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Muted voices: HIV/AIDS and the young people of Burkina Faso and Senegal Lise Rosendal Østergaard & Helle Samuelsen Published online: 11 Nov 2009.

To cite this article: Lise Rosendal Østergaard & Helle Samuelsen (2004) Muted voices: HIV/AIDS and the young people of Burkina Faso and Senegal, African Journal of AIDS Research, 3:2, 103-112, DOI: 10.2989/16085900409490324 To link to this article: http://dx.doi.org/10.2989/16085900409490324

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African Journal of AIDS Research 2004, 3(2): 103–112 Printed in South Africa — All rights reserved

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Muted voices: HIV/AIDS and the young people of Burkina Faso and Senegal Lise Rosendal Østergaard1* and Helle Samuelsen2 AIDSNET —The Danish NGO Network on AIDS and Development, Rosenørns Allé 12-1, DK-1634, Copenhagen, Denmark Department of International Health, Institute of Public Health, University of Copenhagen, 5 Øster Farimagsgade, Building 16, PO Box 2099, DK-1014, Copenhagen,.Denmark * Corresponding author, e-mail: lro@aidsnet. dk 1

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This article explores the discrepancies between the vocal public discourse on HIV/AIDS and sexuality as generally encouraged by policy-makers and donor communities in Africa, and the often hushed voices of their target groups: young people in African communities. Based on fieldwork among urban youth in Senegal and Burkina Faso, we describe the silence of young people with regard to HIV/AIDS and sexuality as a social phenomenon, with focus given to family relations, peer relations and gender aspects in partnerships. Drawing on Foucault and Morrell, an inability and unwillingness to speak about HIV/AIDS and sexuality are analysed as a response to an everyday life characterised by uncertainty. This response represents a certain degree of resistance, while it constitutes a major barrier to any HIV/AIDS prevention effort. Finally, we stress that despite great constraints in their everyday lives, young people have some room to manoeuvre and are able to apply some negotiating strategies to reduce sexuallyrelated health risks. Keywords: Africa, communication, peer behaviour, prevention, sexuality, youth

Introduction To talk or not to talk about the risk of sexually-transmitted HIV infection has become an increasingly visible theme in the fight against HIV/AIDS over the past years. The role of communication as a prevention strategy is predominant in relation to young people in sub-Saharan Africa. The intent of interventions concerned with behaviour change through information, communication, peer education and a variety of organised group activities which facilitate dialogue about sexual risk reduction, relationships and HIV/AIDS has been to create an environment where young people are more open about their sexuality. Such initiatives, however, have not yielded the expected results. Young people in the cities of Mbour (Senegal) and Bobo-Dioulasso (Burkina Faso), where our studies took place, remain reluctant to talk about HIV/AIDS. We addressed young people because of the dramatic toll that the HIV/AIDS pandemic has taken on their communities. Our study looks into the reasons why behaviour-change interventions may not be working in some communities. During the past few years, the theme of sexuality has been discussed more openly in the international donor community as well as among many African governments (Becker & Collignon, 1999; UNFPA, 2002b). Despite sharp political tension and pointed protests from certain countries and religious groups, a less timid discourse on sexuality and women’s rights has gained visibility and has been incorporated in a so-called ‘improved United Nationslanguage’, as for example in the UNGASS declaration on HIV/AIDS from 2001 and the Plan of Action from the ICPD+5 review in 1999, as well as in many national African HIV/AIDS

plans and policies. Although some researchers have recently challenged the assumption that HIV transmission in subSaharan Africa is primarily transmitted by sexual activity (Gisselquist, Potterat, Rothenberg, Drucker, Brody, Brewer & Minkin, 2003), it is clear that the documented high level of sexually-transmitted HIV infection has pushed donors and politicians to discuss sexuality in a way that was uncommon in the mid-1990s. Harmful sexual practices, sexual pleasure, multi-partnership and intergenerational sex are no longer referred to in an anecdotal manner but addressed, to some extent, as serious risk factors that are having a direct impact on the life of young people. Also striking is that the intense rhetoric among policy-makers and opinion leaders has not, according to our findings, generated the same kind of debate among the people most concerned: young people in the early stages of their sexual lives. Even though it is their future that is threatened, HIV/AIDS remains to a large extent an unspoken topic. There seems to be a mismatch between the vociferous rhetoric at the global level and the relative silence at the individual or relational level where the most important stakeholders, young women and men, are remaining reticent about debates concerning HIV/AIDS. In keeping with recent social theory on young people, HIV/AIDS, power, silence and resistance, this article explores why so many young people may remain silent in regard to their own exposure to HIV/AIDS. While more than just talk about sex is needed to overcome the immense obstacles that allow the rapid spread of HIV/AIDS among young people, as evidenced by the failure of many information, education and communication interventions, we

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argue that the first step is to acknowledge and explore people’s reluctance to talk with partners and peers about this risk. The silence of sexually-active adolescents is complex, as it is both a response to a hierarchical family structure as well as a form of discrete resistance to the efforts of authorities — be they adults in general or health care providers and other experts. In that sense silence can amplify the risk of sexually-transmitted HIV infection while it keeps prevention messages from being fully internalised or actively shared.

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HIV/AIDS in sub-Saharan Africa HIV/AIDS is a global catastrophe but sub-Saharan Africa is at the epicentre of the epidemic. According to data from UNAIDS (2004), approximately 23–28 million people are reported to be living with HIV/AIDS in the region. In 2004, approximately 2.7–3.8 million new cases were reported and only 50 000 people were reported to have access to highly active antiretroviral treatment (HAART). Although West Africa is not experiencing a generalized HIV/AIDS epidemic of the same magnitude as in southern and eastern Africa, the condition is causing increased human suffering and having progressive social and economic impact in individual countries. HIV/AIDS in Burkina Faso and Senegal is predominantly heterosexuallytransmitted. Furthermore, both countries have adopted important awareness campaigns and behaviour-change activities, such as those launched under the slogan ‘Rompre le silence’ (‘Break the silence’). In Burkina Faso, HIV/AIDS prevalence among those aged 15–49 is estimated at 6.5% (UNAIDS, 2002b). Prevalence among young people aged 15–24 is characterised by important gender disparities. The prevalence estimate for young men varies from 3.2% to 4.8%, while it is more than double that for young women, at 7.8% to 11.7% (UNAIDS, 2001). In a review of some 50 knowledge, attitudes and practices (KAP) studies from Burkina Faso, Desclaux (1997) found that although basic knowledge about AIDS, its modes of transmission and the most important preventive methods had improved over a 10year period (1986–1996), some groups of people, especially young women in rural areas, remained quite uninformed, and various erroneous ideas about the contagiousness of HIV/AIDS still prevailed. In a study among pregnant women, long-distance truck drivers and prostitutes in BoboDioulasso (Meda, Sangaré, Lankoandé, Compaoré, Catraye, Sanou, Van Dyck, Cartoux & Soudre, 1998), more than 96% of those questioned had heard about AIDS. However, 41% of the pregnant women, 40% of the truck drivers and an alarming 61% of the female prostitutes did not see themselves personally at risk. According to the most recent Demographic and Health Survey (DHS) from Burkina Faso (INSD, 1998/1999), 98.7% of urban females and 99.8% of urban males had heard about HIV/AIDS. In addition, 58.7% and 78.8% of urban females and males, respectively, knew that using condoms could prevent HIV/AIDS (INSD, 2000). However, the DHS also showed that only about 3% of young women aged 15–24 used a condom during their most recent sexual relationship. The

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percentage for men in the same age group was significantly higher (40%) (INSD, 2000). Studies in Senegal similarly show a gap between knowledge and practice (Republique du Sénégal, 1997); people do not necessarily change passive awareness into active self-protection just because they gain new knowledge or information. As statistics show, it is not enough to pass on the message that people should make behavioural changes while knowing little about how those messages are interpreted in a local cultural context and how their meaning is worked out and negotiated among sexual partners. Senegal is considered one of the few success stories in the global fight against AIDS (UNAIDS, 2000; Piot & Coll Seck, 2001; Barnett & Whiteside, 2002; Family Health International, 2001; UNAIDS, 2002a; UNFPA, 2002a; Thompson, 2003). The country has experienced a concentrated epidemic since 1986, when the first six cases there were reported to the World Health Organization, but it now has an estimated prevalence of around 1% of the adult population (UNAIDS, 2004). However, important variations within the adult population can be noted. National epidemiological data from sentinel sites show a prevalence of 0.5–1.5% among pregnant women, 4% among male patients at clinics which treat sexually-transmitted infections (STIs) and a prevalence of 15–33% among female commercial sex workers (Republique du Sénégal, 2002). The official Senegalese discourse — referring to l’exception Sénégalaise (Republique du Sénégal, 2001, p. 13) — points to national political commitment, the religious leadership among the Muslim brotherhoods and a strong national AIDS programme that has been untouched for the past decade by changes in key staff. Other researchers mention the systematic screening for STIs and HIV among female commercial sex workers as well as a delay of age in onset of sexual activity to 17 years for women (Barnett & Whiteside, 2002; Family Health International, 2001). The nascent phases of the epidemic in many parts of Africa were characterised by denial and the blaming of immigrants from neighbouring countries (Becher, 1993). AIDS was initially considered an imported problem, but that attitude has changed, and changing governments have since adopted a number of AIDS action plans. Today there is a growing media and political focus on the impact of the epidemic, and all politicians and intellectuals are familiar with HIV/AIDS-related terms. Yet, it must be noted that the language used in both Senegalese as well as Burkinabe campaigns on ‘Fidelité ou la capote’ (‘Faithfulness or condoms’) is dominated by Western policy and biomedical thinking, sponsored by specialised UN agencies and Western NGOs, and voiced by an increasingly wellorganised AIDS-NGO community. In Senegal and Burkina Faso there appears to be limited established place for anthropologists’ examinations of local perceptions of the complexity of the condition or of the underlying contextual factors that impede prevention. To paraphrase Heald (2002a), it is time to reflect on the absence of ethnographic understanding of local knowledge, especially now when UNAIDS is advocating increased cultural sensitivity and the integration of local practices and institutions into prevention programmes.

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The increase in HIV incidence among adolescent girls in Senegal and Burkina Faso provides a marker for the future direction of the epidemic. This trend inspires the question of how long Senegal, for example, can maintain its relatively low prevalence level even if the focus on so-called high-risk groups is maintained but the broader sexual and reproductive health concerns of young women are ignored.

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Focus on young people If Africa is the geographic epicentre of the HIV/AIDS epidemic, young people (10–24) are certainly the nucleus of this epicentre. Adolescence (10–19) is a formative life period in all cultures, although it will likely manifest itself differently depending on historical, social and cultural factors. In Senegal and Burkina Faso, the years from childhood to adulthood include the management of nascent sexuality, development of gender roles, decreasing authority of parents and increasing links to peers and partners. What happens during this period in any domain is crucial for the quality of life of the individual. Much of the anthropological literature on youth emphasises agency and how young people are actively engaged in the construction and reconstruction of their own identity as well as in shaping their role in the community. But our arguments are more in line with Cole (2004) when she calls for an approach that ‘places youth in changing historical, political and economic circumstances’ (p. 574); hence, it is possible to examine young people’s attitudes towards HIV/AIDS, lover relationships and gender roles in relation to the economic situation they live in. The threat of HIV infection, and having to link the pleasures of sex to death, is a burden to young people. Youth is in most cases a healthy period of life. It is critical to remember that to most people sexuality is about anything other than health protection, as noted by Gammeltoft (2002). Even in communities with a high prevalence of HIV/AIDS and other STIs, people might not fully acknowledge that they know they are exposed to risks (Setel, 1999; Collins & Stadler, 2000; Dilger, 2003). We know little about whether or not young people in reality underestimate their own exposure to risk as compared to adults, but we do know that they do expose themselves to risks. Caldwell (2000) has further suggested that risk-taking — including sexual risks — under peer pressure is an important characteristic of the period of adolescence. The public health reason for focussing on young people in relation to HIV/AIDS is well founded in sheer numbers alone. According to UNAIDS (2002b) and UNFPA (2002a), 67% of all newly-infected young individuals are females between 15 and 24 years. That puts young women as well as the young men that they may later marry under great pressure. It has been argued by Mensch, Bruce & Greene (1998) that while adolescence is a time of critical capacity-building for both sexes, it is in particular a period of heightened vulnerability for girls: ‘During adolescence, the world expands for boys and contracts for girls. Boys enjoy new privileges reserved for men; girls endure new restrictions reserved for women’ (p. 2). It is a basic assumption of this article that gender issues are critical to any analysis of HIV/AIDS, especially effective prevention efforts.

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We began by introducing the discrepancies between global discourse and the realm of local life. Although policy interest in youth and sexual risks and practices has grown considerably over the past two decades, there is still a shortage of data on how and to what extent young people themselves talk about sexuality, gender issues and bodily functions in low-income countries. Furthermore, much of the problem-oriented research has taken place in the context of adult activities and concerns (Bucholtz, 2002), with the many KAP studies serving as an example. As discussed by Desclaux (1997) and Parker (2001), KAP studies provide useful quantitative and comparable data regarding how an individual might answer a question when directly asked. But that type of study provides us with little insight into what people themselves would bring up as an issue had they not been probed. Sexuality and other controversial issues seem particularly unfit for such a study design. We know very little about how young people draw on the catalogue of passive knowledge that they may possess and how they might translate this into active prevention. We still lack detailed and well-founded analyses of the dynamics between local cultural practices, the global cultural discourses articulated in the mass media and the numerous health awareness campaigns (Tufte, 2003). Regardless of the many audience analyses undertaken by health communication specialists, we have limited insight into how young people in reality make sense of the maelstrom of prevention messages and how they perceive their own vulnerability. More striking is how little we know about why young people prefer to be silent about AIDS in a situation where they are increasingly confronted with HIV/AIDS information campaigns. For obvious reasons, KAP studies do not report silence and pauses, but — as we shall see below — in order to understand young people we should pay more attention to the issues that they do not bring up. We argue that the unwillingness to speak should not be understood only as the outcome of individual decisions but also as a sociallyproduced phenomenon which needs to be understood in a broader social context. Public discourses and silence To understand the tension between articulated discourses and silence, we should explore the relationship between sexuality and the phenomenon of ‘not speaking’. The French philosopher Michel Foucault described the ‘discursive explosion’ around and about sex as characteristic of the last three centuries (Foucault, 1998, p. 17). With the HIV/AIDS epidemic, we have experienced a discursive explosion on sexuality particularly during the last few decades, although the purpose and ways of communicating this discourse is very different from the one analysed by Foucault. In The History of Sexuality, Foucault (1998) describes the changing discourses on sexuality in Western Europe from the Victorian period to present-day bourgeois society, with a focus on the relationships between sexuality, knowledge and power. He describes one of the characteristics of this period as: ‘an institutional incitement to speak about it [sexuality], and to do so more and more; a determination on the

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part of the agencies of power to hear it spoken about, and to cause it to speak through explicit articulation and endlessly accumulated detail’ (Foucault, 1998, p. 8). While the overall idea of liberation and individual freedom is not enveloping today’s discourse on sexuality as it did a few hundred years ago, we see the same accelerating tendency of engaging in public and explicit articulations about sexuality at a global level today, where international as well as national institutions and governments are becoming involved in the AIDS pandemic. The current discursive environment is clearly very different from that of the 17th and 18th centuries, but technologies of power and the relationship between sexuality, language and power are important aspects of both discourses. Today, components of HIV prevention and communication activities about AIDS are beginning to be mainstreamed into a great many development projects in all sectors, often without prior consultations with project participants and rarely with solid knowledge of local perceptions about HIV/AIDS (Holden, 2003). ‘In the eighteenth century, when referring to sex …one had to speak of it as of a thing to be not simply condemned or tolerated but managed, inserted into systems of utility, regulated for the greater good of all, made to function according to an optimum. Sex was not something one simply judged; it was a thing one administered’ (Foucault, 1998, p. 24). To speak about sexuality in terms of something that should be administered is also a common feature in today’s public discourse where moral issues related to sex are absent in the public discourses, with the exception of the discourse of the current US administration. Moral issues related to sex and sexuality are not included in the public discourses on HIV/AIDS and sexuality. The terminology is neutral; rather than using words like promiscuity, for example, we talk about multi-partnerships. This approach helps reduce further stigmatisation and discrimination. However, in many communities, at least in West Africa, sex and sexuality is still a highly moral issue. Foucault argues that the need to pronounce a discourse on sex was originally based on an attempt to regulate sex as a technique of power. With capitalism, the administration and regulation of the ‘population’ became important. The future of a society was tied not only to the number of its citizens, their marriage rules and family organisations, but also to the manner in which each individual chose to be sexual (Foucault, 1998, p. 26). The need to regulate the population is perhaps even stronger today where the AIDS epidemic kills many adults during their most productive years, and thus orphans many children and young people whose chances of becoming productive citizens are compromised. Today, the regulating of sexuality is not so much about creating prosperous states but more about avoiding the total collapse of entire societies. Foucault (1998) described an increasing control of where and when one could speak about sexuality, adding in that there were areas or relationships where it seemed totally inappropriate to talk about sexuality: ‘Areas were thus established, if not of utter silence, at least of tact and discretion: between parents and children, for instance, or teachers and pupils, or masters and domestic servants’ (p. 8).

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In other words, it is important not only to focus on what is actually spoken about in public discourses, but also to pay attention to silence. What is the distribution of those who can and those who cannot speak about sex and sexuality? Which types of discourses are authorised and which forms of discretion are required in specific situations? Foucault states that the silence ‘functions alongside things said’; speech and silence together form discourse; speech or silence alone do not (Foucault cited in White, 2000). For the purpose of this article, we draw on the operational definition of silence that Morrell (2003) has developed on the basis of Foucault’s insights. This definition distinguishes between social and personal silence: ‘…[silence] is a social phenomenon experienced collectively. The language of discourse offers a useful way to explain silence. Silence is a result of prohibition and policing (Foucault, 1978). Understood in this way, silence is a suppressed discourse. It is thus an effect of power. Dominant discourses permit and legitimate certain vocabularies and values while marginalizing or silencing others. The second meaning which I give silence is personal. A person who either feels unable to talk about certain subjects or emotions or is unaware of certain aspects of his or her history suffers from silence’ (p. 31). These two definitions of silence should be understood in relation to each other, as they mutually fuel one another. Parallel to the voiced public discourses on AIDS and sexuality, we also find an unwillingness to speak. Silence might be interpreted as a form of repression, as part of a technology of power; individuals or groups of people are muted, and they do not possess the power to speak. Silence can also be an expression of resistance; individuals or groups of people do not want to speak. Or silence might be interpreted in other ways. For example, the silence of suffering as described by Morris (1997, p. 27) is a sign of something which is ultimately unknowable and, as such, silence might also be a sign of feelings of uncertainty or insecurity. Methodology Our findings are based on two methodologically similar field studies conducted in 2002 and 2003. The research design was ethnographic, based on qualitative methods. We conducted a social situational analysis in order to gain an understanding of young people’s own perceptions of their exposure to HIV/AIDS and their related risk-reduction strategies and negotiations. Although the time span of our studies was relatively short (2–3 months), we base our conclusions on the accumulated insights that we gained from work and research in Burkina Faso and Senegal since the late 1990s (see Samuelsen, 1999; 2001; 2004a; 2004b; Østergaard, 1998; 2003). Both field studies were conducted in urban settings and included focus group discussions (FGDs), ethnographic individual interviews and key informant interviews as well as participant observation. In the Senegalese study, the entry point was a youthfriendly reproductive health care centre in Mbour, a town of

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140 000 inhabitants south of the capital Dakar. The town is characterised by massive migration and an extended tourist industry. According to epidemiological surveys (e.g. République du Sénegal, 2002), the sexual and reproductive health problems are similar to those in Dakar. The Mbour study is based on the time that one of us spent living in the centre of town, close to the health centre. Our interviews and discussions were conducted with the youth, their families, the health care staff and their families over long hours. The sites used for sampling were therefore homes, clubs and schools as well as some of the many ‘open spaces’ where young people spend time. The different inquiry activities took place wherever it was convenient for the group (e.g. at a school, youth centre or home), whereas most of the in-depth personal interviews took place in the house of the researcher. The timing of the activities was adapted to the schedule of the informants; that is, when they were not attending classes and not doing their daily chores. All interviews were tape recorded with oral consent of the informant and transcribed. Informal observations were documented in fieldwork diaries. A total of 105 young people contributed to the research in Senegal: 41 by writing essays, 61 through FGDs and three by in-depth interviews. Both separate FGDs with either males or females and mixed FGDs were held. The average age of the informants was 18.8. The participants in the FGDs were recruited with the help of a local female research assistant who had been trained as a peer educator and who also served as an interpreter. The FGDs included an equal number of young people who were either in secondary school, out of school, unemployed, or who had completed a vocational training programme. In addition, data was collected through narratives written by students in two different secondary schools. A total of 40 young people, equally divided in terms of young men and women, were assembled. The writers were asked to describe the most important event in their personal life over the past two years, whether they had had any reproductive health problems, and how they had solved their last conflict with a partner. This methodology allowed for some very open individual accounts of the informants’ life projects. The study in Burkina Faso was part of a comprehensive joint research project on AIDS communication in South Africa, Vietnam and Burkina Faso. The study took place in two different parts of Bobo-Dioulasso: Ouezin and AccartVille. As in the Senegalese case, Bobo-Dioulasso is a large, modern city with high social mobility due to intense trade and migration. A total of 57 young people aged 15–25 (30 males and 27 females) participated in this study. The informants represented a number of ethnic groups but with the majority being Bobo. About half the young people (located in the Accart-Ville) had limited schooling, while the other group consisted of young people who were either still attending school or had reached an advanced level of schooling. These young people were followed over a threemonth period using anthropological fieldwork methods including FGDs, in-depth interviews and participant observation. Four local research assistants participated in the data collection. Both separate FGDs with males and females, and mixed FGDs were held. The main research

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themes were covered over a series of three FGDs with the same group of people as well as in individual interviews. Additionally, key informant interviews with radio journalists and personnel at an anonymous testing facility and at other facilities counselling and informing young people about health and sexuality were carried out. The two study sites were conveniently selected as the research assistants already had contacts in these two quarters of the city. The themes were sequenced so that the most sensitive topics were dealt with last. Most of the interviews were conducted in French with a few conducted in local languages. All the interviews were taped and transcribed, with the ones in local languages translated into French. The most important limitations for both studies were encountered during FGDs in terms of time constraints on sensitive issues. We recognise that to reach a genuine understanding of people’s local worlds it is necessary to devote more than a few months’ to fieldwork. However, the FGDs were carried out until we had reached a point of saturation — when the informants started to repeat and confirm what had been previously said by other participants. The fact that this study is comparative adds strength to the findings that we feel they would not have as stand-alone studies. The use of qualitative interviews as entry points for discussion on people’s practices in sexual matters raises the issue of validity and methodological choices. The issue can be reformulated as a question concerning how far we can trust what people choose to say in interviews on sexuality (see Gammeltoft, 2002). It must be acknowledged that people do not tell the ‘truth’ in any objective sense, particularly not when it comes to sensitive issues such as sexuality. Two analytical strategies were used to overcome the limitations related to FGDs on sensitive issues. Firstly, the FGDs were complemented with ethnographic interviews and participant observations in order to achieve more insight into young people’s dilemmas. Inasmuch as it was difficult during both studies to address sexuality and HIV by the focus group participants, the informal interactions that took place in homes over long meals, listening to music in private rooms, going to local discos, etc. provided opportunity for more in-depth exchanges of concerns and experiences. Our observations were recorded in field notes as soon as possible. Secondly, we felt it was important to identify the unspoken in the communication in order to determine any significant communicative disjunctions in the transcripts of the interviews. The openness and relaxed atmosphere of the discussions, the fact that the informants volunteered and actively sought to interact with the researchers and that they also raised questions on their own indicates to us that the validity of the studies is relatively sound. Silence in the life worlds of young people Silence and family relations In both Senegal and Burkina Faso, the lives of young people are often insecure and unpredictable. A general impression gathered from our numerous FGDs and narratives is that young people’s lives, to a great extent, are characterised by

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instability and restrained choices. This is founded not only in well-defined social constraints and gender-specific expectations that put a particularly heavy burden on young girls, but also in impoverished material and economic conditions. Although our informants did not belong to the poorest fractions of the local population, they live in household conditions characterised by scarce incomes and limited access to financial resources. This adds a certain intangible feeling of seriousness to their worlds. They seem part of a global media-channelled youth culture, yet the accessories required to live up to a globalised youth-identity are hard for them to afford. Consequently, they spend much time and energy on attaining that goal (e.g. to get the ‘right’ shoes or clothes). The striving to attain the ‘right look’ is not only self-imposed — or an effect of the wish to seem attractive in the eyes of other young people — but also very much related to the social roles they are expected to play by society. When they leave the house and enter public spaces, these young people represent not only themselves but also their families. Furthermore, their experimentation with a youth identity is intensified by the fact that in these parts of West Africa, the period of youthful experimentation is relatively short because many of them, especially the girls, are expected to get married before they reach 20. This means that for the young urban girls and boys we interviewed, their experimentation is characterised by a feeling of urgency. Many of the informants expressed a feeling of being lonely or missing a close connection with their parents. We were surprised to find that a large proportion of the informants had experienced a sense of misfortune due to: (i) the death of a parent; (ii) divorce of their parents; (iii) parents leaving the home temporarily, to work or visit their home village; (iv) being sent away as children to live with foster families; and (v) the personal experience of having a severe disease. Aïsatou, an 18-year-old girl from Mbour, Senegal, described in an essay the many dimensions related to the loss of her father: ‘The event that had the greatest impact on my personal life was the death of my father last year when I was 17. Thinking about him, I have had a lot of problems with my health as I have lost weight; his death took me by surprise… Now I suffer from concentration problems in school and I have trouble studying. But I also have financial problems because he used to give me money and that is not the case any more. Since then I think a lot about him.’ Others described how they had to deal with their bereavement alone, or with little support from any adults. Some were not able to talk about their emotions or voice their concerns over the fact that they had lost a parent. Salif, an 18-year-old young man from Bobo-Dioulasso, Burkina Faso, living with his paternal relatives, talked about the constraints he felt after both parents left him: ‘In CM1 [primary school] during the second trimester, my mother left me. I couldn’t say that I was alone, but I understood how life is. During the same class, my father left for the Ivory Coast. I stayed with my grandparents, my uncles, my paternal brothers [same father but different mother]. In CM1 my father had paid my school fees before leaving for the Ivory Coast. My

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father was not there; my mother was not there. I was then with an uncle who paid for my school (he has now passed away). In 1998–99, I got my CEP [primary education certificate]. I wanted to go to secondary school, but my uncle said that he didn’t have money for it because I had passed the age to go to a public institution. It was necessary to pay to go to a secondary school. It was not easy watching my friends go to school. But that is how it was. At that time, I had a grandfather (he is dead now) who found an apprenticeship as a car mechanic for me. That was not the kind of work I wanted.’ Others — especially girls who for various reasons were not living with their parents — often said that their guardian, typically an uncle or older brother, was too strict with them. While the extended household may provide for the basic needs of young people, many of our informants felt that they lacked emotional support and guidance. In relation to sexual and reproductive health matters, it seemed parents rarely talked with their children about sexuality or bodily functions and most of our female informants had not received any information at all about the menstrual cycle from parents or from other adults in their household. These examples of loss of a significant adult illustrate how fragile the world of young people is. A study on the impact of HIV/AIDS on children in Senegal shows how they can feel affected and threatened by the instability of the family unit (Niang & Van Ufford, 2002). Our findings show that young people who sense adults’ social and emotional instability are also clearly subject to a pronounced feeling of discomfort. They rightly perceive themselves as exposed to the risk of loss of social and economic support at a critical stage of their lives. In particular, this is a great risk for young women, who are more likely than young men to experience the impoverished living conditions and weakened social networks which follow the disruption of the family unit (Niang & Van Ufford, 2002). In an environment of degrading life conditions, the risk of HIV transmission becomes one of many threats to deal with. In the communities we worked in, according to tradition, intimate talk about sexuality is restricted to maternal aunts and to mothers. Many informants referred to their mother as the person they preferred to communicate with about reproductive and sexual matters. But quite a few of these young people were actually not living with their mothers. Thus, many choose not to share their financial, emotional or sexual problems with the adults in their extended families, although they were constantly aware of the tremendous power the same adults held over their life and future. To a large extent their silence must be interpreted as an absent discourse as a result of a social situation where they find themselves powerless and with limited agency. Their silence in relation to their parents or other adults seems to be the result of a social phenomenon that mediates the relationships of power between generations. Silence and peer relationships In the previous section, we saw that parents are often not available for their children. Nor, very often, are friends available. Yet, those interviewed called attention to the importance of friends and peer relationships. Throughout

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adolescence, these social bonds grow in influence, possibly diminishing the role of the parents in socialisation. Whereas young men often have a rather big group of male friends [grain] with whom they drink tea and spend time, the girls do not seem to have the same kind of network. The young women are more bound to their homes, where they do specific chores or support their families through income-generating activities. Young women who are still at school often have just a few close friends. Some girls said that they chose not to trust other young females out of fear of the rumours they would start if they told them anything confidential. The relationships between girls seemed to be interwoven with the fear of being let down and the need to have someone to trust. These young women clearly had the impression that their female peers would be judgemental if they disclosed a problem to them, or that they might risk losing their boyfriends. While both young males and females are quite conscious that they represent their families and their family’s honour when they leave their family homes (compounds), the close bond between young women and their households may make them more vulnerable as a consequence of their public behaviour as compared to young men. The lack of trust among female peers contributes to their vulnerability. When young women do not share experiences out of fear of being stigmatised, they lose opportunities to learn from one another and, specifically, may end up neglecting their own exposure to HIV infection and other STIs. This introduces the problem of unreliable information. Locally, young people are exposed to information from many sources, including official and accurate health information as well as rumours and misunderstanding (such as the mistaken notions that condoms are unreliable or only for white Europeans, etc.). In that atmosphere, public health messages are not routinely perceived as fact based on biomedical evidence, but offset by local knowledge and beliefs put together from friends and other sources. In combination with poor or non-existent sex education in schools and limited access to information in youth-friendly health centres, young people’s unwillingness to share experiences becomes grave because young girls especially are left without correct, or only fragmented, information on methods to prevent STIs, HIV transmission or unwanted pregnancies. The gendered silence in lover relationships Silence is not only a widespread phenomenon among samesex peers but also among young men and women in lover relationships. In the absence of a trusted female friend, a lover relationship or having a boyfriend becomes not only a constitutive part of teenage female identity but also a way of extending one’s social network. Adolescent girls find themselves dually confronted with an indirect pressure for sex from their male partners and the social obligation to avoid premarital sex. A young woman informant in Burkina Faso told us: ‘If you want your boyfriend to be faithful to you, you have to satisfy him sexually’. Such dilemmas are very often not voiced because of a lack of trust. Love, attraction and romance are among the first motives for having a boyfriend that were mentioned by the female informants, but exchange of gifts or money and group pressure were also closely associated with a lover

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relationship. During our work in Senegal it became clear that the notion of lover relationships should be put in plural: many girls were seeing more than one boyfriend at the same time. Nomadic fidelity — or infidelity — is not exclusively a male domain but also a female practice. Multi-partnership, called mbarane in the local language Wolof, and the related crisis of wavering trust and distrust, were also recurrent themes in essays collected among college students. To the girls mbarane meant ‘to have many boyfriends at the same time, good ones and bad ones; the bad ones are those who don’t give you anything, that’s the bad ones’ (female informant, FGD, Senegal). Gifts included anything from money for clothes, given before religious feasts, to simple presents such as bracelets. Seen from a male perspective, this practice was often described in terms of competition between generations, since the adult men can afford more expensive gifts than the young men. The competition is further sharpened by the fact that in Mbour, Senegal, European male tourists are known to go out with — and in some cases marry — Senegalese women, and offer them a more secure financial future. One male informant underlined the financial content of mbarane by saying: ‘If you have a boyfriend who is a driver and another one who is a tailor and another one who is a football player, well, then you’re safe’ (male informant, FGD, Senegal). The boys appeared to feel almost ashamed if they did not have a girlfriend. Dating is part of the urban youth culture. The issue of money is extremely important for both boys and young men. Speaking with two young unemployed men in their early 20s gave us a sense of the almost desperate strategies some might use. One of them, Seraphin, a 24-year-old male from Burkina Faso, was the father of a child; he did not live with his child’s mother but had nevertheless accepted his fatherhood (something he was proud of but also frustrated by because he could not support either the child or the mother). His strategy seemed to be to go to the ‘show’, which is the term young people in Burkina Faso use for going to a bar or disco as often as possible in order to amuse and distract themselves. Seraphin said: ‘I don’t have a girlfriend, I have five. Oh, yes [laughing] because, why not — it is not my fault that I have five girlfriends, it is the girls’. It is the girls who make me unfaithful; they betray me because I don’t have anything. To me they are all the same; that is why I also want to be bad to them. I have seduced many. But my base, as I told you, is the first one. If she said ‘yes’ to me today, I would drop the others.’ Being in a lover relationship is therefore of great importance to both young men and women. Yet the acknowledgment does not readily translate into greater trust among men and women, not even in the light of a deadly condition such as AIDS. Very few of our informants said that it would be possible for them to talk about or negotiate with their partner(s) any of the following strategies that are likely to protect them from HIV infection: condom use, monogamous relationships/fidelity or knowledge gained by taking an STI/HIV test. It is exactly the sexual nature of HIV/AIDS that prevents these young people from talking about it. Although most of our informants acknowledged AIDS as a problem and knew the signs and symptoms, they

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considered its existence at a distance instead of openly addressing it. Our informants generally did not recognise themselves as represented in preventive messages, and even those who were sexually active would typically say that protective measures, such as consistent condom use, would only be ‘for girls with many boyfriends, not someone like me’. We argue that young people in this scenario often ‘suffer from silence’, as suggested by Morrell (2003). They are obviously vulnerable to HIV infection but fail to see the common entry points for protection. In lover relationships their silence can be seen as an individualised problem with severe implications for their own self-protection. When sexually-active young people fail to raise issues such as condom use, fidelity, trust and other private topics that have direct implications for their own relationship(s) and healthy sexuality, they expose themselves to many otherwise avoidable risks. Manoeuvring The young urban people included in our study clearly perceive their life situations as vulnerable. Their silence regarding their sexuality is a social phenomenon that is not only restricted to situations of communicating with adults but is also dominant among themselves; to a large extent, this, as argued, can be interpreted as an effect of power. These young people feel powerless both within the domestic sphere where family roles and gender roles limit the possibilities of voicing their problems and concerns, and in public life where they do not see themselves as independent individuals but rather as representatives of their families and kin. Social structures do not empower them to speak about sexuality and respond to the public discourse on HIV/AIDS. However, the meaning of this silence might be more complex. To a certain extent, some of these young people choose to be silent. One young male informant in a FGD in Burkina Faso denied the existence of AIDS; however, in a subsequent individual interview he said that of course he knew that AIDS exists but that he did not want to talk about it: ‘Often I don’t have the time to sit down and talk about AIDS. Among friends we discuss a lot but if they start talking about AIDS, I get up and leave. I don’t like the word AIDS at all. If my friends want to get rid of me in a conversation, they can just start to talk about AIDS. They know that I don’t like it.’ This young man felt especially uncomfortable when AIDS was raised as a topic in informal conversations. Although — or perhaps because — he is well informed about the fatal outcomes of the condition and his own vulnerability, he resists talking about AIDS or even listening to others. He appears in denial in terms of his own risk, and in that sense walking out on the topic becomes a sort of powerless resistance. Silence, whether interpreted as originating from suffering, powerlessness or resistance, does not mean that young people lack agency or become fatalistic. They find ways of manoeuvring in everyday life, at moments when they actively try to manage or overcome their vulnerability. Some of their strategies may seem inappropriate from a health perspective but should be understood within the local context and the world of the informants. Two young men,

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Mohammed and Seraphin (quoted above), agreed during a FGD in Burkina Faso that they could not establish a stable relationship with a girl due to their financial problems; rather, they sought to boost their self-confidence and fight their vulnerability by having one-off affairs: ‘When you have notes [money] you can quickly find one [a girl]. So when you have money you can take a girl, you give her something to eat and you entertain yourself with her afterwards and then disappear.’ In order to cope, on the one hand, with their own vulnerability and pressure from parents and society, and maintain, on the other hand, the benefits of a lover relationship, young women in Senegal repeatedly stated that one must be malin (French for ‘clever, smart and cunning’). In addition to the semantic meaning of being clever, the female informants used the word to designate a woman who could ‘play the game’ and get more from men than what she was offering. Two female informants during a FGD in Senegal explained: ‘A girl who is malin, that’s a girl who can have many boyfriends without sleeping with them; it’s also a girl who knows what she wants, who is experienced.’ More explicitly, the next informant followed with: ‘It’s like me, I’m malin, a girl who goes out with many men without becoming pregnant’. These informants perceived the notion of malin as closely associated with knowing how to communicate — particularly, how to defend yourself in relation to men. To be malin is also to know when not to talk; the economy of information that is so obviously practised among the female informants must be seen as a part of that strategy. It also means to know when not to tell the whole truth, when it becomes necessary to defend yourself. The young people in Burkina Faso had apparently established a strong discourse on fidelity among partners. Fidelity was an issue often discussed among friends. Justine, a 19-year-old woman who did not have a boyfriend, said that when she visits her neighbour they often talk about the problems the neighbour has with her boyfriend: ‘We talk about her ga [boyfriend]. One time when she went to see her boyfriend she met another girl there; she got very angry and the boyfriend tried to give an explanation. This is what we talk about because my neighbour is very jealous.’ To be in a lover relationship appears to have a strong impact on young people’s self-perception, emotional stability and the construction of their own identity. That might be true for adolescents worldwide, but the course is more risk-prone in the context of HIV/AIDS. Many of the young women that we encountered seemed involved in a lover relationship that arguably created more problems than benefits, at least regarding the protection of sexual and reproductive health. Their choice, therefore, may be interpreted as one way of coping with uncertain life conditions. Conclusion We have outlined the global context of an increasingly pronounced public discourse on HIV/AIDS and sexuality and shown the dilemmas that the confrontation with this discourse creates in young urban people in Burkina Faso and Senegal who do not possess a language to negotiate safer sex. Our intention has been to describe the

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discrepancies between the public discourse on sexuality and the ‘silent discourse’ of the young people and to explore possible reasons for young people’s silence. We ended by discussing some strategies that young people do apply in their attempt to cope with these dilemmas. Our observations show that the paradoxical situation of having a strong public discourse on sexually-transmitted HIV, on one hand, and young people’s inability to articulate themselves with regard to sexuality and HIV, on the other hand, constitutes a serious challenge to any HIV prevention effort. This discrepancy calls for a refined analysis of the silence of young people in countries that are greatly affected by HIV/AIDS, and in particular the way that AIDS prevention messages are communicated. Our interpretation is that silence must be interpreted to some extent as an expression of powerless resistance. Knowing that they cannot protect themselves without compromising certain much-needed social and financial opportunities, young people are confronted with a complex dilemma: the pressure and power of their parents who expect them to balance traditional norms and values against their own wishes to live up to the requirements of an urban, sexualised youth culture. While public discourse on sexuality and AIDS may be consciously neutral and strongly public health-oriented with regard to morality, the local discourse on sexuality is loaded with morality and taboos. In that situation these urban African youths often feel powerless and unable to act to protect their own health. Many young people, both male and female, experience difficulties in fulfilling expected gender roles. Although both young boys and girls are subject to moral and religious restrictions, the heaviest burden is on young girls. Both sexes share the risk of STI and HIV transmission, but girls are at risk of early pregnancies and unsafe abortions. Furthermore, where the dilemma for a young man might be between him and his religious conscience, a young girl’s dilemma in relation to premarital sex is between her and society, represented by her family and in-laws. Sexual matters are, by nature, a relational affair and a change in practice requires negotiation among partners. Young people, particularly young girls who are disempowered and without strong communication skills, find themselves incapable of negotiating condom use. In terms of HIV prevention programmes, broad life-skills activities in so-called safe spaces, aimed at creating more life opportunities for young unmarried girls, seem to have the potential to empower young people. As a result of our research, we clearly see a strong need for new approaches to HIV prevention programmes as well as for related research. More critical research is needed that can explore how young people understand the prevention messages they are exposed to and how they employ that information to move from awareness to active selfprotection. We do not, however, propose a talk-about-sex model as the greatest solution to the problem of young people’s silence. We do suggest including the reality of young people and their perceptions of sexual health risk, morality and sexuality much more systematically into HIV/AIDS prevention programmes.

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Acknowledgements — The authors are grateful to the young people in Mbour and Bobo-Dioulasso who participated in this study with openness, generosity and commitment. Our work in Burkina Faso was part of a larger research project called ‘HIV/AIDS communication and prevention: a health communication project’ (2001–2004), headed by Professor Thomas Tufte, Roskilde University, and funded by the Danish Council for Development Research. Helle Samuelsen gratefully acknowledges support from the Carlsberg Foundation for a Senior Research Fellowship at Churchill College, Cambridge, UK and from the Department of International Health, University of Copenhagen. Lise Rosendal Østergaard would like to thank the Enhanced Research Capacity Programme (ENRECA) and Professor Ib Bygbjerg at Copenhagen University. Both authors thank external lecturer Jeffrey V Lazarus for valuable comments and proofreading of the text. The authors — Lise Rosendal Østergaard, MA, MIH, is co-ordinator of AIDSNET, a Danish non-governmental organisation network on AIDS and development. She has a Bachelor of Arts in French (University of Roskilde, 1994), Master of Arts in Development Studies (University of Roskilde, 1998) and Master in International Health (University of Copenhagen, 2003). From 1999 to 2001 she worked for the United Nations Population Fund (UNFPA) in the country office in Benin and in the regional technical advisory office in Senegal, where she provided technical assistance on youth involvement, health communication with adolescents and gender issues. Her research efforts have focussed on Senegal, in the areas of adolescent reproductive health and discourses on HIV/AIDS, including negotiating strategies among men and women, and HIV/AIDS among African immigrant groups in Denmark. Helle Samuelsen, PhD, is an Associate Professor in medical anthropology at the University of Copenhagen and director of the Masters Programme in International Health. Her main research interests are local perceptions of disease and illness and healthseeking behaviour. She has conducted extensive research in Burkina Faso and has recently begun to investigate adolescents and reproductive health, including HIV/AIDS, in other parts of Africa, Denmark and south-east Asia.

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