6 Key Insights on Young People and SRHR in Bangladesh

“We live in a rapidly changing world where it is difficult to keep up. Sexual and reproductive health needs, desires, expectations, and pressures are part of this.” –Sabina Faiz Rashid, Dean, BRAC JPGSPH

From the 30-31 January I was lucky to attend the BRAC James P Grant School of Public Health (JPGSPH) Gender and Sexual Reproductive Health Conference for Young Adults 2018. The first day had a focus on young people (and over 700 university students participated) and on the second day the dialogue was with practitioners. This was a fantastic opportunity to not only hear about cutting-edge research for Bangladesh but also engage in a dialogue with researchers and civil society leaders from the region. It is very rare that I get to hear the views of young people, unmediated by a scholar or a journalist and I very much appreciated their inputs, and their insights into the issues that matter most in sexual and reproductive health and rights (SRHR).

It is hard to do justice to a conference with such riches of ideas. Here are six of the conference themes that stood out for me.

1.     We need to better acknowledge the agency and  power of young people.

Maheen Sultan, who is leading the Centre for Gender and Social Transformation at BRAC Institute of Governance and Development (BIGD), pointed out that today’s adolescents increasingly see themselves as people with agency and a voice. It is beholden on public health practitioners to accept this and listen and learn from younger people in the organisation of services and interventions. As one speaker pointed out, young people talk about desire, emotion, sexual orientation, pornography, and drugs but we don’t engage with them on this. There is no space to talk about the issues that they find pertinent, there is just silence. Luckily the conference bucked this trend.

There was a fascinating insight into young people’s agency in the presentation by Seama Mowri, project coordinator at JPGSPH, on early and child marriage in Bangladesh and how it can be addressed. Early marriage is occurring in urban slums which are in a period of transition (with Dhaka on its way to becoming the sixth largest mega-city by 2030). Young people live with insecurity in the forms of the risk of eviction, fragmented families, and criminality. It is within this environment that they navigate narrow and difficult choices. Mowri’s interviews with 130 young people and other stakeholders found that the average age of marriage was 15-16 years and that love relationships were losing their taboo status. In a context where many young people had access to a mobile device, the older generation were increasingly concerned that this form of communication was leading to clandestine relationships and elopement. We heard that sometimes adolescents blackmailed other young people or their parents into agreeing to early marriage, threatening to run away or commit suicide if their desires weren’t fulfilled. Within marriages the majority of married girls wanted to delay pregnancy and took responsibility for contraception even if their husband did not (and sometimes kept it a secret from husband and in-laws). Furthermore, remaining single and entering the world of work was not necessarily considered empowering. Young working women talked of the need for protections against assault and harassment. This evidence was refreshing as it did not rely on stereotypes about young people’s lives. It demonstrated the agency of young women living in difficult situations. Interventions to halt or reduce early marriage are unlikely to succeed unless they take these women’s views and life experiences into account.

2.     Intersectionality matters.

A strong message from the conference was that we need more discussions of intersectionality and we need to purposefully integrate this analysis into our research and programming. Commenting on a session on mainstreaming sexual and reproductive health education, disability rights activist Anita Ghai lamented the ways in which people with disabilities were excluded from the narrative and the interventions that follow from it. For example, when talking about menstruation how often do educators talk about the forced hysterectomies performed on disabled girls because their menstruation is too ‘difficult to manage’? Or their sterilisation because parents don’t want their daughters to get pregnant? Sabina Faiz Rashid suggested that ‘inclusion’ is often performed in a very tokenistic way, “We cut and paste and replicate, we borrow. If we get compliant and complacent and we don’t look at the heart level about who we are leaving out and what we are uncomfortable with we will lose out.” If sexuality education truly informs young people and empowers them to take control of their lives, as Chief of Health at UNFPA Bangladesh, Sathyanarayanan Doraiswamy argued, we need to ensure that it is sensitive and responsive to all young people not just some imagined norm.

Intersectionality analysis matters when it comes to tackling harmful conceptions of masculinity too. Speaking on masculinities as a social construct, Anand Pawar, Executive Director of SAMYAK, argued that it is not enough for men to simply learn the language of gender equality without embodying these principles. He asked, “What if a gender sensitive man is Islamophobic or racist? Is this enough, if they are not working on power more generally?” There was a strong theme within the conference which stressed the need for a holistic analysis of vulnerability and privilege in sexual and reproductive health education and the way that simultaneous structural power relations shape this.

3.     Race and colourism should be part of the conversation.

“When I was I in ninth grade and relatives would visit they would ask if I was actually my parents daughter because my skin is not fair like my brothers and sisters.” –Audience member

“I am dark skinned, and I am obese and our society always wants to point it out and judge. But I have a supportive family and I am really happy how I am.” –Audience member

We heard a fascinating talk by Azra Mahmood, one of Bangladesh’s top models, who experienced discrimination on the grounds of her darker skin and overcame these notions of beauty to have a successful career and found her own modelling agency.

She encouraged us all to take personal action to end bullying and discrimination based on society’s beauty standards and to use social media to spread the message.

There sometimes appears to be a reluctance among public health practitioners to talk freely about race and its impact on health and wellbeing – despite the ever-broadening evidence base that racial discrimination leads to psychological and physical ill-health the results of which can pass through generations.

4.     Re-writing the masculinity script.

There were a few sessions at the conference that addressed what it is to be a man and how we define masculinity. Adnan Hossain’s presentation was a good reminder that there are many forms of masculinity, but some are hegemonic and others subaltern and there is a tendency to make a hierarchy of them. In Bangladesh, as in all other settings, notions of masculinity are historically dependent underpinned by a governing logic which stems from framings formed in colonial times, the war of liberation and in recent years related to economic growth.

We heard how normative ideas of masculinity tends to begin by constructing men in relation to their biology and social rituals such as heterosexual marriage and being an economic provider. Deviating from these norms can come with health and other costs and vulnerabilities. These issues are compounded for people who are non-binary, gay, bisexual and transgender. Adherence to these norms can also be unhealthy leading to self-neglect, poor health care seeking and underpinning gender-based violence against women, children, weaker men and non-binary people.

Drawing on his research of risky sexual behaviour and masculinity in Dhaka slums, Arifur Rahman painted a picture of a community of young men who were mostly sexually active before the age of 18 and had easy access to various types of illegal drugs. While many were having sex with girlfriends and with sex workers about half said that they were not satisfied with their sexual life. For some it went against social and religious norms and was shameful. Others felt it was unsafe. While they understood that using a condom and other forms of contraception was desirable they didn’t like buying condoms from the local pharmacy for privacy reasons, felt uncomfortable using them or had a lack of knowledge about them. A lack of privacy to have sex was also cited as a source of discomfort and vulnerability in this crowded urban space. The research uncovered tensions around their masculinity with concerns about sexual function and performance, such as premature ejaculation, about their ability to live up to financial expectations. Despite having girlfriends, they had conservative ideas about women’s dress and a victim blaming attitude towards harassment and assault. The majority said that if a woman doesn’t obey her husband then she deserves a beating, others said we should talk, others said that if it is extreme they should file for divorce.

In terms of efforts to challenge harmful masculinities, Sharful Islam Khan provided a wonderful case study from his anthropological studies with icddr,b arguing that global norms around masculinity are tied to notions of money, power and politics and privilege physical strength and toughness. These norms are reinforced by popular messaging, such as in the media. Anand Pawar argued that we need to create intervention with politicians, religious leaders and other powerful people who are creating the notion of manhood rather than only focusing on poor men. And we need to talk about market constructed norms of masculinity and the influence that they have.

Wangda Dorji, the 88th person in Bhutan to be diagnosed HIV positive along with his wife.

5.     Mental and physical health go hand-in-hand.

“When I had my diagnosis, I was more afraid people would know my HIV status than my fear of dying. At the weekend I would go into nature and close my eyes and contemplate that we all share the same universal consciousness. We all go through sadness, happiness… Now I only think about HIV when I take my medication at night. At other times, I don’t [care] about HIV.” –Wangda Dorji

“It is ok to hurt, and it is ok not to be ok.” –Onaiza Owais

Some sessions at the conference highlighted the importance of mental health to young people’s wellbeing more generally. Ms Onaiza Owais reflected on her own experiences of depression during university, seeking psychological assistance and medication and how finding a peer group who she could talk with in a safe space led her to use her experiences in assisting others facing similar challenges. Shila Rashid presented on eating disorders and how these are gendered and shaped by family, society, religion and our own perceptions. The way that mental and physical health are intertwined came through in their presentations, and that of Wangda Dorji, reminding delegates of the importance of seeing sexual and reproductive health in a complete way.

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Azra Mahmood (Right) and Anita Ghai (Left), who shared a book published in collaboration with BRAC JPGSPH on sexuality and disability titled “Untold Desires” during her panel session.

6.     A focus on disability

“In normative society there is a conspiracy of silence about the sexuality of people with disabilities. It is thought that you are either asexual or hypersexual and not prioritised even among advocates for disability rights.” –Anita Ghai

The conference had a strong focus on disability not just in terms of exclusion (how disabled people are infantilised and their needs, desires and inputs are considered unimportant) but also on disability as a knowledge systems which can provide vital insights for those working on sexual and reproductive health. We learned how disability is heterogenous – India has 21 different categories of disability – if we were to build our sexual and reproductive health education system around catering to all students regardless of (dis)ability it would provide a more imaginative starting point for our discussions of love, sex and romance.

What next?

At the conference we heard from a range of implementing organisations about how they were responding to some of the contemporary challenges raised above.

Debarati Halder gave an overview of the subject of cyber-bullying, a more common phenomenon as rates of internet use and connectivity are rising. This has implications for regulation of online spaces but also young people’s self-image and mental health. Others spoke of the rise in young people accessing information about sexual and reproductive health online in lieu of decent sex education. Pornography is readily available in Bangladesh and is one way that young people learn about their bodies and sexuality.  In this there is a challenge in distinguishing accurate from inaccurate information. One young person explicitly asked how young people can navigate ‘fake news’ online.

To provide accurate information we heard that initiatives like Digital Sister for Urban Youth are creating platforms which seek to understand how urban youth access sexual and reproductive health information and develop communication tools to meet their needs. Interestingly, the Digital Sister project had feedback from young people that they should also spread messages through offline channels. Young people were concerned that their parents had insufficient access to information and inaccurate beliefs and that online sources would not meet their needs. This speaks to the need to integrate online and offline spaces in ways which are targeted to the needs of users.

Echoing Jeroen Steeghs’s speech at the conference, it is important that implementers take these issues on board and do not leave them to parents, many of whom are ill equipped and lack information, to deal with. Adolescents have sexual needs, fall in love and feel attraction, explore and develop their sexual identity. They often have to navigate incorrect and distorted sources of information in the process, including from censored or abstinence-based sexual and reproductive health education in schools. More guidance is becoming available on sexual and reproductive health programming and sexuality education such as the recent UNESCO publication on international best practices. However, despite overwhelming evidence that comprehensive sexuality education works there are barriers to its implementation such as the embarrassment of teachers and parents in taking this forward. Similarly, existing legal frameworks can simultaneously protect young people from abuse while constraining access to information and justice, and these need to be critically considered.

Comprehensive sexuality and sexual and reproductive health education prepares and empowers young people to take control and make informed decisions. It can be transformative – and help to build a fair and equitable society by overcoming issues like colourism, sexism, homophobia, ableism, sizeism, marriage normativity and other forms of discriminatory practice. It is the responsibility of those working on policy and interventions to take the concerns of young people seriously and ensure that they are at the forefront of shaping the response.

This blog was written by Kate Hawkins, Pamoja Communications Ltd/REACHOUT Consortium.

The Gender and SRH Conference for Young Adults 2018 was funded by NUFFIC and implemented through a partnership between BRAC JPGSPH, RHSTEP and NIPORT.