In Senegal, an anthropological study analyzes the social constraints faced by adolescents living with HIV when they enter into sexuality.
In Africa, the shortcomings of programs to prevent the transmission of HIV from mother to child during pregnancy still lead to a fairly high number of births of children with HIV. At the same time, with the generalization of drug treatment programs antiretrovirals (ARV) and early medical care of children born with HIV, the number of adolescents living with HIV is gradually increasing. In Senegal, 13-19 year olds represent about 36% of the 6 under 700 living with HIV (estimates, Spectrum 2018.
During adolescence, the question arises for them – and their families – of the entry into sexuality: what are the constraints that adolescents and their families have to face? What support or accompaniment can they benefit from to manage this delicate period in their lives?
An anthropological study, aimed at describe and analyze the socio-cultural and organizational dimensions medical and social care for children and adolescents living with HIV in rural areas, was carried out in Senegal in 2020–2021.
Surveys were carried out in 14 regional hospitals and health centers in 11 regions of Senegal. Interviews and observations involved 85 HIV+ children/adolescents, 92 parents/guardians and 47 healthcare workers. The entry of adolescents into sexuality has been the subject of a specific analysis.
(All first names are fictitious and the story is anonymized.)
“Amy is 22 years old, she lives in a town very far from the capital (Dakar). Her mother died when she was three years old and she was raised by Fatou, her maternal aunt, herself a mother of three children. A strong affective relationship binds Amy and her guardian who was very attached to her mother.
Amy has been on ARVs since a young age, without knowing her HIV status. At 17, she had periods of rebellion and refusal of treatment, and wanted to know the nature of her illness. Her aunt feared the shock of the announcement and the disclosure of the disease that she had always carefully hidden from those around her. Only she and her husband were informed. After consultation with the social worker at the health center where Amy is followed, Fatou revealed her HIV status to her.
His adherence to ARV treatment improved after these discussions. In the following year, the girl became more flirtatious, and often went out with her friends. Fatou was worried about her niece's future and the idea that she might have sex. She confided in the social worker. This one offered to receive, when the time came, the fiancé of Amy, when it would be question of marriage, in order to discuss with him.
A year later, Fatou discovers that Amy is pregnant. This pregnancy triggers a family scandal that forces Amy to leave home and seek refuge with a cousin in a remote village. Fatou was blamed for her lack of supervision and the shame that fell on the family. Far from the health center where she was usually followed, Amy did not say she was HIV-positive and stopped taking her treatment. She gave birth in a clinic near her new home. Three months after the birth – when she had returned to her aunt – a test revealed that her child was HIV-positive. »
Amy's story reveals a set of constraints that determine the ability of adolescents and their family environment to manage the entry into sexuality.
In Senegal, the dominant social norm values virginity before marriage, and establishes abstinence for adolescents as a cardinal moral value. Sexuality outside marriage is condemned and the virginity of girls at marriage is promoted as an ideal; the constraint is less for the boys, to whom a simple temperance is recommended.
The use of contraception is socially reserved for married couples. Dramas linked to clandestine abortions or infanticide regularly make the headlines in a context of criminalization of voluntary termination of pregnancy. Abortions and infanticides constitute the first reason for incarceration women in Senegal.
The attitude of parents towards adolescents varies according to gender. For girls, pregnancies out of wedlock are frowned upon or condemned: they bring stigma to the girl and her family. The heads of families attribute the responsibility to the mothers or guardians who are found guilty of not having been able to “hold their daughter”.
These pregnancies are often the cause of violent family tensions, fear of which explains abortion attempts. In rural areas, the early marriage of girls is often considered to be the best solution to prevent accidental pregnancy. For boys, the appeal to religious morality or discretion is the only instruction.
The sexual health of adolescents in Senegal is a major social and public health issue: the 2017 Demographic and Health Survey revealed that 19% of women had their first birth before the age of 18, 8% of women 17 years old had started their reproductive life (DHS 2017). For several years, various “reproductive health” programs for adolescents have been developed across the country.
Supported by the Ministry of Health and the Ministry of the Family or NGOs, they broadcast information in the form of TV series (eg. Positive ; It's life), smartphone applications (Hello Teen, Bibl CLV), with the aim of combating early pregnancies – the main causes of early school leaving among young girls –, early marriages, female genital mutilation and sexually transmitted infections.
“Teen Clubs” have been set up in the capital and secondary towns. These programs are regularly the object of virulent criticism from social actors, most often religious, who consider their content to be inconsistent with traditions and moral values. Access to these programs is often limited for teenagers in rural areas, whose standard of living does not allow them to own a smartphone.
Pejorative social representations with regard to HIV/AIDS fuel another register of constraints influencing the entry into sexuality. In families, the care of children and adolescents living with HIV is most often marked by various forms of silence around the disease. The primary concern of parents or guardians is to maintain absolute secrecy about the child's illness, as it is indicative of that of its biological parents.
When the child is orphaned by parents who may have died of HIV, guardian silence about these events is appropriate. For the remarried mother of an HIV-positive child, the risk of disclosure of the child's status is perceived as a threat likely to destroy this new union. The nature of the disease is revealed to the child as late as possible, lest he reveal this information indiscriminately in the entourage and neighborhood. Parents wish to protect themselves – and the child – against the risks of stigmatization and discrimination.
Various strategies are put in place to preserve confidentiality among members of the same household or within the family (medications or their consumption are hidden; pretexts are found to justify frequent visits to the health center, etc.). The arrival of an adolescent living with HIV of marriageable age and the possibility of his entry into sexuality reactivate the fears of his parents or guardians. They are torn between the desire that their child can have a normal life while respecting social proprieties through marriage, and the fear that on this occasion the existence of the disease in the family will be publicly revealed.
Responses from health professionals and HIV care providers
In response to government requirements, many health professionals throughout the country are required to participate in the implementation of various reproductive health programs that are in principle open to adolescents. Our survey shows that many professionals disapprove of strategies that facilitate access to contraception for adolescents.
For personal moral reasons or for fear of being accused of promoting sex outside marriage, many are resistant to the idea of providing contraception for adolescents. The criminalization of termination of pregnancy led some to report suspicions of voluntary abortion to the gendarmerie so as not to be prosecuted for complicity.
When questions of sexuality concern adolescents living with HIV, they are most often directed towards the social service of the health structure: social workers and mediators in conjunction with associations of PLHIV. These actors have a central role in supporting children and adolescents living with HIV; they are often the ones who best know the history of the disease of children and adolescents, who advise them and try to reinforce their adherence to medical follow-up.
To reinforce the motivation to take ARV treatment, which is still just as restrictive, they frequently remind us “that with ARVs you can live normally, get married and have children […]; you don't have to say you're sick”. If they address the question of sexuality in a pithy way, it is rare that they develop this subject. For them too, sexuality is considered only within the matrimonial framework: they promote abstinence before marriage – which they recommend as late as possible – and suggest that parents and adolescents return "when the time is right". .
This attitude, which consists in postponing the response, reflects the difficulties of health actors in proposing solutions in line with both their moral values and the needs of the younger generations. When the possibility of a marriage becomes clearer, some mediators offer various strategies to inform the future spouse: carrying out an HIV test for the two suitors, then announcing their seropositivity with warning of legal threats in the event of disclosure of the diagnostic.
In some associations of PLHIV, mediators play the role of matchmaker by facilitating the identification of a spouse among the HIV+ members of the association, thus promoting a kind of serological endogamy which will guarantee the preservation of secrecy around the disease. .
Outside the major urban centers, adolescents have very limited, if any, access to information on sexuality and contraceptives. The high number of teenage pregnancies is the result of difficulties in taking into account the needs of this age group.
Adolescents living with HIV face the silence imposed on the disease and the denial of their sexuality. An individualized approach, centered on their needs, should be promoted, in particular through confidential access to contraceptives. This approach could be supported by associations of PLHIV, whose skills development would make it possible to support adolescents in this crucial stage of their lives.
This article is from the study "Therapeutic failure in children and adolescents living with HIV in a decentralized context in Senegal, anthropological approach" (ETEA-VIH, ANRS 12421) carried out by the research team: Alioune Diagne, Halimatou Diallo, Maimouna Diop, Seynabou Diop, Fatoumata Hane, Ndeye Ngone Have, Oumou Kantom Fall, Ndeye Bineta Ndiaye Coulibaly, Gabrièle Laborde-Balen, Khoudia Sow, Bernard Taverne.
Maimouna Diop, PhD student in community health, University of Bambey (Senegal), research assistant at the Regional Center for Research and Training in Clinical Management of Fann — CRCF, CHNU Fann, Dakar (Senegal), Alioune Diop University of Bambey; Bernard Tavern, Anthropologist, physician, Research Institute for Development (IRD); Gabriele Laborde-Balen, Anthropologist, Regional Center for Research and Training in Clinical Management of Fann (CRCF, Dakar), Research Institute for Development (IRD), and Khoudia Sow, Researcher in anthropology of health (CRCF) / TransVIHMI, Research Institute for Development (IRD)