Approximately 1.5 billion people in about 40 countries currently live in states considered to have active armed conflict, and thus face significant threats.¹ Young women in such situations are particularly vulnerable to threats to their sexual and reproductive health, not only from violence directly related to the conflict but also from the breakdown of law and order and community cohesion.² Identifying risk and protective factors for sexual and reproductive health outcomes will facilitate the development of appropriate policies and programs and will help target women vulnerable to negative outcomes.³

Armed conflict has the potential to dramatically change the way young women obtain access to and benefit from structures that promote their sexual and reproductive health. These structures may include legislative justice mechanisms, stable governance and policing that protect them from sexual violence and coercion, and the health and education infrastructures that facilitate access to good-quality sexual and reproductive health services. In addition, conflict may disrupt political processes, such as voting and taking part in demonstrations, that allow young women to voice their concerns. The development of progressive social policy for sexual and reproductive health—which facilitates sexual education and access to family planning methods—as well as economic safety nets to prevent destitution may also become inhibited.

Infrastructure and resources designed to support young women’s sexual and reproductive health, which may have taken years to develop, can be quickly destroyed during conflict. For example, during the Rwandan genocide, an estimated 80% of health care professionals were killed or fled the country, and medical supplies and equipment were heavily looted and destroyed.⁴ In addition, access to health services may become restricted because providers lack security and fear reprisal and attack.^5–7 During Shia-Sunni hostilities in Gilgit Town, Pakistan, hospital and clinic staff who belonged to certain faith-based groups were killed or were prevented from providing services, which reduced provision of and access to obstetric services and resulted in increased maternal morbidity and mortality.⁸

Forced migration and displacement further increase young women’s vulnerability by breaking down family and community structures. Although refugee camps and other settlements initially may be viewed as places of safety, they may themselves offer new threats.^9,10 Moreover, economic stagnation or decline may limit economic opportunities, which may in turn decrease the lifestyle (including sexual) options available to young women.^11,12

The social and economic breakdown precipitated by armed conflict raises questions about how young women can protect themselves against threats to their survival and to their sexual and reproductive health. There is increasing consensus that notions of risk and protection are largely context specific and consequently are not universally applicable in predicting outcomes.^3,13–15 Yet, despite this recognition, universal frameworks of risk and protection continue to be adopted in the field of sexual and reproductive health, with little consideration of their relevance to distinct groups or contexts. In this article we demonstrate the limitations of this indiscriminate application through consideration of early marriage and transactional sex in the context of conflict. We present these issues to highlight the challenge of supporting sexual and reproductive health in settings of armed conflict, where protection and survival can come at a price, especially given the short- and long-term consequences of sexual and reproductive health choices.

EARLY MARRIAGE

Globally, one-quarter of females aged 20–24 were married before age 18;¹⁶ this figure is much higher in less developed countries. International organizations are committed to preventing the occurrence of early marriage for a variety of social, educational and medical reasons.^17–21 The reasons for early marriage itself are also varied, and are often related to household livelihoods, cultural practices, social norms, financial considerations, and the desire of families to protect their daughters from sexual attacks and ensure that sexual relations occur safely in marriage.¹⁹

Early marriages are associated with additional complexities when they occur in the context of conflict. A study of conflict-affected districts in Sri Lanka found that a third of the 560 women in the sample had married between the ages of 15 and 18, a proportion the authors state was considerably higher than the national average (which they did not report).²² Respondents described early marriage as a "protective strategy" used to reduce the risk of daughters being "recruited" or abducted into military factions. Within military groups, abducted young females faced severe and prolonged sexual violence, including involuntarily being made "wives" of rebel soldiers.²³ In the Sierra Leone civil war (1991–2002), as many as two-thirds of young women involved with rebel groups (as either combatants or captives) had entered such "marriages."²⁴

Other studies support the notion that early marriage serves as a form of sexual security in times of conflict. For example, an analysis of medical records at Panzi Hospital in the Eastern Democratic Republic of Congo found that among women who were receiving care for sexual violence, those who had never married were six times as likely to have experienced sexual slavery as those who were married, abandoned or widowed.²⁵ Similarly, in Angola, married young women were less likely than their unmarried counterparts to be abducted by rebels during raids on villages.¹⁰ In addition, if a young woman is sexually assaulted by a civilian (as opposed to a combatant) in a conflict-affected area, families may have their daughter marry the man who assaulted her to avoid bringing shame to the young woman and the family.^22,26,27

Camps for refugees and internally displaced persons may bring with them a new set of risks, particularly for young women. Some evidence suggests that life in refugee camps increases the risk of early marriage, as parents are increasingly concerned about the breakdown of social norms within this environment and about new types of social contact between the sexes.²⁸

TRANSACTIONAL SEX AND RELATIONSHIPS

Many women experience their sexual debut within marriage, a key transitional life event.²⁹ However, global levels of premarital sex are increasing.²⁹ In many cases, young women engage in transactional sex, in which the informal exchange of money or material goods forms the basis of relationships.³⁰ Because of the age asymmetries that frequently characterize these partnerships, young women often lack power to negotiate safer sexual practices, thus increasing their vulnerability to poor sexual and reproductive health outcomes and to sexual and physical violence.³¹ Motivations for engaging in transactional relationships include not only securing basic needs and educational opportunities, but also the chance to acquire luxury items and attain the associated social status.^30,31

Conflict can affect young women’s likelihood of engaging in transactional sex. For example, changes in household structure due to male mortality, imprisonment or military affiliation, as well as economic trends, can have profound consequences for a woman’s livelihood and economic status. Disruption of agricultural livelihoods as a result of conflict-induced displacement in rural Nepal pushed young women into the sex trade to provide for their families.¹² Similarly, in Northern Uganda, transactional sex was used as a survival strategy when farming was not viable.¹¹ In times of conflict, avoiding starvation and destitution of the family is likely to be given precedence over young women’s sexual and reproductive health. Even in refugee camps, systems for distribution of food and other essentials are often controlled by male-dominated committees whose members may abuse their authority and demand sexual services in return for access to goods;³² inadequate or inconsistent food distribution systems may therefore force women to resort to survival sex. There are even reports of humanitarian aid workers engaging in transactional sex with or sexually abusing vulnerable refugees.³³

Transactional relationships can also be an important survival strategy within rebel groups. In Sierra Leone, one report described the organizational structure of the Revolutionary United Front as being based on "households" in which such resources as water and food were distributed to the "household head."²⁴ Young women could, through sex and "marriage," gain entry to domestic units, allowing them to meet their basic survival needs. To "marry" or become pregnant by a high commander could be a particularly desirable option because of such benefits as exemption from hard labor.

Changes in sexual attitudes and behavior during conflict can have long-term consequences for social norms. In a qualitative study from Northern Uganda, respondents claimed that conflict had undermined sexual morality—as evidenced by early sexual debut, forced marriage and involvement of young people in transactional relationships for needs beyond survival—and that elevated levels of these behaviors persisted in the postconflict period.³⁴ Likewise, focus group discussions with youth attending school in Liberia revealed the perception that transactional relationships had become widespread during the country’s civil war and remained common in the postconflict period. Such relationships were said to be frequently encouraged by parents and used as a means to secure material goods and school fees.³⁵ In contrast, young women in Sierra Leone who had used sex or "marriage" to survive and had given birth as a result were ostracized by their community at the end of the conflict, leaving them unable to earn a living or find a husband after the war.³⁶ For many young mothers who return home after a period of conflict, the inability to reintegrate into society, combined with a lack of formal skills or education, can constrain their access to resources, leaving sex work or informal transactional relationships as their main method of survival.

RISK AND PROTECTION

The literature highlights some of the complexities that arise in the context of conflict and that policymakers, humanitarian workers and others must negotiate when attempting to help young women navigate potential threats to their sexual and reproductive health. Some commonly cited frameworks of risk and protection regarding sexual and reproductive health may oversimplify how these processes work in contexts affected by conflict. Access to education is generally seen as a protective factor that reduces early marriage, yet in conflict situations school attendance may increase the risk of physical or sexual violence or abduction.³⁷ Similarly, camps for refugees and internally displaced persons are considered safe places, yet distribution of food and other essentials is often managed along traditional models through the male head of household,³⁸ leaving unaccompanied women or female-headed households highly vulnerable. And as noted earlier, families, communities, humanitarian workers and military personnel can be important sources of support and protection but also may increase the risk of survival sex, transactional sex, early marriage and even trafficking.^{10,22,33,35,39}

The diversity in the immediate and longer term impacts of armed conflict, even within a single country, bring into question presumed risk and protective factors. Although they are typically considered risk factors during times of stability and peace, early marriage and transactional sex may temporarily act as protective in some conflict situations by ensuring survival and reducing other negative sexual outcomes. Later on, however, those same actions can have long-lasting consequences, not only for sexual and reproductive health (e.g., pregnancy and childbirth) but also for acceptance in the community and future relationship formation. Risk and protective factors are not static, and their dynamic nature, and whether and how they serve to protect or increase risk, can only be understood when wider contexts are identified.^13–15 It is therefore important not just to look for a list of protective or risk factors related to negative sexual and reproductive health outcomes, but also to consider the processes of protection that take place and understand the trade-offs that young women and their families make. In some contexts, survival and protection may come at a price.

FURTHER IMPLICATIONS FOR PRACTICE

In conflict settings, early marriage and transactional sex may be seen as protective strategies or the only option for vulnerable young women and their families. Nonetheless, while such strategies might ensure survival in the short term, in the longer term they can have many consequences for women’s sexual and reproductive health. Recognizing that women’s actions may have been strategic during war is important for designing and implementing postconflict strategies that address the possible longer term consequences of these "decisions."

Generally, young women are portrayed as passive victims during periods of conflict,⁴⁰ yet the literature also describes agency and resilience in their actions—for example, through the use of their sexuality to bargain themselves into "domestic units" in the context of military groups.²⁴ However, often sexuality is used when few other choices and resources are available; consequently, these young women may not have true agency. Yet, however agency is understood, it is frequently considered pivotal in securing assets for protection, highlighting the degree to which power underpins the choices women make.^41,42 Practitioners working with young women in postconflict settings therefore need to draw from a strengths-based perspective to help young women develop strategies to protect themselves and improve their sexual and reproductive health.⁴³ This might mean mapping the resources available to these women—such as their assets, skills, support networks, knowledge (including things they learned during the conflict), aspirations, community resources and social capital—and developing a protection plan based on them. Recognizing agency and building on this recognition (even in relation to survival strategies) form a basis for developing empowering practices with young women.⁴⁴

In addition, young women do not have to cope alone. The protective resources that a community may possess, both during and after conflict, are not always recognized or appreciated, but can be found in people’s daily activities (and struggles) as they live together side by side.⁴⁵ Petchesky has argued for the need to reconnect individuals to new communities in times of insecurity, citing the example of Darfur, where "firewood patrols" have been set up by female leaders to protect women and girls from sexual assault when collecting wood. These groups have also become settings for the consideration and solving of common concerns.⁴⁶

Providing opportunities for action and connecting young women to each other appear to be important actions that facilitate the development of grassroots ­strategies—and access to resources—that can help support safe negotiations of sexual and reproductive health.⁴³ By remaining aware that communities may not only provide opportunities for young women but also create risks, practitioners can work to ensure that these new communities are as protective as possible for young women.

Those working in conflict situations need to recognize the interconnectedness of sexual and reproductive health with livelihoods, education, gender equality and human rights, as well as the role that other types of intervention can play in facilitating good sexual and reproductive health.^22,46,47 Mainstreaming efforts to protect young women and support safe sexual and reproductive health practices requires multidisciplinary and multilevel responses. Humanitarian responses tend to focus on meeting survival needs and often lack the capacity to address the causes of, or reasons for, vulnerability.¹¹ Prevention is also important; while health messages about the negative effects of transactional and unprotected sex have a role to play, providing economic opportunities that reduce poverty and insecurity are likely to be more effective in reducing the number of young women who engage in transactional sex.

In addition, practitioners must remember that some young women resort to risky sexual behaviors to keep themselves safe, and be ready to meet their immediate and ongoing sexual and reproductive health needs in any context. The range of services that young women might need to ensure their sexual and reproductive health is broad and includes services for family planning, maternal and child health, sexual abuse and the development of life skills (such as negotiation and communication skills). Without such wide-ranging and intensive support, it may not be possible to reduce the long-term negative sexual and reproductive health outcomes associated with early marriage and transactional sex.

CONCLUSIONS

Although early marriage and transactional sex may be detrimental to young women’s sexual and reproductive health in the short or long term, they are possible solutions to immediate threats to life and sexual security.³⁶ The examples provided in this short comment illustrate the need for practitioners to reject simplistic notions of risk and protection and to accept these concepts’ ­inherent complexities in relationship both to each other and to resilient outcomes. Events such as early marriage may act both to expose young women to and to protect them from certain risks, depending on the context and duration of those events.⁴⁸

In summary, it is clear that conflict can break down ­protective factors that might have been put into place to ­protect young women’s sexual and reproductive health, but also that one cannot assume that factors considered risky or protective in "normal" times will remain so in the context of conflict. However, there is little evidence documenting how young women in conflict-affected regions successfully negotiate their sexual and reproductive health without putting themselves at risk of poor sexual outcomes. Not enough is known about the difficult choices young women make when there are no safe options, or what might buffer the impact of the risks they take. Further research is needed on the protective factors that might alter the trajectory of risk exposure to poor sexual and reproductive health outcomes for young women affected by conflict.⁴² Such research should examine the trade-offs made by young women, their families and communities that affect sexual and reproductive health, as well as the price of protection. Work in these areas may aid in the development of better postconflict interventions that could support millions of young women around the world who have been put in a position where few, if any, "safe" sexual and reproductive health practices are possible. The role of postconflict care in mediating, buffering and reducing the longer term impact of exposure to such risks is therefore critical, although it is not clear whether empirically informed strategies for such an approach exist.