The four interpretative repertoires that emerged from the analysis were: sex is not for fun, gendered sexuality and parenthood, professionalizing adolescent pregnancies, and idealization of traditional family.
Sex is not for fun
The participants stated that issues related to sexuality should be approached with caution. Sexual intercourse could be dangerous because of the risk of getting a sexually transmitted infection and the risk of an unwanted pregnancy. But especially, sexual intercourse could be dangerous because it could be "misused" or "overused". Dangerous sexual intercourse was described as having too many sexual partners, having sex outside a formal union, having sex without a romantic relationship or having sex too young, and thus not being fully aware of all the implications of having sexual intercourse. The words used -and the avoidance of explicit terms- for referring to sexual intercourse among girls, created the impression of doing something illicit:
"Then all this pushes adolescents to become... [sexually active] what they should not become at that age..." (Hospital social worker, woman, FG social-health workers).
Adolescents were portrayed as unable to take responsibility and unable to understand all the consequences of sexual intercourse, while adults were perceived as more capable of doing that, and mature enough for engaging in sex. That perception conflicted with the acknowledged fact that many pregnancies of adolescent girls were fathered by adult "mature" men.
"Yes, I mean it is not a fixed rule that he is always older or adult, but...., yes, it's a tendency... a big tendency that one can observe...isn't it?... Ten years of difference... five years... [...] I mean, in the majority of cases there is that tendency that women are more attracted towards older men..., and then, because of this... men..., it is maybe easier to get involved with a younger girl..." (Hospital psychologist, man, FG social-health workers)
Participants agreed on the need to implement sex education for adolescents. The approaches to sex education varied, but the stress was mainly put on sex education as a way of preventing the adverse consequences associated with sexuality and sexual intercourse, and very little on acknowledging the pleasant aspects of sexuality. The focus was put on the sexual act, and not on its characteristics: if it was protected or not, if it was consensual or not, if it was enjoyed or not. As the focus was placed on adolescent pregnancy as a consequence of premature sexual intercourse, more than as a consequence of unprotected sex, the approach to contraceptive use among adolescents was inconsistent. Contraceptive use was thus not perceived as the key to adolescent pregnancy reduction. Focus was on delaying sex more than on using contraception. Contraceptives were perceived by some participants as a "double-edged weapon" that could lead to promiscuity or increasing sexual intercourse among adolescents.
"With contraceptives there is a double risk... [...] are we going to prevent all the consequences of early initiation of sexual relations? [...] No, instead we are going to enlarge and increase the problem at the national level. [...] For me contraceptives are like trying to cover up the sun with a finger" (Hospital gynecologist, man, FG health professionals)
As a consequence, messages regarding the promotion of contraceptive use among adolescents were ambivalent: information should be given, but not full access to the means; adolescents should be free to use contraceptives, however it would be better if they delay sexual intercourse. Messages also stressed that adolescents should use contraceptives if they were not capable of "controlling" their sexual desires, although they should control themselves and engage in other kinds of relationships. It was seen as acceptable for adolescents to use contraceptives, but many times they were perceived as unable to use them correctly and prone to overuse of some methods like emergency contraception. Finally, sentiments urged a reduction in the number of adolescent pregnancies, but society was perceived as being unwilling to accept full access to contraceptives for adolescents.
Pregnancy was perceived as a reminder of past sexual intercourse, it was the "body of the crime", as one participant expressed it. For instance, a pregnant student was a visible sign of sexual activity, in an environment where sexual intercourse should not be taking place. Participants expressed how schools' approach had changed compared to a couple of years ago when many pregnant students were discharged for fear of an adolescent pregnancy epidemic at the school or damaging the school's reputation - though this was seldom the case, and attitudes had become more supportive. In this transitional period from banning to supporting, some very strong attitudes backing pregnant girls' right to education coexisted with perceptions of pregnant girls as something that should be "hidden". At the same time that schools maintained discriminatory acts, individual teachers might choose to fight for the rights of the pregnant students.
"What happens at my school,...and it is a public school, is that they don't allow a pregnant girl to finish the academic year. I mean, because it has two schedules [day and night], the pregnant girl is sent to the night schedule. That's how the school authorities camouflage it" (Teacher, man, FG teachers)
"But, colleague, you should have asked that question to the authorities at your school: 'And what would happen if that pregnant girl had been your daughter?'... Just to see how will he look at it from that perspective... We do those things [expel a pregnant student], because they do not personally affect us... [...] Then, that's the task that we who are working in the educational field have: we have to invite our colleagues to reconsider their positions... we have to be aware that those adolescents, those youngsters that are in process... they are part of us... and we have to stand for their rights" (Teacher, woman, FG teachers)
A way of sanctioning sexual intercourse was ensuring that it was performed within a committed relationship, and the institutionalization of this commitment was a formal union or marriage. Thus, sexual intercourse between adolescents -or between an adolescent and an adult-somehow acquired legitimacy if it was done within a formal union.
"She may be a child, but if she has a husband with her, then nothing happens. People might say, 'what a pity she is so young; but, she has a husband'. And she could be older, but has a baby anyway without a husband; she too has problems. I mean, it is problematic to get pregnant without a husband..." (Teacher, FG teachers)
Gendered sexuality and parenthood
Gender influenced the way sexuality and sexual intercourse were perceived. While men were expected to be sexually driven, women were expected to be less in need of sex. Sexual relationships were modulated by these assumptions: men would always try to get sex with girls, and girls should be hard to conquer. Whenever a man had sex it must have been because he wanted to, whenever a girl had sex it could have been because she was talked into it. Boys had sex because that was their nature, girls had sex as a way of expressing compromise.
"Ah..., let's say that when a man is 30 years old, he..., then, what happens?... that men...the...what..., it is in man's nature to have sex fixed inside his head and nothing more. So, the first thing he is going to do is look for a woman... [...] he doesn't measure the consequences" (hospital gynecologist, man, FG health professionals)
"Sometimes girls let themselves be persuaded, seduced, ...that crazy youth who deceives them...This is what happens to those who don't attend school. And after being seduced, they get pregnant" (Head provincial sex education program, man).
Responsibility for preventing sexual intercourse, preventing pregnancy, preventing sexually transmitted infections was placed on the shoulders of girls, since men and boys were perceived as unreliable, not caring at all, and even intentionally wicked.
"[Regarding why boys don't use contraceptives] Sometimes, it is because of lack of information... even men! [...] But many times I think is just wickedness, just to say 'I slept with that girl, I don't care if I get her pregnant! It's her problem"' (Medical doctor working with gender-based violence, woman)
Only providers working with gender-based violence raised the issue of sexual violence. According to them, sexual intercourse for girls often took place within an environment of coercion or overt violence. Males were perceived as violent and abusive, taking advantage of girls' need of love and affection not worried about the possibility of getting them pregnant or infected. The "sugar daddy" phenomenon-dating and sexual intercourse between adult better-off men and local adolescent girls in exchange of gifts or payment for education- was perceived as frequent and labeled as sexual abuse by them. On the other hand, providers not familiar with gender-based violence in their practices, were less stringent in their definition of sexual abuse, and considered sexual intercourse between a girl and an adult not as a sexual offense but merely as a prank.
"The girl used to go to..., in that house some workers from the oil company rented rooms, and the girl, she was 12, or 13, she was only in her last year of primary school. And the girl well, since, since she didn't have money for buying clothes she went to the men's rooms and let them touch her... [...] Her grandparents even encouraged her. And one of these guys decided to risk having sex with this girl... [laughs]. But the money was not for the girl, but for the grandparents" (Teacher, man, FG teachers)
Sexual intercourse was constructed within gender norms, and the same applied to parenthood. Gender norms influenced parenthood and sexuality in opposite directions: while men were "naturally" prepared for sex, they were unreliable as fathers, and while women were not sexually driven, they made sacrificed and selfless mothers. Men and women, sexuality and parenthood were opposed elements:
"Men have the idea that the only one responsible for pregnancy is the woman, OK? It is because shedidn't use contraception" (Medical doctor working with gender-based violence, woman)
For girls, adolescent pregnancy was perceived as dangerous because of the potential obstetric and neonatal complications as well as the socioeconomic impact. However, providers agreed that once pregnancy occurred, the girl should be encouraged to endure it, leaving limited room for abortion.
"In this case I ask her, 'Do you want to see your baby?' ... Since she tells me that because she has not a belly, there is nothing there... I told her: 'Let's have a look...' You don't feel it because he is still little, and there is all this liquid surrounding him...' Imagine after seeing him like that..., 'Well I respect your decision, if you want to have an abortion is your decision, OK?... If you are going to have one, do it in a safe place, with all the warrants, to ensure that you do not put yourself in danger... [...] 'Then she stared..., with tears in her eyes... [...] and I asked her: 'Do you know the father of the baby?' She told me that he has been a classmate, that they went to a party, he made her drunk and sexually abused her... [...] And she told me: 'Doctor, being like this I did not want to have an abortion' [...] From that point on she was a patient that did not miss a prenatal control... Now she takes the baby to the controls... she loves her baby!" (Medical doctor working with gender-based violence, woman)
Fathers were absent in the discourse of adolescent pregnancies in Orellana. Efforts to engage fathers in the care and economic support for the babies were lacking within adolescent pregnancy programs. From this repertoire, the subject of the adolescent mother was constructed as single, lonely, victimized, and economically deprivated since she had not a partner supporting her. At the same time the adolescent mother was expected to sacrifice all for her baby, because she couldn't count on the father, and even the society did not dare to make the father accountable.
"[When asking regarding the fathers] They leave..., they disappear... It's men's irresponsibility as well" (Hospital gynecologist, man, FG health professionals)
"They are the mothers..., they are the ones who have to wake up at night, isn't it so? They have attained a greater responsibility than what they had before..., yet they... continue... being... adolescents. Obviously no..., as I said in the beginning..., they aren't going to be able to go partying all weekend or traveling all week, because they have to take care of their child" (Hospital psychologist, man, FG social-health workers)
Professionalizing adolescent pregnancy
Knowledge regarding adolescent pregnancies in Orellana was compartmentalized and quite hierarchical. For many years adolescent pregnancies had been a common experience within this province, dealt with by families and communities in different ways but now they became labeled as a health and social problem, the field of professionals.
"Only recently during the last few years, people are talking about adolescent pregnancy... we have known about it for many years but nobody said anything, nobody said anything, what should we do? ...Let's say that if there is going to be a campaign to prevent adolescent pregnancy, let's say that people should know, should talk about it..." (Provincial ministry of welfare officer, man)
The construction of adolescent pregnancies as a problem came from the national level, and has produced a number of documents, plans and policies, that also contributed to reinforce the conceptualization of adolescent pregnancy as a problem that should be approached by professionals. Providers and policy makers used a technical language filled with scientific terms-rates, percentages, risks, obstetric complications, adolescent-friendly services, subsequent pregnancies- and references to scientific literature, "experts" opinions, situation analysis, national plans and policies, and professional experience.
Participants distanced themselves from the ones who were "suffering" the problem-lay people, uneducated people, people from the bush, poor people. Since professional knowledge is acquired through years of formal education, it also lead to segregation between the adolescents -who were "suffering" the problem of adolescent pregnancies- and the adults -who were technically qualified for "dealing" with the problem. This, adult-centric approach had consequences in the way providers approached adolescents. They were not treated as autonomous individuals but as incomplete and immature, unable to make their own decisions.
"It is precisely with that kind of patient [pregnant girl] that it is better to do the consultation together with her mother or father; maybe the mother will have more influence on the girl... I mean, to tell her 'this is how you should behave, this is how you shouldn't behave"' (Hospital midwife, woman, FG health professionals)
It has to be acknowledged that providers all seemed interested and willing to help adolescent girls. Many were already seeing pregnant adolescents during consultation or at school, and were worried for them, especially when they didn't follow the advices that were intended to help them. In that sense, adolescents were classified into "good patients" -the ones who comply with the doctor's recommendations- and "bad patients". Many times providers talked about "their patients" or "their adolescents", in an attempt to express their closeness with them. However, this could also be seen as a possessive approach to adolescents. They used diminutives as "mamita" (mommy) or "mijita" (my little girl), which could be regarded as a way of gaining trust, but also as a way of patronizing girls. Confidentiality and privacy were felt as necessary to ensure adolescents' access to services. However, participants recalled many occasions when those were completely disregarded:
"I first approached the girl [a student at his institution], 'hey my little girl' I say 'isn't it possible that you are pregnant? ... I swear that I won't mistreat you'...What can I say? 'No, my little girl, seeing, seeing your changes...., you are pregnant my love.' 'No' she told me, 'they keep on saying that I am pregnant, but I am not.' Well, nothing happens. I go and buy the pregnancy test. I tell her, 'My little girl, let's go get you a pregnancy test.' And just at that moment the concierge was there so I asked her to help me with a urine test [of the girl], and I did the test... I took it and two lines appeared... There I tell her, 'See, my love, you are pregnant"' (Teacher, man, FG teachers)
Youth participation was strongly supported by the providers, however, the way it was understood varied. For many, adolescents' participation meant inviting adolescents to participate in plans and programs developed by professionals, since adolescents' opinions on the issue were not perceived as important as professionals' judgments. Others, mainly the youngest participants, talked of the need, and lack, of a more active and critical adolescent participation at all levels of planning, implementing and monitoring.
"Regional workshops have also been held... where mainly... where... where young people have said how they want health providers to treat them... [Representatives from] all the institutions attended and young people said that they want to be treated like this and like that... [...] And health care providers... said 'that's too idealistic, that can't be done'... So, it was as if...., as if they said ... 'that's impossible [...], of course, we are here to listen to your proposals but..." (Youth representative of the Andean Committee for Adolescence Pregnancy Prevention, woman)
The adult professionals did not constitute a homogeneous group; there were hierarchies between the different professions: the medical profession was perceived as responsible for adolescent pregnancy prevention and management, and medical knowledge was perceived as the most important for dealing with adolescent pregnancies. The expertise of educational providers, social providers and, especially, providers working with gender-based violence, was perceived as complementary to the medical discourse when dealing with adolescent pregnancies and adolescents' health. Doctors were perceived as the most competent in dealing with sexuality and adolescents' health issues, even if many adolescents' health complaints were not defined as medical problems. Thus the possibility of pregnancy due to rape, or the connections between adolescent pregnancies and violence were only expressed by providers working with gender-based violence. Sexual abuse outside, but especially inside, families, was perceived as very frequent, but the connection with adolescent pregnancies was seldom expressed. Participants working on gender-based violence, felt left out of the planning and implementation of programs addressing adolescents' reproductive and sexual health and pregnancy prevention.
"It could be that yes, that [health care providers] are not trained or that they don't have the approach of [gender-based] violence, sexual violence... and they just focus on the pathological aspects, treat the disease and that's all. So, look here, these people need to be trained and just refer the patient nothing more..., that would be great [...] But, unfortunately every time that we want to raise the issue even slightly... they look at us ... I don't know what to think anymore... I, truthfully, I have chosen to not say anything when I go to the meetings" (Head of NGO working with gender based violence, woman).
Idealization of traditional family
Another important repertoire was the idealization of traditional family. Family was perceived as key to adolescent pregnancy prevention, and fundamental for adequately raising children and adolescents, by socially reproducing the values that were perceived as good. Even if the medical sector was perceived as more capable of dealing with adolescent pregnancy, the family remained the most responsible for what might happen to adolescents, in terms of sexuality and reproduction.
"Because education is based there [in the family]. We cannot expect that adolescents will be taught about values and principles and reproductive health at school or high school or the university because these are values that they learn at home. If adolescents are not taught these values at home, it doesn't matter how much they give them at school, they will never learn them" (Hospital gynecologist, man, FG health providers)
The "traditional" family was perceived as a shelter, a positive environment for learning good behavior. The "traditional" family was described more as a heterosexual nuclear family, than as an extended family, following the patriarchal model of father, mother and children, all caring, but also all knowing each others' hierarchical roles: parents deciding, children obeying. Single-parented families were perceived as defective and at higher risk of raising problematic children or girls who got pregnant early.
"For example, father, mother and children... well structured. Father goes to work... that would be a modern family...But, the father migrates to Spain, the mother is left alone... there is no order. The father is father and he is always going to be setting an example for his sons and daughters... and the same applies to the mother" (Hospital midwife, woman, FG health professionals)
Traditional family was perceived as fundamental to the survival of the Ecuadorian way of life, and thus "different" ways of constructing families, or challenges to those traditional values (related to family formation, sexuality and reproduction) were presented as an undesirable foreign influence that should not be followed by Ecuador. There were many opinions in favor of strengthening and educating families as the key to adolescents' proper development, and centering responsibility for sex education in the family.
"Society has put a lot of emphasis on the school, and this is not the solution... [...] We should join together to rescue the families... [...] I think that would be the most effective and suitable... Because the girls who get pregnant, they are girls who are cold, empty, who have not experienced love, affection...and who better than a father, than a mother to give them this affection?" (Responsible for students welfare at a secondary school, woman)
At the same time, participants acknowledged that families, even when fulfilling the characteristics of the "traditional nuclear model", were sometimes dangerous for adolescents' health and proper upbringing. The interviews were full of perceptions and experiences of violence and sexual abuse within the families. There were comments regarding families that forced adolescents to engage with older men for money; domestic violence against children and adolescents was perceived as a strong reason for girls running away from home, or seeking a partner as a way of escaping from abusive families; incest was perceived as common.
"Yes..., they knew..., they knew from the first day. From when the girl tells me that she has been sexually abused until she finds out that she is pregnant, it is a long time and her mother knew! 'And even though you knew' I told her 'even though you knew, you were not able to bring your daughter so that they could help her' [...] It was a girl who suffered from sexual abuse for two years..., the husband, the father has been sexually abusing her..." (Medical doctor working with gender-based violence, woman)