Sexual and Reproductive Health Needs, Knowledge, Access, and Barriers to Services Among Rohingya Adolescent Refugee Girls in Cox’s Bazar, Bangladesh

Abstract

This paper examines the sexual and reproductive health (SRH) knowledge, experiences, service access, and unmet needs of Rohingya adolescent refugee girls living in the camps of Cox’s Bazar, Bangladesh. The refugee population in these camps is approximately 1.3 million, with more than half under the age of 18 and girls representing over one quarter of the total. Given the growing proportion of adolescent girls, SRH knowledge and service provision are critical both for the refugee community and for Bangladesh’s broader sustainable development goals. Drawing on direct accounts from adolescent girls and insights from community-based key informants, this research explores levels of SRH awareness, willingness to seek care, encounters with sexual violence, understanding of sexually transmitted diseases, and reproductive health priorities. It also identifies barriers to service delivery faced by healthcare and humanitarian providers. The findings highlight how cultural norms, social constraints, and religious beliefs intersect with structural barriers—including lack of education, financial dependence, gender-based violence, and the need for parental or spousal consent—to restrict access to SRH services. Despite these challenges, some participants reported successfully receiving reproductive health care. This paper calls for coordinated action from the government, humanitarian agencies, and social service organisations to improve both the availability and accessibility of SRH services for adolescent refugee girls. Strategies should include enhanced outreach, culturally responsive engagement, and sustained follow-up care to promote safety, dignity, and well-being within the camps.

1. Introduction

Sexual and reproductive health (SRH) is a fundamental human right and an essential component of overall well-being. Yet for displaced populations, especially adolescent girls, it remains an area of persistent neglect. The Rohingya refugee crisis—one of the largest and continuing humanitarian emergencies in the world—has forced over a million people to flee from Myanmar to neighbouring Bangladesh since 2017. Among them, adolescent girls face unique vulnerabilities shaped by their age, gender, and refugee status, including human rights abuses, domestic violence, and sexual and gender-based violence (SGBV) (Inter-Sector Coordination Group (ISCG) 2019). In the congested, resource-limited camps of Cox’s Bazar, these girls often contend with inadequate access to SRH information, restricted mobility, cultural norms that discourage open discussion about sexuality, and limited availability of appropriate services.

Global research consistently highlights how adolescent girls in humanitarian settings encounter heightened risks of sexual violence, early marriage, unplanned pregnancy, and reproductive health complications, yet they remain underrepresented in policy and programming. In the context of the Rohingya camps, the intersection of displacement, poverty, restrictive gender norms, and a lack of tailored SRH interventions exacerbates these risks. Understanding their SRH needs, levels of knowledge, access to services, and the barriers they face is essential for designing effective, culturally sensitive interventions that can safeguard their rights and improve health outcomes.

This study responds to that gap by examining the lived realities of Rohingya adolescent refugee girls in Bangladesh’s Cox’s Bazar. It explores their SRH knowledge, experiences, service access, and unmet needs, with the aim of informing humanitarian actors, policymakers, and service providers. By centring the voices and perspectives of these young women, this research seeks to contribute to more inclusive SRH programming that acknowledges the complex social, cultural, and structural factors shaping their lives.

2. Materials and Methods

2.1. Study Sites

This research was carried out in eight Rohingya refugee camps located in the Ukhiya and Teknaf sub-districts of Cox’s Bazar, Bangladesh. These camps were selected for their large adolescent populations and the presence of health facilities operated by a range of service providers, both national and international. This allowed for comparison across different service delivery models and contextual influences. The camps have remained under strict surveillance and limited mobility measures, particularly during the COVID-19 lockdown period in which this study took place.

2.2. Study Design

This was a qualitative study designed to explore the sexual and reproductive health (SRH) experiences and perceptions of adolescent girls in humanitarian settings. The research adopted a rights-based and socio-ecological framework to understand how gender, displacement, age, and access to services interact in shaping SRH needs and behaviours. Semi-structured interviews were used to gather first-person accounts of lived experience. These interviews were conducted face-to-face with 15 adolescent girls aged 13–19, alongside key informant interviews with 10 professionals working in the camps, including healthcare providers, NGO staff, and community leaders involved in SRH programming.

2.3. Participant Recruitment

Adolescent participants were identified using purposive sampling, in collaboration with community health workers and camp-based organisations. This approach allowed us to ensure a diverse range of participants in terms of age, marital status, and exposure to SRH services. Participants under the age of 18 were recruited only after obtaining informed assent and guardian consent, while those aged 18 and over gave their own consent. Recruitment was performed in camp-based community spaces and health facilities.

2.4. Data Collection

Data collection took place between July and September 2020. During this period, mobility restrictions due to the COVID-19 pandemic were in effect across the camps, requiring extra sensitivity to participants’ safety and well-being. All interviews with adolescents were conducted in private rooms within health facilities, with midwives or female community health workers nearby for support. Female interviewers fluent in Rohingya and English conducted the interviews using a semi-structured guide developed in line with the study aims and previous literature on SRH in displacement contexts. Questions explored SRH knowledge, access to services, community norms, decision-making processes, and experiences of care. Interviews with adolescents typically lasted 45–60 min; those with key informants lasted 60–90 min. All interviews were audio-recorded with permission then transcribed and translated into English.

2.5. Ethical Considerations

This study was approved by the Research Ethics Committee of the School of Social and Political Science at the University of Edinburgh (Ref: GP2020APR). Interviewers were trained in ethical procedures, including informed consent, privacy, non-maleficence, safeguarding, and cultural sensitivity. Participants were informed that they could skip any questions and withdraw from the study at any time.

2.6. Data Analysis

The qualitative data were analysed thematically, following Braun and Clarke’s (2006) six-phase approach (Clarke and Braun 2014). The transcripts were read and re-read to enable immersion, with initial codes systematically generated across the entire dataset. Codes were then collated into potential themes, which were refined through iterative comparison and discussion to ensure that they captured both the breadth and depth of the data.

NVivo 12 software was used to organise the material, supporting the coding.

3. Findings

3.1. Socio-Demographic Context

The study included 15 adolescent girls aged between 13 and 19 years, all of whom were born in Myanmar and had resided in Bangladesh for approximately three years. The majority were married adolescents, with the average age at marriage being 15 and the median age of husbands 21. Living conditions were crowded and precarious: thirteen out of fifteen participants described residing in two-room households, with up to six family members sharing one sleeping space. Only one household reported a permanent income source, while the remaining families survived on temporary or aid-based support.

Decision-making power around health matters was rarely in the hands of the girls themselves. Twelve participants explained that reproductive health decisions were taken either by their husbands or fathers-in-law, reflecting entrenched gender hierarchies. None had ever attended formal schooling, though a few had spent time in a madrasa (Islamic religious instruction centre) during early childhood. The combination of early marriage, male-dominated decision making, and the absence of formal education highlights how gendered dependency and displacement intersect to severely restrict autonomy in health-related matters.

As one participant reflected, “We do not decide about our health; my husband tells me what is allowed.” Another explained, “In our home six of us sleep in one room. We cannot think about such matters [health] when every day is about adjusting to each other.” These accounts illustrate how material deprivation and patriarchal norms shaped the everyday realities of the participants, setting the context for their access to SRH services.

3.2. Knowledge Gaps, Misconceptions, and Awareness

3.2.1. Knowledge Gaps

Awareness of sexually transmitted infections (STIs) was limited. Only four of the fifteen participants had any knowledge of STIs, three of whom had learned from community health workers and one from her husband. A few were aware that HIV and hepatitis could be transmitted sexually, but only three participants recognised the role of condoms in prevention. Despite these gaps, twelve participants reported attending community classes led by doctors or midwives, where basic information on sexual health, contraception, and bodily changes was shared. Yet stigma and embarrassment restricted open discussion during these sessions.

One adolescent noted, “Sexually transmitted disease can be transmitted among partners. I never knew about this before, but now I know. Though most of the people in our community do not know about it.” Another explained how family norms shaped access to information: “There are a few girl-friendly spaces, but most of the adolescents are not allowed to go there due to family restrictions. Awareness among family members could be beneficial.”

Service awareness was also inconsistent. Five participants explicitly stated that stigma prevented them from asking questions about SRH services, while six were unaware such services even existed. At the same time, five believed that current services were adequate, and seven recommended expanding provision. Concerns about privacy were evident: eleven participants said they felt uncomfortable seeking services in schools or community centres, preferring to consult with mothers or close female relatives. One explained, “I will feel shy and embarrassed thinking about what others will think about me.”

Transport and distance added further complications. Seven participants mentioned that services were accessible only by walking between 5 and 30 min from their homes, since transport was not available.

3.2.2. Misconceptions and Barriers

Myths and misinformation shaped contraception practices. The average age at first sexual intercourse was 15, almost always within marriage. None of the married participants used condoms, and all reported that religious beliefs and spousal opposition discouraged contraceptive use. Five girls had used some form of contraception, but always under a husband’s direction, and three underwent medical examinations before initiating a method.

One participant shared, “I discussed family planning with my husband. But he scolded me after hearing about it. He does not want it. Also, none of his ancestors ever used it and it is haram (taboo/forbidden), so why would we?” Another explained her fear: “I heard my neighbour’s husband beat her for using birth control. So, I did not dare talk to my husband about it.” The influence of husbands was pervasive: “Women need their husband’s permission in our community to use contraception. Without his permission, they are not supposed to use any.”

Misinformation also circulated through family networks. One girl recalled her mother’s warning: “My mother told me these pills can cause infertility and other physical problems.” The combination of religious prohibition, male control, and intergenerational myths created a cycle of misinformation and fear.

Abortion was particularly stigmatised. Five participants described abortion as both haram (taboo/forbidden) and sinful, and all noted the legal restrictions in Bangladesh. Although some acknowledged that NGO staff could be approached for advice, none reported awareness of safe or accessible abortion services. As one explained, “Abortion is haram and sinful. We should not do that.”

3.3. Early Marriage and Unplanned Pregnancy

Early marriage was a near-universal experience in the sample. All fifteen participants described social and familial pressure to marry young, often in their early teens, and all agreed that marriage curtailed their education. Many saw early marriage as both normal and necessary for their community. One girl explained, “Getting married early is normal. I got married at age 12. It is not a problem for our community; rather, it is a matter of prestige for the girl and her family.”

Economic insecurity also contributed to this pattern. Several participants described early marriage as a strategy to ease household burdens. “People have less work now, so it is tough to support all the family members. So, if a family marries off their girl early, that will lessen their economic burden. Besides, it is in our culture for girls to get married early,” one adolescent said.

The health implications were significant. Early marriage not only ended education but also restricted access to reproductive health information, increased vulnerability to unplanned pregnancies, and reinforced women’s dependency. Girls themselves often internalised these expectations: ten participants believed early marriage was not harmful, but rather a cultural norm that should continue. This reflects how structural inequalities and cultural traditions intersect to perpetuate cycles of early childbearing and reduced opportunities for young women.

3.4. Experiences with SRH Services

Access to SRH services varied considerably between participants. Eight of the fifteen explained that they had no access to such services in Myanmar, while two recalled only limited access before displacement. Several reflected on the difference between their lives in Myanmar and Bangladesh: “We were hardly allowed to go to hospitals in Myanmar due to restrictions,” one adolescent explained. Another contrasted the two contexts: “In my country, I never saw a doctor or nurse, but here in Bangladesh, I have easy and better access to these kinds of services free of cost.”

Perceptions of availability in the camps were mixed. While eight participants described SRH services as relatively accessible, others stressed that they lacked information about where to go, what services were available, or what problems justified care-seeking. One adolescent confessed, “We do not know about this sexual health issue, what problems might arise, and where to seek help.”

Community acceptance was also nuanced. Most participants agreed that reproductive health services were acceptable for young people to use, though marriage and the presence of female staff were often seen as prerequisites. One girl explained, “I do not think it is necessary to seek this service before marriage.” Only two of the fifteen participants expressed outright disapproval of adolescent access to SRH care.

Provider attitudes were largely described as supportive. Twelve participants reported positive experiences with health workers, though thirteen also admitted that they had little knowledge of bodily changes during adolescence. This highlights the paradox of improved physical access to services in Bangladesh compared to Myanmar but limited health literacy and ongoing stigma that undermined effective utilisation.

3.5. Sexual and Gender-Based Violence

Experiences and fears of gender-based violence (GBV) were pervasive. Thirteen out of fifteen participants said they had either experienced or heard of sexual violence in Myanmar, during migration, or in the camps. Although such violence was widely acknowledged as affecting women disproportionately, few felt comfortable speaking about it openly. One explained, “We cannot talk about these things outside the family; people will not understand.”

Nonetheless, some accounts reflected the possibility of seeking support. One adolescent shared, “I was a victim of violence by my husband. During separation from my husband, I asked for help from an NGO, and the staff took me to the authorities and helped me with every step I took against my husband’s violence. They were so helpful.”

Awareness of formal GBV prevention services was limited. Only five participants reported knowledge of camp-based programmes addressing violence against women and girls. Several emphasised the secrecy with which such matters were discussed, reflecting both fear of stigma and the absence of safe disclosure spaces.

Knowledge of STIs was also entangled with discussions of violence and risk. Only four participants knew about STIs, three through community health workers and one from her husband. Eleven of the fifteen had no awareness of STI services. All agreed that such education was urgently needed, but many admitted they had no idea how best to reach their peers. One noted simply, “We do not know how to start such conversations in our community.”

3.6. Perceptions of Mental Health and Support Needs

Mental health emerged as a particularly stigmatised and poorly understood domain. Thirteen participants acknowledged that they had little to no knowledge about adolescent body changes, contraception, or family planning, and most linked this absence of knowledge to broader silence around emotional well-being.

When asked about mental health services, awareness was mixed. Eight participants knew that their local health centres offered some form of psychological support, but six were unaware, and one explicitly rejected the idea. Four recalled neighbours or relatives who had used such services, yet these individuals were labelled “mad” within the community. As one adolescent explained, “People will call me mad if I talk about something like mental health or seek care for that. No one wants that label in the community.”

Despite this stigma, a majority of participants recognised unmet needs. Nine of the fifteen emphasised that adolescents require more support with education, family planning, and the challenges of repeated pregnancies. Preferences for where such support should be delivered varied: five suggested community centres or girl-friendly spaces, three preferred hospitals, and three favoured home-based visits. Yet uncertainty remained, with several stating they were not sure where reliable help could be found.

These accounts underscore how the absence of culturally sensitive mental health provision, combined with deep stigma, leaves adolescent girls without meaningful avenues for psychosocial support. At the same time, their recognition of unmet needs highlights an important opening for interventions that could reduce stigma and increase awareness in ways that feel acceptable within their community.

3.7. Coping Strategies and Agency

Despite the heavy constraints of displacement, gender norms, and poverty, adolescents displayed forms of resilience and agency. Several participants described turning to trusted female relatives—mothers, aunts, or sisters-in-law—for advice, as these relationships felt safer than approaching formal services. One girl explained, “I ask my aunt; she understands and doesn’t judge.”

Others formed informal peer groups where sensitive topics could be discussed discreetly. “We talk in secret, so no one can stop us,” one adolescent noted. These networks, while limited in scope and accuracy, offered emotional solidarity and shared knowledge in the absence of structured adolescent services.

Some participants expressed willingness to engage with NGO workers or female health providers if privacy could be guaranteed. These accounts highlight that, while formal systems often felt intimidating or inaccessible, girls actively sought out small spaces of support and information wherever possible.

This agency, however, was fragile. Reliance on informal or family-based sources of information often perpetuated myths about contraception or reinforced restrictions around marriage and mobility. Yet the very act of seeking out confidantes and forming peer networks illustrates the capacity of young women to negotiate within highly restrictive environments. These coping strategies demonstrate not only vulnerability but also resilience, creativity, and the potential for targeted interventions to build upon existing strengths.

3.8. Key Informants’ Perspectives

Insights from the ten key informants (KIs), representing nine different organisations, offered an important complement to the adolescents’ accounts. Eight of the ten reported that their health facilities provided general services for all age groups but lacked interventions designed specifically for adolescents. While antenatal care, temporary contraception, and management of sexual violence were available, long-term contraception and safe abortion services were described as particularly scarce. Five KIs highlighted the absence of menstrual regulation and other safe termination options, despite clear evidence of demand.

Cultural and language barriers were repeatedly emphasised. Nine informants described how strong social norms and the absence of professional interpreters limited effective service delivery. Most facilities relied on community health workers for translation, who were themselves Rohingya, which sometimes helped with trust-building but often hindered the depth of clinical communication. Five KIs attributed reluctance to a lack of knowledge and awareness, while four of them cited stigma, ignorance, and illiteracy as additional barriers. All ten KIs confirmed that their services did respect cultural practices but said that language and cultural barriers complicated care provision. Nine KIs reported having no professional interpreters and instead rely on Rohingya staff for translation. As one KI noted: “We have our community health workers, and they are mostly Rohingya. They can help us in this aspect, but we have no specific professional interpreters.” None of the organisations produced written information in Rohingya that adolescents could easily read.

Information and outreach were limited. Half of the informants mentioned monthly community meetings involving Majhis (local leaders) or imams, but none of these were targeted at adolescents. No KI reported formal collaboration with schools or youth centres, and few offered awareness sessions on early marriage, adolescent pregnancy, or incentives to delay marriage. As one respondent admitted: “We have our community health workers, but we have no specific materials for adolescents. They depend on whatever messages are given to the whole community.”

Eight of the key informants said their facilities offer multiple contraceptive options, while two provide limited choices. Regarding condom use, all ten KIs stated that adolescents lack information and do not feel comfortable asking about condoms: “To them, it is a sensitive and forbidden topic to be asked or to talk about.”

All respondents confirmed that adolescent refugees rarely sought ANC care, and when they did, they were usually accompanied by family members. According to the respondents, no staff received specific training in adolescent patient care, and none of their facilities have a follow-up system for adolescent patients after appointments; however, a few provide psychosocial support for pregnant women and mental health patients. All indicated that adolescent refugees needed awareness sessions on menstrual hygiene and access to products, safe abortion services, and information on bodily changes, prevention of early marriage, STIs, safe delivery, psychological counselling, and mental health support.

SRH complaints from adolescent refugees mainly relate to sexual violence. All key informants confirmed they maintain strict confidentiality to protect victims. Early marriage, frequent childbirth, illiteracy, unprotected sex, STIs, GBV, religious and cultural norms, lack of health and sex education, ignorance, male dominance, disdain for SRH services, lack of abortion services, and childhood malnutrition were identified by all key informants as significant risk factors. Half of the respondents stated that health centres often refer patients to tertiary-level facilities when services are unavailable locally. They also reported that incidents of sexual abuse are not necessarily presented as cases of abuse but instead as health difficulties, such as genital bleeding, injuries, or other disorders. “In a few cases of sexual abuse of teenage girls, they initially presented to us with genital bleeding, but a thorough history and physical examination revealed that it was a case of rape,” one KI reported.

Overall, the informants confirmed many of the girls’ perceptions: service gaps in long-term contraception, stigma around abortion, cultural restrictions on adolescent access, and the lack of safe disclosure spaces. Several highlighted the reliance on traditional birth attendants for deliveries, which increased risks for adolescent mothers. All informants agreed that adolescent-specific education, safe spaces, and culturally appropriate SRH materials in the Rohingya language were urgently needed.

Together, these findings reveal the multiple and intersecting barriers that Rohingya adolescent girls face in accessing sexual and reproductive health while also highlighting the subtle forms of resilience and agency they deploy within highly restrictive conditions. The next section considers how these lived experiences align with and extend existing literature and what they mean for policy and practice in humanitarian settings.

4. Discussion

4.1. Overview and Synthesis

This study demonstrates how gendered power, cultural and religious norms, and displacement-related precarity combine to limit Rohingya adolescent girls’ sexual and reproductive health (SRH) autonomy in Cox’s Bazar. Many young women lack vital knowledge about sexuality and childbirth and are excluded from education after marriage (Howlader et al. 2023). Few community members recognise the health risks linked to early childbearing (Fowler 2014). Early marriage, male control over health decisions, and the framing of contraception as religiously impermissible converge with low formal SRH education, stigma, and limited adolescent-specific services. At the same time, girls demonstrate everyday forms of agency—turning to trusted women and discreet peer networks—signalling entry points for interventions that are both culturally responsive and youth-centred.

Our findings align with evidence from similar humanitarian contexts: patriarchal decision-making and early marriage reduce girls’ ability to access and use contraception; stigma and privacy concerns depress care-seeking; and adolescent-tailored service models remain patchy (e.g., Santhya and Jejeebhoy 2015; McGinn et al. 2011; Mazur et al. 2018; World Health Organisation 2019; United Nations Population Fund 2022; Palattiyil et al. 2025). We add nuance by tracing how male gatekeeping, misinformation, and language barriers (Logie et al. 2024) interact at household, community, and service levels and by highlighting girls’ small but significant coping strategies that can be amplified safely.

4.2. Cultural and Social Norms Shaping SRH Access

Across interviews, marriage, mobility restrictions, and male authority decisively shaped SRH access. Most girls reported husbands or fathers-in-law as final decision-makers on contraception and care, echoing patterns documented in conservative and displaced settings (Santhya and Jejeebhoy 2015; Jejeebhoy and Sathar 2024). Contraception—particularly condoms—was uncommon, often framed as “haram” or unnecessary, and sometimes explicitly forbidden by spouses. These dynamics directly reinforce early marriage and rapid, repeat pregnancies, consistent with national patterns of adolescent fertility (NIPORT 2023) and observations from other refugee contexts (UNFPA 2018; McGinn et al. 2011; Marphatia et al. 2017). The critical interpretive point is that the “non-use” of contraception here reflects not individual preference but structural power and social sanction.

Mental health problems are common but often stigmatized (Morina et al. 2018), with those affected frequently labelled as “crazy.” Research shows that social contact alone does not effectively lead to long-term attitude change or stigma reduction; instead, comprehensive and accessible mental health services are necessary to make a genuine difference (Thornicroft et al. 2016; Corrigan et al. 2014). In Rohingya camps, adolescent girls face greater risks of maternal mortality and depression, and stigma around mental health is exacerbated by religious interpretations and a lack of trained counsellors (Tay et al. 2019).

4.3. Knowledge Gaps and Misinformation

Formal SRH education was largely absent; girls relied on mothers, peers, and occasional community classes, producing partial knowledge and widespread myths (e.g., pills cause infertility). Awareness of STIs and available services was especially low. This reliance on informal sources and sporadic teaching is well-described in humanitarian literature (Chandra-Mouli et al. 2015; Chandra-Mouli et al. 2019; Tirado et al. 2020; Palattiyil et al. 2022). Existing literature emphasizes the need for education programmes in schools and communities to enhance SRH knowledge (CDC 2024; Chandra-Mouli and Akwara 2020). In Bangladesh more broadly, comprehensive STI knowledge among adolescent girls remains limited, and pathways to services are opaque, which maps closely onto our participants’ accounts (The Share-Net International Digital Platform 2021). Key informants reported adolescents rarely seek SRH care without family involvement and have limited knowledge about contraception, especially condom use, due to cultural taboos. The practical implication is that the content, language, and delivery of information matter as much as coverage: didactic sessions alone are unlikely to shift norms without privacy, continuity, and trusted messengers.

4.4. Barriers to SRH Services

Girls described stigma, fear of judgement, and lack of privacy as primary deterrents, more so than physical distance—although walking 5–30 min without transport was common. Community stigma, superstitions, and limited sex education further restrict access to services (Kesterton and de Mello 2010). Most health facilities were not tailored to adolescents; confidentiality was uncertain; and professional interpreters and Rohingya-language materials were largely absent, mirroring key informants’ reports. Language barriers, insufficient training for healthcare workers, restricted STI and contraception services, and the absence of visual information materials impede effective SRH service delivery (Mumtaz et al. 2012). Even where a menu of services existed (ANC, temporary methods, or clinical care for rape), long-acting contraception and safe termination options were scarce, and referral continuity for adolescents was weak. These findings echo evidence from other crises: confidentiality concerns depress uptake, adolescent-friendly services and models are inconsistent, difficulties in accessing SRH information and unmet SRH needs, and service design often defaults to generic maternal health, rather than community-based GBV prevention (Vu et al. 2014; Mazur et al. 2018; World Health Organisation 2019; Ivanova et al. 2018; Ivanova et al. 2019; Soeiro et al. 2023). The persisting preference for home deliveries with TBAs (Fedha 2013), lack of clear referral systems (Shahabuddin et al. 2019) and fears around hospitals—furthers obstetric risk, despite training efforts that cannot substitute for emergency capacity (Ainul et al. 2018; Dwivedi et al. 2024). Overcoming these obstacles requires multisectoral strategies, including community-led education, youth-friendly service design, and integrating SRH into broader humanitarian programmes, while taking into account the unique cultural, political, and environmental contexts (Women’s Refugee Commission et al. 2012; Tazinya et al. 2023).

4.5. Informal Support as a Safety Net

Despite constraints, girls described quiet adaptations: consulting aunts or mothers or sharing advice in small, discreet peer groups. These networks provide psychosocial safety and some practical guidance; however, they can also circulate misinformation. The lesson for programming is not to displace these supports but to co-design with them: equip peer connectors and trusted women with accurate content, referral routes, and protection protocols. Peer-enabled, privacy-assured models can bridge the space between formal services and lived realities—particularly where male oversight and social scrutiny are strong.

4.6. Implications for Policy and Practice

Taken together, the data point to three layers of action that are mutually reinforcing:

(a)

Near-term programmatic shifts

Prioritise confidential, adolescent-friendly access to contraception (including long-acting options) regardless of marital status, with opt-in, private counselling by female providers. Integrate free, routine STI/HIV testing into ANC and youth visits. Establish girl-only, safe spaces that combine education with on-site services. Pilot mobile/satellite sessions to reduce visibility and travel barriers. In GBV response, expand confidential entry points and ensure rapid referral to clinical care, including clinical management of rape.

(b)

Community engagement and communication

Partner with imams, Majhis, women leaders, and peer educators to normalise accurate SRH information (menstruation, contraception, STI prevention, and danger signs in pregnancy). Produce visual and audio–visual materials in Rohingya, designed and pre-tested with adolescents, and ensure professional interpretation in facilities. Community messaging should explicitly address myths (e.g., infertility fears) and clarify legal options such as menstrual regulation where applicable, given the confusion and stigma around abortion (Bearak et al. 2020).

(c)

System and workforce strengthening

Train providers in youth-friendly, confidentiality-focused care and in engaging adolescents experiencing spousal control. Introduce simple follow-up systems (e.g., consented call backs via female CHWs) to maintain continuity. Where TBAs remain first contact, offer danger-sign training and clear, escorted referral pathways to facilities—complementary to, not a substitute for, institutional delivery. Build school and youth-space outreach with age-appropriate SRH content and private referral routes, addressing the present gap identified by key informants.

These implications replace a long, standalone recommendations list by tying each action to specific barriers identified in the data—stigma and surveillance, misinformation, language gaps, and service design that overlooks adolescent realities.

4.7. Limitations

The fieldwork occurred during COVID-19 mobility restrictions, which likely shaped who could participate and how openly sensitive topics were discussed. Ages were self-reported and could not always be verified. Interviews were conducted via translation and back-translation; while care was taken to preserve meaning, some nuance may have been lost. Given the sensitivity of sexual activity, violence, and contraception, under-reporting and social desirability bias are plausible (cf. Araujo et al. 2019). This study covered eight camps and did not include adolescent boys; the findings should be read as analytically transferable rather than statistically generalisable. These constraints are typical for qualitative research in humanitarian settings but underscore the need for cautious interpretation and complementary mixed-methods work.

5. Conclusions

This study underscores how adolescent girls in the Rohingya refugee camps of Cox’s Bazar experience layered barriers to sexual and reproductive health: early marriage, male gatekeeping, religious prohibitions, stigma, and systemic gaps in youth-specific care. These constraints are not isolated but intersect, leaving girls with limited autonomy and exposing them to heightened risks of early pregnancy, unsafe abortion, and gender-based violence. At the same time, the findings reveal subtle yet significant forms of resilience—from seeking advice from trusted women to forming discreet peer networks—that suggest pathways for culturally grounded interventions.

Improving adolescent SRH in humanitarian settings requires more than service provision: it demands community-wide engagement, culturally sensitive education, and adolescent-friendly delivery models that ensure confidentiality and respect. Partnerships between health actors, NGOs, and religious and community leaders are critical to shifting norms and enabling safe access. Equally, policies must embed SRH within broader protection, education, and psychosocial support strategies, recognising adolescent girls as rights-holders rather than passive recipients of aid.

Future research should adopt longitudinal and socio-ecological perspectives (Bronfenbrenner 1977) to capture how individual, family, community, and policy factors interact over time and to evaluate the impact of targeted adolescent-focused programmes (International Initiative for Impact Evaluation 2023). Comparative work across refugee settings in South Asia and beyond would help identify transferable lessons.

Ultimately, addressing adolescent girls’ SRH in displacement contexts is both a public health imperative and a matter of justice. By tackling stigma, expanding confidential services, and amplifying adolescents’ voices, there is an opportunity to reduce health risks and promote greater gender equity. For Rohingya adolescent girls, whose lives are shaped by displacement and structural exclusion, such action represents not only better health outcomes but also a step towards dignity and self-determination.