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Around 1 in 3 women and girls experience physical and/or sexual violence in their lifetime. Child marriage is a manifestation of this violence. Find here more information on the links between these two issues.

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So the baby boomers were raised in gender-specific clothing. Boys dressed like their fathers, girls like their mothers. Girls had to wear dresses to school, though unadorned styles and tomboy play clothes were acceptable.

Since 2009, prevention of cervical cancer in the Netherlands consists of two measures: first, the Papanicolaou Screening (Pap smear), for which all women aged 30 to 60 years receive an invitation every 5 years, is free of charge [1]. The second measure - the Human Papillomavirus (HPV) vaccination - was introduced in 2009, after the bivalent vaccine (Cervarix) targeting HPV 16 and 18 became available [2]. Since there is a risk of contracting HPV from the first time of intercourse [3], the HPV vaccination program, which is managed by the Centre for Infectious Disease Control (CIb) and is only free of charge for 12-year old girls [2], ensures that most girls can be vaccinated before they become sexually active [4].

In the United Kingdom, embarrassment due to Female Genital Mutilation (FGM) is a barrier for getting Pap smears among Somali women [13]. In the United States (US), FGM is associated with a concern that Pap smears would increase pain among Somali girls and women [14]. Another study in the US has found that Somali girls accept HPV vaccination, but are less likely to complete the HPV vaccination series in comparison with white non-Hispanic girls [15]. Moreover, Somali women in the US are less likely to adhere to cervical cancer screening procedures than non-Somali women in the US [16]. Hence, there is a need to deepen our understanding of the perceptions of Somali women in the diaspora regarding the prevention of cervical cancer.

Information and informed consent letters were available in Dutch for the young women and in Dutch and Somali for the mothers. Individual participants were informed about the study during face-to-face recruitment, by telephone and e-mail, and (again) at the start of data collection. Participants were also informed about the voluntariness of the participation and that only members of the research team would have access to the interview data. We obtained informed consent and the women filled in a small demographic questionnaire.

All individual participants signed the consent letter and filled out the questionnaire. Several mothers from group discussions refused to sign and fill out the questionnaire because they were not used to giving this type of written information during their usual group gatherings. It is common that minority communities decline to provide this kind of information during research at the community level [14]. Also, participants did not feel compelled to stay for the whole session. Nevertheless, these mothers gave oral consent for participating and were actively engaged in giving information. Ethical approval is not required for this type of study in the Netherlands [23], as only particular types of behavioral research fall under the Medical Research Involving Human Subjects Act [24].

The information in the natural group discussions was collected only after JS was introduced by the moderators and she had become acquainted with the mothers who participated in the weekly group gatherings. Information on (the prevention of) HPV and cervical cancer was presented by JS to the participants at different moments. Facilitating a discussion with mothers who only recently moved to the Netherlands would have been difficult without the provision of any information on HPV and cervical cancer.

Another major barrier is related to language. The Somali mothers from the second migration wave are often not fluent in Dutch, while Somali girls have access to Dutch language and culture through school. Hence, some young Somali women have to translate information about the HPV vaccination to their mothers, which daughters then sometimes perceive as a barrier. As a consequence, they have not always informed their mothers.

I think it is stupid [the double sexual standard]. I think you should teach a girl how she could stand up for herself. Boys should learn more rules [and] be taught discipline, so that there is a balance [between boys and girls]. [N 14 (young Somali woman)]

This idea of eternal shame instills fear in young Somali women and mothers. The mothers use social control and education on Islamic norms as ways to promote chastity among daughters and to prevent stigma. With the cultural double sexual standard on the virginity of girls, the HPV vaccination is not considered necessary. Yet, some girls criticize it by expressing their discontent with the Somali cultural norm that stigmatizes girls who are sexually active before marriage.

Finally, although the level of education of Somali people in the Netherlands is generally low (Table 1), most young Somali women in this study followed higher education. The researcher has had limited access to lower educated young Somali women, which could be attributed to her own educational background and the short time available for the research. It is difficult to say how such selection bias influences the results. In hindsight, the results do not show major differences in perceptions towards prevention of cervical cancer between higher educated and lower educated girls. Most girls in this study have expressed the importance of these traditional values, independent of their educational background. The recruitment of girls with lower education levels could perhaps have led to more diverse results and saturation [29]. More studies including quantitative research could be used to increase the validity of our findings.

Third, data triangulation has been reached by collecting data from different sources, including individual interviews and natural group interviews. Fourth, researcher triangulation and a member check have been applied to increase the validity of the study. During the member check, the researcher established credibility by presenting all findings derived from the interviews and group discussions. These findings were recognized, validated, and further clarified by the participants. Finally, some mothers have been recruited from the first, and other mothers were recruited from the second migration wave. Mothers who are only recently in the Netherlands may be less knowledgeable about the Dutch health system and its preventive measures.

A word of thanks to the NEDSOM Foundation, Iftin Foundation, Somali Students Network (SSN), and Community Health Service (GGD) Heart for Brabant (Hart voor Brabant), who helped with recruiting young Somali women and mothers. We thank Whitney Stark for copyediting the English language. We also wish to thank those who helped with the recruitment of participants via Facebook. Moreover, we are grateful to the mothers and girls for openly sharing their perceptions.

Objective: To derive the first systematically calculated estimate of the relative proportion of boys and girls with autism spectrum disorder (ASD) through a meta-analysis of prevalence studies conducted since the introduction of the DSM-IV and the International Classification of Diseases, Tenth Revision.

Results: Fifty-four studies were analyzed, with 13,784,284 participants, of whom 53,712 had ASD (43,972 boys and 9,740 girls). The overall pooled MFOR was 4.20 (95% CI 3.84-4.60), but there was very substantial between-study variability (I2 = 90.9%). High-quality studies had a lower MFOR (3.32; 95% CI 2.88-3.84). Studies that screened the general population to identify participants regardless of whether they already had an ASD diagnosis showed a lower MFOR (3.25; 95% CI 2.93-3.62) than studies that only ascertained participants with a pre-existing ASD diagnosis (MFOR 4.56; 95% CI 4.10-5.07).

Conclusion: Of children meeting criteria for ASD, the true male-to-female ratio is not 4:1, as is often assumed; rather, it is closer to 3:1. There appears to be a diagnostic gender bias, meaning that girls who meet criteria for ASD are at disproportionate risk of not receiving a clinical diagnosis.

UNICEF is working to meet the needs of children affected by the hunger crisis. We identify and treat cases of malnutrition, provide safe water and sanitation, immunize children, protect them from abuse and help them continue their education. The project with Plan andUjamaa aims to protect girls from sexual abuse and child marriage, provide psychosocial support to victims, and keep girls in school. It is run out of 61 schools in Malawi, benefitting over 3,000 children.

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