“He forced me to love him”: putting violence on adolescent sexual health agendas
Introduction
Adolescent sexual and reproductive health has been identified as among the most important health and development problems facing South Africa (ANC, 1994; Department of Health, 1995). Nationally the adolescent pregnancy rate is estimated to be 330 per 1000 women under 19 years of age (RSA, 1995) (no reliable data disaggregated by ethnicity or region are available). While this is undoubtedly very high, the significance of this rate reveals itself more fully if it is regarded as both a determinant and an indicator of poor sexual and reproductive health, and of broader social problems among this group. Other indicators reveal the extent of sexual ill-health among teenagers; the most up-to-date national HIV survey conducted among women attending public ante-natal clinics found the prevalence of HIV-positivity among pregnant teenagers to be 9.5% (Swanavelder, 1996). Improving the sexual health of adolescents in South Africa is a major challenge for all those involved in health promotion, policy-making and research.
In South Africa research on adolescent sexuality has been predominantly characterised by Knowledge–Attitudes–Practices (KAP) surveys (see for example Craig and Richter-Strydom, 1983; Ncayiyana and Ter Haar, 1989; Kau, 1988, Kau, 1991; Flisher et al., 1993; NPPHCN, 1995; Buga et al., 1996), which have enabled a general understanding of some aspects of adolescent sexuality to be acquired. Usually covering similar fields of enquiry, they have revealed that adolescents here, as elsewhere in the world, have a propensity to engage in a set of sexual practices characterised as “high risk”, and have demonstrated gaps in adolescents' reproductive knowledge and poor intergenerational communication on sexual matters. Among adolescents a “KAP-gap”, or failure to use knowledge to modify practices, is commonly observed in this research. Factors such as pressure from female peers and male partners have been suggested as contributing to early (and unprotected) sexual intercourse. Other research conducted in South Africa among African adolescents has revealed pressure to engage in early and unprotected intercourse, and in many contexts to have a child in order to prove love, fidelity and womanhood (Preston-Whyte and Zondi, 1992; Varga and Makubalo, 1996). Other authors, however, have pointed to adolescents' shame, fear of social retribution, and abuse from healthcare providers (Kau, 1988; Boult and Cunningham, 1991; Abdool-Karim et al., 1992; Walker, 1995) for both seeking out contraception and becoming pregnant at an early age.
Internationally, recent social scientific research on sexuality, in partnership with HIV/AIDS lobbies, has brought about changes in the ways individuals' behaviour is analysed. In particular there have been moves away from biomedical and epidemiological constructions of individuals as members of groups designated as high risk (homosexual, intravenous drug-user) or low risk (heterosexual), towards understanding individuals as situated agents engaging in (high or low risk) practices with others. Understanding sexual encounters as sets of practices which are negotiated and enacted by the individuals concerned creates a space for considering how inequities determine and are played out during sexual intercourse, thereby affecting individuals' capacity to control it on their own terms (Worth, 1989; Holland et al., 1990; Wilton and Aggleton, 1991; McGrath, 1993; Orubuloye et al., 1993; Lear, 1995). These new understandings have revealed the need to put violence on health research agendas.
This paper presents the findings of an exploratory qualitative study conducted among Xhosa adolescent women which revealed pervasive male control over almost every aspect of their early sexual experiences, and the male enactment of this in part through violent and coercive practices during sexual encounters. In discussing the findings we argue that violence has been widely neglected in health research and intervention development, and more especially so in adolescent sexuality arenas. There is an urgent need to open up new avenues for research and intervention in the area of adolescent sexuality, in particular focusing on violence, if it is to be possible to create a space in which young women can empower themselves to control their sexuality, sexual experiences and reproductive health.
Section snippets
Background: recent sexuality research
Methods used in sexuality research have undergone a shift in the last decade, with emphasis increasingly being placed on the individual as a social and interactive agent. Most notably for example, recent innovative quantitative studies (for example Laumann et al., 1994) have developed new survey instruments in order to investigate previously unexamined issues such as sexual networks and gender power, constituting a shift away from the documentation of sexual behaviour towards an understanding
Gender violence in South Africa
Violent practices against women in South Africa have been described as endemic, in the sense that they are “widespread, common and deeply entrenched” (Vogelman and Eagle, 1991: 209). The highest per capita figures for rape for a country not at war have been recorded (Human Rights Watch, 1995). However, South African statistics on this are problematic, as the research base of the commonly cited ones is unclear, as are definitions used. Although to the authors' knowledge there have been no
Methods, scope of enquiry and selection of informants
The qualitative research described here was conducted in parallel to a case-control study investigating factors associated with adolescent pregnancy, hence the focus on pregnant teenagers. Originally the scope of enquiry of the qualitative component concentrated on contraceptive (non)-use, circumstances of first sexual experience, bodily reproductive knowledge and perceptions of and reasons for early pregnancy. However, the emergence of violence by male sexual partners as a central part of
Findings: violence and coercion in adolescent sexual relationships
Teenagers reported that their first sexual encounters occurred at a young age, usually around 13 or 14 years (but as young as 11). In the majority of cases male partners (the first and subsequent) were said to be older than the girls by about five years: some were working, some were still at school. In some cases the boyfriend was living in the rural areas, in others in Khayelitsha. Most informants reported ever having had one to three sexual partners, in relationships usually lasting a few
Gender violence in Africa: quantitative data
The extent of coercive sex and violent practices described by informants in the data presented here is reflected in the few South African quantitative studies which have explored these issues. Although teenagers who get pregnant may be a more vulnerable group of adolescents (in terms of socio-economic status) and therefore more at risk of violence, identification of the extent to which teenagers who do and do not get pregnant are different to each other is beyond the scope of a qualitative
Conclusion
Sexual health initiatives, whether in the form of primary research or intervention, need to be cognisant of the power differentials within sexual relationships, manifested in their most extreme form in violent and coercive practices, which limit individuals' capacity for autonomous action and self-protection against unwanted sexual intercourse, pregnancy and HIV/STDs. The violence–sexuality connection and its neglect in discussion of youth reproductive health must be recognised as an area of
Acknowledgements
We are grateful to the teenagers who talked so openly about difficult experiences; to the healthworkers who allowed us access to the Midwife Obstetric Unit; and to Nosisi Dingani who acted as interviewer and transcribed the data. The study was funded by the South African Medical Research Council.
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