Think, Ask, Act: The Intersectionality of Mental and Reproductive Health for Judicially Involved Girls

Childhood Behind Bars: Children and the US Juvenile Legal System

This article examines the epidemiology of the US juvenile legal system, which disproportionately impacts youth with multiple marginalized identities and exacerbates health inequities. Policy changes that can improve the treatment of children who display disruptive behavior are highlighted, so as to lay out a path forward for supporting children and enhancing health equity while bolstering public safety. Finally, this article concludes that the systemic racism pervasive in the juvenile legal system signals an important role for pediatrics to advance racial equity and transform our approach to childhood.

Challenging the status quo: gender norms in Croatian juvenile correctional settings

Gender norms and issues related to gender are highly relevant when it comes to treatment of juveniles in correctional institutions, especially related to their risky behavior and personal characteristics (such as personality traits, intellectual capability, culture, ethnicity etc.). Furthermore, many juveniles in correctional institutions are exposed to violence and are also perpetrators of violent criminal acts. This paper will give an overview of national policies related to gender-sensitive treatment in Croatia as a background to research aimed to describe the reflection of gender issues and gender norms in practical work with juveniles in Croatian correctional institutions. The research is based on qualitative approach and includes focus groups with youth workers from various organizations who implemented programs for youth in correctional institutions. Preliminary results show that gender and gender norms are not specifically targeted in treatment programs within the institutions. The initiative to implement gender issues mainly comes from organizations from the civil sector through different workshops. Juveniles express relatively rigid gender norms that are supported by rigid organization of correctional institutions especially for males. This research shows the importance of clearer focus to gender-sensitive programing and gender sensitive treatment programs that will strongly be integrated in everyday practice of correctional institutions. The precondition for this is largely connected to deconstructing stereotypes about gender and gender norms both for youth and professionals working with them.

Intersectionality Policymaking Toolkit: Key Principles for an Intersectionality-Informed Policymaking Process to Serve Diverse Women, Children, and Families

Health and economic inequities among U.S. racial/ethnic minority women and children are staggering. These inequities underscore a dire need for intersectionality-informed, social-justice-oriented maternal and child (MCH) policies and programs for U.S. women and children. In response, we developed the "Intersectionality Policymaking Toolkit: Key Principles for an Intersectionality Informed Policymaking Process to Serve Diverse Women, Children and Families" to assist U.S. policymakers/aides, practitioners, and other stakeholders in developing more equitable MCH policies/programs. This article describes the Toolkit development process and initial assessments of acceptability and feasibility for use in MCH policymaking. Between 2018 and 2021, we utilized the process that the World Health Organization (WHO) used to develop its WHO Surgical Safety Checklist to develop the content (e.g., case studies) and format (i.e., structure), make strategic decisions (e.g., core items, primary audiences, timing of utilization), test concepts, and receive feedback. We convened a 2-day planning meeting with experts (n = 8) in intersectionality, policymaking, and MCH to draft the Toolkit. Next, we convened half-day workshops with policymaking and program leadership and staff in Washington, DC, New Orleans, LA, and Santa Fe, NM, to refine the Toolkit (n = 37). Then we conducted an initial assessment of the Toolkits' acceptability and feasibility using surveys (n = 21), followed by focus groups (n = 7). The resulting Toolkit distills Critical Race Theory's and intersectionality's most critical elements into a user-friendly modality to promote and enhance equitable MCH policies and programs for diverse U.S. women and families.

Association of pregnancy attitudes and intentions with sexual activity and psychiatric symptoms in justice-involved youth

Context

With over one-third of detained girls experiencing teenage pregnancy, it is critical that the juvenile justice system better addresses the sexual and reproductive health (SRH) needs of youth. Although pregnancy attitudes and intentions (PAI) are associated with pregnancy outcomes among the general adolescent population, this relationship has not been examined among justice-involved youth.

Methods

Participants were drawn from a longitudinal study characterizing trajectories of behavioral and reproductive health and recidivism among newly justice-involved youth in a Northeast family court. Baseline and four-month follow-up data from 288 justice-involved youth (JIY) were analyzed to characterize PAI; examine associations between pregnancy intentions and unprotected sexual activity (i.e., no hormonal, intrauterine, or barrier protection against pregnancy); and explore the relationship between pregnancy intentions and psychiatric symptoms.

Results

At baseline, 39% of JIY youth were sexually active, 44% of these youth reported inconsistent condom use and 14% had not used birth control at last sexual intercourse. Nearly half of sexually active youth reported some intent around pregnancy and those with any pregnancy intentions were more likely to report depression, low self-esteem, substance use, and trauma history. Pregnancy intentions at baseline predicted higher rates of unprotected sexual activity at four months (OR: 16.9, CI = 2.48-115.7).

Conclusions

This study highlights the importance of developing and implementing more comprehensive SRH assessments and brief interventions for youth entering the justice system.

"Little Red Flags": Barriers to Accessing Health Care as a Sexual or Gender Minority Individual in the Rural Southern United States-A Qualitative Intersectional Approach

ABSTRACT

Sexual and gender minorities (SGMs) experience unique challenges when accessing sexuality and gender-affirming, safe health care services in the rural, southern United States. An identified gap in the literature is an intersectional, community-based approach to assessing the obstacles SGM individuals with intersecting identities experience when navigating comprehensive health services in rural southern communities in the United States; therefore, the present study used qualitative inquiry with an intersectional lens to describe these obstacles. The authors analyzed qualitative data from in-depth, semi-structured individual interviews with SGM individuals (N = 12). Common themes emerged that highlighted the compounding effects of the sociopolitical climate of the geographical area, religious attitudes toward SGMs, and the experience of racism. Findings of this study can inform health professions' academic curriculum, provider and support staff training, and implementation of policy that focuses on creating a diverse and inclusive health care delivery experience.

Editorial: Analyzing Treatment and Prescribing in Large Administrative Datasets With a Lens on Equity

In this issue of the Journal, Bushnell and colleagues¹ present findings from their analysis of a commercial insurance administrative dataset, examining the ways that antipsychotics are used in young children (aged 2-7 years) in the United States. From 2009 to 2017, they find that the use of antipsychotics decreased and there was a shift toward use of medications in alignment with evidence-based standards. The most common conditions for use of antipsychotics included pervasive developmental disorders, externalizing disorders, and attention-deficit/hyperactivity disorder. More troubling were the findings that less than half of young children on antipsychotics had a visit with a psychiatrist, and only a third of children had evidence of a minimum dose of psychotherapy. These findings deserve attention and should be a cause for strengthening the use of existing treatment guidelines for preschool and younger children. They should also prompt enhanced advocacy to expand access to evidence-based mental health care for children that includes high-quality psychiatric assessment, treatment, and psychotherapy. The latter includes increasing the number of child and adolescent psychiatrists who focus on preschool-aged and younger children.

Personalizing the BioPsychoSocial Approach: "Add-Ons" and "Add-Ins" in Generalist Practice

Generalist practitioners often find interacting with patients deeply satisfying and joyful; they also experience encounters that are challenging and complex. In both cases, they must be aware of the many issues that affect the processes and outcomes of patient care. Although using the BioPsychoSocial approach is an important, time-tested framework for cultivating one's awareness of patients' presenting concerns, recent developments suggest that additional frames of reference may enhance communication and relationships with patients. In this article, we describe several additions to the BioPsychoSocial approach, considerations we call "add-ons" and "add-ins". We invite generalist practitioners and, indeed, all health care practitioners, to consider how they can improve their ongoing care of patients by personalizing these and other additions in their day-to-day work with patients.

Reproductive health needs of recently incarcerated youth during community reentry: a systematic review

BACKGROUND

Youth involved in the juvenile justice system have high reproductive health needs and, on exiting detention, face the challenging transition of reentry. We conducted a systematic literature review to describe what is known about youths' reproductive health needs during community reentry after incarceration.

METHODS

We searched PubMed, CINAHL, Cochrane Library, and Google Scholar for articles containing key words with the concepts 'child or adolescent', 'incarcerated' and 'reentry'. In the search, we defined the concept of 'reentry' as within 1 month prior to release (to include interventions involving pre-release planning) and up to 18 months after release from incarceration.

RESULTS

Our search yielded 2187 articles. After applying all exclusion criteria, 14 articles on reproductive health remained for extraction. The articles provided data on the following aspects of youths' reproductive health: frequency of condom use (eight articles), sexual risk behaviours other than lack of condom use (seven articles), and prevalence of sexually transmitted infections (three articles).

CONCLUSIONS

The literature on the reproductive health needs of youth undergoing reentry is extremely limited. Current intervention studies yield mixed but promising results and more intervention studies that address both pre-release reentry planning and the post-incarceration period are needed. Given incarcerated youths' well-documented reproductive health disparities compared with non-incarcerated adolescents, the identified gaps represent important opportunities for future research and programmatic emphasis.

Pregnancy Outcomes Among Girls Impacted by Commercial Sexual Exploitation

OBJECTIVE

We measured pregnancy rates and pregnancy outcomes among girls with histories of commercial sexual exploitation (CSE), and then quantified the associations between the outcome of pregnancy with: a) girls' exposure to childhood adversity, and b) their behavioral health. This is the largest study of pregnancy outcomes and associated factors among girls impacted by CSE in the United States.

METHODS

We reviewed court files of participants in a juvenile specialty court for youth impacted by CSE, between 2012 and 2016. We collected data on pregnancy, health, and social factors. Data were updated through 2018 and descriptive statistics were calculated. Two-sample tests for equality of proportions explored associations between pregnancy with adverse childhood experiences and the girls' behavioral health profiles.

RESULTS

Among the 360 biological females, 31% had ever been pregnant. Of the girls ever pregnant, 18% had multiple pregnancies. Outcomes for the 130 reported pregnancies were: 76% live births; 13% therapeutic abortions; 5% miscarriages or stillbirths; and 6% of pregnancies were ongoing at case closure. Parental incarceration and histories of maternal substance abuse were both associated with pregnancy.

CONCLUSIONS

High pregnancy rates among girls with histories of CSE suggest the importance of applying a reproductive justice approach to deliver reproductive education, family planning services, prenatal care, and parenting support to girls impacted by CSE.

A transgender girl’s experience: sexual exploitation and systems involvement

Purpose

The available research on specialized interventions for youth experiencing commercial sexual exploitation almost exclusively focuses on the impact and efficacy related to cisgender girls, despite the inclusion of youth who identify as transgender in these programs. This paper aims to present a case study on the experience of a transgender adolescent girl who experienced commercial sexual exploitation and provides a narrative of the multifarious challenges she faced while involved in institutional systems of care.

Design/methodology/approach

This paper conducted an in-depth case review of all records on “Jade,” a white adolescent transgender girl who experienced commercial sexual exploitation, from a specialty court program in the juvenile justice system between 2012 and 2016. Her experiences throughout childhood exemplify many of the unique challenges that transgender girls and young women with histories of exploitation or trafficking may encounter within service delivery and socioecological systems. This paper applied concepts adapted from the gender minority stress theoretical model to understand how minority gender identity can shape the experiences and outcomes of the youth impacted by commercial sexual exploitation.

Findings

Jade’s narrative underscores the interplay of gender-based sexual violence, heteronormative structural barriers, transphobia and their intersectional impact on her experience while receiving specialized care. The intersectional hardships she experienced likely contributed to adverse biopsychosocial outcomes, including high rates of medical and behavioral health diagnoses and expectations of further rejection.

Originality/value

This paper highlights the extraordinary challenges and barriers faced by an often under-recognized and overlooked subset of the youth impacted by commercial sexual exploitation, who may receive services that do not account for their unique needs related to gender expression and identity. This paper exemplifies how internalized stigma along with expectations of further rejection and victimization have implications for clinical and multidisciplinary intervention settings. Jade’s case underscores the need for improved access to supportive services for youth with minority gender identities, including peer community-building opportunities. Finally, this paper identifies a critical gap in US legislation and social policy. This gap contributes to the structural harms faced by transgender and gender-nonconforming youth receiving services during or following experiences of commercial sexual exploitation.

Adapting a family intervention to reduce risk factors for sexual exploitation

BACKGROUND

Sexually exploited youth are disconnected from societal tethers and need support systems, which makes them some of the most vulnerable of youth. This heightened level of vulnerability increases their risk for violence, abuse, ongoing sexual exploitation and all its sequelae. The purpose of this study was to examine an evidence-based intervention called STRIVE (support to reunite, involve and value each other) that has been a successful family re-engagement strategy with newly homeless youth. We sought to explore its contextual relevance for youth with risk factors for sexual exploitation and identify necessary adaptations to reduce risk factors for sexual exploitation. We deliberately took an intersectional approach in conducting this study.

METHODS

Six community-based focus groups were conducted with youth at risk for sexual exploitation and their service providers. Each group was recorded, transcribed, coded, and thematically analyzed.

RESULTS

Results from 29 youth and 11 providers indicate that there are unique considerations that must be taken into account while working with youth at risk for sexual exploitation to ensure effective service delivery and/or ethical research. Emergent themes included: setting the stage by building rapport and acknowledging experiences of structural violence, protect and hold which balances youth's need for advocacy/support with their caregivers' need for validation/understanding, and walking the safety tightrope by assessing risks and safety planning.

DISCUSSION

Focus groups are an effective methodology when working with traditionally disempowered populations particularly in gaining a range of perspectives to meet unique needs/preferences. Youth at risk for commercial sexual exploitation needs require strengths-based, individualized, multi-systemic approaches.

Behavioral health treatment "Buy-in" among adolescent females with histories of commercial sexual exploitation

BACKGROUND

Adolescent females with histories of commercial sexual exploitation (CSE) have high mental health and substance use treatment needs, yet little is known about their perspectives regarding behavioral health and behavioral health treatment.

OBJECTIVE

We sought to understand the attitudes of adolescent females with histories of CSE regarding behavioral health to identify factors influencing "buy-in" to behavioral healthcare.

PARTICIPANTS AND SETTING

Participants included 21 adolescent females, affiliated with our partner organizations (two group homes, a service agency, and a juvenile specialty court), who reported having exchanged sex for something of value.

METHODS

In-depth qualitative interviews explored participants' perspectives towards behavioral health. We conducted thematic analysis to identify themes concerning behavioral health.

RESULTS

Participants provided insightful definitions of "mental health" that included positive and negative aspects of emotional and cognitive states (e.g. "being happy with yourself" and "not thinking suicidal"), indicating intensified mental health challenges and resilience. Substance use was viewed as a coping mechanism for childhood trauma and their exploitation. Trusted relationships with providers and navigable health systems that encourage autonomy were key to promoting "buy-in" and thus engagement in behavioral health treatment. A conceptual model emerged illustrating factors leading to treatment engagement.

CONCLUSION

Adolescent females with histories of CSE constitute a vulnerable population with high levels of trauma as well as unmet mental health and addiction treatment needs. The delivery of trauma-focused, behavioral healthcare centered on patient-provider trust and shared-decision making that encourages client autonomy should be prioritized.

Barriers to Health Care for Latino Youths During Community Reentry After Incarceration: Los Angeles County, California, 2016-2018

Objectives. To examine barriers to health care for Latino youths during reentry after incarceration.Methods. For this in-depth qualitative study, we conducted 69 semistructured interviews with 22 Latino youths and their parents at 1, 3, and 6 months after incarceration. We performed thematic analysis of interview transcripts, from which a preliminary conceptual model emerged describing barriers to care for Latino youths. We then conducted trajectory analyses of dyadic youth-caregiver pairs to test the conceptual model. We collected longitudinal interviews in Los Angeles County, California, from November 2016 to March 2018.Results. Beyond recognized stressors experienced by youths during reentry, most of which families related to poverty and neighborhood environment, Latino youths also experienced cultural barriers to care (i.e., self-reliance and pride, religiosity and reproductive care as taboo, preference for home remedies, language) as well as barriers to care because of undocumented status (i.e., fear of deportation, job insecurity).Conclusions. Reentry is challenging, and Latino youths face additional barriers to care during reentry related to culture and legal status, but have cultural strengths. Increased access to culturally sensitive, safety-net health care, regardless of immigration status, may reduce health inequalities for Latino youths undergoing reentry.

Editorial: Bullying and Suicide Risk: Restructuring Prevention, Identification, and Treatment to Address a Global Mental Health Crisis

Bullying is a global phenomenon with significant mental health consequences. Although bullying prevention programs have garnered attention over the last several years, the results of these programs have been mixed, at best. As Koyanagi et al.¹ highlight in this issue of the Journal, the consequences of bullying can be dire, particularly when they occur during a critical developmental period. Using the Global School-based Student Health Survey, this article reports on a sample of more than 130,000 youths aged 12 to 15 years sampled in a structured manner across 48 countries with a range of geographic representation and some socioeconomic diversity. The results of this study find that across 47 of 48 countries, children and adolescents have an average 3-fold greater risk of suicide attempt when faced with bullying. In addition, there was a dose-dependent impact of the number of days bullied to odds of suicide attempt. In recent years, rates of suicide have been steadily increasing around the globe, with suicide being the second leading cause of death among 15- to-29-year-olds in 2016.² Koyanagi et al.'s timely article not only illustrates that suicide is a growing global health problem but also emphasizes the need to re-evaluate our existing strategies using a multisystemic approach to screening, prevention, and treating bullied youths.