OUDOMXAY, Laos – Lap’s boyfriend is in the army, and she has no idea what he does when he’s away. All she does know is that she’s had symptoms associated with sexually transmitted infections for over four months now, and they aren’t disappearing with medicine.
Her voice is soft and her eyes begin to well up; it’s taken the 28-year-old months to build the courage to come to the family planning clinic here at a small district hospital, 5km from her home where she and her boyfriend live. She spent the last four months attempting to self-medicate with a private clinic that is closer to her house and easier to get to around her many temporary jobs. But her symptoms keep going and coming back – a herpes-like rash and discharge. Today, the nurse has booked her in for a test and given her several packs of condoms.
“I have said many times that we should use protection,” Lap told VICE World News outside the doors of the clinic. “But he tells me, ‘if we use a condom, we’re not boyfriend and girlfriend’.”
Stories like Lap’s – she asked us not to include her surname because of stigma around using contraception – are everywhere here in the north of Laos, where a sexual health crisis is raging.
Laos is battling one of the world’s highest maternal mortality rates and the highest teen pregnancy rate in Southeast Asia. Experts fear that the country’s speeding population growth will lead to deaths, disease, and human rights violations for years to come. And it is women like Lap who will be hurt the most.
The UN says that fertility has fallen dramatically in recent decades for many countries, while the world’s population is expected to peak around 10.4 billion in the 2080s and remain at that level until the next century. But Laos has the fastest growing population in the region, and this population growth is colliding with poverty and outpacing healthcare systems. Better sex education, and sexual health services, are desperately needed.
Here, a third of women aged between 15 and 19 years are married or living with their partners – while the age of consent is technically set at the age of majority, 18, relationships below that age are widely accepted.
In Laos there is a strong association between marriage and using contraception. Many unmarried couples do not see condoms, the pill or other options like the implant are for them. Even Lap herself has only ever used the rhythm method, plotting her fertile days by tracking her menstruation – widely believed by experts to be unreliable.
“In Laos culture, if you believe contraception is only for after marriage, in the opposite way if you are still single you will think contraceptive use means you are not a good girl or you are a sex worker,” said Dr Southisouk Inthavilay, deputy director of Lao’s Promotion of Family Health Association. It is an idea that has historically been reinforced by the country’s own healthcare centres; in the clinic Lap visited, the nurse told VICE World News she had only recently stopped advising unmarried women to use the rhythm method.
According to one UN survey, up to 75 percent of unmarried women aren’t using any form of contraception.
But this is a country where girls are expelled from school if they marry or fall pregnant. Israt Jahan Baki, the head of adolescent development and participation programme at Plan International, a development organisation advancing children’s rights and gender equality, said that there is a need “for pregnant or married girls to be able to return to secondary schools. Pregnant girls may agree to get married to prevent their family from being shamed. While pre-marital sex is not uncommon, pre-marital pregnancy is not easily tolerated by society.”
“Girls and boys are often nervous to ask for contraception and pills at pharmacies or shops, particularly those living in small communities where they are known.”
Social norms aren’t the only obstacle facing young people. At a village clinic, a volunteer midwife said that there were no jobs for her because of quotas. In the district hospital, a clinic nurse told VICE World News that she needs 75 contraceptive implants to give to patients every three months. But over the last three months, she has only had a stock of 10. The government, which procures contraceptives like implants via the United Nations Population Fund (UNFPA), had not distributed them efficiently according to Sally Sakulku, UNFPA’s sexual reproductive health programme coodinator. “They should have them, we received the shipment,” she said, puzzled.
Sexual health services in Laos and reliant on international aid, and foreign aid workers across the board fear their work will be undone once they leave. The province of Oudomxay in Laos’ north has benefited from UNFPA support, whose interventions have helped train midwives and healthcare staff in contraceptive health.
When Sakulku first started working in this space in 2001, she can remember a number of French NGOs undertaking projects here. Once the projects were completed, they would leave in the hope that the local community and government would take on the learnings and funding needs themselves. “I suspect this was not maintained until the UNFPA came,” she said.
It isn’t only unmarried women who are often forgotten in family planning outreach.
In Oudomxay Provincial Hospital, the family planning doctor Dr Vanny Keopseuth said that she used to reach a lot of sex workers in her clinic when there was a local programme funded by the Asian Development Bank. But now that that funding has disappeared, so have all the sex workers she used to see walk in.
Now, all she sees are men who have told her they have been with sex workers, who come to her because they are displaying STI symptoms. She added that the HIV rate in the province is higher than the national average amongst men who have sex with men, with 144 patients currently receiving her care. “During the pandemic there was no time or budget for public campaigns,” she said. “I fear many died.”
Jahan Baki said that Plan International has had the same experience, and has pressing concerns about foreign interventions in the country that are not associated with healthcare aid.
The Boten–Vientiane railway, set to transform Laos as the only landlocked country in southeast Asia, began running in December 2021. Intended to strengthen trade and tourism with China, Laos paid a substantial amount of the full $6 billion it is said to have cost. For decades, this is where Chinese investment has focused – in transportation, public facilities and education. Sakulku believes that a disinterest from China in supporting sexual and reproductive health in Laos is because “they like infrastructure; hard power.”
But experts fear that sex tourism, and sexual exploitation, could become an even bigger problem in Laos because of this railway, where between 200,000 and 450,000 people are trafficked annually within the Greater Mekong Subregion, according to the local NGO Sengsavang. A local newspaper reported last year of a high rate of STIs amongst sex workers in the Golden Triangle Special Economic zone linking Laos, Thailand and Myanmar where the majority tested were Laos nationals.
“There are key groups who are being missed out on, and we don’t have enough understanding how the sex industry is evolving given the opening of the Lao China railway in December 2021,” Jahan Baki said.
She believes the increase in movement will mean an increase in transactional sex near the stations; research has already found numerous gaps in reaching Laos sex workers to prevent STIs. “These places will become increasingly important for trade. Laos doesn’t have a developed healthcare system that can address the needs of sex workers – the country’s protection system is not developed enough to address the needs of those who are coerced into sex work. Social stigma is high. Our fear is negative health outcomes and rights violations.”
For the marginalised, progress remains too slow. The biggest winners of international aid so far appear to be married women who live close to NGO- and agency-supported clinics. In a small village health centre, the village leader who only gave her first name, Supmanee, drops by to get her contraceptive injections, which she has been taking for 9 years. She told VICE World News that she holds four monthly meetings in the village, during which she directs young people to access the clinic’s services.
Her meetings, and the health clinic, appear to have made a difference. In the village primary school, there used to be 200 pupils from 1st to 5th grade a couple of years ago – now there are 75. This is a health achievement, showing that parents are likely spacing out their pregnancies, but that isn’t how the government always sees it. Sakulku said that the minister of education “complains that the government builds schools, then the UN comes in and now the schools are empty.”
Almost everyone in this village farms, and many of the women have children within their first year of marriage. Over a three hour drive away, at the district hospital, another young woman, Na, visits the family planning services; she also declines to give her surname due to the stigma STIs carry. She is 27, and it is her first time here; she is unmarried and works in a mobile phone shop.
She is exhibiting STI symptoms, and says she has lived together with her boyfriend for a long time. He is a police officer, always posted to another area of the province. “I don’t trust him,” she says, quietly, before gesturing to the packs of condoms in her hands.
“These are for him.”