Introduction
Since the International Conference on Population and Development (ICPD) held in Cairo, Egypt, in 1994, considerable progress has been recorded in programmes and policies targeted at improving adolescent sexual and reproductive health (ASRH), particularly in developing countries (Kabiru, Reference Kabiru2019). This progress has manifested in diverse themes concerning adolescent ASRH, such as adolescent birth rates, HIV, child marriage, violence against adolescent girls, female genital mutilation (FGM) and menstrual hygiene and health. However, these issues have not attained equal attention on the policy agenda within countries and between developed and developing countries (Chandra-Mouli et al., Reference Chandra-Mouli, Ferguson, Plesons, Paul, Chalasani and Amin2019).
Again, between adolescent females and males, the former have largely been treated with poignant silence (Kabiru, Reference Kabiru2019), despite the explicit call for special efforts towards men’s shared responsibility in attaining responsible sexual and reproductive behaviour, prevention of sexually transmitted diseases and prevention of unwanted and high-risk pregnancies (United Nations, 1995). Using rich qualitative data from focus group discussions (FGDs) in Ghana, this study presents stories/accounts of collective sexual and reproductive health and rights (SRHR) experiences of adolescents. This approach deviates from many existing studies where the reproductive health challenges of adolescents have been defined by community gatekeepers and often based on quantifiable indicators from secondary datasets. While quantification is necessary in measuring the progress of interventions, how and under what circumstances these daily encounters are defined and explained by adolescents themselves may offer clearer insights to programmers and policymakers in Ghana. The realities are discussed within the calls for timely and adequate comprehensive sexuality education (CSE), mindful of the co-ordinated opposition to the same by ‘moral entrepreneurs’ (Tettey, Reference Tettey2016).
The SRHR needs of adolescents remain an unfinished agenda, finding adequate recognition in the Sustainable Development Goals (SDGs) (Chandra-Mouli et al., Reference Chandra-Mouli, Ferguson, Plesons, Paul, Chalasani and Amin2019). This is partly because while there has been significant progress in ASRH indicators, the population of adolescents is large and projected to continue to grow, especially in developing countries. At the end of 2019 there were approximately 615 million younger adolescents globally, with around a quarter (22%) being in Africa, and older adolescents numbered 601 million, of which 122 (20%) were in Africa, and these numbers are projected to grow further into 2030 (United Nations Department of Economic and Social Affairs, 2020). Even though it is known that this age bracket represents a window of opportunity for health, it also presents one of the remarkable stages in the life course when the social, cognitive and physiological changes that occur can have life-long implications for the well-being of the individual (Woog & Kagesten, Reference Woog and Kagesten2019).
The adolescence period, therefore, offers opportunities for preparing adolescents for positive health choices, including sexual and reproductive health. It is during this stage that attitudes and behaviours are cultivated, which makes it imperative to set in mechanisms to protect and safeguard their health in the short- and long-term (Sawyer et al., Reference Sawyer, Afifi, Bearinger, Blakemore, Dick, Ezeh and Patton2012, Reference Sawyer, Azzopardi, Wickremarathne and Patton2018). The adolescence period marks an important point in the life of growing people; it is at this point that some experiment or begin sexual activities or drugs or self-harm practices. These are underpinned by rapid biological maturation and active social interactions (Blum et al., Reference Blum, Astone, Decker and Mouli2014). Consequently, adolescents may experience coerced sexual intercourse, unintended pregnancy, induced abortion, perpetration and victimization of sexual violence, forced marriage and school dropout (Chandra-Mouli et al., Reference Chandra-Mouli, Ferguson, Plesons, Paul, Chalasani and Amin2019). Much of these outcomes are, however, modifiable with the timely provision of correct/appropriate interventions to adolescents (Rokicki et al., Reference Rokicki, Cohen, Salomon and Fink2017).
Theory: the social construction of reality
The paper is situated within Berger and Luckmann’s (Reference Berger and Luckmann1991) theory of the social construction of reality in respect of how people come to know what is real. Originally conceived to champion the sociology of knowledge, it draws attention to what people conceive to be real and what is taken for granted in everyday life. Reality is conceptualized as a phenomenon that is independent of one’s own volition (we cannot ‘wish them away’). Knowledge is also defined as the ‘certainty that phenomena are real and that they possess specific characteristics’ (Berger & Luckmann, Reference Berger and Luckmann1991, p. 13). Conceptualizing reality and knowledge in this simplistic sense offers tangible relevance to both the sophisticated philosopher and the lay person as well. The central thesis of ‘reality and knowledge’ in this sense is understood to be different from the lingering questions of philosophers about what is real and how does one know? What is real and how one comes to know is left to the individual to define as such.
Rather than being concerned about what is reality, which would characterize a philosophical inquiry into ASRH challenges, the study asserts the original postulations of Berger and Luckmann (Reference Berger and Luckmann1991) in examining the specific realities of adolescents concerning their sexual and reproductive health. Put differently, this conception of reality offers an intuitive approach to appreciating commonalities or differences in experiences and whether these are driven by peculiarities in societies. It is underpinned by social relativity so that what is real to one group of people may not hold for another. It rejects notions of validity or invalidity based on an a priori criterion of what is real or otherwise.
Vera (Reference Vera, Schlaudt and Lara Huber2015) added that what turns out to be real is sustained by institutions, explained by legitimations and maintained by social and symbolic interactions. Moreover, the social construction of reality is a continuous element of human activity in the world, and one of the essential undercurrents in the production and reproduction of social life. To the extent that reality is connected to institutionalization and legitimations underscores what is taken for granted in one society but not in another. The propositions inherent in the theory recognize multiple realities, even though in different contexts one or another reality may be more pronounced, described as reality par excellence – the everyday reality (Berger and Luckmann, Reference Berger and Luckmann1991)
The use of this theory is hinged on two premises. First, it provides theoretical foundations for understanding what is real about a particular phenomenon – in this context ASRH. Second, social construction of reality provides a clear methodological appeal for exploring the everyday realities of adolescents that is neither purely Durkheimian (objective facticity – social facts as things) nor Weberian subjective meaning of society. It sees the process of knowing as dual in nature: ‘it is precisely the dual character of society in terms of objective facticity and subjective meaning that makes its reality sui generisi [unique]’. The study, therefore, aligns with the interpretative paradigm, drawing on multiple FGDs with female and male young (10–14 years) and older (15–19 years) adolescents.
Ghana in the context of adolescent reproductive health
In 2019, the population of adolescents aged 10–14 years was 3.4 million, of which 1.7 million were females, and for those aged 15–19 years, approximately 49% of the 3.1 million were females (United Nations Department of Economic and Social Affairs, 2020). Teenage fertility (the proportion of all teenagers who have given birth) was estimated at 14%, with rural (18%) and urban (11%) disparities. The median age at first sex for females was 18.4 and 19.8 for males; 18% of adolescent females and 25% of males had comprehensive knowledge about the causes of HIV. Approximately 7% each of adolescent females and males had had an STI in 2014. Current data also show that 12% of females and 9% of males had first sex by the age of 15 years. While 96% of female adolescents (15–19 years) knew about at least one modern method of contraception, just about one-third (30%) and 22% reported using any method and modern methods, respectively, in 2015 (Ghana Statistical Service et al., 2015)
Cognizant of these ASRH indicators, the Government of Ghana, working with other interest groups, has pursued and implemented several interventions to improve SRHR makers. Going back to 1994, the second National Population Policy gave impetus to a deliberate policy space for adolescent reproductive health, culminating in the 2000 Adolescent Reproductive Health Policy, which is now being revised. Programmatically, the HIV Alert Programme under the Ghana Education Service was introduced in 2006 in primary, junior and senior high schools and colleges of education. It was run as a co-curricular activity. The primary focus of the programme was HIV prevention, appealing to chastity and abstinence.
Methods
Data were drawn from a larger study conducted in 2019 as part of a baseline information for an adolescent girls’ intervention jointly implemented by the United Nations Population Fund (UNFPA) and United Nations Children’s Fund (UNICEF) in 36 districts of the following regions of Ghana: Greater Accra, Central, Bono East, Ashanti, Upper East and Volta. The project is intended to empower adolescent girls in school and out-of-school settings through comprehensive sexuality education and rights-based SRHR service delivery. The project districts were chosen by their poor SRHR indicators for adolescents.
Forty FGDs were held with adolescent females aged 10–14 (N=10) and 15–19 (N=10), as well as males aged 10–14 (N=10) and 15–19 (N=10) years. The number of FGD participants ranged from six to ten, with an average of seven participants. A total of 298 adolescents participated in the FGDs. For in-school participants, discussions were held in classrooms/offices assigned by the school authorities. For out-of-school participants, venues for discussions were community halls and convenient areas where conversations could be conducted with minimal disruption.
A semi-structured data collection guide was used. Among the topics discussed were challenges around adolescent sexual and reproductive health and rights; prevalent adolescent sexual and reproductive health norms and practices; sexuality and reproductive health education and services; and community support and safe spaces. The tool was pre-tested for logical flow and relevance to the targeted participants. Twelve graduate students with extensive experience in qualitative data collection moderated the discussions under the supervision of the lead researchers. The FGDs lasted approximately 1 hour 30 minutes.
The audio-recordings were transcribed during and after the data collection. Since the study aimed at covering all the study districts, sample exhaustion rather than saturation informed the termination of additional discussions. This was largely due to operational feasibility, given that fieldworkers were deployed concurrently. Besides, given the comparative approach in the analytical positioning of the study, saturation was not a viable alternative.
An inductive iterative approach was used to assess the narratives for tendencies, relationships and particularities to make sense of the data at the first level. The preliminary nodes for the narratives were developed by one experienced qualitative researcher and peer-reviewed by two other team members. Disagreements in nodes were resolved through consensus. In order to identify and understand any patterns in SRHR challenges of adolescents from different age groups and sexes, analysis took a comparative approach. The study protocol was reviewed and granted clearance by the Institutional Review Board of the University of Cape Coast.
The author’s own experiences growing up in similar contexts were used to complement the stories of the participants. While such personal experiences and familiarities could be illuminating, they could present a dilemma of disconnecting the ‘self’ from ‘otherness’. Yet, by the merits of interpretivism, knowledge production is a shared endeavour and jointly constructed between researchers and their study participants. In consequence, attempts have been made to minimize extensive references to the ‘self’ contrary to ‘the other’. As Tamale (Reference Tamale2005) admonished, the task of researchers in contributing to knowledge ought to outweigh any other loyalties.
Results
Narrative data from the participants revealed considerable similarities as well as some dissimilarities in everyday SRHR experiences of the adolescents studied. Recurrent SRHR experiences were sexual violence and sexual harassment (of girls and by girls), teenage pregnancy, abortion, menstrual and personal hygiene management, peer pressure and influence, transactional sexual relationships, parental neglect and poverty. However, the meanings and interpretations, as well as the weight placed on these ‘realities’, varied by age, sex and location. What follows describes the key experiences and how they are conceptualized by different demographics.
Victimization of sexual violence
Sexual violence predominantly occurs between men and women as a result of power imbalance. Viewed as an extreme form of gender-based violence (Tavara, Reference Tavara2006), it presents both short- and long-term negative consequences for victims. The adolescents who participated in the study were aware and knew of different kinds of unwanted sexual advances or practices in their immediate contexts. There were several spontaneous accounts of sexual violence victimization in their communities. However, the scale/magnitude and conceptualization of these experiences varied. The participants described two kinds of gender-based sexual violence in their communities. On the one hand were sexual acts that involved force/violence and coercion. Younger female adolescents often used phrases and words that pointed to coercion and force as the prevalent forms of sexual violence in their communities. Narratives suggested peculiar vulnerabilities of younger adolescent girls; their sexual experiences were usually devoid of consent. Some of the younger adolescent participants recounted instances of older boys/men kidnapping and forcing and sedating/tranquilizing girls in their networks (mixing alcoholic and non-alcoholic drinks with sedating drugs) for sex. Again, participating adolescent girls – younger and older – often mentioned incidents of gang rape. The form (and nature) was, however, more subtle, calculated and perpetrated by close associates. Clubbing is a popular youth culture in many parts of the world (Davies et al., Reference Davies, Smith, Johansson, Hill, Brown, Conroy and Fiona Measham2019). According to the participants, some peers and older boys and men took advantage of such occasions to abuse their female acquaintances and friends sexually. The local expression common across study communities is gala, reminiscent of how inter-schools sporting activities are named in Ghana. This is more likely to occur when boys and girls jointly attend parties where a sedative could be added to a drink of whatever form – alcoholic or non-alcoholic – to get easy access to victims. ‘On some occasions when they go to nightclubs, the boys will put tramadol into drinks for the girls and have sex with them in turns,’ said a 13-year-old girl from Yonso Mampong. The narratives of the participants resonated strongly with similar stories I often heard growing up in a small town in central Ghana. It was common to hear stories of adolescents who had been gang raped (commonly referred as gala) the night before, especially if there were cinema shows. Looking back, it appeared an acceptable norm, and often the adolescent/young girl(s) involved were blamed as the cause rather than considered as victims. Questions such as ‘what was she doing with the boys at that time?’ and ‘that girl deserved it because she likes to be around boys too much,’ were common comments following such narratives/accounts.
Also, older men/boys sometimes could pose as benefactors only to entrap girls into their rooms and ambush them for sexual intercourse. Girls who are victimized under these pretexts are often requested to run errands for the perpetrators. It is often gradual and incremental to build some form of trust. Many homesteads in Ghana have more than one household, partly due to the housing arrangements in the country. In such homesteads, it is common for adult men to solicit adolescent girls in providing housekeeping support services, and the older men may in turn offer the girls/women financial or in-kind support when the need arises. These mutually ‘beneficial’ relationships may be offered to older men – often outside a girls’ residential unit. The author shares a similar experience; he offered domestic assistance to a teacher, who in turn provided him extra tuition in mathematics. These relationships can sometimes blossom into a strong trusting relationship but may mark the beginning of sexual violence victimization. ‘Sometimes they will ask you to come and do something for them in the room and they lock the door so that no one can hear you scream for help,’ noted a 12-year-old girl in Jamestown, Accra. ‘It happened in that room (pointing to a room). There is a girl [staying there] called Adwoa, who was entrapped by an older boy. The boy told her [the girl] to send maize into the room, and the boy also followed her into the room and had sex with the girl,’ corroborated a 13-year-old boy in Alikope. An older adolescent, 16 years old, had had a similar experience. She was helping a man with household chores, a tenant in her father’s house – about 40 years of age. On one occasion, while she was undertaking a routine task, the man began making unsolicited sexual comments, gave her money and asked her to return in the evening since her mother was away. She was, however, not the man’s only target. She says, ‘I told my friend and she also confirmed that he [that same man] had made similar gestures towards her.’
Sexual harassment
Sexual harassment in Ghana is well documented, especially in workplaces, universities and secondary schools (Agyepong et al., Reference Agyepong, Opare, Owusu-Banahene and Yarquah2011; Norman et al., Reference Norman, Aikins and Binka2013a, Reference Norman, Aikins and Binka2013b). However, it is often framed as a gendered phenomenon, with women and girls being victimized. What is less well documented is whether and how boys/men conceptualize sexual harassment. Adolescent boys frequently talked about their own notions of sexual harassment. The notions of boys about sexual harassment centred around two issues and they differed between younger and older adolescent boys. Younger adolescent boys described certain girls as daring, egalitarian and assertive, freely mixing and interacting with boys, and they were uncomfortable being around them. To some of the boys, such girls were cheapening themselves by intruding too much into boys’ spaces. The notion was that some girls are extremely intrusive of the opposite sex, which can trigger sexual urges in boys. Thus, some girls get into boys’ spaces when they are not invited. ‘Sometimes, the girls mingle with the boys too much and that causes sexual problems for both sides,’ (Boy, 13 years).
The older adolescent boys discussed and described certain behaviours of young girls as a form of sexual harassment. Their concerns included how girls dressed and what they considered to be inappropriate and sexually suggestive and inviting. Adolescent males in this situation described girls’ dress as ‘wilful provocation’, sometimes exposing certain body parts such as the breast to the sexual arousal of boys. To them, such ways of dressing were indirect ways women/girls employ to seduce them (boys/men). This view was mainly evident in the narratives of older adolescent boys. In fact, many perceived that girls dressed in particular styles to primarily attract men’s attention. A boy, 18 years, noted, ‘Sometimes, the ladies [girls] show their breast to attract guys. As a man, you become confused when you see it. If you are not careful, you can get into trouble.’ Nonetheless, the accounts of the participants did not give an indication of people uninformed about the consequences of capitalizing on girls’ so-called sexually provocative dressing to initiate forced sexual practices. As their stories showed, they seem to concede to personal responsibilities for young people to manage and control their sexual arousal, even though they may be provoked.
For adolescent girls, sexual harassment centred around unwelcome comments about their bodies, persistent propositioning and plain insults when boys/men have been unsuccessful in seeking their attention or love. ‘The boys in the community are always pestering us for sex,’ said a 14-year-old girl. Another girl, aged 15 years, added, ‘Aunty [moderator], sometimes they [boys] can give you a dress down for rejecting their propositions. It’s very painful.’ ‘Some of the boys, when they propose to you and you turn them down, they disparage you; they get annoyed and label you as proud. If they were your friends previously, they withdraw from you,’ agonizingly narrated by a 16-year-old adolescent girl.
Parenting, poverty and transactional sex
Adolescence is a complex phase of life. It is a stage characterized by an array of social, physical and emotional needs. The switch from childhood to adulthood can be a turbulent period in the lives of adolescents (Sawyer et al., Reference Sawyer, Afifi, Bearinger, Blakemore, Dick, Ezeh and Patton2012, Reference Sawyer, Azzopardi, Wickremarathne and Patton2018). All categories of adolescents studied spoke of parental neglect as a common life experience of adolescents in their communities. They frequently said this was a major trigger for adolescents, especially girls, to engage in sexual activities very early – which is often transactional sex. They noted that while it was wilful neglect by some parents, in others, it was driven by poverty and the inability to provide for the emerging needs of adolescents, especially girls. These circumstances, according to them, ‘compelled’ some adolescents to make explicit and implicit financial and other forms of demands on boys/men. The girls reported being unable to say no to men who make sexual demands due to a sense of obligation. ‘Due to poverty, some girls make demands from boys/men for different needs. The boys/men then condition the provision on exchange for sexual intercourse,’ said a 14-year-old girl in Grade 7.
Where parental neglect was a stated phenomenon, participants tended to point to fathers, in many instances, as the cause of this predicament. Mothers were nevertheless not absolved of ‘complicity’. In essence, the accounts of the adolescents show that individual agency and parental circumstances asserted an important influence on adolescent sexual behaviours. ‘For some of the adolescents, their fathers do not provide for them so they engage in transactional sex for money,’ said a 13-year-old girl. Adolescents were also aware that parental neglect of the provider role could be caused by adolescents’ own deviant behaviours. In such situations, parents withdrew courtesies to adolescents as retribution or to protest against aberrant attitudes. Linda, a 14-year-old girl in primary/Grade 6, emphasized, ‘Some parents do not take care of the needs of their adolescent children due to their [adolescents’] stubbornness and bad manners. Such girls end up taking on men who take advantage of their already precarious situation for sex–money exchanges.’ For girls who are not resilient enough, recourse to transactional relationships becomes an easier option. This study’s data also revealed stories about parents who consciously or unconsciously pushed their daughters into transactional relationships. Older adolescents shared personal stories about their parents, usually mothers, refusing to provide their basic needs because they [the mothers] felt that they should be able acquire certain things on their own. This was frequently stated by out-of-school adolescents (participants who had either completed Grades 6, 9 or 12 or hadn’t completed any level or never attended school).
Menstrual hygiene and management
The adolescents also discussed issues regarding menstrual hygiene and management. However, this was only mentioned among participants in the Upper East – the only region in the north studied. Interestingly, both adolescent boys and girls consistently emphasized this as a common concern of adolescent girls. The concerns related mainly to pains, and for a few, a lack of sanitary products. For some participants, it was either a personal experience or accounts of other relations – friends or sisters. Even though the participants wished for treatment of the recurrent menstrual pains, many didn’t receive this. Some, with the approval of their mothers, resorted to local herbs to surmount this challenge: ‘I experience pains but I don’t have orthodox medical treatment. Only recently that my mother got me some herbs and it is now getting better,’ (14-year-old girl). Among boys in the same locality, menstrual pains emerged in the FGDs with older adolescent males. Other female participants discussed experiencing irregular flow, coupled with lack of sanitary pads – both on a personal level and that of acquaintances.
Peer and social media pressure
The older adolescent females who participated in the study talked about the traditional peer pressure that almost all adolescents go through transitioning into adulthood. A new dimension that emerged in their accounts was the increasing pressures arising from the ebullient lifestyles showcased on social media. For older girls, both forms of pressures on their lives centred around consumer items like clothing, mobile phones and shoes. They figured that it was always appealing seeing their friends or peers displaying affluence or modernity on social media platforms. Older adolescent girls noted that this was a constant challenge they needed to navigate and circumvent. An 18-year-old participant described: ‘The images we see on social media like Facebook, Instagram, influence many of us young girls. When you see someone displaying riches on social media, you are captivated to attain similar status by getting a male sponsor.’
Pregnancy prevention (access to contraceptives), unintended pregnancies and abortion
Another distinctive reality of older adolescent females was their acknowledgement of a lack of adequate knowledge on the fertility cycle. Many of them thought that sufficient information on the reproductive cycle would help adolescents prevent unintended pregnancies. The participating adolescents knew that complete sexual abstinence was virtually impossible. Access to contraceptives in Ghanaian communities is a common struggle adolescents face on a pervasive scale; either providers decline or adolescents fear being reported to their parents/guardians (Biddlecom et al., Reference Biddlecom, Munthali, Singh and Woog2007), yet many are sexually active at about 15 years – a biological, social and political reality that cannot be ignored. Older female adolescents relentlessly hammered on about the impracticability of complete abstinence: ‘For the thing [sex] no matter what you do people will still do it. They will still have sex so the best way is they should teach how to prevent pregnancy,’ (17-year-old girl). Amidst the difficulties in accessing contraceptives, they frequently urged improved access to information and education to adolescents about how to prevent pregnancies. One means that was a pervasive desire for these adolescents was how to track and apply the ovulation cycle to prevent unintended pregnancies. ‘We the girls do not know that this time when I sleep [have sex] with a man, I could become pregnant.’ They say this is a way to make them smarter because the adolescent stage is characterized by strong desires for sex. Restriction on keeping condoms, especially among older adolescents in secondary school settings, was a pervasive concern among older adolescents. ‘People have been having sex in schools. A lot of people do it especially during entertainment shows (a weekly musical or video show performed in boarding secondary schools in Ghana) so to me the best thing to end it is to allow the students to use condoms. My school, for instance, if they see a condom with you they will dismiss you from the school but the condom is for protection so they should legalize its use in schools.’
Teenage fertility, with its effects on schooling and health of teenagers, is an unbated developmental concern in Ghana and other similar settings. Teenage pregnancy was unanimously mentioned in virtually all the discussions with the adolescents, both male and female. The perception of the magnitude of the phenomenon, however, varied from community to community. Adjectives varied but very high and high were common. Every participant who spoke to this concern also knew one or another contemporary who had become pregnant or impregnated a girl. With many of the adolescent pregnancies being unintended, participating adolescents frequently said that induced abortions were also common in their communities. Similar to participants’ personal knowledge of teenage mothers and fathers, some knew individuals who had either aborted or collaborated in aborting a pregnancy. One participant, a 14-year-old boy, surprisingly cited his sister as having undergone an abortion: ‘My sister has even aborted not long ago.’
However, teenage pregnancy was not a reality in all the study communities. In one rural community, for instance, older adolescent boys were certain that teenage pregnancy was now uncommon compared with a few years back. They, nevertheless, acknowledged that heterosexual relationships among adolescents was a common reality. ‘In this community, we don’t have problems of teenage pregnancy. I have not seen any pregnant teenager in this community,’ stated a 15-year-old boy. Another in the same group corroborated, ‘We don’t experience teenage pregnancies even though sexual relationships among adolescent males–females are common,’ (18-year-old boy). Further analysis of the plots in the transcripts revealed that this particular community was a hotspot for sexual and reproductive health interventions that actively promote contraceptive use among sexually active people, which is perhaps underpinning these histories.
In many communities, participants revealed that teenage pregnancy has become a common trigger of child marriages. They contended that even though children are not explicitly offered for marriage, in many instances parents insist that the men responsible marry their daughters. This is often the case if the man is considered affluent or wealthy. Adolescent girls in these situations rarely get a second chance to return to school, notwithstanding a favourable government policy to encourage this. One girl asserted, ‘Here they still do the child marriage but they do it indirectly. For some of the mothers, when their daughter is impregnated by a boy from affluent home or a rich old man, they might not complain until the girl gets pregnant at which point they insist on marriage, contending her future prospects have been destroyed due to pregnancy. They will do everything possible for the man to marry the little girl because of money’ (14 years, Techiman).
Discussion
The voices of adolescents are important to understanding the sexual and reproductive health environments in which they live and function. With renewed attention towards adolescent sexual and reproductive health and rights, understanding the evolving and emerging realities adolescents face in their communities is relevant for programmes and interventions. This is particularly relevant when such daily experiences are constructed and narrated by adolescents themselves. This was the overarching objective of this study. To aid this understanding, social construction of reality provided a theoretical lens through which to view adolescents sexual and reproductive health dilemmas.
The adolescents in this study experienced diverse forms of unwanted sexual events. Often, adolescents have to navigate through these encounters in silence with little to no information, knowledge or skills on how to traverse such complex and conflicting arenas. Coerced sex, rape and defilement were common sexual and reproductive health realities the young people were often confronted with, yet the data highlighted different nuances for males and female and young and older adolescents. In particular, younger adolescent girls’ stories, generally affirmed by their counterpart males, often pointed to the hazards girls face constantly. Dovetailed in the chronicles of sexual harassment, it was noted that the underlying notions of patriarchal entitlements to female sexuality is a major antecedent that drives men and boys’ inclination to harass young girls who decline their sexual overtures. This is done through threats, insults and open confrontation. As the descriptions show, trusting relationships between adolescents and older men/boys often result in coerced or unwanted sexual advances. The literature on sexual violence asserts a high prevalence/incidence of sexual abuse in trusting relationships (Reemtsma, Reference Reemtsma2012; Eiler et al., Reference Eiler, Al-Kire, Doyle and Wayment2019). While the victims often assume safety around their perpetrators, the latter’s victimization is enacted in the most unexpected circumstances (Macleod & Saraga, Reference Macleod and Saraga1987; McAliden Reference Mcalinden2006). This is the reality of many adolescent girls in the communities studied.
Of note, some adolescent males held the notion that the defining characteristics of an ideal and responsible woman was her dress code, failing which boys/men justified sexually harassing such women. While acknowledging that it was wrong to sexually abuse/violate girls/women over the way they dress, their accounts revealed an unspoken impression of girls/women as the cause of sexual harassment and victimization. Beliefs of this nature are very common across many patriarchal societies where women are located as ‘provocateurs’ who make themselves available and invite sexual comments and advances from men, howebeit aggressive (Lodhia, Reference Lodhia2015; Wolfendale, Reference Wolfendale2016). Such opinions were gleaned from the storylines of both younger and older male adolescents; while the views of younger male adolescents centred around what they described as girls intruding into the spaces of boys, and ultimately suggestive of sexual invitations, older boys saw this largely in what girls/women wore. Lodhia (Reference Lodhia2015), in her study of sexual violence in India, for instance, noted such pervasive views among men. Viewed through another lens, the narratives of younger adolescent boys about girls’ intrusive attitudes signify some limited appreciation of respectful relationship among peers and friends and that people of the opposite sex could not form mutually respectful relationships without sexualizing the motives of the other. This is where some form of sexuality education may become important, particularly at the formation stages of young people as espoused in the International Technical Guidance on Sexuality Education (UNESCO et al., 2018).
The results also highlight the persisting difficulties adolescents face in accessing contraceptives, including condoms, for the prevention of unintended pregnancies and STIs. In school settings, this is made more difficult, as mere possession of any form of contraception is grounds for punishment by school authorities, informed by a presumption of intent on the possessor. However, this is contrary to what has been observed about the actual sexual activities of young people. For instance, the notional/expected age of secondary school students being 15–18 years coincides with the median age at first sexual intercourse for young people aged 15–24 years in Ghana, which is presently estimated at 17 years for both sexes, with 62% and 47% of females and males, respectively, having ever had sex by the age of 24 (Amo-Adjei & Tuoyire, Reference Amo-Adjei and Tuoyire2018). As the participants admit, sexual activity is common in schools regardless of what the authorities seek to do. This makes such norms counterproductive to the health and well-being of adolescents, which authorities consciously or unconsciously seek to protect. Evidence abounds about the important protective role of access to contraceptives among young people (Langhaug et al., Reference Langhaug, Cowan and Nyamurera2003; Shaw, Reference Shaw2009). Duty bearers’ recognition of young people’s sexuality as normal and healthy, exercised within the bounds of adequate knowledge of risks, rights and responsibilities, is an important step towards healthy development.
Peer influence on the lives and choices of adolescents is an age-old experience (McCoy et al., Reference McCoy, Dimler, Samuels and Natsuaki2019). The form and nature of pressures and resultant behaviours are gendered. Risk-taking behaviours that can result in physical injuries and harm (e.g. drunk driving, smoking, drug use) are more common in males (McCoy et al., Reference McCoy, Dimler, Samuels and Natsuaki2019). On the other hand, the literature posits female dominance in other forms of peer pressure such as fashion (McNeill, Reference McNeill2018; McNeill & Venter, Reference McNeill and Venter2019) and sex and sexual relationships (Leclerc-Madlala, Reference Leclerc-Madlala2003; Masvawure, Reference Masvawure2010; Stoebenau et al., Reference Stoebenau, Heise, Wamoyi and Bobrova2016). Whereas any manifestation of peer pressure was not mentioned among the male participants, it was different among the older female adolescents. Many thought having friends constantly posting images of their new acquisitions of modern consumables was a constant struggle they had to traverse. The advent of new forms of media (e.g. Facebook, Twitter and Instagram) presents novel non-personal yet powerful dimensions of peer pressure on adolescents. Celebrity lifestyles manifested in the consumption of high-end consumables (e.g. the latest brands of mobile phone, bag, dress, etc.) are steadily driving many young people to the brink of emotional stress, feelings of inadequacy/failure, and in extreme cases, suicidal ideations (Perloff, Reference Perloff2014). Recent media reports in Ghana and documented in mainstream scholarship contend that actual and attempted suicide among Ghanaian adolescents is reminiscent of social media portrayals of success or failure (Nii-Boye Quanrshie et al., Reference Nii-Boye Quarshie, Osafo, Akotia and Peprah2015). These emerging trends require life skill interventions capable of building the confidence of adolescents beyond social media portrayals.
The findings affirm those of earlier studies (Steobenau et al., Reference Stoebenau, Heise, Wamoyi and Bobrova2016) that illustrate a connection between poverty and initiation of transactional sex and sex work among adolescents in sub-Saharan Africa. Nonetheless, the views shared by this study population are relatively nuanced; while it is considered an easy option to escape consumption for many young women, for others it is a way of expressing agency amidst limited life opportunities. For others, it is a social norm that is ingrained in their immediate family and household background (Wamoyi et al., Reference Wamoyi, Wight, Plummer, Mshana and Ross2010). The assertions of participants in this study are inclined towards the school of thought that downplays agency in transactional sexual relationships of female adolescents. In this study, the participants pointed to some parents as conscious or unconscious promoters of transactional sexual affairs for their daughters. Some available evidence indicates that in some communities, parents (especially mothers) can deliberately or reflexively scorn their adolescent daughters for not being able to meet their basic needs despite knowing too well that their daughters are not working to earn incomes. The unstated but certain indication is the overt encouragement of girls to initiate and form financially rewarding sexual relationships (Wamoyi et al., Reference Wamoyi, Fenwick, Urassa, Zaba and Stones2011). Participating adolescents, for instance, cited some sort of ‘overtly arranged’ marriages of adolescents to older affluent men. While parents do not compel their daughters to marry in the adolescence period, they can overlook sexual relationships of their young unmarried daughters with older men but tend to insist on marriage once the girls become pregnant. This is done in anticipation of the direct financial benefits that will accrue directly to daughters, and to parents indirectly.
Going back to theory, it becomes clear that many sexual and reproductive health realities of adolescents can be genuinely beyond their control or volition, as postulated by Berger and Luckmann (Reference Berger and Luckmann1991). They are daily ‘struggles’ that cannot be ignored and left to adolescents to resolve, even though they know about these realities. These realities, and adolescents’ knowledge of the same, are diverse in time and space. Several of the experiences recounted by the participants reveal a certain image of ‘institutionalized’ practices which place adolescents in situations where their right to safe sexual and reproductive health functioning may be compromised. Worse still, some of these realities (e.g. social media and peer pressure, access to contraceptives, sexual harassment and victimization) may be overlooked or taken for granted (Vera, Reference Vera, Schlaudt and Lara Huber2015) by the appropriate social structures and systems.
In conclusion, this study explored the daily SRHR concerns that adolescents across different communities in Ghana have to constantly cross as they interact with peers and adults alike. While the experiences are similar across communities, there are unique discourses espoused by younger adolescent females and males on the one hand, and older adolescent males and females on the other hand. While some of the stories point to macro-level difficulties (e.g. access to contraceptives, adequate knowledge/information on SRHR, safety and protection against sexual violence), there are equally important micro-level realities adolescents continuously have to circumvent (e.g. social media and peer pressure, parental responsibilities). Multi-dimensional policies and solutions will be useful in tackling these. At the individual level, sexual and reproductive health education programmes that speak to respectful relationships with others, values, knowledge of body physiology, self-confidence and positive self-identity are central to minimizing risks and building resilience to unfavourable socio-cultural and economic obstacles. Beyond the individual level, adolescents need protection against sexual violence and harassment as well as access to contraceptives and the knowledge to use them correctly.
Funding
This research received no specific grant from any funding agency, commercial entity or not-for-profit organization.
Conflicts of Interest
The author has no conflicts of interest to declare.
Ethical Approval
The study protocol was reviewed and approved by the Institutional Review Board of University of Cape Coast. Informed consent, confidentiality, privacy and anonymity of study participants were adhered to during and after data collections.
