Senior Technical Expert, Reproductive Health, Washington, D.C., August 2009

Dr. Margaret E. Greene has more than 20 years experience working in the fields of family planning, gender, and youth sexual and reproductive health policy. Dr. Greene has worked with many instrumental public health and international development organizations, such as the Population Council, Population Action International, Center for Health and Gender Equity, and the International Center for Research on Women. She is also the director of the Center for Global Health at George Washington University (GWU) and teaches several classes at GWU. Dr. Greene is a member of the Technical Advisory Group to USAID’s Interagency Gender Working Group. 

We spoke with Dr. Greene about her experiences in the field of youth reproductive health and policy.

Youth Policy Toolkit:What interested you in youth reproductive health?  

Dr. Greene: I first became interested in reproductive health when I was in college. There are so many obstacles toward attaining good reproductive healthcare for young people and adults as well. Those obstacles are expressed more intensely for young people, and so if you can really figure out what’s going on with young people and solve the problems of accessing information, then you could actually improve things for everybody. There’s something really unjust about the conditions young people face and ignorance around the fact that sexual relationships tend to begin at an earlier age, there is a lot of coercion involved, and early marriage is happening, etc.

The women’s movement raised awareness of the difficulties women faced in accessing things that were commonly available—jobs and so on in society. That same perspective could shed light on reproductive rights and young people, who I believe are not treated as full human beings on some level—that they have not been treated as full citizens. They are the bearers of rights, but they are not given their rights. Parental rights take precedence. In a way, that [precedence] is damaging; in a way, that [precedence] does not even work for parents. So I think there are some insights from the women’s movement, where the dichotomy is male/female, that could be applicable for young people, where the dichotomy is young people and adults. Where you see a whole category of people as lesser somehow, then you are going to have the consequences that we see.

Youth Policy Toolkit: And following up on that, there seems to be a third dichotomy of people in between a child or an adolescent without completely assuming the rights and responsibilities of an adult.

Dr. Greene: This really gets to me—that you can be drafted to the military but you can’t have access to full sex education. I find [it] very inconsistent. It’s not rational. So, big changes have to happen to benefit young people.

Youth Policy Toolkit: What do you think are the most important changes that we need to work toward? Or what are the key policy areas that need to be targeted?

Dr. Greene: I think it’s great that parents and families remain the locus of conversations about values and how the proper conduct of behavior and conduct of relationships is formed, but the society, the education sector, and the health sector in particular have to provide the information so that the young person is able to make a decision about his or her own rights—guided by the ideas that they get from their families.  For me, access to information is so profound. It’s the most important thing. And I think it’s so transformative—when people understand how their bodies work and when they understand some of the challenges they will face in entering relationships or fending off relationships.  They have to have people to talk to, and then if they need additional information, they know they can go somewhere. It’s really mostly adult information. That, to me, is just fundamental.

And I know that one of the big obstacles is this argument that if you provide this information, young people will run wild. But they are hurting their own health significantly without that information. And it seems very punitive and controlling for their parents.

Youth Policy Toolkit: Yeah, it kind of handicaps them in becoming full adults, in becoming health adults.

Dr. Greene: Yes, I think that’s fundamental. Somebody shared something interesting with me about what they saw as [an] obstacle in the provision of services—particularly [with] information to young people—that had to do with adults’ ambivalence with their own sexuality or their sense of loss or misconduct in their own sexual lives, so they resent the beauty and strength of young people. And I see this as a very interesting, psychological explanation. There may be an insight there. I have to think about it in terms of programs and policies.

Youth Policy Toolkit: That’s an interesting perspective because I think most people attribute the lack of attention to youth reproductive sexual health being a result of the stigma placed on sex education. You seem to say it’s a more convoluted issue than that and we need a deeper look at the adult psyche.

Dr. Greene: Well, there’s the joke that sex is so disgusting that you should avoid it at all costs and save it for the one you love the most. I think, in many societies, there is that sort of ambivalence about it.

Youth Policy Toolkit: What kind of polices promote access to information? Have you done any policy-related work to promote access to information?

Dr. Greene: It’s very difficult to point your finger at something in particular. I think I can come up with a couple examples. By simply sharing the example of Iran, which has special schools for married girls. So, just to share the example, instead of having pregnant or married girls out of the school system (they’re done with education), here’s this conservative Muslim society that has found a way of formally structuring girls’ ongoing education and access to information. I think it’s really important that sex education is a fundamental requirement for obtaining a marriage license. It’s so funny, in the U.S., I got married 10 years ago, and all I needed was a syphilis test. It is such a missed opportunity to hand out pamphlets and talk to people and pass out information. The connection that I am making is that in having highlighted this really great example in this review of youth policies I did for Population Action International, so many people have commented on it—expressed interest—because if that conservative society can do it, can we replicate it in other places?  

Youth Policy Toolkit: A similar disconnect seems to exist between education-focused programs or public health programs. There seems to be a gap between public health programs that focus on schools and sex education programs that are out of schools. Do you find there to be a gap?

Dr. Greene: Between the services provided and the information provided through schools?

Youth Policy Toolkit: Many IEC [information, education, and communication] campaigns are not channeled through schools.

Dr. Greene: Sex education varies so much from place to place. And it’s always charged.  In general, I agree with you. I also think there is a gap. In school sex education, it is a lot about the biology. It’s not about the nitty-gritty. It’s not about relationship negotiation—not about how you handle yourself. Maybe increasingly that’s there—more about the decisionmaking—but the curriculum in schools is very biologically oriented; also there is not the interconnection with services because you might think it is incentivizing sex. But if there is [interconnection], you know when it hits. You’re so much more likely to use it. And you’re not intimidated. There is a friendly person sitting behind the desk and it makes a difference.

Youth Policy Toolkit: How do you feel the field of adolescent health has changed over the years? How have the priorities changed while you’ve worked in it?

Dr. Greene: I’m not sure. It’s not something that I’ve thought about. I’ll have to think about it as I speak. Well one thing that occurs to me is that [there is a] greater sense and a stronger international mandate for addressing the reproductive and sexual health of young people. So, it’s not just about contraception; it’s not just about stopping childbearing. Now there is talk about delaying, spacing, managing healthy relationships, STIs. It’s partly a function of the Cairo conference—that there is a greater attention to a broader span of RH issues—that makes it much more appropriate to youth.

I think that many global changes have been empty. There is a lot of talk about their [youth] rights, but you don’t necessarily see it all that much in practical terms. I just think about the tone people are spoken to—in African clinics, young people are spoken to in very judgmental terms. And it doesn’t have to be just there. Ten years ago, I spoke to this doctor in Chennai who basically talked about inserting an IUD [intrauterine device] after doing an abortion without asking the patient and then informing her afterward and telling her that she will have to undergo another procedure to remove the IUD—but without asking her if that was okay. There is a very strong sense of adults knowing what’s right for young people. I don’t think that broader commitment at the international level has transmitted practically to real change for young people.

Youth Policy Toolkit: And why do you think that is? Do you think it’s because there are no representatives for youth or of youth? The people making the decisions for youth are either in international organizations or MOHs [ministries of health]. Do you think that’s the reason for the gap?

Dr. Greene: I think it’s partly that they are not represented. They have the original problem that the older they get, they lose that experience, and then they’re out and then you have new youth. I think that there is more representation over the years. Organizations like IPPF [International Planned Parenthood Federation] have young people on their boards, but I think that young people are not taken as seriously as adults, and that seems to persist. I always feel embarrassed when I go to meetings about youth and people make jokes about how we’re all young at heart. I feel like there needs to be more equal conversations between younger people and older adults, and it just doesn’t happen all that much. And here we are—exposed to the international agreements and the high-faluting language—and we still struggle with it in Washington, D.C.; but if you go to Mozambique, it’ll just be really hard to have serious conversations.

Youth Policy Toolkit: It seems more revolutionary than the women’s movement because…it’s similar in the sense that you are revamping these traditional familial and society structures. How do you begin to engage a child who doesn’t speak, doesn’t have role?

Dr. Greene: I agree. It just seems really hard to accomplish. It may take a long time and require such a different mindset. And it’s ironic that it wasn’t that long ago when the creation of childhood [as a sociological concept] happened in Western society in the last 200 years. And it was like it was overdone. Children are different from adults, but now we have those two categories. And this gets back to what you were saying earlier—can we have more of a transition period where you are adapting to the category and status of being an adult?

Youth Policy Toolkit: I think the culture of the U.S. is unique in that children have the ability to explore; they have a safety net to explore being an adult. Whereas in developing countries, children get married and instantly transform into adults and assume all the responsibilities of an adult.

Dr. Greene: Or [children do not gain any responsibilities or rights once they are married]. Or you are completely disempowered when you go to another household. Or you are an adult in that you are supposed to have a child, or you have this new role, or the mother-in-law snaps her fingers and you have to rush around.

Youth Policy Toolkit:It’s interesting then—I’m wondering if the best way to advocate for youth needs is in a forum separate from adults or whether we have to integrate it into health programs overall, where we have to bring in youth representatives, or whether the adults who speak louder and are bigger would accommodate for the needs of youth within such settings.

Dr. Greene: Honestly, I think that both are necessary. Before I became more educated, a friend of mine was working with a Norwegian children’s organization and the rights of children and children as citizens. And I didn’t really take it all that seriously, and I’m someone who should have been especially attentive to that kind of thing. But look at me; it was my resistance. I am a product of my culture. So, I guess that there are some groups and organizations that are doing that. But then young people have to come forward and make statements about the things they need and the things they want and why they need them; and they need to mobilize resources on their own behalf. And organizations like the IPPF and others need to continue to do their thing and integrate young people into their boards and so on. So, I think it needs to happen. And it’s ironic, but these are the types of conversations women had—should we do things separately or do we want to integrate ourselves into male systems of power? All of the above.

Youth Policy Toolkit:Looking back as an adult, it’s interesting to consider my experience growing up partially in India and partially in the U.S. and how different my upbringing has been from that of children in developing countries.

Dr. Greene: I am writing this report for UNFPA [United Nations Population Fund] that is called “Girls Speak,” which is trying to use qualitative data about what girls say about their own life to give some finer messages about health and schooling, etc., and rights and violence. When someone from the West makes a recommendation about what you should do about your girls, it’s being colonialist and there’s no connection with their lives. But when it’s girls themselves who are saying these things, they have more authority to bring about the change. So, maybe that is just going back to how you do that practically; how do you tell young people—look you are not telling us about sex, but 15 of the 85 girls in our class dropped out because they got pregnant last year. What’s wrong with this picture? I look at the TOSTAN model. The model has taken this concept of rights and helping people come to some of these conclusions on their own and helping them find solutions to their own problems through their own routes. It’s very owned by the people of the culture.

Youth Policy Toolkit:What kind of policy do you think would enable such types of interventions? Such types of projects?

          

Dr. Greene: I think that there has to be some national conversation about rights—just as a general conference; it doesn’t have to be lecture but rather a general awareness raising about rights and capacity building. So, you have some kind of basic reference. Devolution of power to the local level. This may be positive, but devolution could also mean power in the hands of the local religious leader who may be running the show. If it were accompanied by some types of conversations… I just always come back to these abstract conversations when I talk about young people. It’s not about service provision. It’s just not. It’s so much bigger than that. Service provision is literally a bandaid for the giant problem. It’s so limited and it’s so driven by the health sector. And I think one of the big challenges is…everyone says [youth programming] needs to be multisectoral, but what does that mean? When you have government sectors and money is spent sector by sector, multisectoral means that no one is ever going to do anything. And so [youth programming] has to belong to somebody. It can’t be this nice idea—we’re going to create this ministry of youth that has no budget—that is so often the case. We need some fresh ideas about how to drive people toward youth causes. I was really impressed by Zambia. And this is not youth-specific—the ministry has these coordinating bodies at every level (national and district). They visibly replicate these multisectoral advisory groups that reach right down to the local town. And they have conversations like “this is what our epidemic looks like; what do we need to do to address it.” And I think that people at the most local level don’t know what challenges young people are facing as a whole. They don’t have the statistics. It’s no wonder young people are struggling. They don’t have enough information to know how to act in the best way possible.

Dr. Greene: How do you increase communication between youth and adults in an environment where youth feel comfortable? It seems to me that one of the biggest obstacles (based on my field work in Nepal with Save the Children) is that speaking with girls about RH is like pulling teeth. Even young girls in the U.S. don’t want to talk about it. I wonder, what is the best strategy to make them talk?

Youth Policy Toolkit:As you know, a policy is only as good as its implementation strategy. What do you think are the key components to implementing the policy?  

Dr. Greene: I think another obstacle is that because budgets don’t track beneficiaries by age as a general rule, an MOH can say that, yes, we have youth family services—but if they spend $3 on that [the youth services], you would want to know. You want to see how many young people are coming. Just being able to focus on that [the details] is so fundamental. It requires a lot of record keeping, but in general, you need to know more, much more. Budgets are behind a real implementation strategy.

Youth Policy Toolkit:What future directions do you see for yourself in youth health? Where would you like to go?

Dr. Greene: Recently, I have done some work on youth but more on the social science side on early marriage, and I’d like to get back to work on youth RSH more centrally. One of the things that came out of working with men and boys is doing awareness raising about gender inequality at a very early age. That’s really fundamental. I had this utopian view about men and women, boys and girls…what world would we live in if we had mutual respect and support and cooperation for each other? It would be better for everybody. I can’t tell you how many people say, “Well, what do you tell men and boys? What can you say to persuade them? What have they got to gain from it?” They’ve got everything to gain. It’s ridiculous, the thought. And doing the awareness raising early.

Judith Bruce, from the Population Council pounds away about rights—basic human rights education that is well structured. Everything that we are talking about can be placed in a human rights context with a little bit of RSH education. A properly structured curriculum on human rights gives people the basis for understanding their ability to negotiate healthy relationships, how to have equal relationships with future employers, and their ability to respect the other sex. It [this understanding] can be an umbrella—so many fundamental things that end up being important in societies across the world. It is way upstream in many ways, but I think it affects so many facets of our lives—a boy that learns through a human rights-related education about how one should never force anyone to do something they don’t want to—it would be so incredible. You would have a generation of people who are thinking twice before engaging in coercive sex. I know that’s very abstract, but I think there is something really important there.

Brad Kerner at Save the Children USA has this idea that he has developed a game in Nepal called the gender equality game. Or Ravi Verma at the ICRW [International Center for Research on Women] Asia Regional Office has been working with the Family Violence Prevention Fund on a project called Coaching Boys into Men. That’s using cricket—working with a cricket coach to support boys…the gender socialization is often reinforced by sports to get them to be thinking differently or talking differently about sports. The worst insult you can possibly give somebody when they don’t kick the ball or do whatever they are supposed to do with the ball is to call them a girl or female genitalia. There is just a really huge opportunity there.

I guess that continues to be very exciting to me. I guess it’s still very upstream, but it includes RSH and is so directly connected. I think that’s maybe where it’s going to overlap with the work that I’m doing with men and boys and youth RSH.

Youth Policy Toolkit:Are there any other ideas that came to your mind as we were speaking?

Dr. Greene: Another obstacle that I see that has to be reconciled before a lot of progress can be made—we perceive conflict between the rights of parents and the rights of children.  Two places that come to mind where that really plays a role are in the U.S. and Mexico. Parents are deciding that what’s being shared with their children is smut.  I don’t know how to resolve that, but I think it’s one of the great challenges of our time and it totally illustrates the point we discussed earlier about the rights of children as lesser [being less important]—my right to information is less than your right to deny access to that information. And the whole kind of private control of children that is taking hold in our legal system.

Youth Policy Toolkit:That makes me think of how families are the unit of relations to society—whether it is an extended or nuclear family that has the authority to make decision about the child.

Dr. Greene: I’m trying to think about how they solved the problem in Iran. I think that parents had the right to prevent their children from going to school, but there is an alternative. If you are not going to put your child in school for this program, then you accept a health worker coming to your house to discuss what you need to talk about with your child. There needs to be a back-up plan. I know that it’s costly, and it can be relatively costly. But if this information is provided early, then large groups of kids can have this exposure.