Could Comprehensive Health Education Be the Key to Empowering Girls Worldwide?
By Gaby Grebski, Board Member, Girls Health Ed
“No one really uses condoms.”
“I feel pressured to do things even though I don’t really want to. But I don’t feel like I have a choice because he will leave me if I don’t.”
“Of course we all get our periods, but we’re not supposed to talk about it.”
These comments highlight some shared views and experiences of adolescent girls from two vastly different cultural, socioeconomic, and geographic backgrounds: Washington, DC and Lusaka, Zambia. Despite being “worlds apart”, the messages these girls are receiving about their bodies and their place in society are, in fact, strikingly similar. Unfortunately, these messages also reveal very real and problematic global attitudes towards girls and their sexual behavior as well as their relationships, autonomy, self-esteem, body image, and overall disease prevention — topics that ought to be addressed in any comprehensive health education curriculum.
One might assume that an advanced country like the United States, where the high school graduation rate is as high as 82%, would not only provide girls with accurate and comprehensive health education, but also encourage them to make informed and healthy choices about their own bodies. One might also assume that the experience of girls in the U.S. would contrast the experience of girls in developing countries like Zambia, where tremendous cultural and economic hurdles prevent many girls from obtaining even a basic primary school education, let alone a secondary one. And yet, while teen pregnancy rates in the U.S. have declined since their peak in 1990, which is being attributed to improved sex education programs, teens continue to engage in unhealthy behaviors and be influenced by negative cultural and societal norms.
Studies by the Center for Disease Control and Prevention state that 1 in 4 teen girls in the U.S. will contract a sexully transmitted infection (STI). In her latest book, Girls & Sex: Navigating the Complicated New Landscape, journalist, award-winning author, and advocate, Peggy Orenstein, talks about how teens and young adults account for half of all new STI diagnoses annually, with the majority being women.
In addition to health and medical risks, girls also experience shame when it comes to their bodies and bodily functions. Instead of associating menstruation with women’s ability to give life, it is often a source of embarrassment for adolescent girls. Ironically, the very source of what makes women unique is perceived as “gross” and not to be discussed in public. In developing countries, the stigma around menstruation and the ostracization of menstruating women can be far more cruel and even life-threatening, especially in rural areas where specific cultural practices go so far as to confine girls and women to ‘menstrual sheds,’ where too many have lost their lives.
As girls are taught to feel shame in adolescence and internalize negative messages about puberty, boys are getting bigger and stronger and benefiting from patriarchal values that promote male dominance. It is during this time in adolescence when girls tend to drop out of school while boys are more likely to continue their education. Sarah Hendricks, Director of Gender Equality at the Bill & Melinda Gates Foundation, describes adolescent years as the time when gender disparities become more prominent which ultimately affects girls negatively - a problem not limited to the developing world.
More than half of girls in the U.S. have no or minimal exposure to information about puberty, and the number rises significantly when limited to low-income girls. Decisions about curricula are often made on a state-by-state basis, and sometimes at the district level, with only thirteen states mandating that sex education have “medically accurate” information. According to Advocates for Youth, 27 states receive federal funding for “abstinence-only” sex education, despite research demonstrating that this approach is ineffective at delaying sexual activity or reducing teen pregnancy rates. The Journal of Adolescent Health and the Society for Adolescent Medicine both report that programs that advocate abstinence until marriage threaten various aspects of adolescent health and that medically inaccurate or the willful withholding of relevant information violates the fundamental human rights of adolescents.
Unfortunately, in addition to setting expectations and norms for sexual behavior, our media and pop culture often go too far in policing girls’ bodies with regard to weight, diet, body type, shape, clothing, and even shaving habits. Girls are 2.5 times more likely to develop an eating disorder than boys. A review by Common Sense Media states that 1 in 4 children have dieted before the age of 7, with the majority of girls ages 6 to 8 wishing they were thinner. The Keep It Real Campaign reports that 53% of 13-year-old girls are dissatisfied with how their bodies look, a number that rises to as high as 78% by the time they are 17.
Despite efforts by advocacy organizations to make improvements, we have not seen a lot of change in the delivery of health education in the United States in the last 10 years. To the contrary, according to the Guttmacher Institute, sex education in schools has declined around a number of topics, including how to resist peer pressure, the anatomy of human development (including puberty), and methods of contraception with coverage of correct usage.
Research shows that the status of health and reproductive education in developing countries in regions like Sub-Saharan Africa fares even worse, as many pertinent topics such as condom use are not discussed effectively enough, if at all, for cultural or religious reasons. With the HIV prevalence in young women ages 15-24 being double the prevalence in young men in regions of the world like Sub-Saharan Africa, the need for appropriate health education is even more dire.
The numbers in Zambia tell a similar story where 1 in 6 women are living with HIV. Gladys Mwewa, founder of the small community-based organization, Daughters With a Vision, in Lusaka, provides basic education and life skills to girls unable to attend traditional schools. While she understands how important it is for her girls to learn about sexually transmitted infections, particularly HIV, and the importance of condom use, she worries about community reactions to such a curriculum.
“They will think I am encouraging the girls to have sex,” says Gladys, “when I only want them to be safe.”
She knows that teaching abstinence is more acceptable but not realistic. Without access to such health information, however, the girls are at a higher risk of contracting sexually transmitted infections, becoming pregnant at an early age, facing the possibility of death in childbirth, and sacrificing their education and the ability to financially support themselves. Fortunately, for the girls, Gladys has had success establishing herself as a parental figure in whom they can confide. She continues to work on building their confidence in seeking healthy relationships and providing them with the life skills to rise above their challenging life circumstances. But she continues to struggle with the limitations on information and resources she can make available to these girls.
For girls who don’t have a Gladys figure in their lives, grassroots organizations like Girls Health Ed are helping to fill the gap. Sarah Hillware, Founder of Girls Health Ed and longtime champion of women’s and girls’ empowerment, recognized the lack of appropriate health education in school systems and felt there was a missed opportunity to empower girls during a critical window of time in adolescence.
“The programs often relay information, but do not necessarily empower adolescents to make long-term change,” states Ms. Hillware. She strongly believes that programming must emphasize positive social and cognitive development, be relevant to youth and applicable to daily life, and address adolescent girls’ future roles as strong and capable adult women.
Sarah’s journey to empower young girls started when she was young but solidified while obtaining her undergraduate degree in International Affairs and Global Public Health at The George Washington University. There she received a small grant to pilot health education workshops in Washington, DC and secondary research in other low-income communities throughout the United States, Kenya, and India. What she found was a missed opportunity to empower adolescent girls during the critical window of time and it inspired her to formalize her operations and establish Girls Health Ed.
Girls Health Ed leverages existing community structures such as schools, community centers, and after-school programs to provide accurate and comprehensive health education to girls. Girls Health Ed’s focus remains primarily on girls from low-income areas, addressing the importance of physical activity and good nutrition, body image, personal care and hygiene, and reproductive health. Workshops are taught by volunteer female Teaching Fellows who live and work in the communities they serve, enabling them to form mentor-mentee relationships with the girls. They undergo training from the organization to teach a curriculum that has been built by experts in the public health field and to prepare them to navigate the intangible socio-emotional complexity of these girls’ lives. Girls are encouraged to ask personal questions that will help them make healthy and informed decisions about their own bodies.
Teaching Fellows often marvel at the myths and misconceptions that many girls bring to their workshops — stories they have been told by their mothers, aunts, older sisters, or friends. “Although interesting, the stories are often untrue,” says Angela Young, a Teaching Fellow with Girls Health Ed since 2014. Angela places high value on her opportunity to educate girls and establish relationships with them that nurture inquiry and boost their confidence. She always feels privileged to witness these young girls starting to recognize their own self-worth and identify their strengths while receiving positive feedback from their peers.
Other Teaching Fellows have been struck by the fact that many of the girls are unable to identify a physical trait they admire about themselves, a reflection of the unattainable beauty standards by which they are taught to define themselves. Girls learn from a very young age that female physical appearance is highly valued, and is often the primary, if not singular, standard by which they are judged. Girls Health Ed workshops help them develop awareness about the power of the media in defining unrealistic and unhealthy norms of beauty and in objectifying and sexualizing women. In creating a safe space for the girls to explore the issue, more communities of peer support can emerge.
Girls Health Ed recognizes the need for this work on a global scale. Through its first global partnership with the Mama Sarah Obama Foundation, Girls Health Ed has expanded its programs to urban and rural areas in Kenya. In addition to delivering its curriculum, Girls Health Ed is also partnering with small-to-medium-sized enterprises, such as Tampon Tribe and others, to deliver much-needed sanitary supplies in efforts to empower the girls and help them destigmatize menstruation in the greater community. As a result, the organization has seen an increase in class participation from the girls, 86% of whom stated they wanted more opportunities to attend such workshops and 100% of whom said they learned new information about such topics as menstruation, personal hygiene, and self-esteem. Armed with more and accurate information about their own bodies, access to health education has the potential to change the path their lives take simply by helping them to stay in school with the hope of minimizing the disparity between them and their male counterparts.
In Washington, DC, and throughout the U.S., low-income girls are benefiting from the Girls Health Ed curriculum as well. 85% of the girls could respond correctly to questions about reproductive health after taking the workshops as opposed to 30% pre-workshop, allowing them to make more informed choices regarding their sexual health. The majority of girls also expressed increased comfort in talking to their partners, parents, and doctors after taking the workshops, exhibiting an increased ability to communicate about various health issues and safety.
From rural areas in Kenya and urban areas in Zambia to the U.S., it is clear that the development of and access to such programs as Girls Health Ed and Daughters With A Vision among others are providing girls with important information about their own bodies that will help guide them in health-related decision-making. Acquiring such knowledge and developing these important life skills will play a role in the fight to educate our girls, overcome cultural stigmas, and ensure the well-being of girls worldwide.