Imagine a 12-year-old girl recently settled in a refugee camp with her family. She is the eldest daughter and has five siblings. She tries to help her mother every day with cooking, collecting water, taking care of her younger brothers and sisters. She has none of her friends there and feels like she has no one to play with or talk to. Sometimes, she feels like she wants to be alone, where no one is asking her to do anything. At first, she thought she could go to the field where the latrines are located. But there are many men around, soldiers too, and they say things to her, whistling, making gestures she knows are bad. She liked going to school and knows there is a school in the camp where she sees others her age going every day. However, she does not know how she can attend. She wants to have a friend or a teacher or an older sister to talk to and make her feel less vulnerable.
In the transition from childhood to adulthood, adolescents normally benefit from the influence of adult role models, social norms and structures, and community groups (peer, religious or cultural). When people are displaced, however, family and social structures are disrupted. Adolescents may be separated from their families or communities, while formal and informal educational programmes are discontinued, and community and social networks break down. Adolescents may be fearful, stressed, bored or idle. They may find themselves in risky situations that they are not prepared for dealing with and they may suddenly have to take on adult roles without preparation, positive adult role models or support networks.
Adolescents who live through crises may not be able to visualise a positive outlook for themselves, and may develop fatalistic views about the future. The loss of livelihood, security and protection provided by the family and community places adolescents at risk of poverty, violence, and sexual exploitation and abuse. In particular:
- Displaced very young adolescents (10-14 years), especially girls, are at risk of sexual exploitation and abuse. Because of their limited life experience, they may not recognise the sexual nature of abusive or exploitative actions in strange settings.
- Pregnant adolescent girls, particularly those under 16, are at increased risk of obstructed labour, a life-threatening obstetric emergency that can develop when the immature pelvis is too small to allow the passage of a baby through the birth canal. Delay in treatment can lead to obstetric fistula or uterine rupture, haemorrhage and death of the mother and child.
- Adolescents separated from their families and adolescent heads of household lack the livelihood security and protection afforded by the family structure, and are therefore more at risk from poverty and sexual exploitation and abuse. Separated adolescents and adolescent heads of household may be compelled to drop out of school, marry or sell sex in order to meet their needs for food, shelter – or protection.
- Adolescent girls selling sex are at risk of unwanted pregnancy, unsafe abortion, STIs and HIV, and sexual exploitation and abuse.
- Survivors of sexual and gender-based violence are at risk of unwanted pregnancy, unsafe abortion, STIs including HIV, as well as mental health and psychosocial problems and social stigmatisation. In post-earthquake Haiti, a significant proportion of survivors of sexual violence treated by the NGOs GHESKIO and Médecins du Monde were adolescent and prepubescent girls.
- Children Associated with Armed Forces and Armed Groups, both boys and girls, are often sexually active at a much earlier age and face increased risk of sexual violence and abuse, mental health and psychosocial problems, unwanted pregnancy, unsafe abortion, STIs and HIV infection.
The disruption to families, education and health services during displacement may leave adolescents without access to sexual and reproductive health information and services during a period when they are at risk. Emergency obstetric care services, for example, are often compromised in crisis settings generally, increasing the risk of morbidity and mortality among adolescent mothers and their babies.
Ensuring access to family planning services can be a life-saving intervention in unstable, crisis environments. It can also promote a young woman’s rights to health, education and independence. Likewise, training of youth peer educators to raise HIV awareness, exhibit correct and consistent use of condoms and make condoms available helps protect adolescents from the transmission of STIs, including HIV, that are known to be rampant in this highly vulnerable age group. Similarly, adolescents will only have access to the life-saving provision of post-exposure prophylaxis – provided as part of clinical management of sexual assault survivors – if they are made aware of sexual violence as a violation and of their right to counselling and treatment.
Recognising the unique needs of adolescents facing such situations, the United Nations Population Fund (UNFPA) and Save the Children developed a tool to help humanitarian programme managers and healthcare providers meet the sexual and reproductive health needs of adolescents. The Adolescent Sexual and Reproductive Health Toolkit for Humanitarian Settings was conceived as a practical companion to the Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings. As well as including guidance on mapping out key interventions to be undertaken by various sectors or functions in different phases, the ASRH Toolkit includes:
- MISP tools – specific ways to include interventions focused on adolescents as part of the Minimum Initial Service Package (MISP) for Reproductive Health.
- Participation tools – guidance on directly engaging adolescents in humanitarian interventions, and on involving parents and communities on adolescent sexual and reproductive health issues.
- Assessment tools – questions focused on adolescent sexual and reproductive health, either for initial rapid assessments, for broader situational analysis or for comprehensive surveys.
- Facility-based tools – guidance for health workers in humanitarian settings in working with adolescents.
- Community-based distribution and peer education tools – concrete tips and actions to support community-based outreach.
Since early 2010, the ASRH Toolkit has been used to help strengthen adolescent-focused services and programmes in several humanitarian contexts, such as in post-earthquake Haiti, with refugees from Libya in 2011 and in the Dollo-Ado camps in Ethiopia.
Some civil society organisations – such as the Straight Talk Foundation in Uganda and the Adolescent Reproductive Health Network on the Thai-Burma border – have embarked on truly innovative work from which we as a community can learn.
Straight Talk Foundation is a Ugandan NGO providing newspapers, radio shows and youth centres for teenagers, as well as radio shows for parents and newspapers for teachers, all focusing on HIV, sexuality and adolescence. www.straighttalkfoundation.org
The Adolescent Reproductive Health Network on the Thai/Burma border runs a youth centre in Mae Sot, for example, where young people gather for social activities and where they can also access reproductive health and family planning information, contraception and counselling services. www.arhburma.net/.
But efforts to truly reach and engage adolescents in emergencies with comprehensive sexual and reproductive health information and services are still in their early days. While there are a few organisations that have committed to integrating a focus on adolescents into their sexual and reproductive health programming, in general intentional targeting of this age group is often an afterthought and the facilitation of meaningful adolescent participation has been challenging, despite empirical evidence of their very specific and damaging risks and vulnerabilities.
Brad Kerner BKerner@savechildren.org is Adolescent Reproductive Health Advisor, and Seema Manohar SManohar@savechildren.org is Emergency Adolescent Reproductive Health Specialist, at Save the Children. www.savethechildren.org Cécile Mazzacurati email@example.com is Programme Specialist, Youth and Gender, Humanitarian Response Branch, UNFPA. www.unfpa.org Mihoko Tanabe MihokoT@wrcommission.org is Reproductive Health Program Officer, Women’s Refugee Commission. www.womensrefugeecommission.org
For more information or to share your best practice, email ASRHToolkit@savechildren.org
 Developed under the guidance of the International Rescue Committee, John Snow, Inc., Pathfinder, the RAISE Initiative at Columbia University, Save the Children, UNFPA, UNHCR, UNICEF and Women’s Refugee Commission http://unfpa.org/public/home/publications/pid/4169
 In 2011 UNFPA and Save the Children also launched a one-hour interactive e-learning course on adolescent sexual and reproductive health in humanitarian settings www.iawg.net/resources/arhtoolkit.html