Many young people in developing countries have weakened or severed family ties, are subject to social stigmatization, and are not connected to institutions such as schools, youth clubs, or the formal workplace. These youthwhom we refer to as "socially marginalized"are vulnerable to sexual exploitation and are at disproportionately high risk of unintended pregnancies and sexually transmitted infections (STIs), including HIV/AIDS. They often lack access to reproductive health information, counseling, legal protection, and health and other services, so reaching them requires special planning, advocacy efforts, and supplemental resources.
What characterizes socially
Socially marginalized youth often have weakened or severed family and social ties. Some have been abandoned by their families, lured or abducted from their families, or sold into bonded labor or brothels. War and the AIDS epidemic have turned many into orphans. Psychological and physical abuse at home may have led many to prefer life on the street. Living or spending most of their time on the streets, they may beg, hustle, steal, or sell sex to survive. Others, especially the girls, are domestic workers who live at their place of employment. Cut off from families and the larger society in which they live, these youth have little or no system of social protection. The social support they receive is usually from peers living in similar circumstances.
Lack of family and social ties can be worsened by social stigmas. Whether they are members of ethnic, national or religious minorities; migrants or young people in "floating populations;" street children viewed as nuisances or criminals; or homosexual youth facing discrimination or repression; the indifference or hostility with which society treats these youth may further traumatize them. They may be subject to harsh discrimination at mainstream health service delivery points1,2,3,4 and in the marketplace, and they may internalize societys negative views of them, damaging their self-esteem and their ability to have healthy relationships with others.2,5,6,7
Poverty may require these youth to work long hours to support themselves or their families, but they often are not recognized officially as workers. They may be forced to work under exploitative and hazardous conditions that endanger their physical, mental, and social development.* Lacking job skills, they tend to work in informal sectors of the economy.8,9
Many of these youth are victims of violence and physical abuse, including sexual abuse. Domestic workers may be forced to provide sex to their employers, street youth may be abused by other street youth4,10 or by adults, and refugees and youth in areas of armed conflict may be obligated to grant "sexual favors" in return for documentation, relief goods, or both.11,12 Young girls are trafficked into slave-like conditions in brothels.2 This abuse can result in STIs, unwanted pregnancy, and physical injury, as well as psychological trauma that increases vulnerability to future abuse.2,13
Some of these youth, especially those who live on the street, use drugs to diminish hunger, cold, and emotional pain or to help them sleep or stay awake.3,8,14 Repeated use of these drugs can cause physical and psychological problems, including hallucinations, pulmonary edema, kidney failure, and brain damage.2,5 When intravenous drugs are used, the additional risk of contracting HIV, hepatitis, and other diseases exists.
Collectively, all of these characteristics make these youth more vulnerable to unintended pregnancy and STI/HIV infection. Poverty and lack of education and job skills make them more vulnerable to all kinds of exploitation. Social stigma and lack of a stable, supportive environment diminish the self-efficacy needed to undertake self-protective behavior. Sexual abuse stunts the skills needed to prevent unintended pregnancy and STIs.2,8,13 Drugs diminish inhibitions and impair judgement, making it less likely that youth will use information and skills to protect themselves from risk.15
How many youth are socially marginalized?
While it is difficult to quantify the extent of the problem, the following statistics show that many youth need information and services beyond what is provided by traditional school- and clinic-based programs.
§ The United Nations estimates that 404 million youth
under the age of 18¾38% of youth in developing
countries¾do not attend school.
§ The International Labor Organization (ILO) estimates that
190 million youth between the ages of 10 and 14 work.9
Three quarters of these youth work six days a week or more,
and one half of them work nine hours a day or more.9
§ UNICEF estimates that approximately 100 million youth work
on the streets in activities such as picking garbage, hawking
small goods, parking and washing cars, shining shoes, and
begging.8,9 It is estimated that 10% of these youth actually
live in the streets, with no connection to their family or a
§ United Nations agencies and non-governmental
organizations (NGOs) estimate that at least one million
young people under the age of 14 are lured or forced into
commercial sexual exploitation each year.2,9 While the vast
majority of these are young women, young men are also
What can be done to address the needs of socially marginalized youth?
Because their preoccupation with daily survival can outweigh concern about possibly dying of AIDS in the distant future,1,16,17,18,19 reproductive health interventions for these youth must take into account the full range of issues they face. Many of them live in situations characterized by violence and distrust,5,6,8,9 so programs need to establish an environment of respect, acceptance, and stability.
Mechanisms to reach these youth
To make initial contact, outreach programs find youth in places where they spend most of their time. In Guatemala, Honduras, and Mexico, Casa Alianza outreach teams provide street youth with emergency medical care, HIV education, informal education, and counseling.20 In Benin, women who work with the NGO Enfants en Situation Difficile search markets for girls who have been sold into domestic service.21 When they find them, they teach basic skills and try to make sure that employers are treating them adequately.
Telephone hotlines are another strategy employed because they offer information to youth and preserve anonymity. In Manila, Philippines, local organizations have established a hotline to allow domestic workers to report cases of abuse.22
homes and group homes prepare youth for independent living or help reunite them with
In more structured and intensive settings, drop-in centers and shelters provide a place to rest and protection from violence and abuse, as well as food, clothing, medical care, and recreational activity. These facilities can also provide a sense of stability and community that youth might lack.
Programs should work with those members of the community who have already earned young peoples trust, such as market or street vendors, shopkeepers, or health care providers.23 By understanding where young people go when they need help, programs can strengthen and build on support networks that already exist. Influencing young peoples development requires that they receive consistent support through as many channels as possible.23
Services programs provide
Through the mechanisms mentioned, programs offer youth a wide range of services. Individual or group counseling helps youth build self-esteem and achieve more control over their lives. Some counseling programs are designed specifically for abused or drug-dependent youth. Some programs use creative ways of helping youth express themselves. A Childhope Asia program in Manila uses art therapy to enable youth to examine their lives and their hopes for the future.24 The Brincar Curando initiative of the Mozambique Red Cross has used games, songs, and storytelling to help youth traumatized during the countrys civil war.25 Programs throughout the world have used Street Kids Internationals "Karate Kids" and "Goldtooth" animated videos to facilitate communication with street youth.26
To help these youth develop viable alternatives to the low-skill occupations they are engaged in, many programs offer formal and informal education, providing training in literacy, numeracy and life skills, as well as job training and apprenticeships.26 Ideally, youth learn marketable skills that increase their likelihood of gaining employment. Casa Alianza in Latin America provides child day-care services so young mothers can participate in these activities.20 Street Kids International (SKI) helps street youth start and run small businesses by offering access to micro-credit and help with budgets, market analysis and business plans;27 to date youth have established bicycle courier services in India and the Sudan, a shoe shine collective in the Dominican Republic, a wholesale candy business in Peru, and a pizzeria in Tanzania.26
Finally, programs can offer health education and services to these youth. Many programs offer STI/HIV/AIDS education, and some are affiliated with nearby clinics so that youth have access to health services. Mamobi Refuge, a group home for street girls run by a Ghanaian non-governmental organization, Urban Aid, is located next to a maternal and reproductive health clinic. The clinic provides pregnant girls from the Refuge with free family planning and HIV/AIDS counseling, health care before and after birth, and immunizations and checkups for their babies.28
Advocacy and awareness-raising activities
Many programs complement their services with education and communication activities to help youth understand and assert their rights and with advocacy activities to raise awareness and mobilize society to protect these rights. At the national and international level, these groups promote and enforce legislation that fosters young peoples well-being and development, such as laws against exploitative labor and the trafficking of youth and the International Convention on the Rights of the Child. Other activities include:
Providing legal services to youth. Established in 1990 in response to the brutal murder of a 13-year old street youth by four uniformed police officers, Casa Alianzas legal aid office in Guatemala has managed hundreds of criminal law suits on behalf of street youth and assisted them with civil law matters such as the acquisition of birth certificates and identity cards needed to matriculate in school or benefit from other social services.20
Helping youth understand and protect their rights. Organizations like Reach Up in the Philippines and the Bosco Project of Bangalore, India, help youth working in garbage heaps band together and collectively defend their interests.9
Warning youth, their families and their communities about potential risks. In Nepal, the NGO Maiti Nepal works in rural districts that have high rates of sex trafficking to raise awareness about how girls are kidnapped or lured into the sex industry, and Media Alert, also an NGO, is creating a film exposing the realities of life in Indian brothels to be shown in villages.13 In Thailand, the Daughters Education Program alerts youth, their families, and community members to the dangers of prostitution.9 In Benin, Enfants en Situation Difficile has organized a radio campaign and village awareness workshops to warn parents of the risks their daughters face when they are sold or abducted to work as domestic servants in cities and neighboring countries.21
What obstacles do programs for socially marginalized youth face?
Conducting needs assessments and involving youth in program planning.
All too often, adults who are not familiar with the real needs and concerns of young
people pour resources into establishing services for them. Although adults
motivation may be their heartfelt concern, services will be rejected if they
do not meet youths greatest needs. Programs should undertake comprehensive situation
assessments in which young people are the key source of information. In addition to
exploring risk-taking behavior and the reasons for it, assessments should try to identify protective
factors that help youth avoid risks.
3,30,31,32 It is often difficult for programs to find staff who have the patience,
sensitivity, cultural understanding, and skills to build trusting relationships with these
youth. Programs seeking to empower youth find it necessary to invest time and resources
training staff to interact in a participatoryrather than authoritative or
paternalisticmanner.8,32 Once staff have
been found and trained, programs face the challenge of preventing the burnout that often
accompanies intense, and sometimes dangerous, work at low pay.
Finding and retaining the right staff .
Securing funds.1,30,31,33 It is extremely difficult for programs working with these youth to secure funds, especially long-term financing. Providing direct services can easily absorb existing funds, leaving little or nothing left for broader-based community education and awareness programs.33 Forming alliances of agencies that provide complementary services and setting up a referral system can reduce costs, and networks of youth-serving organizations may be more likely to secure funding than individual programs.
Securing community support. As previously noted, programs should try to win community support for these youth and the programs serving them. Program staff will need patience and hard work to win this support, but they will find it hard to operate without it. For example, programs may be prevented from establishing drop-in centers or shelters if people living in the area do not want the program established near their homes.7 Furthermore, youth may avoid going to programs if people in the area treat them poorly.
Measuring progress and results.29,31,32 Programs should establish measurable indicators of their progress and results. While impact takes time to occur and can be difficult to measure, it is crucial that programs measure their progress regularly and consistently; renewed and scaled-up financial assistance often depends on demonstrated results.29,31
Penetrating a world of abuse, violence, and crime. Commercial sexual exploitation of youth is a multi-billion dollar industry.2,9 Its underground nature and the high profits involved make it extremely hard to penetrate, especially when government officials, police and border guards benefit from the trade.2,9 Youth who try to escape from forced prostitution may be subject to severe beatings by brothel owners and may rightly fear that if they do escape they will be arrested, deported, or shunned by their families and communities.2 Those youth who are repeatedly sexually abused on the streets may learn that abuse is acceptable and end up becoming abusers of other youth.2,13,30 This cycle, and the habit of exchanging sex for money and favors, can be very hard to break. Because police are often guilty of harassing or abusing these youth, turning to them for assistance may not be an option.2,5,6 Casa Alianzas "List of Shame" details the deaths of scores of Latin
Influencing the larger context in which these youth live.9 Perhaps the greatest obstacle programs face is their limited ability to influence the larger social, political and economic context in which these youth and their families live.6,8 Without free, compulsory, and relevant education, poor youth stay out of school. Discrimination against girls and women, homosexuals, and ethnic minorities contribute to marginalization and exploitation. A lack of basic services and social safety nets forces families to rely on the economic contribution of their children to survive and forces youth into potentially dangerous working conditions. National economic policies, global market forces, and structural adjustment programs can widen the gap between rich and poor and exacerbate these problems. Programs that confront these issues generate controversy and can expect to encounter social and political resistance.8
However, by struggling on the dual fronts of providing services and addressing the root causes of youths marginalization, programs are creating a better world for all.31
The In FOCUS series summarizes for professionals working in developing countries some of the program experience and limited research available on young adult reproductive health concerns. This issue was developed by Christine Stevens, FOCUS consultant. The In FOCUS series and other publications can be downloaded from the FOCUS website <www.pathfind.org/focus.htm>.
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2 Center for Development and Population Activities (CEDPA). 1997. Girls Rights: Societys Responsibility. Taking Action Against Sexual Exploitation and Trafficking. Facts on Asia and Country Profiles (Report from the conference in Mumbai, India, December 8-10, 1997). Washington, DC: CEDPA.
3 Ringers, P. 1999. Formerly of Mkombozi Center for Street Children (Moshi, Tanzania). Personal communication. February 3.
4 Ruiz, J. 1994. Street youth in Colombia: lifestyle, attitudes and knowledge. AIDS Health Promotion Exhange 1.
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6 Harris, B. 1999. Casa Alianza. Personal communication. January.
7 Birch, A. 1999. Casa Alianza. Personal e-mail communication. March 5.
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10 Barker, G. 1993. Research on AIDS: knowledge, attitudes and practices among street youth. Children Worldwide 20 (2-3).
11 Family Health International. 1998. The Health of Adolescent Refugees Project. (Unpublished program description.)
12 UNICEF. 1996. "Children in war." The State of the Worlds Children 1996. Oxford and New York: Oxford University Press.
13 Shanler, S. 1998. Sexual Abuse & Young Adult Reproductive Health. Washington, DC: FOCUS on Young Adults.
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21 Shapiro, W. Winter 1998. "The Problems of the Videmegons in Benin". SC&D News (Newsletter of the Program on Social Change & Development, the Paul. H. Nitze School of Advanced International Studies, Johns Hopkins University). <http://www.sais-jhu.edu/depts/mideast/scnd/index.html> (online cited February 17, 1999).
22 Anti-Slavery International. 1998. <http://www.charitynet.org/~asi> (online, cited December 29, 1998).
23 Ball, A. 1999. World Health Organization. Personal e-mail communication. February 26.
24 Wright, R. June 18, 1997. Street Kids Find Help at Home. <http:/www.casaalianza.org/children/artchild/ artchil2.htm> (online cited December 21, 1998).
25 UNICEF. n.d. Transcending the legacy of apartheid: Rights and rehabilitation. <http://www.unicef.org> (online cited December 21, 1998).
26 Street Kids International. 1999. <http://www.streetkids.org/> (online cited December 21, 1998).
27 Sutherland, A. and S. Richardson. 1998. Micro-Enterprise Credit for Street Youth: The Experiences of Street Kids International <http://www.streetkids.org/micro.html> (online cited December 21, 1998.
28 Brooker, E. n.d. Ghanas pregnant street girls find refuge. <http://www.unicef.org/features/feat173.htm> (online cited February 17, 1999).
29 Rizo, A. 1999. Pathfinder International. Personal e-mail communication. March 5.
30 Bond, K. 1998. FOCUS on Young Adults. Personal communication. November 18.
31 Copping, P. 1999. Street Kids International. Personal communication. January 19 and February 26.
32 Torres, V. 1999. Street Kids International. Personal communication. December.
33 Kirby, K. 1999. Mkombozi Center for Street Children (Moshi, Tanzania). Personal e-mail communication, February 4.
34 Casa Alianza. 1998. The List of Shame. <http://www.casa- alianza.org/EN/shame> (online cited February 17, 1999).