The arrival of the Zika virus is not the only threat to young women’s health and human rights in El Salvador. The virus, its potential link to microcephaly and other complications, and the inadequate government responses to it so far all bring into sharper focus the grave situation girls and women already face in the country. Such danger, highlighted in both government reports and the work of activists on the ground, includes sexual violence, a lack of access to medical care, and gang activity.
El Salvador’s health ministry recently recommended that because of the virus, women contemplating pregnancies should take measures to postpone their pregnancies for at least two years. However, as Rewire reported, feminists responded that the recommendation is inadequate. It does not address the realities in El Salvador, they said, a country where 31 percent of all pregnancies registered with the El Salvador Ministry of Health in 2014 occurred among girls and women ages 10 to 19. Because of a number of societal restrictions, many of these girls may not have a choice in whether to put off pregnancy.
A November 2015 report from the United Nations Population Fund (UNFPA) and the Salvadoran Ministry of Health (MINSAL) gives the most up-to-date details so far about this large segment of the population, especially where issues of relationships, pregnancies, and reproductive rights are concerned. Although the report was released before news of Zika became widely recognized, it describes interconnected systems of coercion and abuse any strategies to address the virus must take into account.
The UNFPA and MINSAL report stemmed from two stark figures in a National Health Survey in 2014: One out of every three women ages 20 to 49 in the survey had a pregnancy before the age of 18. One out of four lived in a relationship with a man, married or unmarried, before the age of 18.
These numbers, notes Minister of Health Violeta Menjívar in the 2015 report’s introduction, reflect the environment young women must often navigate in El Salvador:
The relationships as well as the early pregnancies are the result of circumstances beyond the control of the girl and the adolescent, and they impede her from making key decisions about her life adequately. The situation of violence in the family and in the society places girls and adolescents in situations in which their rights are violated. The relationships and pregnancies before age 17 are a product of the social violence that they suffer daily, and which is not taken on as such by the society or the State.
Using interviews with girls between the ages of 10 and 17 who had a live birth in 2012 at a Ministry of Health facility, the authors of the 2015 report attempted to flesh out the stories behind those statistics. The majority of the relationships, it found, were “not among peers,” meaning an age difference of three years or less. Rather, two-thirds of the girls had a male partner at least four years older at the time they gave birth, and 18 percent had a partner at least 10 years older.
This, the report states, creates “very unequal power” in the relationships, which leaves the girls and young women with “very little margin with which to make decisions about their lives.”
The study recognizes the problematic and conflicting laws in the country that criminalize some of these relationships but legalize others. For unmarried individuals, for example, any sexual relation with a minor younger than 15 years old is a crime. But there are still laws in effect in the penal code, it says, that “permit marriage under the condition that the girl or adolescent is pregnant or [they] have children in common, and there exists the express permission of the parents or guardians.”
The study also shows that “one of every ten relationships was formalized through marriage, including some with girls ages 10 to 12.”
The report also highlighted the inadequate medical services many of the girls received. In the case of the 10-to-12-year-old group, 20 percent had no postpartum care, even though, as the report says, they are the most vulnerable to obstetric complications. Half the girls and young women who gave birth in 2012 were not using contraceptives at the time of the study in 2015. By that time, 29 percent had already had a second pregnancy or were pregnant.
Girls and adolescents with histories of sexual violence, as self-reported in the interviews, comprised 37 percent of the interviewees overall, but two-thirds of girls ages 10 to 12 in 2012. One out of five of the girls who were 10 to 12 years old in 2012 had their first sexual relation with a family member, which constitutes the crime of aggravated sexual aggression. Though the report did not discuss individuals’ experience with the justice system, feminist groups that collect data on violence against women say that few police reports are ever filed of crimes like these—and if they are, there is rarely any follow-up.
“Sexual aggressions committed against girls and adolescents take place in an environment of social permissiveness around assaults, abuse and deception, fed by neglect, violence and poverty,” wrote Menjívar in her introduction.
“The fact that a girl of 10, 11 or 12 years of age is pregnant or finds herself in a relationship, that she leaves school, that she does not have access to services to protect her, et cetera, should be considered a national priority especially, when the persons who should protect them, and the institutions that should guarantee their rights, permit that these rights be violated,” she continued.
Right now, local health educators say that combating this problem is not a national government priority—and their own community-based work reinforces the report’s conclusions. Zuleyma Lovo, psychology student and leader from the activist group Jóvenes Voceras y Voceros en Derechos Sexuales y Reproductivos, gave workshops in rural communities and in middle schools on sexual and reproductive health—until increasing gang violence caused the program to be suspended in late 2015.
In an interview with Rewire, she affirmed the frequent incidents of violence and sexual abuse among the students she knew, and the many young girls who lived with older men:
At the school we asked for anonymous written comments, and in addition to questions about our talks, the girls would tell us about the physical, sexual, and emotional violence they experienced at home. Many think they can escape it by leaving home and living with a man, almost always a man who is older. But, the same dynamics repeat themselves, the violence, the abuse, the control.
This coercion extends to the control of pregnancy planning. “The men decide whether or not the women can use contraceptives. The men almost never agree to use condoms,” she said.
“Then the Ministry of Health arrives and tells women to abstain or to keep from getting pregnant,” she added.
This is not the only situation, advocates say, in which adolescents have difficulty accessing contraceptives. Lovo, and Noel Gonzalez, health educator and national director of Voceros y Voceras, described the difficulties the young people they serve face when attempting to obtain birth control available at no cost from local health centers operated by the government. Such clinics are the providers for the majority of poor people, both urban and rural; those who can pay for private pharmacies tend to have more options.
Gonzalez explained that the centers are directed to offer “youth-friendly” services, but that is rarely the case. Frequently, Gonzalez said, the young people he’s interacted with are met with “judgmental, prejudice-laden treatment and a lack of confidentiality” from the time they walk in the door. When young people do request contraceptives, he said, they are often told, “You’re too young. It won’t matter. You’re just going to get pregnant, anyway.” As a result, Gonzalez said, “many never go back.”
Clinics, Gonzalez said, often have limited supplies of certain kinds of birth control. “They only have the three-month injections, which have more side effects for young women,” noted Gonzalez. In its 2014 report On the Brink of Death: Violence Against Women and the Abortion Ban in El Salvador, Amnesty International found that “these clinics have … been associated with provision of fewer options and poorer levels of service for young women including denial of services and discriminatory treatment.”
And if that contraception fails, Lovo noted, women have few options: Abortion is 100 percent illegal in all cases in El Salvador. “Pregnant women who are abused or whose partners deserted them might be considering interrupting their pregnancies, but they are afraid to talk about it because of the strong religious biases against abortion,” she said.
All this is worsened, Lovo explained, by the threat of gang violence, which shut down her project in 2015. “They murdered a woman leader in one community, and we can’t go back there,” she said.
Gangs claim territories, which makes access to some health clinics a dangerous matter. Gonzalez elaborated, “The gangs stop you and ask you for your [identification], and if you live in the area of a rival gang, they won’t let you into their area. That can be where the clinic is.” A young person with the resources can take a bus to a distant clinic, but most don’t have that option.
Working as a health promoter is also dangerous: Some, Gonzalez said, have been murdered by gangs as they move from one community to another. He also explained that gangs kidnap or threaten to kidnap young women from their families and rape them, which has caused families to relocate within the country or to leave the country in order to protect their daughters. Some health clinics are reluctant to report rapes when women come to them for fear of reprisals from gangs.
Violence and poverty work together to curtail school attendance, including access to sexual education. Rates of students who leave their school out of fear have doubled in the past five years. In some cases, schools have closed as families flee to other regions of the country or leave the country altogether. Lovo noted that independently run sexual education programs such as hers have been effective but small, and limited by safety concerns.
Various projects and programs to improve matters have been written at the ministerial level and partially implemented, but have not met their goals. A proposed law on sex education in the schools has stalled in various committees.
The potential risks and impacts of the Zika virus interact with and exacerbate the chronic dangers of being young and female in El Salvador. Any efforts to deal with Zika need to recognize those contexts, and to work on making the country safer for girls and women beyond the threat of the virus alone.