Navigating a sensitive developmental stage, adolescents and young people must learn about the biological and social aspects of safe and meaningful intimate relations. For many, access to confidential sexual and reproductive healthcare services is a crucial part of this process. Based on the findings of a qualitative study, Mokhantšo Makoae, Tholang Mokhele, Tsidiso Tolla and Zitha Mokomane describe how the unsupportive and hostile attitudes of healthcare workers might discourage help seeking, constituting ‘structural violence’ towards young people.
South Africa has a comprehensive framework of laws and policies for the provision of sexual and reproductive health services to adolescents and young people. These typically include contraception, pregnancy testing and care, and treatment for sexually transmitted infections.
Studies have, however, documented healthcare workers’ unsupportive and hostile treatment of young people at these points of care. Much of the hostility seems to be driven by stigma related to people’s age of sexual debut, but it discourages them from accessing care, which may lead to negative outcomes such as teenage and unwanted pregnancies, unsafe abortions, and infections.
Photo: Klaus Nielsen, Pexels
Drawing on the findings of a large qualitative study, HSRC researchers and their colleagues explored the extent to which healthcare workers’ behaviour constitutes a form of ‘structural violence’.
The HSRC’s Dr Mokhantšo Makoae and Dr Tholang Mokhele, Tsidiso Tolla from the University of Cape Town, and Prof Zitha Mokomane from the University of Pretoria describe this work in a paper published in the International Journal of Qualitative Studies on Health and Well-being.
They looked at data from a 2014 in-depth analysis of programmes for adolescent and youth sexual and reproductive health services at South Africa’s public primary healthcare facilities, including clinics, hospitals and community health centres. The researchers focused on data from group discussions with young people aged 15–24 years who had sought these services in eight of the country’s nine provinces.
The focus group discussions revealed a scenario of condescending attitudes and inappropriate questions; the ‘delegitimising’ of adolescents’ and young people’s use of certain sexual and reproductive health services; and a disregard for their confidentiality.
The following excerpts from the focus group discussions show how healthcare workers’ unfriendly, unhelpful and disrespectful conduct discouraged help-seeking behaviour:
… it is very difficult because of the attitude that we get from the [nursing] sisters … if I come here and I am not well received or they don’t speak well with me, the next time I can’t come to the place where I know I will not be treated good. (Male, 15–19 years)
… they refuse to help with family planning; it is also just the manner in which they address us. (Female, 20–24 years).
The nurses should learn to communicate well with people because we end up getting angry and not coming to the clinic or losing our respect for them … (Female, 20–24 years)
Instead of providing relevant information, healthcare workers tended to ask ‘embarrassing and inappropriate’ questions that the young people described as ‘being lectured to’, ‘interrogated’ and being ‘asked ridiculous questions’.
We are sometimes asked questions that make us feel ashamed, like whether we had sex when we go for pregnancy testing and HIV testing. I was once asked that question and that made me feel upset. (Female, 15–19 years)
When you come to get condoms, you are asked: “What you are going to do with them?” That question is embarrassing, and it makes it difficult for shy people to go and get condoms. (Male, 15–19 years)
I wanted to test for pregnancy. They asked me why I’m testing for pregnancy; am I sleeping with guys? I said I’m not sleeping with guys, and they told me to go home and why do I want to test for pregnancy if I’m not sleeping with guys. I felt very ashamed … (Female, 15–19 years)
The politics of age
Many healthcare workers seemed to believe that young people were ‘too young to be accessing such services’.
… some of the girls, when they come for contraceptives, the clinic staff ask them funny questions like “At your age are you having sex?” That makes it difficult for us to come to the clinic now. (Male, 20–24 years)
The young people felt they were framed ‘as undeserving users of sexual and reproductive health services’ and that healthcare workers underestimated their ability to assess their own needs and adopt help-seeking behaviour.
I am old enough and I know what I am doing. Whether or not I am using a condom is not her business. (Female, 20–24 years)
Photo: Klaus Nielsen, Pexels
Disregard for confidentiality
Needing services such as contraception, HIV and pregnancy testing, or treatment for sexually transmitted infections implies intimate sexual activities. Therefore, young people preferred to access these services in strict confidence. Fear of disclosure discouraged them from approaching these facilities.
Now the problem is that the clinic staff takes confidential information and shares it with parents and that makes us not want to come to the clinic. (Male, 20–24 years)
The perceived breach of confidentiality was deemed to be more prevalent in smaller communities.
The worst thing is when they know you or your relatives. They will be like “You are so young: does so-and-so know that you are here?” The result is that the next time you feel like coming to the clinic, you feel that there is no use because sometimes you don’t want your parents to know that you are coming to the clinic. So, what’s the use if they end up knowing and asking you why you went to the clinic? (Female, 20–24 years)
Those who had the financial and time resources to travel often sought services from health facilities outside their communities.
There is no privacy here – you can come here for testing [HIV] and the nurse will talk about you to the clinic staff, and the news spread[s], and everyone will know. It’s better to go to [a] clinic where you are unknown. (Female, 20–24 years)
Unlike physical violence, structural violence is not a crime-related form of violence; it is ethics related and can take the form of psychological, physical and social harm. When healthcare workers use their power and authority to deny young people access to sexual and reproductive health services, the resultant emotional discomfort or distress, including feelings of shame, embarrassment or feeling disrespected, constrains young people’s agency to be responsible for their safe sexuality, the researchers write.
There was little reassurance or information provision and some healthcare workers complained in a hostile manner that the young people’s needs were taking up their time.
I was there for family planning and that nurse … she told me that all the girls she had been testing were for pregnancy and HIV … she said she was doing the same task for the whole day and that she was tired of testing pregnant girls, and she was going on about why we were not using condoms. (Female, focus group)
Contestations about which sexual and reproductive health services were legitimate and deserving of healthcare workers’ time, and about the validity of young people’s needs, undermine collaboration between healthcare workers and patients. Even if these actions were not intended, they could have placed young people in harm’s way, the researchers write.
An implicit form of discrimination
In South Africa, people have battled a legacy of discrimination based on class, race and gender – issues that public health researchers have considered.
This study underscores that, in addition to these, young people and adolescents also face an implicit form of discrimination—such as on account of age, morality and culture —that some healthcare workers use under the guise of moral guidance to discourage sexual activity.
Photo: RODNAE Productions, Pexels
The importance of recognising structural violence
A new contribution by this paper is the finding that healthcare workers in public facilities commonly used their power to create a system of invisible obstacles that discouraged young people from using sexual and reproductive health services and put them in harm’s way.
According to the researchers, these obstacles and the mechanisms through which they were presented neatly fit the description of structural violence, as described by the Norwegian sociologist Johan Galtung (1969) as the ‘avoidable impairment of fundamental human needs or … the impairment of human life, which lowers the actual degree to which someone is able to meet their needs below that which would otherwise be possible’.
According to Galtung, the harm to people does not have to be direct and interpersonal: ‘The violence is built into the structure and shows up as unequal power and consequently as unequal life chances’.
Framing these experiences as ‘structural violence’ helps us to see the abnormalities inherent in healthcare practices.
The array of discriminatory and hostile attitudes of public healthcare providers towards young people seeking sexual and reproductive health services mirrors previous research and may be attributed to a lack of youth-friendly health services training among staff.
This paper, therefore, underscores previous recommendations calling for attitudinal training of, and sensitisation among, healthcare workers aimed at breaking down prejudices based on age and cultural norms about young people’s sexuality.
This treatment oppresses and dehumanises young people and violates their rights to sexual and reproductive healthcare. Young people must be recognised as sexual beings, and sexual and reproductive healthcare service provision must be aligned with national and international legislative and policy guidelines.
The researchers also recommend that future research explore the direct and indirect sexual and reproductive health outcomes of young people, given that structural violence produces social inequalities through social control and oppression of those who are less powerful.
This includes exploring the various mechanisms used by healthcare providers to delegitimise young people’s use of sexual and reproductive health services and how to enhance reporting and accountability at all levels.
Edited by: Antoinette Oosthuizen, a science writer in the HSRC’s Impact Centre
Dr Mokhantšo Makoae, a research director in the HSRC’s Developmental, Capable and Ethical State research division; Dr Tholang Mokhele, a senior research specialist in the HSRC’s eResearch Knowledge Centre; Tsidiso Tolla, a PhD student in the School of Public Health and Family Medicine at the University of Cape Town; and Prof Zitha Mokomane, professor and head of department in the Department of Sociology at the University of Pretoria