No Te Tratan Bien Porque Eres Mexicana: Intersectional Systemic Violence and Precarity in Latina Adolescent Life in the U.S. South

Abstract

Young Latina women (YLW) in Alabama are disproportionately affected by sexual health disparities. However, to access needed reproductive services, YLW must navigate a healthcare landscape that restricts access for youth. YLW also face racialized immigration enforcement in their communities which is designed to attrition the region’s emergent Latina/o/x immigrant population. This paper describes the intersectional, structural forces that contribute to experienced systemic violence for YLW as they try to access sexual healthcare services. In 2017, we conducted semi-structured qualitative interviews with 20 YLW and 24 key stakeholders (parents, providers, Latino/a/x community leaders etc.) in West Alabama to examine attitudes and perceptions about sexual health and healthcare access (HCA) among YLW in the region. We used purposeful convenience sampling and snowballing to recruit a community-based sample. That is, we purposefully recruited YLW, adjusting through the recruitment period for a diverse sample, who represented the various voices that we were trying to capture in the study (i.e., younger and older adolescents, adolescents born in the U.S. and those born in other countries etc.). Through a focus on YLW’s access to sexual/reproductive healthcare, we conclude that YLW experience systemic violence and resulting precarity because laws and health policies restrict access to evidence-based sexual health education and reproductive healthcare services. We discuss implications for future research and policy recommendations.

Introduction

The U.S. South had a significant influx of Latinas/os/x between 2000–2011 (Passel, Cohn, & Lopez, 2011). In the years following this population increase, Alabama (HB 56), Georgia (HB 87), South Carolina (SB 20), Tennessee (HB 670) and a number of cities, counties and other states enacted anti-immigration laws criminalizing immigrant communities (Lohr, 2012; National Conference of State Legislatures, 2012). These legislative actions and their enforcement in combination with historical legacies of slavery and racism contribute to a challenging environment for Latinas/os/x as they try to live out all aspects of their daily lives (Oboler, 2012). Our work focuses on how one subgroup, Young Latinas Women (YLW), navigates an important dimension of wellbeing: sexual health and rights and access to sexual healthcare.

Defining Terms

Hispanic and Latina/o are ethno-racial categories used to describe individuals of Latin American descent and are often used interchangeably. The former emphasizes language and the latter region. The term Latinx is a gender-neutral term meant to center the broad range of gender identities present among individuals of Latin American descent (Chavez-Dueñas et al., 2019). We will use Latina/o/x in this paper. For the purpose of this paper, we define the South as those states that share a history of slavery, racial segregation, the Civil Rights movement, and finally an increased engagement with Latina/o/x immigration legislation since the 1980s: Alabama, Arkansas, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia (Odem & Lacy, 2009).

YLW and Sexual Health

YLW in Alabama are disproportionately affected by sexual health disparities (Centers for Disease Control and Prevention, 2014a, 2014b; Franzetta, Schelar, & Manlove, 2007; Prejean, Tang, & Hall, 2013; Ventura, Hamilton, & Mathews, 2014) and experience significant barriers to sexual health care access (HCA). Almost half of Alabama youth of high school age are sexually active and the Centers for Disease Control (CDC) recommends regular HIV/STI screenings for sexually active adolescents 15+ years (CDC, 2015; Kann et al., 2016). All young women regardless of race, ethnicity, national origin, or immigration status, should have access to sexual healthcare services to adequately plan their futures and care for their health.

The purpose of this paper is two-fold: (1) To provide an overview of Latinas/os/x in the South and describe the structural forces that contribute to experienced systemic violence for YLW as they try to access sexual healthcare services (e.g., restrictions on reproductive rights and anti-immigrant legislation). (2) To illustrate this systemic violence through the voices and perspectives of the YLW and other community stakeholders that we interviewed as part of our qualitative study where we examined their attitudes and perceptions with regard to sexual HCA in West Alabama.

Overview of the Latino/a/x population in Alabama

Alabama’s Latina/o/x population grew 164% between 2000 and 2014 (Stepler & Lopez, 2016). Latina/o/x make up the largest immigrant population in Alabama. The South’s Latina/o/x population is also relatively young, with 32% of Latina/o/x aged under 18 (Yee, 2016). As of 2014, Hispanics constituted 4% percent of the state population in Alabama and, of these, 63% were U.S.-born with a median age of 14 (Pew Research Center, 2014). Fifty percent of Hispanics ages 17 and under live in poverty (Pew Research Center, 2014). It is important to better understand Latina/o/x youths’ lived experiences to implement evidence based, multi-level, culturally relevant strategies. Research on Latina/o/x populations in the South is relatively new and, to our knowledge, no other researchers have worked with adolescent populations to better understand their lived experiences with HCA in West Alabama.

Structural Violence and Immigration as Social Determinants of Health

Structural violence includes the indirect violence that forms part of repressive social orders, in place to create differences between “potential and actual human self-realization (Galtung, 1969).” YLW navigate intersectional oppression by facing structural racism and xenophobia, heterosexist patriarchy, and structural limitations in seeking sexual and reproductive healthcare (García, 2009). Authors have argued that gender-based inequalities can result in poor health outcomes through the mechanisms of discriminatory practices, healthcare system imbalances, inequities in health research, and differential exposures and vulnerabilities to diseases (Jiwani, 2005; Motta, Cáceres, Skordis-Worrall, Bowie, & Prost, 2017). These mediators are encompassed within the larger framework of structural violence as it reflects how different marginalizing experiences (i.e. poverty, racism, and sexism) intersect. Given this context, we use the philosophical lenses of structural violence and intersectionality (Collins & Bilge, 2016) to guide our analysis on sexual HCA among YLW in AL.

Emerging literature points to the need to study immigration as a social determinant of health and to examine the health impact of immigration laws and policies (Asad & Clair, 2018; Castañeda et al., 2015; Harrigan, Koh, & Amirrudin, 2017; Kline, 2017; Martinez et al., 2015a; Philbin, Flake, Hatzenbuehler, & Hirsch, 2017; Quesada, Hart, & Bourgois, 2011; Vargas & Ybarra, 2017; Venkataramani, Shah, O’Brien, Kawachi, & Tsai, 2017). Our paper follows calls to expand our conceptualization of “structural vulnerability” in addressing undocumented Latina/o/x immigrant health (Quesada et al., 2011). Others have suggested that the threat of deportation functions as a primary and proximal social determinant of mental health amongst migrant workers (Harrigan et al., 2017). The combination of structural racism and state-level immigration-related policies has been found to impact Latina/o/x physical and mental health by generating stress and affecting undocumented immigrants’ access to social institutions, health-related services, and material conditions (Philbin et al., 2017). Yet there is a dearth of research that goes beyond cultural and behavioral explanations and addresses the social determinants of immigrant health broadly (Viruell-Fuentes, Miranda, & Abdulrahim, 2012), especially with regard to sexual health. In so doing, we are addressing the call for intersectional approaches to understanding Latino/a/x immigrant health (Viruell-Fuentes et al., 2012).

Studying Latina lives in southern states has allowed us to understand how YLW are navigating the everyday challenges of living in a socially conservative state (Pew, 2014) and how these ideologies become institutionalized and affect racial/ethnic minority populations and women. This includes recognizing the laws and policies that frame Latina/o/x life in the U.S. South. These adverse social factors function as social determinants of health and can impose challenges on YLW as they plan out their sexual and reproductive lives. Therefore, understanding the lives of YLW as they seek sexual HCA is important to our understanding of peace.

Sexual health education and contraceptive/abortion access for minors.

The World Health Organization recommends that sexual health programs, including sexuality education, move away from sexual ill-health to address sexual well-being and pleasure (World Health Organization, 2018). Unfortunately, access to comprehensive, sex-positive, evidence-based sexual health knowledge is largely lacking in the state of Alabama (Population Institute, 2017). The State of Alabama requires sexual education in public schools to emphasize abstinence (Minimum Contents to be Included in Sex Education Program or Curriculum, 1975). Specifically, the state requires that sexual health education emphasize that contraceptives are not completely effective to prevent pregnancy and stress the negative financial repercussions of child rearing (Minimum Contents to be Included in Sex Education Program or Curriculum, 1975). Experts have argued that programs that promote abstinence-only-until-marriage and those that solely promote sexual risk avoidance threaten fundamental human rights to health, information, and life and that they are scientifically problematic and ethically unsound (Santelli et al., 2017).

Education scholars have also found that public school teachers in the South are not adequately trained to address the cultural and linguistic needs of immigrant youth or prepared to work with English Language Learners (ESL) and immigrant students (Sox, 2009). The State of Alabama is considered an “English-only state” because it instituted a constitutional amendment that made English its official language in 1990 (Tatalovich, 1995). Therefore, we can surmise that students who are not English-fluent are unlikely to receive sexual health education instruction in the language with which they are most comfortable.

Sexual and reproductive rights.

The World Health Organization recommends that: “For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled (World Health Organization, 2006).” Some laws and policies in Alabama limit access to sexual and reproductive healthcare and contraception (Population Institute, 2017). For instance, women in southern states report having difficulty attaining prescriptions for hormonal contraception more frequently than in other regions in the U.S. (Grindlay & Grossman, 2016). Alabama has also been designated a contraceptive desert, defined as a region that does not have enough public clinics offering the full range of methods (especially intrauterine devices and implants) to meet the needs of the state’s number of women eligible for publicly funded contraception (Power to Decide, 2018). Unlike other states, Alabama does not have any laws that protect the right of women to attain emergency contraception in emergency rooms and does not explicitly grant minors the right to consent to contraceptive services (Population Institute, 2017).

Abortion access.

The State of Alabama requires that a person seeking an abortion must: receive state-directed counseling; comply with a 48 hour waiting period before the procedure is provided; and undergo an ultrasound before obtaining an abortion and the physician must offer the patient the option to view the image (Guttmacher Institute, 2018; Grossman, White, Hopkins, & Potter, 2014; Roberts, Turok, Belusa, Combellick, & Upadhyay, 2016). On May 15th, 2019 Alabama’s governor signed a bill into law that, when and if it goes into effect, will make abortion and attempted abortion felony offenses, except in cases where the procedure is necessary to prevent risk to the mother’s health (Alabama Anti-Abortion Law, 2019). The combination of legal limitations to sexual education, contraceptive access, and abortion access work in unison to create barriers for women in Alabama seeking sexual wellbeing.

The Violence of Anti-immigrant Legislation and its Effects on Latina/o/x Youth in Alabama

State-level laws and policies.

Census data suggest that YLW in Alabama (and broadly across the southeast) are largely first and second-generation immigrants (Pew Research Center, 2014). Therefore, these women largely come from mixed-status families and, therefore, federal immigration laws and policies impact their lives. (Mixed-status refers to families which consist of a combination of members who are undocumented and others who have authorized presence or are citizens (Ferreti, 2016).) As Alabama’s Latina/o/x population increased, state lawmakers sought to resist the settlement and incorporation of these new populations. In 2011, the Alabama legislature passed a state immigration law that pushed for “attrition via enforcement,” otherwise known as “self-deportation” (Arrocha, 2011–2012; Ferreti, 2017; Lopez, Tsitouras, & Azuma, 2011; Mohl, 2016). Alabama Representative and bill sponsor Mickey Hammon explained that the law was designed to “attack every aspect of an illegal alien’s life” and “make it difficult for them to live here so they will deport themselves.” (Chandler, 2011). Although various parts of the law have since been enjoined, many parts of this legislation are still in effect (Mohl 2016).

The Beason-Hammon Alabama Taxpayer and Citizen Protection Act, herein referred to as “House Bill 56” or “HB56,” targeted immigrants. The law prohibited undocumented students from attending Alabama public colleges and universities. The original version of the bill also required K-12 public schools to collect and document the immigration status of all newly enrolled children as well as that of their parents, to assess the economic impact of educating undocumented children and the children of undocumented adults (Alabama Immigration Law - Act No. 2012–491 § 28). The law also forbade state and local agencies, including schools, from maintaining any policies or practices that limited communication between its officers and federal immigration officials (Alabama Immigration Law - Act No. 2012–491 § 5). Despite this part of the law being enjoined by the courts, the provision created a distrust of schools and led to record high school withdrawals and absences by Latina/o/x students across the state (CNN Wire Staff, 2012; Reeves, 2011). Lastly, HB56 criminalized all attempts to conduct “business transactions” with the state, which continues in effect, elevating them to a Class C felony (Márquez, 2014). Business transactions with the state included, but were not limited to, “applying for or renewing a motor vehicle license plate, applying for or renewing a driver’s license or non-driver identification card, or applying for or renewing a business license” (Alabama Immigration Law - Act No. 2012–491 § 30). HB56 caused a wave of panic in the lives of undocumented immigrants in the state that prompted many to flee the state (Robertson, 2011). The totality of the various provisions of HB56 criminalized the everyday life of immigrant youth, their parents, and communities.

Federal laws and policies.

National immigration restriction policies, such as the increase of raids by Immigration and Customs Enforcement (ICE), combine with state-level policies to affect immigrants’ lives (Sacchetti, 2018). Other examples include the passing of the two Executive Orders in January of 2017 that ordered the building of a physical wall along the U.S.-Mexico land border. The Executive orders also allowed the removal of anyone currently present in the U.S. who had been previously issued a deportation order, regardless of whether they had a criminal record (Presidential Executive Order: Border Security and Immigration Enforcement Improvements,, 2017; Presidential Executive Order: Enhancing Public Safety in the Interior of the United States, 2017). These federal mandates further intimidated immigrant communities living all over the country, including in the U.S. South.

Institutionalized Xenophobic Racism

Finally, Alabama, like other southern states, continues to reckon with its legacy of slavery, racism, and continued socioeconomic and political marginalization of ethnic minorities, including political disenfranchisement (Asad & Clair, 2018). Authors have pointed to how racialized legal status has been used as a mechanism of social inequality, which in turn functions as a negative social determinant of health (Asad & Clair, 2018). The convergence and implementation of immigration and criminal law (Menjívar, 2014) constitutes a form of “legal violence” that affects immigrants and their families (Menjívar & Abrego, 2012). This conversion, known as “crimigration” has been described as a “racial project” that subordinates and systematically criminalizes Latina/o/x residents in the United States (Armenta, 2017). State and federal actions against immigrants have shaped the context under which YLW have come to maturity and try to plan their futures.

Current Study

STI’s and unplanned early pregnancy disproportionately affect YLW in Alabama and in the U.S. (Centers for Disease Control and Prevention, 2014a, 2014b; Franzetta et al., 2007; Prejean et al., 2013; S. Ventura et al., 2014). Yet, to our knowledge, no other researchers are studying how YLW’s sexual HCA is impacted by intersecting layers of marginalization in the spheres of immigration and sexual health. Therefore, the aims of our study were to examine the lived experiences and perceptions of YLW and other key stakeholders with regard to navigating sexual HCA in West Alabama.

Methods

Participants and Procedures

We conducted 20 semi-structured qualitative interviews in 2017 with adolescents who: self-identified as Latina, were between 15 and 20 years of age, had been in the U.S. 5 or more years, and lived West Alabama. Seventy-nine percent of the YLW in our study self-identified as Mexican/Mexican American and 65% were U.S.-born. Sixty percent reported that they had health insurance. Ninety-two percent of key stakeholders identified as female and 63% as Latina/o/x or African American, while 37% identified as white. Through our topic guide, we sought to elicit YLW’s perceptions and experiences with regard to sexual HCA in West Alabama.

We also conducted 24 interviews with key community stakeholders, which included: Latina/o/x parents of YLW who resided in West Alabama (n=5); community leaders that work with or advocate for the Latina/o/x population in West Alabama (n=11); and sexual and primary healthcare providers who practice in West Alabama (n=8). Semi-structured interview topic guides for YLW’s interviews and stakeholder interviews (similar but tailored to each population) were developed collaboratively by the principal investigator and project director. We asked open-ended questions to examine community stakeholders’ perceptions and experiences with regard to the lived conditions of Latina/o/x in Alabama and YLW access, or lack thereof, to sexual healthcare education and services. These included:

• What challenges do YLW your age face in getting the sexual health services they need? (YLW topic guide)

• What are some of the biggest challenges you and your family have faced in Tuscaloosa? (Parents of YLW topic guide)

• Are there services available that, you feel, YLW are currently underutilizing? If so, why do you think they are underutilizing this service? (Healthcare Provider’s Topic guide)

We used purposeful convenience sampling and snowballing to recruit a community-based sample of participants. That is, we purposefully recruited YLW, adjusting through the recruitment period for a diverse sample, who represented the various voices that we were trying to capture in the study (i.e., younger and older adolescents, adolescents born in the U.S. and those born in other countries etc.). We recruited from a network of community contacts that the first author of this paper/project director had established in previous ethnographic research (over the course of eight years) with the Latina/o/x community in Alabama for her dissertation study (Ferreti, 2016). We contacted YLW and their parents via phone or electronic message with an invitation to participate. We used the same process for the recruitment of community stakeholders. We used an Institutional Review Board (IRB) approved recruitment script and screening tool to invite participants and determine eligibility. Once screened, if eligible and interested, we obtained parental consent and adolescents’ assent from all youth younger than 18 years of age. Adolescents between 18 and 20 years of age provided their own consent. Community stakeholders were all 18 years of age or older and provided their own informed consent. All interviews were conducted in private locations (e.g., participants’ homes or workplaces) or University spaces (in our project office or conference room) in the participant’s language of preference (Spanish, English, or both). The recordings were transcribed verbatim in the language in which they were conducted (i.e., Spanish recordings were transcribed to Spanish transcripts) by a professional transcription company whose staff were Human Subjects certified. In line with the practice of community-based, participatory research (Israel et al., 2008), we worked closely with a community advisory board (CAB), whose perspectives informed all steps of this research. The first author, who is a scholar-advocate and community leader and has deep ties to the local community, recruited the CAB. We recruited CAB members who were key stakeholders with regard to YLW’s health: YLW, parents, providers, and community leaders. The CAB met (and continues to meet) on a quarterly basis. We employ simultaneous Spanish-English interpretation (with two interpreters and headsets) in CAB meetings so that all stakeholders can communicate seamlessly in the language of their preference.

Data Analysis Methods

We conducted thematic coding of the transcript data through a phenomenological approach (i.e., with the intent to better-understand the participants’ lived experiences) (Lewis, 2015). Two coders used an iterative process between coding and consensus building to develop the coding guide. Once consensus on the codes, subthemes and themes had been reached, the rest of the transcript data was coded independently. Recruitment and analyses occurred concurrently. Recruitment of participants was discontinued when theme saturation for our questions of interest was reached. We maintained detailed audit trails including notes on data analysis and coding decisions, throughout the data collection, coding and analyses processes. The interpretation of the data was also informed by previous ethnographic research by the first author on Latina/o/x immigrant life in Alabama (Ferreti, 2016).

Results

Overall, two main themes and six subthemes emerged from these analyses. These are discussed in detail below.

Theme 1: Sociopolitical Environment Poses Challenges to Latinas Seeking Good Sexual Health and Wellbeing

Concerns regarding sex education in West Alabama.

YLW respondents in our study expressed concerns over the quality of sexual health education. These concerns ranged from expressing that sexual education across Alabama public schools was inconsistent, that there was uncertainty on whether it was mandated by school curricula, and that it did not adequately inform youth about their sexual health and reproductive choices. One YLW expressed uncertainty over whether it was requirement:

They say you are required to take it, but they will not… When you have your schedule… they put down English and Math, but… with the health, you have to put it as an elective. So, unless you put down health, they are not going to give it to you…

(101)

Another YLW described how she was not required to take a sexual education at her school.

I wasn’t even required to take a sex ed… But, people who did take it…tell me you just wrote definitions, sat there, and you were done. There was no actual [sexual/reproductive health] education…[un]like [when] …I took [a class] last semester at the university [and there] we went in-depth into all forms of birth control and in-depth into what kind of STIs you can contract and what dangers each bring… Whereas, in the public schools you may get a funny little video about a condom being put on. I don’t think it’s enough (115).

That same YLW discussed how she felt that her city did not prioritize women’s health.

Outside the university, still very much a city that puts women’s health on the back burner. So, there’s not much outreach just casually every day. So just an average person who maybe had never stepped foot on this university… you wouldn’t just come across it saying, oh, here’s a pamphlet on women’s sexual health… I feel like this city’s just not very much up-to-date and in line with a lot of other cities out there that are much more advanced in getting that information out there (115).

Lack of “deservingness” for healthcare.

The YLW and community stakeholder interviews pointed to lack of health-related “deservingness” (Sargent, 2012; Willen, 2012) among healthcare providers. One nurse practitioner/health-quality specialist explained:

…we [health providers] don’t always make an attempt to be inclusive of the community… there are some personal biases some providers of the community have towards…[the] Latino community…[that impact care provision because] how I feel about [you] is transferred into the level of care that I give you…they feel like they are taking services from someone else…to say this community is taking…services that they are unworthy of, I think, is unfair. (210)

In this case, the participant was articulating that she sees health providers who believe that providing adequate care to Latinas/os/x means using resources meant for others in the state.

YLW and stakeholders also expressed concerns about the accessibility of available sexual healthcare resources, especially given the legal environment. For example, one of our community stakeholder participants, who advocates for abortion access and reproductive justice, explained the legal restrictions for minors to access abortions and highlighted institutional restrictions that women face to receive sexual healthcare.

…it’s not uncommon for all kinds of people along the way in the judicial bypass procedure to put up sort of arbitrary roadblocks because of their own politics. Teens will call down to somewhere to start the process [of getting a judicial bypass to allow an abortion without parental consent], and the person will tell them, “Oh, no, I don’t know what you’re talking about” or “we don’t do that,” basically mess them up from doing that (208).

In addition to this, she shared her own failed attempt to obtain an IUD when she was 19 years old. She recounted how a nurse practitioner at the clinic warned her that doctor who performed IUD implants was very reticent to perform the procedure on YLW and coached her to mention that she was engaged to be married. Despite following this advice, this participant had to wait four hours at the providers’ waiting room before being told that the provider had left for the day and was not going to be able to perform the procedure.

And I ended up being there for a total of four hours but still didn’t get the service that I needed, and I didn’t file a report about the treatment that I received or what had happened because it was really demoralizing and frustrating. So I just kept with the same kind of birth control routine that I had been until this past year, and I actually went back to [clinic name] to get an IUD, and I was actually successful this time.

(208)

A YLW woman explicitly said that Mexicans are not “treated well”, with regard to going to the doctor and how this keeps people from going for care unless they are very ill:

They don’t treat you well because you are Mexican…they look at you ugly. They make you feel badly or the treat you badly. And it’s better not to go to get a checkup at all. Unless you are really sick… A lot of people have died because of that.

(113)

Theme 2: Latinas Encounter Different Forms of Racialized Violence in their Everyday Lives

Personal experiences of racism or xenophobia.

Although HCA was the original focus of this study, our interviews revealed that experiences of discrimination and xenophobia were present in other spheres of YLW’s lives. YLW recounted being targets of racism. A 21-year-old Chicana college student and leader shared incidents where individuals exhibited explicit racial/ethnic animosity toward Mexicans.

…[A girl in a sorority I joined] didn’t know I was Mexican, so they said that Mexicans were dirty, ugly, and poor… I’m never going to forget that. At that point I had no one there to talk to about that. I mentioned it to my family, but they weren’t here to help me go through that and adjust. I don’t know. It was one of the worst experiences I’ve ever been through. When I reached out to different Latinos I started to realize that that was happening to a lot of people on campus (202).

Another YLW discussed how her neighbors were “bullied” because they did not know how to speak English:

I had a neighbor… they didn’t know how to speak English… and they would try to learn and how to speak it fluently, but they would get mocked on by people on the bus.

(114)

A different interviewee described feeling that she had been discriminated against while trying to rent formal-wear for a quinceañera (15-year old birthday party).

I remember when it was the quinceañera. Well, this doesn’t have nothing to do with health, but we went to go get the tuxedos and there was this white lady and, you know, we came up to her in a nicest way, obviously, because we wanted her help with the tuxedos, and she came up to us, like - I mean, she came at us [was rude], like, with an attitude and we didn’t do anything to her. I don’t know why, ‘cause, I mean, other people will come in there, you know, other races, and she would act fine. But then when we came in, we would ask her questions she would ask us with attitude… And then… when we came to pick up our suits that day after the party, everything was messed up.

(118)

Finally, another YLW described being “grabbed” by young men in fraternities.

in some occasions like when you go to class or like you are out and stuff like that and then they see you [fraternity guys], they just come up to you and they try to hold onto you and stuff like that. It has happened to me like I have gone to the fraternities, yeah, mostly the fraternities, like I would walk by and people would try and grab my ass because apparently Latina, “oh, Latinas have a nice ass”. I would be like “don’t touch me!”

(109)

Alabama is unwelcoming or hostile toward immigrants.

Key stakeholder respondents and YLW identified how Alabama has either an unwelcoming or a hostile environment toward Latina/o/x and/or undocumented immigrants. The reasons ranged from perceived negative attitudes or actions based on race or ethnicity to fears of or experience with deportation. For example, when asked if she thought Latina/o/x faced racism one YLW who worked in the service industry responded:

Yes, especially now…they [customers] won’t smile back especially now [reference to the 2016 Presidential election] that I’m at work—well, now that I’m working…[they] throw shade or something…but I have to keep my composure because I’m at work so I can’t be saying nothing (119)

Another young woman also referenced the 2016 Presidential election as the reason why people judged her by “her ethnicity”.

Interviewee: …people, like people just judge us by ethnicity. Interviewer: How do you feel judged by your ethnicity? Interviewee: Currently with what is happening with the presidency (103)

A third YLW who grew up in the Midwest reflected on how different it was to live in the South.

…the south is bad but I didn’t know how bad it was because I’ve never experienced it… I feel like a lot of people don’t know what it’s like to live here and especially in the Black Belt in Alabama because it’s hard. It’s so hard.

(202)

One Mexican immigrant woman who is an active community member, church leader and mother to two preadolescent Latinas stated:

The political environment, always, one of my daughters was in a debate class and then they ran a mock [presidential] election. So, the kids were going to vote and at the same time they had to act how they had seen others act. And my daughters came and talked to me that various [of them] had made Trump posters and that all people should leave [the country], that only Whites [should stay]. They said things like that would say, we [my husband and I] couldn’t believe that the children would do that, but they did it for some reason, because it’s what they see at home, in their environment…And then they were, like, sad because of this incident, because they lived through this with their friends…they were a bit sad to see that this was their reality (201).

These examples help to illustrate how Latinas form a racialized ethnic group that experiences racism and xenophobia. We interpret this as both stemming form and contributing to the structural violence that young Latinas face as a result of state/federal laws and policies.

Fear of deportation.

Legitimate concerns over deportation, either of themselves or of friends and family, also contributed to the violence YLW faced in Alabama. Although we did not ask any of our respondents to identify their immigration status, this came up in a number of interviews. As one mother described:

The greatest challenge [we face] is fear of deportation. This the greatest challenge we have. I am afraid that police will come for me and stop me and send me to Mexico and my daughter will remain here alone with strangers, since I don’t have any family here, I start thinking about what might become of her…what will happen? This is the greatest challenge we have (401)

A YLW discussed how being “taken advantage of” due to their legal status was a concern for young Mexican women.

Interviewer: …what do you think are the biggest concerns that young Mexican women your age face with regards to their sexual health? Interviewee: People taking advantage of them because so many people know that Mexican girls aren’t legal. They could take advantage of them… “oh I am going to tell this person that you are illegal if you don’t have sex with me” or something like that.

(105)

Another YLW talked about how fear of deportation meant lower wages for her father and family as well as a sense that they are not “equal” with others.

…when it comes to immigration status. It’s always a fear…in the Hispanic community to go places, to do certain things that everybody else is also doing. You don’t see yourself as equals… And also, you don’t see yourself as being good enough or just being the same as other people to get the same services. How do I put this? My dad was, like, “Well this is what we have to endure. A lot of jobs don’t pay the same because we are illegal here.”

(112)

A local immigrant rights activist relayed her involvement in “Know your Rights” campaigns with immigrant communities and workshops to create legal documents for parental rights, in the case of deportation.

We have a “know your rights” project, also one for affidavits for parental rights. This is very important because many people, they will get detained and end up in immigration jail, they leave their kids and belongings behind, so we want to make sure that they can get their kids back in Mexico, and their things. Someone can sell them [their things] and they could lose everything.

(201)

Two of the YLWs in our sample shared that their fathers had been deported. Others made comments that implied that they were likely Deferred Action for Childhood Arrivals (DACA) program beneficiaries, a program with an uncertain future (Singer, 2013).

Discussion

Our study focused on sexual HCA among YLW in West Alabama. As part of this work, we examined YLW’s and other community stakeholder’s perceptions of structural violence in the context for their everyday lives, including in attaining healthcare. Our interviews reflect how Alabama’s laws and policies with regard to immigration and sexual health can create barriers to care for YLW as they try to live out their sexual lives. In Alabama, the combination of laws that limit the availability of evidence-based sexual education and sexual HCA, and the enforcement of anti-immigrant laws and policies that target Latinos as the largest foreign-born population in the state, creates HCA challenges for young Latinas.

This generation of YLW is coming into sexual maturity and adulthood in a state that received a grade of “F-” on reproductive health and rights (Population Institute, 2017) and which has overtly (as stated by the law’s sponsors), worked to remove members of their communities through anti-immigrant legislation. These structural conditions are not conducive to positive health outcomes for women who seek good sexual health and wellbeing. The systems and laws in place can discourage YLW from seeking sexual healthcare and our interviews show that some of them experience racialized xenophobia in healthcare settings and in their everyday lives.

In understanding YLW’s health, scholars and public health experts should continue to examine how the multiple layers of oppressive power bear down YLW’s reproductive rights. These findings are in line with other research that critiques healthcare institutions by pointing to how these entities implement differential notions of “deservingness” of care for variant groups (Sargent, 2012; Willen, 2012). We argue that these legal restrictions create conditions that serve as a form of structural violence toward adolescent Latinas.

Implications

Given our findings we suggest the following structural and policy implications:

Sexual Health Education, Sexual/Reproductive Health Provision, and Family Planning

Understanding the social determinants of health is vital to ensure the success of medical and public health interventions (Farmer, Nizeye, Stulac, & Keshavjee, 2006; Lane et al., 2004; Mosley & Chen, 2003). Sexual health education policies should support comprehensive K-12 sexual health education and remove barriers to adolescents’ access to sexual healthcare services, as these are widely considered “basic human rights” for young people by Public Health experts (American Public Health Association, 2014; Santa Maria, 2018). Sexuality and reproductive health education should be sex positive, comprehensive, evidence-based, and LGBTQIA+ inclusive. Access to this education should be ensured and consistently provided to youth. Family planning and sexual health programs should be nonjudgmental, youth-friendly, culturally tailored and acknowledge how variant immigration status may impact one’s access to social institutions, health-related services, and material conditions. Furthermore, there is a critical need for cultural humility training among providers to enable them to work more effectively with Latina/o/x youth and attend to their unique needs as a racialized immigrant group (Halman & Baker, 2017; Hardeman, Medina, & Kozhimannil, 2016). Lastly, women themselves should be empowered to seek resources. Thus, sexual health interventions targeting YLW should have an empowerment component to help youth navigate the social and health provider landscape and better advocate for their own needs and for better laws and policy.

Immigration-related Laws and Policies

Empirical evidence demonstrates that there is a relationship between anti-immigration laws and policies (state and federal) and decreased access to health services for immigrant populations (Martinez et al., 2015b). Policy makers should keep in mind that these laws and policies have the potential to produce negative health outcomes for their constituents.

Conclusion

Laws and policies can exclude particular groups of people in our society, structure their lives and have repercussions on their health. Exclusionary policies restrict YLW adolescents from asserting their sexual rights and seeking good sexual health. Our study suggests that contextual forces (including laws and health policies) constrain YLW from seeking good sexual health and wellbeing because intersecting structural forces prevent them accessing the care that they need. In order to address these structural and health inequalities it is crucial that sexual health education, sexual/reproductive health provision programs, and family planning programs provide and support evidence-based, sex-positive sexual health education that upholds women’s sexual rights (including migrant women) and that federal and state laws and policies move away from criminalizing immigrants (World Health Organization, 2006; Martinez et al., 2015b).

Public Significance Statement.

Through a focus on young Latina women’s access of sexual and reproductive healthcare, this paper finds that YLW in the U.S. South experience systemic violence and a resulting precarity. These findings assist scholars to better understand intersectional, structural violence and the lived experiences of YLW/immigrant youth in the U.S. South.