Since the uprising in Syria in March 2011, over 4.3 million Syrians have fled to neighboring countries. Over a million have sought refuge in Lebanon, constituting almost a quarter of the Lebanese population and becoming the largest refugee population per capita in the world. With inequitable health coverage being a longstanding problem in Lebanon, Syrian refugee women's health, and specifically their sexual and reproductive health, is disproportionately affected. An increase in gender-based violence and early marriage, a lack of access to emergency obstetric care, limited access to contraception, forced cesarean sections, and high cost of healthcare services, all contribute to poor sexual and reproductive health. In this commentary, we conceptualize violence against Syrian refugee women using the ecological model, exploring the intersections of discrimination based on ethnicity, gender, and socioeconomic status, while critiquing interventions that focus solely on the intrapersonal level and ignore the role of microsystemic, exosystemic, and macrosystemic factors of negative influence. These social determinants of health supersede the individual realm of health behavior, and hinder women in taking decisions about their sexual and reproductive health.

BackgroundSexual activity accompanied by substance use can impair youth decision-making and enhance risk-taking behaviors. Less is known, however, about the sexual values, perceptions and subsequent sexual practices of youth whose sexual debut occurs while using alcohol/drugs.MethodsA cross-sectional anonymous online survey was conducted in April-August 2012 among undergraduate and graduate university students (aged 18 to 30) attending the 4th largest private university in Beirut. Pearson’s Chi-square and regression models were run using Stata/IC 10.0.Results940 university students had engaged in oral, anal and/or vaginal sex, of whom 10% admitted to having had consumed alcohol or taken drugs at sexual debut, a behavior that was more common in the males, less religious, non-Arabs, students living alone or who had lived abroad. Students who used alcohol/drugs at sexual debut were twice as likely to have: their first oral and vaginal sex with an unfamiliar partner [odds ratio (OR) = 2.6, 95% confidence interval (CI): (1.6, 4.2) and OR = 2.1 (1.2, 3.5), respectively], controlling for sex, nationality, current relationship status, living abroad after the age of 12, and spirituality. Students who had sex the first time while using alcohol/drugs were three times as likely to report having had 11 or more subsequent sexual partners versus one or two [OR = 3.0 (1.5-6.0)]; and almost twice as likely to ever engage in something sexual they did not want to do [OR = 1.7 (1.1, 2.8)]. Perceived peer pressure to have sex by a certain age [OR = 1.8 (1.1, 2.9)], and perceived peer norms to consume alcohol/drugs before sex [OR = 4.8 (2.3, 9.9)] were also strong correlates of having sex for the first time while using alcohol and/or drugs.ConclusionsFindings stress the importance of sexuality education for youth, and the need to begin understanding the true interplay – beyond association - between youth sexual practices and substance use behaviors from a broader public health perspective.

Informed consent forms (ICFs) maintain the integrity of research ethics and preserve participants' rights. Using cross-sectional online survey data on sexuality and sexual practices of private university students from Lebanon, this paper questions whether participants thoroughly read ICFs, and whether time taken to read ICFs is associated with data completeness. A total of 2,534 surveys were completed; a median time of 18.66 seconds was taken to read the 815-word ICF; 65% of participants consented within the first 30 seconds and 90% in less than the minimum predicted time (2.7 minutes). Our data indicates potential participant neglect of ICFs, raising the question of whether participants who endorse an informed consent form are truly informed of the study objectives and their rights.

The socially engrained notion that motherhood is essential to womanhood is strongly portrayed in how states view women's political participation through their reproductive capacities. In Lebanon, the state's political agenda influences laws and policies that restrict or encourage women's procreation, depending on their nationality, sect, marital, and legal status. Since 1943, Lebanon's system of proportionally allocating parliamentary seats to sectarian political parties, based on their population size, has spurred fears of demographic changes across sects. This fear is also referenced by politicians as the reason why Lebanese women are legally denied their rights of passing citizenship on to their children and non-Lebanese spouses. With Lebanon holding the highest refugee population per capita in the world, the fear of disturbing the "sectarian balance" directly collides with the reproductive autonomy of both Syrian and Palestinian refugee women. Migrant women living in Lebanon are also restricted to playing out their role as workers and therefore have their sexual and reproductive health and rights denied. Another fear of the state is that of changing moral values, whereby motherhood and parenthood in single women, queer, transgender, and intersex persons are perceived as deviant and a threat to traditional values. This review aims to display how, through fearof changing moral values and demographic shiftsthe Lebanese state practices reproductive oppression on part of the population, while neglecting them and exacerbating their difficult living conditions.

This study aimed to investigate gender differences in reasoning influencing the postponing of sexual debut among university youth in Lebanon. Findings aimed to develop understandings that might help inform future research on, and programme implementation of, young people's reproductive and sexual health. A cross-sectional survey of sexuality and sexual practices, attitudes and perceptions was conducted among private university students in Lebanon using a secure online method. Of 1838 participating students, 48.7% indicated they had never engaged in oral, anal or vaginal sex (i.e., penetrative sexual activity) during their lifetime (n =  895). Common socio-cultural concerns regarding sexual initiation included: gaining a bad reputation (47%), social rejection (58%), religion (70%) and parental disapproval (61%). Women were four times more concerned than men regarding loss of reputation and self-respect, six times more so regarding parental disapproval and three times more likely to be concerned with societal disapproval. Intrapersonal concerns included fear of contradicting one's own beliefs (67%), feeling guilty afterwards (62%) and losing self-respect (55%). Women were four times more likely to feel loss of self-respect and six times more likely to think sex was disgusting. Underlying reasons for postponing sexual intercourse are linked to adopted fears and social pressures that are internalised, and reinforce existing gender inequalities and reaffirm discriminatory gender norms.

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Women concerned about hymen-breaking engage in alternative sexual practices, yet experience pressure, guilt, worry, and indecisiveness regarding their sex-related decisions. The navigation of sexual decisions is a more vulnerable process for these women because of prevailing patriarchal values and discriminating gender norms in Lebanon.

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