The trip took us to ten districts where we were interacting and working with adolescents and health workers on adolescent sexual and reproductive health. It gave us new insight and knowledge about the situation of adolescent health in the rural areas of Nepal. Obviously, the needs and expectations of adolescents were changing in the rapidly changing society. More imperative than ever was for the national government and local communities, as well as parents and immediate family members, to understand the value of open discussions with the adolescents about their feelings on sexuality, sexual relationships, their concerns and find safe and effective ways to resolve them. From our discussions with adolescent boys and girls, it was clear to us that many lacked good parental guidance and good counseling, which can lead to larger societal and health problems.
During this situation analysis, issues concerning poor social status of girl child and adolescent girls, lack of knowledge of young boys and girls about sexual and reproductive health and the responsible behavior associated frequently came up. In some of the districts, some participants said child marriage is not practiced in the village. However, eloping without family consent at a young age was common and therefore child marriages still existed in a different form. We heard of an incident of a 13-year old girl eloping with a 14-year old boy. One mother reported, "I had thought of supporting my daughters for higher studies. I wanted them to study a lot. My elder daughter ran away while studying in class 12. I fear the same would happen in the case of my younger daughter. So I arranged her marriage while she was in class 10 although I wished I did not have to do that."
Elopement and child marriage are thus having consequences that affect the whole family.
We also learned that engaging in pre-marital sex was thought to be common, even though it is considered a taboo in many places. Adolescents (males) talked openly about their sexual behavior, although some were initially hesitant. In some remote hilly areas, boys as young as 16 reported having sex before marriage and even having multiple sex partners and practicing unsafe sex at times. This type of practice has concerned parents. Many mothers pointed out that "our children do not go to health facilities to discuss about their sexual and reproductive health, as health workers are unavailable there most of the time. Even if health workers are available, they are not trained to provide education and counseling on sexual and reproductive health issues."
This concern expressed by parents illustrates that they understand the needs of their adolescent children but are worried that health care workers cannot provide any services, guidance or counseling to them. Adolescents themselves also raised the issue of confidentiality in health centers time and again. Participants said health facilities need to have a separate room for the adolescent consultation. They pointed out that "counseling services should be provided to young people by ensuring privacy and confidentiality. Because of unavailability of a separate room, we find it difficult to talk freely and openly with health workers and if we have some reproductive health problems we go to another city or even a district far from our village so that no one would know about our problem and it takes money and time, but we do not have other option.”
Participants also pointed out that in some of their communities if a girl gets pregnant or the community finds out she is, then the girl is married to the man with whom she had engaged in sexual relations, even in cases of sexual abuse. Though there are options for safe abortions, the community gives priority to marriage rather than opting for abortion. Only if the man (sexual partner) runs away or is otherwise unavailable, then abortion services are sought. In some of the Tarai regions, it was found that the girls were taken to India for abortion so that no one would know about that.
While the talks on sexual and reproductive health of the girls center around pregnancies and abortion, it was found that adolescent boys had their own sexual health issues. Many times they are told by others that nightfall (swapna dosh ) was a disease and they were worried about it. They went for treatment from quacks and spent money and time only to get disappointed. Many times they were worried that they would not be able to have good sexual life after marriage if they had nightfall. It is clear that boys are also in a great need of knowledge about their bodies and should be taught that it is a natural process and nothing to worry about. In the far west, the issue of Chhaupadi (staying inside a small hut outside of home) was raised again and again and it was pointed out that reproductive health of the young girls has been negatively affected by this practice and mothers and faith healers are still afraid to omit this practice. However it was found that some local organizations are trying to raise voices against this. "It may take a long time to erase this bad practice from our society," some FCHV pointed out in many places.
FCHV said adolescent girls should be involved in mothers' group and educated on RH issues and boys should be given education and knowledge about what is harmful and what is natural. A father from Far West realized and was vocal about this, "There is a problem of not discussing sexual matters in home. They (adolescents) seem to be unknown about with whom they can keep sexual relationship and when to do so. They have understood it as recreation.”
From most of the districts, the most frequent recommendation was providing sex and reproductive health and right education in schools to boys and girls. This would alleviate some of the problems associated with reproductive health issues. Many parents also pointed out that adolescents should also be given education about their responsibilities as well.
(This article is based on the situation analysis report conducted by Britain Nepal Medical Trust in ten districts, namely, Achham, Bajura, Doti , Kailali , Dang, Sindupalchowk, Nawalparasi, Kapilbastu , Panchatar , Kalikot of Nepal in 2011.)
Dr. Aruna uprety is Technical Adviser of BNMT