Introduction: Global Dynamics of Displacement

A refugee is an individual who has been forced to flee their country of origin due to a well-founded fear of conflict, violence, human rights violations, or events that have seriously disturbed public order [1]. The decision to seek refuge is often driven by a substantive need for safety and protection, as the individual's life, liberty, or well-being may be at risk in their home country. Refugees may face conflict based on factors such as race, religion, nationality, membership in a particular social group, and/or political opinion [1]. The predicament of refugees underscores the importance of humanitarian efforts and international cooperation to address the complex challenges faced by individuals forced to flee their homes in search of safety and a better future. This includes education and employment opportunities, financial and social resources, and healthcare support and facilities.

As of mid-2023, a staggering 110 million individuals worldwide found themselves forcibly displaced due to persecution, conflict, violence, human rights violations, or events significantly disrupting public order. Among this vast population, 36.4 million are classified as refugees, individuals compelled to seek safety beyond their national borders. Remarkably, over half of all refugees originate from just three countries. These individuals fall under the United Nations High Commissioner for Refugees’ (UNHCR) mandate. The Syrian Arab Republic leads this distressing statistic with 6.5 million refugees, followed by Afghanistan with 6.1 million and Ukraine with 5.9 million [2••]. This stark reality highlights the vast challenges faced by Syrian refugees, emphasizing the urgency of comprehensive and targeted interventions to address their unique needs and vulnerabilities. The significance of the Syrian refugee situation in Lebanon is crucial, not only because Lebanon stands as one of the world's largest host of refugees per population, but also because it accommodates the highest number of Syrian refugees, globally [2••]. Moreover, Lebanon grapples with ongoing economic, political, and social instability, and being the foremost host of refugees in the world further exacerbates the country’s own challenges. This compounded burden underscores the critical need for sustained global support and collaborative efforts to address the multifaceted issues faced by both the Syrian refugees and the host country, Lebanon. [3,4,5]

Numerous studies and reports emphasize the multifaceted nature of sexual and reproductive health and rights (SRHR) for refugee women and highlight the intricate interplay of social, economic, and legal factors. For example, the "Reproductive Health in Refugee Situations: An Inter Agency Field Manual," jointly created by UNHCR, WHO, and UNFPA in 2010, underscores the necessity of a comprehensive understanding of SRHR that transcends traditional healthcare frameworks and considers the broader socio-cultural context [6]. Despite being often overlooked in broader discussions, refugee women grapple with a unique set of challenges, which extend beyond the immediate concerns of displacement [7••]. In this context, SRHR becomes a crucial aspect of refugee women’s healthcare and it reaches beyond medical services and delves into societal and cultural attitudes and norms, legal protections, and individual agency.

Disparities in Refugee Research: A Global Imbalance

Despite the fact that a significant majority, approximately 75%, of the world's refugee population seeks shelter in low- and middle-income countries in the global south [2••], the existing body of research disproportionately focuses on refugees residing in middle and upper-income countries in the West. This disparity in research attention raises critical questions about the representation and understanding of the diverse experiences faced by refugees worldwide. The global south hosts the majority of refugees, grappling with unique challenges related to resource constraints, limited infrastructure, and distinct political and cultural contexts. However, the bulk of scholarly research, policy discussions, and humanitarian initiatives predominantly center around refugees in more affluent regions. The tendency to prioritize research on refugees in Western countries may stem from logistical and institutional factors, including the availability of funding, academic institutions, and established research infrastructure. Nevertheless, this skewed focus risks overlooking the specific needs, coping mechanisms, and resilience demonstrated by refugees in low- and middle-income countries. The experiences of displacement and the associated struggles, rights, and healthcare challenges can significantly differ in these contexts. This research imbalance not only reinforces a singular narrative but also perpetuates a significant gap in the literature, resulting in a lack of contextual solutions and policy-related reformations that are specifically tailored to address the needs of refugees residing in low- and middle-income countries. The scarcity of comprehensive studies hinders the development of nuanced strategies to address the specific challenges faced by refugees in these regions, ranging from healthcare disparities to socio-economic integration.

Furthermore, the skewed focus on refugee populations in middle- and high-income countries significantly impacts the collective understanding of SRHR within this demographic. It also fails to recognize the resilience of individuals living in vulnerable settings along with their diverse coping mechanisms; it can also limit the framing of their specific experiences to surface-level victim narratives that are limited. SRHR needs among refugees in low- and middle-income countries are often distinct due to factors such as limited access to healthcare services, cultural norms, and the prevalence of sexual violence in conflict settings. However, the lack of research attention to these specific contexts hampers the development of targeted interventions and policies aimed at addressing SRHR disparities. Without comprehensive and person-centered studies that encompass the diverse experiences of refugees across different socio-economic contexts, there is a risk of overlooking crucial aspects of SRHR, including access to contraception, maternal healthcare, and prevention of gender-based violence (GBV).

Refugees, Sexual Health and Reproductive Rights, and Gendered Experiences

The refugee experience is inherently complex, marked by a multitude of challenges, and among these challenges, SRHR and access to quality healthcare emerge as critical dimensions that are essential to the overall well-being of individuals, especially women. Beyond the mere biological considerations, it is imperative to recognize that SRHR encompasses sociocultural, economic, and legal dimensions, significantly shaping the experiences of women navigating displacement.

In the Arab region, and in Lebanon, the prominent cultural norms, values, and traditions often perceive and deal with SRHR with a conservative approach. Cultural values and traditions significantly influence SRHR needs and desires, as illustrated in reports such as UNHCR’s 2022 Global Reports [8, 9]. The conservative approach is informed by gendered misconceptions about the body and the kind of SRHR knowledge and services individuals can and cannot access. These cultural norms may clash with healthcare provision models or societal expectations, posing challenges in service utilization. Displacement profoundly impacts vulnerable populations’ SRHR, including refugee women and youth. It affects their sense of safety, autonomy, and access to essential healthcare services [10]. Experiences of violence, loss, and uncertainty create unique challenges. There are also specific SRHR needs and challenges faced by young migrants and refugees, where there is a lack of culturally sensitive and age-appropriate education and services [11]. Navigating issues such as sexual relationships, consent, and accessing SRHR information and care can be particularly challenging for these young individuals. Initiatives that empower women and youth economically, socially, and educationally have been proven to contribute to their well-being and help break the cycle of vulnerability [12].

Women refugees confront distinct challenges and vulnerabilities shaped by their gender, which introduce layers of complexity to their experiences of displacement. A notable issue is the heightened risk of GBV, encompassing sexual harassment, assault, and exploitation during the journey and within refugee settings [13]. Insecure housing and privacy gaps expose women to increased risks, while the disruption of social structures exacerbates existing gender inequalities, impacting access to education, employment, and healthcare. Many women find themselves heading households, shouldering family responsibilities without sufficient support, contributing to considerable mental health strain compounded by gender-specific stressors [10, 14]. Conversely, significant barriers to SRHR access, particularly in low-income settings, persist due to cultural stigma and inadequate healthcare infrastructure, particularly concerning essential sexual and reproductive health (SRH) services such as maternal care, contraception, family planning services, and safe abortion [7••, 15••, 16••]. The intersectionality of identity, incorporating factors such as ethnicity, age, and socioeconomic status, further shapes women's experiences. While discrimination and marginalization persist, comprehensive and gender-sensitive humanitarian responses are imperative to address these multifaceted challenges.

Women refugees, despite facing significant challenges, demonstrate remarkable resilience, drawing upon their innate agency to navigate adversity. As evidenced by studies such as Kanal and Rottmann's (2021) exploration of Syrian women rebuilding their lives in Turkey, these individuals exhibit a spectrum of coping strategies shaped by their cultural context. Kanal and Rottmann's findings underscore the importance of recognizing the multifaceted nature of refugee women's agency, transcending simplistic dichotomies of victimhood versus liberation. Within the intricate tapestry of their experiences, familial bonds, social roles, and community networks emerge as critical pillars of support, which enable women to confront stressors and adapt to their new realities [17•]. Moreover, the study conducted by Syam et al. (2019) sheds light on the enduring resilience of Syrian refugees in protracted displacement, emphasizing the metaphorical "melting" of their existence amidst prolonged uncertainty. Despite such existential challenges, these refugees exhibit a tenacity rooted in their shared experiences and communal solidarity, which echoes the sentiments of endurance and perseverance observed among refugee women in various contexts [18]. Nevertheless, the resilience and agency of women refugees often remain obscured within the broader discourse and overshadowed by prevailing narratives of victimization. While women refugees continue to demonstrate resilience and resourcefulness, their contributions risk being overlooked or diluted within research frameworks that prioritize victim narratives over agency. In confronting these challenges, it becomes imperative to adopt a more nuanced and intersectional approach to understanding and supporting women refugees. By acknowledging the complexity of their experiences and amplifying their voices, interventions and support systems can be tailored to address their specific needs effectively. Only through such recognition can the true resilience and agency of women refugees be fully recognized, realized and honored.

A Microcosm of Complex Challenges: Insights from The Case of Syrian Refugee Women in Lebanon

Approximately 1.5 million Syrian refugees sought refuge in Lebanon among the 4.3 million Syrians displaced by the 2011 uprising and ensuing civil war. This equates to about 1 in 4 individuals in Lebanon being a Syrian refugee, establishing Lebanon as the host to the largest per capita refugee population globally [4]. Syrian refugee women and girls constitute half (50.5%) of the Syrian refugee population in Lebanon, with nearly 1 in 5 refugee households headed by females [3]. Their vulnerability exposes them to systemic violence, gender inequality and GBV exacerbated by Lebanon's societal dynamics [19, 20]. Refugees in the Middle East and North Africa (MENA) region face challenging living conditions, discrimination, and restricted access to essential services such as education, employment, and healthcare [21,22,23,24,25]. In Lebanon, existing social, political, and economic instability, including a recent civil war, an ongoing economic crisis, and shortages in fuel and medicine, exacerbate the vulnerability of refugee populations. Lebanon also shelters over 16,000 refugees from Iraq, Sudan, and other regions, along with more than 200,000 Palestinian refugees under UNRWA’s mandate [4]. Moreover, Lebanon's fragile infrastructure, particularly in education, employment, and healthcare, has been further strained by the COVID-19 pandemic; this all shapes the inadequate living conditions and restrictive government policies that persist, with insufficient resilience and capacity-building programs.

In Lebanon, although public primary and secondary healthcare services theoretically extend to Syrian refugees, most services necessitate out-of-pocket payments, beyond the means of many refugees [26]. From January to August 2020, UNHCR supported over 37,200 primary healthcare consultations for refugees, with approximately 4% related to antenatal care. Hospital care is accessible through a network of contracted hospitals at a subsidized rate but is limited to urgent life-saving conditions, conditions leading to permanent disability, and obstetric care. By the end of 2021, UNHCR also facilitated 62,049 hospital admissions, with over half linked to pregnancy and childbirth (58.4%) and other perinatal conditions (6.6%) [4]. Despite this, a recent study by El Kak et al. (2021) revealed a higher maternal mortality rate among Syrian refugee women in Lebanon compared to Lebanese women from 2010 to 2018. The study identified hemorrhage and indirect causes as the leading mortality factors, emphasizing the imperative to enhance healthcare quality and provide closer perinatal monitoring. Maternal deaths were notably higher among younger Syrian refugee women [27]. This alarming fact is exacerbated by the fact that teenage marriage and pregnancy remain prevalent among Syrian refugee women in Lebanon, with 1 in 5 adolescent girls aged 15 to 19 being married, as per the 2021 Vulnerability Assessment of Syrian Refugees in Lebanon (VASyR) survey [5, 28].

Gender-based violence has also been linked to various SRHR-related problems among refugee women. These problems include medical complications such as injuries, gynecological disorders, mental health issues, adverse pregnancy outcomes, and sexually transmitted infections [11, 29]. Globally, nearly one in three women, totaling around 736 million, have encountered physical and/or sexual intimate partner violence or non-partner sexual violence at least once in their lives, representing approximately 30% of women aged 15 and older [30]. This statistic notably excludes instances of sexual harassment. In the context of displacement, the vulnerability of women and girls is exacerbated. Refugees are often severed from the traditional support systems provided by family and friends, as well as from connections with neighbors and broader community networks. This isolation is particularly acute for women and girls, who may find themselves confined within their homes, further diminishing their ability to access social support and vital services. The combination of displacement-related stress and isolation creates a perilous environment ripe for physical, sexual, and emotional abuse [31]. These forms of abuse can manifest in various ways, including physical assault, verbal threats, intimidation, rape, and coerced early marriage. Moreover, the psychological toll of such experiences extends beyond physical injury, contributing to depression, anxiety, and diminished self-efficacy among survivors.

Given this backdrop, there exists a pressing concern regarding the accessibility of healthcare services, particularly sexual and reproductive healthcare, for Syrian refugees. SRHR encompass individuals' capacity to make decisions regarding their sexual experiences and reproduction. This extends to issues such as gender inequality, violence, stigma, and bodily autonomy, all of which have significant impacts on psychological, emotional, and social well-being [32]. Across most Arab countries, including Lebanon, there tends to be a conservative stance on SRHR, which in turn affects the overall health of both men and women. This conservative approach is deeply entrenched in socio-cultural and religious norms, perpetuating the perception of SRHR as a taboo subject associated more with morality than with scientific and medical discourse [33, 34]. However, female refugees in Arab countries face compounded challenges due to their gender and refugee status. Syrian women in Lebanon encounter a complex legal system limiting their access to resources, services, and opportunities, leading to a higher risk of violence, abuse, and exploitation [3, 5]. Lack of agency, specifically bodily autonomy, emerges as a major risk factor, perpetuating a cycle of abuse and inequality, which further compromises SRHR [18, 19].

Multifaceted Intersectional Challenges and Experiences

The ensuing findings and insights into the experiences and perspectives of Syrian refugee women stem from the previously cited desk research and a previous qualitative research endeavor. Funded by IDRC in 2023, this research effort highlighted the lived experiences and voices of Syrian refugee women in Lebanon [35]. The research was qualitative in nature and centered participant testimonies from over 109 refugee women.

To conceptualize the findings, intersectionality stands as a key concept. Originating from Kimberlé Crenshaw's work in 1989 [36,37,38], it underscores the inadequacy of examining gender exclusively through a singular perspective, urging instead the consideration of how different facets of identity intersect. This theory and framework acknowledges the interplay of various systems of privilege and oppression that individuals encounter, encompassing dimensions such as gender, race, class, sexuality, disability, and beyond. By embracing the complexity of these interactions, intersectionality offers a richer comprehension of individuals' realities and the societal contexts they navigate. In scrutinizing SRHR among Syrian refugee women in Lebanon, integrating an intersectional perspective into the research is imperative. This approach recognizes the multifaceted dynamics and power dynamics that mold these women's experiences. Through an intersectional lens, the layered influences of geographical location, gender, nationality, socioeconomic status, education, marital status, and ethnicity on individuals' identities are recognized. These intersecting factors shape the unique experiences and barriers faced by Syrian refugee women residing in Lebanon.

The socio-economic landscape intertwines with the challenges faced by Syrian refugee women in Lebanon. Across regions like Beirut, the Bekaa Valley, the North, and the South, varying economic disparities compound displacement issues, shaping women's experiences differently. In Beirut, while improved access to certain resources is evident, societal norms limit employment options, leading to prevalent concerns such as street harassment. The Bekaa region presents economic isolation, restricting mobility due to limited financial resources and dependence on agriculture. In the impoverished North and conflict-affected South, forced marriages, early pregnancies, and cyclical GBV become pronounced, which highlights the multifaceted nature of challenges in socio-economic environments.

The Lebanese legal system introduces another layer of complexity, reflecting nationality-based discrimination against Syrian refugee women. Lack of formal recognition as refugees and non-ratification of key international agreements exacerbate legal violence. Discrimination is further perpetuated by poverty, Syrian nationality, refugee status, and gender. This all fosters a culture of fear and mistrust within the legal system [39]. With this context, accessing healthcare services becomes a critical hurdle, encompassing logistical, financial, and attitudinal barriers. Protracted waiting times, limited seating, discrimination based on UNHCR coverage, and xenophobia create a dearth in healthcare access. Challenges extend to mistreatment during obstetric care, emphasizing systemic issues within the healthcare system. The intersectionality of xenophobia, sexism, and classism amplifies the struggles. There’s a clear prevalence of GBV in refugee households and the impact of GBV on agency and bodily autonomy emerges as a pervasive issue. Practices like preference for sons, parental disciplinary violence, and forced marriages normalize violence within households. These practices position women in a subordinate position, which is reinforced through discrimination that also results in restriction of access to education and mobility. Forced marriages, which are driven by economic considerations, compromise autonomy. Overall, cultural nuances and religio-cultural beliefs further complicate the fight for bodily autonomy, which shapes women's behaviors and choices. Essentially, the normalization of violence, structural inequalities, and discriminatory practices present Syrian refugee women with a complex web of intersectional challenges in their pursuit of adequate SRHR, agency, and bodily autonomy.

Discussion: Towards a Holistic Approach for Women Refugees

The case of Syrian refugee women echoes challenges faces by women refugees and SRHR globally and it highlights the critical need for more nuanced understandings of their experiences. Amplifying the voices of refugee women in feminist discourse and decision-making processes is vital for creating culturally sensitive healthcare services and policies tailored to address their unique challenges. Targeted interventions are needed to bridge knowledge gaps and raise awareness of SRHR among both male and female refugees. Empowering women to participate actively in decision-making ensures that policies are grounded in their realities, with their experiences taking center stage. This shift in power dynamics can render interventions more responsive to the unique challenges faced by women refugees. Additionally, bridging the research gap and expanding research effort is not only an academic imperative but also a practical necessity for formulating policies that promote the well-being and rights of all refugees, regardless of their geographical location or economic context. By expanding research efforts to include refugees in low- and middle-income countries, we can gain a more comprehensive understanding of their SRHR needs and develop more effective strategies to promote their well-being and rights. This inclusive approach will ensure that policies and interventions are grounded in the realities of all refugee populations, which creates more equitable and responsive global humanitarian response.

Drawing parallels with existing literature on SRHR and GBV reveals universal challenges faced by refugee women globally. Common threads of discrimination, violence, and limited access to essential services underscore the need for a collective, global response transcending geographical boundaries. Collaborative efforts between governmental and non-governmental organizations, alongside international involvement, are necessary in addressing root causes. A multi-pronged strategy combining legal advocacy, awareness campaigns, and community empowerment programs is critical for sustainable change. Additionally, prioritizing evidence-based interventions, community-driven solutions, and sustained advocacy is imperative to help refugee women and girls exercise their SRHR and lead healthy lives. These recommendations bridge existing gaps between research, policy, and practice, fostering an environment enabling refugee women and girls to better exercise their SRHR.

Culturally sensitive healthcare services also play a critical role in enhancing access to SRHR for refugee women. Comprehensive training and awareness programs for healthcare providers equips them to navigate the intersection of cultural, legal, and socio-economic factors shaping the experiences of women refugees. Tailored, context-specific and culturally-informed programs, including reproductive sexual health education and mental health support, contribute to creating an environment promoting overall well-being.

Bridging the knowledge gap is a priority, necessitating targeted interventions that raise awareness about SRHR among refugee communities. Disseminating information to both men and women challenges patriarchal norms and fosters supportive environments, effectively shifting societal attitudes and dismantling structures perpetuating discrimination and violence. The complex web of challenges faced by refugee women demands nuanced approaches recognizing various inequalities and contextual variables. Intersectionality serves as a central theme, tool, and framework in understanding their experiences. Gender, nationality, legal status, and economic disparities intersect to shape encounters with SRHR and GBV. Recognizing the complexity of these experiences is crucial for developing effective interventions addressing root causes.

Conclusion: Future Directions: Empowering Refugee Women Through Inclusivity

In conclusion, the insights gleaned from the experiences of Syrian refugee women in Lebanon underscore the imperative for tailored interventions that navigate the intricate interplay of socioeconomic, legal, and healthcare factors impacting SRHR. Recognizing the nuances of displacement, cultural sensitivities, and the intersectionality of identities becomes paramount in developing policies and programs that foster empowerment and enhance the overall health outcomes and quality of life for women refugees across the globe.The resilience and strength exhibited by Syrian refugee women in Lebanon offer a poignant reminder of the fortitude required to navigate displacement. Their voices, often marginalized and overlooked, stand as essential contributors to informing policies and interventions aimed at addressing the challenges faced by women refugees globally. Through the adoption of a nuanced and inclusive approach, the global community can actively contribute to ensuring the SRHR of women refugees are safeguarded, ultimately fostering their empowerment and well-being.

Moving forward, it is imperative to prioritize evidence-based interventions, community-driven solutions, and sustained advocacy. This underscores the need to bridge existing gaps between research, policy, and practice, fostering an environment that empowers refugee women and girls to freely exercise their SRHR and lead healthy lives. Beyond healthcare, investing in exploring refugee women's SRHR experiences becomes a cornerstone of empowerment, enabling them to lead lives that are healthy, dignified, and self-determined. By actively listening to their voices and addressing their specific needs, we contribute to building a more just and equitable world where all women have the fundamental right to enjoy their SRHR.