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Access to safe and legal abortion for teenage women from deprived backgrounds in Hong Kong
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Access to safe and legal abortion for teenage women from deprived backgrounds in Hong Kong Suet Lin Hung Assistant Professor, Department of Social Work, Hong Kong Baptist University, Kowloon, Hong Kong. E-mail: [email protected]
Abstract: This paper reports on a qualitative study in 2007–08 on the abortion experiences of teenage women from deprived backgrounds in Hong Kong. Twenty-nine young women aged 13–24 who had undergone one or more induced abortions in their teen years were interviewed and participated in group empowerment sessions. Ten were unemployed, four were students, the rest were employed on low pay in unskilled occupations. Abortion services are legal and available in public and private services, but they charge fees ranging from HK$310 to $10,000, and do abortions only up to 24 weeks of pregnancy. Many young women resort to poor quality illegal clinics and clinics in mainland China because the cost is lower, they do not wish to tell their parents, who would be asked for consent, and/or they want to protect their sex partners, who may be reported and prosecuted if the girl is under-age. There is a need to strengthen services for teenage women in Hong Kong, especially those who are pregnant and from deprived backgrounds. There is also a need for professionals who deliver adolescent health and social welfare services, and for society to rethink and re-examine its views and attitudes towards teenage pregnancy, sexuality and abortion. ©2010 Reproductive Health Matters. All rights reserved. Keywords: abortion law and policy, adolescents and young people, reproductive rights, unwanted pregnancy, women's health services, Hong Kong
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TIGMA has long been attached to teenage pregnancy across the world, including in Hong Kong. While teenage abortion and parenthood are well researched in the west, and social support programmes have been developed for young mothers in deprived communities, such as Sure Start and Head Start in the UK and US, respectively, teenage pregnancy is under-researched and not addressed in Hong Kong. Little is known about the group of girls who have experienced induced abortion: their age, marital status, educational or employment status; reasons for abortion; use of legal or illegal services in Hong Kong or mainland China; post-abortion concerns; or the ways they create meaning from the experience for themselves or in intimate relationships. Western studies have revealed that the experience of teenage pregnancy is influenced by 102
gender, race, class and cultural factors, and that women who are young, poor or from ethnic minorities cannot afford expensive or private abortion services.1–6 This is also the case for Hong Kong. Drawing on a qualitative study from 2007 to 2008, this paper attempts to fill the knowledge gap regarding the experience of teenage women in Hong Kong from deprived backgrounds who seek an abortion and the extent to which their access to legal services is constrained by age, income and class.
Abortion law and services in Hong Kong and mainland China Abortion law reform in Hong Kong in 1972 has allowed women to terminate their pregnancies lawfully if two medical practitioners consider that continuation of the pregnancy would risk
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the pregnant woman's life, cause injury to her physical or mental health, or if there is a substantial risk that if the child is born, it would suffer from physical or mental abnormalities as to be considered seriously handicapped. A revision in 1981 extended the law to include young women under 16 and victims of rape, seduction or incest. Termination of pregnancies of more than 24 weeks is normally not allowed unless it is necessary to save the life of the woman.7 Abortion services are available in public and private hospitals and clinics, which charge fees based mainly on length of pregnancy, type of procedure, and days of stay in hospital. There are also illegal abortion clinics and Chinese medical doctors who provide herbal medicines to terminate pregnancies, which are widely known. There are also easily accessible and less expensive abortion services in mainland China, where women can have the procedure without having to provide reasons. Along with rapid economic development in China's southern cities, public hospitals and clinics, in Shenzhen and Guangzhou in particular, are targeting Hong Kong people to increase their patient population. Abortion services are available to Hong Kong women of all ages, including those with pregnancies over 24 weeks. Private hospitals and clinics targeting poor communities charge even less than others. The Youth Sexuality Study conducted by the Family Planning Association of Hong Kong (FPAHK) in 2001, among 579 women aged 18–27, found that of the 43 participants who had had an induced abortion, some may have had more than one abortion. Among the 20 who said they had had illegal abortions, 17 went to local illegal providers and three to Shenzhen on the mainland.8 According to information released by the Department of Health, reported widely in the newspapers, there were 20,234 abortions and 49,144 live births in Hong Kong in 2001, making the number of abortions 29.2% of registered pregnancies. That percentage would be higher if illegal abortions in Hong Kong and abor-
tions in mainland China were included.9 Further enquiry revealed that no disaggregated statistics on teenage abortions were available or have been published. Teenage pregnancy, abortion and mothering only draw public attention in Hong Kong society when there are news reports, e.g. of tragic outcomes for women from unsafe abortions or sensationalist claims. In 2004, there was a report about young women who had contracted chlamydia and pelvic inflammatory disease after undergoing illegal abortions. 10 In 2008, there was a report that five newborn babies had been killed and dumped in public toilets or tossed down from high-rise apartment blocks over a period of seven months. 11 The Caritas Hyacinth Project, collaborator of this research, that pioneered services for young women with unwanted pregnancy, reported in 2008 that they were expressing feelings of stress and self-blame post-abortion, saying they missed the baby, feared revenge from its spirit, or were worried about the health-related consequences of unsafe, illegal abortions.12 Some statistics on the extent of induced abortions among young women are available, but they cover different age groups or are not broken down by age, and therefore only provide a broad picture. The Youth Health Care Centre of the FPAHK, the only clinic targeted at young people under 26 in Hong Kong, provides abortion services only until the tenth week of pregnancy and refers those over ten weeks to public or private hospitals. Table 1 shows the number of their clinic attendees who requested services for induced abortion from 1992–2007. These figures have not been broken down by age and the number of young women who were in their teens is not known.13 The Department of Health was able to provide unpublished data on those aged 19 or below who had had abortions in all 41 public hospitals from 1992 to 2007 (Table 2) at the author's request in early 2008, but the totals did not tally with the Hospital Authority's statistics.
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The number, they said, fluctuated before 2000 and has decreased since 2000. The decrease seems to coincide with the overall declining rate of abortions in Hong Kong, but social services key informants believed that the growing popularity among young women of using private hospitals or illegal abortion services may also explain the decline. The great majority of the young women under age 19 in the years reported were single (92–99%), but no further breakdown of information by age was available. A far greater number of abortions at all ages, in fact, took place in private hospitals. According to figures released by the Hospital Authority, there were 6,506 and 5,070 abortions conducted in public hospitals and 11,199 and 19,814 in private hospitals in 2002 and 2007, respectively, but again breakdown by age is not available.14 Mother Choice, the only social welfare organization which provides shelter for pregnant girls, consider these figures under-reported, and argue that many more young women are using hospitals and clinics in mainland China. They base this view on the increasing number of enquiries concerning pregnancy received by them from teenage women under the age of 18, which rose from 2,286 in 2007 to 2,854 in 2008.15 Other data reveal an increasing number of teenagers who are having sexual experiences in the absence of inadequate knowledge about or use of contraception. Studies on youth sexuality conducted by the Family Planning Association of Hong Kong in 1991, 1996, 2001 and 2006 among those aged 15–17 reveal an increasing percentage of reported first sexual intercourse below 15 years of age, rising from 1.0% to 8.7% for teenage girls and from 5.8% to 12% for teenage boys in 1991 and 2006, respectively. In the 2006 study, only 54.5% of teenage girls and 59.9% of teenage boys who had had sexual intercourse reported using contracep104
tives, with the majority using male condoms or withdrawal.16 Overall, in spite of incomplete data, existing studies reviewed highlight a growing prevalence of sexual intercourse at a young age, insufficient knowledge and use of contraception among young people, and an increasing number of young pregnant women seeking help, including for abortions.
Methods This was an exploratory study conducted from December 2007 to September 2008 of the abortion experiences of 29 young women in their teenage years from deprived backgrounds in Hong Kong. A qualitative methodology was adopted using individual, in-depth interviews. Young women from deprived backgrounds were targeted because they are particularly vulnerable when pregnant. The topics covered included past and current relationships with men, use of contraception, experience with abortion and contraceptive services, meaning ascribed to abortion and impact of abortion. The research was conducted in collaboration with the Caritas Hyacinth Project, the only social work project that provides case counselling and group work for this specific group. The young women were recruited by social workers from the Project during their visits to public hospitals, or were referred by other social workers from youth outreach service teams. All 48 abortion service users with a similar background – teenage, low income and unwed – seen by social workers during the study period were invited to participate in the research. Of the 48 invited, 29 took part. The rest declined, citing personal reasons such as unwillingness to talk about abortion or unavailability for long interviews. A semi-structured interview guide was developed, piloted with three young women and then
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revised. Interviews lasted one and a half to two hours. After the interviews, all participants were invited to join “empowerment groups” conducted by the author with social workers from the Caritas Hyacinth Project. These groups addressed post-abortion concerns and worries, helped young women to find ways to regain control in intimate relationships and agency in sexuality, and facilitated mutual support. The groups ran for 6–8 sessions of two and a half hours each. Both the individual interviews and group sessions were tape-recorded and transcribed. Analysis involved conceptualizing the categories of topics discussed and their interrelationships. Consent was obtained from each participant. Ethical approval was obtained from the Hong Kong Baptist University's Committee on the Use of Human and Animal Subjects in Teaching and Research. Names of all respondents quoted have been changed. Four key informants provided information about abortion and reproductive health services in Hong Kong and verification of the information provided by participants, e.g. regarding the cost of abortions. They included two medical doctors who were working in public hospitals and two social workers in the Caritas Hyacinth Project.
Findings The background of the participants was characterized by great childhood social and economic disadvantages, dysfunctional families and poor family relationships. The participants' ages ranged from 13 to 24 at the time of interview, with a mean age of 18. All of them had undergone one or more induced abortions in their teen years, the youngest at age 13. Five of them had had abortions under the age of 16 while eight had had abortions at ages 16–17, and the rest at age 18–19. Twenty-five had experienced one abortion while four had had two abortions. None had used contraceptives, nor were their sex partners regular users of condoms. Ten had a history of drug addiction or alcohol abuse. Ten were unemployed; four were students. Nine were employed full-time at the time of pregnancy, with a monthly income of around HK$4,000–8,000 (US$512–1,025) and six were employed part-time, all 15 in unskilled occupations. Three of the 29 had used illegal abortion services in Hong Kong and four had used services
in Shenzhen in mainland China. Two had used herbal medicines prescribed by Chinese medical doctors in Hong Kong and had successfully aborted. Seventeen abortions took place in public hospitals while five were in private hospitals. Two had the procedure at a non-profit youth health clinic. Although the majority of respondents had used public services, this is because we used public hospitals to identify participants. It does not imply most young women have abortions in those hospitals. The proportion of illegal abortions among the 29 women was 27.3%. The sex partners of these young women at the time of abortion were of a similar age and socioeconomic background to them. Five were students; three were unemployed. Twenty-one were working but only 10 had stable jobs; the others were doing casual jobs and did not earn a regular income. Twelve of them had a history of drug and/or alcohol abuse and five had a background of belonging to a triad society. Four of the participants were cohabitating with these partners at the time of interview. Six of the nine who reported a stable relationship had changed partners. Many barriers to legal and safe abortions for young women were revealed, in spite of a law that permits abortions and the availability of abortion services in local public and private hospitals. Among those who went to illegal abortion services, the cost of a legal abortion, the legal consequences for their sex partners of being identified, and the requirement of parental consent on the part of public abortion services were key factors deterring them from using legal abortion services. Those who were under 16 reported the greatest stress and were most inclined to seek and use illegal abortion services. Participants aged 16–17 years old who were unwilling or unable to involve their parents also tended to resort to illegal services. Risks to physical health and post-abortion stress from illegal abortions were expressed as concerns by participants either due to their own experiences or picked up from media reports and the experiences of peers. Economic deprivation and cost of abortions Given their low-income backgrounds, the cost of abortion services was of great concern to all the respondents. Charges for an abortion in 2007–2008, the year of this study, ranged from a few hundred to more than tens of thousands of Hong Kong dollars (Table 3). These amounts 105
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came from first-hand information given by the participants of this study and confirmed by key informants. Five of the respondents, either out of their own savings or with the financial support of family members, were able to afford the costs of private medical services, including visiting private doctors and having the abortion in a private hospital which is of better quality, less stigmatized and can better ensure privacy than using public services. For the others, the first thing they had to do was to find the money needed for the abortion. The contribution of boyfriends to the fees involved was very often seen by them as a sign of commitment to the relationship and of a sense of responsibility. In many cases, where the relationship had ended before the discovery of pregnancy or the ex-boyfriend had denied the paternity, the women had to shoulder all the financial costs of abortion. Even for those young men who were willing to contribute, their own low-income background also rendered financial support difficult. The price of an abortion at the FPAHK clinic or illegal clinics in Hong Kong was a huge sum and beyond affordability for them. For the women who were working, personal savings might have been used, but were still insufficient. For those who were studying, borrowing money from their peers was a common strategy when boyfriends were not able to give financial support. Delaying abortion was not uncommon, caused by the time needed to find the money. 106
“I had a [pregnancy] test at [an illegal clinic] in [a local district]. She told me that I was pregnant and that I needed to come back the next day to take pills. How would I have such a large amount of money? {How much was it?} HK$1,500 (US$193). I had not been paid yet. How could I give them the money? Then I asked about the cost of surgical abortion. She said that it would be HK$3,000 (US$386), including anaesthesia as well… That's what she said, but when I returned after collecting enough money from friends, she said that my pregnancy was too far advanced. {How many months?} It was ten weeks, one month after my first visit. She raised the price.” (Mary) Mary was very frustrated by the delay caused by her lack of money, and she realised that if she had had HK$1,500 dollars at the time of her first visit, taking the abortion pills rather than having a surgical abortion would have been sufficient. Ah Man knew about the legal services provided by the FPA Hong Kong from the media and from social workers. However, she finally had the abortion in mainland China also because of cost. “[The FPA] required me to have a pregnancy test again and referred me to a clinic. It would have cost about HK$2,000. {What did you do when you did not have the money?} I continued to look for ways to gather the money. I did not go to the FPA in the end because they referred me to a private clinic which charged more than HK$7,000 because both the FPA clinic and the [public hospital] did not have a place for me… so I went
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to the mainland to [a public hospital] in Shenzhen. My friend introduced it to me.” (Ah Man) These statements reflect the way in which poverty influenced the choice of abortion clinic, even as the fact of poverty was one of the primary reasons for the young women's decisions to abort. Law against sex with minors The access of teenage women to legal and safe abortion services is obstructed also by the threat of prosecution of their sex partners, due to the young age of the young women themselves. In Hong Kong law, sexual intercourse with girls under 16 is unlawful, irrespective of whether consent has been given by the girl concerned. Men who are convicted of having sex with a girl under 16 may be imprisoned for up to five years17 or subject to life imprisonment if the girl is under 13.18 Yet, young people's values and attitudes towards sex have been changing rapidly in recent decades.19,20 Although there are certainly cases of unwanted and coerced sex, there are an increasing number of girls under 16 giving their consent for sex, which challenges the law that is supposed to protect them. By the threat of punishment of men to deter sexual intercourse, these laws have also increased teenage girls' vulnerability to unsafe abortions or having babies at a young age. Those who were under 16 at the time talked of struggling to protect their sexual partners from prosecution and in doing so, tried hard to hide their pregnancies from parents and teachers. A girl may also shoulder the blame for damaging the prospects of her boyfriend, who may be equally young, should he be arrested. As a result, these young women opted for illegal abortions in Hong Kong or across the border. “I was 15 at the time. I didn't want my boyfriend to face charges… [or] be put in jail. I thought that it would be best to wait until I was 16 and then have the abortion. But in the end, for my abortion, I could not go to a public hospital. They would still find out that I became pregnant when I was 15. So, I did it at an illegal clinic… I didn't let my mum find out about it because she would scold me to death.” (Kitty) An unwanted pregnancy can cause great stress for teenage girls under 16, who are unprepared for it. However, if their priority concern when considering abortion lies with protecting their sex
partners, it may preclude protecting their own needs, including health risks. Autumn, who was in form four of secondary school, found herself pregnant at the age of 16. Thinking that it may cause her boyfriend trouble if she revealed the pregnancy, she followed his suggestion to have the abortion in mainland China. She suffered from serious pain after the abortion and had to visit a local doctor for treatment. Parental consent for minors Although not a statutory requirement, both public and private hospitals in Hong Kong require parental consent for abortion for girls under age 18. In certain respects, this makes sense, as with other important decisions in a teenager's life. Parents are supposed to provide guidance to their children regarding important decisions and support for such decisions. However, as revealed in this study, it may also drive teenage women who do not want to inform their parents about the pregnancy, to illegal abortion services. The narratives of these young women suggest a strong motivation to avoid being blamed by parents, not merely for “selfish” reasons but also to avoid upsetting their parents or having to burden them with paying for the abortion, a problem especially for low-income families. The requirement of parental consent has therefore become a deterrent to using the services. Some of the girls reluctantly informed their parents in order to get a legal abortion, but felt remorse afterwards. “It was only one more month before I turned 18. On the second day, they asked my mother to sign. It was troublesome for her. So far away and my mum doesn't like to go different places… I tried to get her not to worry about me… But she was in fear and worried a lot, and could not sleep every night.” (Gillian) “…For public hospitals, they must call my parents. I won't let my parents find out about it. Even for the private [hospitals], parental signature is needed. I am not yet 16…” (May) “My father still thinks I am a virgin. I behave well at home and never show any sign of having had sex. It would kill [my father] if he finds out that not only have I had sex, but even an abortion.” (Vicky) “Those ‘under-weight’ (Hong Kong slang for underage) must use services across the border.” (Kitty) 107
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“I have thought about many different methods [of abortion], but all means only work for those who are over 16… there is just no other way.” (Sau Ling) Health risks from illegal abortion The seven young women who were driven to use illegal abortion services in Hong Kong or services in mainland China said they were fully aware of the health risks. In fact, all participants said they had heard of women experiencing complications, including serious pain, heavy bleeding, the uterus not being “cleaned out” and the threat of infertility, though they had never attempted to verify the information. These experiences were considered common events by participants in the group sessions. They also mentioned media reports of cases of heavy bleeding, sexually transmitted infections and risk of death from illegal abortions both in Hong Kong and mainland China.21–23 Nor were they worried only about physical health risks. They also associated post-abortion feelings of stress with illegal services in Hong Kong and services in China that had poor facilities and poor hygiene, as described by two participants who had abortions in illegal clinics in Hong Kong: “Picture being in a small dark room…no windows, only a bed, very horrible… the sucking pipe on the floor, big glass jars with liquids that have a stinking smell… the bed sheet was greyish, looked dirty… I didn't feel like lying on it…” (Autumn) “The room was dark. I only saw a bed and many steel tanks around with liquid and things stuffed inside. Were they babies? Was my son dumped in there as well?” (Mary)
Discussion and recommendations While public reproductive health services are supposedly available to women of all ages in Hong Kong, and young women are not denied access to contraceptive and abortion services on principle, access to abortion services in particular has been constrained by factors related to age, parental authority, laws that govern sexual abuse of girls, income and class. Induced abortion for girls under 18 has remained a highly contentious issue, and even more so for those under 16. Unwanted pregnancies and abortions constitute a tremendous cost to 108
young women, who have to cope with conflicting perspectives on sexual autonomy, moral and legal sanctions, having sex while still minors, and assuming responsibility with respect to abortion and/or mothering. Both public and private abortion services in Hong Kong are more concerned with legal responsibility and parental authority than providing needed care, guidance and support for young women to make informed decisions about their sexuality, pregnancy, mothering and abortion. They have constrained their access to legal abortion services, and fail to help them prevent unwanted pregnancies. While parental consent, from the perspective of family communication and protecting minors, may support parental authority,24 it also punishes girls for having sex,25 and makes safe, inexpensive abortions harder to get, and makes lowincome young women in Hong Kong, as also shown in the US, vulnerable to malpractice in poor quality abortion services. It is in the world of deprived and marginalized young women, such as those who participated in this research, that the hidden side of the abortion experience in Hong Kong is revealed, largely due to practices and discourses representing the dominant, negative adult morality about sex and young people. Despite research findings that increasing number of young girls are having sex before age 18,26 sex education and health service promotion for young people in Hong Kong have never attempted to address unintended pregnancy, but instead condemn teenage sex.27 This has contributed to vulnerability and lack of support for teenage pregnant women. The number of prosecutions of young men for sex with under-age girls has been decreasing in the past decades, from 119 in 2003 to 84 in 2005, and convictions from 106 to 76.28 Perhaps there is some acknowledgement that consensual sexual relations that involve girls under 16 is increasing, to explain the drop. Society faces a dilemma, on one hand to respect the personal choices of minors to have sex, yet also wanting to protect them from sex, which is mostly seen as harmful at their age. Because a pregnancy may be the result of poor knowledge or inconsistent or incorrect use of contraception among young women and men, and in the context of the gender power imbalance in intimate relationships, the solution will never be found entirely in the law, but must include empowering young
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girls to protect themselves from unwanted sex and unwanted pregnancy. Society must also face the fact that there are young women who have a need for abortion services which are safe and legal. In order to achieve reproductive justice for young, pregnant women, in which access to safe, legal abortion services is not constrained by age or class, reform of the relevant laws and practices should be considered, particularly in light of their impact on young women from deprived backgrounds. While lowering the age of consent for sex has not received wide support in the Hong Kong community, in consideration of the need to protect minors in general, health services can still take account of the needs of young women. According to key informant doctors in public hospitals, in actual practice, public health services will not inform parents or police unless they have information provided by the patients themselves or there is evidence of sexual violence or coercion. Yet, hospital authorities have never made this widely known. Social services for pregnant teens are vital for providing information and helping to facilitate informed decisions whether to continue a pregnancy or not, and the kinds of reproductive health services available. Illegal clinics should be shut down if
they are unsafe, and prices for abortion services regulated. Financial assistance to receive public services should also be made accessible to young women in poverty via social service organizations. On the whole, there is a need to strengthen services for teenage women in general in Hong Kong, and those who are pregnant in particular. Fundamentally, there is a need not only for professionals who deliver adolescent health and social welfare services, but for society to rethink and re-examine its views and attitudes toward teenage pregnancy, women's sexuality, abortion and teenage abortion. Acknowledgements This research was conducted in collaboration with the Caritas Hyacinth Project, Hong Kong. I would like to thank Charlie Chan, Winnie Ng and Justine Tsui of the Project for their involvement and support for this research. The study was presented in Chinese at: International Conference on Social Work, Social Welfare and Children's Rights in Chinese Culture; 1–2 May 2009; Providence University, Taichung, Taiwan; and at: Gender & Family in East Asia International Conference. 12–13 December 2008, Chinese University of Hong Kong.
References 1. Ross LJ. Understanding reproductive justice: transforming the pro-choice movement. Off Our Backs 2006;36(4):14–16. 2. Third Wave Foundation. Reproductive health and justice initiative report: supporting youth-led social change. New York: TWF; 2007. 3. Davies L, McKinnon M, Rains P. Creating a family: perspectives from teen mothers. Journal of Progressive Human Service 2001;12(1):83–100. 4. Greene S. Becoming responsible: young mothers’ decision making regarding motherhood and abortion. Journal of Progressive Human Services 2009;17(1): 25–43. 5. Sudhir A, Fabinenne P, Sen A. Public Health, Ethics and
6.
7.
8. 9.
10.
Equity. Oxford: Oxford University Press; 2004. Levy BL, Sidal VW. Social Injustice and Public Health. New York: Oxford University Press; 2006. Offences against the Person Ordinance. Chapter 212, Sections 46, 47, 47A; Crimes Ordinance. Chapter 200, Sections 47, 118, 119, 120 and 121. At:. Accessed 24 February 2010. Youth Sexuality Study. FPA Hong Kong, 2001. Hong Kong has the highest abortion rate (30%) in the world, more than 60% of young people interviewed accept extra-marital sex. Tai Kung Pao. 24 December 2005. Sect.A09. Female student got sex disease
11.
12.
13.
14.
15.
16.
after illegal abortion. Ming Pao Daily. 15 June 2004. Sect.A131. Five cases of abandoning dead babies in seven months. Ta Kung Pao. 7 September 2008. Sect.A051. Girls repeating abortion leading to trauma. Ming Pao Daily News. 14 February 2008. Sect.A04. Family Planning Association of Hong Kong. Annual Reports for 1992 to 2007. At:. Hospital Authority Statistical Report (2002–2003) and (2007–2008). Lam A. Drop in number of teenage abortions may be misleading. South China Morning Post. 1 May 2008. Sect.CITY3. Family Planning Association of Hong Kong. Youth sexuality study 2006.
109
SL Hung / Reproductive Health Matters 2010;18(36):102–110 17. Intercourse with girl under 16. Crimes Ordinance. Cap 200 s124, 30 June 1997. At:. Accessed 24 February 2010. 18. Intercourse with girl under 13. Crimes Ordinance. Cap 200 s123, 30 June 1997. At: . Accessed 24 February 2010. 19. Fan S, Pu A. More open attitude towards sex among Hong Kong youth. People and Development Challenges 1998; 5(9):24–25. 20. Ip WY, Chau JPC, Chang AM, et al. Knowledge and attitudes toward sex among Chinese adolescents. Western Journal
21.
22.
23.
24.
of Nursing Research 2001; 23:211–23. Falling into the trap of illegal doctors in Shenzhen, woman suffered from serious bleeding after abortion. The Sun. 6 March 2004. Sect.A14. Female student contaminated sexual disease, medical doctor blamed sex education. Ming Pao Daily 15 June 2004. Sect.A13. Registered Chinese herbal doctor charged for possessing abortion medicine was discharged. Tai Kung Pao. 31 January 2009. Sect.A05. Harper CC, Henderson JT, Darney PD. Abortion in the United States. Annual Reviews Public Health 2005;26:501–12.
Résumé En 2007–08, une étude qualitative a porté sur les expériences de l'avortement d'adolescentes issues de milieux défavorisés à Hong Kong. Vingt-neuf jeunes femmes âgées de 13 à 24 ans qui avaient avorté une ou plusieurs fois pendant leur adolescence ont été interrogées et ont participé à des séances d'autonomisation de groupe. Dix étaient au chômage, quatre étaient étudiantes, les autres occupaient des emplois non qualifiés et peu rémunérés. Les services d'avortement sont légaux et disponibles dans des services publics et privés ; mais ils perçoivent des honoraires allant de HK$310 à HK$10 000 et ne pratiquent les avortements que jusqu'à 24 semaines de grossesse. Beaucoup de jeunes femmes ont recours à des centres illégaux de mauvaise qualité ou des centres en Chine continentale car ils sont moins coûteux, elles ne souhaitent pas le dire à leurs parents qui devraient donner leur consentement, et/ou elles veulent protéger leur partenaire sexuel, qui pourrait être dénoncé et poursuivi si la fille est mineure. Il faut renforcer les services pour adolescentes à Hong Kong, en particulier celles qui sont enceintes et issues de milieux défavorisés. On a également besoin de professionnels qui assurent des services de santé et de protection sociale des jeunes alors que la société devrait repenser et réexaminer ses idées et ses attitudes à l'égard de la grossesse, la sexualité et l'avortement chez les adolescentes.
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25. Sanger C. Regulating teenage abortion in the United States: politics and policy. International Journal of Law, Policy and the Family 2004; 18(3):305–18. 26. Family Planning Association of Hong Kong. Youth sexuality study, 1991; 1996; 2001; 2006. 27. Man SW, Choi PK. Rethinking sex education: reference manual for educators. Hong Kong: Chinese University of Hong Kong; 1997. 28. Legislative Council. Sex crime and related matters. At:
Resumen En este artículo se informa acerca de un estudio cualitativo realizado en 2007–08 sobre las experiencias de aborto de mujeres adolescentes de clases carenciadas en Hong Kong. Se entrevistaron 29 jóvenes de 13 a 24 años de edad, que habían tenido uno o más abortos inducidos entre los 13 y 19 años, quienes también participaron en sesiones de empoderamiento en grupo. Diez estaban desempleadas, cuatro eran estudiantes y el resto de ellas estaban empleadas en ocupaciones no especializadas de bajo salario. Los servicios de aborto son legales y accesibles en establecimientos públicos y privados, pero estos cobran entre HK$310 y $10,000 y realizan abortos sólo hasta las 24 semanas del embarazo. Muchas jóvenes recurren a clínicas ilegales de mala calidad y a clínicas en China continental porque el costo es más bajo, no quieren informar a sus padres, a quienes se les pediría su consentimiento, y/o quieren proteger a su pareja sexual, quien podría ser denunciada y enjuiciada si la niña es menor de edad. Es necesario fortalecer los servicios para mujeres adolescentes en Hong Kong, especialmente para aquéllas que están embarazadas y son de clases carenciadas. Además, es necesario que la sociedad y los profesionales que proporcionan servicios de salud y asistencia social a las adolescentes reconsideren y reexaminen sus puntos de vista y actitudes hacia el embarazo, la sexualidad y el aborto en la adolescencia.
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Access to safe and legal abortion for teenage women from deprived backgrounds in Hong Kong Suet Lin Hung Assistant Professor, Department of Social Work, Hong Kong Baptist University, Kowloon, Hong Kong. E-mail: [email protected]
Abstract: This paper reports on a qualitative study in 2007–08 on the abortion experiences of teenage women from deprived backgrounds in Hong Kong. Twenty-nine young women aged 13–24 who had undergone one or more induced abortions in their teen years were interviewed and participated in group empowerment sessions. Ten were unemployed, four were students, the rest were employed on low pay in unskilled occupations. Abortion services are legal and available in public and private services, but they charge fees ranging from HK$310 to $10,000, and do abortions only up to 24 weeks of pregnancy. Many young women resort to poor quality illegal clinics and clinics in mainland China because the cost is lower, they do not wish to tell their parents, who would be asked for consent, and/or they want to protect their sex partners, who may be reported and prosecuted if the girl is under-age. There is a need to strengthen services for teenage women in Hong Kong, especially those who are pregnant and from deprived backgrounds. There is also a need for professionals who deliver adolescent health and social welfare services, and for society to rethink and re-examine its views and attitudes towards teenage pregnancy, sexuality and abortion. ©2010 Reproductive Health Matters. All rights reserved. Keywords: abortion law and policy, adolescents and young people, reproductive rights, unwanted pregnancy, women's health services, Hong Kong
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TIGMA has long been attached to teenage pregnancy across the world, including in Hong Kong. While teenage abortion and parenthood are well researched in the west, and social support programmes have been developed for young mothers in deprived communities, such as Sure Start and Head Start in the UK and US, respectively, teenage pregnancy is under-researched and not addressed in Hong Kong. Little is known about the group of girls who have experienced induced abortion: their age, marital status, educational or employment status; reasons for abortion; use of legal or illegal services in Hong Kong or mainland China; post-abortion concerns; or the ways they create meaning from the experience for themselves or in intimate relationships. Western studies have revealed that the experience of teenage pregnancy is influenced by 102
gender, race, class and cultural factors, and that women who are young, poor or from ethnic minorities cannot afford expensive or private abortion services.1–6 This is also the case for Hong Kong. Drawing on a qualitative study from 2007 to 2008, this paper attempts to fill the knowledge gap regarding the experience of teenage women in Hong Kong from deprived backgrounds who seek an abortion and the extent to which their access to legal services is constrained by age, income and class.
Abortion law and services in Hong Kong and mainland China Abortion law reform in Hong Kong in 1972 has allowed women to terminate their pregnancies lawfully if two medical practitioners consider that continuation of the pregnancy would risk
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the pregnant woman's life, cause injury to her physical or mental health, or if there is a substantial risk that if the child is born, it would suffer from physical or mental abnormalities as to be considered seriously handicapped. A revision in 1981 extended the law to include young women under 16 and victims of rape, seduction or incest. Termination of pregnancies of more than 24 weeks is normally not allowed unless it is necessary to save the life of the woman.7 Abortion services are available in public and private hospitals and clinics, which charge fees based mainly on length of pregnancy, type of procedure, and days of stay in hospital. There are also illegal abortion clinics and Chinese medical doctors who provide herbal medicines to terminate pregnancies, which are widely known. There are also easily accessible and less expensive abortion services in mainland China, where women can have the procedure without having to provide reasons. Along with rapid economic development in China's southern cities, public hospitals and clinics, in Shenzhen and Guangzhou in particular, are targeting Hong Kong people to increase their patient population. Abortion services are available to Hong Kong women of all ages, including those with pregnancies over 24 weeks. Private hospitals and clinics targeting poor communities charge even less than others. The Youth Sexuality Study conducted by the Family Planning Association of Hong Kong (FPAHK) in 2001, among 579 women aged 18–27, found that of the 43 participants who had had an induced abortion, some may have had more than one abortion. Among the 20 who said they had had illegal abortions, 17 went to local illegal providers and three to Shenzhen on the mainland.8 According to information released by the Department of Health, reported widely in the newspapers, there were 20,234 abortions and 49,144 live births in Hong Kong in 2001, making the number of abortions 29.2% of registered pregnancies. That percentage would be higher if illegal abortions in Hong Kong and abor-
tions in mainland China were included.9 Further enquiry revealed that no disaggregated statistics on teenage abortions were available or have been published. Teenage pregnancy, abortion and mothering only draw public attention in Hong Kong society when there are news reports, e.g. of tragic outcomes for women from unsafe abortions or sensationalist claims. In 2004, there was a report about young women who had contracted chlamydia and pelvic inflammatory disease after undergoing illegal abortions. 10 In 2008, there was a report that five newborn babies had been killed and dumped in public toilets or tossed down from high-rise apartment blocks over a period of seven months. 11 The Caritas Hyacinth Project, collaborator of this research, that pioneered services for young women with unwanted pregnancy, reported in 2008 that they were expressing feelings of stress and self-blame post-abortion, saying they missed the baby, feared revenge from its spirit, or were worried about the health-related consequences of unsafe, illegal abortions.12 Some statistics on the extent of induced abortions among young women are available, but they cover different age groups or are not broken down by age, and therefore only provide a broad picture. The Youth Health Care Centre of the FPAHK, the only clinic targeted at young people under 26 in Hong Kong, provides abortion services only until the tenth week of pregnancy and refers those over ten weeks to public or private hospitals. Table 1 shows the number of their clinic attendees who requested services for induced abortion from 1992–2007. These figures have not been broken down by age and the number of young women who were in their teens is not known.13 The Department of Health was able to provide unpublished data on those aged 19 or below who had had abortions in all 41 public hospitals from 1992 to 2007 (Table 2) at the author's request in early 2008, but the totals did not tally with the Hospital Authority's statistics.
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The number, they said, fluctuated before 2000 and has decreased since 2000. The decrease seems to coincide with the overall declining rate of abortions in Hong Kong, but social services key informants believed that the growing popularity among young women of using private hospitals or illegal abortion services may also explain the decline. The great majority of the young women under age 19 in the years reported were single (92–99%), but no further breakdown of information by age was available. A far greater number of abortions at all ages, in fact, took place in private hospitals. According to figures released by the Hospital Authority, there were 6,506 and 5,070 abortions conducted in public hospitals and 11,199 and 19,814 in private hospitals in 2002 and 2007, respectively, but again breakdown by age is not available.14 Mother Choice, the only social welfare organization which provides shelter for pregnant girls, consider these figures under-reported, and argue that many more young women are using hospitals and clinics in mainland China. They base this view on the increasing number of enquiries concerning pregnancy received by them from teenage women under the age of 18, which rose from 2,286 in 2007 to 2,854 in 2008.15 Other data reveal an increasing number of teenagers who are having sexual experiences in the absence of inadequate knowledge about or use of contraception. Studies on youth sexuality conducted by the Family Planning Association of Hong Kong in 1991, 1996, 2001 and 2006 among those aged 15–17 reveal an increasing percentage of reported first sexual intercourse below 15 years of age, rising from 1.0% to 8.7% for teenage girls and from 5.8% to 12% for teenage boys in 1991 and 2006, respectively. In the 2006 study, only 54.5% of teenage girls and 59.9% of teenage boys who had had sexual intercourse reported using contracep104
tives, with the majority using male condoms or withdrawal.16 Overall, in spite of incomplete data, existing studies reviewed highlight a growing prevalence of sexual intercourse at a young age, insufficient knowledge and use of contraception among young people, and an increasing number of young pregnant women seeking help, including for abortions.
Methods This was an exploratory study conducted from December 2007 to September 2008 of the abortion experiences of 29 young women in their teenage years from deprived backgrounds in Hong Kong. A qualitative methodology was adopted using individual, in-depth interviews. Young women from deprived backgrounds were targeted because they are particularly vulnerable when pregnant. The topics covered included past and current relationships with men, use of contraception, experience with abortion and contraceptive services, meaning ascribed to abortion and impact of abortion. The research was conducted in collaboration with the Caritas Hyacinth Project, the only social work project that provides case counselling and group work for this specific group. The young women were recruited by social workers from the Project during their visits to public hospitals, or were referred by other social workers from youth outreach service teams. All 48 abortion service users with a similar background – teenage, low income and unwed – seen by social workers during the study period were invited to participate in the research. Of the 48 invited, 29 took part. The rest declined, citing personal reasons such as unwillingness to talk about abortion or unavailability for long interviews. A semi-structured interview guide was developed, piloted with three young women and then
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revised. Interviews lasted one and a half to two hours. After the interviews, all participants were invited to join “empowerment groups” conducted by the author with social workers from the Caritas Hyacinth Project. These groups addressed post-abortion concerns and worries, helped young women to find ways to regain control in intimate relationships and agency in sexuality, and facilitated mutual support. The groups ran for 6–8 sessions of two and a half hours each. Both the individual interviews and group sessions were tape-recorded and transcribed. Analysis involved conceptualizing the categories of topics discussed and their interrelationships. Consent was obtained from each participant. Ethical approval was obtained from the Hong Kong Baptist University's Committee on the Use of Human and Animal Subjects in Teaching and Research. Names of all respondents quoted have been changed. Four key informants provided information about abortion and reproductive health services in Hong Kong and verification of the information provided by participants, e.g. regarding the cost of abortions. They included two medical doctors who were working in public hospitals and two social workers in the Caritas Hyacinth Project.
Findings The background of the participants was characterized by great childhood social and economic disadvantages, dysfunctional families and poor family relationships. The participants' ages ranged from 13 to 24 at the time of interview, with a mean age of 18. All of them had undergone one or more induced abortions in their teen years, the youngest at age 13. Five of them had had abortions under the age of 16 while eight had had abortions at ages 16–17, and the rest at age 18–19. Twenty-five had experienced one abortion while four had had two abortions. None had used contraceptives, nor were their sex partners regular users of condoms. Ten had a history of drug addiction or alcohol abuse. Ten were unemployed; four were students. Nine were employed full-time at the time of pregnancy, with a monthly income of around HK$4,000–8,000 (US$512–1,025) and six were employed part-time, all 15 in unskilled occupations. Three of the 29 had used illegal abortion services in Hong Kong and four had used services
in Shenzhen in mainland China. Two had used herbal medicines prescribed by Chinese medical doctors in Hong Kong and had successfully aborted. Seventeen abortions took place in public hospitals while five were in private hospitals. Two had the procedure at a non-profit youth health clinic. Although the majority of respondents had used public services, this is because we used public hospitals to identify participants. It does not imply most young women have abortions in those hospitals. The proportion of illegal abortions among the 29 women was 27.3%. The sex partners of these young women at the time of abortion were of a similar age and socioeconomic background to them. Five were students; three were unemployed. Twenty-one were working but only 10 had stable jobs; the others were doing casual jobs and did not earn a regular income. Twelve of them had a history of drug and/or alcohol abuse and five had a background of belonging to a triad society. Four of the participants were cohabitating with these partners at the time of interview. Six of the nine who reported a stable relationship had changed partners. Many barriers to legal and safe abortions for young women were revealed, in spite of a law that permits abortions and the availability of abortion services in local public and private hospitals. Among those who went to illegal abortion services, the cost of a legal abortion, the legal consequences for their sex partners of being identified, and the requirement of parental consent on the part of public abortion services were key factors deterring them from using legal abortion services. Those who were under 16 reported the greatest stress and were most inclined to seek and use illegal abortion services. Participants aged 16–17 years old who were unwilling or unable to involve their parents also tended to resort to illegal services. Risks to physical health and post-abortion stress from illegal abortions were expressed as concerns by participants either due to their own experiences or picked up from media reports and the experiences of peers. Economic deprivation and cost of abortions Given their low-income backgrounds, the cost of abortion services was of great concern to all the respondents. Charges for an abortion in 2007–2008, the year of this study, ranged from a few hundred to more than tens of thousands of Hong Kong dollars (Table 3). These amounts 105
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came from first-hand information given by the participants of this study and confirmed by key informants. Five of the respondents, either out of their own savings or with the financial support of family members, were able to afford the costs of private medical services, including visiting private doctors and having the abortion in a private hospital which is of better quality, less stigmatized and can better ensure privacy than using public services. For the others, the first thing they had to do was to find the money needed for the abortion. The contribution of boyfriends to the fees involved was very often seen by them as a sign of commitment to the relationship and of a sense of responsibility. In many cases, where the relationship had ended before the discovery of pregnancy or the ex-boyfriend had denied the paternity, the women had to shoulder all the financial costs of abortion. Even for those young men who were willing to contribute, their own low-income background also rendered financial support difficult. The price of an abortion at the FPAHK clinic or illegal clinics in Hong Kong was a huge sum and beyond affordability for them. For the women who were working, personal savings might have been used, but were still insufficient. For those who were studying, borrowing money from their peers was a common strategy when boyfriends were not able to give financial support. Delaying abortion was not uncommon, caused by the time needed to find the money. 106
“I had a [pregnancy] test at [an illegal clinic] in [a local district]. She told me that I was pregnant and that I needed to come back the next day to take pills. How would I have such a large amount of money? {How much was it?} HK$1,500 (US$193). I had not been paid yet. How could I give them the money? Then I asked about the cost of surgical abortion. She said that it would be HK$3,000 (US$386), including anaesthesia as well… That's what she said, but when I returned after collecting enough money from friends, she said that my pregnancy was too far advanced. {How many months?} It was ten weeks, one month after my first visit. She raised the price.” (Mary) Mary was very frustrated by the delay caused by her lack of money, and she realised that if she had had HK$1,500 dollars at the time of her first visit, taking the abortion pills rather than having a surgical abortion would have been sufficient. Ah Man knew about the legal services provided by the FPA Hong Kong from the media and from social workers. However, she finally had the abortion in mainland China also because of cost. “[The FPA] required me to have a pregnancy test again and referred me to a clinic. It would have cost about HK$2,000. {What did you do when you did not have the money?} I continued to look for ways to gather the money. I did not go to the FPA in the end because they referred me to a private clinic which charged more than HK$7,000 because both the FPA clinic and the [public hospital] did not have a place for me… so I went
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to the mainland to [a public hospital] in Shenzhen. My friend introduced it to me.” (Ah Man) These statements reflect the way in which poverty influenced the choice of abortion clinic, even as the fact of poverty was one of the primary reasons for the young women's decisions to abort. Law against sex with minors The access of teenage women to legal and safe abortion services is obstructed also by the threat of prosecution of their sex partners, due to the young age of the young women themselves. In Hong Kong law, sexual intercourse with girls under 16 is unlawful, irrespective of whether consent has been given by the girl concerned. Men who are convicted of having sex with a girl under 16 may be imprisoned for up to five years17 or subject to life imprisonment if the girl is under 13.18 Yet, young people's values and attitudes towards sex have been changing rapidly in recent decades.19,20 Although there are certainly cases of unwanted and coerced sex, there are an increasing number of girls under 16 giving their consent for sex, which challenges the law that is supposed to protect them. By the threat of punishment of men to deter sexual intercourse, these laws have also increased teenage girls' vulnerability to unsafe abortions or having babies at a young age. Those who were under 16 at the time talked of struggling to protect their sexual partners from prosecution and in doing so, tried hard to hide their pregnancies from parents and teachers. A girl may also shoulder the blame for damaging the prospects of her boyfriend, who may be equally young, should he be arrested. As a result, these young women opted for illegal abortions in Hong Kong or across the border. “I was 15 at the time. I didn't want my boyfriend to face charges… [or] be put in jail. I thought that it would be best to wait until I was 16 and then have the abortion. But in the end, for my abortion, I could not go to a public hospital. They would still find out that I became pregnant when I was 15. So, I did it at an illegal clinic… I didn't let my mum find out about it because she would scold me to death.” (Kitty) An unwanted pregnancy can cause great stress for teenage girls under 16, who are unprepared for it. However, if their priority concern when considering abortion lies with protecting their sex
partners, it may preclude protecting their own needs, including health risks. Autumn, who was in form four of secondary school, found herself pregnant at the age of 16. Thinking that it may cause her boyfriend trouble if she revealed the pregnancy, she followed his suggestion to have the abortion in mainland China. She suffered from serious pain after the abortion and had to visit a local doctor for treatment. Parental consent for minors Although not a statutory requirement, both public and private hospitals in Hong Kong require parental consent for abortion for girls under age 18. In certain respects, this makes sense, as with other important decisions in a teenager's life. Parents are supposed to provide guidance to their children regarding important decisions and support for such decisions. However, as revealed in this study, it may also drive teenage women who do not want to inform their parents about the pregnancy, to illegal abortion services. The narratives of these young women suggest a strong motivation to avoid being blamed by parents, not merely for “selfish” reasons but also to avoid upsetting their parents or having to burden them with paying for the abortion, a problem especially for low-income families. The requirement of parental consent has therefore become a deterrent to using the services. Some of the girls reluctantly informed their parents in order to get a legal abortion, but felt remorse afterwards. “It was only one more month before I turned 18. On the second day, they asked my mother to sign. It was troublesome for her. So far away and my mum doesn't like to go different places… I tried to get her not to worry about me… But she was in fear and worried a lot, and could not sleep every night.” (Gillian) “…For public hospitals, they must call my parents. I won't let my parents find out about it. Even for the private [hospitals], parental signature is needed. I am not yet 16…” (May) “My father still thinks I am a virgin. I behave well at home and never show any sign of having had sex. It would kill [my father] if he finds out that not only have I had sex, but even an abortion.” (Vicky) “Those ‘under-weight’ (Hong Kong slang for underage) must use services across the border.” (Kitty) 107
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“I have thought about many different methods [of abortion], but all means only work for those who are over 16… there is just no other way.” (Sau Ling) Health risks from illegal abortion The seven young women who were driven to use illegal abortion services in Hong Kong or services in mainland China said they were fully aware of the health risks. In fact, all participants said they had heard of women experiencing complications, including serious pain, heavy bleeding, the uterus not being “cleaned out” and the threat of infertility, though they had never attempted to verify the information. These experiences were considered common events by participants in the group sessions. They also mentioned media reports of cases of heavy bleeding, sexually transmitted infections and risk of death from illegal abortions both in Hong Kong and mainland China.21–23 Nor were they worried only about physical health risks. They also associated post-abortion feelings of stress with illegal services in Hong Kong and services in China that had poor facilities and poor hygiene, as described by two participants who had abortions in illegal clinics in Hong Kong: “Picture being in a small dark room…no windows, only a bed, very horrible… the sucking pipe on the floor, big glass jars with liquids that have a stinking smell… the bed sheet was greyish, looked dirty… I didn't feel like lying on it…” (Autumn) “The room was dark. I only saw a bed and many steel tanks around with liquid and things stuffed inside. Were they babies? Was my son dumped in there as well?” (Mary)
Discussion and recommendations While public reproductive health services are supposedly available to women of all ages in Hong Kong, and young women are not denied access to contraceptive and abortion services on principle, access to abortion services in particular has been constrained by factors related to age, parental authority, laws that govern sexual abuse of girls, income and class. Induced abortion for girls under 18 has remained a highly contentious issue, and even more so for those under 16. Unwanted pregnancies and abortions constitute a tremendous cost to 108
young women, who have to cope with conflicting perspectives on sexual autonomy, moral and legal sanctions, having sex while still minors, and assuming responsibility with respect to abortion and/or mothering. Both public and private abortion services in Hong Kong are more concerned with legal responsibility and parental authority than providing needed care, guidance and support for young women to make informed decisions about their sexuality, pregnancy, mothering and abortion. They have constrained their access to legal abortion services, and fail to help them prevent unwanted pregnancies. While parental consent, from the perspective of family communication and protecting minors, may support parental authority,24 it also punishes girls for having sex,25 and makes safe, inexpensive abortions harder to get, and makes lowincome young women in Hong Kong, as also shown in the US, vulnerable to malpractice in poor quality abortion services. It is in the world of deprived and marginalized young women, such as those who participated in this research, that the hidden side of the abortion experience in Hong Kong is revealed, largely due to practices and discourses representing the dominant, negative adult morality about sex and young people. Despite research findings that increasing number of young girls are having sex before age 18,26 sex education and health service promotion for young people in Hong Kong have never attempted to address unintended pregnancy, but instead condemn teenage sex.27 This has contributed to vulnerability and lack of support for teenage pregnant women. The number of prosecutions of young men for sex with under-age girls has been decreasing in the past decades, from 119 in 2003 to 84 in 2005, and convictions from 106 to 76.28 Perhaps there is some acknowledgement that consensual sexual relations that involve girls under 16 is increasing, to explain the drop. Society faces a dilemma, on one hand to respect the personal choices of minors to have sex, yet also wanting to protect them from sex, which is mostly seen as harmful at their age. Because a pregnancy may be the result of poor knowledge or inconsistent or incorrect use of contraception among young women and men, and in the context of the gender power imbalance in intimate relationships, the solution will never be found entirely in the law, but must include empowering young
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girls to protect themselves from unwanted sex and unwanted pregnancy. Society must also face the fact that there are young women who have a need for abortion services which are safe and legal. In order to achieve reproductive justice for young, pregnant women, in which access to safe, legal abortion services is not constrained by age or class, reform of the relevant laws and practices should be considered, particularly in light of their impact on young women from deprived backgrounds. While lowering the age of consent for sex has not received wide support in the Hong Kong community, in consideration of the need to protect minors in general, health services can still take account of the needs of young women. According to key informant doctors in public hospitals, in actual practice, public health services will not inform parents or police unless they have information provided by the patients themselves or there is evidence of sexual violence or coercion. Yet, hospital authorities have never made this widely known. Social services for pregnant teens are vital for providing information and helping to facilitate informed decisions whether to continue a pregnancy or not, and the kinds of reproductive health services available. Illegal clinics should be shut down if
they are unsafe, and prices for abortion services regulated. Financial assistance to receive public services should also be made accessible to young women in poverty via social service organizations. On the whole, there is a need to strengthen services for teenage women in general in Hong Kong, and those who are pregnant in particular. Fundamentally, there is a need not only for professionals who deliver adolescent health and social welfare services, but for society to rethink and re-examine its views and attitudes toward teenage pregnancy, women's sexuality, abortion and teenage abortion. Acknowledgements This research was conducted in collaboration with the Caritas Hyacinth Project, Hong Kong. I would like to thank Charlie Chan, Winnie Ng and Justine Tsui of the Project for their involvement and support for this research. The study was presented in Chinese at: International Conference on Social Work, Social Welfare and Children's Rights in Chinese Culture; 1–2 May 2009; Providence University, Taichung, Taiwan; and at: Gender & Family in East Asia International Conference. 12–13 December 2008, Chinese University of Hong Kong.
References 1. Ross LJ. Understanding reproductive justice: transforming the pro-choice movement. Off Our Backs 2006;36(4):14–16. 2. Third Wave Foundation. Reproductive health and justice initiative report: supporting youth-led social change. New York: TWF; 2007. 3. Davies L, McKinnon M, Rains P. Creating a family: perspectives from teen mothers. Journal of Progressive Human Service 2001;12(1):83–100. 4. Greene S. Becoming responsible: young mothers’ decision making regarding motherhood and abortion. Journal of Progressive Human Services 2009;17(1): 25–43. 5. Sudhir A, Fabinenne P, Sen A. Public Health, Ethics and
6.
7.
8. 9.
10.
Equity. Oxford: Oxford University Press; 2004. Levy BL, Sidal VW. Social Injustice and Public Health. New York: Oxford University Press; 2006. Offences against the Person Ordinance. Chapter 212, Sections 46, 47, 47A; Crimes Ordinance. Chapter 200, Sections 47, 118, 119, 120 and 121. At:
11.
12.
13.
14.
15.
16.
after illegal abortion. Ming Pao Daily. 15 June 2004. Sect.A131. Five cases of abandoning dead babies in seven months. Ta Kung Pao. 7 September 2008. Sect.A051. Girls repeating abortion leading to trauma. Ming Pao Daily News. 14 February 2008. Sect.A04. Family Planning Association of Hong Kong. Annual Reports for 1992 to 2007. At:
109
SL Hung / Reproductive Health Matters 2010;18(36):102–110 17. Intercourse with girl under 16. Crimes Ordinance. Cap 200 s124, 30 June 1997. At:
21.
22.
23.
24.
of Nursing Research 2001; 23:211–23. Falling into the trap of illegal doctors in Shenzhen, woman suffered from serious bleeding after abortion. The Sun. 6 March 2004. Sect.A14. Female student contaminated sexual disease, medical doctor blamed sex education. Ming Pao Daily 15 June 2004. Sect.A13. Registered Chinese herbal doctor charged for possessing abortion medicine was discharged. Tai Kung Pao. 31 January 2009. Sect.A05. Harper CC, Henderson JT, Darney PD. Abortion in the United States. Annual Reviews Public Health 2005;26:501–12.
Résumé En 2007–08, une étude qualitative a porté sur les expériences de l'avortement d'adolescentes issues de milieux défavorisés à Hong Kong. Vingt-neuf jeunes femmes âgées de 13 à 24 ans qui avaient avorté une ou plusieurs fois pendant leur adolescence ont été interrogées et ont participé à des séances d'autonomisation de groupe. Dix étaient au chômage, quatre étaient étudiantes, les autres occupaient des emplois non qualifiés et peu rémunérés. Les services d'avortement sont légaux et disponibles dans des services publics et privés ; mais ils perçoivent des honoraires allant de HK$310 à HK$10 000 et ne pratiquent les avortements que jusqu'à 24 semaines de grossesse. Beaucoup de jeunes femmes ont recours à des centres illégaux de mauvaise qualité ou des centres en Chine continentale car ils sont moins coûteux, elles ne souhaitent pas le dire à leurs parents qui devraient donner leur consentement, et/ou elles veulent protéger leur partenaire sexuel, qui pourrait être dénoncé et poursuivi si la fille est mineure. Il faut renforcer les services pour adolescentes à Hong Kong, en particulier celles qui sont enceintes et issues de milieux défavorisés. On a également besoin de professionnels qui assurent des services de santé et de protection sociale des jeunes alors que la société devrait repenser et réexaminer ses idées et ses attitudes à l'égard de la grossesse, la sexualité et l'avortement chez les adolescentes.
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25. Sanger C. Regulating teenage abortion in the United States: politics and policy. International Journal of Law, Policy and the Family 2004; 18(3):305–18. 26. Family Planning Association of Hong Kong. Youth sexuality study, 1991; 1996; 2001; 2006. 27. Man SW, Choi PK. Rethinking sex education: reference manual for educators. Hong Kong: Chinese University of Hong Kong; 1997. 28. Legislative Council. Sex crime and related matters. At:
Resumen En este artículo se informa acerca de un estudio cualitativo realizado en 2007–08 sobre las experiencias de aborto de mujeres adolescentes de clases carenciadas en Hong Kong. Se entrevistaron 29 jóvenes de 13 a 24 años de edad, que habían tenido uno o más abortos inducidos entre los 13 y 19 años, quienes también participaron en sesiones de empoderamiento en grupo. Diez estaban desempleadas, cuatro eran estudiantes y el resto de ellas estaban empleadas en ocupaciones no especializadas de bajo salario. Los servicios de aborto son legales y accesibles en establecimientos públicos y privados, pero estos cobran entre HK$310 y $10,000 y realizan abortos sólo hasta las 24 semanas del embarazo. Muchas jóvenes recurren a clínicas ilegales de mala calidad y a clínicas en China continental porque el costo es más bajo, no quieren informar a sus padres, a quienes se les pediría su consentimiento, y/o quieren proteger a su pareja sexual, quien podría ser denunciada y enjuiciada si la niña es menor de edad. Es necesario fortalecer los servicios para mujeres adolescentes en Hong Kong, especialmente para aquéllas que están embarazadas y son de clases carenciadas. Además, es necesario que la sociedad y los profesionales que proporcionan servicios de salud y asistencia social a las adolescentes reconsideren y reexaminen sus puntos de vista y actitudes hacia el embarazo, la sexualidad y el aborto en la adolescencia.