We now turn to discuss the key findings, beginning with a review of the gendered health vulnerabilities facing adolescent girls and boys, then moving on to discuss their experiences of service provision and uptake.
Health awareness and gender norms
Our findings indicate that adolescents in Gaza have limited access to information about health or healthy lifestyles. For boys, their main source of knowledge was friends (50%), followed by books (31%) and teachers (14%). None of the participants mentioned health care providers as a source of information [10]. School health programs do exist, but these are limited in scope and focus on children younger than 10 years. In many schools, sports classes for girls are either cancelled or replaced with regular classes; girls’ involvement is often not encouraged, with some girls reportedly even asked to clean classrooms instead of doing sporting activities. As one girl explained: ‘During sport class, we do not play or practice. Instead, we are handed sweepers to clean the place’ (FGD, older girls, Shajaia).
Our findings also indicate that gendered social norms play a critical role in hindering girls’ ability to practice a healthy lifestyle. Unlike boys, girls are not allowed to go out to do sports at gyms, and their movement outside the house is sharply constrained and scrutinized. Deeply rooted social norms about protecting family honor are the main driver limiting girls’ movement outside the house. This means that most adolescent girls spend much of their time at home watching TV, vicariously observing lives they are prohibited from living.
In terms of sexual and reproductive health, our findings underscore that in Gaza, menstruation and puberty issues are not openly discussed due to cultural taboos. Most girls said they only approached their mothers or older sisters upon reaching menarche. Many girls reported feeling fearful and shocked by it, though the situation was harder for younger girls (aged 10 or 11) and those who had never heard about periods either at home or at school. One older girl in an FGD in Jabalia noted:
‘I was 11 years old when I had my first period, I was so scared. It happened that I was doing exams. I rushed to my mother and sisters. I was scared and young. I cried for a week. I didn’t know that there is something called a period, and that it happens every month.’
Given the prevailing stigma around menstruation, family members are either not aware or not supportive of girls during menstruation. While boys did not mention anything about girls’ menstruation, girls themselves mostly reported experiencing embarrassing comments or teasing from family members, as the following quotes illustrate:
‘In Ramadan [the fasting month in Islam], when I have my period, she [younger sister] tells everybody at home and they laugh at me because I can’t fast like them.’ (FGD, older girls, Shajaia)
‘If I have my period, my husband’s family gets angry and says, “She has her period, that means she is not pregnant!”’ (FGD, older girls, Jabalia)
Schools (teachers or counsellors) start introducing information about menses for seventh grade students (aged 13 years) but according to participants, the knowledge they give is not sufficient. Some teachers refused to talk about menses with their students, believing that mothers should discuss the topic with their daughters at home instead. One girl explained how:
‘Our teacher told us to go home and ask our mothers to explain this lesson for us … The teacher
said “let your family explain this disgusting topic!”’ (FGD, older girls, Shajaia)
Another participant reported:
‘There are some teachers who would be shy and don’t talk about such topics [puberty and menses] and they would skip the pages that have this in the notebook, asking us to read it alone.’
Similarly, in Jabalia, teachers either discussed the topic superficially or provided wrong information, as one girl reported:
‘In that lesson, our teacher explained that girls will have their period one day, and that means they will bleed for a week or so. This blood is poisonous and it causes pain. That’s all she said.’
The girl continued: ‘We were young, so we needed more information’ (FGD, older girls, Jabalia).
Another highly gendered aspect of adolescent health vulnerabilities is substance abuse. Many young people in Gaza––especially adolescent males––are addicted to Tramadol, an opioid painkiller, which has also been reported to affect 50%–80% of the adult population [25]. Our findings suggest that substance abuse is widespread among adolescents, especially boys/young men, reflecting the many stressors they face, including unemployment and anxiety. One boy commented:
‘Tramadol use is common among youth. The worry comes not only from using it, but many are involved in dealing, because of the unemployment.’ (FGD, older boys, Jabalia)
Many participants who were interviewed individually admitted having tried Tramadol or knowing people who take it. One 14-year-old noted:
‘The day before yesterday, I was at a wedding party for my friend, and someone came and he had Tramadol, he put it in juice and distributes to all.’ (IDI, orphaned boy, Shajaia)
Girls reported knowing people who take drugs, but did not admit to doing so themselves. Girls also reported feeling more insecure moving around in the community because of increasing substance abuse. As one girl explained:
‘Males are becoming more dangerous in Gaza. Safety is less in Gaza with the many male Tramadol users … They turn violent and tend to steal to secure the money needed to buy the stuff. Our families prevent us going outside in order to protect us from those bad people and thieves.’ (FGD, older girls, Jabalia)
A 19-year-old young woman elaborated:
‘I heard many stories of females using Tramadol, my cousin and two girls at school [grade 9] are using it. They use it in the school toilets … and one day, the cleaner caught them and the school informed their parents.’ (IDI, girl who married early but is separated, Jabalia)
Age- and gender-responsive gaps in service provision
Our research highlights the range of barriers that prevent vulnerable adolescents accessing health care services in Gaza, an in particular the dearth of age-tailored information and services that respond to adolescents’ changing bodies and needs. Adolescents who did not seek treatment cited the following reasons: not knowing where to go (11%); not being able to get permission (17%); not being able to get money (36%); not being willing to go alone (particularly girls) (39%); and a lack of female health workers (32%). By contrast, and most likely reflecting the stresses induced by the context of a protracted conflict, girls are more likely to seek treatment for psychosocial problems. Nearly half of adolescents in our survey (53%) reported that adolescents go to see a counsellor or therapist when they are worried or sad. Of those, 16.3% indicated that they had already approached a counsellor or therapist about how they are feeling (23% boys and 9% girls).
In terms of the specific barriers to service uptake, a range of interconnected challenges emerged. As boys in an FGD in Shajaia emphasized:
‘Medicines are not available. Doctors don’t seem to be interested in treating us. They prescribe the medicines so quickly without diagnosing us well. The clinic isn’t clean either.’
They also pointed out that overcrowding and uncleanliness of public health services as well as inadequate privacy act as further barriers to approaching these services. When asked whether young people in their community ever speak to doctors or nurses about concerns they may have about their growing bodies and puberty, only 22% said yes, while less than 5% reported having already spoken to a health care provider about such concerns. This reflects inadequate access to and utilization of adolescent-related services and information.
Adolescents also reported that medical staff at public services are often insensitive to their needs:
‘In Al-Shifa hospital, for example, the treatment is not good unless you know someone there.’
‘As for the cleanliness of places, bathrooms there are super dirty.’ (FGD, older girls, Shajaia)
Another girl explained that:
‘I was so afraid when I went to the dentist in the UNRWA [United Nations Relief and Works Agency for Palestine Refugees in the Near East] clinic. The dentist shouted at me and said “if you don’t want to be cured, go home!” Then I went home without getting my teeth checked.’ (FGD, younger girls, Jabalia)
A 17-year-old boy noted that:
‘The doctors are not good. I once went to a clinic and I was complaining of a headache and the doctor prescribed me a brace for my leg!!’ (FGD, older boys, Jabalia)
Adolescents’ access to sexual and reproductive health care and information appears to be particularly limited. Most boys defined puberty simply as growing up, or as one boy noted: ‘It means I can marry’ (IDI, 16-year-old boy, Shajaia). Other signs of puberty mentioned by boys include body hair, facial hair, their voice deepening, and feeling more like an adult. Some boys expressed anxiety about going through puberty and the prospect of the ‘scary adulthood’ stage. In some instances, these feelings reflect young men’s concerns over their sexual ability or ability to father children:
‘I am afraid of being infertile and not being able to have children. I heard there are men who cannot have children. I’m afraid to be one of them.’ (IDI, 16-year-old boy, Shajaia)
Among girls, talking about sexuality is a taboo; hence sufficient information is rarely communicated and, in many situations, avoided. It was very rare for unmarried girls to mention that they had access to such information. This is compounded by the fact that parents often do not allow unmarried girls to visit a gynecologist because they are concerned that any invasive procedure might break the hymen. One girl explained:
‘Fathers will prevent girls from visiting a doctor no matter how severe the condition because they believe there is a chance that her virginity will be ruined, and as a result she will not get married.’ (FGD, older girls, Shajaia)
Even for those girls who were about to become sexually active (because they were about to marry), information was minimal. Due to their limited access to appropriate information, even on maternity-related matters, adolescent mothers appear to have insufficient knowledge/awareness of important warning signs related to sexual and reproductive health. Our discussions with adolescents confirmed that they know only a little about these topics, rendering them completely unprepared for the changes brought by puberty, marriage and motherhood. Poor communication between adolescent mothers and service providers was also evident. As an 18-year-old married girl with two infants from Khanyounis reported:
‘The health personnel at the hospital were not supportive … I had no information. I am a child. I don’t know about these things.’
In sum, adolescents’ level of trust in and satisfaction with health care services is low. Some participants described their first day of marriage as the worst experience of their life, as they were completely unaware that they would be expected to have sexual intercourse with their husband. As one girl reported:
‘I had no idea what marriage was. I thought that marriage is all about supporting my husband. I had no idea that it included a sexual relationship. The biggest shock I had about getting married was at the night of my wedding, I ran away from home and went back to my family. I was terrified. My husband came to my family’s home and he told them to leave me as I wish, I returned to my husband after a month, I was afraid.’ (IDI, 16-year-old girl, Shajaia)
A 14-year-old married girl from Khanyounis similarly noted:
‘Early marriage is a disaster. For a 14-year-old girl it is suffocation … No one should be terrified like I was.’
Unsurprisingly, females rarely talk about their sexual needs, as one girl noted:
‘I do love him but I don’t feel pleased like he may do, we never talked about such things.’ (IDI, 16-year-old girl, married early, Shajaia)
Moreover, issues around reproductive health create considerable stress for girls, who rarely have a say about the timing or spacing of pregnancies, how many children they have, or what type of family planning method they use. To a large extent, social norms dictate that it is not acceptable for a woman to leave an infertile husband, although it is acceptable for a man to leave an infertile wife or marry another woman. As one girl explained:
‘Husbands divorce their infertile wives while wives stay with them forever even if they are infertile. These women endure all difficulties and remain patient.’ (FGD, older girls, Jabalia)
Adolescent girls who married early face particular challenges with health care services. As noted earlier, though access to antenatal care is nearly universal, the quality of services is suboptimal. The gender of the health care provider can be a barrier, with most participants preferring female health care staff given the very personal nature of problems. As one participant explained:
‘I feel shy to tell a male physician that I have a severe inflammation.’ (FGD, older females, Jabalia)
‘There are no clinics to support girls at our age … staff in clinics do not understand our needs.’ (FGD, older girls, Shajaia)
As a 17-year-old married girl from Khanyounis explained:
‘I was afraid when the baby was moving … because I had never been told what to expect during pregnancy, even by doctors at the UNRWA clinic.’
Other participants considered service provision by male doctors or nurses problematic, especially for unmarried girls. Participants reported concerns in prenatal care that included lack of cleanliness and privacy, waiting times and drug shortages. As one older girl commented:
‘When I go to the midwife, I feel like I’m in a shop not in a clinic, because everybody enters and leaves at the same time. There is no respect for appointments.’ (FGD, older girls, Jabalia)
Health service affordability
Despite their families having medical insurance, most study participants cited drug shortages, cost of treatment and availability of laboratory tests as among the main challenges they face when visiting health facilities. Some families borrow or seek help from non-governmental organizations (NGOs) or charitable bodies to pay for medications while others either just skip treatment or use traditional remedies. This is especially true for more costly treatments, as one younger girl explained:
‘I have some problems related to growing normally; and my family can’t afford growth hormone education, which costs around $1,000 monthly. We take financial aid from the Ministry of Social Development and we have to borrow the rest of the money from people.’ (FGD, younger girls, Jabalia)
Some girls also reported that young people try to simply endure sickness until they feel better. One younger boy explained: ‘When I need medicine that I cannot afford, I just sleep it off till I feel better’ (FGD, Shajaia). In the same focus group, another boy noted that, ‘When I need medicine that I cannot afford, I eat garlic.’ Another explained: ‘I do not go anywhere. I drink juice when I am sick.’ And a 16-year-old adolescent mother noted:
‘Once l had a stomach ache and I told my mother about it. She advised me that I have to drink boiled parsley and eat watermelon.’ (IDI, Jabalia)
Some girls believe that poor families would prefer to spend money on their sons because according to gender social norms and gendered opportunities for education and employment it is they who are likely to financially support the family in future, so investment in girls’ health is therefore a lower priority. However, adolescents generally reported that families decided on health expenditure based on the severity of the child’s illness, regardless of gender. One girl commented:
‘Females are usually denied health services because they don’t work, while males work and earn money.’ (FGD, older girls, Shajaia)
Boys mentioned that younger children are prioritized, followed by girls:
‘Younger children go to the health facilities more because they get sick more than older ones and girls also go more.’ (FGD, younger boys, Shajaia)
Disparities were also highlighted by older girls, who thought that their parents cared more about their younger sisters’ health, as child illnesses are perceived as more dangerous.