Taking charge: How young people are encouraging sexual health conversations among peers

Wasim Khan, a 24-year-old resident of Dharavi in Mumbai, had never discussed anything about the changes in his body with his family members. "If I had a problem, I used to ask my friends and used to visit a doctor only when something was serious," he says. "And to do that I used to visit a doctor outside my area in Sion so that no one should get a hint about my sexual concerns."

Since 2016, however, friendly conversations with local health volunteers of Mumbai-based SNEHA foundation have expanded Khan's knowledge about sexual and reproductive health (SRH) and with time he has grown more confident about discussing the same with his partner in a healthy manner.

He is one among many young persons who are in need of accurate explanations to their questions about puberty, sex and contraceptions, but are often deprived of information and access to health services due to social, economic and cultural barriers.

According to a 2011 study by the Population Council, adolescents in India rarely get information or guidance on sexual health and reproductive matters from their parents. Barely 1 percent of youth reported that a parent had discussed reproductive processes with them.

As advocacy networks are actively working on the ground to cater to the needs of adolescents, we look at methods deployed in engaging with the youth and why these are important in the absence of a concrete policy framework for education and protection.

Safe and accessible spaces to tackle misinformation

Owing to the social and cultural stigma associated with matters of sexual health, adolescents in the age group of 18 to 25 years or younger are often discouraged from openly discussing their queries and problems with their family members. The lack of information leads to further isolation of young adults, who are unaware of whom to reach out to.

According to Mamta Verma, a community volunteer for The YP Foundation at Siddharthnagar district of Uttar Pradesh, the youth majorly turn to their friends for information, who are often equally unaware of certain aspects. Additionally, schools do not advocate sex education in detail, because the teacher too is hesitant to discuss biological topics. This deepens the stigma and furthers misinformation.

"We conducted our sessions with groups of 15 girls and boys separately and when we spoke about puberty or sex, they used to laugh. Sometimes, we had to stop our class in between due to unhealthy discussions," says Mamata, adding that eventually there was a growing acceptance among the youth and even the teachers. She observed that the young adults in her area have also initiated conversations with local authorities for counsellors and for affirmative actions concerning adolescent sexual and reproductive health services.

Young people who volunteer to encourage conversations about sexual and reproductive health emphasise on creating a safe zone through anonymous or one-on-one interactions. This enables adolescents to empathise with fellow young adults, overcome their hesitation and have conversations about topics concerning their physical and mental health.

"We need to develop empathy and create a comfort zone. People are hesitant initially, and hence we start with soft topics like menstruation, puberty changes, hormonal changes, attractions, relationships, sex and contraceptives. It's a process," says Pragati Vaishya, a 23-year-old youth facilitator associated with SNEHA Foundation's Ehsaas programme at Shahu Nagar area of Dharavi in Mumbai.

The inquisitive approach of the young is regularly subjected to shame and stigma by family members, school teachers and sometimes even friends. According to community health workers, this largely impacts the physical as well as mental health of adolescents. This is especially observed in cases where girls below 18 years of age are dealing with unwanted pregnancy and are facing violent behaviour of family members, who are worried about social status and respect. According to National Family Health Survey (NFHS) data, eight percent of women between the ages of 15 and 49 had begun childbearing in 2015-16.

"Advocacy and a friendly discussion are important. Due to lack of information about physical relationships and use of contraceptives, youth often end up harming their health. If they were informed, the harm could have been avoided," says Verma.

From menstruation to masturbation, what adolescents are curious about

When provided with safe spaces to discuss topics that are usually considered taboo in the traditional setting of families and society, young individuals interact with fellow young peers and bring up the questions that bother them. From polycystic ovary syndrome (PCOS) and hormonal changes to masturbation and use of contraceptives, they want to be made aware of everything that concerns their body.

Lata Mazhde, community supervisor for U-Respect foundation in the suburban Vikhroli area in Mumbai, says that while girls generally discuss their menstrual issues, boys inquire about nightfalls, masturbation and changes in their body during puberty. These exchanges mostly happen anonymously through letters, during the curriculum sessions.

"We get questions about sex, unwanted pregnancies and how and when to emergency contraception pills and their effects. Sometimes we have to explain to the boys why contraception is important and they have gradually accepted the importance of using condoms," says Mary Jayappa Aarkar, who also works as youth facilitator in Dharavi.

While boys usually open up to male mentors, Vaishya says they are gradually opening up to female peers and volunteers too. There is also a growing discussion about consent, polygamy and sex for pleasure rather than just family planning.

How pleasure, contraception and patriarchy are intertwined

A common observation by a number of community health workers is that females generally do not talk about pleasure or their needs, while males are quite assertive about their sexual desires and needs. Entrenched patriarchal beliefs and norms evidently restrict females from exercising their choices or consent.

"Boys are more concerned about pleasure when using condoms. They also feel that they just can't be with only one girl. We explain to them that pleasure has to be both ways and that you don't have to be married for it," explains Vaishya.

"Girls don't really talk about pleasure. They share things like they don't want to have sex and how can they say no to their partners. Then we talk about consent. Girls are also concerned about whether they are able to satisfy their partners, fearing they will leave them," she continues.

More young men talk about masturbation, polygamy and sex for pleasure than women, who usually prioritise their partners' satisfaction over theirs - that is if they open up about their physical relationships at all. They also require to be made aware of their consent and that they do not need to engage in physical relations just for the sake of their partners.

"Girls still feel talking about pleasure is a taboo and something they should be guilty about. While some want to feel the pleasure, they try to suppress their needs because they have been taught at home that unmarried sex is a sin," says Aarkar.

A contraception advocacy toolkit--a document with detailed information, guidelines, and recommendations for policy makers, social workers and other stakeholders--by the YP foundation says young people need to be made aware of their right to pursue pleasure, without discrimination and harm, which can be made possible if, in policy, law and practice, they are recognised as individuals who could be sexually active, independent of marriage.

Among married young couples between the ages of 19 and 25, it is observed that the burden of family planning or contraception majorly lies with the women.

Data from the NFHS-4, or fourth survey for 2015-2016, suggests that 31.5 percent and 37 percent of adolescent men between ages 15-19 and 20-24 years think that ‘contraception is women's business and a man should not have to worry about it'.

"For sterilisation, only women come forward. Men generally have a negative approach towards contraception and are worried that sterilisation would affect their strength and masculinity. In slums, some addicted men, wagers and labourers have undergone sterilisation for money. No one does it willingly," says Mazhde, adding that local health posts are generally concerned about achieving targets and in a way it becomes a forceful initiative.

According to The YP Foundation's analysis of NFHS data, female sterilisation accounts for more than 75 percent of the overall modern contraceptive use in India.

While there are only two methods of modern contraception available for men - condoms and vasectomy, these methods are greatly associated with myths of masculinity and inability to experience pleasure. Vaishya observes that unmarried young boys are more receptive towards using condoms than married men, because there's a fear about consequences of having unprotected sex and unwanted pregnancies.

As per NFHS-4 data, only 5.6 percent of the married men between the ages 15 to 49 years were using condoms in 2015-16.

There are also cases wherein males state that they are discouraged to use contraceptives by their female partners, but at large women resort to emergency contraceptive pills more often than not without medical consultation and are left to bear the physical consequences alone.

Though conversations about contraceptives, family planning methods such as limiting (vasectomy and tubectomy) and spacing (gap between pregnancies) have increased, there are very few couples who attend counselling sessions together, irrespective of their education or awareness levels.

"Many couples do not want to talk together. Husbands are mostly out for work and sometimes we face challenges from the woman's in-laws as well such as in cases where the woman has to undergo multiple abortions due to husband's reluctance over using a condom," says Vaishya.

Promoting inter-generational discussion

"There was an instance in Dharavi when we were talking about puberty and bodily changes when a 15-year-old boy went and complained to the parents that our coordinators are talking about dirty things," says Onil Kulkarni, programme coordinator at SNEHA, sharing that the incident was followed by candid discussions with the parents as well, beginning with social accepted topics like anaemia, child sexual abuse, gender violence and emotional resilience among adolescents.

Most of the local community health volunteers cater to the socio-economically backward communities in the rural and urban areas. When asked about the challenges involved in communicating about sexual and reproductive health services to young persons on-ground, volunteers state that social and cultural beliefs of the guardians greatly hamper constructive dialogues.

Home visits, parent-teacher sessions and personal interactions with family members are some of the strategies deployed to increase engagement of parents with their children. According to Verma, working with the local health workers such as the Accredited Social Health Activists (ASHAs) and Nursing Midwife (NM) under the National Urban Health Mission (NUHM) helps in gaining confidence of the parents as a government authority is involved in the process.

"We start the discussions with guardians first and convince them to send their wards for our sessions. They have realised that they can't stop the youth from having sex and that they should do it safely, considering the repercussions of it if not done safely. Now more parents are sending their kids to our sessions. And those who are already there, they want their kids to work more on this and spread awareness," Verma adds.

There is a growing positive reception from parents as well. However, here too, women are more forthcoming than men who rarely attend these discussions.

Working amid legislative drawbacks

Experts state legislative drawbacks act as one of the major challenges which limit the access to sexual and reproductive health services among adolescents. These concern the Protection of Children from Sexual Offences Act (POCSO), which prevents sexual act with minors (under 18 years), and the Medical Termination of Pregnancy Act or the abortion law, which requires the consent of husband or a parent which discourages many young women to open up about unexpected pregnancies due to fear of social backlash.

The toolkit provided by The YP Foundation states that while the ostensible intent for increasing the age of consent to 18 years under the POCSO act was to protect children from sexual assault and abuse, there is a need to create a legally acceptable framework for young people below 18, to engage in consensual, sexual relationships.

According to Dr Souvik Pyne, senior program officer at The YP Foundation, while government authorities acknowledge the conversations about adolescent sexual and reproductive health services, it should translate into action in terms of avenues for meaningful youth engagement in policy making and implementation.

"Evidence based information dissemination thus becomes important in setting a precedent to encourage service delivery as well such as setting up adolescent friendly health clinics," Pyne adds.

A number of organisations have set up their own help desks, adolescent friendly health clinics under the Rashtriya Kishori Swasthya Karyakram--a government scheme launched in 2014 for adolescent sexual and reproductive health services. However, the scheme was majorly limited to married women and adolescent married girls.

One such help desk is provided by the network run by Verma in coordination with The YP foundation in UP. Verma says these desks are accessed by young persons for sanitary napkins, contraceptive pills, condoms and medical aid for terminating pregnancy via medical counsellors and clinical psychologists who sometimes even provide financial aid along with protection from any anticipated harm by family members.

As noted by Verma above, programmes conducted in association with public health authorities help instil confidence in the public at large; experts reiterate that the policies and laws need to be expanded to cater to the needs of married and unmarried adolescents across spectrums. They should also include the needs of the LGBTQIA+ community and people with disabilities, which still need to be addressed across levels of advocacy programmes.

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