Do They Match Report Bangladesh - World Population Foundation

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Do They Match Report Bangladesh - World Population Foundation

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 illhealth

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 coresearchers.

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


Do they match? August, 2010

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


August, 2010 Do they match?

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


Do they match? August, 2010

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 people 1 . 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

years 3 ; 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 Declaration 5 (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-youngwomen

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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August, 2010 Do they match?

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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Do they match? August, 2010

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 models 6 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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August, 2010 Do they match?

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

Service

Providers

1.3 Research objectives

What do service providers need in order to offer good YFS?

Sufficient organizational support, management systems and resources, and

training and motivation of staff in order for them to conduct their jobs in the best

possible way.

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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Do they match? August, 2010

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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August, 2010 Do they match?

� 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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Do they match? August, 2010

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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August, 2010 Do they match?

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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August, 2010 Do they match?

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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August, 2010 Do they match?

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 wideranging

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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August, 2010 Do they match?

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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August, 2010 Do they match?

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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August, 2010 Do they match?

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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Do they match? August, 2010

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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August, 2010 Do they match?

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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Do they match? August, 2010

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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Do they match? August, 2010

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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August, 2010 Do they match?

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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Do they match? August, 2010

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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August, 2010 Do they match?

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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Do they match? August, 2010

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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Do they match? August, 2010

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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August, 2010 Do they match?

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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Do they match? August, 2010

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 selfreflection

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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August, 2010 Do they match?

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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Do they match? August, 2010

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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Do they match? August, 2010

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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August, 2010 Do they match?

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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Do they match? August, 2010

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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August, 2010 Do they match?

differences between boys and girls and between adolescents from different backgrounds:

their experiences and needs are diverse. The study shows that certain groups like sexworkers

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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Do they match? August, 2010

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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August, 2010 Do they match?

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 destigmatize

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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Do they match? August, 2010

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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August, 2010 Do they match?

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

Service

Providers

What do service providers need in order to offer good YFS?

Sufficient organizational support, management systems and resources and

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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Do they match? August, 2010

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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August, 2010 Do they match?

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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Do they match? August, 2010

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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August, 2010 Do they match?

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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Do they match? August, 2010

� 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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August, 2010 Do they match?

� 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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Do they match? August, 2010

� 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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August, 2010 Do they match?

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/fillingunmet-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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August, 2010 Do they match?

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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Do they match? August, 2010

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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August, 2010 Do they match?

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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Do they match? August, 2010

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 wetdream?

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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August, 2010 Do they match?

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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Do they match? August, 2010

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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August, 2010 Do they match?

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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Do they match? August, 2010

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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