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Youth who face prejudice and discrimination by virtue of their identity, life experience, or fam-ily circumstances disproportionately experience teen pregnancy and sexually transmitted infec- syphilis study, and recent efforts to restrict states from offering health services to immigrants all reflect racist and discriminatory reproductive health policies in the United States, as do ef- tions (STIs), including HIV. Such young people may forts focused on distributing Norplant and Depo- include youth of color, those from low-income Provera to low-income adolescents and welfare families, immigrants, and gay, lesbian, bisexual, and transgender (GLBT) youth. Research demon-strates the relationship between socioeconomic 2) Prejudice and discrimination have strongly factors1 -such as poverty, family distress, sexual negative impacts on the health of young people. networks2, and access to health care as well as Prejudice and discrimination, at individual and the impact of race/ethnicity, being young3, gender institutional levels, contribute to high morbidity (including young men)4, class, and/or perceived sexual orientation5 on negative health outcomes. African Americans suffer from negative sexu- This paper encourages those who work with al health outcomes at greatly disproportion- youth to understand the impact of prejudice and ate rates, with young women and young men discrimination on vulnerable adolescents, to as- who have sex with men particularly at risk.7,8 A sess and address their needs, and to build on their common misconception is that young African assets. In prevention programming, it is essential Americans simply are not as careful as whites in to empower young participants by involving protecting their sexual and reproductive health them in all aspects of developing and implement- - but studies have shown that even with equal or ing programs for youth. It is equally essential fewer sexual risk behaviors, African Americans/ to provide culturally appropriate interventions, Blacks are more at risk. An individual's risk is not with culturally competent adult and youth staff. solely a result of personal risk behavior, but is also a function of the "pool" of disease in their sexual network.9 Poverty, unemployment, unstable Step One: UnderStand the Impact
neighborhoods, and unequal rates of incarcera- Of prejUdIce and dIScrImInatIOn On
tion all contribute to unequal access to health YOUng peOple
care and raise a young person's risk of contracting Learn as much as possible about the connections between oppression and the sexual and repro-ductive health of young people. Prejudice and Research also demonstrates that institutional- discrimination have a powerful impact on vulner- ized homophobia results in high rates of violence able youth. Policy makers and program planners toward GLBT youth in schools and communities. The Gay, Lesbian and Straight Education Net-work's (GLSEN) 2007 report on the experiences 1) The historical and cultural context of reproduc- of gay, lesbian, bisexual and transgender (GLBT) tive and sexual rights, especially for women of students surveyed 6,209 middle and high school color and low-income women, is one of persistent students and found that nearly 9 out of 10 GLBT inequality. In designing prevention programs, students (86.2 percent) experienced harassment service providers must recognize the impact of at school in the past year, three-fifths (60.8 per- inequality on youth, especially on young women cent) felt unsafe at school because of their sex- of color and youth from impoverished communi- ual orientation and about a third (32.7 percent) ties. Persistent inequality in U.S. health care has skipped a day of school in the past month because resulted in communities having painful memories of feeling unsafe.11 Service providers estimate of medical abuses, as well as anger, distrust, that 25 to 40 percent of homeless youth may be and suspicion of public health and medical pro- GLBT.12 According to one study, 50 percent of gay viders and government agencies.6 Prevention teens experienced a negative reaction from their programs that work with young women of color parents when they came out and 26 percent were must not overlook the United States' history of reproductive rights violations. For example, by 1982, approximately 24 percent of African Ameri- Thus, it is evident that prejudice and discrimina- can women, 35 percent of Puerto Rican women, tion often have an increasingly negative impact and 42 percent of Native American women had on the health of young people - with young been sterilized, compared to 15 percent of white people who are members of more than one minor- women.6 The eugenics movement, the Tuskegee ity group facing even greater challenges. cial well-being. This study also suggested that these conditions can be mediated by a sense of 5) Media strongly influence adolescents' self-perceptions and self-concept. Mass media, policy debates, and community programs often present an image of young people as problems. Too often, the focus is on school failure, substance use, gang violence, teen pregnancy, and/or HIV/STIs. Cultural images fluctuate from that of the uncon- trollable, hard-to-reach, angry, and rebellious teen to the poor, disconnected, and distraught teen. Meanwhile, advertising builds the image of the sexy, carefree teen. What happens when ado-lescents repeatedly see and hear these images, internalize them, and then struggle to live into an idealized or distorted picture inconsistent with youth's true identity? For example, Many GLBT 3) Young people face barriers and obstacles youth report relying on television to learn what in sexual and reproductive health programs. it means to be lesbian or gay. In one study, 80 per- Culture in the United States reflects extremely cent of these youth ages 14 to 17 believed media ambivalent feelings about the rights of minors, stereotypes that depicted gay men as effeminate especially in regard to sexuality and reproduc- and lesbians as masculine. Half believed that all tive health care. Contradictions and age-based discrimination are clearly evident in reproduc-tive health programs and policies. Americans want teens to be sexually responsible. Yet, Ameri- Step twO: aSSeSS the needS and
cans also develop and fund programs that deny aSSetS Of YOUth In the cOmmUnItY
teens the information and services they need to Understanding the connections between dif- protect themselves from unintended pregnancy ferent forms of oppression and adolescent or HIV/STIs. Numerous legal barriers, such as con- sexual and reproductive health is the first step fidentiality restrictions and parental consent or in building effective programs. The next step notification laws, restrict teens from obtaining requires an examination of community programs adequate reproductive and sexual health infor- mation and services. While all youth are nega-tively affected by these age-related restrictions, 1) Assess the health status of youth and the some youth face additional barriers posed by accessibility of services. Gather demographic prejudice and discrimination. For example, lack information on youth in the community: age, of health insurance among the working poor can gender, race/ethnicity, and family income levels, prevent teens from these families from receiving as well as health, education, and economic indi- urgently needed care, such as contraception and cators. Assess the extent to which substance use, testing and treatment for HIV and other STIs. teen births and abortions, HIV/STI, and school Immigrant youth face additional barriers as well failure and dropout affect different populations due to lack of culturally and linguistically appro- of youth. Evaluate teens' access to health care and social services by examining fee schedules, hours of operation, locations, the availability 4) Teens who experience prejudice and discrimi- of public transportation, and laws and policies nation may have less self-esteem and fewer on confidentiality. Evaluate neighborhood envi- resources and skills to meet the challenges that ronments by assessing the local availability of all teens face. During adolescence, teens experi- healthy foods and fresh produce, recreational ence a variety of physical, social, cognitive, and facilities, employment opportunities, and qual- emotional developmental changes. For high self- ity health services. Involve youth and adult mem- esteem and a strong self-concept, teens need bers of the community in the process of creating to feel that they belong (peer identification), assessment tools and making decisions about and they need positive role models. Research assessment techniques, such as surveys, focus indicates that adolescents with high condom use self-efficacy, optimism about the future, and re-ported behavior change attributable to HIV/AIDS 2) A ssess the cultural appropriateness of are significant predictors of condom use at most services. Program planners must assess the recent intercourse.14 Teens with less self-esteem environment of their organization, including may feel less effective at negotiating safer sex, management, operations, outreach, community communicating with peers and partners, and involvement, and service delivery. This means accessing health care. Feeling less effective can evaluating the mission and activities of the orga- leave teens unwilling to act-unwilling to negoti- nization; the level of cultural competence among ate, communicate, or take other important steps board members, staff, and volunteers; agency to protect their health. For example, one study policies and procedures on discrimination and among GLBT people found that young adults harassment; staff training; whether programs were one of the groups with disadvantaged so- are culturally appropriate and/or multicultural; and the reading levels and appropriateness of do minors share with adults? What rights do they the educational materials for young people at not share? Young people could use conscious- different developmental stages. Is the staff rep- ness-raising-a term from the turbulent 1960's resentative of the target population? Who con- and 1970's in the United States-to explore at- ducts community outreach and how? Each staff titudes and beliefs among today's youth and member needs meaningful ways to examine at- to raise concerned awareness of youth's social titudes, beliefs, and knowledge in regard to ado- issues. Consciousness-raising is distinctly dif- lescent sexuality and reproduction, adolescent ferent from educational sessions where adults relationships, and teen parenting. What experi- teach, and young people learn, specific skills and ence influences staff's perceptions of adolescent knowledge. Or, youth might utilize I have a dream sexual health? Does staff have biases or hold ste- to envision their future. These types of work reotypes? In what subtle or blatant ways might focus attention on the assets, contributions, staff be communicating these biases to young people? The ability of staff to interact with each individual openly, flexibly, and respectfully will 2) Create opportunities for youth to talk openly affect the program's success. In the end, there is and frankly about racism, sexism, homopho- no magic solution-just continuous efforts- for bia, class discrimination, and other forms of oppression. Programs should offer a safe envi-ronment where teens can feel comfortable talk- 3) Learn about the cultural and family back- ing about individual identity, experiences, hopes, ground, health beliefs, and religious practices and fears. Teens need to feel and understand of each young person in the program. Values, how they and others have experienced prejudice attitudes, and beliefs, levels of knowledge, and and discrimination. Interactive and experiential communication patterns about health, sexu- exercises, such as case studies and role-playing, ality, relationships, contraception, and child- can help teens think through the barriers and bearing vary significantly across cultural and obstacles that oppression creates. For example, ethnic groups and from family to family. Tailor- youth can better understand gender discrimina- ing programs to the cultural background(s) of tion by exploring how ideas about gender roles participating youth can increase the program's limit young people's growth and future and how gender role stereotypes can damage relation-ships. Or, youth might explore economic issues 4) Assess the experience and knowledge of youth by analyzing the costs and benefits to a teen in the community. Needs assessment tools and with little money of spending allowance or hard- techniques typically provide statistical facts and earned dollars on condoms. Role-playing can figures on which to evaluate adolescents' behav- allow youth to experience how someone of a dif- iors and their sexual health. Focusing exclusively ferent race/ethnicity might feel at a clinic staffed on objective data and trends, however, can cause only by clinicians and counselors of a different adults to overlook the insights and experiences racial/ethnic background. In this way, activities of teens and to measure teens' health solely can frame reproductive and sexual health deci- in relation to adult standards. Finding ways to sions within the overall context of adolescents' record teens' perspectives, interpretations, and lives and help teens to understand how oppres- viewpoints-through surveys, focus groups, and interview-can help to ensure that a program truly meets the needs of the community's youth.
3) Replicate and adapt HIV/STI and pregnancy prevention programs that have been evaluated Step three: empOwer YOUth and
and shown to achieve positive outcomes for Offer cUltUrallY cOmpetent
young women, youth of color, low-income youth, prOgramS In the cOmmUnItY
and/or GLBT youth. A number of strategies and programs have been proven to work at the com- Information from the needs assessment will help munity level to influence sexual risk behaviors. inform the design, operations, and continuous improvement of programs. Planners can use the information from the needs assessment to develop strategies that will empower teens and ensure that programs are culturally appropriate. 1) Support peer education and the leadership of youth. Adolescent health professionals in-creasingly recognize the powerful effect that teens exert when they speak out for themselves, define the issues that matter to them, and craft an agenda to address those issues. Youth can create initiatives that address inequities and disparities in health care, drawing upon other social movements, such as civil rights, women's rights, and HIV/AIDS activism. For example, the civil rights movement challenged separate but equal as being inherently racist. Is separate but equal applied today to adolescents? What rights These include sex education that includes mes- referenceS
sages about both abstinence and contraception; 1. Santelli JS, Schalet AT, A New Vision for Adolescent Sexu- contraceptive and condom availability programs; al and Reproductive Health. Act for Youth Center of Excel- and youth development programs that offer mentoring, community service, tutoring, and employment training.16 Planners should cultur- 2. A. Adimora, V. Schoenbach, M. Floris-Moore Ending the Epidemic of Heterosexual HIV Transmission Among Afri- ally adapt evidence-based programs for the com- can Americans. American Journal of Preventive Medicine 4) Ensure that prevention efforts are culturally 3. Kertzner, RM, Meyer IH, Frost, DM, Social and Psycholog- specific. Youth-serving organizations are most ical Well-Being in Lesbians, Gay Men, and Bisexuals: The successful when their programs and services are Effects of Race, Gender, Age, and Sexual Identity. Ameri- respectful of the cultural beliefs and practices can Journal of Orthopsychiatry 2009 of the youth they serve. A culturally competent 4. Dzung X. Vo, M. Jane Park, Racial Ethnic Disparities program values diversity, conducts self-assess- and Culturally Competent Health Care Among Youth and ment, addresses issues that arise when different Young Men. American Journal of Men's Health 2008 cultures interact, acquires and institutionalizes 5. Almeida J. et al. Emotional Distress Among LGBT Youth: cultural knowledge, and adapts to the cultures The Influence of Perceived Discrimination Based on Sexu- of the individuals and communities served. This al Orientation, Journal of Youth and Adolescence 2009 may mean providing an environment in which youth from diverse cultural and ethnic back- 6. Center for Reproductive Law and Policy. Exposing Ineq- grounds feel comfortable discussing culturally uity: Failures of Reproductive Health Policy in the United derived health beliefs and sharing their cultural States. New York: The Center, 1998.
practices. Creating culturally competent pro- 7. Centers for Disease Control and Prevention. HIV Surveil- grams is not difficult, but it requires conscien- lance Report, 2008; vol. 20. Published June 2010. Accessed tious attention and the understanding that it is a life long process of learning and adaptation. 8. Kost, K., Henshaw, S., & Carlin, L. (2010). U.S. Teenage Pregnancies, Births and Abortions: National and State In conclusion, programs must recognize and Trends and Trends by Race and Ethnicity. Retrieved Janu- deal with the broad social, economic, and politi- ary 26, 2010, from http://www.guttmacher.org/pubs/ cal framework within which teens live. Program planners must ensure that services are both cul-turally appropriate for and also friendly to young 9. Doherty IA et al. "Determinants and consequences of people. Focusing on the young people's right sexual networks as they affect the spread of sexually trans-mitted infections." Journal of Infectious Diseases 2005; 191 to information and services can also empower young people to demand honest, accurate, cul-turally relevant information and unrestricted 10. Steele BC et al. Health Disparities in HIV/AIDS, Viral access to health services. Empowering youth can Hepatitis, Sexually Transmitted Diseases, and Tubercu- encourage adolescents to take responsibility for losis: Issues, Burdens, and Response, A Retrospective Re- their own reproductive and sexual health and to view, 2000-2004. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Preven- tion, 2007. Accessed from http://www.cdc.gov/nchhstp/healthdisparities/docs/NCHHSTP_Health%20Dispari- * For information on evaluated programs, contact ties%20Report_15-G-508.pdf on Dec 1, 2010.
Advocates for Youth or visit www.advocatesforyouth.org 11. GLSEN. The 2007 National School Climate Survey. Ac- Written by Laura Davis. Revised by Urooj Arshad, Associate cessed from http://www.glsen.org/binary-data/GLSEN_ Director, Racial Disparities and Social Justice ATTACHMENTS/file/000/001/1306-1.pdf on Sept 1, 2010. 12. Ryan C, Futterman D. "Lesbian and Gay Youth: Care and Counseling. [Adolescent Medicine State-of-the-Art Re-views; v.8, no. 2]" Philadelphia: Hanley & Belfus, 1997.
13. Ray, N. Lesbian, gay, bisexual and transgender youth: An epidemic of homelessness. New York: National Gay and Lesbian Task Force Policy Institute and the National Coali-tion for the Homeless. 2006.
14. Hendriksen ES et al. Predictors of condom use among young adults in South Africa: the Reproductive Health and HIV Research Unit National Youth Survey. Am J Public Health. 2007 Jul;97(7):1241-8.
15. A. Adimora, V. Schoenbach, M. Floris-Moore. Ending the Epidemic of Heterosexual HIV Transmission Among Afri-can Americans. American Journal of Preventive Medicine 2009 16. Alford S et al. Science and Success, 2nd Ed.: Programs that Work to Prevent Teen Pregnancy, HIV and STIs in the U.S. Washington, DC: Advocates for Youth, 2008.

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