THE EUROPEAN MAGAZINE FOR SEXUAL AND REPRODUCTIVE HEALTH No.76 - 2012 This issue was published with the fi nancial and technical support of the Eastern Europe and Central Asia Regional Offi ce of the United Nations Population Fund CHILD MARRIAGE 2 Dr Assia Brandrup- Lukanow Senior Adviser, Danish Center for Health Research and Development Faculty of Life Sciences Ms Vicky Claeys Regional Director, International Planned Parenthood Federation European Network Dr Mihai Horga Senior Advisor, East European Institute for Reproductive Health, Romania THE EntrE nous EDIToRIAL ADvISoRy BoARD Dr Evert Ketting Senior Research Fellow, Radboud University Nijmegen Department of Public Health, Netherlands Dr Manjula Lusti- Narasimhan Scientist, Director’s office HIv and Sexual and Reproductive Health Department of Reproductive Health and Research WHo headquarters, Geneva, Switzerland Prof Ruta Nadisauskiene Head, Department of obstetrics and Gynaecology Lithuanian University of Health Sciences, Kaunas, Lithuania Dr Rita Columbia Reproductive Health Advisor UNFPA Regional office for Eastern Europe and Central Asia CoNTENTS The European Magazine for Sexual and Reproductive Health Entre Nous is published by: Division of Noncommunicable Diseases and Health Promotion Sexual and Reproductive Health (incl. Maternal and newborn health) WHo Regional office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø Denmark Tel: (+45) 3917 17 17 Fax: (+45) 3917 18 18 www.euro.who.int/entrenous Chief editor Dr Gunta Lazdane Editor Dr Lisa Avery Editorial assistant Jane Persson Layout Kailow Creative, Denmark. www.kailow.dk Print Kailow Graphic Entre nous is funded by the United Nations Population Fund (UNFPA), Regional office for Eastern Europe and Central Asia, with the assistance of the World Health organization Regional office for Europe, Copenhagen, Denmark. Present distribution figures stand at: 3000 English, 2000 Spanish and 1500 Russian. Entre Nous is produced in: Russian by the WHo Regional office for Europe Rigas, RGH Baltic, Rounborg Grafiske Hus; Spanish by the Instituto de la Mujer, Ministerio de Sanidad, Servicios Sociales e Igualdad, Condesa de venadito, 34, 28027 Madrid, Spain. 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Please order WHo publications directly from the WHo sales agent in each country or from Marketing and Dissemination, WHo, CH-1211, Geneva 27, Switzerland ISSN: 1014-8485 © World Health Organization 2012 Editorial By Werner Haug 3 Early marriage: cause and consequence of gender inequality and a violation of human rights By Åsa nihlén and Isabel Yordi Aguirre 4 Child marriage and Roma By rita Columbia 6 Child marriage in Central Asia By Marko rankovic 10 Early marriages and global research priorities on adolescent sexual and reproductive health By Charlotte Christiansen 14 Early age of first sexual intercourse: its relationship to early marriage and sexual health risks in Albanian female adolescents By Lumturi Merkuri and Alban Ylli 16 Child marriages in Kyrgyzstan: disadvantages without advantages By nurgul Kinderbaeva 18 Child marriage in Tajikistan By Lola Yuldasheva, Aziza Hamidova, nargis rakhimova and Khurshed Irgitov 20 The destiny of young people in Turkey By Ayse Akin and sare Mihciokur 22 INTERNATIONAL DAY OF THE GIRL CHILD 2012: My life, my right, end child marriage 24 Resources By Lisa Avery 26 ,, 3 No.76 - 2012 EDIToRIAL Too yoUNG To WED: CHILD MARRIAGE IN EASTERN EURoPE AND CENTRAL ASIA The International Day of the Girl Child was marked for the first time on the 11th of October this year. The occasion is about protecting and empowering girls. They are a vulnerable group that continues to suffer from human rights violations and there are few issues that highlight this more than child marriage. Children are considered incapable of giving free and full consent, making child marriage a violation of human rights and the rights of the child. Numerous interna- tional treaties and conventions have been signed to prevent it from taking place. These pertain to abolishing harmful customs and traditions (such as female genital mutilation), preventing violence against girls, ensuring marriage consent, verifying spouses are of marriageable age, requiring that marriages are registered and granting everyone the freedom to choose who they marry. Much of eastern Europe and central Asia is known for its rapid development in re- cent years. However, as in all parts of the world, outstanding human rights issues need to be addressed across the Region and room for improvement exists. Child marriage is one such issue, primarily af- fecting girls, that needs more attention. Child marriage and childbearing affect girls’ physical and psychological health. Girls are not only at risk of early and unwanted pregnancies, but the complica- tions associated with pregnancy and child birth are among the leading causes of death for girls aged 15-19 worldwide. In addition there are issues associated with empowerment. If a girl is married before she completes her education, her chances of finding employment and achieving a career are limited. This contributes to the cycle of poverty that often leads to the continuation of child marriage. According to anecdotal information available in the Region, child marriage is on the rise. As a result of socioeconomic turmoil, conflict and the reassertion of cultural identities the phenomena has increased. Child marriage generally tends to occur in disadvantaged areas and in groups lacking access to education, employment and health services, including in Roma communities. As a result of this, the girl spouse’s sexual and reproductive health can suffer tremendously. Since child marriage generally takes place in communities that face limited govern- mental monitoring and is sometimes completely undocumented, the state is often unaware that the problem exists. If authorities are aware, they usually do not realize the scale of the problem and don’t adequately address it through national legislation and programmes. The UNFPA supports governments in all countries in the Region, especially in those where issues of child marriage are acute, to: • Develop and implement adequate legislation and policies; • Raise awareness about women’s and adolescents’ human rights, includ- ing their right to information and education on sexual and reproductive health and access to reproductive health services; • Improve the quality of health services provided to disadvantaged popula- tions and guarantee access to contra- ception; • Introduce and scale up sexuality education in and out of schools; • Strengthen mechanisms to collect disaggregated data; and • Support programmes on domestic violence prevention. If we can end child marriage, we can change the lives of girls everywhere. We can help them enjoy their childhood, enroll them in schools, protect them from complicated pregnancies and births. We can keep girls safe. Therefore, as we do all of this we can break the cycle of intergenerational poverty and eliminate discrimination. We call on governments, civil society, pri- vate sector, faith based organizations and the international community to accele rate efforts to: • Enforce legislation to prevent child marriage; • Improve equal access to quality education and health services for boys and girls; • Mobilize communities to change discriminatory practices against girls and to create social, economic and civic opportunities for girls; • Raise awareness among disadvantaged populations on human rights, sexual and reproductive health and gender equality; and • Address root causes of child marriage including violence against women and girls. The publication of this edition of Entre Nous is a positive step for raising aware- ness of the issue. Additionally, I invite you to visit http://eeca.unfpa.org/public/ pid/12420 to review the available evidence in its entirety. Werner Haug, PhD, Director, Eastern Europe and Central Asia Regional office, UNFPA Werner Haug 4 INTERNATIONAL HUMAN RIGHTS INSTRUMENTS AND EARLY MARRIAGE A number of human rights instruments lay down norms to be applied to marriage, cover ing issues of age, consent, equality within marriage, and the personal and pro- perty rights of women. The key instruments and articles are as follows (paraphrased for clarity in some cases): Article 16 of the 1948 Universal Declaration of Human Rights (UDHR) states: (1) Men and women of full age (… ) have the right to marry and found a family. They are entitled to equal rights as to marriage, during mar- riage and at its dissolution. (2) Marriage shall be entered into only with the free and full consent of the intending parties. Similar provisions are included in the 1966 International Covenant on Economic, Social and Cultural Rights and the 1966 Interna- tional Covenant on Civil and Political Rights. Article 1 of the 1956 Supplementary Conven- tion on the Abolition of Slavery, the Slave Trade, and Institutions and Practices Similar to Slavery includes in the institutions and practices similar to slavery: Article 1(c) Any institution or practice whereby: (i) A woman, without the right to refuse, is promised or given in marriage on payment of a consid- eration in money or in kind to her parents, guardian, family (…). Articles 1, 2, and 3 of the 1964 Convention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages state: (1) No marriage shall be legally entered into without the full and free consent of both parties, such consent to be expressed by them in person (…) as prescribed by law. (2) States Parties to the present Convention shall (…) specify a minimum age for marriage (“not less than 15 years” according to the nonbinding recommendation accompany- ing this Convention). No marriage shall be legally entered into by any person under this age, except where a competent authority has granted a dispensation as to age, for serious reasons, in the interests of the intending spouses (…). (3) All marriages shall be regis- tered (…) by the competent authority. Article 16.1 of the 1979 Convention on the Elimination of All Forms of Discrimination against Women prescribes equally for men and women: (a) The same right to enter into marriage; (b) The same right freely to choose a spouse and to enter into marriage only with their free and full consent; (…). Article 16.2 states: The betrothal and the marriage of a child shall have no legal effect, and all nec- essary action, including legislation, shall be taken to specify a minimum age for marriage. Article 12 of the 1950 European Convention for the Protection of Human Rights and Fundamental Freedoms states: Men and women of marrigeable age have the right to marry and to found a family, according to the national laws governing the exercise of this right. Text Box 1. source: unICEF, 2001 (5). EARLy MARRIAGE: CAUSE AND CoNSEqUENCE oF GENDER INEqUALITy AND A vIoLATIoN oF HUMAN RIGHTS To get married is a human right. Article 16 of the Universal Declaration of Human Rights clearly states that men and women of full age, without any limitations due to race, nationality or religion, have the right to marry and found a family. It further specifies that men and women are entitled to equal rights as to marriage, during marriage and at its dissolution. It also says that marriage should be entered into with the free and full consent of the intending spouses (1). A number of different and important international human rights treaties also stipulate that a person’s right to choose when, if, and whom he or she will marry must be protected and enforced by na- tional laws (Text box 1). Marriage may, therefore, also be a violation of human rights – both in itself and through the limitations marriage may pose on an individual in certain circumstances. All countries in the WHO European Region have set a minimum age for mar- riage, and in most countries this is 18. This is because under the Convention of the Rights of the Child a person under the age of 18 is generally considered a child (Text box 2) (2). Many countries are setting a lower age for marriage with parental consent and in countries where there is a discrepancy between the mini- mum age of marriage between men and women it is consistently lower for women. A different legal age of marriage between women and men is discriminatory and reflects gender inequalities. The issue of free and full consent for entering into marriage is a complex mat- ter and even more so when it concerns children. Moreover, in many European countries parents’ consent overrides the legal age of marriage, which poses difficult questions from a human rights perspective. The Committee on the Elimi- nation of Discrimination against Women is clear in its recommendation: “When men and women marry, they assume important responsibilities. Consequently, marriage should not be permitted before they have attained full maturity and capacity to act” (3). Gender inequality is both a main cause and a consequence of early marriage. In most cases of early and forced marriage, the younger spouse is a girl and mar- riage has only a further disempowering impact on her. From a rights-perspective a number of serious concerns accompany child marriage for girls, such as: denial of childhood and adolescence; limits to per- sonal freedom and development; reduced educational opportunities; as well as limitations to her right to health, includ- ing reproductive health and psychological well-being. Due to gender inequalities, young girls who get married are more likely to be forced into sexual intercourse, less likely to negotiate safe sex, and more likely to experience domestic violence. They are also less likely to take action against abuse (4). Early marriage is present across the European Region. In western countries this is most predominant among migrant populations and among minorities such as Roma and travellers. It is important that governments take action to prevent early marriage and its impact. Existing laws should be strengthened in line with human rights commitments and correctly enforced and there should be a health and social support system available for girls who suffer the impacts of early marriage and/or are trying to avoid or escape from it. More importantly, however, there is a need to address the gender inequali- ties behind early marriage and invest in girls’ empowerment, protecting and supporting adolescence by keeping girls in school. Action is also needed across society through a wide range of actors to No.73 - 2011 5 6 2 Isabel Yordi Aguirre Åsa Nihlén EARLY MARRIAGE AND THE CONVENTION ON THE RIGHTS OF THE CHILD (CRC) The CRC has been ratified by all countries with the exception of the United States and Somalia. virtually every provision of the CRC is of some relevance to the issue of early marriage. Among the most pertinent, however, are the following (paraphrased for clarity in some cases): Article 1: A child means every human being below the age of eighteen years unless, under the law applicable to the child, majority is attained earlier. Article 2: Freedom from discrimination on any grounds, including sex, religion, ethnic or social origin, birth or other status. Article 3: In all actions concerning children … the best interests of the child shall be a primary consideration. Article 6: Maximum support for survival and development. Article 12: The right to express his or her views freely in all matters affecting the child, in accordance with age and maturity. Article 19: The right to protection from all forms of physical or mental violence, injury or abuse, maltreatment or exploitation, including sexual abuse, while in the care of parents, guardian, or any other person. Article 24: The right to health,and to access to health services; and to be protected from harmful traditional practices. Articles 28 and 29: The right to education on the basis of equal opportunity. Article 34: The right to protection from all forms of sexual exploitation and sexual abuse. Article 35: The right to protection from abduction, sale or trafficking. Article 36: The right to protection from all forms of exploitation prejudicial to any aspect of the child’s welfare. Text Box 2. source: unICEF, 2001 (5). bring marriage out of the private sphere and publicly discuss the many negative consequences early marriage may have, for the spouses, for the family and for society as a whole. Åsa Nihlén, Technical officer, Human Rights, WHo Regional office for Europe, aan@euro.who.int Isabel Yordi Aguirre, Technical officer, Gender and Health, WHo Regional office for Europe, iyo@euro.who.int References 1. The Universal Declaration of Human Rights. http://www.un.org/en/docu- ments/udhr/index.shtml 2. Convention on the Rights of the Child (article 1). 3. Committee on the Elimination of Discrimination against Women, General Recommendation No. 21 (13th session, 1994), Equality in mar- riage and family relations. 4. Brown, D and Bogaarts Y. Child mar- riage: a violation of human rights/ Marriage des enfants: une violation des droits humains The Free Library. (2007). Retrieved November 22, 2012 fromhttp://www.thefreelibrary.com/ Child marriage: a violation of human rights/Marriage des enfants: une...- a0171018170 5. Early Marriage – Child Spouses. Inno centi Digest No. 7, March 2001. New York: UNICEF, 2001. 6Early or child marriage is the union, whether official or not, of two persons, at least one of whom is under 18 years of age. By virtue of being children, child spouses are consid- ered to be incapable of giving full consent, meaning that child marriages should be considered a violation of human rights and the rights of the child. Rates of child marriage are low in Albania, but the practice is found among Roma, and in some isolated rural communities. Child marriage is a gendered phenomenon that affects girls and boys in different ways. overall, the number of boys in child mar- riages around the world is significantly lower than that of girls. Girl child spouses are also vulnerable to domestic violence and sexual abuse within relationships that are unequal, and if they become pregnant they often experience complications during pregnancy and childbirth, as their bodies are not ready for childbearing. on marrying, both boys and girls often have to leave education to enter the workforce and / or take up domestic responsibilities at home. various international treaties, conventions, and programmes for action address child marriage. These include: the 1962 Conven- tion on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages; the Convention on the Elimination of All forms of Discrimination Against Women (1979); the Convention on the Rights of the Child (1989), and; the 1995 Beijing Platform for Action (which followed the UN Fourth World Conference on Women). These inter- national instruments cover the abolishment of harmful customs and traditions, violence against the girl child, marriage consent, marriageable age, registration of marriage, and the freedom to choose a spouse. Introduction International human rights standards classify marriages before the age of 18 as child marriages, reasoning that those under age 18 are unable to give informed consent. Child marriages involving parental, partner and/or social influence, collusion or pressure are, de facto, forced. Forced and early marriages are serious human rights violations. Today, only a few coun- tries in the eastern Europe and central Asian Region have specifically criminal- ized the practice of child marriage. How- ever, even when legal protections against child marriage exist, legislation enforce- ment mechanisms are limited. Child marriage is a complex issue. Poverty, lack of value placed in girls’ education, geographical isolation, social exclusion, trafficking and emigration are all factors that are driving child marriage in many countries of central Europe. Roma girls are especially vulnerable to be married at early ages due to existing values, traditions, poverty and social exclusion. Within this context, the UNFPA Eastern Europe and Central Asia Regional Office conducted a study on child mar- riages in south eastern Europe ( Albania, Bosnia and Herzegovina, Kosovo, the former Yugoslav Republic of Mace donia, Serbia), central Asia (Kazakhstan, Kyr- gyzstan, Tajikistan and Uzbekistan) and Turkey in 2012. The study included a review of secondary data on child mar- riages, as well as, collection and analysis of limited primary data input (from interviews with key experts and women/ men who have experienced early mar- riage) (1). This article is based on the results of the survey that covered the issue of child marriage among the Roma in five coun- tries: Albania, Bosnia and Herzegovina, Kosovo, the former Yugoslav Republic of Macedonia and Serbia. Albania For the Roma in Albania life is marked by unemployment, low income, poverty and low levels of education. Studies reveal that Roma girls tend to marry at a much younger age and become mothers earlier than other ethnic groups. A study in 2002-2003 showed that the average age of marriage for Roma girls was 15.5 years, while the average age of Roma mothers at the birth of their first child was 16.9 years. In 2011, 31 percent of 13-17-year-old Roma girls were married or in union (2). The available studies found that the main factors driving child marriages are cultural values, poverty, parents’ fear of child kidnapping and prostitution and limited education on marriage and family planning. The outcomes of child marriage and childbearing, reported by the avail- able studies, include low levels of educa- tion and high divorce rates (2). While poverty is a major predictor of child marriage among the Roma, their values, beliefs, and attitudes towards what is considered honourable, moral and pure are important as well. Physical growth is considered an indicator of the readiness to enter marriage, rather than the child’s actual age. Parents worry that once a child has reached puberty, he or she will begin dating and enter into a sexual relation- ship. Parents will arrange a marriage to ensure that the girl does not lose her virginity and to avoid the shame that would be brought onto the family’s hon- our if this were to happen. In many cases, parents force their daughter to marry the boy she is dating. The Criminal Code in Albania does not criminalize child marriage. The Civil Code states that a person attains full juridical capacity when he or she reaches 18 years of age. The code specifies, however, that if a girl marries before the age of 18, she automatically attains juridical capacity. Child marriage among the Roma af- fects boys as well as girls. Two types of child marriages are common in Roma communities. The most frequent are arranged marriages as soon as the child is considered ready to marry (about 12-14 in females and 14-16 in males). The second type is marriage by elope- ment, where the couple decides to marry without their parents’ approval. Roma marriages are rarely registered. Child marriage is not common in all Roma communities in Albania. It is mostly found among more marginalized communities, who speak only Romani and are organized in big, extended fami- lies. Discrimination against them follows two primary routes: 1) the attitude of the majority Albanian population and 2) the legal and policy environment, which does not consider the specific needs of this group. Roma child spouses usually continue the cycle of poverty into which they were born and, as their marriages are illegal, it is difficult for them to continue their education and to secure adequate housing or employment. Child marriages often do not last and a couple may separate and soon after remarry. CHILD MARRIAGE AND RoMA No.76 - 2012 7 Bosnia and Herzegovina Almost as a rule, Roma do not register marriages and live births in the official registries. They practice common law marriages and they raise their children to follow the same customs. Roma consider such marriages as valid marriages in their community. While arranged mar- riages and early betrothals take place, it is more common for young Roma couples to elope without seeking their parents’ advice or approval. The act of elopement then becomes the act of marriage. Once the ‘marriage’ is consummated all the par- ties are presented with a fait accompli. As marriages and births are rarely registered, there are no reliable records of who is related to whom by blood within Roma communities. This means that close rela- tives may end up living together in a com- mon law marriage, sometimes resulting in health problems for their offspring. According to the FGiH Family Law a person cannot contract a marriage if less than 18 years of age. A court can allow exceptions for a person who has reached 16 years old to contract a marriage if the person is physically and mentally able to fulfill the duties and rights of matrimo- nial life. Legally it is not possible for a person under 16 years of age to contract a marriage. If an adult is in a common law relationship with a juvenile under 16 years of age, it is considered a crime and according to the criminal code should be penalized. However, if marriage is con- tracted in such cases, criminal prosecu- tion is not instituted. Importantly and interestingly, Roma do not attribute child marriages to Roma tradition, but rather to the circumstances in which they live and to the consequenc- es of these circumstances. They corrobo- rate this claim by drawing attention to the marriage habits of Roma who are literate and have received an education, which resemble the patterns of the rest of the society. One Roma Non Governmen- tal Organization (NGO) representative voiced the opinion that illiterate people are more prone to enter child marriages, which serve as a source of comfort and a ‘place’ to escape life’s realities. One of the important consequences of Roma lifestyle is that few Roma children have birth certificates, which makes it difficult for them to be enrolled in school. Later on, they face problems obtaining identification documents and registering with relevant authorities. The problems of illiteracy, lack of education, lack of skills, unemployment, poverty, poor health care, low standard of living, discrimination, and lack of perspective can make it very hard for some within the Roma community to avoid engaging in criminal activity. Kosovo Although statistical data is unavailable, in the past, it appears that child mar- riage was fairly widespread in Kosovo. Anecdotal evidence suggests that child marriage remains prevalent among Roma, Ashkali and Egyptians, with some mar- rying as young as 12. In a 2008 survey of 270 Roma, Ashkali and Egyptian women, one-third believed child marriage could facilitate healthy childbirth and 60 per- cent felt parents should decide who their daughters marry (3). Anecdotal information suggests that child marriage increased during the 1990s, especially during the war in 1999. Parents believed early marriage could protect their daughters. Young women who were left as heads of households hoped marriage would enable them to provide for their siblings. Other young women wanted to ensure that they could remain with their boyfriends who were emigrating. Nowadays, reasons cited for early marriage include love, family pres- sure, security, socioeconomic conditions, unplanned pregnancy, peer pressure and tradition. Immediate registration is particu- larly rare in child marriages. One of the reasons why parents, guardians, or adult spouses who practice forced marriages are unlikely to alert the authorities to such marriages is the existing criminal penalties against child marriages. The existing Family Law regulates against forced marriages by coercion, threat, mistake or “any other lack of free will of the future spouses” (4). Forced marriages are punished by imprisonment of parents or guardians under the Criminal Code. However, the survey respondents indicat- ed that these legal provisions are not suf- ficiently implemented. For example, often when the authorities investigate suspected cases of child marriages community lead- ers might intervene to negotiate between police and parents (3). Another reason for unregistered marriages involving younger girls is the administrative procedures for legal child marriages, including court and forensic fees, which can be both time- consuming and costly. Instead, spouse(s) often wait until they reach the age of 18 to register their marriage. Serbia According to the Multiple Indicator Cluster Surveys as many as 14 percent of Roma girls in the age group 15-19 years were married before reaching 15 years of age and one third had their first child be- fore turning 18 (5). Nearly half of young Roma women in the age group 15–19 years were currently married or in union (44 %). This proportion varies between the urban (40 %) and rural (52 %) setting and is strongly related to the level of edu- cation. By contrast, only 19 % of Roma men in the age group 15–19 years were currently married or in union (5). As a rule, marriages in the Roma community are contracted in an unofficial manner, are not registered and are not reflected in the official statistics. Although the Criminal Code of the Republic of Serbia stipulates that an adult living in a common law marriage with a minor shall be punished by imprison- ment for a term of between three months and three years or, if the criminal offence was committed for gain, for a term of between six months and five years, in practice, few people convicted of this charge face imprisonment. During 2011, in the Republic of Serbia, 123 persons were reported for the criminal offence of common law marriage with a minor. Fifty-nine of them were convicted, but of these, in 47 cases the sentence was sus- pended, 4 people received unconditional Rita Columbia 8prison sentences, 3 people were sentenced to a fine, 3 people were sentenced to a community order, 1 person was warned and 1 person was found guilty but freed without punishment (6). These statistics clearly portray the lenient treatment this criminal offence receives in the criminal justice system. For a significant number of Roma women the cessation of education, rein- forced by a lack of employment oppor- tunities, paves the way to child marriage and early childbirth. This situation is re- flected in the primary school dropout rate among girls from Roma settlements. Due to the belief that their daughters need to prepare for marital life and motherhood, Roma parents often withdraw them from school while they are still very young (12- 14 years old). Furthermore, Roma girls face additional discrimination in relation to education. On one hand the school system is discriminatory with no meas- ures to ensure the inclusion of Roma, while on the other, the family seldom supports schooling of female children. In addition, families also fear that social ac- tivities at school could lead to girls losing their virginity, which would inflict shame upon the girl and her family. The tradi- tion of remaining a virgin until marriage, reinforced by the practice of virginity testing, is still very common among Roma families in Serbia and is thus also closely linked to the high school-dropout rates of Roma girls in puberty. The level of women’s autonomy in the majority of Roma families is restricted in many aspects – in education, em- ployment, family relations, and family planning. Serbian society in general and the Roma community in particular are very patriarchal and this is reflected in the low, subordinate status of the Roma women. Roma women enter the process of biological reproduction very early and are active during the whole period of fertility (7). Young married Roma women face another challenge – domestic violence, not only from their husbands, but also from their in-laws. Roma families are often large with several generations sharing a communal household. The former Yugoslav Republic of Macedonia In general, according to NGO respond- ents in the former Yugoslav Republic of Macedonia, child marriages are most frequently found among the Roma popu- lation in the country. There are numerous reasons to justify the contracting and existence of child and common law mar- riages. The most frequent are the girl’s pregnancy, the need to preserve the fam- ily’s honour, and “a better life in western countries”. The “better life” justification particularly applies to cases where the groom, who is employed abroad, comes back home to find a bride to take back with him. This is a particularly desir- able outcome for families experiencing economic hardship. Failure to continue with education (school dropout) is also particularly associated with child mar- riage. According to the interviews with child spouses, as well as NGO activists, the decision to drop out of school at an early stage of education is made by the parents predominantly among the Roma population. This attitude towards girls’ education is rooted in the belief that a girl’s place is at home and that removal from the school environment will ensure that she receives a proper preparation for marriage and that her virginity will be preserved. The patriarchal values and attitudes of parents to family honour, morality and girls’ virginity perpetu- ate the discrimination of the Roma girls within the Roma population. According to the Criminal Code, the act of an adult living in a common law marriage with a juvenile between 14-16 years of age is a crime punishable by imprisonment. The same punishment is applicable to parents or guardians who allow or force a juvenile to live in a com- mon law marriage. However, the courts have adopted a lenient approach towards the perpetrators of this criminal offence. A study undertaken by UNICEF in 2010 on child sexual abuse found that “for the crime of extra-marital life with a juvenile between 14 and 16 years of age, a condi- tional sentence has been issued in 78.5 % of the cases” (8). The current practice on marriages among the Roma is not to register mar- riages officially. It is a distinct feature of young Roma to live in common law marriages, which are regarded as valid marriages in their community. In the case of common marriages, child spouses are left without any institutional support and protection. The issues underlying this pattern are numerous but include: lack CHILD MARRIAGE AND RoMA (ContInuEd) No.76 - 2012 9 of personal identification documents; poverty; low levels of education; unem- ployment; costs associated with obtaining the required documents for contracting a marriage; and the fact that one (usually the girl) or both members of the couple are too young to legally contract a mar- riage. Conclusion and Recommendations While the findings from the study high- light the diversity of the factors contribut- ing to Roma child marriage, in all of the countries common issues were identified where increased attention needs to be focused. Common issues that need to be addressed include, but are not limited to: 1. Data: Data on child marriages is lack- ing and or scarce in all of the studied countries, which makes effectively being able to address the issue chal- lenging. Efforts need to focus on finding ways to provide reliable data on the issue so that the extent of child marriage, including who is affected and where it is occurring, can be known and progress and challenges in tackling child marriage can be ap- propriately measured and evaluated. 2. Education: Education was identi- fied across all countries as both a risk factor for and outcome of child marriage. Measures to ensure that Roma children are not excluded from existing educational systems should be implemented by governments. In addition, education activities on women’s and children’s human rights, including consequences of child mar- riage, should occur on a regular basis in the Roma settlements and should be supported and introduced in the Roma Health Mediators programmes. 3. Reproductive health: Access to free reproductive health services and education, including family plan- ning, is needed in communities most affected by child marriages. Increas- ing access and education will help to decrease unplanned pregnancy, which was a common factor cited leading to child marriage and also help to delay pregnancy in those who are in child marriages. 4. Policies and legislation: Lack of iden- tification documents and absence of registration of existing common law marriages in Roma communities con- tributes to the vulnerabilities faced by these communities and to their social exclusion. Access to proper documentation and registration of marriages (both child and common law) is needed in order to reduce and prevent child marriages. Child marriage is not an isolated event. It is related to other social problems faced by the Roma families, such as economic difficulties, lack of adequate housing and lack of access to education and health services. If we wish to make progress in addressing the issue we need to recog- nize the importance of the contributing factors and encourage action at all levels of society and across all social, cultural, religious and economic disciplines. Rita Columbia, MD, Reproductive Health Advisor, UNFPA, EECA Regional office, columbia@unfpa.org The author wishes to thank and acknowl edge the Early Marriages in central Europe Research Team, whose findings form the basis of this paper: Ms B Hancilova; Ms J Hoare; Ms E Boce; Mr D Barisic; Ms A Khairullina; Ms N Farnsworth; Ms L Ilibezova; Ms S Mirceva; Ms A Popovicki Capin; Ms S Shonasimova; Ms I Bayraktar; and Ms S Velieva. References 1. Early Marriages in Central Europe: Country Fact Sheets 2012. UNFPA. 2. De Soto H, Beddies and Gedeshi. Roma and Egyptians in Albania: From social exclusion to social inclusion. New York: The World Bank, 2005. 3. A convenience sample of 270 women ages 16 and older in Gjakova, Peja, Gracinica, and Fushe Kosova. Kosovar Gender Studies Center and RRO- GRAEK. 4. The Law on Gender Equality (2004/2) Section 3, Art. 18. Chapter VII, Art. 23. 5. Republic of Serbia Multiple Indicator Cluster Survey 2011, Final Report. Bel- grade, Republic of Serbia: Statistical Office of the Republic of Serbia, 2011. 6. Saopstenje: “Statistika pravosudja ‘Punoletni ucinioci krivicnih dela u Republici Srbiji, 2011’ (Press release: “The Justice Statistics ‘Adult Perpetra- tors of Criminal Acts in the Republic of Serbia, 2011’”), Statistical Office of the Republic of Serbia (2012a). 7. Strategy for Improvement of the Sta- tus of Roma in the Republic of Serbia, 2009. 8. Caceva V, Mirceva S. Research Report: Forlorn and Scared A Situation Analysis of Child Sexual Abuse. Skopje: UNICEF, 2010. CHILD MARRIAGE AND RoMA (ContInuEd) 10 CHILD MARRIAGE IN CENTRAL ASIA Introduction It is difficult to make generalities when describing the attitudes and trends of the diverse societies that inhabit the central Asian republics. More than 150 ethnic groups from different socioeco- nomic, religious and ethnic backgrounds live in the Region, which, at 4 million square kilometres, is almost the size of the European Union. Approximately 65 million people live here in geography that varies from desert, to steppe, to lush green valleys and mountain ranges. Levels of development are also as varied, from isolated traditional homes in the Pamir Mountains to newly built skyscrapers in Astana. These differing attitudes and trends also apply to the issue of child marriage in the Region. Child marriage is perpetu- ated by a variety of different factors that differ not only when describing the issue on a country level, but also when detail- ing the nature of the phenomenon in different communities. Factors including history, cultural background, community desire to perpetuate gender roles, eco- nomics, armed conflict, lack of registra- tion and non-enforcement of legislation all contribute to child marriage being an ongoing issue in the Region. The following article examines the issue in light of these factors and is based on UNFPA field research completed earlier this year. Historical and Cultural Background Historically, the prevalence of child marriage during pre-Soviet times in the central Asian republics (Kazakhstan, Uz- bekistan, Kyrgyz Republic, Turkmenistan and Tajikistan) is hard to determine due to a lack of records prior to the collapse of the Russian Empire. In addition, the attitudes and values of the people living in this vast territory towards gender roles were not at all homogenous. Much of the population, including the Kazakhs, Kyr- gyz and Turkmen, lived as nomads, while settled populations existed predominantly in areas that are now part of Uzbekistan and Tajikistan. Amongst many of the nomadic populations, women were rela- tively empowered and typically not veiled. Tribal laws, as opposed to Islamic ones, were more prevalent in such societies. The opposite could generally be applied to the settled populations. That women were subservient to men is widely documented. That child mar- riage took place is also known, with the minimum age for marriage being 13 for boys and only 10 for girls. A tradition of paying Kalym (bride price) for brides was also in place. Such a practice would mean that grooms were generally older than their brides due to the time taken to earn and save the amount of wealth demanded for Kalym. It is important to note that European influence was limited in central Asia - the southern flank of the Russian Empire. For the most part, Tsar’s vassals, who were mostly local nomadic leaders and feudal Khans, ruled this vast territory. There was little cultural and social influ- ence from the European areas of Russia. Accounts from travelers visiting a century ago describe a society more analogous to neighbouring Persia or Afghanistan rather than the areas of eastern Europe under Russian control. The establishment of much firmer Bolshevik rule brought radical social change to the area that would become the central Asia republics. Access to education and healthcare became almost universal. The tradition of Kalym was outlawed and the legal age for marriage was raised to 18. Marriage registration was introduced. Efforts to eradicate child marriage were made with varying degrees of success (often ways were found to de- ceive the authorities). In addition to this, Soviet propaganda aimed at emancipa- tion played a strong role in influencing attitudes towards women, especially in the urbanized areas. However, despite these changes, child marriage continued to take place unofficially. After almost seven decades of Soviet rule the Region underwent dramatic economic and political change following the collapse of the USSR. The 1990s were difficult times for the newly independent central Asian states and vulnerable groups suffered as a result. During this time many of the gains to women’s empowerment made during so- cialism evaporated as newly independent states struggled to stabilize economically, socially and politically. Soviet era positive discrimination policies, which mandated quotas for the number of women em- ployed by state controlled entities, became a thing of the past. Critically, a return to traditionalism and newfound nationalism became prevalent in much of the Region. No.73 - 2011 11 6 2 Marko Rankovic Figure 1. Cyclical relationship between causes and consequences. source: Early and Forced Marriages and Girls’ Education. Plan uK, 2011. The reassertion of ethnic identities led to more women taking on the tradition- ally subservient role, especially in rural areas. This has led to a marked increase in child marriage. Trends and Contributing Factors The issue of child marriage in central Asia is itself extremely complex. The condi- tions that create it are often perpetu- ated by the practice itself. For example, non-completion of secondary school is a high risk factor for child marriage. Being born to a child mother lessens a child’s chance of completing secondary school and thus raises the chance of becoming a child spouse. Other factors that both result from and contribute to the likelihood of child mar- riage include: socioeconomic conditions, attitudes towards sexuality from cultural, religious and social perspectives and com- munity attitudes towards women. The primary cause of child marriage relates to gender discrimination. It mostly affects and is propelled by a lack of value for girls’ potential, in terms of educa- tion and career. It is also perpetuated by the idea that a wife should be a servile, domestic woman who raises children and whose sexuality is linked to a concept of community honour and should thus be controlled. Furthermore, both the absence of laws to protect girls, or the lack of enforcement of such laws by authori- ties, are critical contributing factors to the continuation of the practice. The cycle is further exacerbated by poverty, geographical isolation and conflict. The latter was most recently seen during ethnic clashes in the southern Kyr- gyz Republic in 2010. Continuation of Traditional Gender Roles One of the reasons that communities support child marriage is the fact that it is seen as a continuation of the traditional role of women. It is also perceived as a measure to protect the girl herself: by being married a girl does not lose her virginity out of wedlock and find herself unable to attract a husband as a result. Fear of the latter was documented in some instances as a motivation to remove girls from secondary school. Parents, afraid their daughters would meet a boy in school and become ‘ruined’, decided the best way to prevent such a terrible thing happening was to take the girls out of secondary education altogether. This approach is also fed from the lack of value placed on girls’ education. Men also perceive child spouses to be better choices due to the fact that they are less assertive. This means that they are more likely to be a good, servile tradi- tional wife. Exploitation of Child Brides Because the majority of female child brides end up living with their hus- band’s family, they are often vulnerable to exploitation. Being the lowest ranked member of the extended family they are often overly burdened with unpaid domestic duties, or in some cases physical labour (in rural settings). As children they find it difficult to standup for themselves against adults in the households, and find themselves in a servant-like position. Once Kalym has been paid the husband’s family often feels a sense of entitlement for treating the girl bride this way. The girl herself may feel as if the family has ‘bought’ her. Family matriarchs play a role in this situation. Firstly, they are often instigators of the marriage to begin with, identifying and arranging suitable matches. Secondly, mother in-laws have been known to abuse and bully child brides while instructing child brides on how to be good wives. Sexual exploitation in this environment has also been reported. Dominated by her husband and his family, child brides have found themselves having no control over sexual contact. Married Against Their Will As already touched on, the fact that many child marriages in central Asia are arranged by parents and grandparents means that a child bride’s decision to enter a marriage is not her own. While the girl may not be physically forced into the marriage, the substantial pressure applied by family members can be overwhelm- ing for the girls involved. This is often motivated by the desire to rid the family of the burden of supporting the girl, or a response to the attention she is receiving from men. 12 CHILD MARRIAGE IN CENTRAL ASIA (ContInuEd) Globally ten million girls under the age of 18 marry each year. That’s around … • 833,333 a month • 192,307 a week • 27,397 a day • 19 every minute Or, around one girl every three seconds. The practice of bride kidnapping still takes place across central Asia. Tradition- ally it was often a rehearsed event carried out so that young couples could elope without family permission. Now, it is a literal abduction of the bride against her will, which often results in sexual and physical assault at the hands of the husband. The Role of Economics Poverty, intersecting with other cultural issues, is often a contributor to child marriage. With little value placed on a girl’s economic potential due to prevail- ing cultural attitudes, she is often seen as a burden. By marrying her off she is no longer a drain on family resources. The payment of Kalym is also a financial incentive for many families to continue to practice child marriage – the financial gain is an important consideration for parents struggling to raise a family. In both the Kyrgyz Republic and Kazakhstan cases have been documented of girls be- ing married off as a means of continuing their younger siblings’ education. Yet, despite the contributing role of poverty to child marriage, child marriage is not limited to the poor and not all economically disempowered communi- ties in central Asia practice the tradition. In Uzbekistan and Tajikistan there are documented cases of wealthy families also arranging marriage for their children. In these cases it appears the tradition of child marriage is done primarily with the motivation of finding a husband from a ‘good family’ who would be a suitable match for the girl involved. As well, there are also cases of poor and isolated communities in the Pamir Mountains where child marriage is rare. This is due to the value the communities place on girls’ education. With marriage being an obvious impediment to a girl’s studies it is not promoted. In contrast communities that face exclusion are much more likely to practice child marriage. For example, marginalized minority groups in Kazakh- stan demonstrate the highest levels of child marriage in the country. Lack of Registration The vast majority of child marriages in central Asia are unregistered. The mar- riage may be carried out with a religious ceremony (despite not being condoned by most religious leaders) but official docu- mentation of the event usually does not take place. In many cases documentation may be postponed until after the girl has reached an age whereby she can legally be married, years after the actual event took place. Such lack of registration represents a serious impediment to efforts by the authorities to address the issue. Without concrete evidence and documentation of such events it is difficult for authorities to know both the scale of the phenomenon and where it is occurring in the country and Region. The Influence of Conflict Despite the numerous potential pos- sibilities for armed conflict created by overlapping ethnic and geographical borders, rising nationalism and economic uncertainties, central Asia, to date, has experienced relatively little armed conflict since the collapse of the Soviet Union. This is particularly true when compared to neighbouring regions such as the Caucasus. The exception to this trend is Tajikistan, which suffered civil war during the 1990s and the south of the Kyrgyz Re- public, which saw wide scale inter-ethnic violence most recently in 2010. Both of these conflicts caused child marriage to increase in the affected areas. Parents looking to protect their daugh- ters from the horror of these conflicts, including rape, saw child marriage as a means of achieving this. Men who lost their wives in the course of these conflicts sought out replacement wives to care for themselves and their children. There are even documented cases of girls being forced to marry under threat of violence by armed men. The polarizing effect of conflict in terms of emphasizing ethnic identity and traditions also played an im- portant role in perpetuating the practice. The Need to Enforce Legislation It must be noted that in all 5 repub- lics, laws are in place to prevent child marriage. However these are not always effectively enforced; legal dispensations are sometimes granted and authorities No.73 - 2011 13 6 2 sometimes choose not to intervene. This may be because local law enforcement sees the custom as benign, or is simply not aware of it taking place. Families often know how best to prevent detection and evade these laws. As a result the prac- tice continues, despite being outlawed and condemned from the highest levels of government. Conclusion While briefly touching on many of the trends and drivers of child marriage in central Asia, this article is by no means a completely extensive analysis of the issue. It is a complex phenomenon that demon- strates diverse differences both within (at community level) and across countries (at national level). Common drivers across the Region include: history, cultural back- ground, community desire to perpetuate gender roles, economics, armed conflict, lack of registration and non-enforcement of legislation. For further information, please visit http://eeca.unfpa.org/public/pid/12420 to view additional UNFPA research detail- ing the specifics of child marriage in the republics of central Asia. Marko Rankovic, UNFPA, EECA Regional office, rankovic@unfpa.org 14 Adolescent sexual and reproductive health: research priorities Problems associated with sexual behavior and sexual and reproductive health (SRH) contribute to significant morbidity and mortality among adolescents, particularly in low and middle income countries. In these countries, complications of pregnancy and childbirth are the leading cause of death for girls aged 15-19 (1). Another cause of death in the 15-29 years age group is HIV/AIDS (2) and in 2009 an estimated 40% of all newly acquired HIV infections were among those aged 15-24 years old (3). Unsafe sex (leading to sexually transmitted infections (STIs)) and lack of access to contraception (lead- ing to pregnancy) are key risk factors for disability adjusted life years lost (DALY) among 10-24 year olds (4). While political commitments have been made to address these problems, inadequate evidence deters action. Where evidence does exist, it often reflects the adult population exclusively. The evi- dence is also often more descriptive than intervention oriented and is rarely being translated into programmes and policies (5). Findings from research are important to provide vital information for the pub- lic and to influence health policies. To stimulate greater attention to re- search on adolescent sexual and repro- ductive health (ASRH), the World Health Organization (WHO) conducted a global exercise to set priorities for research on ASRH by using the Child Health and Nutrition Research Initiative approach. The first step of the process was to iden- tify ten ASRH outcome areas, based on their contribution to the global burden of disease. This list was ranked by almost 100 ASRH experts and was narrowed down to seven outcome areas, used for the remainder of the exercise. The seven outcome areas are: • To improve adolescents’ access to and quality of antenatal, delivery, postpar- tum and newborn care; • To improve adolescents’ access to contraception; • To prevent and mitigate gender-based violence; • To improve testing, treatment and care for HIV; • To prevent unsafe abortion and im- prove access to post-abortion care; • To improve strategies for the integra- tion of family planning and HIV/ AIDS services; and • To improve adolescents’ access to interventions for the prevention, diagnosis and treatment of STIs (5). In the next phase, approximately 300 researchers, programme managers and representatives from various UN agencies, governments, donor communities, na- tional and international non-governmen- tal organizations from all the six WHO regions were involved. They were asked to identify priority research issues and formulate these into research questions relating to each of the outcome areas. In the last phase of the exercise these research questions were scored by the same persons using the criteria: clarity, answerability, impact, implementation and equity. The exercise resulted in a ranking of research questions for each of the outcome areas (5). In spite of the diversity of the people in the generation and scoring of the ques- tions the results showed a high degree of consensus. Results are being published separately (5, 6). Early marriage and ASRH: missing on the agenda One of the key determinants of ado- lescent SRH problems is marriage at a young age. In fact, early marriage is a key determinant for most of the conditions in the seven outcome areas. Contrary to the common thought that marriage is a safe institution, it may expose an adolescent girl to various risks associated with frequent and unprotected sex (7, 8). Studies from developing countries show that most unprotected sex in adolescents occurs within marriage (7, 8). There is often a disparity in age between the adolescent girl and her husband, increas- ing the likelihood that he has had other sexual partners and has acquired an STI, which could include HIV (8). Married adolescents are more likely to experience violence, as well as, being coerced into having sex (7). Data from 2000-2009 show that early marriage is most common in sub-Saharan Africa and South Asia, with Niger (75%), Chad (72%) and Mali (71%) ranging highest, followed closely by Bangladesh (66%), Guinea (63%) and the Central African Republic (61%) (9). Even though not as widespread as in these regions, early marriages are also an issue in the European Region. Amongst European countries, data from the same period shows that up to 19% of women between 20-24 years old were married or in union before they were 18 years old, with the highest rates found in the Republic of Moldova (19%), Georgia (17%), Turkey (14%) and Tajikistan (13%) (9). In contrast, in most parts of the world the average age of marriage is rising (7). Despite the relationship between early marriage and the ASRH outcome areas, early marriage was infrequently raised by the respondents in the research priority exercise. Of a total number of 212 ques- tions raised, early marriage was the focus of only four questions. After the scoring, only one of the research questions related to early marriage was highly ranked: “What are effective strategies for delaying first births among married adolescents?” (6). Placing early marriage on the agenda WHO published guidelines on “Prevent- ing early pregnancy and poor reproduc- tive outcomes among adolescents in developing countries” last year. Among six main recommendations, one relates to the prevention of marriage before the age of 18 (1). The guidelines present guidance regarding what is required to prevent early marriage, such as: • Prohibit early marriage – a call for policy makers to put in place and enforce laws that prohibit marriage before the age of 18; • Keep girls in school – education opportunities for girls must be increased, as this has positive effects EARLy MARRIAGES AND GLoBAL RESEARCH PRIoRITIES oN ADoLESCENT SExUAL AND REPRoDUCTIvE HEALTH No.73 - 2011 15 6 2 Charlotte Christiansen on their health, and also decreases the chance of getting married; and • Influence cultural norms that sup- port early marriage – a need to work with all stakeholders to challenge and change norms around early marriage (1). At the request of one of the WHO’s Mem- ber States, the 65th World Health As- sembly in 2012 discussed early marriage, where the WHO secretariat prepared a paper for discussion (10). In total, 30 countries (of which many represented additional countries) from all the WHO Regions and seven observers made comments on the paper in the discus- sion. A majority of these comments were supportive of the recommendations in the paper, which were based on the WHO guidelines (1). Some countries reported on the situation of early marriage among adolescent girls, others on the action they were taking to address it. Numerous countries acknowledged early marriage as a human rights violation undermining the health and development of adoles- cents (11). The positive reception of the paper from a diversity of countries reflects a readiness to address the topic. However, evidence of the effectiveness of inter- ventions to prevent early marriage is inadequate. The WHO guidelines point to various areas requiring further investiga- tion: interventions that result in formula- tion and enforcement of laws and poli- cies; the impact of providing econo mic incentives to adolescent girls and their families to delay the age of marriage; the effect of informing and empowering girls in combination with influencing family and community norms; the impact of im- proved education and school enrolment; and lastly how livelihood programmes can delay the age of marriage (1). Attention to early marriage is coming from a number of organizations outside of the UN. “Girls not brides” is an exam- ple of a global partnership consisting of more than 170 organizations working to end child marriage globally. They work to raise awareness of the impact of child marriages, to facilitate learning between organizations and to mobilize policy, financial and other support to end child marriage (12). In addition, for the first time ever, the International Day on the Girl Child was celebrated this year, on October 11th. Focusing on barriers to education, poverty, early and forced mar- riage (14), this day provides an important opportunity to spread awareness and advocate for girls’ and adolescents’ health and rights. The WHO is also fully committed to focus on prevention of early mar- riages in order to improve the health of adolescents. One of its priority activities within adolescent SRH is to “Understand the determinants of early pregnancy and identify effective and feasible legal, social and economic measures of preventing it” (13). Early marriages must receive enough attention as an important part of improving ASRH. Improved evidence in this field will help both existing and new initiatives to move forward. Charlotte Christiansen, Technical officer, Maternal, Newborn, Child and Adolescent Health Department, WHo headquarters, Geneva, christiansenc@who.int The author would like to acknowledge the contribution of BJ Ferguson ( Scientist, Adolescent Health, Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization) and MJ Hindin (MHS, PhD, Associate Profes sor, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health,) in preparation of this paper. References 1. WHO Guidelines on Preventing Early Pregnancy and Poor Reproductive Out comes Among Adolescents in Develop ing Countries. Geneva: WHO, 2011. 2. Patton GC, Coffey C, Sawyer SM et al. Global patterns of mortality in young people: a systematic analysis of population health data. Lancet. 2009; 374: 881-892. 3. WHO Factsheet. Young People: Health risks and solutions.2011 avail- able at: http://www.who.int/media- centre/factsheets/fs345/en/ 4. Gore FM, Bloem PJN, Patton GC et al. Global burden of disease in young people aged 10-24 years: a systematic analysis. Lancet 2009; 377: 2093-2102. 5. Adolescent sexual and reproductive health: Global research priorities. Geneva: WHO, 2012. 6. Hindin MJ, Christiansen CS, Fergu- son BJ. Setting Research Priorities for Adolescent Sexual and Reproductive Health in Low- and Middle-Income Countries. 2012. Paper accepted for publication in the Bulletin of World Health Organization. 7. Married adolescents: No place of safety. Geneva: WHO, 2006. 8. Clark, S. Early marriage and HIV risk in sub-Saharan Africa. Studies in fam ily planning 2004; 35(3): 149-160. 9. The state of the world’s children 2011: Adolescence, An Age of Opportunity. New York: UNICEF, 2011. 10. World Health Assembly, A65/13. Early marriages, adolescent and young pregnancies. Geneva: WHO, 2012. 11. Sixty-fifth World Health Assembly. Committee A: Provisional summary record of the eight meeting. Geneva: WHO, 2012. 12. Girls Not Brides. www.girlsnotbrides. org. Members. 2002-2011. Cited 15 August 2012. Available at: http://girls- notbrides.org/members/ 13. www.who.int. Sexual and reproduc- tive health. 2012. Cited 13 August 2012. Available at: http://www.who. int/reproductivehealth/topics/adoles- cence/background/en/index.html 14. Plan International. www.plan.org. Be- cause I am a girl. October 11 declared the day of the Girl! Cited 20 August 2012. Available at: http://becauseia- magirl.ca/page.aspx?pid=4430 16 EARLy AGE oF FIRST SExUAL INTERCoURSE: ITS RELATIoNSHIP To EARLy MARRIAGE AND SExUAL HEALTH RISKS IN ALBANIAN FEMALE ADoLESCENTS Introduction The beginning of sexual relations at an early age, as well as, the tendency of marriages at a younger age is character- istic of the time-period in Albania today. This article provides an overview of the relationship between sexual debut, early marriage and sexual and reproductive health of adolescent females in Albania. General overview of sexual debut Median age at first sexual intercourse among women has decreased since 2002. Based on recent studies, it appears that the age of sexual debut is between 15 and 19 years of age, although a small percentage of girls less than 15 have had intercourse. In a study conducted with 400 high school students in 2006, the average age of first sexual experience for girls was 16 years of age (1). Another study conducted by the National Public Health Institute in 2009, with a rep- resentative group of 2172 high school students, found that 29% of respondents had sexual intercourse, with a mean aver- age age of 15.2 years (2). The Health Be- haviour in School-Aged Children Study, conducted in 2009-2010, showed that 14% of students aged 13-15 years were involved in sexual relations (3). This data appears consistent with findings from the 2008-2009 Albanian Demographic Health Survey (ADHS) which found that more than a third of the 15-49 year old women surveyed (36%) had their first sexual intercourse between the ages of 15 and 19 and a small percentage (1%) reported their first sexual intercourse before the age of 15 years. Women in rural areas had the first sexual intercourse somewhat earlier than urban women (4). Sexual debut, early marriage and reproductive health In Albania, the number of early mar- riages for females under 19 years of age is higher, especially in rural areas. Data from the 2002 ADHS showed that 26.2% of marriages in Albanian occurred under the age of 19 for females (5). According to the 2008-2009 ADHS approximately one in ten women aged 20-49 were married for the first time before the age of 19. There was an increase in the percentage of women married for the first time before the age of 19 years and the percentage of women in the ages of 15-19 years currently married or with someone (7% of women in the age group of 15-19 are currently married or within a relationship) compared to the 2002 study. The ADHS also revealed important differences in early marriage based on location and education: the percentage of women married before age 18 is higher in rural areas (11%) than in urban areas (7%); and the percentage of women mar- ried before their eighteenth birthday has been decreasing significantly with higher level of education (22% among women with no education or primary education versus 1% of marriages among women with college education or higher educa- tion). Similarly, the percentage of women married before age 19 has an indirect relationship with socioeconomic status – the higher the socioeconomic level the lower the number of marriages before the age of 19. While early marriage results in early sexual debut, the reverse is not neces- sarily always true. Yet, both early sexual debut and early marriage have been well documented to increase risk of exposure to adverse sexual and reproductive health consequences, such as unplanned preg- nancy, abortion, pregnancy complica- tions (due to an underdeveloped physical body) and sexually transmitted infections, including HIV. ADHS data showed that in the same rural areas that early marriage is preva- lent, pregnancy and childbearing under the age of 19 was three times higher when compared with under 19 year old females in urban areas, where early marriage is less common (5). Not surprisingly the same factors that also influence early marriage, education and socioeconomic status, also affect early pregnancy and childbearing. Female under 19 with 8 years of education or less and with lower socioeconomic status were more likely to have started childbearing early when compared to those with higher education and socioeconomic status (5). In 2010, the Albanian Ministry of Health, under the technical support of the WHO, implemented the programme “Working with individuals, the family and communities-IFC framework”, a method- ology which contributes to strengthening the participation of individuals, families and communities in the identification of and problem solving of key issues and implementation of maternal, newborn and child health interventions, in three pilot districts of the country. During the round-table discussions, as part of this programme, one of the key issues identified affecting maternal, newborn and child health by the community was that of early marriage and pregnancy. The issue of early marriage and pregnancy was especially prevalent in the traditional rural areas (6). According to roundtable discussions with mothers, husbands and local leaders in these districts parents from these areas had a tendency to encourage or to impose girls to marry at an early age. This is due to the fact that Albanian traditional rural society’s value system dictates that sex and childbearing is only socially acceptable within mar- riage. In many cases the reason why par- ents have forced their daughters to marry early is due to unplanned pregnancy before marriage. Although there are no gender disag- gregated data for contraceptive use for the age group of 15-19 year olds, the ADHS reports that 41% of young adults aged 15-24 (male and female) use traditional methods. The frequency of not using condoms at first sexual intercourse in the 15-24 year old age group is higher among women (22.8%) than males (18.8%), and specifically for 19 year old females (28.8%) when compared to 22 year old (51.2%) and 24 year old females (58.4%) (4). Also, there is a growing trend in the number of abortions amongst young women. Based on national statistical data from 2011, 5.1% of the total numbers of abortion were in the 14-19 year old age group and 7% of these cases were unmar- ried women. (7). Abortion was also sig- No.73 - 2011 17 6 2 Alban Ylli Lumturi Merkuri nificantly higher among those with only eight years of education (46.9%) when compared to those with higher levels of education (7). Early sexual debut also increases risk of exposure to sexually transmitted infec- tions (STIs). Despite the few and often missing data for STIs in the adolescent age group, in recent years there has been a trend towards increasing numbers of STIs in young women aged 15-24, includ- ing gonorrhoea, Chlamydia and herpes viruses (1). An Albanian study conducted over the last three years on the prevalence of Chlamydia trachomatis infections in women showed that 4.8% of the total cases occurred in women who were 20 years of age or less (8). HIV also appears to be increasing among this age group. According to the most recent epide- miological data, over the past few years there has been a feminization of the HIV epidemic, with an increase in the number of HIV cases among females including those between the ages of 15-24. Data from 2011 found that 30.7% of the total cases of HIV were among females, with the 16-24 year old age group representing 36.4% of the cases (9). Conclusion Determining the exact extent of the relationship between sexual debut, early marriage and sexual and reproductive health is not easy. As mentioned earlier, while early marriage does lead to early sexual debut and exposure to pregnancy, it is not necessarily true that early sexual debut will lead to early marriage, except perhaps in those circumstances where unplanned pregnancies occur. Even in these situations it is fair to assume that not all unplanned pregnancies will lead to early marriages. What is certain is that early sexual debut, whether as a result of early marriage or personal choice, does increase the risk of adverse sexual and reproductive health consequences, especially if access to reproductive health education, information and care is not easily available. Thus, while community- based mobilization programmes need to be implemented to raise awareness to young people, parents and all of the Albanian community toward the negative impact that early marriages have upon the sexual and reproductive health of adolescent females, improved access to reproductive health services, education and information must also be a priority to reduce the risks of sexually active mar- ried and unmarried adolescents. Lumturi Merkuri, MD, Sexual and Reproductive Health Specialist, Health Promotion Department, Institute of Public Health, Tirana, Albania, lumturimerkuri@hotmail.com Alban Ylli, MD, Head of Health Policy and Chronic Diseases Sector, Department of Epidemiology and Health Systems, Institute of Public Health, Tirana, Albania, albanylli@yahoo.co.uk References 1. Albanian National Reproductive Health Strategy. Situation analysis. Tirana, Albania: Albanian Ministry of Health. 2007. 2. KAP Survey about sexual and repro ductive health at Albanian young peo ple. Tirana: Institute of Public Health [Albania] and UNFPA. 2009. 3. Currie C et al., eds. Social determi nants of health and wellbeing among young people. Health Behaviour in Schoolaged Children (HBSC) study: international report from the 2009/2010 survey. Copenhagen, WHO Regional Office for Europe, 2012 (Health Policy for Children and Adolescents, No. 6). 4. Albania Demographic and Health Sur vey 200809. Tirana, Albania: Institute of Statistics, Institute of Public Health (Albania) and ICF Macro, 2010. 5. Albania Reproductive Health Survey 2002. Atlanta, Georgia, USA: Centres for Disease Control and Prevention (CDC), Institute of Public Health (IPH) and Institute of Statistics (IN- STAT) [Albania], 2005. 6. Maternal, Newborn and Child Health Care Reform, Report 2011. Tirana, Albania: Ministry of Health Albania and WHO Albania Country Office, 2011. 7. Annual Statistical Data 2011. Tirana, Albania: Institute of Public Health [Albania], 2011. 8. Prevalence of Chlamydia infection in Albanian females, National Confer ence of STIs, 2011 Institute of Public Health [Albania]. 9. HIV/AIDS Epidemiological Situation Report, 2011. Tirana, Albania: Insti- tute of Public Health [Albania], 2011. 18 CHILD MARRIAGES IN KyRGyzSTAN: DISADvANTAGES WITHoUT ADvANTAGES “Child marriage is an ap- palling violation of human rights and robs girls of their education, health and long- term prospects. A girl who is married as a child is one whose potential will not be fulfilled. Since many parents and communities also want the very best for their daugh- ters, we must work together and end child marriage.” Dr. Babatunde Osotimehin, Executive Director, UNFPA Introduction The minimum legal age for marriage in Kyrgyzstan is 18, however, 12.2 percent of women in Kyrgyzstan get married before they reach 18 years of age (1). This occurs more widely in rural areas, where 14.2 percent of women marry before they reach the legal adult status. In urban ar- eas, this statistic stands at 9.7 percent (1). Child marriages are generally not le- gally registered. As a result, children born in such marriages either have no birth certificate or receive a birth certificate at a later stage. Furthermore, women and girls coerced into child marriage often become the victims of forced domestic labor; they are denied opportunities for education and are rarely granted property rights (2). This social drama is complicated by the fact that in most cases child marriages are accompanied by family violence and considered to be a normal practice in the public consciousness of some groups of the population (2). In spite of the fact that international legal instruments, as well as, country- specific laws have been created to condemn and criminalize the practice of child marriage, it continues and is actu- ally increasing in the country. Therefore, efforts are needed to raise awareness among young people and adolescents, as well as, policy makers to protect girls’ rights and prevent the continuation of such a harmful practice through media, public events and national campaigns. Country policy and legislation Under the Kyrgyz Republic’s Children’s Code, Criminal Code, Civil Code, and Code on Administrative Violations, as well as other laws and regulations, people under 18 years of age are recognized as minors. The Criminal Code states that “forcing and entering into de facto mar- ried relations with a person under 17 years of age is punishable by a fine of 100 to 500 standard units or corrective work for a period of up to 2 years or depriva- tion of liberty for up to 5 years” (Article 154, Criminal Code). In practice only a few cases have been registered under Article 154 of the Crimi- nal Code. Between 2000 and 2012 only 159 cases were brought forward, which does not adequately reflect the scale of the problem of child marriage. The fact that so few cases are registered is because the victims do not seek law enforcement due to the fear of public condemnation and stigmatization. Within the country, child marriage has not been discussed widely in public and is not recognized as a major problem. Moreover, it is not a priority issue in the country’s child protection agenda. Rather the issue of child marriage problem has been looked at as a supplementary aspect under the umbrella of violence against women and girls, as well as, adolescents’ sexual and reproductive health issues. Central Asian study on early marriages In 2012, the UNFPA Regional Office in Eastern Europe and Central Asia sup- ported the Central Asian Study on Early/ Child Marriages (3), an analysis aimed to provide an insight of current practices and attitudes towards child marriage in the Kyrgyz Republic, as well as, statistical information about the prevalence of the practice. The methodology for this study involved a review of the existing legal frameworks and interviews with child spouses and experts working in the fields Young girl in Bishkek learns about child marriage No.73 - 2011 19 ` 6 2 CHILD MARRIAGES IN KyRGyzSTAN: DISADvANTAGES WITHoUT ADvANTAGES Nurgul Kinderbaeva of children’s and women’s rights. The research was conducted in Osh, Jalalabad, Bishkek, and Chui oblasts. Reproductive health impact of child marriage Child marriages are usually not officially registered and often break up. According to the 2012 Central Asian Study on Early/ Child Marriage in Kyrgyzstan, out of the 11 child spouses interviewed, 7 were divorced without any right for family property and no child support (3). The reproductive and other rights of citizens that allow for reproductive health are guaranteed under the Constitution (Article 47). Under the law “On reproduc tive rights of the citizens and guarantees of their implementation” reproductive health protection services for children and ado- lescents are guaranteed free of charge by healthcare organizations. Almost none of the child spouses who participated in the recent study con- ducted by UNFPA in Kyrgyzstan knew anything about reproductive health and family planning before their marriage. This was primarily because culturally it was not acceptable to visit a gynaecolo- gist. They had very little knowledge about modern contraceptive methods or sexu- ally transmitted infections, including HIV and AIDS. The girls learned about their reproductive functions from either older sisters or aunts. Very few mentioned the anatomy school classes where they learned about human physiology. This finding of little to zero knowledge on reproductive health lends additional support to one of UNFPA’s most strongly advocated recommendations: design and introduce healthy life style programmes for middle and high school students with culturally sensitive and age appropriate curriculae that includes information on sexual and reproductive health. UNFPA prevention actions on end- ing child marriage On this year’s International Day of the Girl Child, the UNFPA called for action against child marriages in Kyrgyzstan by renewing local attention to the critical issue and promoting accountability from the decision makers. The campaign also included the opening of “TOO YOUNG TO MARRY The sold childhood”, an art exhibition highlighting the personal narratives of Kyrgyz girls married against their will at early ages. An additional activity supported by the UNFPA is the creation and strengthening of the youth networks at the national and community levels to address gender based violence and HIV prevention, includ- ing gender transformative program- ming. These educative sessions focus on changing gender norms in society and target men, women, girls and boys in becoming agents for change on gender norms and stereotypes. Topics focused on include women’s reproductive health and the roles of men and boys in the family planning, gender-based violence and HIV prevention. The ultimate goal of these educational sessions is to end harmful practices, such as child marriages and bride kidnapping, in this generation and to change cultural attitudes to the protec- tion of the rights of girls in the country. Furthermore, as religious conservatism plays a strong explanatory role in the increasing number of child marriages in Kyrgyzstan, the UNFPA also supports the development and dissemination of information and educational materials among religious groups. These materials are aimed at educating religious commu- nities about the negative impacts of such a harmful practice on adolescent girls’ reproductive health and future potential. Nurgul Kinderbaeva, National Professional officer on Gender, youth, Advocacy and Communication, UNFPA, Kyrgyzstan, kinderbaeva@unfpa.org.kg References 1. Multiple Indicator Cluster Survey 2006, Kyrgyz Republic. Final Report. National Statistical Committee of the Kyrgyz Republic. Bishkek, Kyrgyzstan: United Nations Children’s Fund, 2007. 2. Moldosheva A. Violence Against Women, Baseline assessment. UNFPA, 2009. 3. Ilibezova L. Central Asian Study on Early/Child Marriage in Kyrgyz Re public. UNFPA, 2012 20 CHILD MARRIAGE IN TAJIKISTAN Table 1. Characteristics of child-married women (n= 5 216), Tajikistan, 2005. Indicator Percentage of women 15-19 married/in union Percentage of women 20-49 married before age 18 Percentage of women 20-49 married at 18 and after Reproductive Health Received antenatal care by skilled provider* 3.57 8.71 87.72 Delivered at health facility* 4.68 8.92 86.32 Used any method of contraception to avoid pregnancy 0.66 4.03 95.03 Ever heard of HIv/AIDS 1.09 4.17 93.92 Domestic Violence** Believe husband is justified in beating his wife for any reason 87.7 80.17 75.75 * out of women who had given birth within two years prior the interview ** Column percentages Introduction Child marriages are a widespread albeit hidden problem. In Tajikistan child mar- riages are intrinsic to the local culture. Until recently, the legal minimum age of marriage was 17 (1). Historically, girls in Tajik families were considered as temporary family members. Upon marriage, they become part of the in-laws’ family and have low status. To raise their status in their husband’s family, child brides are pressured to demonstrate childbearing, even if biologically they may not yet be ready. During the Soviet times these traditions were repressed, but were revived after the country’s independence. Poverty, male labor migration and the impact of the civil war exacerbated gender inequalities. Civil armed con- flict induced child-related social stress, including child neglect. According to the Tajikistan Millennium Development Re- port school attendance decreases among girls as they reach age 15, with up to 17% of girls dropping out of school (2). Child marriage further cuts off girls’ opportuni- ties for continuing education: young and early-married women become eco- nomically disempowered while also being overloaded with unpaid domestic work. Nowadays, marriage of a female child is often seen as a strategy for the economic survival of a family in an attempt to reduce the number of dependents. Since parents of a young bride could be penalized under the law, child marriages are usually not legally registered. As a result, the problems of child-married women are invisible, their rights are ne- glected and the government is not able to make policy decisions based on valid and reliable information. Impact of child marriage Currently, the Tajikistan Living Stand- ards Survey of 2009 (3) and the Multi- Indicator Cluster Survey (MICS) of 2005 (4) are two major multi-topic nationally representative surveys used to assess progress towards achieving the Millen- nium Development Goals and to monitor various country-level programmes. According to these two surveys, 8.5% (3) and 6.4% (4) of women aged 15-19 are currently married or in union. Of the child-married women the majority were rural women with incomplete secondary education. They were also more likely to marry older men and tend to have more children (4). To further explore factors associated with child marriage and its impact on women’s status in Tajikistan the authors used the MICS 2005 database (10 626 interviewed women) to construct a cohort of 5 216 women aged 15-49 to perform comparison of select reproduc- tive health indicators recommended by the WHO (5). The MICS database was chosen as it provides up-to-date infor- mation of women and children’s status in the country. The sample was divided into 3 comparison groups: 1) women 15-19 years of age currently married or in union; 2) women aged 20-49 whose first marriage was before 18; and 3) those aged 20-49 married at 18 and above. Statisti- cal analysis was performed using STATA 10. Table 1 presents results as weighted percentages across the selected indicators. Child married women in Tajikistan are less likely to receive antenatal care during pregnancy and opt for assisted delivery at a health facility. Married 15-19-year-olds make up only 0.66% of women using any family planning method, compared to older women married before 18 (4.3%) and those married at or after 18 (95.03%). Also, just over 5% of women who ever heard about HIV/AIDS are 21 No.76 - 2012 Khurshed Irgitov Nargis Rakhimova Aziza Hamidova Lola Yuldasheva young girls married before 18 and among women ever tested for HIV/AIDS this group accounts for the smallest share (only 4%). In terms of attitude to domestic violence, women were surveyed about whether they believe their husband is justified in beating his wife for various reasons, including: 1) when she goes out without telling him, 2) when she neglects the children and 3) when she argues with him (6). Our analysis shows the vast majority of child-married women think it is normal for a husband to beat his wife for any of the above-mentioned reasons. The wide husband-wife age gap further widens the power gap between men and women, favoring greater power to men, which is already often found in tradi- tional Tajik families. Challenges Tajikistan has made significant steps to promote child rights and eliminate child marriages. Article 16 of the Convention on the Elimination of all Forms of Dis- crimination Against Women (CEDAW) stating that “…the marriage of a child shall have no legal effect, and all necessary action, including legislation, shall be taken to specify a minimum age for marriage...” In response to the recent CEDAW recom- mendations, in July 2010 the Parliament made amendments to the Family Code shifting the legal marriage age from 17 to 18 years (1). This law became effective in January 2011. Yet challenges remain. Despite this positive action from the government, implementation of the new Family Code is not as simple. For example, “excep- tional” circumstances, provided for by the Civil Code, allows for marriage to happen under the official age minimum. In addi- tion, parents have been tempted to falsify the supportive documentation (including birth certificate) needed to apply to the court for making decisions about child marriages. In some cases, the clergy may approve child marriage and perform an “unofficial” marriage: as a result mar- ried young wives lose all legal rights they might have had under the Family Code if married officially. In fact, one of the religious leaders serving the population in the capital of Tajikistan stated that in “marriage” season he gets up to 7 requests weekly for child marriage approval. Currently, because of close and fruitful collaboration between the government and clergy, religious leaders tend to refuse requests to approve child marriages. Such action by the religious leaders is essential as public education on women’s rights and their role in the family is pivotal and largely depends on what religious leaders promote. The challenge of endogamous mar- riages is also a reality in Tajikistan, as for reasons of economic safety parents are tempted to give daughters to closely related family. Tajik scientists think the tendency to endogamous marriages has been increasing since the 1990s (7). Marriage between close relatives may have political and social consequences, in addition to the well-documented risk of increased health problems (developmen- tal, congenital) in their offspring. Finally, the majority of child marriages are unregistered and their numbers thus underestimated. Current independ- ent estimations are based on nation- ally re presentative surveys and smaller independent studies that mainly rely on respondents’ answers and are subject to recall bias. Sparse official statistics of registered child marriages do not reflect the actual situation, as a result, important data that would otherwise inform and impact policy decision-making is lacking. Thus, while Tajikistan’s steps to elimi- nate child marriage and promote child rights should be applauded, it is impor- tant that we remain aware of the contin- ued, existing challenges on the ground in our effort to raise awareness of young women about their rights and decrease the number of child marriages that occur in the country. Lola Yuldasheva, MD, MSPH, Epidemiologist, National Consultant, Tajikistan, lola.yuldasheva@gmail.com Aziza Hamidova, MD, PhD Assistant Representative, UNFPA, Tajikistan, Aziza.Hamidova@undp.org Nargis Rakhimova, UNFPA National Programme Analyst on RH Khurshed Irgitov, UNFPA Project Associate on FP/RHCS References 1. Family Code of the Republic of Tajikistan. 2. Millennium Development Goals. Tajikistan Progress Report 2010. Republic of Tajikistan, 2010. 3. Tajikistan: Living Standards Measure ment Survey. 2007. Indicators at a Glance. Dushanbe, 2009. 4. Monitoring the Situation of Children and Women. Tajikistan Multiple Indicator Cluster Survey 2005. Final Report. Dushanbe, Tajikistan: State Committee on Statistics of the Re- public of Tajikistan, 2007. 5. Reproductive Health Indicators: Guide lines for their generation, interpreta tion and analysis for global monitoring. Geneva: WHO, 2006. 6. Tajikistan Multiple Indicator Cluster Survey, 2005. Questionnaire for In- dividual Women. Available at: http:// www.childinfo.org/mics3_question- naire.html 7. Saidov F, Karimov B. Qualitative de- mographic growth is a guarantee for steady development of the society. Ta jikistan and Contemporary World. The Herald of the Strategic Research Center under the President of the Republic of Tajikistan. 1(26); 2011: 9-19. 22 Introduction According to data from the Turkish Sta- tistical Institute in 2011 the population of Turkey was 74 724 269, with adolescents and young people (10-24 year age group) accounting for 25. 9% (19 144 779) of the population (1). In many countries, including Turkey, the health of young people has been somewhat neglected, as youth are per- ceived as generally healthy and relatively disease free. However, research on youth has revealed that negative socioeconomic and cultural factors may affect their physical, mental and social development. For example sexual and reproductive health (SRH) problems experienced in this period may impact many other health concerns in the future (2). This paper provides an overview of the current health situation of youth in Turkey, focus- ing on age of first marriage and SRH. Age of first marriage and marital status In Turkey, early marriage is defined as marriage at 17 years of age or younger and can include both official and unof- ficial religious marriages. In Turkey early marriage is traditionally widespread. Even though the age of first marriage has been decreasing steadily over the past 20 years (3), early marriage remains a very real issue in Turkey. Historically data has been scarce as many of the marriages are unregistered and thus go undetected by the state. Since 2008 a team from the Hac- ettepe University Institute of Population Studies’ has been working on a national study of marriage practices. Data from the study, presented to the Turkish Grand National Assembly in January 2011, found that the rate of early marriage in Turkey was much higher than previously thought. At least 40% of Turkish women between the ages of 15-49 were married before the age of 18, with the highest rates in the rural and poor regions of the country (4). In 2002, Civil law regulations were changed to ensure that the minimum age for marriage for both men and women was 17 years of age and that this age limit was the same for both sexes. Despite this legal requirement young women are usually forced into a religious marriage before the required legal age (5); in 2011 24.2% of young women were married compared with only 5.8% of young men (6) and one in ten had dowry paid for the marriage (6). Such early marriage impairs young girls’ future life in terms of education, employment, reproduction and overall health. Among young women 31.9% encountered physical violence, 13.5% had sexual violence and 21.3% encoun- tered physical or sexual violence in their lifetime (6). At least a quarter of female suicides among women in Turkey occur in girls between the ages of 14-16 (6). Furthermore, the majority of women married at an early age have quite low levels of education and were more likely to be married to relatives (6). SRH status of adolescents/youth SRH is one of the most important issues for the health and the future of adolescents, including those in early marriages. When sexual activity starts at an early ages in combination with insufficient knowledge and/or decision making capabilities on sexuality and reproduction, adolescents are at risk of severe educational, economic, psycho- social and health problems caused by unwanted pregnancies, sexually transmit- ted infections (including HIV), tobacco and alcohol use, drug substance abuse, unhealthy nutritional habits, accidents and suicide attempts (6,7). For example, as the husbands of child brides are often older men with more sexual experience, these girls are at higher risk of contract- ing HIV. They are also more vulnerable to sexual and domestic violence at the hands of their husbands – and are more likely to think that it is okay when they are victims of abuse. As well, due to the age gap that is often present between child brides and their husbands, the power to negotiate safe sexual practices and/or to seek SRH care may not be possible. It has been well documented that preg- nancy before the age of 18 is more likely to lead to complications of pregnancy or death in childbirth. In fact, the leading cause of death among girls ages 15-19 worldwide is medical complications due to pregnancy (8). Girls between the ages of 10 and 14 are five times more likely to die in pregnancy or childbirth than women aged 20 to 24 (8). In addition early motherhood impairs the social development and education of young girls (9). Despite this, childbearing is an expected outcome following early mar- riage in Turkey. According to the latest nationwide survey around one in every ten married women at the age of 15-19 is either a mother or pregnant. Among these women 36.5% has one child, 3.7% has two and 0.6% has three children. Termination of unwanted pregnancies in this age group is 3.2 % (3). In terms of appropriate SRH knowl- edge, studies in Turkey have shown that even among higher educated young people knowledge is quite limited. For instance: • 3666 first year students from 2 universities in Turkey thought that only men could be affected by gonor- rhea and nearly the same number of students were not aware of the period in the menstrual cycle where women have the highest chance of conceiving (7); and • In an other study carried out on 3101 first year students from 8 Turk- ish universities, despite evidence of sexual activity (12.4% of all students) only one in 5 students had correct knowledge about menstruation and only half the students knew about emergency contraceptives. Every 9 out of 10 students stated that they either needed or wanted to receive SRH services (9). Given that girls in early marriage are often less educated and forced to leave school upon marriage, it may be reason- able to assume that their knowledge would be even more limited when it comes to SRH. THE DESTINy oF yoUNG PEoPLE IN TURKEy No.73 - 2011 23 6 2 Sare Mihciokur Ayse AkinTHE DESTINy oF yoUNG PEoPLE IN TURKEy The Role of Youth Friendly Health Services The National Strategic Action Plan of the Ministry of Health (MoH) identified young people as one of the five priority areas in SRH. Development and imple- mentation of access to Youth Friendly SRH (YFSRH) services was planned for the period 2005 – 2015, with the Action Plan clearly stating that “Access to YFSRH services will be increased to have one unit providing these services for every 150 000 young people by the year 2015” (10). Following the joint 2001 WHO col- laborating study on SRH in youth (7), YFSRH services had already been devel- oped as a pilot model with the collabo- ration of UNFPA in 8 university health centres. The MoH had also established YFSRH units at the primary health care level, either as a part of health centres or Maternal Child Health–Family Planning centres. Yet, by the year 2007 the number of such centres had increased to only 38 in number. Thus, the majority of youth remain unable to access much-needed YFSRH. A further challenge to the estab- lishment of the YFSRH has been a major change in the Turkish health care system, called the “Family Physician’s Health Care System”. Begun as a pilot programme in 2004, it was expanded across the entire country at the end of 2010. In this new system all primary health care services are provided by family physicians who are general practitioners with some ad- ditional training of ten days duration. Additional health care providers with more specialized skills are no longer part of the health centre team. Recognizing the loss of these specialized skills, the reestablishment of “YFSRH services” should be considered seriously. Other- wise young people, despite their high risk taking behaviors and needs in SRH, are very likely to remain deprived of YFSRH services. Given the poor knowledge of Turkish youth when it comes to SRH and the high rates of early marriage, access to such services is essential if we wish to improve the health outcomes and lives of our young population. Conclusion The high rates of early marriage in Turk- ish society combined with the large gaps in SRH knowledge and access to services among all youth means that a significant number of young people in Turkey are faced with very real SRH challenges. Beside the activities related to combating poverty, ensuring gender equality in all fields of life and changing the traditional patriarchal structure of the society are extremely important in order to im- prove the future life of young people, particularly girls, and make their destiny brighter. A brighter future for our youth will translate into improvement of the country as a whole. Ayse Akin, MD, Professor and Head, Public Health Department, Medical Faculty, Baskent University, Director of Baskent University Women-Child Health and Family Planning Research and Implementation Centre, Ankara, Turkey, ayseakin@gmail.com Sare Mihciokur, MD, PhD, Academic staff, Public Health Department, Medical Faculty, Baskent University and Baskent University Women-Child Health and Family Planning Research and Implementation Centre, Ankara, Turkey. saremihciokur@gmail.com References 1. Turkey’s Statistical Yearbook 2011, TurkSat, Ankara 2. Khan S, Mishra V. Youth Reproductive and Sexual Health DHS Comparative Reports No 19. Calverton, MD USA: Macro International Inc., 2008. 3. Turkey Demographic and Health Sur vey, 2008. Ankara, Turkey: Hacettepe University Institute of Population Studies, Ministry of Health General Directorate of Mother and Child Health and Family Planning, T.R. Prime Ministry Undersecretary of State Planning Organization and TÜBİTAK, 2009. 4. Beeston Kym. Why is early marriage a problem in Turkey? The Guard- ian. June 28 2011, !5:35 PM BST. The Guardian. Available online at: http://www.guardian.co.uk/journal- ismcompetition/why-is-early-mar- riage-a-problem-in-turkey 5. Türkiye’nin Demografik Dönüşümü, Doğurganlık, Aile Planlaması, Anne-Çocuk Sağlığı ve Beş Yaş Altı Ölümlerdeki Değişimler 1968-2008, Hacettepe Üniversitesi Nüfus Etütleri Enstitüsü, T.C. SB AÇSAP Gn. Md., T.C. Başbakanlık DPT, TÜBİTAK 6. Youth in Statistics 2011, TurkSat, Ankara. 7. Akin A., Ozvaris SB. Study on The Influence Factors of Sexual and Repro ductive Health of Adolescents / Young People in Turkey. Ankara: Hacettepe University Faculty of Medicine, Pub- lic Health Department, April 2004. 8. Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM et al. Global patterns of mortality in young people: a systematic analysis of population health data. Lancet. 2009;374:881– 892. 9. 2007 Türkiye Gençlerde Cinsel Sağlık ve Üreme Sağlığı Arağtırması, (2007 Turkey, Survey on Youth Sexual and Reproductive Health Survey) Nüfus Bilim Derneği, UNFPA, Ankara, De- cember 2007, s.5. 10. Cinsel Sağlık ve Üreme Sağlığı, Sağlık Sektörü için Ulusal Stratejik Eylem Planı 2005-2015, (Sexual Health and Reproductive Health, National Strategic Action Plan 2005-2015 for Health Sector) Ministry of Health, 28/07/2010, Ankara. Accessed August 6, 2012 at: http://sbu.saglik.gov.tr/Ekutuphane/ kitaplar/a%C3%A7sap9.pdf 24 The following is a reprint from a document prepared by UNFPA, UNICEF and UN Women, in consultation with the Inter-Agency Network on Women and Gender Equality (IANWGE). Key Messages Girls face discrimination and violence every day across the world. The Inter- national Day of the Girl Child focuses attention on the need to address the challenges girls face and to promote girls’ empowerment and the fulfillment of their human rights. For the inaugural day, UN agencies have come together to focus on child marriage, which is a fundamental human rights violation and impacts all aspects of a girl’s life. Child marriage denies a girl of her childhood, disrupts her education, limits her opportunities, increases her risk of violence and abuse, and jeopardizes her health. Globally, more than one in three young women aged 20-24 years were first mar- ried before they reached age 18. One third of them entered into marriage before they turned 15. Child marriage results in early and unwanted pregnancies, posing life- threatening risks for girls. In developing countries, 90 per cent of births to adoles- cents’ aged 15-19 are to married girls, and pregnancy-related complications are the leading cause of death for girls in this age group. Girls with low levels of schooling are more likely to be married early, and child marriage has been shown to virtually end a girl’s education. Conversely, girls with secondary schooling are up to six times less likely to marry as children, making education one of the best strategies for protecting girls and combating child marriage. Preventing child marriage will protect girls’ rights and help reduce their risks of violence, early pregnancy, HIV infection, and maternal death and disability, includ- ing obstetric fistula. When girls are able to stay in school and avoid being married early, they can build a foundation for a better life for themselves and their families and participate in the progress of their nations. Governments in partnership with civil society actors and the international com- munity are called upon to take urgent ac- tion to end the harmful practice of child marriage and to: – Enact and enforce appropriate legisla- tion to increase the minimum age of marriage for girls to 18 and raise pub- lic awareness about child marriage as a violation of girls’ human rights. INTERNATIoNAL DAy oF THE GIRL CHILD 2012: My LIFE, My RIGHT, END CHILD MARRIAGE No.76 - 2012 25 – Improve access to good quality primary and secondary education, ensuring that gender gaps in school- ing are eliminated. – Mobilize girls, boys, parents, leaders, and champions to change harmful social norms, promote girls’ rights and create opportunities for them. – Support girls who are already married by providing them with options for schooling, sexual and reproductive health services, livelihoods skills, op- portunity, and recourse from violence in the home. – Address the root causes underlying child marriage, including gender discrimination, low value of girls, poverty, or religious and cultural justifications. Empowering girls and safeguarding their rights is at the heart of the issue. Govern- ments, civil society and UN agencies are working together to end child marriage; further commitment and resources are required to accelerate action that will empower girls and scale up successful interventions’. 26 RESoURCES Marrying too young: end child marriage, UNFPA, 2012. This excellent report documents the current status of child marriage, highlighting its scope and prevalence. It calls for decision makers, families and communities to take action to end child marriage through various means such as prevention programmes, national laws, education and empowerment. Available in English at: http://www.unfpa.org/public/home/publications/pid/12166 Breaking Vows: Early and Forced Marriage and Girls’ Education Plan, 2011. This in-depth review of the causes and consequences of child and forced marriage, explores its global impact and the action needed to increase girls’ access to their rights, including the role of education. Available in English at: http://www.plan-uk.org/resources/documents/Breaking-Vows-Early-and-Forced-Marriage-and- Girls-Education/ Girl Power and Potential: A Joint Programming Framework for Fulfilling the Rights of Marginalized Adolescent Girls, United Nations Interagency Task Force on Adolescent Girls, 2009. This brief provides a programming framework overview that targets those adolescent girls who are most vulnerable, including those involved in child marriages and its consequences. Available in English at: http://www.unfpa.org/public/cache/bypass/home/publications/pubs_youth Ending Child Marriage: A Guide for Global Policy Action, International Planned Parenthood Federation and the Forum on Marriage and the Rights of Women and Girls, 2006. This guide uses statistics and evidence to appeal to key policy makers to take urgent action to improve the quality of life of millions of girls and young women forced into child marriages. Available in English at: http://www.forwarduk.org.uk/resources/resources#id7 Too Young to Wed: Child Marriage Advocacy Toolkit, International Center for Research on Women, 2006. The contents of this toolkit provides an overview of child marriage around the world, focusing on key issues such as child marriage and domestic violence, education, health, poverty and laws and civil society. Available in English at: http://www.icrw.org/publications Solutions to End Child Marriage: What the Evidence Shows, International Center for Research on Women, 2011. This systematic review of existing child marriage prevention programmes provides important evidence on interventions that work. Available in English at: http://www.icrw.org/publications/solutions-end-child-marriage Early Marriage: A Harmful Traditional Practice, UNICEF, 2005. Using data from the Demographic and Household Surveys, this publication estimates the prevalence of child marriage and seeks to identify and understand the factors associated with child marriage and cohabitation. Available in English at: http://www.unicef.org/publications/index_26024.html 27 No.76 - 2012 Lisa Avery Child Protection Information Sheets, UNICEF, 2006. This information booklet highlights how child protection is crucial to the achievement of the Millennium Development Goals. Covering different forms of abuse, including child marriage, these sheets also outline how to build a protective environment for children. Available in English, French and Spanish at: http://www.unicef.org/publications/index_34146.html New Insights on Preventing Child Marriage. A Global Analysis of Factors and Programs, USAID and the International Center for Research on Women, 2007. Designed for policy makers and programme implementers, the information contained in this report provides an overview of programmes that work and enables development workers to identify points of intervention to help prevent child marriage. Available in English at: http://www.pactworld.org Advancing Equal Rights for Women and Girls. The Status of CEDAW Legislative Compliance in Eastern Europe and Central Asia, UNFPA, 2009. This report reviews the degree to which national legislation in eastern Europe and central Asia is congruent with international legal norms and instruments, focusing on gender equality and sexual and reproductive rights, including child marriage. Available in English at: http://eeca.unfpa.org/public/pid/11789 Preventing Early Pregnancy and Poor Reproductive Outcomes among Adolescents in Developing Countries: What the Evidence Says, WHO, 2011. This excellent resource for policy makers provides evidence to help develop or reshape national policies and strategies, emphasizing optimal approaches to prevent early pregnancies among adolescents and on reducing morbidity and mortality associated with pregnancy and childbirth. Available in English, French and Spanish at: http://www.who.int/reproductivehealth/publications/adolescence/ Ending Forced Marriage, Plan and Demos, 2012. This report provides insight into the issue of forced marriage in the United Kingdom and recommends a shift of the current approach to stopping forced marriages from prosecution to prevention. Available in English at: http://www.plan-uk.org/assets/Documents/pdf/Demos-Ending-Forced-Marriage.pdf Useful websites International Center for Research on Women: www.icrw.org Care International: www.care.org Forward UK: www.forwarduk.org UNFPA: www.unfpa.org UNFPA Eastern Europe and Central Asia Regional Office: www. eeca.unfpa.org UNICEF: www. unicef.org Girls not Brides: www.girlsnotbrides.org Save the Children: www.savethechildren.org Plan: http://www.plan-uk.org UN Women: www.unwomen.org The European Magazine for Sexual and Reproductive Health WHO Regional Office for Europe Division of Noncommunicable Diseases and Health Promotion Sexual and Reproductive Health (incl. Maternal and newborn health) Scherfigsvej 8 DK-2100 Copenhagen Ø Denmark Tel: (+45) 3917 17 17 Fax: (+45) 3917 1818 www.euro.who.int/entrenous
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Entre Nous: the European magazine for sexual and reproductive health: no. 76: child marriage
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