then, um, share their ideas for what intervention should look like and continue to be involved, um, to support the safe space staff in collecting data from their peers, uh, in regard to how well the program is responding to their needs. Um, and this is also helpful to build their capacity and to really, um, make them feel confident as active members of change, uh, in their communities.

Jennie: I really love that there is participatory involvement, uh, with the girls through the whole process. So often you hear about wanting to make sure we're engaging adolescents and that they're brought in at the end or consulted at the beginning and not throughout the whole thing. And giving them so much ownership of it, I feel like helps ensure it's meeting what they want and ensuring that they'll use it.

Julianne: And I think it's promising that we are trying this approach in a humanitarian setting where often people think, oh, there's not enough time to really figure out what people want, we have to deliver services right away. We have to just go in there and deliver this sort of tailor or this generic package of services. Um, because it is true that there is urgency to deliver certain, um, information or services, but I think that can be done in a way that is more engaging and participatory.

Jennie: So I know we had talked about before we started recording, um, when we first met was different kinds of safe spaces that, uh, WRC was using to, do you want to talk a little bit about that?

Julianne: Sure. So safe spaces for women and girls is, um, a pretty common, uh, program model that's used in humanitarian settings. Um, typically, uh, the setup is that the safe spaces will be sort of funded by um, uh, UNICEF or UNFPA, UN Women and then local organizations or international NGOs will be, uh, responsible for program delivery within that physical safe space. In our current work WRC, his role is to sort of evaluate whether or not these physical safe spaces are the right way to deliver SRH information or to link girls to SRH services. And, uh, in those three countries I mentioned that we're working in Iraq, Lebanon and Bangladesh. We found that yes, these are great ways to um, help adolescent girls get the right kinds of information, um, as well as like build a sense of community with other girls. Um, and beyond SRH information and services, there's a range of programming that's offered in safe spaces, um, livelihood activities, um, life skills training, a lot of, um, services for gender based violence, response and prevention as well as mental health and psychosocial support.

Julianne: UNICEF was interested to know, um, what are alternative ways of reaching girls with information on sexual and reproductive health outside of a physical safe space. Why? Because we know that these safe spaces are only reaching a very small percentage of girls in a humanitarian setting, especially girls who might have more barriers in accessing services, such as girls with disabilities, married adolescents who might have more restrictions on their movement, um, girls who are out of school, um, or who have low literacy. So these girls, um, are often excluded from programming. And even when girls can reach the physical safe space, they might feel embarrassed or shy to ask about, you know, things related to their sexual and reproductive health. So considering that, and based on some assessments we did last year, we realized that girls in Lebanon and Iraq are really, really engaged with their cell phones. Like teenagers anywhere, they're tied to their cell phones. They, you know, have smart phones. They're going on snapchat, they're going on Facebook, they'rewhatsapping, they have whatsapp groups. They're doing all those things that you would expect a teenage girl to do on her phone. Um, and we were really curious if that could be a good entry point to providing girls with SRH information and services. Really surprisingly. Um, we didn't hear of any existing resource on the Internet for adolescents, um, in the Arab region, so nothing in Arabic that existed online that was like a reliable source of information. Um, and girls often are looking on the internet. They're googling, they're seeing, you know, they, they want to know things about why their body is changing or, um, how to prepare for marriage and these sorts of things. And there's really a risk that they might be guided to incorrect information, inappropriate information. Um, heard lots of stories from parents and caregivers saying that, you know, they're happy for their daughters to use the internet, but they're really afraid that when they search for certain things, they're gonna end up watching pornography or, you know, seeing a really inappropriate image.

Julianne: Um, so we are currently designing, um, a virtual safe space, which will replicate the sorts of information and links to services that would be available in a physical safe space but through a mobile device. So it will be a web based platform, um, where girls can enter, um, anonymously and access information related to puberty, um, menstruation, menstrual hygiene, and for older girls. Also information on, uh, pregnancy and contraceptive methods. And we're going to be piloting this application in Lebanon and Iraq later this year. And as I mentioned before, in terms of engaging girls in the process, we're really going to, um, try our best to make sure that they're leading the piloting, but also feel comfortable giving feedback in an ongoing so that we can continue to improve the app before launching it for more widespread use.

Jennie: Yeah. And again, with the, making sure you're working with, uh, adolescents to have them involved, it's also important to meet them where they are and oftentimes that is the Internet.

Julianne: Sure. Yeah.

Jennie: So now that we know about these great things and now I'm sure listeners want to be engaged, what can our listeners do to help take action?

Julianne: Great question. Um, I mean, I think a takeaway point from this is that sexual and reproductive health is a right and it is a right no matter what one's age is and no matter in what context they live. Um, and you know, as we started off this podcast talking about, you know, food, water, shelter are the automatic sort of things that people think about are needed in humanitarian contexts. And yes they are. But, um, there's really a great need to invest more in sexual and reproductive health services, especially for young people and adolescents. So, um, you can find out more information about the kinds of work that, um, we at Women's Refugee Commission are doing in humanitarian contexts, not only, um, in SRH but, and prevention of gender based violence, uh, cash and livelihoods, etc. So I would encourage people to visit our website, a womensrefugeecommission.org

Jennie: And we'll make sure to include it in the show notes so everybody can have easy access and their social.

Julianne: Um, and they're, you can find different ways also of helping, um, as well as all the resources that we have, um, information and guidance for programming. Um, and for those people listening who maybe are working with adolescents, are interested in working with adolescents, I would just say to really, um, try and put yourself in their shoes and remember what it was like to be an adolescent, but also to remember that, well, if you are no longer an adolescent or young person such as myself, that even if you can try to put yourself in their shoes, you aren't in their shoes. And so to really take the time to, um, listen to them and not to go in with any preconceived notions of what it means for them to be an adolescent. Um, and that there are, even though I'm keep referring to adolescents as a group, that it is not a homogeneous group and there are so many different types of girls and boys, um, so many different types of adolescents. Um, and just to meet them where they're at and really, um, listen to them when they say what they need and want.

Jennie: And we'll definitely make sure to include in our show notes as well. The great blog posts you wrote, talking about, um, research needs and, uh, conducting this research with adolescents so that you can read also what Julianne was talking about today.

Julianne: Thank you.

Jennie: Julianne, thank you so much for doing this. It's been fun!

Julianne: Thanks Jenny. Thank you.

Jennie: For more information including show notes from this episode and previous episodes, please visit our website reprosfightback.com. You can also find us on Facebook and Twitter at rePROs Fight Back. If you like our show, please help others find it by sharing it with your friends and subscribing, rating and reviewing us on iTunes. Thanks for listening.