32/32 Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health
Human Rights Council Thirty-second session
Agenda item 3
Promotion and protection of all human rights, civil,
political, economic, social and cultural rights,
including the right to development
Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health
Note by the Secretariat
The Secretariat has the honour to transmit to the Human Rights Council the report of
the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable
standard of physical and mental health. Prepared pursuant to Council resolution 24/6, the
report focuses on the right of adolescents to the enjoyment of the highest attainable
standard of physical and mental health and on the imperative to implement measures
necessary to guarantee optimum health and development in accordance with the unique
nature of adolescence.
In the report, the Special Rapporteur elaborates on mental health, the rights to sexual
and reproductive health, and substance use and drug control, in view of the particular
challenges they pose in balancing adolescents’ emerging autonomy with their right to
Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health
I. Introduction ...................................................................................................................................... 3
II. Understanding adolescence and its implications for the right to health ........................................... 4
A. A period of transition ............................................................................................................... 4
B. Challenges to the right to health for adolescents ..................................................................... 5
C. Opportunities for realizing the right to health .......................................................................... 6
III. Right to health in adolescence .......................................................................................................... 7
A. Understanding the right to health ............................................................................................. 7
B. Health care and other health-related services essential for adolescent health .......................... 7
C. Underlying and social determinants of health .......................................................................... 8
D. Right to non-discrimination ..................................................................................................... 11
E. Participation ............................................................................................................................. 11
F. Accountability.......................................................................................................................... 13
IV. Promotion of emotional well-being and mental health..................................................................... 14
A. Nature and prevalence of mental health problems in adolescence ........................................... 14
B. Promoting effective mental health services ............................................................................. 15
V. Adolescents’ rights to sexual and reproductive health ..................................................................... 17
A. Nature of and challenges associated with sexual and reproductive health rights ..................... 17
B. Providing effective sexual and reproductive health services for adolescents .......................... 18
VI. Adolescents, substance use and drug control ................................................................................... 20
A. Nature of and problems associated with substance use in adolescence ................................... 20
B. Providing appropriate services to address adolescent substance use ....................................... 21
VII. Conclusions and recommendations .................................................................................................. 22
1. Adolescence (10-19 years of age) is a life stage when inequities become more
sharply differentiated in terms of access to services, life decisions and future trajectories.
Foundations laid down during adolescence, in terms of emotional security, health,
education, skills, resilience and the understanding of rights will have profound implications
for the social, economic and political development of adolescents. The costs of failing
adolescents are high, which is why a powerful case exists for paying greater attention to the
right of adolescents to the highest attainable standard of health and development.
2. There is a growing focus on adolescence within the international health and
development community, as reflected, most notably, in the Global Strategy on Women’s,
Children’s and Adolescents Health 2016-2030. These are important and welcome
commitments that now need to be translated into action on the ground.
3. The population of adolescents globally is estimated to be over 1.2 billion, 88 per
cent of whom live in developing countries.1 Adolescents represent 18 per cent of the
world’s population. Although adolescence is inherently characterized by relatively low
mortality compared to other age groups, it is associated with emerging and complex risk
factors, resulting in patterns of behaviour that affect long-term morbidity and mortality.2
Likewise, adolescents are one of the groups that existing health services serve least well.3
4. It is estimated that 1.3 million adolescents died in 2012 from preventable or treatable
causes.4 Road traffic accidents, suicide and homicide, violence and war, drowning and fire-
related incidents account for about 40 per cent of all deaths among youth (people aged
between 15 and 24 years).5 A small percentage of adolescents suffer from life-limiting and
sometimes terminal illness, of which a majority are estimated to have no access to palliative
5. Lack of access to safe reproductive health services and information contributes to
adolescent girls among the most at risk of dying or suffering from serious or lifelong
injuries associated with early pregnancies and childbirth. The lack of effective adolescent
mental health policies and services leads to significant failures in emotional and social
development, including violence against and among adolescents. Nearly all these risks are
preventable, with outcomes grounded in physical and social environments and frequently
mediated by their behaviours.
6. The rate and breadth of developmental change during adolescence is second only to
that experienced in early childhood.7 While investments during the past 20 years have
resulted in enormous gains for children in the early years,8 far less recognition has been
1 United Nations, World Population Prospects: The 2010 Revision (2011).
2 World Health Organization (WHO), World Health Statistics 2014.
3 WHO, Health for the World’s Adolescents. Available from http://apps.who.int/adolescent/second-
4 WHO, “Adolescents: health risks and solutions”, factsheet No. 345 (2014).
5 George Patton and others, “Global patterns of mortality in young people: a systematic analysis of
population health data”, The Lancet, vol. 374 (2009), pp. 881-892.
6 Stephen Connor and others, “Assessment of the need for palliative care for children in South Africa”,
International Journal of Palliative Nursing, vol. 20, No. 3 (March 2014), pp. 130-134; and WHO and
the World Palliative Care Alliance, Global Atlas of Palliative Care at End of Life (2014), p. 19.
7 R.M. Viner and others, “Adolescence and the social determinants of health”, The Lancet, vol. 379,
No. 9826 (April 2012), pp. 1641-1652.
afforded by policymakers to the implications of development in the second decade of life.
Over the past 50 years, health has improved far less among adolescents than it has among
7. While there are many health issues of concern during adolescence, in the present
report the Special Rapporteur focuses on mental health, substance use and drug control, and
the rights to sexual and reproductive health, in view of the particular challenges they pose
in balancing adolescents’ emerging autonomy with their right to protection. Using the right-
to-health framework, the Special Rapporteur underlines the importance of valuing
adolescents’ strengths and engaging with them as partners in informing and shaping the
measures needed to realize the right to health and the optimum development of adolescents.
8. The Special Rapporteur recognizes the heterogeneity of adolescence and that
definitions vary by country and region. However, to promote consistency and facilitate the
measurement of adolescent health, this report adopts the definition of the World Health
Organization, which views adolescents as persons between the ages of 10 and 19 years
(until the twentieth birthday).10
II. Understanding adolescence and its implications for the right to health
A. A period of transition
9. Adolescence is a life stage of intrinsic value, not merely a transition between
childhood and adulthood. It is a critical developmental stage characterized by growing
cognitive abilities and emotional competencies, during which the brain has substantial
neural plasticity.11 The physical, mental and social potential established during the second
decade contributes to enhanced intellectual ability and emotional functioning throughout
10. Adolescent health is the result of interactions between early childhood development
and the specific biological and social role changes that accompany puberty, shaped by
social determinants and by risk and protective factors that affect the uptake of health-related
behaviours.13 While adolescents themselves have the capacity to contribute to their own
health and well-being, they can only achieve this goal if States respect and protect their
rights and provide them with access to the necessary conditions, services and information.
11. Adolescence is a period of development towards increasing capacity for independent
decision-making, moving away from the protective environments associated with earlier
childhood. It is accompanied by greater experimentation, risk-taking and impulsivity and by
the increased influence of the peer group. These behaviours contribute to building
resilience, character and self-confidence and to the exploration and understanding of
boundaries, and reflect the gradual adjustment from protection towards autonomy.
Accordingly, while adolescents under 18 years of age continue to be entitled to protection
from violence, abuse and exploitation, as well as to consideration of their best interests,
9 Susan Sawyer and others, “Adolescence: a foundation for future health”, The Lancet, vol. 379,
No. 9826 (April 2012), pp. 1630-1640.
10 See www.who.int/maternal_child_adolescent/topics/adolescence/en/ and
11 Susan Sawyer and others, “Adolescence: a foundation for future health”.
12 WHO, Health for the World’s Adolescents.
13 Susan Sawyer and others, “Adolescence: a foundation for future health” (abstract).
under the Convention on the Rights of the Child, the nature of those protections and their
application must reflect the emerging competencies acquired throughout adolescence.
12. The transition towards adulthood is characterized by the changing nature of
relationships. Across cultures, adolescents begin to attach far greater significance to and are
increasingly influenced by their peer group and less by family and caregivers.14 Adolescents
also begin to explore their sexuality, sexual orientation and gender identity. There is
considerable diversity in combinations of gender identities, expression and sexual
orientation, irrespective of whether such diversity is culturally accepted.15 It is increasingly
clear that sexual orientation and gender identity derive from a complex interplay of
biological, genetic and social factors and that individuals have little or no choice in its
13. Supporting adolescents to navigate successfully the challenging path towards
healthy emotional, psychosocial, physical and sexual development requires recognition of
their rights to information, freedom of expression and association, protection from all forms
of violence, safety, bodily integrity and family life, and respect for their dignity and
B. Challenges to the right to health for adolescents
14. Although opportunities for adolescents in many parts of the world have improved in
recent years, the second decade of life is associated with exposure to increasing risks to the
right to health, including violence, abuse, sexual or economic exploitation, trafficking,
harmful traditional practices, migration, radicalization, recruitment into gangs or militias,
self-harm, substance use and dependence and obesity. Gender inequalities become more
significant as, for example, girls become exposed to child marriage, sexual violence and
lower levels of enrolment in secondary education. The world in which adolescents live
poses profound challenges, including poverty and inequality, climate change and
environmental degradation, urbanization and migration, radical changes in employment
potential, aging societies, rising health-care costs and escalating humanitarian and security
15. States policies towards adolescents are too often characterized by targeted or
punitive interventions aimed at addressing problems such as juvenile delinquency and
violence, as well as perceived challenges, including substance use and sexual activity; too
little attention is typically paid to building positive environments in which adolescents can
thrive. Punitive and excessively biomedical interventions ignore the powerful social and
economic determinants influencing adolescent behaviour, opportunities and well-being.
Stigmatizing, demonizing and discriminating against adolescents by, for example,
criminalizing or pathologizing their behaviours and diversities, negatively affects their
socially perceived roles, self-esteem, well-being and sense of empowerment. These
approaches fail adolescents, their holistic development and their right to health.
16. One-size-fits-all policies designed for children or youth often fail to address
adolescents, particularly 10-14 year-olds. Lack of awareness or understanding of their
unique health needs can render adolescents invisible. Adolescents face multiple barriers to
14 Clea McNeely and Krishna Bose, “Adolescent social and emotional development : a developmental science perspective on adolescent human rights”, in Human Rights and Adolescence, Jacqueline
Bhabha, ed. (2014).
16 See www.apa.org/topics/lgbt/orientation.aspx.
17 UNICEF, The State of the World’s Children 2011: Adolescence — An Age of Opportunity (2011).
health services, including the following: restrictive laws and policies; unavailability of
contraception or safe abortions; inaccessible services owing to lack of information, distance
or cost; failure to ensure privacy and confidentiality; parental consent or notification
requirements; provision of services in a manner that is disrespectful, hostile, judgemental or
lacking sympathy; and discrimination against particular groups of adolescents, including
those with disabilities, those living and working on the streets or in the sex trade and those
from historically marginalized groups.18 States have positive human rights obligations to
guarantee adolescents’ rights and meaningfully engage with them in identifying their needs
17. Rapid globalization and associated social and cultural changes, reinforced by the
digital world, mean that many adolescents inhabit a world very different from that of the
adults around them in relation to information, the speed of change, social norms, risks,
aspirations and opportunities. While these rapidly changing environments offer important
opportunities for adolescents, they can also pose significant challenges to their rights, for
example to privacy, informed consent and freedom from exploitation, with significant
implications, in particular for their mental health and well-being. Furthermore, the speed of
change can inhibit intergenerational understanding, challenging the capacity of parents and
other caregivers to provide the guidance necessary to protect and promote adolescents’
right to health.
18. The lack of data disaggregated by age, sex and disability poses one of the biggest
challenges to promoting adolescent rights.19 Without adequate data, States lack evidence to
inform health policy, identify gaps and support the allocation of appropriate resources.
C. Opportunities for realizing the right to health
19. Adolescents are actors for social change, and are able to bring dynamism, flexibility,
creativity and energy towards the realization of their own and others’ rights to health. States
should adopt a human rights framework for adolescent health guided by the recognition of
their strengths, capacities and contributions, while also addressing the impact of social
determinants of health. Respecting and engaging with adolescents and treating them as a
resource contributes to building foundations for emotional security, health, education and
the skills needed for the full and effective realization of the right to health.
20. Adolescents have the right to play an increasingly important role in the
determination of their own health care. Respect and recognition of their capacities is
intrinsic to the enhancement of positive health outcomes. Forging partnerships with
adolescents is the key to shaping an environment that enables the realization of their right to
21. In particular, adolescents’ leading role in using and shaping new communications
technologies places them in a position to build and utilize networks to promote their right to
health, for example through information dissemination, data gathering, health campaign
design, health education, peer-to-peer education and counselling and conflict mediation. A
number of e-health and web-based interventions and mobile applications can provide
information, increase access to care, engage adolescents in treatment and initiate aftercare.
These skills and capacities mean that adolescents are uniquely positioned to contribute to
the attainment of the Sustainable Development Goals, in particular Goal 3, as well as to
18 WHO, Making Health Services Adolescent Friendly (2012).
19 UNICEF, The State of the World’s Children 2011.
monitoring and holding Governments to account on the commitments made (General
Assembly resolution 70/1).
III. Right to health in adolescence
A. Understanding the right to health
22. The Convention on the Rights of the Child provides a comprehensive normative and
legally binding framework to address the right to health of adolescents under the age of 18,
while other treaties, such as the International Covenant on Economic, Social and Cultural
Rights, provide a framework relevant for all adolescents, including those aged 18 and 19.
23. Further group-specific protections are found in other human rights treaties, but the
Committee on the Rights of the Child has been at the forefront of efforts to apply the right
to health in the context of adolescents, notably in its general comment No. 4 (2003) on
adolescent health and development in the context of the Convention on the Rights of the
Child and general comment No. 15 (2013) on the right of the child to the enjoyment of the
highest attainable standard of health.
24. The right to health of adolescents is closely related to other human rights included in
these treaties, such as the rights of the child to healthy development, education, play and
recreation, social security and privacy, and to being free from torture, all forms of violence
and economic, sexual and other forms of exploitation. The right to health is also
inextricably linked to non-discrimination and equality, participation and accountability.
Adolescent health and development need to be promoted in the context of a holistic and
comprehensive approach to the wider determinants affecting the opportunities, choices and
consequent development of adolescents.
25. The right to health provides a valuable normative framework grounded in a
commitment to promote the best interests of adolescents while acknowledging their
evolving capacities to take increasing levels of responsibility for their own health care. It
also places a legal obligation on States to progressively realize the highest attainable
standard of health of adolescents; eliminate discrimination and inequalities that obstruct
equitable enjoyment of the right to health; ensure the participation of adolescents in
relevant efforts; devote maximum available resources to the right to health of children;
develop suitable laws and policies, including a comprehensive national health plan that
addresses adolescents’ right to health; and ensure accountability, including effective
26. The private sector is a significant provider of health care in many countries and
plays a major role in the development and refinement of drugs and health-related products
and technology. States should ensure that benefits accrue to all adolescents.20
B. Health care and other health-related services essential for adolescent
27. States must ensure that health systems, including health-care services, in cooperation
with other relevant services, such as social, child protection and education services, are
responsive to the right to health of adolescents. They should address the full spectrum of
adolescent health and development, including health promotion, sexual and reproductive
20 Committee on the Rights of the Child general comment No. 15, para. 42.
health, mental health, palliative care, unintentional and intentional injuries, violence, and
health-compromising behaviours that may begin during adolescence.
28. Rather than only setting up separate interventions and facilities for adolescents,
efforts should be made to ensure that adolescents receive adequate attention in all policies,
strategies and programmes that are relevant to them. Health systems should be designed
and services should be delivered in a way that respects the right to health and other related
rights of adolescents, in accordance with their evolving capacities. This can only be
achieved by guaranteeing the right of adolescents to be heard and to contribute to the
planning, implementation, monitoring and evaluation of services.
29. The right to health gives rise to an obligation of States to ensure the availability,
accessibility, acceptability and quality of health services, goods and facilities. States must
ensure that sufficient health facilities, goods, services and programmes are available to
meet the needs of adolescents, especially the most marginalized.
30. Services, goods and facilities must be accessible to all adolescents without
discrimination on any grounds. This includes access to information on their health, as well
on the nature, availability, location, costs and timing of services. Services must be
physically accessible, including to adolescents in remote or rural communities and
adolescents with disabilities, and be located in spaces that provide adolescents with
confidence that their specific health-care needs will be met.
31. Services and goods must be affordable, considering that adolescents rarely have
financial means or autonomy, and accessible, directly and without parental support. In
practice, it should be recalled that user fees can obstruct access to services.
32. States should develop a core package of interventions for adolescents, including to
sexual and reproductive health services, that are available free of charge. Services must be
designed and delivered in a manner consistent with the evolving capacities, developmental
needs and the best interests of adolescents. They must respect adolescents’ right to privacy
and confidentiality, address different cultural needs and expectations and comply with
ethical standards. Services must be sensitive to gender and lesbian, gay, bisexual,
transgender and intersex status, they must be non-judgemental regarding adolescents’
personal characteristics, lifestyle choices or life circumstances and they must treat all
adolescents with dignity and respect, consistent with their status as rights holders.
33. All health-related services must be appropriate and of good quality, with skilled
personnel who have been adequately trained, in particular on adolescents’ right to health.
Equipment and drugs must be appropriate for adolescents and regular assessments of the
quality of health-care services undertaken.
34. The health sector should take the lead in development plans for adolescents’ right to
health. However, intersectoral collaboration is vital, including among the education and
social protection sectors, and right-to-health considerations must be integrated into relevant
policies and strategies.
C. Underlying and social determinants of health
35. The right to health is not only a right to health care, but a right to underlying and
social determinants of health. Social determinants are the conditions in which people are
born, grow, live, work and age that influence their health. The evidence overwhelmingly
shows that the strongest determinants of adolescent health worldwide are structural factors
such as national wealth, income inequality, gender systems and access to education.21
Additional determinants include social norms, laws and policies and the physical
environment, as well as the online social media environment, which plays an increasingly
influential role in adolescents‘ lives.
36. States must take legal, policy and other measures to address the underlying and
social determinants of adolescent health, including: road and environmental safety; racial
prejudice; access to education; persistence of forced and early marriage; corporal
punishment; social, economic, political, cultural and legal barriers to health services,
including sexual and reproductive health services; inadequate social protection;
institutionalization; punitive drug laws; absence of comprehensive sexuality education;
criminalization of exposure, non-disclosure of HIV status and transmission of HIV;
criminalization of same-sex relationships; and lax legal frameworks governing the sale of
tobacco, alcohol and fast foods.
37. Measures to address the right to health should be holistic and integrated, go beyond
the provision of health services and be underpinned by cross-departmental commitment.
States should take account of and respond to the particular challenges faced by different
groups, such as younger and older adolescents, males, females and lesbian, gay, bisexual,
transgender and intersex persons.
Right to protection from all forms of violence
38. Exposure to violence increases during adolescence, to the point that it is a primary
cause of mortality and morbidity in the second decade.22 Violence occurs in the family, in
the community, at work or at the hands of State actors.
39. Adolescent girls, adolescents with disabilities, lesbian, gay, bisexual, transgender
and intersex adolescents, adolescents living in institutions and adolescents from
communities with a proliferation of unregulated weapons or experiencing armed conflict
are among those particularly vulnerable to violence. The risks for girls include, for
example, exposure to sexual violence and exploitation, forced and early marriage, honour
killings and abusive practices often carried out in health-care settings, such as forced
sterilization and forced abortion for girls with disabilities, and forced virginity testing.23
40. Violence in intimate relationships among adolescents is also common, resulting in
both immediate and potential long-term consequences for their physical, mental and social
health. In addition to its immediate health consequences, the trauma of violence perpetrated
by an intimate partner can lead to long-term physical injuries, to both immediate and
delayed-onset health problems and to experiences of repeated revictimization.24
41. Lesbian, bisexual and transgender youth are at risk of “punitive” rape on the basis of
their sexual orientation or gender identity. Adolescents suffer disproportionately from the
effects of gun violence and significant numbers of adolescents face serious harm or death as
a consequence of armed conflict.
42. The focus in the Sustainable Development Goals on tackling violence against
women and girls is welcome. However, significant levels of violence are also experienced
21 R.M. Viner and others, “Adolescence and the social determinants of health”.
22 WHO, Health for the World’s Adolescents.
23 See joint general recommendation No. 31 of the Committee on the Elimination of Discrimination
against Women/general comment No. 18 of the Committee on the Rights of the Child on harmful
24 C.C. Pallitto and V. Murillo, “Childhood abuse as a risk factor for adolescent pregnancy in El
Salvador”, Journal of Adolescent Health, vol. 42, No. 6 (2008), pp. 580-586.
by adolescent boys. Boys caught up in violent crime are often exposed to harsh punitive
responses by States that create a downward spiral of increasing violence with profound
detriment to their physical and mental health and well-being.
43. In line with the Convention on the Rights of the Child and the recommendations of
the Committee on the Rights of the Child, States must introduce measures addressing the
specific forms of violence faced by adolescents.25 Recognizing the right of adolescents to
exercise increasing levels of responsibility should not obviate States’ obligations to
guarantee them protection.
44. Rights to protection and increasing participation are mutually reinforcing.
Guaranteeing adolescents the right to be heard, to challenge rights violations and to seek
redress empowers them to exercise agency in their own protection.26 Failure to do so will
condemn millions globally to continuing and extreme violations of their rights.
45. The right to protection extends to violence in the digital environment. With growing
use of social media and online activity, adolescents are increasingly vulnerable to
cyberbullying, which is associated with a wide range of mental, psychosocial, cognitive,
educational and health problems, including depression and suicide, as well as other poor
coping responses such as problems with alcohol and other drug use. However, it is neither
appropriate nor possible to seek to restrict adolescents’ access to the digital environment.
Therefore, States should fulfil their obligations through the adoption of holistic strategies
aimed at enhancing adolescents’ capacities to protect themselves from online harm,
strengthening legislation and law enforcement mechanisms to tackle online abuse,
including cross-border abuse, combating impunity and training parents and professionals
who work with children.
46. The family, in its diverse forms and arrangements, refers to the essential
environment for the well-being, protection and development of children and adolescents.
The recognition of diverse family forms is necessary to ensure the protection and promotion
of the rights of all of children and adolescents, without discrimination of any sort.
47. Safe and supportive families are crucial to helping adolescents develop to their full
potential and attain the best health into adulthood. Therefore, support of the family
environment is very important for the physical and mental health of children and
adolescents. States should develop policies and services that support families and
strengthen their parenting competencies so that all children can grow in healthy family
48. Policies designed to protect families and family values should avoid measures that
undermine the human rights of individual family members, including women, adolescents
and younger children.27 Such approaches can be detrimental as they may, in the name of
traditional values, tolerate or condone violence, reinforce unequal power relations within
family settings and, therefore, deprive adolescents from the opportunity to exercise their
49. States should take specific measures to ensure that adolescents with disabilities
enjoy their right to family life and are not removed from their families against their will.
25 See articles 19, 37 and 39 of the Convention on the Rights of the Child and Committee on the Rights
of the Child general comment No. 13 (2011) on the right of the child to freedom from all forms of
26 Committee on the Rights of the Child general comment No. 13, para. 63.
27 See A/HRC/31/37, para. 23.
States should ensure that information, training and support are provided to parents to enable
them to help their adolescent children attain the highest attainable standard of health.
D. Right to non-discrimination
50. The right to non-discrimination is fundamental to realizing adolescents’ right to
health. Discrimination encompasses any distinction, exclusion or restriction that has the
purpose or effect of nullifying or impairing the recognition, enjoyment or exercise by all
persons, on an equal footing, of all rights and freedoms.28
51. Adolescence itself can be a basis for discrimination, with many adolescents treated
as dangerous or hostile, incompetent to make decisions, incarcerated, exploited or exposed
to violence as a direct consequence of their age. Health-care providers may perpetuate
discrimination against adolescents when they deny them health services or contraceptive
supplies or treat them poorly, which can make adolescents reluctant to seek the health-care
they need. Adolescents belonging to marginalized groups or sectors, such as girls, racial or
ethnic minorities, indigenous populations, lesbian, gay, bisexual, transgender and intersex
adolescents, refugees and adolescents with disabilities, face a heightened risk of exclusion.
52. To achieve substantive equality, States must take special measures in order to
diminish or eliminate conditions that cause discrimination”29 by introducing comprehensive
legislation and policies, as well as affirmative action measures, to diminish or eliminate
structural barriers and historic conditions that result in direct or indirect discrimination
against any group of adolescents on any grounds.
53. International human rights standards require the free, active and meaningful
participation of people in decisions that affect their lives.30 In particular, States’ obligations
under article 12 of the International Covenant on Economic, Social and Cultural Rights
require that the right of individuals and groups to participate in decision-making processes
affecting their health and development must be an integral component of any relevant
policy, programme or strategy.
Right of adolescents to be heard and regarded as the subjects of rights
54. Children, including adolescents, lack the full autonomy of adults while being
subjects of rights. Article 12 of the Convention on the Rights of the Child addresses the
legal and social status of children, recognizing their capacity to form their own views and to
express them freely in all matters affecting them and giving them due weight in accordance
with age and maturity.31
55. This has been broadly conceptualized as the right to and principle of participation,
and is central to the realization of adolescents’ right to health, both in individual matters
relating to their own health care and in wider issues such as the design and development of
28 See Human Rights Committee general comment No. 18 (1994) on non-discrimination.
29 See Committee on the Rights of the Child general comments No. 15, para. 12, and No. 5 (2003) on
general measures of implementation of the Convention on the Rights of the Child, para. 12.
30 Universal Declaration of Human Rights, art. 21, and the International Covenant on Civil and Political
Rights, art. 25.
31 See Committee on the Rights of the Child general comment No. 12 (2009) on the right of the child to
health-related services. It implies a fundamental shift in the traditional status of the child as
a passive recipient of adult decisions and interventions.
56. In order to ensure the relevance and efficacy of interventions, adolescents’
experiences, concerns, knowledge and creativity should be utilized in the development,
implementation and monitoring of relevant legislation, policies, services and programmes
affecting their right to health and development at the school, community, local and national
levels.32 Consultative mechanisms alone are insufficient to fulfil the right to be heard and to
be taken seriously. Adolescents must be afforded safe spaces with opportunities to identify
for themselves issues of most concern to them and to enable them to act on those concerns.
Particular attention should be paid to adolescents with disabilities, who must be provided
with disability and age-appropriate assistance to realize this right.33
Right to respect evolving capacities
57. During adolescence, the right to be heard and to be taken seriously transitions into
the right to make autonomous decisions about one’s health care and treatment. The concept
of children’s evolving capacities is an enabling principle addressing the process of
maturation and learning through which children progressively acquire competencies and
58. Not only is adolescence a period of considerably enhanced cognitive development, it
is also associated with greater self- and social awareness, and the ability to grapple with
complexity and to take into consideration the perspectives of others.35 These developments
have profound implications for adolescents’ capacities to take increasing levels of
responsibility for decision-making in respect of the right to health.
59. However, all too often States continue to deny adolescents the right to make
autonomous and confidential decisions with regard to accessing health services by requiring
parental notification or consent. These restrictions often make adolescents reluctant to
access needed services so as to avoid seeking parental consent, which may result in
rejection, stigmatization, hostility or even violence.
60. States are urged to consider the introduction of a legal presumption of competence
that an adolescent seeking preventive or time-sensitive health goods and services, including
for sexual and reproductive health, has the requisite capacity to access such goods and
services. Where minimum ages of consent exist, as the Committee on the Rights of the
Child has argued, any adolescent below that age and able to demonstrate sufficient
understanding should be entitled to give or refuse consent. At a minimum, States should
ensure a minimum age well below 18 years at which adolescents have the right to consent
to or refuse services without mandatory authorization or notification of parent, guardian,
spouse or intimate partner. The right to counselling and advice is distinct from the right to
give medical consent and should not be subject to any age limit.36
33 Convention on the Rights of Persons with Disabilities, art. 7 (3).
34 See Convention on the Rights of the Child, art.5, and Committee on the Rights of the Child general
comment No. 7 (2006) on implementing child rights in early childhood.
35 Sarah-Jayne Blakemore and S. Choudhury, “Development of the adolescent brain: implications for
executive function and social cognition”, Journal of Child Psychology and Psychiatry, vol. 47, Nos.
3-4 (2006), pp. 296-312; and Sarah-Jayne Blakemore and Katheryn L. Mills, “Is adolescence a
sensitive period for sociocultural processing?”, Annual Review of Psychology, vol. 65 (2014), pp.
36 Committee on the Rights of the Child general comment No. 12.
61. Particular regard must be afforded to the barriers faced by adolescents with
disabilities, as their views should be given due weight in accordance with age and maturity
on an equal basis with others and as they must be provided with opportunities for supported
62. Accountability, including its constituent components monitoring, review and
redress, is essential if the right to health is to be more than an aspiration.38 Accountability
reveals where progress has been made and where it has not been made, allows duty bearers
to explain what they have done and make adjustments, and provides an opportunity for
rights holders, including adolescents, to engage with duty bearers in the promotion and
protection of their rights and to seek redress where violations have occurred.39
63. The commitment expressed in the Global Strategy on Women’s, Children’s and
Adolescents’ Health 2016-2030 to improve national and global accountability, including for
adolescent health, is welcome, as is the broader commitment to accountability in the
Sustainable Development Goals. In this connection, States should ensure the quality and
timely collection of appropriately disaggregated data and that laws, policies and
programmes concerning adolescent health are transparently and regularly reviewed.
National assessments or public inquiries into adolescents’ right to health are welcome and
could be conducted by national institutions.
64. Adolescents, together with other key civil society stakeholders, should play an active
role in accountability. They should be actively involved in the determination of indicators
at the national and local levels that reflect the issues they consider to be of critical
importance in realizing the right to health.
65. To achieve this, all relevant policies should be devised, and periodically reviewed,
on the basis of a transparent process and with the participation of adolescents, and should
include right to health indicators and benchmarks.40 Indicators should be disaggregated on
suitable grounds, including those identified in the Sustainable Development Goals, namely
age, income, gender, race, ethnicity, migratory status, disability and geographic location, in
order to monitor the health status of marginalized groups and sectors of adolescents (see
target 17.18). Adolescents and other relevant civil society actors should also be actively
involved in review processes.
66. States should ensure adolescents have access to effective remedies to adjudicate
violations of their right to health, through the provision of supportive, child-friendly redress
mechanisms with the authority to adjudicate claims made by adolescents and filed on their
behalf, as well as access to subsidized or free legal services and other appropriate assistance
(see A/HRC/25/35). Furthermore, States should put in place preventive remedies where
adolescents can challenge denials of access to health services.41
37 Committee on the Rights of Persons with Disabilities general comment No. 1 (2014) on equal
recognition before the law.
38 WHO Commission on Information and Accountability, Keeping Promises: Measuring Results (2011).
39 Helen Potts, Accountability and the Right to the Highest Attainable Standard of Health (2008).
40 Committee on Economic, Social and Cultural Rights general comment No. 14 (2000) on the right to
the highest attainable standard of health, para. 43 (f).
41 See LC v. Peru; P&S v. Poland.
IV. Promotion of emotional well-being and mental health
A. Nature and prevalence of mental health problems in adolescence
67. Globally, it is estimated that approximately 20 per cent of 14-24 year olds
experience a mental health condition each year.42 The transition from childhood to
adulthood is a period of heightened vulnerability (half of all lifetime mental disorders
appear by the age of 14 years) caused to a significant extent by the physical, psychological
and emotional changes arising during this period. Research indicates that depression is the
primary cause of illness and disability among adolescents and suicide is the third leading
cause of death.43
68. Poor mental health can affect the health and development of adolescents more
generally and is associated with many damaging health and social outcomes, such as
substance use, the inability to form relationships, dropping out of school or academic
underperformance and delinquent behaviours, together with increased likelihood of poverty
and poorer employment opportunities.44
69. The risk of experiencing mental ill-health is heightened by poverty and by adverse
childhood events, including, for example, sexual and emotional abuse, bullying and
parental loss. Adolescents in post-conflict or disaster settings or who are homeless and
street-involved, orphaned, lesbian, gay, bisexual, transgender and intersex or involved with
the juvenile justice system are also at greater risk. Adolescents in the juvenile justice
system suffer substantially higher rates of mental health conditions than those in the general
population, with an estimated 70 per cent having at least one diagnosable mental health
70. The international human rights framework establishes the clear duty of States to
promote adolescents’ mental health and emotional well-being, provide appropriate mental
health treatment and care and ensure that mental health laws fully recognize the rights of
those with mental illness.46 Target 3.4 of the Sustainable Development Goals is to reduce
by one third premature mortality from non-communicable diseases through prevention,
treatment and the promotion of mental health and well-being. That target must be applied
fully to adolescents.
71. Despite these obligations and commitments, there is a worrying lack of recognition
or awareness of the nature and scale of mental health problems among adolescents in many
countries. Evidence indicates that many adolescents consider emotional well-being to be
the most important health problem they face and would like more access to quality mental
72. The nature of adolescents’ mental health needs differs from that of adults and
requires targeted services. However, a national health system of well-functioning, effective
42 Vikram Patel, Benedetto Saraceno and Arthur Kleinman, “Beyond evidence: the moral case for
international mental health”, American Journal of Psychiatry, vol. 163, No. 8 (2006), pp. 1312-1315;
and UNICEF, The State of the World’s Children 2012: Children in an Urban World (2012).
43 WHO, “Adolescents: health risks and solutions”, factsheet No. 345.
44 United Nations, Mental Health Matters: Social Inclusion of Youth with Mental Health Conditions,
46 Convention on the Rights of the Child , arts. 24 (1) and (2) (b) and 6; Committee on Economic, Social
and Cultural Rights general comment No. 14; and E/1995/22-E/C.12/1994/20.
47 WHO, Health for the World’s Adolescents.
and adolescent-friendly services remains the exception rather than the rule. Less than one
third of low- and middle-income countries have a designated youth mental health entity and
most lack youth-focused mental health policies.48 Where they do exist, they often fail to
meet quality standards and may even be harmful to the health and development of
adolescents. Adolescents may be detained for a long time in overcrowded, in-patient
facilities where little attempt is made at rehabilitation or social integration.49 These
approaches violate adolescents’ human rights and worsen, rather than ameliorate, mental
73. Public and self-stigmatizing attitudes towards mental illness, concerns about
confidentiality and lack of general understanding all serve as barriers to getting help,
particularly among adolescents, a problem compounded by the lack of quality mental health
services in low- and middle-income countries.50 For adolescents, the attitude of service
providers is more important than their technical expertise. Adolescents who seek services
often experience negative or hostile responses from health-care providers, leading to a
further reluctance to access help. Same-sex attraction is still considered by doctors in many
countries to be a mental disorder.51 Lesbian, gay and bisexual adolescents may be subjected
to harmful therapeutic interventions intended to eliminate or suppress their sexual instincts.
Such therapies have been deemed unethical, unscientific, ineffective and, in some instances,
tantamount to torture.52
B. Promoting effective mental health services
74. Prevention of mental health problems and promotion of mental well-being in
adolescence should be a central part of national health policies. Action plans should include
programmes for evidence-based interventions that are well-funded and monitored and that
aim to reinforce protective factors within adolescents, their families and communities.
75. Accordingly, the focus should be on building resilience, supporting parents,
stimulating adequate help-seeking behaviours, creating positive peer groups and school
environments, ensuring opportunities for influence and decision-making, increasing
empowerment and emotional literacy. Furthermore, such programmes can also address risk
behaviours such as bullying, suicidal behaviour, domestic violence and substance use.
76. Models based on over-medicalization and institutionalization should be abandoned
and replaced with early interventions and comprehensive community-based multisectoral
responses. Adolescent health policies must be developed with the involvement of
professionals in the health, education and social welfare sectors, who can provide a flexible
network of services, including schools, community outpatient and day care mental health
services rooted in the evidence-based biopsychosocial model.53
48 United Nations, Mental Health Matters.
49 Vikram Patel and others, “Mental health of young people: a global public-health challenge”, The
Lancet, vol. 369, No. 9569 (2007), pp. 1302-13.
50 Amelia Gulliver, Kathleen Griffiths and Helen Christensen, “Perceived barriers and facilitators to
mental health help-seeking in young people: a systematic review”, BMC psychiatry, vol. 10, No. 1
(2010), p. 113.
51 United Nations Development Programme and USAID, “Being LGBT in Asia: China country report”
and “Being LGBT in Asia: Cambodia country report”.
53 G. Thornicroft and M. Tansella, “The balanced care model for global mental health”, Psychological
Medicine, vol. 43, No. 4 (2013), pp. 849-863.
77. Cost-effective public health and psychosocial interventions, including social
protection, psychoeducation, coaching, counselling and psychotherapy, as well as parent
training, should be available and accessible to all adolescents in need and their families.
Such approaches aim at improving behaviour, holistic development and specific life skills,
and reduce the need for medication.54 Medications and inpatient services may be needed as
part of treatment plans in complex cases of mental conditions, but these treatment
modalities should be used with caution. Schools are well-placed to promote emotional well-
being and mental health and to prevent mental health problems, for example, through
classes on mental health literacy.55
78. Psychosocial interventions are not a luxury: on the contrary, when used in a manner
consistent with adolescents’ rights, ethically and on the basis of evidence, they are essential
interventions. Indeed, the World Health Assembly, in its resolution 65.4, has noted the
increasing evidence of effectiveness and cost-effectiveness of such approaches to promote
mental health and prevent mental disorders particularly among adolescents. Furthermore,
the Committee on the Rights of the Child has strongly encouraged States to adopt and scale
up these interventions, in line with their obligations to promote adolescents’ right to
79. States should invest in programmes to challenge outdated beliefs and negative
attitudes about mental conditions through the dissemination of information. Adolescents of
different ages and representing different perspectives should be consulted in the design,
development, implementation and monitoring of mental health services. Investments must
be made to address gender discrimination in mental health and to reach out to marginalized
communities, which are disproportionately vulnerable to mental health problems and
experience greater barriers in accessing services.
80. The right to mental health must be underpinned by legal frameworks that are fully
compliant with human rights standards, which demand respect for the evolving capacities
of adolescents with disabilities and their physical integrity. Adolescents with disabilities are
vulnerable to neglect, mental and physical abuse, sexual violence and forced sterilization or
contraception while detained in mental health care settings.
81. Accordingly, all institutions should adopt and publish principles and standards of
care and establish safe and effective reporting mechanisms and systems for redress in line
with international standards.57 Monitoring mechanisms should be in place to ensure that
violations of the rights of adolescents in mental health care settings can be reported and
82. The vulnerability of the growing number of adolescents in refugee camps or seeking
asylum is worrying. States are reminded of their broad international obligations to protect
refugees58 and ensure necessary assistance in the enjoyment of their rights, including the
right to optimum mental health and well-being.
54 Peter Fonagy and others, What Works for Whom?: A Critical Review of Treatments for Children and
55 “A preparatory action related to the creation of an EU network of experts in the field of adapted care
for adolescents with mental health problems: final report” (2015).
56 Committee on the Rights of the Child general comment No. 15.
57 See www.unicef.org/protection/alternative_care_Guidelines-English.pdf.
58 Convention on the Rights of the Child, art. 22.
V. Adolescents’ rights to sexual and reproductive health
A. Nature of and challenges associated with sexual and reproductive
83. Healthy sexual development requires not only physical maturation, but an
understanding of healthy sexual behaviours and a positive sense of sexual well-being.
Sexual initiation can be a natural and healthy aspect of adolescence, and adolescents have
the right to be provided with the tools and information to navigate sex safely. Sexual
activity among adolescents is widespread, although rates vary significantly. Yet,
adolescents around the world face significant discrimination and barriers in accessing the
information, services and goods needed to protect their sexual and reproductive health,
resulting in violations of their right to health.
84. Many adolescents, in particular girls and those identifying as lesbian, gay, bisexual
and transgender, are deterred from approaching health professionals in anticipation of a
judgemental attitude that results from social norms or laws that stigmatize or criminalize
their sexual behaviour. Rights to sexual and reproductive health for many adolescents are
further compromised by violence, including sexual and institutional violence, coercion into
unwanted sex or marriage, and patriarchal and heteronormative practices and values. This
reinforces harmful gender stereotypes and unequal power relations that make it difficult for
many adolescent girls to refuse sex or insist on safe and responsible sex practices.
85. The vulnerability of boys to physical and sexual abuse and exploitation should be
highlighted, together with the significant barriers they face in accessing sexual and
reproductive information and services. Intersex adolescents often experience particular
challenges because of irreversible and non-consensual surgeries performed during their
early childhood and because of the natural development of their bodies.59 Discrimination
within the family and society, as well as discriminatory attitudes by health providers, can
result in the denial of access to health services, while lack of knowledge and awareness
within the medical profession further impedes access to quality care.60
86. Adolescents with disabilities are frequently subjected to forced medical treatment,
including sterilization, abortion and contraception, which can constitute torture or cruel,
inhuman or degrading treatment.61 Girls with disabilities in particular experience alarmingly
disproportionate levels of physical and sexual violence, frequently without any means of
redress or access to justice.62 Many health-care providers hold inaccurate, stereotypical
views about individuals with disabilities, including assumptions that they are asexual,
which serves to deny them access to sexual and reproductive health information, services
and goods, as well as comprehensive sexuality education.63
87. AIDS is the second most common cause of death among adolescents globally.64
Worldwide, adolescents in key population groups, including gay and bisexual boys,
transgender adolescents, adolescents who exchange sex for money, goods or favours and
adolescents who inject drugs, are also at a higher risk of HIV infection. Adolescent girls in
63 Handicap International and Save the Children, Out from the Shadows: Sexual Violence against
Children with Disabilities (2011), p. 13.
64 WHO, Health for the World’s Adolescents.
high-HIV burden countries are particularly vulnerable, making up 75 per cent of new
infections in Africa in 2013,65 with gender inequality, harmful traditional practices and
punitive age of consent laws identified as drivers of the epidemic.66 These sectors and
groups face a disproportionately high risk of experiencing stigma, discrimination, violence,
rejection by families, criminalization and other human rights violations when seeking
sexual and reproductive health services, including denial of access to health-care services,
such as HIV testing, counselling and treatment.
88. Rights to sexual and reproductive health are therefore of critical importance. Sexual
health is defined as a “state of physical, emotional, mental and social well-being related to
sexuality, not merely the absence of disease, dysfunction or infirmity”.67 Article 24 (2) (f)
of the Convention on the Rights of the Child and article 12 (2) of the Convention on the
Elimination of All Forms of Discrimination against Women both recognize the right to the
provision of family planning education and services, including to adolescents, without
discrimination on any grounds.68 However, United Nations treaty bodies consistently raise
concerns relating to the provision of sexual and reproductive health information, services
and goods. They have also strongly affirmed that adolescents’ sexual and reproductive
health implicates a broad range of human rights, including to non-discrimination, freedom
from torture or ill-treatment, privacy and education.69
B. Providing effective sexual and reproductive health services for
89. Given the scale of these concerns, target 3.7 of the Sustainable Development Goals,
on ensuring universal access to sexual and reproductive health-care services, is welcome.
To achieve this target, States will have to adopt a comprehensive gender-sensitive and non-
discriminatory sexual and reproductive health policy for all adolescents and to integrate it
into national strategies and programmes.70
90. These policies must be consistent with the human rights standards and recognize that
unequal access by adolescents constitutes discrimination.71 All adolescents must be
guaranteed access to confidential, adolescent-responsive and non-discriminatory sexual and
reproductive health information, services and goods, including family planning, modern
forms of contraception, counselling, pre-conception care, maternal care, sexually
transmitted infections, diagnosis and treatment, and safe abortion.72 Adolescent sexual and
reproductive health services must be welcoming, adolescent-friendly, non-judgemental and
guarantee privacy and confidentiality. Health providers should also consider the
establishment of dedicated clinic times and alternative locations for adolescents,
particularly with regard to sexual and reproductive health services.
65 UNAIDS and the African Union, Empower Young Women and Adolescent Girls: Fast-Tracking the
End of the AIDS Epidemic in Africa (2015).
67 Paul Hunt and Judith Bueno de Mesquita, The Rights to Sexual and Reproductive Health (2006).
68 Committee on the Rights of the Child general comment No. 15.
69 KL v. Peru, CCPR/C/DJI/CO/1 and CAT/C/PER/CO/4.
70 WHO, Ensuring Human Rights in the Provision of Contraceptive Information and Services:
Guidance and Recommendations (2014).
71 Committee on Economic, Social and Cultural Rights general comment No. 20 (2009) on non-
discrimination in economic, social and cultural rights.
72 Committee on the Rights of the Child general comments No. 4 and No. 15.
91. Furthermore, States should introduce measures to raise adolescents’ awareness of
their rights to sexual and reproductive health and to services and goods at the family, school
and community levels. Age-appropriate, comprehensive and inclusive sexuality education,
based on scientific evidence and human rights, should be part of the mandatory school
curriculum, with special attention given to relationships, sexuality, gender equality and
identity and sex characteristics, including non-conforming gender identities, responsible
parenthood and sexual behaviour, and preventing early pregnancy and sexually transmitted
92. States are strongly encouraged to decriminalize abortion, in accordance with
international human rights norms, and adopt measures to ensure access to legal and safe
abortion services. Criminal laws with respect to abortion result in a high number of deaths,
poor mental and physical health outcomes, infringement of dignity and amount to violations
of the obligations of States to guarantee the right to health of adolescent girls.74
Furthermore, information about and access to abortion services must be available,
accessible and of good quality, without discrimination, at a minimum in the following
circumstances: when the life or health of the mother is at risk, when the mother is the
victim of rape or incest and if there is severe and fatal foetal impairment. Post-abortion care
must be available and accessible to all adolescent girls irrespective of the legal status of
93. Prevention, care, treatment and support are mutually reinforcing elements in
providing a comprehensive and effective response to HIV/AIDS.75 All adolescents should
have access to HIV testing and counselling, and evidence-based HIV prevention and
treatment programmes. Health services should offer HIV-related information, testing,
sexual and reproductive health services, contraception, condoms and HIV-related care and
treatment, including antiretroviral and other medicines, diagnostics and related technologies
for the care of HIV/AIDS, related opportunistic infections and other conditions, good
nutrition and social, spiritual and psychological support, as well as family, community and
94. The Special Rapporteur deplores the imposition of treatments to try to change sexual
orientation and gender identity, including forced sex assignment surgeries for intersex
youth, forced sterilizations and abortions for girls with disabilities, the use of surgery and
hormone therapy to stunt the growth of children with developmental disabilities and
remove their reproductive organs, and the pathologizing of transgender identity and same-
sex attraction as psychiatric disorders. States should eliminate such practices and to repeal
all laws criminalizing or otherwise discriminating against individuals on the basis of their
sexual orientation or gender identity and expression.76 There is a need to reform and update
national health information systems to include human rights concepts and variables such as
lesbian, gay, bisexual and intersex status.77
73 General Assembly resolution 70/137 and UNESCO, International Technical Guidance on Sexuality
74 A/66/254 and A/HRC/32/44.
75 Committee on the Rights of the Child general comment No. 3 (2003) on HIV/AIDS and the rights of
76 See A/HRC/22/53; CRC/C/RUS/CO/4-5; CRC/C/GAM/CO/2-3, paras. 29-30; and
CRC/C/CHE/CO/2-4, paras. 42-43.
77 Pan American Health Organization resolutions CD50.R8 and CD52.R6.
VI. Adolescents, substance use and drug control
A. Nature of and problems associated with substance use in adolescence
95. Adolescence is a period of risk-taking and experimentation with greater likelihood
of initiation into substance use. Adolescents are at higher risk of drug-related health harms,
while substance use initiated in adolescence can more often lead to dependence than during
adulthood. The most commonly used substances are alcohol, tobacco and solvents. Illicit
drug use, in particular cannabis, is also common and in recent years unregulated novel
psychoactive substances have become an important concern.78
96. Outside of high-income countries, data relating to adolescent substance use and
related health harms are poor. Important differences exist among and within countries,
between adolescents and their older counterparts and among groups of adolescents. For
example, heavy episodic or binge use, especally of alcohol, is more common among young
people.79 Adolescents’ access to services is limited in comparison to adults, for example,
being under the legal age of majority can block adolescents from accessing certain services.
Those identified at greatest risk of drug-related harms are those who are street-involved,
excluded from school, have histories of trauma, family breakdown or abuse, and those
living in families coping with drug dependence. Adolescent girls are at a higher risk of
certain kinds of harm than boys, including HIV infection due to both sexual transmission
and unsafe injecting practices. These factors demand concerted efforts to gather
appropriately disaggregated data to better understand patterns of vulnerability so that
services can be targeted and properly budgeted.
97. In addition to substance use, there are significant physical and mental health
consequences to adolescents’ involvement in the production of and trade in substances.
Adolescents are involved at all stages of the licit and illicit drug supply chains. With regard
to illicit drugs, in addition to sometimes hazardous work, adolescents can be exposed to
organized crime, violence and counter-narcotics operations. More research is needed into
the adolescent health implications linked to the production of drugs and the violence
associated with the criminal market.
98. The harms associated with drug use and involvement in the drug trade cannot be
disentangled from State responses. Evidence shows that repressive and punitive responses
to drugs have not been effective in reducing drug use or supply80 and that they have
produced negative consequences, including violence and corruption.81 Criminalization of
drug use and personal possession, as well as drug user registries and police violence, drive
young people from services, producing a health-deterrent effect. Prevention and education
programmes that focus on zero tolerance create an environment where adolescents may be
less likely to seek information about harms related to use. Adolescents have lost parents to
drug-related violence and to prolonged incarceration for non-violent offences, with
significant implications for their mental health.
78 UNODC, World Drug Report 2015 (United Nations publication, Sales No. E.15.XI.6). 79 WHO, Global Status Report on Alcohol and Health 2014.
80 Louisa Degenhart and others, “Toward a global view of alcohol, tobacco, cannabis and cocaine use:
findings from the WHO World Mental Health Surveys”, PLOS Medicine, vol. 5, No. 7 (2008); and
European Commission, Netherlands Institute of Mental Health and Addiction and Rand Europe, A
Report on Global Illicit Drugs Markets 1998-2007 (2009).
B. Providing appropriate services to address adolescent substance use
99. States should adopt appropriate measures to protect children from illicit drug use
and involvement in the illicit drug trade.82 However, this must be read in the context of the
protections afforded by the Convention on the Rights of the Child and other human rights
obligations.83 Almost all States have obligations under the three United Nations drug
control conventions, which must be read in conformity with concurrent human rights
obligations.84 The Framework Convention on Tobacco Control contains specific provisions
aimed at the protection of children and young people, and which complement the right to
100. States should provide prevention, harm reduction and dependence treatment
services, without discrimination, and allocate a budget sufficient to the progressive
realization of the right to health. These are not competing or alternative strategies but
required components of a comprehensive approach to enable adolescents to seek the health
services and information they are entitled to receive. All such services should comply with
the availability, accessibility, acceptability and quality framework.
101. With regard to the prevention of substance use, children and young people should be
provided with accurate and objective information,85 which should be available in easy-to-
understand formats or Braille. Scare tactics and misinformation are known to be ineffective,
whereas building resilience and trust while focusing on those demonstrating risk-taking
behaviours has delivered promising results. The United Nations Office on Drugs and Crime
(UNODC) has produced guidance on drug prevention standards86 to be used when
designing prevention policies and porgrammes.
102. Prevention cannot justify disproportionate infringements of adolescents’ rights,
including their rights to privacy, bodily integrity and education. States are encouraged to
continue to restrict and, when necessary, ban alcohol and tobacco advertising, which has
too often targeted young people.
103. Substance dependence treatment must be tailored to the specific needs of
adolescents. Adolescents must not lose their participation rights in any circumstance,
including because of their substance use or dependence. Adolescents have the right to be
heard when expressing opinions on their own health care and to give consent to treatment in
accordance with their evolving capacities.87 Confidential counselling and information must
be available without parental consent. All drug detention centres where adolescents are
arbitrarily detained and suffer extreme abuses must be closed.
104. There is an alarming lack of HIV-related harm reduction services designed for
adolescents who inject drugs, as well as multiple barriers to accessing such services,
including age restrictions in law, and absence of data on injecting drug use among children
and young people in most countries.88 Technical guidelines on HIV prevention, treatment
82 Convention on the Rights of the Child, art. 33.
83 Damon Barrett and John Tobin, “Article 33: protection of children from narcotic drugs and
psychotropic substances”, in A Commentary to the United Nations Convention on the Rights of the
Child, John Tobin and Philip Alston, eds. (Oxford University Press, forthcoming).
84 See A/65/255, para. 13.
85 See CRC/C/GUY/CO/2-4, para. 50 (d); CRC/C/ALB/CO/2-4, para. 64 (b); CRC/C/ROM/CO/4,
para. 71; CRC/C/SWE/CO/4, para. 49 (a); and CRC/C/BGR/CO/2, para. 50.
87 Committee on the Rights of the Child general comment No. 15.
88 Harm Reduction International, Global State of Harm Reduction 2012 (2012), p. 140.
care and support for young people who inject drugs have been developed,89 and should
form the basis of States’ efforts in this regard.
105. The growing international debate and efforts by certain States to seek alternatives to
punitive or repressive drug policies, including decriminalization and legal regulation, are
VII. Conclusions and recommendations
106. Investing in the right to health of adolescents offers huge potential to capitalize
on positive investments in early years, while providing the opportunity to ameliorate
the impact of negative early experiences and building resilience to mitigate future
107. In their health-related and other policies aimed at investing in adolescents,
States should be guided by the principle that adolescence is a period of development
towards increasing capacity for independent decision-making. Adolescents need to be
protected from violence, exploitation and other adversities, but the nature of those
protections and their application must take into account the emerging competencies
and evolving capacities acquired throughout adolescence.
108. States should invest in empowering adolescents by respecting their rights and
autonomy, recognizing their capacities and investing in their health and resilience. All
initiatives to address the physical, mental and sexual health of adolescents should be
implemented in compliance with international human rights obligations, taking into
account the views of adolescents and adopting evidence-based approaches.
109. Policies and services supporting families are a very important part of the
efforts by States to ensure that adolescents thrive and grow up as healthy and
responsible adults. These policies should respect and protect the human rights of all
individual members of family and should exclude measures that undermine the rights
of individual members of the family, including adolescents.
110. The Special Rapporteur would like to link his recommendations with the global
call to double investment in adolescence as a major precondition of successfully
attaining the 2030 Agenda for Sustainable Development and the Sustainable
111. In this connection, the Special Rapporteur recommends that Governments:
(a) Meet their core obligation to recognize adolescents as rights holders by
respecting their evolving capacities and their right to participate in the design,
delivery and evaluation of all policies and services affecting their health and well-
(b) Remove all legal barriers to health facilities, goods and services, such as
consent laws that unduly infringe upon the rights of adolescents to be heard and to be
taken seriously and, ultimately, upon their right to make autonomous decisions;
(c) Ensure the quality and timely collection of appropriately disaggregated
data to inform public policy, and make the reality and needs of adolescents visible;
(d) Adopt a human rights framework for adolescent health, ensuring that
health plans and strategies prioritize a holistic approach addressing underlying and
social determinants and balancing curative service provision with investment in the
resilience and autonomy of adolescents;
(e) Guarantee that health systems are responsive to the whole spectrum of
health and psychosocial needs of adolescents, and ensure an integrated, multisectoral
approach across social, child protective and education sectors;
(f) Ensure that health services are delivered in such a way as to respect
adolescents’ rights to privacy and confidentiality, address their different cultural
needs and expectations and comply with ethical standards;
(g) Ensure that adolescents’ health-care and other service providers,
including social workers and educators, do not obstruct access to health facilities,
goods and services by addressing discriminatory and stigmatizing attitudes and
behaviours through information and awareness-raising campaigns;
(h) Ensure that a core package of health services, including both mental
health and sexual and reproductive health services, are accessible to adolescents free
of charge, and remove practical barriers presented by user fees with a view to
developing a basic basket of services for adolescents as a part of their commitments to
universal health coverage;
(i) Protect from interference and harm by non-State actors and third
parties, including private service providers, by ensuring that they do not compromise
the availability, accessibility, acceptability and quality of health-care and other
relevant services, facilities and goods for adolescents;
(j) Protect adolescents from violence and neglect, including in family
settings, by, inter alia, upholding their right to confidential services and counselling
without parental consent;
(k) Take the measures necessary to support families, including through
training and services, to increase the abilities of parents to raise children and
adolescents in a competent and confident manner and reinforce skills to manage
situations in a non-violent way;
(l) Support national human rights institutions to conduct national
assessments or public inquiries into adolescents’ right to health.
112. In connection to mental health, the Special Rapporteur recommends that
(a) In line with target 3.4 of the Sustainable Development Goals, formulate
and implement a national adolescent mental health policy enabling the development of
a spectrum of preventive and curatives services, in consultation with adolescents, that
is sensitive to their rights and needs;
(b) Develop a system of adolescent mental health services that is
mainstreamed into the community-based infrastructure of health, education and
social welfare sectors;
(c) Design and implement adolescent-friendly psychosocial interventions at
the community level in a manner that is ethical and consistent with adolescents’ rights
and on the basis of available evidence, in order to make such services accessible and
acceptable and to avoid institutionalization and the excessive use of psychotropic
(d) Ensure independent monitoring of mental health facilities providing
services for adolescents with mental health conditions, including psychosocial and
intellectual disabilities, so that standards set by the Committee on the Rights of
Persons with Disabilities are progressively implemented.
113. In connection to sexual and reproductive health rights, the Special Rapporteur
recommends that Governments:
(a) In line with target 5.6 of the Sustainable Development Goals, adopt or
integrate a comprehensive sexual and reproductive health policy for all adolescents
into national strategies and programmes in order to ensure universal access to sexual
and reproductive health-care services;
(b) Decriminalize abortion and guarantee all adolescents access to
confidential, adolescent-responsive and non-discriminatory sexual and reproductive
health information, services and goods, including on family planning, counselling, pre-
conception care, maternal care, sexually transmitted infections, diagnosis and
treatment, as well as modern forms of contraception, including emergency
contraception, and safe abortion and post-abortion services;
(c) Ensure that sexual and reproductive health services are welcoming,
adolescent-friendly, non-judgemental and guarantee privacy and confidentiality;
(d) Guarantee the provision of age-appropriate, comprehensive and
inclusive sexuality education, based on scientific evidence and human rights, as part of
the school curriculum;
(e) Repeal laws criminalizing or otherwise discriminating against
individuals on the basis of their sexual orientation or gender identity, and put an end
to practices and treatments aimed at changing sexual orientation and gender identity.
114. In connection to substance use and drug control, the Special Rapporteur
recommends that Governments:
(a) Close without delay all drug detention centres for adolescents, ensure the
provision of prevention, harm reduction and dependence treatment services, without
discrimination, and allocate a budget sufficient for the progressive realization of the
right to health;
(b) Seek alternatives to punitive or repressive drug control policies,
including decriminalization and legal regulation and control, and nurture the
international debate on these issues, within which the right to health must remain
(c) Use the right to health framework to pursue strategies to prevent drug
use among adolescents through evidence-based interventions as well as accurate and
objective educational programmes and information campaigns.