Identity, self-regulation, and gender inequality: Sexual and reproductive health and rights of Adolescent girls and Female sex workers In South Africa

Many sexual and reproductive health inequities are rooted in gender inequality that place women in South Africa, especially adolescent girls and sex workers, at increased risk of adverse outcomes. Gender inequality causes multiple layers of stigma, discrimination, and marginalisation, including misuse of criminal law, gender-based and sexual violence, and denial of sexual and reproductive health rights, which continue to create barriers to realising these rights. This thesis adopts a social approach that recognises that the individual capacities of adolescents and female sex workers are intimately tied to social norms (gender inequality), practices and institutions (the health system), human and sexual rights (policy framework), and the legacy of apartheid in South Africa. The case is made for an enabling environment in which these vulnerable groups can improve their sexual and reproductive health outcomes despite agonising barriers. Adolescent girls and sex workers have possible identities, and they use transactional sex to attain their ideals given their resource poor and gender unequal circumstances. Using identity-based motivation to encourage gender transformation will redress the barriers of the vulnerable group to adopting safer behaviours (Chapter 4). For adolescent girls and sex workers, seeking health information and care often competes with other priorities and needs (Chapter 5). As self-regulatory scores can be increased through situational cueing, health promotion messages can be matched to the regulatory focus of adolescent girls and sex workers to ensure that health communication reaches both chronic and situationally self-regulated females. Considering the social, structural, and behavioural determinants that contribute to poor sexual and reproductive health outcomes, there is a need to understand the context in order to respond appropriately (Chapter 6). A harm reduction framework removes the reliance on individual-level behaviour change as a stand-alone activity for improving access to sexual and reproductive health and sexual and reproductive health rights (Chapter 7). Vulnerable women are frequently exposed to coercive practices institutionalised under the biomedical model of healthcare (chapter 8). Understanding how to ensure that women have capacity, are informed, and are free from the disruptive role of power dynamics when accessing health care, strengthens their realisation of their human rights (Chapter 9). Behaviour change research must focus on group norms and ways to assemble vulnerable groups to influence the design of research. It is essential to consider sexual and reproductive health rights, power imbalances, and agency of vulnerable groups in research design. Only once sexual and reproductive health rights and social public health principles are incorporated into research on vulnerable females, will their sexual and reproductive health outcomes improve. For as long as unequal gender norms dictate the expected behaviour of girls and sex workers, their aspirations will remain pipedreams. For as long as sex workers are not recognised as mothers and spouses, will they be exploited and violated. For as long as the biomedical model and individual-level behaviour change theories reign, context and human rights will not get the due attention