DO THEY MATCH? Young people’s realities and needs relating to sexuality and youth friendly service provision in Bangladesh
A participatory research on the quality of and acces to youth friendly sexual & reproductive health services for young people
This research and report were made possible through support from IPPF and Rutgers WPF (formerly Rutgers Nisso Groep and WPF), with funding from the Dutch Government (SALIN+ and MFSII).
DO THEY MATCH?
YOUNG PEOPLE’S REALITIES AND NEEDS RELATING TO SEXUALITY AND YOUTH FRIENDLY SERVICE PROVISION IN BANGLADESH
A PARTICIPATORY RESEARCH ON THE QUALITY OF AND ACCESS TO YOUTH FRIENDLY SEXUAL & REPRODUCTIVE HEALTH SERVICES FOR YOUNG PEOPLE
A research commissioned by IPPF Carried out by Rutgers WPF in consultation with Dr. Papreen Nahar and the youth research team:
Akhter Moshammat Sabina Islam Mainul Hasan Islam Mohammad Jahidul Khatun Parijat Pervas Kamal Rahman Mahfuza Ray Mithon Kumar Sume Afroza Khanam Tanzir Azmarina in cooperation with FPAB Bangladesh and IPPF
August 2010 Report by Papreen Nahar Project nr: 1303 OV
Dr. Miranda van Reeuwijk and Henri van den Idsert MA (Eds)
FOREWORD - IPPF
Young people are at the heart of the International Planned Parenthood Federation’s work. IPPF is one of the leading service providers, working to ensure universal access to sexual and reproductive health for young people around the world. We have a successful record of working with young people; 1 in every 3 clients who visits our clinics is young.
We still feel that we need to increase demand amongst under-served young people – a group that continues to bear a disproportionate burden of sexual and reproductive ill- health across the world. We must constantly strive to improve the quality of our services and to think critically about why some young people do not want to come to our services. One of the best ways to gain a better understanding of how to increase demand is to partner with young people themselves.
IPPF has a long history of working in equal partnership with young people at all levels, from peer education to governance. In this publication we highlight how young people in our Federation are making major contributions to the improvement of our services through research. Having over twenty years of experience working with young people, the Family Planning Association of Bangladesh (FPAB) was invited to embark on the Do They Match research project alongside researchers from Rutgers WPF and supported by IPPF Central Office and South Asia Regional Office.
The Do They Match research illustrates the true value of involving young people as co- researchers. Given the youth research team’s unique insight into the ‘real lives’ of their peers, the findings provide reliable evidence that can inform the development of FPAB’s youth programmes and services for years to come. Furthermore, FPAB now has a superbly trained group of youth researchers who are able and willing to conduct more research and assist in the monitoring and evaluation of other youth programmes.
We want to thank the young researchers and staff of FPAB for their commitment to excellence in the provision of sexual and reproductive health services and information for young people. Also, many thanks to the Rutgers WPF team for their dedication, hard work and vision. Lastly, we must thank the 237 respondents for their honesty and courage in speaking out about the realities of their everyday lives.
Doortje Braeken
IPPF - Senior Advisor, Adolescents + Young People
January 2011
LIST OF ABBREVIATIONS CHW: Community Health Worker CO: Central Office CRC: Convention on the Rights of the Child ECP: Emergency Contraceptive Pill FGD: Focus Group Discussion FPAB: Family Planning Association of Bangladesh HIV / AIDS: Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome IEC: Information Education & Communication IPPF: International Planned Parenthood Federation KI: Key Informant M.A: Member Association MDG: Millennium Development Goal M&E: Monitoring & Evaluation MR: Menstrual Regulation NGO: Non Governmental Organisation NHQ: National Head Quarters PE: Peer Educator PMC: Programme management Committee RHP: Reproductive Health Promoter SALIN: Strategic Alliance with International NGOs SARO: South Asia Regional Office SDP: Service Delivery Point SIS: Service improvement System SRH: Sexual Reproductive Health SRHR: Sexual Reproductive Health & Rights STI: Sexually Transmitted Infection STD: Sexually Transmitted Disease UTI: Urinary Tract Infections YR: Youth Researcher YFS: Youth Friendly Service YIF: Youth Incentive Fund
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Table of contents
1 Introduction 1.1 Why this research? 1.2 Research framework and questions 1.3 Research objectives 1.4 Research setting: Tarar Mela (FPAB YFS) in Jessore 1.5 Research location: Jessore 1.6 Structure of this report
2 Research methodology 2.1 Youth participation and ‘emic’ approach 2.2 Data collection phases 2.3 Methods used for data collection 2.4 Limitations
3 Significant sexuality issues for adolescents 3.1 Curiosity 3.2 Desires and pleasure 3.3 Misconceptions and concerns 3.4 Sources of information about sexuality
4 Sexual behaviour of adolescents 4.1 Romantic love and dating 4.2 Sexual activities 4.3 Pornography 4.4 Stigma and fear 4.5 Eve-teasing and harassments 4.6 Suppressing sexual arousal and curiosity
5 Quality and access of youth friendly services 5.1 Enabling factors to access Tarar Mela from young people’s perspective 5.2 Limiting factors to access Tarar Mela from young peoples’ perspective 5.3 Limiting factors to providing youth friendly services from a provider's perspective
6 Stakeholder workshops
7 Research process
8 Ethics
9 Analysis of key findings 9.1 Introduction 9.2 Analysis of main findings relating to young people’s sexuality in Bangladesh 9.2 Need and demand: Are the services that the MA is offering relevant for adolescents? 9.3 Awareness, access, and quality: Analysis of key factors that limit and enable adolescents to use the YFS
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10 Discussion and key recommendations 10.1 Introduction
10.2 Need and demand: Increasing relevance of services by matching adolescents' primary sexuality concerns 10.3 Awareness of and motivation to use YFS 10.4 Access: De-stigmatize YFS and find alternative acceptable ways to offer information and services to adolescents 10.5 Quality: Increase 'safety' at YFS and invest in skills of staff 10.6 Organisational and management factors influencing the delivery of YFS
References
Annex- 1 Hypothetical cases (boys and girls) Annex- 2 Question-box questions Annex- 3 Standards for good quality and accessible YFS
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1 Introduction
1.1. Why this research?
Access to services is a central concern in the promotion of sexual and reproductive health and rights (SRHR) of young people1. In developing countries, approximately 45% of new HIV infections occur among 15-24 year olds (and in Africa 75% of them are girls)2; worldwide the largest proportion of STIs is believed to occur in people younger than 25 years3; adolescents account for an estimated 2.5 million of the approximately 19 million unsafe abortions that occur annually in the developing world; almost 70% of the adolescents in Sub-Sahara Africa and south central and southeast Asia have an unmet need for contraceptives; and Malawi and Bangladesh have among the highest teenage pregnancies in the world (more than 120 per 1000)4. Provision of services for adolescents and young people, like the provision of information, contraception, STI and HIV testing and counselling, are believed to play a key role in the prevention of unwanted pregnancies and STI’s including HIV.
For the International Planned Parenthood Federation (IPPF) and its Member Associations the role of SRH services is not only important in terms of public health and the prevention and treatment of diseases. Access to information and services are seen as basic human rights necessary to guarantee healthy sexual development and sexual wellbeing of individuals. This entails a more holistic (so-called ‘positive’) approach towards sexual health compared to the more narrowly defined biomedical approach and includes mental and social aspects of sexuality that influence self esteem, fulfilment, enjoyment and safety in sex and sexuality. Concretely, this means that IPPF expects its Member Associations (MA’s) to commit to the Sexual Rights Declaration5 (IPPF 2008a) and to offer services that include addressing issues like sexual and gender-based violence, sexual diversity, discrimination, relationship issues and fears and concerns about sex and sexuality. MA’s are also expected to commit to the declaration in the way they work: to offer service “… that young people trust and feel is there for them and their needs, and is supportive of young people’s sexuality so that they have a happy, healthy and safe sexual life regardless of gender, sexual orientation, disability, income level or marital status” (Springboard, IPPF 2008b). Such services are referred to by the term Youth Friendly Services (YFS).
Despite the efforts of MA’s to provide services in a youth-friendly manner and executing strategies to increase access and quality of their services for young people, uptake of services by young people, and in particular adolescents (12-18 yrs), is considered to be low. IPPF has commissioned Rutgers WPF, the Dutch Member Association of IPPF, to conduct research in cooperation with young people and the MA’s in Bangladesh and Malawi, to investigate why this uptake is low and to formulate recommendations that can help to increase the uptake. Much research that investigates access and quality of YFS focuses on youth in general, often including primarily older youth in the age range between 18 and 24 years. These young people are more frequently married and it is
1 For this research the term ‘young people’ refers to those aged between 10-24 years; the term ‘adolescent’ specifically refers to young people between the ages 12-18. 2 UNAIDS (2008) Report on the global AIDS epidemic. 3 Bearinger et al (2007) 4 IPPF WHR (2010): http://www.ippfwhr.org/en/news/filling-unmet-need-contraception-can-we-deliver-young- women 5 The IPPF Sexual Rights Declaration is a direct translation of the UN convention of Human Rights, in terms of what this means for human sexuality.
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more accepted that they are sexually active. There is a need to take into account the specific barriers and needs for younger youth and therefore the focus of this research lies specifically on adolescents in the age between 12 and 18.
This report details the results of the research that was carried out between March and July 2010 in Bangladesh. In addition to this report, a report will be written with the results of the research in Malawi, as well as a report that brings the findings of both research sites together and a report that describes the process of meaningful participation of young people in research.
1.2 Research Framework and Questions
In order to formulate recommendations for improving the uptake of services by adolescents in general, and in Bangladesh specifically, it is necessary to investigate why the uptake is low. In order to investigate and analyse this in a systematic way, we have developed a research framework:
1. Adolescents’ Primary Concerns in relation to Sexuality: Need and Demand Uptake of services first of all depends on the need and demand for these services. For instance, if adolescents are not sexually active, their need and demand for contraceptive or VCT services will be low. Therefore, relevant questions in this respect are: - What kind of services do young people need? - What kind of services do young people want? - What kind of services are offered to them?
In other words: Are the services that the MA is offering relevant for adolescents?
In order to formulate an answer to this research question, it is necessary to investigate what young people themselves identify as primary concerns relating to sex and sexuality. These primary concerns can relate to problems, fears, desires, needs, wishes and curiosities and as such are not limited to physical health problems alone. Understanding adolescents’ sexual behaviour and what matters to them in this respect, can improve the providers’ ability to responsively meet the needs of this particular group. Understanding the root causes of these issues and the consequences for adolescents’ sexual health and wellbeing can help formulate or strengthen strategies for prevention and care.
In this analysis it is important to make a division between what young people themselves feel they need, which translates into demand, and what adolescents need as deduced from a public health perspective. For instance, adolescents might not feel at risk for HIV which translates into a low demand for condoms, while from a public health perspective they are vulnerable to HIV and therefore need to use condoms. These two perspectives are called emic, or insider’s perspective and etic, or outsider’s perspective. The insider’s perspective is necessary to understand the why and how of behaviour and experiences. The outsider’s perspective is necessary for making a more objective analysis. In the case of this research, the etic perspective includes an analysis that takes the sexual rights declaration and a broad, holistic definition of sexuality as its basis into account (see original research proposal for theoretical framework and conceptualization, Rutgers WPF 2009). To represent as closely as possible the emic perspective of adolescents on sexuality issues and youth friendly services, this research is to a large extent conducted by young people themselves (see proposal and Chapter 2 on methodology).
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Next to experienced needs, the demand for services is influenced by the degree of motivation to use the services that are offered. We hypothesise that in order to be motivated enough to visit the YFS, adolescents need to: a) perceive the YFS as a place where there is a certain possibility that their issue or problem can be solved (efficacy: the capacity to produce a beneficial effect), b) have a high priority problem that needs immediate solving for which they cannot go to more easily accessible sources for help, c) perceive the urgency and efficacy as outweighing the risks and barriers of going there.
To give a clear example, people will be more likely to be motivated to go to SRH services if they have an uncomfortable STI, for which they believe they can get treatment there, as compared to going there to get help with relationship problems.
An important influence on the motivation to use YFS, and thus on demand, are people’s (perceptions of) options they have for coping with a particular concern. For instance, people might prefer to visit a traditional healer rather than a SRH service. Choice between options depends on perceived efficacy, which is strongly influenced by how people explain health and diseases (so called local explanatory models6 for health and diseases). For example, ideas about fertility and infertility can influence how people perceive modern contraception and lead them to prefer traditional forms above the use of modern contraception. Next to local explanatory models, alternative sources for help might be easier to access compared to SRH services.
These aspects of need and demand need to be taken into account if we want to get a fuller picture of factors that influence the uptake of SRH- and youth friendly services. The question of relevance of YFS for adolescents is whether the offered services match adolescents’ primary sexual concerns, realities and needs, in order for them to enjoy sexual health and wellbeing.
2. Youth Friendly Services: Awareness, Access and Quality Even if services match the needs and demands of adolescents, adolescents will not make use of these services if they are unaware that these services exist for them, when they cannot access these services or if the quality of the services is low. In order to investigate the reasons for low uptake of services by adolescents, it is therefore important to ask questions relating to awareness, access and quality:
- Are adolescents aware that there are YFS available to them where they can go with their sexuality-related concerns? - Are the YFS effectively attracting adolescents to come to their static services or actively reaching adolescents by offering mobile/outreach services? - Are the YFS considered to be acceptable and affordable by adolescents? - Do the YFS have a welcoming, non-judgemental, non-discriminatory, motivated and skilled staff? - Do the Service Providers have an adequate supportive organisational and management system in order for them to deliver good quality services?
The number and complexity of all the factors that influence need, demand, awareness, access and quality of services is vast and investigating all these factors in detail goes
6 Explanatory model: concept by Arthur Kleinmann (1978) that refers to how illness is explained in different cultures, which can be distinctly different from biomedical explanations for diseases and health.
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beyond the scope of this research. However, the research team has asked adult and adolescent informants questions relating to the following central research questions:
What are primary sexuality-related concerns for adolescents and what causes these concerns?
Are the services that the MA is offering relevant for adolescents?
What factors limit or enable adolescents to use the youth friendly services that the MA is offering?
What factors limit or enable the MA to deliver services that match the realities and needs of young people and serve their wellbeing?
The answers were then analysed according to the research framework and sexual rights declaration, e.g. what the data mean in terms of need, demand, awareness, access, quality and commitment to the declaration.
Box 1: Overview of Analytical Framework
ADOLESCENTS’ PRIMARY CONCERNS RELATING TO SEXUALITY Need: What do they need? Are the services that the MA offers to young people relevant for adolescents, do they match what adolescents need, their primary concerns and realities?
FACTORS INFLUENCING UPTAKE OF YFS Demand: Do they want to use the services? Are adolescents motivated to use the services that are offered? Influenced by experienced needs, perceptions about efficacy, local explanatory models for health and diseases, and alternative options for coping with sexuality related concerns. Awareness: Do they know? If adolescents do not know about the existence of services, that they are there, their location/outreach activities, then they will not make use of them. Access: Can they use the services if they want to? Can services attract and reach adolescents, are they acceptable and affordable for them and is it easy and comfortable for them to use the services? Quality: Are they satisfied? Do adolescents perceive the services as helpful and relevant and are they happy with how they are treated? Are services respectful of their rights as clients? Support for What do service providers need in order to offer good YFS? Service Sufficient organizational support, management systems and resources, and Providers training and motivation of staff in order for them to conduct their jobs in the best possible way.
1.3 Research objectives
This research is designed as qualitative, exploratory research aiming to gain insights into adolescent sexuality issues and factors that influence the uptake of services by adolescents, taking the experiences, ideas and opinions of adolescents into account as a central point of focus.
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The main objective of this research is based on these insights in formulating recommendations for increasing the uptake of SRH services by adolescents.
In addition to this main objective, an important goal of the research project is to build young people’s capacity to conduct qualitative research, and, through the research process, to explore and build new forms of partnerships between young people, MA staff and community stakeholders that will continue after the end of the research project within the MA’s intervention projects and service provision.
By actively involving MA staff and community stakeholders, the research project aimed . to increase reflection on the influence of norms, values, opinions, knowledge, skills and attitudes on the quality and accessibility of the services to young people; . to increase acceptance of young people’s sexuality and . to increase support for youth participation within SRHR-related research and interventions. Therefore this report will also pay some attention to analysing the research process. However, the results regarding the achievement of those additional objectives will be more elaborately reported on in a separate report by Rutgers WPF. That report will describe more specifically the methodology and ethics for youth participation in research.
1.4 Research setting: Tarar Mela (FPAB YFS) in Jessore
The research was conducted in cooperation with the Family Planning Association of Bangladesh (FPAB). FPAB was established in 1953 and is a member association of the International Planned Parenthood Federation (IPPF). FPAB operates 43 clinics throughout Bangladesh which oversee various SRHR interventions (e.g. provision of sexuality education for in- and out of school youth, empowerment and skills training, peer education, advocacy and media campaigns, etc.) as well as the provision of SRH services (at the clinic and through outreach). FPAB contributes roughly 7% of Bangladesh’s national achievements to Family Planning (FP) (see www.FPAB.org).
The research was carried out in the context of a youth friendly service centre that is part of the FPAB branch clinic in Jessore, in the west of Bangladesh. The ‘regular’ SRH/FP services in the Jessore branch were recently expanded to include a youth centre, called Tarar Mela (a Bengali word which literally means ‘Carnival of Stars’). Tarar Mela consists of separate rooms within the branch clinic that offer recreational facilities for young people and where information and counselling is provided by youth counsellors (who are younger than 24 years of age). Tarar Mela was designed to attract more young people and increase the uptake of services. In addition to the recreational facilities and youth counsellors, Peer Educators (PE) and Youth Organizers (YO) are involved in Tarar Mela, as well as a Programme Management Committee (PMC) consisting of young people:
. PMC: 60 young volunteers (three boys and three girls in each branch) are members of the Project Management Committee (PMC). The PMC was formed to ensure youth participation in planning and monitoring of projects. The PMC has bi-monthly meetings at each branch and reviews the progress of youth project activities, in order to identify successes and challenges. In the branches where the SALIN + project is being implemented, the PMC’s role also includes monitoring of construction/ renovation and decoration work of Tarar Mela facilities (IPPF 2010 Programmatic Report).
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. PE: Peer Educators organize four-monthly meetings in different schools, colleges, madrasa (religious education institutes in Bangladesh) and coaching centres. They provide information on SRH and introduce Tarar Mela and its services to the pupils. . YO: Youth Organizers conduct two-monthly sessions in schools, colleges, madrasa and coaching centres. They also organize meetings with guardians and young people in the slum areas. They distribute contraceptives and provide the address of Tarar Mela and the phone numbers of two counsellors at the end of each session. Youth Organizers report to the coordinator by the 27th of each month. . Counsellors: The youth counsellors (one male and one female at each branch) are available at Tarar Mela from Monday to Saturday. Working hours are 1 pm to 6 pm every day in winter and 2 pm to 7 pm in summer, as these are the opening hours of Tarar Mela. The counsellors used to be Peer Educators. Based on performance and motivation some Peer Educators were selected and trained as counsellors, and are now FPAB staff, working as youth counsellors. A paramedic (adult) is available at Tarar Mela from 4 pm to 6 pm daily (IPPF 2010 Programmatic Report). If needed, the youth counsellors can refer their clients to adult counsellors or other service providers for further clinical and counselling services.
In the report, the terms Tarar Mela and YFS are used interchangeably.
1.5 Research location: Jessore The research was carried out in Jessore, a south west district town in Bangladesh. The district is in the Khulna division, with a population of 2,440,693, of which approximately 1.2 million live in Jessore town (51% male, 49% female). The population is predominantly Muslim (86.5%, Hindu 13.21% and others 0.29%). The average literacy rate is 33.4% (male 41% and female 25.1%). Jessore is a border district town, to the east of West Bengal, India. It was declared a district (government second-level administrative unit) during British colonial rule in 1781.
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Map of Jessore District in Bangladesh
(Source: http://www.priobangla.net/geography.php?action=browse&option=district&name=Jessore)
1.6 Structure of this report
The next chapter will elaborate on the participatory and qualitative methodology used for this research. This will be followed by a presentation of the research data in Chapters 3 – 6. Chapters 7 and 8 contain a reflection on the research process and ethics. Chapter 9 contains an analysis of the data in accordance with the research framework described above, which is followed by a discussion and a selection of recommendations that also follows the research framework.
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2 Research Methodology
2.1 Youth participation and ‘emic’ approach
Contemporary research that investigates barriers in access to youth friendly services is often based on bio-medical models for understanding health related behaviour, which tend to de-contextualise young people and ignore ‘what is at stake for them’ (Bradley et al., 2002; Price & Hyde, 2008). As mentioned earlier, we propose to conduct research in which the experiences and perceptions of adolescents are central. This implies an approach that aims to capture an ‘insider's’ perspective, which gives a better understanding of the meaning behind the decisions, behaviours, experiences and perceptions of the actors, who in this case are young people. Such an approach is called an ‘emic’ approach and is necessary to allow us to understand the sexuality of groups of young people, and whether and how SRHR services can be better managed to serve the realities and needs of the clients in line with their rights.
A qualitative in-depth research design allowed to depart from young people’s definitions and priorities instead of those of the donors, service providers or adult stakeholders of the project. The research aimed to produce spontaneous and open discussion on sexuality issues, between adolescents and researchers. This is one of the reasons for the choice to train young people as researchers and involve them in data collection and analysis. Young people are less restrained to discuss sexuality issues amongst peers as compared to with adults. Young researchers and informants will draw on similar youth cultural references which results in interpretation and analysis that more closely reflects young people’s realities. However, the young researchers were inexperienced and needed guidance and support. This was provided by an experienced adult local research coordinator. Maintaining good relationships within the team was an important aspect for meeting the ultimate research goal. A research assistant was also appointed to help the research coordinator who also helped in translating texts when necessary.
2.2 Data collection phases
The data collection was conducted in two phases. In the first phase the needs, desires and concerns of young people in relation to their sexuality were explored. In the second phase the barriers in relation to access and quality of YFS provided were investigated. All the data was collected by eight youth researchers (4 girls and 4 boys between the ages 17 and 22 years) from five different districts of Bangladesh. All eight youth researchers (YRs) were related to FPAB, either as peer educators or PMC members. FPAB selected the 8 YRs on the basis of recommendations made by M.A. staff, their CVs and the letters of motivation they had written when applying to become involved in the research. A two week intensive training was provided to them at the beginning by highly qualified and experienced researchers (for a description of the research training see the Rutgers WPF ‘Research Training Report’, Rutgers WPF Training Manual and the upcoming report on methodology and ethics of Youth Participation in Research).
The first phase of data collection began soon after the completion of formal training. The whole data collection phase followed a ‘learning by doing’ format. At the beginning of data collection, training on rapport building, note-taking and transcription were emphasized by the research coordinator. A guideline for qualitative data collection was prepared based on existing literature and by discussing with the young researchers the key issues among youth in relation to sexuality. Later a Bengali translation of the
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guidelines was prepared in consultation with the youth research team. In order to make the interview sessions culturally sensitive, specific terms and colloquial expressions were used, since sexuality is a sensitive issue. The field research took place between March 10th and June 10th 2010. The first data collection phase was followed by two stakeholder workshops and a break for first analysis and identification of gaps in the data. After the break followed the second data collection phase, which was followed by two large stakeholder workshops, one in Jessore and one in Dhaka.
The YRs conducted all the interviews in Jessore FPAB training centres. Only two FGDs with rural participants were done in a village of Jessore. A villager’s guestroom was used for conducting these two FGDs.
2.3 Methods used for data collection
As per the objectives of the research, a number of qualitative methods were used for data collection, which included Focus Group Discussions (FGD), In-depth Interviews, Key Informant Interviews and Participant Observations. In the first data collection phase the age range of the respondents was between 12 and 18 years. Within this age group respondents were divided into two categories, namely the younger group, with participants from 12 to 15 years of age, and the older group, with those from 16 to 18 years. Both the age groups contained both sexes, but boys and girls were in separate FGDs, and these were conducted in different settings. Various respondents from a wide range of socioeconomic backgrounds were included in the research, like boys and girls from mainstream schools and colleges, religious schools and colleges (known as Madrasa), slum dwellers, orphans, sex workers, rural dwellers, and visitors to Tarar Mela. In total 237 boys and girls of ages 12 to 18 participated in 20 FGDs. Among these 125 were girls, of which 58 were between the ages of 12-16 and 67 were between the ages 17-18. 112 were boys, of which 55 were between the ages of 12-16 and 57 were between the ages of 17-18.
In addition to FGDs, and for triangulation purposes, 48 Key-Informant (KI) interviews were conducted in the first phase, which included both young and adult interviewees. Of the key-informants interviewees, 11 were adults and 31 were young boys and girls (15 girls and 16 boys), and 6 young staff from FPAB. Due to the sensitivity of this information, it was not generally possible to obtain personal information about the interviewees in relation to certain issues of sexuality during FGDs, so 29 informants were selected from FGDs to explore the issues further. These respondents were chosen based on their potential (noted by the YRs) to be more knowledgeable and/or willing to talk about sexuality issues and they consented to participate in further individual interviews. Among these participants were young people such as a (male) STD patient and a (female) unmarried contraceptive user. Among the young staff, there were two peer educators of FPAB (male and female), and two project management committee members of FPAB. For the adult interviewees, a school teacher (male), two street canvassers (both male), two paramedics of FPAB (male and female), a father, a mother, a religious leader (male), a rural and an urban reproductive health promoter (RHP, both female), and a government Community Health Worker (CHW, female) were chosen.
Alongside this, five Participatory Observations were conducted in two public parks, two cyber cafe (as these were most frequently mentioned by the respondents as the dating places for young people in Jessore), and two sessions with street canvassers (a type of street hawker who sells medicines particularly for sexuality problems).
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The primary sorting and coding of data was done by the young researchers, in consultation with the research coordinator. Each and every code was finalised in consultation with the research coordinator and research assistant.
Two stakeholder workshops with 22 stakeholders were held in Jessore in order to verify the data collected and conclusions drawn by the young researchers. Another objective was to open the dialogue on youth sexuality issues between community members, young people (researcher) and service providers. Additionally, we have tried to overcome the lack of information that parents/adults have about sexuality education, and the services provided by Tarar Mela, through our stake holder panel. Moreover the workshops contributed a forum to get recommendations, and to stimulate collaboration between FPAB and important community institutions and people. The first workshop included NGO Officials (male and female), Religious Leaders (male and female), High School Head Teachers (male and female), Government Officials e.g. a Upazilla Youth Development officer (male), a senior health education officer (male), elected representatives of Government; a female Sub-district elected member, and a male Sub-district elected member. The second workshop included two Youth Counsellors (1 female and 1 male), four Peer Educators, four Youth Organisers (2 female and 2 male), a Project Management Committee member, and a Project Coordinator.
In the second data collection phase 12 participant observations were conducted in the YFS centre for six days. Tarar Mela clients were observed from entry to exit. Along with this counselling sessions of five males and five females were also observed. In the second phase additional data was collected, focusing on the access and quality of services, by using individual in-depth interviews with 24 Tarar Mela visitors (12 boys and 12 girls) and 22 FPAB staff (male, female) in Jessore branch. Two more workshops were also conducted in the second phase, one in Jessore and the other in Dhaka mainly to present the second phase results and to get feedback as well as recommendations from the workshop participants. In the Jessore workshop mainly civil society members and FPAB staff attended while the Dhaka workshop was attended by Jessore FPAB staff, FPAB head office staff, other MA members, donor representatives and academics. Additionally, the research coordinator carried out content analysis of various written, visual and audio sources, which included local music –video and audio, local magazines, jokes/ CDs, films and mobile phones. The content analysis was needed to verify the sources of information on sexuality mentioned by the respondents.
2.4 Limitations
On the one hand using FGDs helped us to recruit a good number of respondents in a short period of time. On the other hand there were some limitations on gathering information on a sensitive issue like sexuality through FGDs, as the boys and girls talked very little about their own experiences. During the discussion they mostly referred to experiences of their friends or cousins, but not their own. This did not hamper to achieve the major aim of the research, as we were not interested in how many of the respondents were sexually active themselves, rather we wanted to know the general patterns of sexual reality among the young group. However, data from FGDs tends to be normative and needs to get triangulated with data from individual interviews and observations. In order to get some individual experiences we also conducted individual in-depth interviews from selected FGD participants. In the second phase 8 hypothetical cases separately for boys and girls were developed from the findings of the first phase regarding sexuality issues for young people. These cases were presented to the
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respondents (only Tarar Mela visitors) to find out their opinions. This process helped the respondents to express their views in a depersonalised way. The cases and responses are presented in Annex 1. We also analysed the questions raised by the young people anonymously in the question box of Tarar Mela. The result is added in Annex 2. These additional tools helped us to decrease the limitations of data collection through FGDs or in-depth interviews on such a sensitive topic.
Maintaining homogeneity of FGD in terms of age was difficult. Although we repeatedly mentioned this to the FPAB staff who helped us to collect respondents, they apparently failed to understand the importance of making the group homogeneous, as they would ask, ‘why does it have to be the same age, what is the big deal if they are one year older or younger?’. Sometimes at the beginning of an FGD we realised that some respondents’ ages did not match the others', but we still had to continue, as sending them back could have had a negative impact on the group dynamics. Also maintaining the same number of respondents in every FGD was not possible. There were too many young people interested in participating and it was sometimes hard for FPAB staff to reject them. On the other hand in certain groups, for example male street sex workers, many were not willing to participate in a FGD, so the group was smaller than usual. Providing financial incentives to the research participants created problems; in a few cases this attracted false respondents. As soon as we realised this we rejected them. Also using a tape recorder was a constant problem, as either the respondents didn’t consent to it or the recording quality was very poor. The constant sound of the fans was often responsible for the low quality of the recording. Because of not being able to use tape recorders we lost some data.
In the second phase it was hard to decide whether we should increase the number of FGDs with the same groups or include some new groups. Finally we decided to focus on YFS in the second phase. Collecting more data from the same groups would provide rigorous in-depth knowledge of diversity of sexuality among the youth of different groups. However, within the scope of this research, we were unable to explore some relevant issues, for example the sexuality of rural illiterate people, patterns of rural commercial sex, and views of rural parents and rural religious leaders. Also, not enough exploration was done into orphans’ and slum girls' sexuality. Collecting more in-depth data from the above-mentioned groups would have provided more comprehensive insight into differences between the groups.
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3 Significant sexuality issues for adolescents
The findings presented below are mostly based on young people’s perceptions. Nevertheless in some cases the providers’ perspectives on young people’s sexuality have been analysed also. We categorised the young respondents into two groups by age. In the following section, I will mention older boys and girls (age range 16-19), and younger boys and girls (age range 12 -15). The key findings of the research will be presented under the following three themes, in order to cover the various research questions raised:
Significant sexuality issues for adolescents Sexual behaviour Quality and access of youth friendly service (Tarar Mela)
One of the main research questions of this project was to find out what young people need from sexual reproductive health services in order to match their sexual realities and fulfil their sexual rights. In order to address this question we explored sexual wellbeing issues from the youths’ point of view. To understand the significant sexual issues of Bangladeshi adolescents, the following aspects were explored.
3.1 Curiosity
We tried to explore the nature of general curiosity among the boys and girls concerning sexuality. The young researchers observed that while young boys' curiosity mainly surrounded women’s bodies and sexual intercourse, the girls' curiosity ranged from virginity to sexually transmitted diseases. The most frequently mentioned curiosity among girls was about virginity. It seems the girls had constant worries and various misconceptions about the issue of virginity, and thus were insecure about it, which will be discussed in detail shortly. The YRs found that many older girls were curious about homosexuality and lesbianism. Girls wanted to know how a boy can actually have sex with another boy or a girl with another girl. Some older girls wanted to know of ways a girl could increase her ‘sexual power’ to please men.. The word ‘sexual-power’ refers more to pleasing the husband sexually and also probably for their own pleasure. They were specifically curious about this because there was insecurity amongst the girls about their ability to please their husbands sexually. This seems to be related to the idea that if a wife cannot satisfy her husband, the husband goes to a sex worker or has extramarital sexual relations. As one girl commented, “I have heard husbands go to other women if the wife cannot give him sexual satisfaction.”
Both older and younger girls had questions around menstruation. They wanted to know why menstruation happens, why there is pain during menstruation, and how to ease this pain. A few of them were curious about female masturbation. The slum girls group wanted to know about sexually transmitted diseases. They had questions like, how one can get an STD or what are preventative measures for STDs, what are the treatments for STDs and so on. These particular curiosities or questions regarding STDs may be triggered by the fact that they are sexually active but know very little about STDs and methods of prevention. Slum girls groups were also curious about HIV/Aids, which they are aware of from different NGOs working in the areas. Some younger girls wanted to know if a girl could become pregnant after touching/kissing/hugging a boy.
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On the other hand the older boys mentioned their endless curiosity about the female body. The younger boys were also curious to see the different body parts of the girls. They were especially curious about the girls' breasts and the vagina. As one boy said, “I wish I could see what’s in between two legs!” The older boys were more curious about sexual intercourse. Among the older boys those who had not had sex were curious to know how sex takes place. While older boys were curious about the size and shape of the penis and duration of intercourse, younger boys were curious about masturbation and wet dreams. Some of them also mentioned that they wanted to watch other people having sex. Some slum and rural boys admitted that they had seen other people having sex. Those who were curious had seek information from various sources, most of which were not providing accurate information (more will be discussed later), so they developed many misconceptions regarding sexuality. It can be said that the underlying cause of all this curiosity about sex is not only puberty but also sex being such a taboo in Bangladeshi society and the fact that there is so little information available to the young people about sex and sexuality which plays a big role. We found that very little is covered in the school curriculum on sexuality issues. While going through the high school text books we found that partial, and to an extent misleading information is given on HIV and AIDS. In the text book of class six and seven all HIV/AIDS transmission routes were described except sexual intercourse. In order to be culturally sensitive they avoided any indication regarding sex. In the textbook for class eight, they added that HIV could also spread through unethical and unsafe physical relation. It did not mention the word ‘sexual relations’ neither does it explain the word ‘unethical’. It also did not explain about possibility of getting HIV in married relations or partner’s extra marital sexual relations. This kind of incomplete and misleading information actually makes the young people more curios which could lead to higher risks related to misconceptions.
3.2 Desires and pleasure
Keeping the curiosity in the background, we also wanted to know what sort of sexual desires the boys and girls had. The older boys had mentioned to the YRs that they had an overwhelming desire to have sexual intercourse. This desire was found across the groups from slums to orphans, from rural illiterates to college going boys. Most of them mentioned that they felt a sexual urge whenever they see girls in real life or in cinemas. We found that the slum boys groups admitted their sexual activities more than any other groups. Slum girls were more curious about sexually transmitted diseases, its’ treatment and prevention. It was also revealed that Tarar Mela has limited services for the slum areas. Because of their lower level of education and lack of service provision young people from slum areas run the risk of being affected by various sexually transmitted diseases including HIV/AIDS .
One boy from the religious institute ‘Madrasa’, who had experienced sex, said: ”I forget about religion when I get a chance to have sex.” In contrary to the common belief that Islamic religion in Bangladesh would prevent young people from pre-marital sexual activities, this example rather shows that young people do get engaged in sexual acts. A boy who had sex once said: ”I am longing so much but God knows when will I ever get another chance to have sex!” Some of the slum and the rural boys mentioned that they had seen married couples (relatives) having sex and they got sexually excited. A few older boys said that they even wanted to get married early mainly to experience sex, because there are no obstacles to having sex for married couples.
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Unlike the older boys, many younger boys mentioned that instead of intercourse they wanted to get closer to a girl's body. One boy mentioned: ”I would feel my life is satisfied if I could only hug a girl.” This example emphasizes the fact that such behaviour would not be tolerated in Bangladeshi society, which has a serious constraint on the ability of boys and girls to develop intimacy. Many of them mentioned their desire to have romantic relationships with girls. They said that through having a relationship with a girl they wanted to kiss her and get closer to her body. However, some of the younger boys also mentioned that they wanted to have sexual intercourse.
The girls, on the other hand, talked about having a desire to experience sexual excitement, not sexual intercourse as such. Most of the college-going older girls said that they wanted to be exited by watching erotic films, and pictures on TV and in magazines. However, they all said that they would wait until they got married to have sexual experiences. Older girls mentioned that they loved to hear stories about sex from their friends who had already got married. While listening to them they had the desire to have sex. The girls said they wanted to get closer to boys, hold their hands, spend time together and talk with them. The younger girls said they had a desire to see boys' naked bodies. Only a few of them mentioned about having sex in their dreams while sleeping. But there are a lot of barriers and negative consequences to having premarital sex in real life for Bangladeshi young boys and girls (see 3.3.2 and 4.4).
3.3 Misconceptions and concerns
We found through this research that in most cases boys and girls did not have the right information regarding various issues around sexuality. This lead to misconceptions regarding the following issues:
3.3.1. Masturbation: Most of the boys, both younger and older, from all 10 groups admitted that they masturbated regularly. They said that when they were sexually exited by seeing a girl or pornography they masturbated afterwards. Most of them however thought that due to excessive masturbation their penis might get deformed. They believed the penis might become thick at the top and thin at the bottom (aga mota gora chikon). There is a wide- ranging belief that masturbation makes boys physically weaker. Many of the boys believed that 40 blood cells are needed to create one drop of semen and because masturbation results in losing lots of semen, they will become physically weaker as a result. It was believed by many boys that the penis runs out of semen due to frequent masturbation. They thought masturbation would affect their sexual performance as it can cause premature ejaculation. Many younger boys said that masturbation is bad for the health and is a kind of disease. A few boys said that according to Islam, masturbation is a sin. One younger boy thought that if somebody masturbates excessively, he might lose his reproductive power. A number of boys reported to the young researchers that they suffered from guilty feelings after masturbating. Only one boy said that it is normal to masturbate.
Older girls said they knew that boys masturbate and they thought this was bad for their health; they thought it made the boys weak “as calcium is lost with semen.” A number of girls said masturbation is against Islam. One girl thought that boys lose their virginity by masturbating. All the girls said that they had heard about girls masturbating but they themselves hadn’t tried it. Almost all of them had heard that girls masturbate using eggplants, bananas, carrots, cucumbers, Coca Cola bottles etc. However, their reasons
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for not masturbating could be because of a fear of losing their virginity (see more in the following section) before marriage or perhaps the young girls did not dare to admit that they masturbate in a closed society like Bangladesh. It can be said that there is a wide range of guilty feelings about masturbation among the youths.
3.3.2. Virginity Both older and younger girls mentioned that they had heard about the hymen being broken during first sexual intercourse, and that blood is shed from their vagina as a result. According to them if a girl doesn’t bleed on her nuptial night, it indicates that she had sexual intercourse before marriage and is not a virgin. Almost all the girls have showed their concern about virginity loss which can create a marital disruption as men do not want to marry a girl who has had sex before marriage. Apart from marital disruption this creates a substantial amount of problems ranging from family shame to stigmatization and abuse from the husband and community. It can even have financial consequences relating to dowry payments. The younger girls thought that if their breasts were too big before marriage it would be seen as a sign that they had been touched by boys, which is another indication of the loss of their virginity or purity. Only a few thought that the hymen could be damaged due to physical hard work or getting involved in sports, or that the size of breasts actually depends on physical growth.
The data confirms that keeping their virginity was a serious matter for all the girls. As a common notion regarding this was uttered by one older girl who said, “My body is the property of someone else (her husband to be) and I’m taking care of it on his behalf. If I give it to someone else, it means I’m betraying my husband to be.” The boys also talked about the hymen and said it is important for all girls to keep their hymen intact in order to prove their virginity on their wedding night. The girls were curious to know if there are other ways of checking the virginity of a woman. There is a big fear among girls surrounding keeping or losing their virginity. This is probably the major reason for abstaining from having sex.
3.3.3. Wet dreams: The older boys said they had experienced wet dreams between the ages of 10 to 14 and then they stopped. Many of them believed that wet dreams make a boy weak. According to one older boy, “If it happens twice a month, it is a ‘good wet dream’ (shopno gun) but if it happens twice a week, it is a ‘bad wet dream’ (shopno dosh).” In general they all felt bad for having wet dreams. As one of the participants said, “I felt terrible and sad when I had a wet dream.” One of the younger boys said “Someone told me, you will die if you have wet dreams.” Another younger boy said, “I feel helpless and frustrated thinking of my wet dreams, I also feel afraid.” Most of the younger boys said that they believe wet dreams lessen the amount of blood and calcium in the body. Only one of the younger boys said: “Everybody experiences wet dreams. It is normal.” Another boy said: “Having wet dreams is good for health as it prevents boys from having premarital sex.” Only a small number of girls said they had experienced wet dreams, while the rest of the girls said that only boys have wet dreams, not girls. However, there are negative ideas attached to the matter of wet dreams, e.g. bad boys have wet dreams, not good ones.
3.3.4. Sexual Power: The young researchers found out that the boys had various concerns and ideas about sexual ‘power’. The boys often mentioned the word ‘sex power’ according to their explanation which includes the sexual stamina and libido. The boys thought that it was possible to increase sexual power by taking the pill (sreebori) which the canvasser sells. According to them, hot milk can also enhance ‘sexual power’. They believed that if sexual
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power could be enhanced, a man could have sexual intercourse with a woman without ejaculating for an hour. The boys also believed that in order to have more sexual pleasure for themselves, they needed a bigger penis. Longevity of penetration or a longer penis are signs of masculinity which indicate the sexual power of a man.
3.3.5. Menstruation: Mostly among the younger girls, there were some taboos in relation to food and mobility during menstruation. They believed that they should not eat fish, meat or eggs during menstruation. They also should not eat sour fruits and turmeric spice during menstruation, as these would cause excessive, odorous bleeding. Younger girls also believed that during menstruation girls should not touch anyone, and should not go outside at certain times. If they went out, they would be affected by a bad wind (evil spirit), which could also cause excessive bleeding. Culturally menstrual blood is considered to be impure, and bad spirits always are attracted by dirty things. Thus it is the women who will always be possessed by evil spirits, since they are the ones who only menstruate, not the men. This belief portrays the patriarchal views of the culture (Nahar 2007).
3.4 Sources of information about sexuality
We tried to explore where young people go to find information in order to satisfy their curiosities regarding sexuality. We found that the sources of information regarding sexuality among the young people in Jessore varies from family members, books, music and jokes to street canvassers. Treatment from street canvassers ranges from menstrual problems to problems with penis size, ejaculation, STDs, impotence, infertility and so on. They are known for their charismatic way of selling medicines and are very popular among the public. The type of medicines varies from biomedical tablets to herbs and amulets. The types of books the young people mentioned included religious books as well as erotic books. The most popular source of information is erotic books, commonly known as choti boi. The content analysis of these books shows that these are basically novels where the characters get involved in sexual acts and the author gives graphic descriptions of those acts. The books depict extramarital sex, incest etc. On the other hand the religious instruction books are manuals for intercourse, foreplay etc., mainly targeted towards married couples. A few of the older boys said they regularly went to watch the performances of the street canvassers, who sell various herbal medicines to increase potency. As part of their performance they also provide information regarding sexuality. The observation data confirms that the street canvassers provide a range of unrealistic and false information regarding the size of the penis, duration of intercourse, masturbation, wet dreams, menstrual pain etc. The canvassers also give (false) information on signs and symbols of virginity; shapes of breast, hymen and so on. Some boys said they got some information from their grandparents. Many of the boys admitted that they had also got ideas about sexuality from pornographic movies. Only two boys mentioned learning from health centres.
Most of the older and younger girls said they have learned about sexuality from their elder sisters, cousins, sisters in law, grandparents as well as from pornography. Few of them have said that they learned about sexuality from internet in cyber cafés, and from watching English movies on television. Many of the younger girls said they have learned about sexuality from a health centre called ‘gono-kendro’ (public centre). Only one girl has mentioned that she learnt about sexuality from Tarar Mela.
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Some boys, both younger and older, mainly either from slums or orphanages, mentioned that they went to herbalists (kobiraj, who treats only with herbs, following Ayurveda tradition) and street canvassers for information concerning sex and sexuality. Others said they were told by the street canvasser and herbalist that by massaging leech oil sold by them onto the penis, it could be enlarged by up to 1 inch in 7 days. Girls did not go to the street canvasser, as that is completely the boy’s domain. This is probably because canvassers sell their medicines mostly in a crowded place, either in the middle of a town, weekly bazaar (haat) or in the regular bazaar. Women hardly go to these places as Bangladeshi women’s mobility is still restricted (starts from adolescent’s age for the girls). Also probably in Bangladesh the culture of gender segregation is strong till date. Moreover, canvassers openly talk about sexuality; they show pictures of genital organs, and STDs. It is culturally inappropriate that women and men would stand on the street side by side and listen together to someone who is talking about sexuality issues (Nahar 2007). It is also interesting that these sexuality issues become a taboo as soon as both genders are exposed to them together in such an open setting. The girls, however, went to the herbalist for various suggestions for menstrual pain. As well as herbs, the herbalists give holy water as medicine. The girls said they have heard that after marriage women go to the herbalists to have a male child and also for infertility problems. The girls mentioned that they had heard that herbalists can also give solutions regarding problems within love affairs or marriages. Herbalists are more commonly sought by women for their sexuality and reproductive health issues. The herbalists in some cases provide door to door services. So Bangladeshi women/girls who are often restricted to the domestic domain, can easily get herbal medicines from an herbalist at home. Sometimes these herbalists are women, in which case it makes even more acceptable and accessible for the women/girls to get herbal medicine. Moreover, alternative medicines (herbalist, canvassers, spiritual and megico-religious healers) are cheaper compared to the biomedicines. It also complies with the general people’s causal belief system (Nahar 2007). It was observed that almost all the boys and girls had not learnt about sexuality from proper sources, neither did they discuss it openly. It is all hidden, and as a result parents are not aware about where their children are getting information from.
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4 Sexual behaviour of adolescents
We found that the curiosities and desires expressed by the young boys and girls influenced their sexual behaviour, as follows:
4.1 Romantic love and dating
A number of boys and girls mentioned that they had become involved in romantic relationships, so we explored their ideas around romantic love. According to older boys this is a feeling that they experience when they imagine their girlfriends. One boy however said: “There is nothing called love, but boys talk about it to cheat the girls.” Younger boys, on the other hand, could not come up with a definition of romantic love. This is can be due to inexperience or to the restricted interaction between boys and girls. The cultural practice of sex segregation creates taboos, which in turn act as a barrier to the development of intimate relationships between boys and girls.
While defining love, most of the girls said this is a deep emotion which feels good, which also makes them shy. We observed that the girls who talked about love openly had visited Tarar Mela a number of times, while others were relatively shy in talking about this. For many younger girls love is an issue of fear, because they think it is forbidden by society. According to them falling in love is almost like a crime or sin in the society. There is some form of punishment attached with it. As a rural older girl said, “If someone falls in love and people know about it she will be punished, as if it is a crime.” Some of the girls said romantic love has negative effects on life, as it can make girls absent minded.
The young boys and girls reported that those who were engaged in romantic relationships liked to keep it a secret from their parents. They said they would inform their parents only if the issue of marriage arose. Older boys said they usually talked about their relationships with their friends, while younger boys hardly talked about this to anyone. Among the older girls, most of them shared their experience of love with their friends, cousins of same age or their sisters-in-law. Only one slum girl and a religious school-going boy said that their family knew that they were involved in a relationship. Interestingly, some girls who were regular visitors of Tarar Mela mentioned that they would like to inform their parents if they got involved in any romantic relationships in future. We cannot be sure what Tarar Mela visitors would do in real life practice but the realization of the importance of openness between parents and children, and the desire of breaking the taboo on sexuality issues is probably an influence of counselling sought at Tarar Mela. Another assumption can be that their parents are already open and not very conservative therefore they have admitted their children to visit Tarar Mela. So these young clients are less fearful of sharing their love relations with their parents.
According to the older boys, a romantic relationship gives the boy access to the girl's body. This does not necessarily mean having sex. Older boys who were involved in romantic love mentioned that they had kissed their girlfriends, and sometimes they had exchanged kisses through mobile phones. They also exchanged love letters between them. Most of them said they wanted to wait for sex until after marriage. One slum boy said: ”Romantic love is a sacred secret and sex is a dirty thing. So one should not have sex with his girlfriend. If they really have the urge to have sex, they can go to other girls but should keep the girlfriend a virgin.” Some of the younger boys who had gotten involved in romantic love mentioned that they mainly talked with their girlfriends in school after class hours. There were incidences when the boys brought their girlfriends
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home when the parents were away. None of the younger boys mentioned having sex. For most of them romantic love is a mental passion not a physical one. While talking about romantic love some of them referred to the legendary story of Laila and Majnu (a traditional love legend, local Romeo and Juliet). One boy said ”I love her so much that I can’t touch her.” A case was mentioned in every FGD (4) in the village where a boy attempted suicide because his parents did not approve of his romantic relationship with a girl.
Interestingly, unlike the boys, both young and older girls differentiated between ‘good’ and ‘bad’ love. According to them good love is one where the boys are trustworthy, romantic, educated and have a good family background, and the relationship results in marriage, as the boy is acceptable to the parents. Another major criterion for good love is not having pre-marital sex. They consider that a good love is one where the boy does not insist on having sex. On the contrary a bad love is one where the boy is not educated and got involved in the relationship mainly in order to have sex. Extra-marital love is also considered to be bad love. The girls mentioned cases where boys had gotten involved in love and then cheated on the girl, whom they then sold to a brothel.
The respondents who were engaged in romantic love mentioned that in general they have problems finding places for dating. It is not easy for a boy and girl to meet in a public place and spend time together as they are afraid of being caught by their family members. The only public place the boys and girls could meet is the parks. The boys and girls would usually meet after school or college as the girls were not allowed to stay outside during late afternoon or evening. This is however difficult for younger boys, as they wear their school uniform during the day time and it is very hard to date with a school uniform on, as they will be easily identified. Sometimes they date in classrooms after school. The rural boys mentioned bushes (ara, bashchar) as their dating places. A few girls mentioned paddy fields and bamboo gardens as dating places. The respondents mentioned a few private places for dating, which included friends' or relatives' houses or even their own house when their parents were away. The respondents also mentioned rickshaws, cyber cafés and cinema halls.
Both older and younger boys said that they mainly chatted, hugged, and held hands with their girlfriends when they dated. Some of them mentioned kissing, or caressing the breasts as part of the date. The girls also similarly mentioned kissing, chatting and hugging as the main dating activity. Girls mentioned that boys caress girls' breasts during dating, they also pull at their dopatta (a modesty scarf to cover the breasts), and some even touch the girl's vagina. Both boys and girls said sexual intercourse during dating was rare but not unheard of. Our park observations confirm that the park is a popular place for dating between young boys and girls. We observed that a number of couples were walking and sitting closely with each other. We observed that some of the couples were more physically intimate than others and were also engaged in sexual actions, for example, touching breasts, touching penis (over clothes), hugging each other for a couple of minutes. To do these activities the couples would find a quiet place within the park, which might be some distance from the main area or in a bushy area. Most of them were young, although one married woman wearing sindur on her forehead (red powder, the symbol of a married woman among Hindus) was found dating a younger boy than her. Many of the girls were wearing veils (burkha); we were not sure though if they were dating with their boyfriends or if they were sex workers selling sex. It was revealed in our research that both school and college girls use the burkha to hide themselves while dating. Even if they do not have a burkha, they borrow it from a friend who has one. The same is true for the sex workers who our YR interviewed. They found
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that the sex workers pretend to their families and neighbours that they are working in NGOs. Every morning or evening they come out of their house wearing a burkha with normal dress. Later they change their makeup and clothes in their madam’s (pimp's) house or in their business place.
Although the respondents had not experienced this themselves, they had heard that girls go to residential hotels or boys' hostels for dating. In general finding a private dating place is considered a problem for boys and girls who are engaged in romantic relationships. As it came from FGDs that cyber cafés are also used for virtual dating and in real life dating place. Our visit to two cyber cafés observation did not reveal this. However, we made our participant observations during the day time, the café managers told us it is in the evening that young people use cyber cafés for dating. We could not do the evening observation due to time constraints.
4.2 Sexual activities
Among the respondents some of the boys admitted that they had experience with sexual intercourse. However, none of the girls admitted their own experience of having sex. The young researchers revealed that the boys have mainly had sex with commercial sex workers. Very few who are engaged in romantic relationships mentioned that they had sex with their girlfriends. During their interviews with the service providers, they mentioned that they had plenty of evidence to show that young unmarried boys and girls are sexually active. Service providers reported that they provide Menstrual Regulation (pills to induce abortion) to unmarried girls. Paramedics mentioned that they handled cases of STDs among unmarried boys. Counsellors from Tarar Mela reported that both unmarried boys and girls collect contraceptives from Tarar Mela, however boys collect contraceptives more often than girls.
4.2.1 Commercial sex workers We interviewed young boys and girls who were engaged in commercial sex work. Both male and female sex workers mentioned that they began sex work mainly for economic reasons. The age range for female sex workers were between 16 to 20 except two who were 22 and 25. (Only for this group we could not maintain the age range of our designed sample) The female sex workers were mainly girls who had been abandoned by their husbands. Some of the girls said they were forced into prostitution by their boyfriends or husbands. Only one girl sex worker mentioned that she enjoyed having sex with different clients as her husband is impotent. The girls said they got clients from all sections of society but mainly professionals. The regular clients were the men who were away from their wives, for example army soldiers and policemen. Some men visited them despite the fact that they had their wives at home, according to the sex workers because the commercial sex workers provide variations in sex acts which their wives do not provide. Some men came to them when their wives were pregnant. The girl sex workers reported that they went to the boy/men’s residences to solicit sex, but they also used hotels for their sex work. The girl sex workers said there is an NGO that provides various kinds of support to them. However, none of the girl sex workers ever came to Tarar Mela.
The boy sex workers (age range between 10 to 17) said they also got clients (male) from different age groups and professions, but their clients were mainly young students. In response to our query the boy sex workers told us that the clients prefer them because they think when students hang out with a boy it is socially safe, but accompanying a girl
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raises suspicion in society, so many young students go to the boys to meet their sexual needs. The boys go to hotels for sex, and sometimes they also go to student hostels. When one of the sex workers who was only ten was asked if he enjoyed having sex with men, he said he feels attraction neither for men nor for women, but he just does it for money. An NGO called ‘Bondhu’ provides them with services and education. None of the boy sex workers have visited Tarar Mela either. We are not aware of any study on the first sexual experiences of Bangladeshi men. However, it cannot be said that many boys' first sexual experience is with a prostitute. Some might have first sexual experience with their girlfriends, others with their relatives or maid servants and many wait to get married to have the first sexual experience.
4.3 Pornography
Although the majority of the boys and girls were not either involved in romantic love or sexually active, they satisfied their curiosity and found pleasure in watching pornographic movies or erotic videos, reading pornographic magazines, masturbating etc. The young researchers observed that various erotic visual and written materials are found in the town. Boys and girls go to cyber cafés to watch porn movies on the internet. The young researchers have found that mobile phones are widely used for erotic purposes. All the older and younger boys said that watching pornographic clips on mobile phones is a common practice. Boys buy a 7 minute pornographic movie clip for only three taka from mobile shops (equivalent of 0,04$ or 0,03€). Boys download pornography from friends' mobiles through Bluetooth. They described the varieties of pornography available on mobiles: for example, ‘foreigners’, ‘cut-paste’ and ‘cut piece’ etc. (usually uncensored pieces of film). In addition to mobile porn there are locally made musical videos or joke videos which have lots of erotic elements. There are also cheaply printed magazines with erotic pictures and texts which are also popular, mainly among boys. Many boys and girls said they use mobiles for romantic or erotic pleasure. Girls said they get engaged in erotic conversations through mobile phones late at night. It should be noted that this kind of erotic pleasure is obtained also by the boys and girls who are involved in romantic love or sexual relationships.
4.4 Stigma and fear
The YRs found that although some of the older and younger boys were involved either in romantic relations or in sexual relations, the majority kept themselves away from any such engagement. The reason they gave for this was that they were afraid of familial and societal stigmatization. The boys said society had a negative attitude towards premarital romance, and in particular sex. According to the boys, adults think that romantic love may lead to sexual relations, which are prohibited in this society before marriage. As a result the family has no tolerance for romantic relationships between young people. Many boys and girls said that they thought their parents, extended family members, and even their teachers would be very angry if they heard that they were engaged in romantic love. They thought that their movements might be restricted. However, this fear was more intense among the girls. The girls mentioned that if they were found to have love affairs, the reputation of their families in society would be decreased. They thought this might hamper their future marriage, as girls who have a history of love relationships find it difficult to get a bridegroom, and also they need to give more dowry7 than the others.
7 Dowry: money or goods that a woman (through her family) brings to her husband or husband’s family upon marriage.
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Some girls were also afraid of the fact that after marriage if their husbands found out that they had premarital relationships, the husbands may then physically torture them, and divorce them. The young researchers found that for the orphaned boys and girls it was not only the family or society that worried them, but that they might be expelled from the orphanage if the authority found out that they were involved in romantic relationships.
During the Jessore stakeholders workshops the participants (adult stakeholders) approved of love relationships between young people, with some conditions such as; the relationships has to be between a boy and a girl from a similar social background (mostly economic and also educational) and most importantly the relationships cannot be in public. If the love relationship between a boy and a girl is from the same social strata and both families agree to marriage, only then the young couple is allowed to show public displays of affection. In Bangladeshi society marriage is commonly arranged by the parents, in the case that a young couple are discovered having a pre-marital relationship (with or without love), then marriage will often be the consequence. The whole notion of keeping love relationships hidden relates to stigmatization of being sexually active. The stakeholders’ opinion regarding keeping love relations secret also shows that premarital sex (and love relationships) is common in Bangladeshi society, but occurs under cover and in denial. It can also be said that young people in Bangladesh are more sexually ‘active’ (i.e. engaged in relationships) than its society would like to admit.
Only some young people mentioned that there were personal barriers that prevented them from being involved in romantic relationships, such as shyness, having a lack of communication skills, lack of time, and extra pressure on studies, as well as not having the economic means to carry on with a relationship. Only a few of them mentioned that it is not right from a religious point of view, as Islam prohibits premarital sex. Although in Islam premarital romantic love relationships are allowed according to the Bangladeshi Islamic doctrine, young people that are not involved in romantic love relationships probably do not do so because of the perception that premarital love relationships lead to premarital sex, which is considered to be a serious sin in Islam. Some younger girls said they did not get involved in romantic love relationships as they thought most boys cheated and had multiple girlfriends. One girl said ”Love is nothing but pain.” Some of the girls said they were not interested in love, as getting involved in romantic love would hamper their studies. Some of them said they did not get involved with any boys because boys turn romantic relationships into sex, which increases the risk of premarital pregnancy.
We found that the stigma is stronger around premarital sex than romantic love relationships. Both boys and girls said that getting involved in premarital sex carries a great risk of being stigmatized. However, both acknowledged that girls are more a victim of the stigma than the boys. In the rural areas if a boy is caught having premarital sex, a local trial will be set up by the community leaders/elites (i.e. religious leaders, elderly people, political leaders, school teachers, and government elected local leaders). The elites will force the boy to marry the girl. If the girl is from a poor background and the boy is well off, the matter could be settled by monetary compensation to the girl instead of marriage. On the other hand if the girl is identified first as having premarital sex it will have serious consequences both in rural and in urban areas. Society will blame the girl for the offence and humiliate her family. The older girls mentioned that there have been incidences of suicide by girls due to such stigma in society. Girls generally do not get justice even if they are raped. The older girls said the news of a girl’s involvement in sexual intercourse (kharap kaj) spreads faster than any boy's misdeed. Some of the
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older boys said people call the girls who have premarital sex ‘used property’ (khaoa maal), or ‘sucked piece’ (chata maal). One younger girl mentioned: ”My aunt was kidnapped and she returned after a day. Since then nobody talked with her, made fun of her and her family faced problems when they tried to marry her off.” However, despite the fact that premarital sex is stigmatized, the girls and boys said they knew this happened amongst young people and that the people involved kept this a secret.
4.5 Eve-teasing and harassments
Another activity which the boys were exclusively found to be involved in is eve teasing and harassing of girls. Both older and younger girls said they were constantly being eve teased and sometimes harassed by the boys. The girls said that on their way to school or in some public places the boys made bad comments towards them. The researchers tried to make a list of the comments made by the boys. Most of these comments made by older boys referred to girls' physical appearances and body parts, for example, ‘Look at her breasts! What’s the size?’ ‘Oh! Size of her buttock is 40 and breasts 36’ , ‘Such an awesome piece!’ ‘Hi sexy, how did you grow such big breasts?’ ‘ Walking, shaking.’ Younger boys' comments were more indirect, for example they might say “Is there any place for me, in your heart?” Older girls walked holding their books in front of their bosoms. Boys passed comment on this: “Wish I could be that book in her hand! I could have got closer to her heart.” Sometimes they referred to a pair of coconuts or a pair of apples to indicate the breasts.
Older girls said the boys not only showed attraction through their comments but they also showed their distaste when they disliked a girl. For example, if the girl was skinny boys called her “shutki” (dried fish). If the girl was tall boys called her “logi” (bamboo). When they saw a fat girl they would comment “Can we make use of her?”. If the girls did not respond to the boy’s offer, the boys would say “this girl is sour like a green mango”. Sometimes the boys would also whistle, wink, clap, laugh loudly, sing songs, blow kisses, or show their bare bodies instead of making comments. When the boys make comments most of the girls would silently pass, with lowered heads. Some girls involved their older brothers to handle the boys. One girl said she was very sad to face this teasing and asked her mother to make her a burkha so that the boys would stop making comments. However even the girls who wear burkhas are not safe from being teased or harassed. One of the religious school girls explained how she was teased while she was going to school: the boys told her “Hi sexy, Arabian nights.” Usually girls got scared or upset at these kinds of comments. Only one girl however said she replied back to a boy who made bad comments about her. She said to the boy, “So what if our breasts are bigger? Do you want it? Don’t you know girls are human beings? I’ll beat you up and distort your face.” The girl said she was inspired by a TV show where she saw a girl beat up a boy who teased her.
Many girls mentioned that they had experienced physical harassment by boys. The boys acknowledged that they had been engaged themselves in harassing the girls physically. One boy said: “Friends told a boy that if he could touch a girl’s breast in front of them, he would get a cigarette. So the boy ran up to a girl and suddenly squeezed her breast.” Many of them admitted that whenever they got a chance to touch a girl they did that in crowded public places, for example at carnivals or festivals. As one boy said: “I went to a fair and when the lights went off during load shedding, I pressed girls’ breasts and buttock.” One respondent from the slum admitted that he was involved in a gang rape. The older girls said they had experienced being kicked on their legs, their clothes being
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pulled, and their bottoms being slapped. The girls also said that some of their teachers touched their breasts. Girls mentioned that they had heard stories about when a boy threw acid over a girl who had rejected his love offer. They also mentioned about girls being kidnapped and raped. When boys were asked why they tease the girls, both older and younger boys said they enjoyed doing this and they got ‘pleasure’ out of it. The latter points towards a negative interaction competence between girls and boys, which could be a result of the taboos surrounding youth sexuality, as well as the societal stigmatization of (normal) public interaction between girls and boys. Eve teasing and harassment are used as alternative forms of interaction between the two sexes. Perhaps sexual frustration and peer pressure also motivates boys to act in this manner.
4.6 Suppressing sexual arousal and curiosity
We found only three respondents (2 boys and a girl) out of 237 who mentioned that they had never been involved in any sort of sexual activity whatsoever, including romantic love, having sex, watching or reading erotic videos or texts or masturbating. They mentioned religious reasons for keeping themselves abstinent from these activities. It was also found that they engaged in rituals like reciting verses from the Quran, taking holy baths etc in order to suppress any sexual arousal.
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5 Quality and access of youth friendly services
Another major research question was to find out the factors (physical, social, cultural, economic) that limit or enable the MA’s of IPPF to deliver services that match the realities and needs of young people. In order to address this we explored the issues of quality and access of youth friendly services of Tarar Mela in Jessore.
Data on quality and access of YFS was collected in two phases. During the first phase this issue was explored with the general youth during the FGDs, and in the second phase individual interviews were conducted with the YFS clients, as well as observations within the YFS centre. Additionally the issue of quality and access were also explored from the perspectives of the service providers.
5.1 Enabling factors to access Tarar Mela from young people’s perspective
Tarar Mela provides two kinds of services; one is health related, and includes counselling, family planning, vaccinations, blood tests and referrals for various health conditions. The other is non health services, which includes a library, computers, music lessons, dance lessons, games and TV facilities. Aspects of both types of services were mentioned by the young people as encouraging or discouraging them from visiting Tarar Mela. First we will present the enabling factors, which will be followed by the limiting factors.
The respondents mentioned that most of the boys and girls visit Tarar Mela mainly for non health services, and to spend their free leisure time. A number of boys and girls said that they come to the YFS centre to take different lessons e.g. computers, music and dance, they also watch TV, read newspapers and books, listen to music and chat with friends. Only some girls, both older and younger, mentioned that they felt encouraged to come here because they found the environment friendly, and they could spend their leisure time in a nice, friendly, clean air conditioned environment, and they could talk freely with the female counsellor. Having a separate room for girls was also considered an enabling factor. For the older boys the majority comes for computer lessons and to spend their leisure time, and some come here to get free contraceptives. Young boys come to Tarar Mela to play games which they do not have at home like carom board, chess etc. Because of the clients’ financial background, many families probably cannot afford to buy an ‘expensive’ toy for their children. The library is popular amongst both boys and girls.
We observed that the health related services which are the main focus of the YFS are relatively underutilized. However, amongst the health services counselling was found to be relatively popular. Both boys and girls mentioned their positive experiences of counselling at Tarar Mela. We further explored the issues that young people seek counselling for, and our participant observation showed that boys mainly come for counselling concerning wet dreams, masturbation, use of condoms, STDs, and HIV/AIDS, and to get contraceptives. Only one came with a problem with his penis size. Among the girl clients the common issues for counselling were menstruation, Emergency Contraceptive Pill (ECP), white discharge, Tetanus vaccination, information about Urinary Tract Infections (UTIs), blood group tests, family planning methods, use of condoms. Only one married girl came with a question of lack of sex power etc. However, observation of the counselling sessions also revealed that although the counsellors show positive and non-judgmental attitudes towards the young people, they are not equipped to respond to many questions posed by their clients. It was also found that the questions
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dropped in the question box kept in Tarar Mela matched with the curiosities that were expressed by the young people during our FGDs and individual interviews. Many of these questions demanded the provision of accurate and complete information, however such information was not provided by Tarar Mela or during counselling. Although the counsellors were not always able to provide the required information, they maintained a friendly and non-judgmental attitude towards the young people.
The boys had generally heard about Tarar Mela from someone of their own age who had visited the centre before. Most of the boys did not tell their parents that they were spending time in Tarar Mela, as they feared that their parents might forbid them from going there. Most of the girls said that they informed their parents that they were coming to Tarar Mela and their parents did not prevent them from coming. Only a few come without their parents' consent.
5.2 Limiting factors to access Tarar Mela from young peoples’ perspective
Many young people mentioned that the activities of Tarar Mela are not properly known by the community. Most of the respondents in FGDs identified the unfamiliarity of Tarar Mela as the main reason for not utilizing its services. After completion of FGDs with 237 boys and girls in the first phase of the research, we realised that amongst the 125 female respondents of FGD, only 51 (41 %) of the girls visit it regularly. Sixty eight girls (54 %) had never heard of Tarar Mela and the rest had heard of it but never came to the YFS centre. Among the 112 boys, only 56 (50 %) have visited Tarar Mela, 52 (46 %) had never heard of it and the rest had heard of it but never came to the YFS centre. Through the FGDs the young researchers found that many boys and girls did not come to Tarar Mela because they were not aware of its services.
Amongst those who had visited the YFS centre many mentioned that they were discouraged from visiting it, as the space is too narrow, which makes it overcrowded. The girls specifically mentioned that as they needed to pass the boys' room to enter the YFS centre, they felt discouraged. Our observation data shows that girls were eve-teased while passing through the boys' room. Because of the crowd there are lots of interruptions during counselling sessions. In one room they have a computer, TV, reading space, games, question box, music, newspapers and a washroom. Too much noise is a problem, and the privacy of counselling services is hampered due to disruptions by others. Having multiple activities in one room hampers the quality of the service provision. We also observed that the limited facilities has resulted in boys dominating usage of most of the computers.
The clients, particularly the girls, expressed their dissatisfaction with the fact that YFS do not provide any legal support or advice for clients, and available services in this regard are limited. The girls wanted services in cases of rape, harassment, eve-teasing, marital or love relationship related abuse or force, sexual abuse and so on.
Although counselling is one of the more popular services of Tarar Mela, young people complained that sometimes the counsellors fail to respond to their queries, and they also complained that as the counsellors are very busy they often need to wait a long time to meet them. We observed that the counsellors are responsible for many tasks. They do library management, computer teaching, training, providing newspapers, providing orientation to the newcomers, overall management of the YFS, keeping the centre tidy, monthly report preparations, referring clients to the clinic, and so on. As a result they do
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not have enough time for counselling and the clients have to wait a long time for their service.
The clients also mentioned that the equipment in the YFS centre, for example computers, games, IEC materials, TV sets etc. is not adequate for the number of visitors. They do not have enough books to meet their needs; although they have many religious books, they do not have many books of other kinds, particularly books relating to the SRHR.
The fact that Tarar Mela refers its clients to FPAB also discourages many young people from using the YFS centre. The boys and girls stated that they felt embarrassed to discuss their problems with the adult FPAB doctors and paramedics, who they felt are not friendly to young people and can be judgmental. For many clients, only being able to get a prescription from Tarar Mela, and not being able to get the medicine itself, is an obstacle to coming into the YFS centre. In particular, if an unmarried STD patient just gets a prescription, it is hard for him or her to then go to a pharmacy and ask for this type of medicine. The clients feel that a separate paramedic for Tarar Mela and a supply of medicine from the YFS centre would serve them better.
The location of the YFS centre itself is a problem for some of the youth. The YFS centre is located in the same premises as FPAB, and historically the reputation of FPAB, as a family planning clinic, is stigmatized in the society. Youths are scared of their family members, worrying that adults would question them about their visits to FPAB. As YFS centre and FPAB have the same entrance, both groups will see each other. Moreover, the adult visitors to FPAB sometimes wait in the corridor of the YFS centre entrance. The young people imagine that if their adult family members, neighbours or any adults in general from the community find them at the YFS centre they might think that the young persons have come for the family planning services, which will be viewed very negatively, as they are not supposed to be sexually active. Also the youth are afraid of the fact that word spreads quick in a small district town namely Jessore concerning youth sexuality, particularly with girls.
Some clients mentioned that some staff from Tarar Mela are unfriendly to the youth visitors. Further probing confirmed that these staff are actually from FPAB. Others mentioned that the approach is not tailored to young people. Some mentioned that there is an age difference between the clients and the staff, for example they would like the paramedic to be younger than the current ones. It was said that the guard and old aya (female service staff), who welcome the youth at the entrance of the YFS centre, are not friendly to anyone. They do not take the youth clients seriously. As one said: “I have to face the non smiley guard and the rough behaved aya to register. Only after that I get a nice behaved counsellor.” Another concern made by the young female clients of Tarar Mela is about some FPAB male adult staff who sit and watch TV in the air conditioning room of Tarar Mela in their free time. The young girls do not feel comfortable to come to Tarar Mela in their presence.
The young people who come to Tarar Mela are concerned about the confidentiality of their visit and any other information that they share. They particularly mentioned about the registration process, which is not anonymous. They have to register at least twice, and if counselling is involved then they are required to register 3 times. By doing so they end up providing information about their name, father's name, address, class, age, signature, cell no., and home address.
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Some of the younger boys mentioned that they did not visit Tarar Mela because their parents discouraged them from doing so. They noted that as Tarar Mela talks about sexuality issues and kids can get contraceptives for free from there, parents are not in favour of the YFS centre. This point shows the lack of information parents have about sexuality education, and the services provided by Tarar Mela.
More girls than boys mentioned the unfavourable opening times of the YFS centre. Some girls said that if they wanted to come to Tarar Mela then they would have to be absent from school. The girls specifically mentioned that the YFS centre was too far away for them and the transport cost was not affordable for them. Although this was not a problem for the boys, the girls mentioned that because they could not find anyone to accompany them they are unable to come to the YFS centre. A girls walking alone is not culturally appropriate. One older girl mentioned that she felt discouraged from coming to the YFS centre as she was scared of the watch dog at the door of the YFS centre. Like the boys, some girls mentioned that their parents did not encourage them to come to the YFS centre because discussions around sexuality take place here. They said that sometimes parents think girls are using Tarar Mela as an excuse to do something else, meaning to hang around with the boys. One older girl said she couldn’t get an answer to her query when she asked the counsellor of Tara Mela. As she put it: “I asked the female counsellor how do lesbians have sex but she couldn’t answer.”
5.3 Limiting factors to providing youth friendly services from a provider's perspective
The providers of Tarar Mela mentioned a number of factors that they think discourage clients from visiting Tarar Mela or hamper quality service provision. The providers think that the unavailability of medicine discourages clients from visiting the YFS centre; as the clients cannot afford to buy medicine themselves, just being given a free prescription does not help them much. This was expressed by the clients as well. Moreover, the YFS centre cannot provide a one stop service, and as a result the clients need to visit other places for services like ultrasound scans, X-rays etc. There is also a problem regarding the catchment area of the YFS centre; this is limited to 5 km, so the young people out of this range are not encouraged to attend the YFS centre. The providers mentioned that not having extensive collaboration and partnerships with stakeholders like school teachers, parents, and community leaders also affects the quality of service at the YFS centre.
The providers also mentioned that there are several underlying organizational and structural obstacles that hamper access and quality of the YFS centre. Such as bureaucracy, budgets, salaries, motivation, monitoring & evaluation, and structural feedback on functional performance of staff. The low salaries was mentioned primarily by almost all of the staff members Supervisors said that it was hard to motivate their staff to work hard for such a low salary. Lack of training came as the second highest organizational limitation for quality YFS. None of the staff who are related to YFS, including physicians, peer educators, youth organisers and program management committee members have received any training. Only youth counsellors received training: one training course of 5 days on value clarification and one on counselling. From the interviews it was clear that the staff did not have any basic training on issues like gender sensitivity and youth friendliness. It was also stated by the providers that the mid level and lower level staff did not receive enough appreciation from their superiors. Two staff mentioned that staying away from home for too long demoralized them,
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making it difficult for them to provide proper service. They could not bring their families from outside Jessore because they would not be able to meet the needs of the family with such low salaries. All of the providers mentioned that they were overburdened with work, and all of them had to carry out many tasks in the course of their jobs. Along with these factors, too much bureaucracy within the organization was considered another obstacle to providing quality service. The budget constraints of SALIN+ and FPAB in general were also mentioned.
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6 Stakeholder workshops
At the end of the first and second data collection phases, workshops were organised with stakeholders from the community and FPAB staff from the branch office in Jessore and representatives from FPAB Headquarters in Dhaka. The aim of the workshops was to present and verify with the adult stakeholders the research findings. The participants were encouraged to discuss about the issues and formulate recommendations together.
In the first phase workshop with the civil society members, the activities of FPAB and Tarar Mela were presented and then a detailed presentation was given of the sexuality research. The stakeholder members were warm and enthusiastic about the workshop. They all acknowledged the importance of the issues and the need for discussion. As one participant said: “Concerns about sexuality issues among our youth have been going on for ages. But this is the first time it is shown as a research finding. I believe this is a very timely approach to address sexuality issues.” For everyone this was the first time they had talked about sexuality in a formal setting. As one of the attendees said: “This is a very good attempt. I read about sexuality issues when I was very young. Today, after 30 long years, this is the second time I’m hearing a discussion on sexuality issues or speaking about it myself.”
The stakeholders mentioned that although they do not discuss these issues publicly, they very much agree with the research findings presented to them about the young people’s sexuality in Jessore. However, some raised concerns about the age of the informants, as they thought 12 years old was too early to discuss sexuality. However after a debate with the young researchers most of the participants agreed that it is wise to start discussions from the age of 12. As one member said: “12-18 years is perfect as the target group as this is the most important time of life to learn new things.” The participants acknowledged that it was time to be tolerant regarding romantic love between young people, as well as to make them aware of the consequences of ‘bad’ romantic love.
The participants enthusiastically supported the idea of arranging sex education sessions for both boys and girls. They mentioned that this was particularly important for boys, as they have more freedom than girls and they misuse it. This idea was supported by school teachers who were willing to work together with FPAB to develop a more comprehensive sexuality education curriculum in their schools. The participants also highlighted that it would be important to have training sessions with parents, as they also have many misconceptions and do not know how to communicate with their children about sexual issues. They suggested it would be helpful to involve religious leaders and other opinion leaders of the society in this process. The participants however emphasized that we should be careful about providing information about sex, as we should not make sex too open, as this would hamper their traditional values. They also mentioned the risk of AIDS. All the participants of the workshop mentioned that they were willing to provide support to FPAB concerning this programme. In this regard the workshop succeeded in opening the dialogue on youth sexuality issues between FPAB staff, community members and young people.
The results of the research were also presented to the FPAB staff in another workshop. The staff members said that the findings very much matched their own everyday experiences in the field. They said that when they went to the village the boys and girls expressed the same curiosities as those presented in the workshop. This helped verify the findings of our research, which was one of the objectives of the stakeholder workshops. They also mentioned that in their field experience they had heard of and seen
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the issues around sexuality that had been presented. Conducting field activities around sexuality issues in the community is problematic for FPAB staff, as they face challenges and resistance from elderly people and parents. The staff said they usually did not tell the parents that sexuality issues were discussed in Tarar Mela as they thought they would prevent their children from attending there. Which is a serious constraint to the quality and access of services provided by Tarar Mela, it also creates an ambient of secrecy surrounding the services, while the objectives of the SALIN+ project are exactly the opposite: i.e. to enhance and improve both the quality and access of YFS in the region. The FPAB staff members highlighted the importance of educating and sensitising parents and other important adults in the community, including religious leaders. The FPAB staff made specific suggestions for improving the services of Tarar Mela; these are mentioned in the recommendation section below.
The third workshop at Jessore was attended by both local FPAB staff and two members from FPAB head office (head-youth program focal point and head- M&E ), as well as civil society members. The workshop mainly looked at the limitations in access and quality of Tarar Mela, learned from the second phase of data collection. This was done primarily to get recommendations for improvement. The participants came up with a number of recommendations which will be presented later in this report. However, the fact that the negative factors of FPAB were discussed in front of the civil society members was not appreciated by the staff of FPAB, and tension emerged in the workshop. This was resolved through discussion. However it was an important learning point for us on how to go about discussing sensitive issues with stakeholders from different backgrounds. The Dhaka workshop comprised of NHQ staff members; the director general, the youth officer, M&E officer, as well as local staff members from Jessore (a doctor and paramedic, the SALIN+ coordinator), a research scientists from Dhaka university, representatives from different NGOs, and representatives from ARO and IPPF CO. The results of the research were well received by these participants. Project management staff from the headquarters rightly pointed out that, despite the limiting factors, it is a great achievement that young people are now coming to the services while before they did not. However, the concern was raised that if publicity about and access to Tarar Mela would increase, this might have negative consequences for the quality of the services due to limited staff and project funding (SALIN+) to close by 2010. However, the IPPF representative highlighted that they were keen to improve the SALIN+ project, and that based on these findings FPAB can try to extend SALIN+ in 2011 to 2015, with IPPF’s support. Headquarter staff of FPAB also commented positively on the new insights that were provided by the research, as the M&E activities that monitor the SALIN project generate only quantitative data that does not provide insight into the limitations of service provision and into youth sexuality issues.
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7 Research process
We found that the research process contributed to building skills in qualitative research amongst the youth and to exploring new forms of partnerships between young researchers, M.A. staff and community stakeholders. It also helped to increase the self- reflection of M.A.’s on the influence of the norms, values, opinions, knowledge, skills and attitudes of staff on the quality of their services to young people.
As mentioned earlier, the data collection and preliminary analyses were carried out by young researchers recruited from the local community. They were all involved with FPAB either in the capacity of peer educators or PMC members. Two weeks of intensive training on the research project were provided at the beginning by Rutgers WPF. The training included information on the theories underlying the research themes as well as on qualitative methodology (for more details see Rutgers WPF training report) .
Although there were doubts about whether these young activists could become researchers in such a short period, our experience shows that they very successfully transformed themselves through the research process and developed critical research minds. They successfully collected and organized the data. The initial two weeks of training helped them to prepare their mindsets, and equipped them for research. Later on some sessions were arranged to practice various research methods. During data collection every morning and evening an instruction and a feedback session were conducted with the youth researchers and local research coordinator (supervisor) and assistant. In the evening session the youth researchers would share their experiences from the day in terms of new information, difficulties, and differences between the groups of respondents and so on. In the morning session the local researcher gave positive feedback on and limitations of their previous day’s work. One person’s mistakes or excellent work, for instance using an entry point or a probing interview technique, were used as examples for others. The two daily sessions were useful for the researchers, as they gave them a critical orientation towards the research project. All these activities were arranged by the l research coordinator.
The team was very motivated, hardworking and enthusiastic. Working in a team proved to be very useful, as they used each others' skills through mutual cooperation. There was a positive competition between the male and female researchers. The proximity of age between the researchers and the respondents proved to be very advantageous as it encouraged the respondents to open up more. Having a link with FPAB gave the young researchers confidence and an atmosphere of working in an organisational set-up. The researchers were creative in building rapport and generating data.
However, there were also challenges in dealing with this young group. It was observed that although they quickly developed research skills they were not equipped enough to work independently and needed constant supervision. This is an understandable limitation, and could only be overcome through long term engagement with such research activity. The researchers lacked skill in certain aspects of the research, namely note taking and transcribing. We also experienced tension developing between the selected and non-selected peer members of SALIN+. As only a few of the FPAB peer members were selected to be researchers, the rest felt deprived. As researchers the selected ones also earned more money, which made the rest jealous. This affected the first workshop with the FPAB staff members. During the session the young staff that were not selected ones did not cooperate in the discussion, and thus the workshop was not as useful as it could have been. It was revealed later on that they had done this
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purposefully. This tension was neutralised during the second phase through an open discussion with the research coordinator.
Interview and FGD facilitation skills also remained a problem. The female researchers were shy, while the male researchers were dominated by the respondents during the interview sessions. Sometimes during the interviews it was difficult for the researchers to withhold their own views regarding premarital sexuality. The researchers also mentioned that they sometimes felt overworked and exhausted.
Although there was positive competition between the boys' and girls' teams, there were also personality clashes between the team members, probably partly because of overwork, job challenges, and being away from their families for long periods of time. The research coordinator had to intervene when there were personal problems and gave regular counselling to the team members in the evenings. Sometimes if these matters were ‘not very serious’ according to them, they would go to the research assistant to solve the problem. The research coordinator used to go for evening walks in rotation with each of the team members separately, this was a time for them to share their personal problems if they had any. During the weekends the coordinator sometimes used to take the team for a walk along the lake side as a team building event, where they would interact more with each other in a personal manner. Almost half of the team members could sing songs, and in their break times they used to sing, or sometimes if they were too tired they would take a five minute music break. It was found that giving them a music break encouraged them in their work. Overall the process helped young people to develop skills, confidence and a sense of responsibility. For information on the perspectives of the young researchers on participation in this research project, see upcoming Rutgers WPF report on youth participation in research.
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8 Ethics
Through the training process researchers were made sensitive to ethical aspects of the research. They were required to recite an oath at the end of the training on maintaining ethical conduct, during the data collection period. This helped the YRs to understand the value of maintaining ethics not only in their research but also in their everyday life. There was no policing system to keep the team honest about their data or behaviour, but the very word ‘ethics’ itself worked as a gatekeeper for them. The word ethics became an everyday part of their life during the research period. The team never faced any serious ethical issues during this study. There were a few occasions when some of them made minor breaches in ethical conduct, for example taking pictures of the respondents without seeking permission. However, as they mostly worked in a group the others immediately corrected the person concerned by just saying “Watch ethics”. ‘Watch ethics’ became a popular phrase for all the young researchers during the data collection period. Overall the young researchers proved to be very promising, and the experience of working with them was an extremely positive one.
The research also gave the young researchers the opportunity to interact closely with various stakeholders in the community. During the workshops with stakeholders the young researchers presented the findings of the research, as well as the obstacles to Tarar Mela, in terms of access and quality. This gave the young researchers the opportunity to practice public speaking as well as to talk about their own work with a wider audience. These workshops helped to form partnerships between the young researchers, M.A. staff and community stakeholders. They also helped to increase the self-reflection of M.A.’s on the influence of norms, values, opinions, knowledge, skills and attitudes of staff on the quality of their services to young people.
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9 Analysis of key findings
9.1 Introduction
FPAB staff mentioned that more young people are visiting the YFS now compared to a few years ago, before the establishment of the Tarar Mela. However, the research team observed that the services provided for young people were under-utilized by adolescents and that the centre was not used to its full potential. The Tarar Mela, which provides information, contraceptives and recreational activities, attracts some young people, but not from those groups who are most under-served (e.g. those living in slum and rural areas, unmarried girls). From the services provided in the Jessore branch, the counselling services provided by the youth counsellors were relatively popular. However, uptake of other (medical) services by adolescents was limited.
The research was conducted in order to investigate why the uptake is low and to formulate recommendations that could help to increase the uptake. The aim was to gain insight into the sexuality-related concerns and behaviour of adolescents in Jessore, as well as assessing whether the activities and youth friendly services at the ‘Tarar Mela’ match the adolescents’ needs in this regard. This chapter will formulate answers to the four research questions that were raised in chapter one:
. What are primary sexuality related concerns for adolescents and what causes these concerns? . Are the services that the M.A. is offering relevant for adolescents? . What factors limit or enable adolescents to use the youth friendly services that the MA is offering? . What factors limit or enable the M.A. to deliver services that match the realities and needs of young people and serve their wellbeing?
The analysis will first look at the primary concerns relating to sexuality that were found and will interpret what these mean in terms of (violations of) sexual rights of young people. Then, by analysing factors that influence need and demand, the following question will be answered: Are the services that the M.A. is offering relevant for adolescents?
The analysis will continue by looking at the key factors that limit or enable adolescents to use the YFS in terms of awareness, access and quality. It will also analyse the key factors that influence FPAB’s ability to deliver services in Jessore to the best of their ability. As such, this chapter follows the outline of the analytical framework as presented in box 1 in the first chapter of this report.
The report will finish with some main points for discussion and suggestions for priority recommendations for SRHR promotion and service provision for adolescents and young people, Chapter 10.
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9.2 Analysis of primary concerns relating to adolescents’ sexuality in Bangladesh
9.2.1 Sexual taboo and inadequate information leading to misconceptions and fear During the study, it was noted that a serious threat to the sexual well-being of the adolescents was their fears and insecurities regarding their sexuality and sexual activities, in particular relating to menstruation, masturbation, wet dreams and size and shape of sexual organs. Fears and insecurities were mainly related to getting diseases or disabilities, losing virginity, fertility and/or sexual power.
Many of these fears and insecurities were caused by misconceptions, which result from a lack of accurate and complete information. This can be seen as a direct result of social taboos relating to the sexuality of unmarried young people in Bangladesh. As a result, adolescents turn to peers, pornographic material, street hawkers and herbalists to satisfy their curiosities and to look for information and help. The information they receive from these sources is often limited and inaccurate. Concerns about getting diseases or disabilities relating to menstruation, wet dreams and masturbation are also related to local explanatory models (see Chapter 1) for health and diseases.
As a consequence, girls feel afraid when they first start to menstruate, boys and girls feel afraid and guilty when getting aroused or masturbating and boys and girls feel insecure about their sexual organs and ability to sexually perform and have children in the future. These feelings negatively impact on adolescents’ self image and sexual wellbeing and can have a negative impact on their sexual development and future sexual functioning.
In terms of adolescents’ sexual rights, sexual taboo and inadequate information leading to misconceptions and fears, this is a violation of the right to education and information.
9.2.2 Social restrictions to freedom of choice regarding romantic and sexual relationships In Bangladesh strong social-religious norms oppose pre-marital sex. This is particularly enforced through the pressure placed on girls to preserve their virginity until marriage. The result is social stigmatisation and punishment by family or community for getting involved in any pre-marital romantic or sexual relationship. A history of pre-marital romantic or sexual relationships can also jeopardise the reputation of girls' families, spoil the girls' future prospects for marriage and makes them vulnerable to abuse and violence. A Bangladeshi girl’s value and identity seem to depend, to a large extent, on the social status of her (future) husband. This is enforced through the dowry system whereby the girls’ families have to pay money or goods to the family of the husband. Because of this cultural system, families have high stakes in who their son or daughter marries, resulting in arranged and forced marriages and the regulation of boys’ and girls’ interactions. This regulation takes place especially by restricting girls’ mobility.
As a result girls are very anxious about not bleeding on their nuptial night or creating the impression that they are involved with boys. Both boys and girls fear stigma and punishment by their family or wider community for getting involved in any romantic or sexual relationship. But despite this fear many adolescents express their interest and longing for romantic and sexual relationships and engage in various kinds of romantic and sometimes sexual interactions. However, social control severely limits boys and girls space for interaction and dating, and when it happens it has to take place in secret. The research data indicates that adolescents with less parental supervision and relatively
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more freedom, like those in boarding schools and living in slum areas, are more involved in sexual activities and this seems to be true more so for boys than for girls. But adolescents from all types of backgrounds expressed the fear of being caught, punished, or stigmatized. They were also concerned for their own and their family’s reputations and loss of marital opportunities due to prior relationships. They also expressed fear of arranged and forced marriage to someone not loved and of losing a romantic partner of their own choice because of parental refusal.
In terms of adolescents’ sexual rights, forced marriage and the social restrictions to freedom of choice regarding romantic and sexual relationships, this is a violation of the right to privacy, the freedom to choose a (sexual) partner, to marry and reproduce, to freedom of thought, opinion and expression and to the right to association.
9.2.3 Discrimination, harassment and forced sexual experiences among girls Because of the cultural segregation of boys and girls there is a lack of space for normal interaction between them. When boys and girls meet outside the control of adults, the situation automatically is interpreted as sexual. Many boys respond to this by making sexual remarks, while girls become shy and fear to be seen and punished for the interaction. The research shows how common ‘eve-teasing’ of girls by boys is and how widespread girls’ experiences of harassment are. Sometimes this harassment exacerbates in force and violence, including rape and acid-throwing, something especially slum girls were very anxious about.
Gender and peer norms among boys seem to encourage harassment as a form of showing masculinity. At the same time, gender norms for girls dictate shyness, inferiority and inhibition. Regulation of pre-marital sexuality takes place predominantly through regulating girls’ sexuality. As a result, girls have to wear conservative clothing and avoid boys. If girls get harassed or forced into unwanted sexual experiences society tends to blame girls for this, making it very hard for girls to report on sexual violence.
Forced marriage and the limited space for dating and developing non-sexual intimacy between boys and girls also have consequences for the quality and character of (future) relationships between boys and girls and how sex and sexuality are experienced. Sex can be experienced by women as a social service for men or a marital obligation. Remarks like “my body is the property of my husband (to be)”, illustrate this. Men consequently can see sex as their right, something women cannot refuse. For both women and men, male pleasure is then the central concern and male extramarital sexual relationships are interpreted as the failure of the wife to please her husband.
In terms of Adolescents’ Sexual Rights, discrimination, harassment and forced sexual experiences among girls are a violation of the right to equality, personal autonomy, to life, liberty, security of personal and bodily integrity.
9.3 Need and demand: Are the services that the MA is offering relevant for adolescents?
The data on adolescent sexuality and sexual behaviour indicates that, in general, sexual activity (intercourse) among the adolescents in this study is relatively low, especially among girls. Consequently, the need and demand for services related to contraceptives, STI’s and pregnancy are relatively low. It is however important to recognize the
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differences between boys and girls and between adolescents from different backgrounds: their experiences and needs are diverse. The study shows that certain groups like sex- workers and male adolescents from slum areas form an exception and have more need for these services.
However, the majority of adolescents (12-18) in this study were in need of “non-medical” SRH services and needed support to cope with the issues described above. In particular there seems to be a high need for correct and complete information and for counteracting the widespread misconceptions relating to menstruation, masturbation, virginity and size and shape of sexual organs. There is also a high need for support and counselling services pertaining to issues of gender-based and sexual violence, like forced marriage, stigmatization, harassment and forced sexual experiences.
Although the YFS, through Tarar Mela, the youth counsellors and the youth volunteers attempt to address some of these needs and demands, they only serve a small proportion of the adolescents in need of these services. There are three important aspects to be considered as to why YFS providers are limited in adequately addressing these needs and demands. One aspect relates to key factors that limit or enable adolescents to use the YFS in terms of awareness, access and quality; this will be discussed in paragraph 9.3. Another aspect relates to the conservative socio-cultural norms that are at the root of causing the sexuality-related concerns of adolescent’s. The third aspect has to do with the formation of motivation of adolescents to use the services, which will be analysed in the sections below.
9.3.1. Socio-cultural norms as underlying cause of the violation of adolescents’ sexual health, rights and wellbeing Many of the primary concerns relating to sexuality as experienced by the adolescents in this study result from deeply-rooted cultural and religious norms relating to gender and sexuality. In order to address adolescents’ primary concerns in relation to sexuality, it is necessary to deal with the taboo that prevents adolescents from accessing correct information, the gender inequality that discriminate against girls, including the dowry system and gender norms relating to masculinity and femininity that dictate virginity and lead to harassment and force. In order for boys, girls, men and women in Bangladesh to enjoy their sexual rights and wellbeing, there is a need for social change regarding these norms and regulations. The complex and difficult question that then arises is: to what extent can youth friendly services address these harmful gender norms and detrimental taboos and, importantly, should it be their task to do so?
Traditionally, FPAB and many of IPPF’s MA’s have had a strong focus on family planning. Although the focus has shifted in more recent times so as to include young people as a target group and to promote a more comprehensive approach that includes a focus on prevention, provision of information and behaviour change, much of the focus remains health- and treatment-oriented.
If youth friendly services are to responsively meet the needs of adolescents, services will have to be further expanded beyond physical health. Misconceptions that lead to fear and insecurities will have to be actively counteracted and more support and counselling related to issues of gender-based and sexual violence as well as forced marriage, stigmatization, harassment and forced sexual experiences will have to be provided.
In addition to offering care and treatment, there is a strong need to address societal and gender norms that violate sexual rights and harm adolescents’ sexual well-being and
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development. This means that YFS should be more firmly integrated into a wider approach whereby staff and volunteers engage more with important community institutions and the public to effectuate social change. In addition more focus and activities need to go to empowering and sensitizing boys and girls to recognize and respect their own and other persons’ wishes and boundaries relating to sex and sexuality. More concrete recommendations follow in the next chapter.
9.3.2 Motivation to use YFS and perception of efficacy As explained in Chapter 1, demand is influenced by the perceptions adolescents have about the efficacy of the services provided as well as the other options that are available to them for coping with their sexuality-related concerns.
Looking at the concerns that were described above, e.g. the social restrictions to freedom of choice regarding romantic and sexual relationships and sexual harassment and violence, adolescents most likely do not perceive YFS as a place to go for solving or helping them with these problems. In addition, most of the issues are probably not perceived as acute, or at least do not outweigh the risks or barriers of going to YFS. In addition, adolescents access alternative sources to try to solve their problems relating to curiosity, fears and insecurities regarding bodily sexual functioning:
- Street hawkers are a very popular source of information relating to fears and insecurities about sexual organs, sexual power and weakness through masturbation, especially for boys. For girls it is less acceptable to visit street hawkers, but herbalists who go from door to door seem to be able to reach girls with similar information and treatments for their most important fears and insecurities. Street hawkers and herbalists are popular because they are able to responsively tend to adolescent (and adult) insecurities and fears (and partly create and maintain them).
- Media sources like internet and magazines are an important source of information for boys and girls, answering to their demand for information, their curiosity and their desire to experience sexual arousal and excitement.
- Peers and (married) older siblings, cousins or sister/brother in laws are often the first persons that are consulted in cases of problems or inquiries.
To increase uptake of services by adolescents, YFS have to compete with these alternative options, and/or copy strategies that make these options successful. There is also a need to improve perceptions amongst adolescents that YFS can help them with their issues.
9.4 Awareness, Access and Quality: Analysis of key factors that limit and enable adolescents to use the YFS
In addition to the factors relating to needs and demands that influence adolescents’ uptake of services, there are also factors relating to awareness of, access to and quality of services that need to be addressed. Below follows a summary of the main factors that influence the use of FPAB’s YFS in Jessore that were mentioned by adolescents and adults during this research and a reflection on the successfulness of current strategies that Tarar Mela deploys to increase access and quality.
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9.4.1 Factors relating to awareness In order to take up services those who are in need of them need to be aware of the existence of the services. It seems that unawareness of Tarar Mela is one of the main reasons for not utilizing the services. It was observed during the research that in general YFS mainly attract young people from the nearby community. Many of the adolescents who lived in the slums and rural areas, or a bit further away from the centre, were unaware of its existence. Advertisement and active encouragement of young people to visit the centre was insufficient outside the official catchment area of 5 km from the YFS centre.
9.4.2 Factors relating to access One of the most significant barriers for adolescents in accessing the services is the strong social stigma connected to the services. The services are perceived by the community as a place where only sexually-active people go. Therefore, adolescents fear what adults, including adults present at the branch, will think of their presence at the YFS and that the word will spread. Parents and other adults discourage their children to go to YFS even for recreational activities or Peer Education activities. Related to this fear of stigma is the lack of confidence that some adolescents expressed relating to confidentiality and the problem many of them have with the registration system.
To attract adolescents to the centre, Tarar Mela offers recreational facilities. It is, however, too early to evaluate the effectiveness of the recreational facilities in Jessore. Our impression is that it mainly attracts the youth living in the surroundings of the facility and those working as volunteers for FPAB, and less the underserved groups of young people. Furthermore, boys seem to dominate the facilities. On the other hand, the recreational facilities might provide youth a socially acceptable ‘excuse’ to visit the YFS and meanwhile access contraceptives, information and counselling. The youth counsellors’ involvement in recreational activities and presence at the facilities help young people to get to know them and might contribute to their approachability.
Physically accessing the youth friendly centre is another major problem for many adolescents who live further away from the centre. Many cannot afford the transportation costs involved in travelling to the centre. Because of the social stigma, many adolescents have to visit secretly. Finding time and money to get to the centre is therefore also more difficult. In addition, the opening times were said to be unfavourable for some adolescents. Outreach seems to help counter this barrier for some people, but the likelihood of being seen accessing services is even greater if it is within one’s own community. In these cases, social stigma can be experienced even more strongly by young people accessing services.
Barriers of social stigma and physical access are stronger for girls. Because of social restrictions on girls’ mobility, they are not allowed to walk alone. They need to be accompanied, which forms an additional barrier to access YFS.
For the uptake of services by adolescents to increase, it is necessary to find ways to de- stigmatize the services and/or to find ways to provide services for adolescents in a very private and safe setting away from adult judgement.
9.4.3 Factors relating to quality Since the start of the Tarar Mela project, more young people are coming to the branch and those who come generally value the services offered by the youth counsellors and the recreational activities. Working with young male and female youth counsellors makes
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adolescents feel more comfortable when coming to the YFS with questions or problems. Key in this is the positive and non-judgemental attitudes of the youth counsellors and their involvement in recreational activities of TM. The counsellors are empathetic to young people’s issues, but their level of knowledge is limited. Investment in extra trainings and in good resource materials where they can look up additional information is strongly recommended, especially regarding the sexuality concerns that are described above (fear, stigma, forced marriage and harassment). In that way, they can also better answer the questions and issues that young people put in the question box. The question box itself seems to be a very useful tool for adolescents to put forward their priority issues and questions in an anonymous way. In addition to putting the answers on the wall, the counsellors could also hold group meetings to discuss the questions and answers. It would be good to document questions and answers to be put (later) in a booklet or on a website.
Although the staff who are directly involved in Tarar Mela are considered youth friendly, not all staff within the branch are considered friendly and non-judgemental by the adolescents. Unfriendly or judgemental personnel and adult service providers to whom adolescents might be referred to for services are considered to discourage young people from using the centre. The registration process is considered to undermine confidentiality. In addition, it was said that sometimes adults make use of the Tarar Mela facilities while this is supposed to be a ‘safe’ environment for young people to freely access information and interact with Tarar Mela staff and volunteers. Presence of adults is threatening this safety.
With regard to the content of the services, adolescents complain about insufficient sources of complete and correct (non-religious) information on SRHR at Tarar Mela, lack of knowledge and ability of youth counsellors to answer all questions, limited access to medication at the centre and insufficient legal protection or referral systems in case of rape, harassment, even teasing, marital or love-relationship related problems.
9.4.4 Organisational factors influencing the delivery of YFS Quality is not only related to resources, skills and values of staff. An important barrier in providing good quality youth friendly services is related to the motivation of staff to provide such services and to pro-actively respond to challenges and opportunities. If staff are overworked, do not feel sufficiently valued, or do not have access to the support and resources to conduct their jobs in a productive and helpful way, there is a risk of demoralization. This needs to be monitored carefully and prevented. At the moment, some staff feel over-burdened and are not motivated to attract more adolescents, and thus work.
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10 Discussion and key recommendations
10.1 Introduction
This chapter discusses the implementations of the research findings that were analysed in the previous chapter. It follows the analytical framework with six categories of influences on the uptake of YFS, as explained in Chapter 1, and applied in Chapter 9:
Box 2: Overview of Analytical Framework
ADOLESCENTS’ PRIMARY CONCERNS RELATING TO SEXUALITY Need: What do they need? Are the services that the MA offer to young people relevant for adolescents; do they match what adolescents need, their primary concerns and realities?
FACTORS INFLUENCING UPTAKE OF YFS Demand: Do they want to use the services? Are adolescents motivated to use the services that are offered? Influenced by experienced needs, perceptions about efficacy, local explanatory models for health and diseases, and alternative options for coping with sexuality related concerns. Awareness: Do they know? If adolescents do not know about the existence of services, that they are there, their location/outreach activities, then they will not make use of them. Access: Can they make use if they want to? Are services able to attract and reach adolescents, are they acceptable and affordable and are they easy and comfortable to use. Quality: Are they satisfied? Do adolescents perceive the services as helpful and relevant and are they happy with how they are treated? Are services respectful of their rights as clients? Support for What do service providers need in order to offer good YFS? Service Sufficient organizational support, management systems and resources and Providers training and motivation of staff in order for them to conduct their jobs in the best possible way.
Per category key barriers were identified and analysed in the previous chapter. This chapter builds on the analysis by presenting key recommendations per category as formulated by the research team and the stakeholders involved in the panel and workshops, as well as by Rutgers WPF and IPPF. Recommendations are formulated for service providers and for programme developers. Some recommendations are very concrete and context-specific, others are more generally applicable. Some barriers are easier to address than others. Especially complex barriers caused by socio-cultural norms are difficult to concretely address. However, we hope that by discussing these here, we can at least create more debate about what needs to be addressed, who is responsible for addressing them, and about our options to contribute to change.
10.2 Need and Demand: Increasing relevance of services by matching adolescents’ primary sexuality concerns
To increase adolescents’ uptake of services, it is important that the services offered to young people match their realities and needs. In this respect, it is important to recognize diversity in experiences and needs among different adolescents and young people of
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different ages, gender and social backgrounds. This means that different strategies and services are needed to reach and serve different groups of adolescents and young people in different contexts. In this respect, it is important to realise the difference between the needs and demands from youth who are sexually active, and those who are not yet sexually active, as well as the difference between those for whom it is socially accepted that they are sexually active (e.g. married) and those of whom it is not. Currently the youth friendly services (YFS) provided by FPAB (Tarar Mela) consist of a part that focuses on the provision of clinical services by adult and youth counsellors and a part that focuses on providing information, mainly through peer educators and materials available at Tarar Mela. The clinical services have a strong focus on treatment and care and emphasize physical health aspects of sexuality and reproduction. This means that those services are regarded as services for sexually active persons, increasing the stigma of those who are younger and/or unmarried and creating a barrier for the latter to make use of the services. On the other hand, YFS also have to be there for adolescents and youth who are NOT sexually active, and offer services that are in line with the specific needs of those youth.
Recommendations for service providers: To reach younger groups who ARE sexually active and have a high vulnerability to unwanted pregnancy, STIs and HIV, it is necessary to: Invest in outreach, medical and contraceptive services for high-risk adolescents, especially those in slum areas and those working as sex workers. It is important that the service providers become more mobile and actively bring their services to places where adolescents can more easily access them. In addition to this, it is important to specify such outreach activities, particularly to target adolescents (see concrete recommendations under access).
To also reach younger groups with relevant services, including those who are NOT (yet) sexually active, it is important to: Expand the clinical services beyond physical health, to include services where adolescents can discuss fears and insecurities and that deal with issues of gender-based and sexual violence, like forced marriage, stigmatization, harassment and forced sexual experiences. It is important that those adolescents and youth receive support from YFS in making informed sexual decisions and that this support is in line with their rights and evolving capacity. It is also important to make sure that adolescents receive non-judgemental counselling on sexual choices and relationships and know that these services exist for them. Ensure access to relevant and accurate sexuality information Currently, the information and educational materials that are available through Tarar Mela are so few and do not provide accurate and complete information on the primary concerns of adolescents. Informants also indicated that the service providers and peer educators were not sufficiently able to answer their questions in clearly.
There is a strong need to develop information materials with complete and accurate information, specifically on the concerns expressed by adolescents in this research and that can help to reduce misconceptions, fears and insecurities. For Bangladesh this means answers to questions about virginity, sexual power and weakness relating to sexual activity and menstruation, forced marriage and sexual violence. A way to make this information accessible to a larger group of adolescents is by actively discussing these concerns on radio programmes and in magazines that are popular with young people. Making use of mobile phones could also be considered for information dissemination. The question box at the YFS is popular: adolescents can anonymously post questions and the
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answers are put on the wall. A similar system could be used but applied to media technology: publish questions and answers in magazines, on the FPAB website, and/or make them downloadable for mobile phones.
Recommendation for programmers: Improve referral systems (increase legal support) and support service providers to expand their counselling services to include counselling on violence and relationship issues, and to provide such sessions for groups as well as individuals. Develop the materials as recommended above and train peer educators, teachers and counsellors to work with these. Make sure these materials are readily available for educators and at the facility and can be handed out during outreach and CSE sessions. Continue to collect information on misconceptions and concerns and add these to IEC materials. (Further) promote a rights-based and positive approach towards sexuality and encourage implementers to broaden their focus from health to wellbeing. Still too little intervention and research activities are paying attention to the social and mental aspects of sexuality that influence self esteem, fulfilment, enjoyment and safety in sex and sexuality. (Further) promote youth participation in research and interventions, as it is crucial in further matching interventions with young people’s realities and needs. Develop and improve management systems to (re-) assess the quality of care of youth-friendly programmes, supportive supervision and ongoing capacity building.
10.2.1 Effectuate social change by addressing socio-cultural norms that violate adolescents’ sexual wellbeing At the moment, the provision of youth friendly services focuses on provision of clinical services and provision of information. However, in order for adolescents to access information and services and to enable them to practice their sexual choices, it is extremely necessary to address deeply rooted cultural and religious norms relating to gender and sexuality that violate young people’s (and adults’) sexual health, rights and wellbeing. Providing services and information is only half the battle, as most young people are not even allowed to access the information or services. Although this is a very difficult and complex challenge, FPAB, including the youth friendly services, have an important role to play in this respect. Like other IPPF MA’s, as an NGO, FPAB is in a unique position to not only fill the gap (where the government is not providing information and services) but to be a force for social change.
Recommendations for service providers: Increase individual empowerment and public discussion on harmful norms and practices Include, as part of the activities at Tarar Mela, peer education and counselling activities that empower girls to communicate their wishes and boundaries and teach boys to empathise and respect wishes and boundaries. The MA could use IPPF’s peer education guidelines (Included, Involved, Inspired) and examples of activities in ‘It’s All One Curriculum’ which have a strong focus on gender and empowerment.
Increase public discussion on the social, cultural and religious norms relating to gender and sexuality that negatively impact on adolescents’ sexual health and wellbeing. Make use of cases that you as service providers see to raise awareness of adults in the communities about the problems that their children are facing and advocate for change. Create understanding among adults of how norms and inequity negatively impacts young people’s health and wellbeing. It is necessary to actively
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engage with the communities about these issues, especially as service providers, as you are taken seriously as professionals. Engage with communities through radio, internet and other media, as these are very relevant tools to reach many people and create public debate. Be proactive and contribute to this public debate, do not leave it up to young people or advocacy officers only, but work together as a team.
Recommendations for programmers: Firmly integrate the YFS with other programmatic aspects like comprehensive sexuality education (CSE), advocacy and community-based activities (including Peer Education and awareness raising). The service provision side of your organisation should not forget they too are part of an NGO. And as an NGO they are not simply filling the gap where governmental agencies should be, they also pursue a wider social aim that promotes positive social change, which demands a more activist stance and public engagement. A closer integration of the YFS with ‘other interventions’ can help to actively address societal and gender norms that violate sexual rights and harm adolescents’ sexual well-being and development. MA staff and volunteers, together with the service providers, can then combine efforts to help with individual cases of abuse, forced marriage, stigmatization, etc. If YFS staff could actively visit schools or activities with out-of-school youth as part of CSE, this may help to actively counteract misconceptions, to increase access to mobile services offered at the spot, to increase awareness of the YFS and to lower the threshold for adolescents to visit the clinic as they will have a better idea of the ‘youth friendliness’ they can expect there.
Increase sharing and learning among staff and volunteers Support youth and adult counsellors and other staff members and volunteers to share and discuss challenges, lessons learned and good practices. Actively support this exchange and enable a learning culture in your organisation. At the moment staff and volunteers feel too vulnerable to discuss challenges as they fear it will be seen as a personal short coming, especially between adults and youth. Yet if closer cooperation, sharing and support can be established, adult staff will be more sensitized towards adolescent issues and younger staff and volunteers could more easily approach adult staff for support in case they ‘get stuck’ in answering young people’s questions.
Increase inter-programmatic learning within your organisation and between MAs Make use of and share examples of good practices from other MAs who manage to successfully address gender and social norms, and cases of early forced marriage, sexual violence, etc. Copy for instance from the Madrasa school project successful activities that lead to postponement of forced marriages. Copy from the MA in Malawi successful community mobilization campaigns to develop by-laws on sexual violence. Copy from the MA in Rwanda successful ways to mobilize youth friendly services and bring them to vulnerable and hard to reach youth. Include sessions on communicating and respecting wishes and boundaries in your programme that address local cultural norms and expectations and that other MA’s have positive experiences with. For instance, include practical sessions whereby boys and girls in role-play learn how to deal with sexual comments and harassment.
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10.3 Awareness of and motivation to use YFS
Unawareness is one of the main reasons for not utilizing the services.
Recommendations for service providers and programmers: Advertise the YFS in a way that specifically targets adolescents, and at places and through media that are popular with adolescents. Provide peer educators with business cards and flyers that explain what YFS offer for adolescents. Advertisement can increase awareness, and can at the same time improve adolescents’ perspectives of FPAB and Tarar Mela as a place where they can bring their problems, if this is made explicit in the advertisement.
Copy “street hawker” strategies that attract young people Currently, adolescents cope with their primary sexuality concerns by going to street hawkers, looking for information on internet or magazines, or asking advice from peers or older siblings. Make more use of the internet, magazines and mobile phone services that are popular with adolescents to bring accurate information on their priority sexuality issues. Clearly young people who are still young, but slightly older and more experienced than the adolescents themselves are respected and accessible sources of information for adolescents, as shown by the popularity of the youth counsellors. Train more youth counsellors and make them mobile. Experiment with ways youth counsellors and peer educators can bring advice to young people in a way that is similar to street hawkers: use drama and humour to attract young people and make them aware of the YFS that FPAB offers.
10.4 Access: De-stigmatize YFS and find alternative acceptable ways to offer information and services to adolescents
Currently, the YFS are not effectively attracting adolescents. It is especially difficult to attract girls and adolescents from underserved groups. The YFS have limited success in providing an environment in which young people are encouraged to communicate their needs relating to sexual health and well-being, with the exception of the counselling sessions of the youth counsellors but other than that the environment is not regarded safe from judgement. There is a clear need to de-stigmatize the YFS, yet it will be very difficult to achieve this in the short term. Therefore, it is necessary to find alternative acceptable ways to offer information and services to adolescents. This could be done by finding environments that are already regarded ‘more safe’ by adolescents or which are easier to make ‘safe’, and to provide services there, for instance environments where adolescents are already present and which adolescents claim as ‘their space’, like schools, cricket fields, certain workplaces and other ‘hang out’ places. There are three strategies that can be used to increase safety from judgment in the areas specified.
Recommendations for service providers: Ensure that no adults are present This means sending away teachers or adult supervisors and making sure no adults can interrupt or overhear what is being said, except perhaps the adult counsellor leading the session. It is important that the adult gatekeeper who has to give permission to use the space understands the importance of creating a safe ‘adolescents-only’ environment.
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Start with more ‘neutral’ activities Drama performance by peer educators can be a good way to open up the discussion about sexual harassment. Such activities are not immediately judged as ‘for sexually active people only’ and provide an entry point for interactive discussions about adolescent priority sexuality issues.
Provide anonymity through the group Interactive discussions can be seen as ‘group counselling sessions’. Adolescents can raise issues or questions in a general way, without revealing anything personal. If necessary, boys and girls groups can be split up. Such group sessions form a very good way to create ‘rapport’ and trust between counsellors and adolescents and an opportunity to create awareness and positive perceptions about the YFS offered by FPAB. As such, the group counselling sessions can serve to lower the threshold to accessing private counselling or medical services. After the group session: provide ‘private counselling’ opportunities whereby it is unclear to others if one goes there only to ask questions, or for counselling, contraception or medical services.
Recommendations for programmers: Strategically combine peer education activities with outreach activities and specifically and uniquely target adolescents There is a clear resemblance to certain peer education activities and outreach activities. But the emphasis here is that the activities should not be limited to information only or services only, but to combine them strategically. An important limitation of peer education is that peer educators cannot answer all questions, cannot offer counselling or medical services, and might find it harder to manage big groups. For peer educators it is often more difficult to get permission from adult gatekeepers to use a certain area to meet. An important limitation of outreach services is that it often does not specifically and uniquely target adolescents only, nor attract adolescents or make it easier for them to access the services without being seen by adults. Therefore it is important to combine elements and team up peer educators, youth and adult counsellors.
Provide peer educators with business cards It was also recommended that if the peer educators could distribute business cards during various sessions it would increase the network of the YFS centre. The peer educators mentioned that if some clients who were present at a particular session wanted to visit the YFS centre after a week or two, they often couldn’t locate the YFS centre. A business card left by the peer educator, containing contact details and a map, could help them to access the YFS centre more easily.
10.5 Quality: Increase ‘safety’ at YFS and invest in skills of staff
Recommendations for service providers: Ensure safety and confidentiality Ensure there are no adults present in the Tarar Mela rooms and that the registration process is confidential. Adolescent clients were insecure about the confidentiality of their visits to Tarar Mela. The registration process should be changed. For example, clients could be given a number rather than using their name. In order to implement this, the organisation would need to develop a numerical client ID system.
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Feel co-responsible for Tarar Mela as part of the FPAB clinic Adult service providers are too distanced from the Tarar Mela and tend to see it as an add-on for youth, and the youth counsellors and volunteers as responsible for dealing with youth issues (see also below). This is partly due to the workload that adult staff are experiencing, which might lead to the perception that the YFS are ‘extra’ work, inhibiting motivation to actively engage with young people and adolescent sexuality issues. However, the quality of the YFS is a responsibility of the adult staff as well and adult service providers should take more responsibility to safeguard this quality.
Recommendations for programmers: Ensure safety and confidentiality Sensitize and train all staff, including guards, cleaners, etc. in being non-judgemental and welcoming to youth. Ensure that a child protection policy is developed and implemented.
Invest in youth counsellors Make use of the popularity of youth counsellors and invest in them. The main problem at the moment is that they are limited in the information, help and solutions they can offer. It is necessary to further professionalize them and to have a functional referral system available at the YFS. Also, consider hiring recently graduated psychology students to train as youth counsellors. Ensure ongoing support and supervision of the youth counsellors is in place but also invest in further increasing the youth friendliness of adult counsellors.
Youth participation Continue to involve adolescents and young people to raise issues that are important to them, so that the information and services continue to be tuned to their needs and realities. Ensure they are being listened to and taken seriously by adult staff.
10.6 Organisational and management factors influencing the delivery of YFS
Recommendations for programmers: Find ways to increase and maintain staff motivation So that they proactively and responsively can change strategies to increase uptake of services by adolescents, based on what they see works or does not work and to make use of opportunities when they arise. For example, during the workshop with community stakeholders at the end of this research project, heads of schools actively asked FPAB and the service providers to come to their schools to discuss issues and offer services. Lack of staff and a heavy workload prevents service providers availing of such opportunities.
Performance-based feedback to staff members The research shows that personal, performance-based feedback can be a key solution to keep staff motivated. The quality of their contribution to youth-adult partnerships should be a theme for assessment (and part of regular M&E) and might help to increase interest from adult staff in the involvement of young people through the PMC, as Peer Educators and Youth Organisers. Teaming up junior and senior counsellors can be very rewarding to both, if there is enough respect, interest and willingness to learn from each other.
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Integrate qualitative assessments of barriers experienced in access and quality in M&E Undertake more qualitative assessments (as integrated part of M&E) on how young clients experience the access and quality of youth friendly services and discuss the outcomes with the specific service providers and youth volunteers to develop action plans to further decrease barriers and improve quality.
Prevent division between adult and youth services Guard against the undesired effect of staff seeing the youth friendly services and youth counsellors as the department that has to deal with youth. This could lead to division between adult and youth services, whereby the youth services are not further professionalised and youth friendly services are not mainstreamed. Most crucial is to increase the commitment of all staff to young people and services for young people. Quality of Care assessment tools and Provide could help to integrate youth friendly services as part of all services in the MA.
Director of programmes should continuously assess and address challenges and obstacles in young people’s way in accessing services: 1. Before young people reach the services: . How to get information to young people about the services. . How to empower them to come to the services. . How to make them trust the services. . How to create social change in the community to accept and promote the services.
2. Once they are in the clinic: . How to ensure that the services are confidential and safe. . How to ensure that there are systems in place to guarantee the quality of the services. . How to ensure supervision and capacity building. . How to integrate the youth friendly services in the overall programme of the MA.
3. After they have left the services: . How to ensure that referral is managed to safe and confidential services. . How to ensure that young people have the possibility to give feedback.
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References AYA/Pathfinder 2003 Youth Friendly Sexual and Reproductive Health Services; An Assessment of Facilities.
Bearinger, L. et al 2007 Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential. Lancet 2007; 369: 1220–31
Bradley, J.E. et al. 2002 Participatory evaluation of reproductive health care quality in developing countries. Social Science and Medicine 55 (2002) 269-282.
IPPF Manuals, guides and tools relating to Quality of Care (QOC) Programme: available at:http://www.ippf.org/en/Resources/Medical/Quality+of+Care+training+manuals .htm 2007 Included, Involved, Inspired. A framework for peer education Programmes 2008a Sexual rights: an IPPF declaration. Published by IPPF London, United Kingdom 2008b Springboard: A hands-on guide to developing effective youth friendly centres 2008c Provide: Strengthening youth friendly services. Published by IPPF London, United Kingdom. 2009 It’s All One Curriculum: Guidelines and Activities for a Unified Approach to Sexuality, Gender, HIV, and Human Rights Education. Published by the Population Council, New York. Available at: http://www.popcouncil.org/publications/books/2010_ItsAllOne.asp 2010 Programmatic Report, SALIN+ Bangladesh
IPPF/WHR (Barroso, C.) 2010 Filling the unmet need for contraception: can we deliver for young women? Source: Reality Check. Available at: http://www.ippfwhr.org/en/news/filling- unmet-need-contraception-can-we-deliver-young-women
Kleinman, A. 1978 Concepts and a model for the comparison of medical systems as cultural systems. Social Science and Medicine, 12(2-B), 85–93.
Nahar, P. 2007 Childlessness in Bangladesh: Suffering and resilience among rural and urban women. University of Amsterdam, The Netherlands. PhD Thesis
Price, M.N., & Hyde, J.S. 2009 When Two Isn’t Better Than One: Predictors of Early Sexual Activity in Adolescents Using a Cumulative Risk Model. Springer Science and Business Media, LLC 2008. In: Journal Youth Adolescence (2009) 38: 1059-1071.
Rutgers WPF (Van Reeuwijk, M. & Van den Idsert, H.) 2009 Do they match? Young people’s realities and needs relating to sexuality and youth friendly service provision. Proposal for a participatory research on the quality of and access to youth friendly sexual & reproductive health services for young people. (Unpublished research proposal)
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UNAIDS 2008 Report on the global Aids epidemic. Report can be downloaded at: http://www.unaids.org/en/dataanalysis/epidemiology/2008reportontheglobalaidse pidemic/
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Annex- 1 Hypothetical cases (boys and girls) In the second phase hypothetical cases were used for data collection with all respondents (12 boys+12 girls). Following are the cases and the analysis of the responses: Separate cases were presented for boys and girls:
Cases- Girls Hypothetical Case girl 1 Moyna (15) had her first experience of menstruation three years back. Elders in her family warned her about going outside during menstruation period. She may get affected by the influence of bad spirits and wind. She experiences white discharge twice a month. So, she stays home most of the time. In this condition how can Tarar Mela help her? Hypothetical Case girl 2 Ruma is a student of class 9 and bad boys used to tease and disturb her very often. Those boys gave her love proposal but she rejected them. Revengefully those boys physically harassed her by pulling her hand or cloth. Also they threatened to kidnap and throw acid on her. Ever since her return, neighbours keep saying ill of Ruma. So she is very tensed and worried now. She is afraid that she will never be able to get married to a good person. If she does, her father will have to pay a big amount of dowry. In such a condition, how can Tarar Mela help Ruma? Hypothetical Case girl 3 Khushi is a girl of 16 and has a boyfriend. She went to park with her boyfriend and on their way back home they visited her friend’s place. Her friend’s parents were not in house. So it was kind of empty. She was chatting with her boyfriend and after sometime he started to insist her to have sex. Initially Khushi refused to do it because pre marital sex is not allowed in Islam. But in the end they had sex. Her boyfriend used condom during sex but he did not know how to use it properly. Nowadays Khushi is experiencing itchy feeling surrounding her vaginal area. She is very much worried now as she thinks she got affected by STD. She is also tensed wondering if she got pregnant or not. All these made her feel guilty for having sex before marriage. How can Tarar Mela help her in this condition? Hypothetical Case girl 4 One day Moina (15) was watching porn movie on mobile and became sexually excited. But she did not want to have sexual intercourse with a boy because it is forbidden by her religion. Also because she heard that if boys touch girl’s breast, it loses firmness and the girl may lose virginity as well. In future she may get caught by her husband if there is no blood during sexual intercourse with him. She heard that it is possible to have sex with girls, but she does not know how. Then she thought about masturbation, but again she did not know how to do it. Also she thinks it may damage her hymen. In this condition how can Tarar Mela help her?
Responses on girls’ cases: For all 4 cases all the 12 respondents thought that they should come to Tara Mela and get counselling from the counsellor. For the first case they believed that the counsellor can explain the superstitions around menstruation. Some even think that parents of this case also should get counselling. The second case on harassment, the respondents thought firstly the parents of the girl should know about it. Tarar Mela should educate the girl about life skills including interaction with boys. All 12 respondents though that the parents of the girls and the boys should also take counselling from Tarar Mela. Eight out of 12 think that if the boys do not listen to Tarar Mela, then Tarar Mela should inform police and take legal actions against the boy. All of them thought that Tarar Mela can help the third case by teaching her the use of ECP and condom use. Alternatively she could be provided with MR facilities and pregnancy test. Three of the respondents
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suggested that counsellor should make the boy and the girl understand that it is wrong to have pre marital sexual relation and to avoid this kind of activity in future. Only one of them mentioned that Tarar Mela should console her by saying that ‘making mistakes is natural for human’ so that she would feel better. Nine of them thought that counsellor can help the case four by advising regarding misconception of virginity loss. More than half also thought that counsellor should advice her not to engage in sexual intercourse and control her sexual desire, as well as restrain from watching porn. Only one think that she should be referred to the psychiatrist doctor for her ill desire (pre marital sexual urge). Analyzing the responses of four cases it can be said that maximum respondents (Tarar Mela visitors) admitted that Tarar Mela can and should help in such kinds of cases. These cases/ issues can be included in the service provision lists. The respondents thought that Tara Mela should help in removing all sorts of misconceptions, help the victims of various sexual abuses including harassments, rapes etc also preventing the girls from facing early marriage, dowry. However, the respondents particularly emphasized that Tarar Mela should also take
Cases- Boys: Hypothetical Case boy 1 Shanto (student of class 11) is in love with Rima (student of class 9). One day Rima went to a park for date with Shanto and missed her class. On their way to the park they were hugging and kissing on a rickshaw. Suddenly one of her school teachers’ saw them in that position. Next day he insulted Rima in front of her classmates and complained about her activities to her parents. As a result her father put restriction on her going to schools. Neighbours came to know about the incident as well. Shanto, on the other hand, got rebuked by his parents. He was very upset as he could not meet Rima anymore. He became inattentive in studies because he kept thinking about her all the time. Also he became worried thinking her parents may force her to get married. serious steps to prevent any possible pre marital sexual acts in future. Hypothetical Case boy 2 Dipu went to park with his girlfriend and on their way back home they visited his friend’s place. His friend’s parents were not in house. So it was kind of empty and the friend went to market to buy food for Dipu and his girlfriend. In the meantime Dipu kissed her and they had sex without condom. Now he is tensed because his girlfriend might get pregnant or he might get affected with STD. besides he started to feel guilty as his religion strictly condemns pre marital sex. How can Tarar Mela help him in this condition? Hypothetical Case boy 3 Rafique (17) had wet dream one night. He shared this information with his friend Suvash in his school. Suvash advised him “I suppose you did not have fun in dream. Do something after going home today- go to your bathroom and masturbate. You’ll have fun.” So, Rafique masturbates regularly since then. One day he heard a street canvasser saying, “masturbation distorts the shape and size of your penis and decreases sexual power.” Since then Rafique is worried about himself. How can Tarar Mela help him? Hypothetical Case boy 4 Your friend Joynal’s parents force him to get married. But he is reluctant because he is worried about the size of his penis. He thinks it is too short and he cannot enjoy prolonged sexual intercourse due to this reason. He had sex with his girlfriend and went to brothel several times. In those cases duration of his sexual intercourse was too short. So, he does not want to get married. How can Tarar Mela help him?
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Responses on Boys cases: Most of the boys thought that for the first case parents should come to Tarar Mela and all of them together should take counselling regarding this. Five of them thought that counsellor can provide him with effective advise so that he won’t do the same again. For the second case nine of them thought that the boy in the case should visit Tarar male counsellor so that he can convince him to stay away from such kind of activities. The counsellor can make him aware about the risk of STDs and that premarital sex is prohibited in Islam. Four of them suggested that Tarar Mela can arrange for a HIV test for them. Four also felt that Tarar Mela should advice them to get married. Three of them thought that Tarar Mela could do pregnancy test for his girlfriend. Two thought that Tarar Mela could demonstrate the boys about the proper use of condom. For the case third, all of them think that Tarar Mela could help the case by providing advice. The advices could range from abstinence to religious instructions. For example most of them thought that Tarar Mela could advise him to control his sexual desire, to concentrate in studies and tell him that it is forbidden by religion. Seven of them though thought that Tarar Mela can explain to him that masturbation does not affect physical well being and make him understand that it is normal. Three of them thought that Tarar Mela should advise him not to pay attention to the street canvasser’s words as they give wrong information. Three of them thought that counsellor should tell him that masturbation is a bad thing and they should not do anything in future like this. Most of the respondents believed that Tarar Mela could solve case four’s problems to some extent by taking him to the medical facility from FPAB clinic. Three respondents thought that Tarar Mela could advise him to get married because small size of penis does not create problem. Analyzing this data it can be said that most of the clients are against pre marital sex. Some of them are open about accepting one’s ‘mistakes’ and willing to help the youth. Boys like girls also thought that Tarar Mela is in a position to tackle these cases. However, suggestion regarding including parents in counselling service is lesser among the boy than the girl clients.
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Annex- 2 Question-box questions By analyzing the one month’s questions from the question box it was found that most of the questions of the boys are about the size and shapes of the pennies. Some wanted to know how to correct an abnormal penis. Others questions were regarding ‘normal’ size and shapes of pennies, sex power of boys and girls. Many questions are in relation to masturbation and wet dream. They wanted to know if this is right or wrong to do masturbation or to have it. Questions were about the normal frequency of wet-dream, relationships between wet-dream and bodily energy loss. They also wanted to know the cleanliness process of wet dream. Also wanted to know the consequences of masturbation. Some of them have showed curiosity about sexual diseases like HIV, other STDs and the ways one may have these disease. They also wanted to know the ways to protect themselves from having these disease. Some questions were about increasing weight, management of white discharge, menstrual pain, pregnancy, sex during pregnancy and so on. Although the sex of the person was not mentioned with the questions but from the counselling observation and interviews it can be assumed that these questions are from the girls. We do not know how accurately the answers are given as we did not have the data. Following are some examples from question, here I have categorized them in to four groups.
A: What is the treatment of penis distortion? How can a boy enlarge his penis? What is the reason of distorted shape of penis? How can I make my penis healthier? Why do boys ejaculate right after penetrating their penis inside vagina? What is the normal size of penis? What should I do if the shape of my penis become distorted? What is the most sexually powerful organ of a male body? What is the most sexually powerful organ of a female body? According to Islamic law when (what time) should we have sex with wife?
B: Its not possible to take shower on a winter morning, what can I do then after wet- dream? Wet dreams result in scar in the penis, how can I prevent that? Does wet dream take out all the energy of body? How can I stop wet dream and hold semen back in my body? Is masturbation bad for health? What are the consequences of masturbation? What is sexuality?
C: How should I treat a HIV positive person? What is the consequence of condom leakage during sexual intercourse? What are the symptoms of STD? How does HIV contaminate? What can I do to cure urinal infection and body pain? What should I do if I experience pain in my penis?
D:
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How can I gain weight? What is white discharge? What should I do if I have menstrual pain? What is sexual harassment? What is the reason of white discharge? How long should I continue sexual intercourse to become pregnant? Is it possible to have sex during pregnancy? What is the level of girl’s sexual power? How long should I work to have children? (most of the questions were asked using metaphor to refer to sexuality related words).
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ANNEX- 3 Standards for good quality and accessible YFS IPPF’s Medical Advisory Panel describes YFS as: “… able to effectively attract adolescents, responsively meet their needs, and succeed in retaining these young clients for continuing care. Youth friendly services should offer a wide range of sexual and reproductive health services relevant to adolescents’ needs.” (IPPF 2008: Provide) Similarly YFS are often associated with youth centres. A youth centre is a youth friendly place or venue which aims to serve a specific group of young people. Young people make use of the centre to access information and services which address their needs and wants, including sexual reproductive health needs as well as other needs such as life skills and recreational activities (IPPF 2008: Springboard). IPPF argue that “With the right attitude and understanding of young people’s sexuality and sexual reproductive rights, high quality youth friendly services can indeed be provided” (IPPF 2008: Springboard: 3) YFS should be based on a comprehensive understanding of what young people in a particular community want and not just what providers believe they need: in other words respectful of the realities of young people’s diverse sexual and reproductive lives. A service that young people trust and feel is there for them and their needs, and is supportive of young people’s sexuality so that they have a happy, healthy and safe sexual life regardless of gender, sexual orientation, disability, income level or marital status (IPPF 2008: springboard). Similarly AYA/Pathfinder International (2003) argue that YFS should: Effectively attract young people; Meet the varying needs of young people comfortably and responsively; Succeed in retaining these young clients for continuing care.
IPPF makes use of a rights-based approach in defining YFS, and states that YFS should respect young people’s life choices and sexual and reproductive health decisions. Clients have the right to: Accurate information Access Choice Safety Privacy Confidentiality Dignity Comfort Continuity of services Opinion
Closely linked to the client’s rights are the providers needs. Service providers need: Training Information Good infrastructure Supplies Guidance Back-up Respect Encouragement Feedback Opinion
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1.1 With regard to the specific services that youth need. IPPF suggest that the sexual reproductive health related services for youth should include: SRH counselling (focusing on attitudes and relational interaction competence) Contraceptive provision (including emergency contraception) Sexually transmitted infection/HIV prevention, counselling, treatment and care HIV testing Pregnancy testing Sexual abuse counselling (Sexual) relationship counselling Safe abortion and/or abortion related services (antenatal care etc) Information, education and communication activities, and behavioural change communication activities such as quizzes, debates and workshops (IPPF 2008: springboard)
1.2 The non-sexual reproductive health activities of a youth friendly centre should include: Indoor and outdoor games Library: education material (IEC brochures etc) Internet facility Snack shop Training in life skills Training in vocational skills Career development activities Music and film shows Festivals Treatment for minor ailments
Young people should have ownership over the centre and should be involved at all levels of decision-making, implementation and monitoring activities. Based on the information above, and according to various studies, the following checklist can be used to assure that services are youth friendly: Access: Convenient open hours Privacy/confidentiality is ensured Effective referral & marketing system Young adolescents 12-15 are also served Registering and administration is discreet and easy Location of clinic and/or centre does not repel youth Mobile services and referral systems to reach underserved youth Comfortable setting: entertainment and relaxation facilities are offered to youth (see 1.2) Affordable Fees/separate fees for young people Peer educators/counsellors available Non-medical staff oriented (staff who provide supportive or auxiliary roles (such as receptionist, security guard, cleaner, etc.) are oriented to communicating with youth in a friendly and respectful manner).
Quality: Friendly staff Competent staff Strategies in place that focus on needs and desires of youth youth participation: Youth input/feedback to operations facilitated
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Non-discriminatory & non-judgmental service provision Acceptance of youth sexuality Respect for youth client Minimum package of services (see 1.1) Sufficient supply of commodities and drugs Range of FP methods offered Emphasis on dual protection/condoms Waiting time not excessive Delay of blood test and pelvic exam possible Awareness raising strategies about rights (youth empowerment) Gender sensitivity
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