The Humanitarian Sexual and Reproductive Health response to adolescents living in post- disaster settings

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The Humanitarian Sexual and Reproductive

Health response to adolescents living in

post-disaster settings

Analysis of the humanitarian SRH response for adolescent in

Post-2015 Earthquake Nepal

Master Thesis Final Draft

Words Count: 27 975

In the

Faculty of Arts – University of Groningen, The Netherlands and

Faculty of Theology – University of Uppsala, Sweden

By Guillaume Pocard (S3528049/940919-T252)

Supervisor: Professor Ron Holzhacker Second Supervisor: Dr. Lars Lofquist

This thesis is submitted for obtaining the Master’s Degree in International Humanitarian Action. By submitting the thesis, the author certifies that the text is from his hand, does

not include the work of someone else unless clearly indicated, and that the thesis has been produced in accordance with proper academic practices

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Abstract

Over the past decades, extensive academic literature has been written on the adolescent transitional process as well as its sexual and reproductive health (SRH) component. However, there is limited information regarding the adolescent transitional process in post-disaster settings and the role of humanitarian actors on this crucial life stage transition. To tackle this academic gap, the following research aims to develop a “theoretical bridge” between literature on 1) adolescent psychology, 2) sexual and reproductive health humanitarian programming, as well as 3) globalization theories. To analyze the interaction between the three main topics, the academic paper is applying selected theories and concepts to a specific humanitarian crisis which is as follows: the post-2015 earthquake adolescent SRH situation in Nepal and its humanitarian response. Based on the selected case study, five International Non-Governmental Organisations (INGO) have been selected as research subjects to observe the impact of humanitarian programs on the adolescent transitional process in a post-disaster setting.

This following research highlights the existence of a standardized humanitarian SRH response promoting a globalized adolescent SRH identity among the local adolescent population. From the promotion of globalized SRH values to the rejection of traditional practices, humanitarian actors have profoundly shaped the sexual and reproductive behaviours of Nepalese adolescents. Overall, the following thesis contributes to analyzing the impact that humanitarian actors can have on the local population SRH as well as their role in the integration of local populations within a globalized system.

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Table of figures

Figure 1. Humanitarian space as consisting of humanitarian principles (Zwitter, 2018, p.107) ... 13

Figure 2. Response mechanisms for adolescents and youth's SRH needs (Pathak &Pokharel, 2012, p.139) ... 30

Figure 3.Adolescent Human Right Framework (UNFPA,2009) ... 42

Figure 4. Right Here Right Now Model of Change (Right Here Right Now, 2018b) ... 61

Figure 5. Restless Development Model of Change (Restless Development, 2019b) ... 61

Figure 6. Drawing activities during a SRH workshop conducted in Kathmandu with Restless Development (15th December 2018). ... 62

Figure 7. Introduction session to mental health for young boys. The training was conducted by psychologist who was using a specific humanitarian language (mixing acronyms and humanitarian vocabulary) (in Kathmandu, 15th December 2018 ... 63

Figure 8. Street Drama organized as part of IPAS SRH awareness campaign (Source: IPAS, 2015) ... 67

Figure 9. Screenshot of the Khuduli smartphone application, developed by UNFPA and the Chaudhary foundation (Source: Khuduli, 2019) ... 68

Figure 10. SRHR card game, designed by Restless Development (Source: Restless Development, 2018d) ... 73

Figure 11. Rupataran chapter about wet dreams (Module 15) (Source: Restless Development, 2016) ... 76

Figure 12. Right Here Right Now Facebook Post regarding their LGBTI SRH workshop (Right Here Right Now, 2018) ... 83

Figure 13. Average drop-out rate of students due to early marriage in sampled targeted schools (Restless Development 2018) ... 85

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Accronyms List

AFS – Adolescent Friendly Service

AIDS - Acquired Immunodeficiency Syndrome

CBO – Community Based Organisations

DFIF – Department For International Development

ECHO – European Civil protection and Humanitarian Aid

HIV - Human Immunodeficiency Viruses

HPV – Human Papillomavirus

ICS – International Citizen Service

INGO – International Non-Governmental Organisation

LGBTI – Lesbian Gay Bisexual Transsexual and Intersex

MEL – Monitoring, Evaluation and Learning

SRH – Sexual and Reproductive Health

SRHR – Sexual and Reproductive Health Rights

STI – Sexually Transmitted Disease

UN – United Nations

UNFPA – United Nations Population Fund

UNICEF - United Nations Children's Fund

USAID – United States Agency for International Development

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Introduction

“Adolescence is one of life’s fascinating and perhaps most complex stages, a time when young people take on new responsibilities and experiment with independence. […] When adolescents are supported and encouraged by caring adults, they thrive in unimaginable ways, becoming resourceful and contributing members of families and communities. Bursting with energy, curiosity and spirit that are not easily extinguished, young people have the potential to change negative societal patterns of behaviour and break cycles of violence and discrimination that pass from one generation to the next. With their creativity, energy and enthusiasm, young people can change the world in astonishing ways, making it a better place not only for themselves, but for everyone.” UNICEF - Adolescence: A Time That Matters (2002)

Despite the rainy season, the setting sun to the west was bright and illuminating the dusty streets of Katmandu where foreign tourists, merchants, cows and errands dogs were trying to avoid the pools of rainwater. It was a Friday night in Thamel, the heart of the Kathmandu’s nightlife and I was heading to a bar, to join my colleagues after a busy day at the NGO office. Around me, the bars and restaurants were full of young Nepalese people holding cocktails with one hand while eating Momo (Tibetan-style dumplings) with the other one. While I was waiting for my colleagues, I noticed a group of young women who were sitting next to me, taking selfies and posting pictures on Instagram. Speaking English, one of them was telling her friends about a date she had last night with a classmate. Rapidly, her friends got excited and started to interrogate her: “What is he doing?”, “Did you kiss him?”, “Is he sexy? Show me a picture!”.

This moment may seem insignificant for many of us. From Amsterdam to New York, informal discussions related to romance and sexuality are quite common. Over the past decades, the sexual liberation movement has profoundly reshaped the sexual and reproductive behaviours of western populations, especially the youngest generation. The changing social environment has allowed adolescents to openly discuss dating and sexual practices in Western societies. However, these daily-life situations as the one depicted above, have been mainly limited to western countries. That is why the emergence of an

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8 open SRH dialogue in developing countries such as Nepal is a ground-breaking dynamic. While limited to specific social groups (urban and middle class), the expansion of a global sexual liberation movement can deeply influence the adolescent identity process, especially in sensitive contexts such as post-disaster settings.

Thesis Problematic

Adolescence is indeed a crucial life stage where the individual is going through biological, intellectual and social changes based on the individual specific social and cultural context (social class, urban/rural settings, e.g.) (Thompson, 2006, p.21). Through adult roles models, social norms, existing structures as well as community groups (peer, religious, cultural, e.g.), the individual can build a specific sexual identity based on a set of norms, values and practices, heavily influenced by his/her environment. In the context of post-disaster settings, existing social structures are disrupted, leading adolescents to high-risk SRH situations which they are not prepared to deal with due to a lack of power, resource or knowledge: “Five million adolescents between the ages of 15 and 18 have unsafe abortions each year […]. Half of new HIV infections occur in 15-to-24-year old, and one-third of new cases of curable sexually transmitted infections (STIs) affected people younger than 25” (UNFPA, 2009, p.9). Nowadays, the majority of adolescent living in post-disaster settings have their SRH needs unmet for several reasons:

Lack of adequate SRH services

According to numerous INGOs (Plan International, Save the Children, Marie Stopes International), the majority of adolescents living in post-disaster settings have to face a lack of adequate SRH services due to structural, cultural and personal barriers (Outterson et al., 2008, p.6). Due to these three barriers categories, many adolescents do not have access to a wide range of SRH services such as contraception, HIV prevention testing, counselling, as well as the provision of HPV vaccines and safe abortion cares (Thompson, 2006, p.62).

On the other side, governmental actors, as well as INGOs, must also face several constraints. With significant financial and material resources lacks, it is difficult for SRH-services providers to organize tailored programs. Furthermore, most of the existing tools are focusing on a narrow field of humanitarian areas such as SHR, education for adolescent girls or livelihood (Ibid, p.64). Therefore, there is a growing need to address adolescent

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9 SRH issues through an intersectional approach, supported by in-depth background research.

Lack of information as well as existing gaps in existing academic literature.

To provide SRH services, research on the sexual and reproductive behaviours of adolescents living in post-disaster settings are required. However, there are research gaps in adolescent SRH, according to Darroch et al. (2016). Due to several factors (complicated research settings, funding gaps e.g.), there is a lack of information regarding vulnerable adolescent SRH such as young adolescent (10-14 years old), unmarried women, adolescent males as well as marginalized adolescents (street youth, Lesbian Gay Bisexual Transexual Intersex e.g.) (Darroch et al, 2006, p. 2). In several countries, there is insufficient information regarding stigmatized or illegal behaviours such as child-marriage or premarital sexual activities (Ibid, p.3).

Furthermore, if there is an extensive academic literature on adolescent psychology, adolescent SRH and child development, there is limited academic literature on adolescent SRH in humanitarian settings.

The lack of information, as well as poor data quality (non-sex/age-disaggregated information), can genuinely harm the efficiency of existing SRH adolescent programs (Thompson, 2006, p.62). Thus, due to a misperception of adolescent SRH needs, it can be difficult for INGOs to reach adolescent in post-disaster settings.

Underrepresentation of adolescent SRH programs in the humanitarian actor

Due to 1) a lack of appropriated program-delivery tools, 2) limited financial and material resources and, 3) sparse information/data, it is difficult for SRH-service providers to have access to vulnerable adolescent populations. Furthermore, the segmentation of the humanitarian sector is reinforcing the misrepresentation of adolescents. Because of the transitional nature of adolescence, teenagers are a boundary group at the border between children and adult’s humanitarian projects. While they are not considered “adult-enough” to be included within adult SRH programs, they have reached a life stage where they are not willing to participate in child activities (Thompson, 2006, p.63). As a transitional stage, adolescent SRH is at the intersection of several humanitarian programs; between adult and

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10 child programs as well as the intersection between education, sexual and reproductive right, health and livelihood domains.

Due to a lack of adequate services and information as well as an underrepresentation of adolescent SRH programs, there is a growing need to provide information regarding adolescent sexual and reproductive health in post-disaster settings. Based on a comprehensive and intersectional vision of the adolescent SRH situation, it would be possible to analyze major trends and dynamics, such as the role of globalization in the development of global sexual and reproductive behaviours.

Research Objectives

Due to the problems mentioned above, the following thesis will aim to:

• Analyze the impact of globalization on adolescent SRH in post-disaster settings as well as the contribution of the humanitarian response in the development of a global adolescent sexual identity through SRH programming in post-disaster settings. • Develop a “theoretical bridge” between academic literature on adolescent psychology,

sexual and reproductive health humanitarian programming, as well as globalization theories.

• Apply discussed theories and concepts within the following case study: The adolescent SRH situation in Nepal and its humanitarian response after the 2015 earthquake.

Through these research objectives, the following thesis aims to tackle existing gaps in the academic and humanitarian literature on Adolescent SRH situation in post-disaster settings. Through a new perspective on these research topics, the master thesis will allow humanitarian actors to have a better understanding of humanitarian SRH programs impact on the adolescent population in post-disaster settings. It will be an opportunity for aid agencies to be more aware of the global ideology conveyed by their SRH programs and how it is shaping their beneficiaries' behaviours and values.

Based on the existing problematics discussed above as well as research objectives, this master thesis is based on the following research question:

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To what extent, do INGO adolescent SRH programs influence the sexual and reproductive identity (norms, values, knowledge, behaviours, e.g.) of adolescent living in post-disaster settings?

In order to develop a comprehensive vision of the thesis topic, it is necessary to include the following sub-questions:

• Which globalized flows and actors play a role in the construction of the adolescent SRH identity, especially in post-disaster settings? To what extent, are INGOs SRH programs in post-disaster settings, influenced by globalized flows and actors?

• What impact, do natural disasters have on the adolescent SRH transitional process and local supportive structures?

• What is the humanitarian SRH response to a natural disaster? What SRH identity has been conveyed by INGOs as part of the humanitarian response?

• How has Nepalese adolescent SRH evolved following the 2015 earthquake? Which norms, values and behaviours have been adopted by local actors regarding adolescent SRH?

Based on this set of research questions, it will be possible to analyze the existing patterns and dynamics within the humanitarian sector regarding adolescent SRH programs. Furthermore, it will be an opportunity to analyze the role of globalization on the development of adolescent SRH behaviours in post-disaster settings as well as the contribution of INGOs within this global process.

Literature Review

As mentioned before, there are existing gaps regarding academic literature about SRH adolescent program in post-disaster settings. However, there is an extensive literature on globalization, adolescent sexual and reproductive health as well as the psychology construction of adolescent identity.

Based on preliminary academic researches, the concept of globalization emerged as a cornerstone principle which has an impact on the development of adolescent sexual and reproductive behaviours as well as adolescent SRH programming. Indeed, in both literature (adolescent sexuality and humanitarian SRH programming), the concept of globalization

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12 is frequently analyzed through different phenomena such as: the globalization of adolescent identity (Arnett, 2002; Demtrovics, 2012; de Souza, 2009), the expansion of normative values (Padilla, 2007; Appadurai 1996) or the standardization of humanitarian programs around the world (Ronald, 2010; Swiss, 2017; Böstrom and Hallström, 2010).

First, several authors, such as Appadurai or Arnett, analyzed the role of globalization in the development of global identities based on various cultural flows such as ideoscape or ethnoscape (Appadurai, 1996, p.31). These global identities are based on shared values and practices, reproduced by a group of individuals such as adolescent. According to Arnett, due to their psychological flexibility and keen interest for global media, adolescent around the world are developing common norms, values and behaviors (Arnett, 2002, p.776) which have an impact on their sexual and reproductive health around the world such as India (De Souza, 2009), Brazil (Padilla, 2007) or Nepal (Pathak and Pokharel, 2012). Furthermore, Padilla (2007) analyzed the impact of this new globalized SRH identity on traditional social structures such as the rejection of marriage based on economic convenient in Brazil or a new temporary conception of love in Mexico. This ideational transition also described by Pathak and Pokharel (2012) allows the development of specific SRH risky behaviours, which has been observed by several authors in Uganda (Maro et al., 2012) as well as Western European countries (Demtrovics, 2012, p.15).

Secondly, there is limited literature regarding adolescent SRH programming. Most of the related sources are UN agencies reports (UNICEF, 2018) as well as demographic surveys conducted by local governments. Only a few authors have studied the impact of adolescent humanitarian programs such as Hannah Thompson (2016) or Pokharel and Pathak (2012). Regarding adolescents in post-disaster settings, the majority of the academic literature focuses on the psychological impact of the disaster among adolescents. For example, Erika and al., has analyzed the development of psychiatric disorders among Puerto Rican adolescents following a natural disaster (Erika and al, 2011). Therefore, there is a lack of documentation regarding natural disaster impact on the sexual and reproductive health of adolescents.

On the other side, numerous authors have analyzed through a political science analytical lenses, the role of INGOs within a globalized political system (Lee et al., 2002) as well as

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13 their role of global counter-power to traditional international actors such as States (Bostrom & Hallstrom, 2010). Indeed, numerous authors have studied the professionalization of the humanitarian sector as well as the creation of a humanitarian space over the past decades. According to Zwitter (2018), humanitarian space can be described in several ways such as: “the operational space of humanitarian agencies necessary to meet humanitarian needs in accordance with the humanitarian principles” as well as “a product of the dynamic and complex interplay of political, military and legal actors, interests, institutions and processes” (Zwitter, 2018, p.103). Therefore, the humanitarian space is the operating environment where humanitarian actors are implementing programs to cover the needs of the beneficiaries while respecting donors’ requirements.

As described below (figure 1), humanitarian actors are playing an intermediary role between the local population needs and global requirements from international donors. Delimited by humanitarian principles such as impartiality, independence and neutrality (from the XXth International Conference of the Vienna Red Cross, 1965), humanitarian actors are working in a regulated zone, called the “humanitarian space.” The implementation of humanitarian space and its impact on the local population have been studied by several authors such as Petras and Veltmeyers (2005). According to the authors, the normative framework of the humanitarian space is fundamentally influenced by the Western neo-liberal ideology. Smith (1999) also argues that the emergence of global humanitarian space has been possible due to the creation of global norms and standards such as the Sphere Standards or Core Humanitarian Standards.

Figure 1. Humanitarian space as consisting of humanitarian principles (Zwitter, 2018, p.107)

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14 Aziz Choudry and Dip Kapoor (2013) have also analyzed the standardization of the humanitarian sector as part of a global phenomenon, called the NGOization process. According to the authors, successive humanitarian crises such as Kosovo in 1998 and Rwanda in 1994 have profoundly shaped the humanitarian sector. With UN reforms (UN Resolution 46/182), the creation of humanitarian coordination agencies (OCHA, e.g.) and the development of humanitarian norms, the authors described an NGOization phenomenon, composed of an institutionalization and professionalization process (Choudry & Kapoor, 2013, p.16). According to Zwitter:

“The professionalization of aid can be attributed to the increasing awareness of the humanitarian community, and other stakeholders that aid is not intrinsically beneficial because of the well-attention motivation underlying that when conducted unprofessionally it may result in negative (albeit unintended) consequences” (Zwitter, 2018, 111).

As described by David Rieff, in A Bed of the Night: Humanitarianism in Crisis (2002), humanitarian crises such as Bosnia in 2002 or Afghanistan in 2001 have swung the spotlight onto humanitarian actors and their works in sensitive settings (post-disaster or conflict settings). According to Zwitter, humanitarian actors have to currently work under pressure to effectively implement programs according to UN agencies and donors’ requirements (Zwitter, 2019, p.110). Through the incorporation of accountability-related concepts, such as collateral damage, long-time impacts as well as gender equality or cultural appropriateness; the humanitarian community has become a professional sector, regulated by specific norms (Ibid). This set of existing standards is coupled with a regular program management cycle, composed of seven stages (assessment, planning, implementation, monitoring, reporting, audit and evaluation) according to Pennink and Herold (2018).

On the other side, Ronalds (2010) has analyzed the contribution of global flows to the professionalization of the humanitarian sector. Due to the increased interdependency between countries, the author argues that three main global issues have particularly played a role in the emergence of INGO as globalized entities: 1) security threat (including natural disaster), 2) economic transactions and 3) migration flows (Ronalds, 2010, p.17). With the emergence of global security threats such as terrorism and global warming, international aid has been an opportunity for developed countries to prevent and mitigate humanitarian crises in developing countries. This dynamic has been depicted by David Rieff, for the

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15 1991 Kosovo UN intervention. According to Rieff, increased cooperation between humanitarian actors and military forces has allowed Western governments to reach their geopolitical goals through humanitarian action (“winning hearts and minds” strategy) (Rieff, 2003).

Since the 1970s, financial support to humanitarian organizations has significantly increased with the creation of government funding agencies such as USAID in 1961 (United States Agency for International Development) or ECHO in 1992 (European Civil Protection and Humanitarian Aid Office). According to Zwi and al (2002, p.142), the increased number of funding actors have supported the professionalization of the humanitarian sector. However, with the development of a humanitarian industry, a relationship of dependency has emerged between humanitarian actors and funding actors (Ibid, p.145). Depending on donors’ contributions, INGOs have to adapt their programs according to the donor’s requirements. Therefore, governmental policies can profoundly impact the funding cycle of humanitarian programs based on governmental political standings — another factor described by Zwi and all. , is the impact of mass media on the humanitarian sector. According to the authors, media coverage is playing a crucial role in the mobilization of financial and material resource in case of humanitarian crisis (Ibid, p.143). Due to media volatility, humanitarian actors need to quickly adapt their programs or/and implement projects to get funds where humanitarian crises are under media coverage. Therefore, the emergence of conflict or natural disasters can be followed by a large-scale humanitarian response or not, depending on the international media coverage (Ibid, p.141).

According to Gumucio-Castellon (2018), there has been limited academic literature on humanitarian emergency response in post-disaster settings. Over the past decades, anthropologists have instead studied the impact of development projects on the affected population. Since the 1980s, development has been indeed a key-concept in the anthropology field through ethnographic studies as well as theoretical analyses and reflections (Gumucio-Castellon, 2018, p.388). On the other side, humanitarian action has received little scrutiny from anthropologist for several reasons. Despite, limited literature on the topic, several authors such as Hyder or Minn have developed in-depth critics against the implementation of humanitarian programs in post-disaster settings.

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16 First of all, many scholars have criticized the inability of the humanitarian sector to fully close the program management and their tendency to develop aid dependency among the local population. According to Hyder (2007), humanitarian responses in several post-disaster settings have been unable to move forward into a rehabilitation and development stages. Gumucio-Castellon has studied the case of the Javanese Mudflow in 2018 as well as the 2010 Haitian Earthquake where the humanitarian actor’s inability to close the emergency response phase had negative impacts on the local society (Gumucio-Castellon, 2018, p.388). Therefore, the humanitarian response in post-disaster settings frequently failed to restore livelihood, support local social structure or improve the national economy (Hyder, 2007).

In a second part, the systematic overlapping between humanitarian, reconstruction and development programs has been perceived by many scholars as a significant obstacle to understanding the impact of the humanitarian response fully. According to Minn (2007):

“While development and humanitarian assistance are two distinct phenomena, they are not without significant overlap. Much of the activities described as “development” (improving the lives of impoverished populations through education, health care, agriculture, etc.) can be (and often) glossed as humanitarian activities, and vice-versa. In addition, both development and humanitarian projects, despite the differences, entail relationships between individuals and institutions in wealthy and impoverished countries and have developed sizable infrastructure to facilitate these relationships and the processes that emerge from them” (Minn, in Gumucio-Castellon, 2018, p.389).

As highlighted by Minn, we observe over time a strong convergence between humanitarian and development programs in post-disaster settings. These two intertwined domains have a significant impact on the local population through the implementation of a wide range of activities. Due to the implementation of humanitarian/development programs in complicated post-disaster settings, anthropologists have to rely heavily on a communicative and holistic conception of culture to analyze the impact of humanitarian/development actors on the local population (Gumucio-Castellon, 2018, p.389). According to Gumucio-Castellon, it is necessary to develop a holistic approach regarding the concept of culture to consider fully:

“The implication of social structures, various classification, symbolic systems and other cognitive domains, as well as the constraints and possibilities of local material and economic conditions” (Gumucio-Castellon, 2018, p.390)

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17 Through a holistic anthropological approach, it will be possible for the researcher to analyze the impact of humanitarian programs as well as its cultural appropriateness. Indeed, several authors have highlighted the wide gap which can exist between the local population needs and implemented humanitarian programs. For example, O’Neil (2015), have analyzed the humanitarian response in the Nicobar Islands, following the tsunami of 2004. During his fieldwork, the author realizes that the humanitarian agencies did not take into account the social structural patterns of the Nicobarese culture, which is based on extended family structures (O’Neil, 2015, p.34). Instead, humanitarian actors have built 700 “modern” temporary houses for nuclear family structures. Therefore, O’Neil’s article highlights the cultural gap which potentially exists between humanitarian agencies and the local population living post-disaster settings. Indeed, Western donors heavily influence INGOs working in humanitarian space through funding requirements. However, western donors’ perception of humanitarian aid can profoundly diverge from the needs/social construction of the local population. Therefore, there is a risk for humanitarian agencies to convey western values among beneficiaries in post-disaster settings.

At least, there is another source of misunderstanding existing between anthropologists and aid workers regarding humanitarian response in post-disaster settings. According to Gumucio-Castellon, both sides have a different approach toward the local population. On one side, one of the most fundamental principles of the humanitarian sector is the existence of collective, universal human moral community composed of: “individuals capable of free communication and its principle, able to interact and collaborate according to rules of mutual respect” (Gumucio-Castellon, 2018, p.392). Therefore, the humanitarian community convey a global identity based on the fundamental principle, such as respect or humanity. On the other side, anthropologists emphasize the uniqueness of human social structures and dynamics existing in each culture. Several authors, such as Gumucio-Castellon, claim that the humanitarian sector is an inter-cultural domain where global aid workers are implementing programs among vulnerable populations in a specific cultural setting, disturbed by a natural or human-made disaster.

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18 Furthermore, several authors, such as Gumucio-Castellon or Reiffers (2018) have been critical regarding the universal principles of the humanitarian community. Indeed, if aid workers claimed to belong to a universal moral community, beneficiaries should be included in the humanitarian decision-making process instead of being its passive recipients. Indeed, Reiffers (2018) has analyzed forced migration flows (including disaster-induced displacement) as well as its humanitarian response from an anthropological perspective. The author argues that several factors, such as political-economic context or the displace perspective, should be considered by humanitarian actors to fully understand how forced migration flow can influence the identity and needs of the displaced population. While analyzing the case of Bhutanese refugees in Nepal, Reiffers highlights the necessity for aid agencies to develop grassroots initiatives reflecting the needs of local communities. According to Reiffers:

“An anthropological perspective of the humanitarian sector stressed that decisions on aid should be more often be placed in the hands of aid recipients, in consultation with beneficiaries, instead of decisions about them […]. Ethnographic research and views can support people in getting back to managing their lives again. Anthropologists and affected people can provide a view of the situation and their perspective of people in humanitarian settings, which is of paramount importance for the appropriate design and implementation of any humanitarian intervention” (Reiffers, 2018, p.383).

Therefore, anthropological theories can significantly contribute to the humanitarian sector, especially regarding adolescent sexual and reproductive health in post-disaster settings. As anthropology have a long history of analyzing the intricacies of socio-cultural patterns, anthropology literature can allow aid workers to fully understand the impact of their SRH programs on vulnerable populations such as adolescents. Through an anthropological analytical lens, it will be possible to analyze humanitarian SRH programs in post-disaster settings deeply. It is an opportunity to observe dynamics existing between the aid agencies, donors and beneficiaries as well as the resultant interaction between globalized and local social constructions.

Methodology and Research Set-up

To understand the current dynamics around adolescent SRH programs in Nepal, as well as the globalization of adolescent SRH behaviours, the ontological orientation of this thesis, will be a social constructionist approach. Due to the complexity of sexuality, reproductive health, and adolescence, it is necessary to include different realities and perspectives

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19 through the application of social-constructionist theories developed by various authors such as Appadurai (1996), Anderson (1983) and Bakhtin (1895).

Moreover, I decided to choose a flexible design which can be advantageous for my topic. (Robson, 2016, p.147). A flexible design could be described as a research approach which focuses on an original idea and let relationships and causality links emerge along the research process (Ibid). Through a specific case study (humanitarian sexual and reproductive health programs for adolescents in Nepal after the 2015 earthquake), I tried to analyze the main patterns and dynamics within this specific context (cultural and social context). Moreover, it is crucial to emphasize the cultural norms existing regarding sexuality and adolescence within the local population as well as INGOs.

Through a social constructionist approach, this thesis aims to analyze the interactions between the main variables of my thesis topic. Based on my thesis topic, it seems that the globalization of adolescent sexual and reproductive practices is the independent variable which profoundly influences adolescent SRH programming as well as adolescents living in humanitarian settings.

Case Study Research Set-up:

To observe the current dynamics around humanitarian adolescent SRH programs, a specific case study has been selected for the following thesis. Through a case study, it would be possible to apply the thesis theoretical framework within the following specific context: INGO sexual and reproductive health programs for adolescents in Nepal after the 2015-earthquake.

The case study is based on a comparative study of several INGOs’ adolescent SRH programs in Nepal. In total, 5 INGOs have been selected for the thesis case study: Plan International, Restless Development, Save the Children, Rutgers, Marie Stopes Foundation.

1) Restless Development

Founded in 1985, Restless Development is a global agency for youth-led development. With ten hubs around the world (Nepal, India, Zimbabwe, South Africa, Sierra Leone, e.g.). Since 1991, Restless Development has been working with youth people in 45 of the 71

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20 administrative districts of Nepal. Over time, Restless Development has been delivering eight programs related to the sexual rights of girls and women, youth leadership, marginalized communities and LGBTI related issues. (Restless Development, 2018)

2) Save the Children

Save the Children is an INGO which has been operating in Nepal since 1976. Based on the National Plan of Action for Children and the UN Millennium Development Goals, Save the Children is working with over 100 partners in 63 districts of Nepal with programs related to child rights governance, child protection, education and livelihood (Save the Children, 2017). Regarding adolescent sexual and reproductive health program, Save the Children is promoting the use of family planning services and develops adolescent-friendly health services in Nepal. Also, the NGO has implemented a youth SRH awareness campaign through education, information material, counselling and behavioural changes programs.

3)Marie Stopes International

Founded in 1976, Marie Stopes International is an INGO promoting sexual and reproductive rights around the world. With projects implemented in 38 countries, Marie Stopes International has mainly developed health projects related to abortion, contraception and family planning services (Marie Stopes International, 2018).

In Nepal, Marie Stopes has been developing family planning services, including educative activities as well as providing short- and long-term contraception methods (Ibid). Moreover, they have conducted awareness campaigns related to sexual and reproductive rights of vulnerable populations such as women and youth.

4) Rutgers: Right Here Right Now Program

Rutgers is an aid agency, focusing on SRH issues as well as gender equality and gender-based violence. As part of their global strategy, they have developed an international project called, “Right Here Right Now”, which is a five-year program aiming: “to create a world where everyone is able to access quality and youth-friendly health services, and no one is afraid to express who they are and whom they love openly” (Rutgers, 2019). Through

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21 a consortium of eight organizations, Rutgers’ program focuses on strengthening development cooperation across national, regional and international levels in order to implement long-term advocacy actions in developing countries.

In Nepal, the Right Here Right Now network has actively participated in capacity strengthening programs for young people and CSOs as well as advocacy initiatives in order to improve Nepalese SRH legislation, especially regarding LGBTI SRH rights(Right Here Right Now, 2018).

5)Plan International

Founded in 1937, Plan International is an INGO implementing child-related (education, psychosocial support, health, e.g.) as well as gender-equality programs. Plan International has been working in Nepal since 1978, supporting marginalized children and their communities through education, nutrition and health projects (Plan International, 2016). Currently, the organization is running direct programs in 8 districts and works through partners in 42 districts.

To collect data from the selected INGOs, several data collection methods have been used for six months while I was working as a MEL intern at Restless Development, in Kathmandu.

Data collection methods:

As mentioned before, the ontological orientation of this thesis is a social constructionist approach. Due to the complexity of sexuality, reproductive health, and adolescence, it is necessary to include different realities and cultural perspectives. From the Nepalese adolescent perspective to the social reality of aid workers, it is essential to emphasize adolescent sexuality as a socially constructed idea which has different connotations within the humanitarian domain due to global and local dynamics.

Based on flexible design and social constructionist approach, this thesis research is using qualitative data collection technics such as participant observations or documents analysis. Indeed, qualitative methods allow the researcher to focus on meanings and the crucial role of context for the research participants.

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22 Moreover, due to the contextual complexity of the thesis topic, it was not possible to apply in laboratory settings. Therefore, my internship with Restless Development in Nepal has been an opportunity to collect primary data among targeted respondents directly. According to Colin Robson (2016), the qualitative approach emphasizes that “the social world is viewed as a creation of the people involved.”(Robson, 2016, p 29).

Therefore, various data collection methods have been used depending on the following levels of analysis.

Macro-level:

Document Analysis:

At the macro level, literature from aid agencies (UNICEF, Nepalese governmental institutions, humanitarian think tank, NGOs, e.g.) has been analyzed to study the key actor’s perceptions on SRH issues in Nepal. Keywords such as “adolescent,” “youth sexuality,” “sexual and reproductive health,” “Nepal,” “Kathmandu,” “Globalization” and “Sexual and reproductive health program” were used to limit the document analysis process.

In the context of a comparative analysis of selected INGOs SRH programs, the focus was put on the literature from the selected NGOs (Restless Development, Save the Children, Right Here Right Now, Plan International and Marie Stopes International). Based on a comprehensive selection of reports, surveys, toolkits and public statement redacted by the INGOs, it was possible to distinguish patterns which have emerged during the coding process.

Systematic Literature Review:

For the thesis research, academic and non-profit database (Relief web, ALNAP) have been used to find relevant academic articles related to the research topic. Keywords described above have also been used on these electronic databases.

To analyze the data collected from the systematic literature review, a qualitative meta-synthesis was done. Through a qualitative meta-meta-synthesis, it was possible to distinguish the

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23 central concepts, lines of arguments and existing debates regarding youth SRH programs in Nepal as well as the impact of globalization of Nepalese adolescent SRH behaviours.

Meso-Level:

In addition to macro-level data collection methods, I had the opportunity to collect primary data in Nepal while interning with Restless Development, between August 2018 and January 2019. As an Evaluation and Monitoring (M&E) intern, I was supporting the M&E cycle of Restless Development projects such as the Colors of Rainbow program (Organizational capacity enhancement project for local LGBTI NGOs) or the ICS program (youth-led livelihood project).

Working for several months in an INGO in Kathmandu, was an instructive opportunity for me to observe internal dynamics related to my thesis research. However, due to internship contract confidentiality clauses, limited information from the internship period can be shared in this thesis. Therefore, primary data collected during the internship are limited to participant observations during external events or meetings with Restless Development staff members.

Participant Observation

Seven participant observation sessions have also been conducted in various settings with targeted populations. Due to the internship with Restless Development MEL, I had the opportunity to assist in several meetings with various actors such as rural adolescent groups, LGBTI CBOs, INGO staff as well as local partners. Trough participant observations, I have been able to analyze “nonverbal expression of feelings, determine who interacts with whom, grasp how participants communicate with each other and check for how much time is spent on various activities” (Kawulich, 2005). Based on three primary elements (place, actor, and activities), the research has been able to identify the social situation and analyzes dynamics, which has been useful for the thesis. Moreover, it has been essential for the researcher to analyze also non-material information such as the atmosphere as well as its feelings during the observation session (see Annex).

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24

Coding and Analysis

Following the collection of data in the field, the coding process has started to develop a comprehensive analysis. In the context of the research topic, the research analysis has been based on the iterative inductive approach (Ibid, p.178) According to O’Reilly (2005), the iterative inductive approach can be described as an analytical journey. While the research is collecting data, categories and theories are continuously emerging based on the data collected. The categorization process has been possible through thematic coding analysis, which allowed the researcher to categorize data based on broad and inclusive categories. These categories have been redefined during the analytical process.

Ethical concerns and potential barriers

In every step of this research, it was necessary to consider a post-positivist approach. According to the post-positive view of research, it is necessary to consider contextual factors (researcher personal background, local context) as well as possible power relation which can exist while researching on the field (Colin, 2016, p.25). Therefore, facts and evidence are considered as imperfect and fallible information’s which should be interpreted carefully. With sensitive topics such as youth sexuality, it is necessary to develop a strict code of conduct which defines the research behaviour.

Ethical guidelines

Firstly, it was necessary to define clear academic boundaries based on Wayne ethical framework (2016). As a researcher, I did not plagiarize, misreport resources, inventing data or conceal objections (Wayne, 2016, p.272). These academic ethical limits have been developed according to the University of Groningen guideline regarding ethical research behaviours.

On the second part, it was necessary to make ethical choices while collecting data on the field and be aware of the researcher’s pre-conceived ideas and possible impacts on the local population. For example, it was necessary to be fully aware of the local context, dynamics and guaranteed the anonymity of the respondents through coded names and clear communication.

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25 Thirdly, it was crucial to develop a clear channel of communication with Restless Development regarding the following thesis and confidentiality issues. As mentioned before, I was doing an internship with Restless Development at the MEL unit, between August 2018 and January 2019. This internship was an opportunity to collect primary data regarding Restless Development SRH programming approach. Therefore, I have a clear and open dialogue with the internship supervisor regarding the thesis topic, objectives and interests.

At least, based on the thesis topic, the main research population is the Nepalese adolescent population. However, it is necessary to follow a specific ethical protocol while researching on non-adult respondents. During my internship, I had the opportunity to interact with Nepalese adolescents to better understand their perception of INGOs’ SRH programs. To conduct observation sessions among adolescents, I had to follow specific ethical rules designed by Restless Development. From the adolescent parents’ formal agreement to the interdiction of taking any pictures of the adolescents, I have followed a specific ethical process to preserve the INGO beneficiaries’ confidentiality. The ethical protocol has been explained to me by my internship supervisor after my arrival in Nepal during our induction meeting.

Main Research Challenges

Finally, during the data collection process, I had to overcome several challenges. First, due to practical reasons (schedule issues, logistic problem and lack of access), it was complicated to collect primary data from other aid agencies than Restless Development. To learn about their SRH programs, I had to collect secondary data through their online resources, for example.

Secondary, due to the language barrier and local cultural context, it was difficult sometime to collect information among Nepalese adolescent regarding sensitive topics such as sexuality and reproductive health. Thus, I had to find alternative ways to collect primary/secondary data such as observation sessions or indirect testimonies, conducted by CBOs or local journalists (Sherpa, 2018). Furthermore, based on logistic and linguistic barriers, it was challenging to collect data among adolescents living in rural areas of Nepal.

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26 Therefore, it is essential to consider that most of the primary data have been collected among adolescents living in urban areas such as Kathmandu Valley.

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From globalization to post-disaster settings: the evolution of adolescent

SRH and its humanitarian response

The following thesis research is analyzing the impact of humanitarian programs on adolescent sexual and reproductive behaviours in post-disaster settings. As an initial step, an overview of the existing literature, regarding 1) globalization, 2) adolescent identity as well as 3) sexual and reproductive programs in post-disaster settings, is necessary. Based on the development of a comprehensive conceptual framework and in-depth analysis of the thesis concepts, it will be possible to study the role of INGOs as globalized actors promoting specific SRH values and behaviours among adolescent in post-disaster settings.

Chapter 1: The globalization of adolescent sexual and reproductive

health behaviours and its impact on adolescent living in post-disaster

settings.

The impact of globalization on the adolescent identity development: From globalized identity to personal narrative construction

With the development of innovative communication technologies as well as increased international flows of people and resources, general rupture regarding intersocietal relations is currently happening. Reshaped by mass media and communication platforms, our way to interact with the world has profoundly changed over time. With increased intercultural dialogue, we have developed new ways to think, communicate as well as perceive our social environment. Through these new flows, individuals are building a shared modern subjectivity, based on new ways to imagine ourselves and our environment (Appadurai, 1996, 31). Through new technologies, migration and mass media, individuals are participating in the development of global identities, called “work of imagination,” where groups of people are starting to feel and imagine collectively based on the same set of values and behaviours (Ibid, p.32). In a way, it can be argued that Appadurai is developing a globalized version of Anderson’s concept of imagined community (1983). According to Anderson, imagination has become a set of common social practices, involving individuals from different cultural settings (Ibid, p.33)., These “imagined

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28 worlds” are the fruit of numerous actors constantly interacting at the global, regional and local levels:

“They are deeply perspectival constructions influenced by the historical, linguistic and political situatedness of different sorts of actors: nation-states, multinationals, diasporic communities as well as subnational groupings […] and even intimate face-to-face groups such as villages, neighbourhood and families”. (Appadurai, 1996, p.33)

Therefore, imagined worlds are fluid and complex global identities, involving a wide range of actors (states, NGOs or local communities, e.g.), that individuals can join and reproduce in their local environment. However, there is a constant struggle between local cultural heterogenization and global homogenization within these imagined worlds, which can reshape the individual identity and behaviours (Ibid, p.35).

Regarding the global homogenization process, several global flows are supporting the dissemination of common behaviours, norms and values around the world. According to Appadurai, there are five global flow categories, supporting the construction of globalized identities: ethnoscape (flow of people), financescape (financial flows), technoscape (flow of technologies), mediascape (mediatic flows) and ideoscape (ideological flows) (Padilla, 2007, 10). As norms and values are crucial components of individual identity, ideoscape flows are having an essential role in the development of global identities. From institutional ideologies to alternative movements, these various flows of shared ideas are deeply shaping the construction of global identities through the development of normative frameworks. According to Appadurai, the Enlightenment values (freedom, welfare, rights, sovereignty, self-representation and democracy, e.g.) have been particularly emphasized over the past decades through institutional actors (US government, UN agencies) and mass media (Appadurai, 1996, p36). Through these ideological flows, several global identities have been incorporating these values and adapting them in diverse cultural settings:

“Nor this is just a matter of Third World people reacting to American media, but it is equally true of people throughout the world reacting to their own national electronic media.” (Appadurai, 1996, p.7)

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29 In other words, global identities, shaped by these various flows, are promoting a specific set of values and behaviours, which are thus incorporated by individuals in their daily interactions with their local surroundings.

At the personal level, individuals are incorporating these global identities to their existing set of norms, behaviours and values which they have developed at different stages of their life, such as the adolescence stage. Based on these different influences, the individual is developing its self-narrative, which is the cornerstone of its identity (Skinner et al., 2001, p.2). According to Bakhtin, the individual is going through a dialectic process where he/she is appropriated different narratives/languages from various imagined worlds. The past meanings and intentions of each imagined worlds are thus merged to create the individual subjective language shaped by its intentions. According to Bakhtin:

“In essence, the language, as a living social-ideological entity, as a heteroglossia standpoint (mnenie) lies for the individual consciousness on the border of the own (svoe) and the foreign (chuzhoe). The world in language is half-foreign. It becomes one’s ‘own’ only when the speaker populates it with his own meaningful (smyslovoi) and expressive tendency” (Skinner et al., 2001, p.2)

As a member of a broader global community, the individual is integrating a collective language in order to communicate its intentions. For example, it is possible for an adolescent to express its sexual identity based on a specific language incorporating concepts and vocabulary from different social groups such as its ethnic, religious group or global online community for example. Therefore, an individual narrative could be described as heteroglossia; a combination of various languages (social, religious, professional, generational, e.g.) which are potentially engaged in opposition or struggles (Ibid, p.5).

As we will see in the following section, the opposition of several internal languages is particularly prominent during the adolescent stage, where the individual is developing its own identity at various levels (societal, sexual, social, gender, e.g.). Due to the globalization, this identity struggle has now taken on an entirely new dimension with the emerging struggle between local heterogenized youth perspectives and a global homogenized adolescent identity.

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The emergence of a new globalized adolescent identity: Impact on the adolescent identity construction process and sexual health and reproductive behaviours.

Before discussing the impact of globalization on the adolescent identity construction process, it is necessary to define the concept of adolescence.

Adolescence can be defined as a biological and physiological changes process. It is a life stage where the individual develops experimental behaviours and constructs its self-identity (Pathak & Pokharel, 2012, p. 138). The construction of this self-self-identity mainly depends on socio-cultural norms, surroundings social structures (family, peers, community, state, e.g.) as well as existing role models (gender roles, e.g.). The surrounding social environment is especially playing a significant role in the adolescent sexual and reproductive behaviors developments. As depicted below, numerous factors such as gender, culture or social and economic environment are supporting the development of specific SRH behaviours instead of others.

Figure 2. Response mechanisms for adolescents and youth's SRH needs (Pathak &Pokharel, 2012, p.139) Therefore, during this critical life stage, composed of fundamental changes, the adolescent transition is deeply shaped by its surrounding environment (Pathak & Pokharel, 2012, p.138). Indeed, according to Plan International: “Adolescence may be characterized as a series of interconnected biological or physical, intellectual (including cognitive), emotional (including psychological), behavioural or social changes that take place in a child’s life.” (Thompson, 2016,

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31 p.20). Therefore, the adolescent process can be depicted by numerous empirical changes (biological, psychological, e.g.).

Beyond general observation, it is necessary to emphasize that adolescence is, first of all, a socio-cultural transitional stage. Indeed, fundamental cultural structures (institution, family, peers, individuals, communities, e.g.) have a significant impact on the development of the adolescent identity. According to Arnett, it is, therefore, necessary to distinguish different adolescence experiences which profoundly differs between cultures (Arnett, 2010, p.263).

The difficulty in delimiting a universal age bracket, defining adolescence or youth, is a striking example of the fundamental cultural nature of adolescence. Indeed, there is no consensus for a global age-range for adolescence. From ECHO (13-25 years old) to UNICEF (10-19 years old) and DFID (10-18 years old), each international actor has a specific age-range. On the other side, Plan International has developed nine adolescence age-brackets, depending on its country programmes (Thompson, 2016, p.18). Despite the multiplicity of adolescence experiences, we can observe a homogenization of the adolescent identity around the world due to globalization.

Even if the relationship between adolescence and globalization has been discussed before by scholars, since the early 2000s, it became a growing issue among international actors as well as academics. In 2003, the UN general assembly adopted the 58/133 resolution regarding policies and programmes involving youth. In the resolution’s article 3, the General Assembly described for the first time, the impact of globalization on young men and women as a rising concern. The key document underpinning the relationship between adolescence and globalization is the “2003 World Youth Report”, conducted by the United Nations. According to the United Nations, we can currently observe new dynamics influencing the adolescent transitional process. Due to the interconnectedness nature of the globalized system, adolescents are nowadays synthesizing global and local socio-cultural components (UN, 2003, p.285). In the past decades, the UN noted an intensification of worldwide communication, allowing different local realities to influence each other (Ibid, p.290).

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32 Therefore, global interconnection has been shaping adolescent behaviours. Based on new flows of consumption, adolescents are nowadays developing similar social behaviours at the intersection between local/global culture. According to the UN report, the adolescents are building their own “individual landscape” (Ibid, p.299), like a third space, mixing various cultural influences. This new adolescent hybrid culture is based on the de-territorialization of their identity. Indeed, due to globalization, adolescents are developing a transboundary identity based on shared norms and values. Furthermore, socio-economic dynamics, such as the middle-class emergence in developing countries, are having a severe impact on the growing expansion of this global adolescent identity.

Beyond international agencies, the impact of globalization on the development of adolescent identity has deeply interested several authors such as Jensen Arnett (2002), who analyzed the psychological influence of globalization on issues of identity. According to Arnett, adolescents are playing a pivotal role in the globalization process. As a new economic target (labelled as “global teens”), teenagers are developing similar consumptions trends around the world (Arnett, 2002, p.775). According to the author, the transitional nature of adolescence plays a pivotal role in their interaction with globalization:

“Unlike children, adolescent have enough maturity and autonomy to pursue information and experience outside the confines of their families. Unlike adults, they are not yet committed to a definite way of life and have not yet developed ingrained habits of beliefs and behaviour; they are more open to what is new and unusual” (Arnett, 2002, p. 774).

Due to their psychological flexibility, adolescents are more sensitive to the globalization, thus more inclined to develop changes in beliefs and behaviours (Ibid, p.774). Furthermore, socio-economic changes such as access to education and new technologies are reinforcing the dissemination of a global adolescent model, called “emerging adulthood” (Ibid, p.779). Already existing in OECD countries (Japan, EU, United States, Canada, e.g.), the emerging adulthood model is expanding through the growth of the middle-class archetype in developing countries. Indeed, according to Saraswathi and Larson (2002), “In many ways, the lives of middle-class youth in India, South-East Asia and Europe have more in common with each other than they do with those of poor youth in their own countries” (Saraswathi & Larson, 2002, p.334). Through the expansion of global flows and the emergence of international consumption trends, middle-class adolescent all around the world is consuming identical

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33 cultural products. Over time, based on similar consumptions practices, middle-class adolescents from different countries are sharing a similar identity while the gap is widening between adolescents from various socio-economic groups within the same country. Despite the increased global interconnection, peripheric populations (rural or poor adolescents) do not have access to these consumption flows due to various barriers (geographic, economic, social or political). Therefore, it is crucial to highlight the role of socio-economic and geographic factors which can profoundly influence the expansion of the emerging adulthood model (which can potentially overcome by external actors such as humanitarian agencies).

The emerging adulthood model could be described as a global adolescent model composed of the following components: 1) identity exploration (developing crucial choices regarding sentimental and professional life), 2) instability (frequent changes, tension with close family), 3) focus transition (reduced family obligation, development of self-expression), 4)feeling in-between (between adulthood and childhood) as well as 5) new ranges of possibilities (professional opportunities, new life choices, e.g.) (Arnett, 2010, p.263). Therefore, the emerging adulthood model depicts adolescent as a life stage of expression where the individual can experiment through new behaviours. This self-exploration stage is particularly explicit in the case of the sexual and reproductive health with the rejection of traditional sexual practices considered as restrictive and backwards:

“Rate of premarital sex and pregnancy are rising as the traditional system of sexual control through initiation rites, chaperones and folklores lose their relevance in the eyes of young. This problem is sometimes blamed on the introduction of Western media, with their relentless sexual stimulation” (Arnett, 2002, p.776).

Thus, as a global product, the emerging adulthood model is also a source of tension where global concepts collided with traditional cultural values.

According to several authors (Arnett, 2002; Padilla, 2007), there are several fundamental values which are conveyed by the emerging adulthood model: 1) romantic love should be the basis of marriage, 2) self-sufficiency should be attained before reaching adulthood, 3) work should be an expression of identity and 4) adolescent should be a time of self-reflection and leisure.

The Humanitarian Sexual and Reproductive Health response to adolescents living in post- disaster settings