Culture, Conservatism, Conflict: Challenges in Promoting the Health of Youth on the Thai-Burma Border

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Culture, Conservatism, Conflict: Challenges in Promoting the Health of Youth on the Thai-Burma Border

Nancy Goldstein

Two million Burmese refugees live as undocumented migrants on the Thai-Burma border.  Advocates seeking to promote the health and rights of adolescent refugees see peer education and perseverance as essential to their task.

Anyone who’s worked to bring sexual and reproductive health services to youth in the United States over the past decade knows what it’s like to feel challenged — embattled, even. It’s tough for individuals and organizations that work in conservative areas or on tight budgets. It can be even tougher when working with youth who are homeless, transient, steering clear of the law, struggling with literacy, or otherwise so engaged in simply surviving that sexual health-related issues rank low on their list of concerns.

Thailand’s Adolescent Reproductive Health Network (ARHN) is facing all of these challenges and more, as demonstrated by their publication last month of Protecting Our Future: A Report on Adolescents’ Knowledge, Attitudes, and Practices Related to Reproductive Health & Rights on the Thai/Burma Border. Good information about the beliefs, attitudes, and practices of youth regarding sex, gender, and reproductive health is hard enough to come by in stable societies. In this case, the 400 youth ages 12-24 surveyed by ARHN’s peer educators are among the estimated two million Burmese refugees that have fled the conflict zones created by their country’s 60-year civil war. Most live in and around United Nations refugee camps as undocumented migrants slipping back and forth across the Thailand border, avoiding the authorities.

“Ten years ago, most refugee camp leaders wouldn’t let birth control into the camps at all,” says Cari Sietstra, a technical advisor to ARHN. Today this grassroots, run-on-a-shoestring network of nine community-based organizations (CBO’s) is a primary provider to young Burmese refugees of condoms, birth control pills, and education via workshops, pamphlets, and posters.

RHN owes its ability to connect with young Burmese migrants to its intrepid, fiercely dedicated young peer educators. Inside Burma, any kind of humanitarian work that creates health for people outside of the army is considered political and can get a worker arrested, beaten, or even killed. And Burmese culture itself remains both highly conservative and very private regarding sex and sexuality. Few if any parents in the camps would think it’s cool that their son or daughter works as a peer sex educator, and peer educators have to be cautious about what they teach and where. “Every time ARHN’s peers go out into the community to conduct workshops on sexual safety and health, distribute contraception, or collect survey information, they risk arrest, violence, deportation, and the displeasure of their families,” says Tarjina Hai, ARHN’s current technical advisor.

Sex. Abortion. Parenthood. Power.

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As one peer educator explained to me, a relatively easy, obstacle-free training session is one that has the blessing of the village leader and religious leader or pastor, and takes place in a church. It involves incredibly expensive travel, but only one or two illegal border crossings, and requires bribing only a handful of authorities. That’s if you’re lucky: if there are too many people around when the educator is stopped at the border, no bribery can take place, meaning that his or her half done and fully paid for trip ends there.

Yet the work must continue. As Leila Darabi has noted, Thailand’s fairly rigorous family planning program is not reaching these young Burmese migrants, who are at significant risk for unplanned pregnancy, sexual assault, and sexually transmitted diseases. Many of these youth are working and living in factories (some legally, most not). They don’t have ready access to contraception, and they’re easy prey for both transactional and coercive sex. Most refugees have scant access to any kind of health care at all, let alone sexual and reproductive health care. Education efforts are stymied by low literacy rates, limited access to television, and virtually no access to the Internet.

“Reproductive health is too often ignored in the face of other ‘more important’ health issues,” says former ARHN technical advisor Meredith Walsh. “Yet preventing unintended pregnancies among youth, coupled with providing opportunities for meaningful education and work, is one of the most important public health measures in securing a future for refugee and migrant populations who otherwise face extreme hardship living in limbo.”

Of course, women are the ones who pay most dearly for this gap between need and availability. Unsafe abortion is a leading cause of maternal death among unmarried women in their teens and early 20s along the Thai-Burma border. Yet pregnancy outside of marriage is considered so shameful that even professionals trying to educate local medical providers can find themselves facing dead silence when they first offer information and answers to questions. This is not to say that local medical providers don’t want to help — just that they can’t speak openly about what they’re really seeing in their practices. The same group that swears that there is no demand for birth control or abortifacients is often is eager to hear — hypothetically — about how one might go about using them.

So consider Protecting Our Future a snapshot of a work in progress — the initial stages of a long-term strategy to integrate reproductive and sexual health and women’s rights into Burmese refugee youth culture. Because in this early period even the good news (over half of the participants had heard of condoms and birth control pills) is heavily leavened with the bad: only 23% of the 100 participants who reported sexual activity had ever used a condom, while only nine of those 100 reported using one every time.

Worse yet, as Lynn Harris notes, “More than half of adolescent males (and almost one third of females) “strongly agreed that female partners sometimes deserve beatings”; a majority also said they find it “acceptable for husbands to restrict wives’ access to family planning.”

ARHN’s staff understands the importance of perseverance: changing youths’ attitudes and behaviors will take time. “This is the first generation to grow up with birth control,” Sietstra explains. “Even if teenagers don’t change immediately, ARHN believes in the power of exposing them to this information repeatedly. Some day they’re going to marry, and they may decide they want to stop at two children. We think that the same may happen when it comes to gender equity. These teens come from a place where authority comes at the barrel of a gun: the human rights framework ARHN uses in trainings can be very powerful for them.”