Abstract
IntroductionThere is a strong evidence base that the stigma, discrimination and criminalization affecting adolescent key populations (KPs) aged 10–17 is intensified due to domestic and international legal constructs that rely on law-enforcement-based interventions dependent upon arrest, pre-trial detention, incarceration and compulsory “rehabilitation” in institutional placement. While there exists evidence and rights-based technical guidelines for interventions among older cohorts, these guidelines have not yet been embraced by international public health actors for fear that international law applies different standards to adolescents aged 10–17 who engage in behaviours such as selling sex or injecting drugs.DiscussionAs a matter of international human rights, health, juvenile justice and child protection law, interventions among adolescent KPs aged 10–17 must not involve arrest, prosecution or detention of any kind. It is imperative that interventions not rely on law enforcement, but instead low-threshold, voluntary services, shelter and support, utilizing peer-based outreach as much as possible. These services must be mobile and accessible, and permit alternatives to parental consent for the provision of life-saving support, including HIV testing, treatment and care, needle and syringe programmes, opioid substitution therapy, safe abortions, antiretroviral therapy and gender-affirming care and hormone treatment for transgender adolescents. To ensure enrolment in services, international guidance indicates that informed consent and confidentiality must be ensured, including by waiver of parental consent requirements. To remove the disincentive to health practitioners and researchers to engaging with adolescent KPs aged 10–17 government agencies and ethical review boards are advised to exempt or grant waivers for mandatory reporting. In the event that, in violation of international law and guidance, authorities seek to involuntarily place adolescent KPs in institutions, they are entitled to judicial process. Legal guidelines also provide that these adolescents have influence over their placement, access to legal counsel to challenge the conditions of their detention and regular visitation from peers, friends and family, and that all facilities be subject to frequent and periodic review by independent agencies, including community-based groups led by KPs.ConclusionsControlling international law specifies that protective interventions among KPs aged 10–17 must not only include low-threshold, voluntary services but also “protect” adolescent KPs from the harms attendant to law-enforcement-based interventions. Going forward, health practitioners must honour the right to health by adjusting programmes according to principles of minimum intervention, due process and proportionality, and duly limit juvenile justice and child protection involvement as a measure of last resort, if any.
Highlights
There is a strong evidence base that the stigma, discrimination and criminalization affecting adolescent key populations (KPs) aged 10Á17 is intensified due to domestic and international legal constructs that rely on law-enforcementbased interventions dependent upon arrest, pre-trial detention, incarceration and compulsory ‘‘rehabilitation’’ in institutional placement
It is well settled that adolescent key populations (KPs) face heightened health risks as a result of law and policy barriers to accessing HIV treatment, diagnostic and prevention services and that the stigma, discrimination and criminalization experienced by adolescent KPs aged 10Á17 is intensified, as compared to their older cohorts
Those adolescents who sell sex or inject drugs more often face aggravating circumstances such as family rejection and street-involvement, combined with legal constructs concerning consent and age of majority. These constructs may condition access to life-saving treatment on parental consent or proof of ‘‘emancipation,’’ or lower the age of consent to sell sex or use drugs as compared to general consent-to-sex law, resulting in increased police encounters and commitment to state custody [1,2]. This commentary addresses only adolescent KPs aged 10Á17 and not adolescents aged 18Á19 in order to spotlight the specific, legal guidelines for health and protective interventions that apply to persons under the legal age of majority
Summary
It is well settled that adolescent key populations (KPs) face heightened health risks as a result of law and policy barriers to accessing HIV treatment, diagnostic and prevention services and that the stigma, discrimination and criminalization experienced by adolescent KPs aged 10Á17 is intensified, as compared to their older cohorts. Adolescent KPs report abuse by health practitioners themselves, including discrimination and service denial, and even physical and sexual violence, forced abortions, breach of confidentiality and mandatory HIV testing [1,2,8] Despite this frightening reality, a child protection framework is frequently applied at the country level to justify arrest-based interventions without reference to international human rights law governing the administration of juvenile justice, child protection and the right to health. The strong, evidence-based technical guidelines that exist for rights-based health interventions among sex workers and injecting drug users over the age of majority decline to extend rights-based recommendations to KPs aged 10Á17 even when medical science invites an equivalent approach [12,13] This commentary calls for a reexamination of the treaty framework, situating child-protective interventions firmly within international law and guidance governing the right to health, and regulating juvenile justice and child welfare interventions according to principles of minimum intervention, last resort, due process and proportionality. The commentary advances concrete guidelines for framing health programme interventions, specifying that: 1) The principle of non-criminalization mandates noncompliance of healthcare providers with arrest-based interventions, an immediate end to arrest and prosecution of adolescent KPs aged 10Á17, and the abolition of involuntary custodial placement in the name of ‘‘rehabilitation’’; 2) Voluntary, confidential and adolescent-friendly primary, sexual and reproductive health services; 3) The right of adolescents aged 10Á17 who sell sex or use drugs to be heard includes meaningful participation in policy and decision-making in health services and other programmes that concern them, as well as reliable complaint procedures and remedies for rights violations; 4) Parental consent waiver for life-saving sexual and reproductive health services, HIV and harm-reductionist treatment; 5) Client-centred informed consent and right to refuse or consent to participation in medical treatment and research trials
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