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Comment: Breaking the Silence about Adolescent Sexuality

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kid2.jpg

Literally brimming over with enthusiasm, these teenagers can't wait to participate at

one of RHAC's events aimed at "breaking the silence" about previously taboo topics.

This program, held on Dec 1, World AIDS Day, near Sihanoukville, featured dancing, music and a quiz show about reproductive health. Events like this are regularly held on holidays at schools around the country, and always attract wildly enthusiastic audiences.

Sex education and AIDS education are inextricably linked. To mark World AIDS Day

at the beginning of December, Maggie Huff-Rousselle highlights some of the

social issues, and the innovative new approach to adolescent sex education developed

by the Reproductive Health Association of Cambodia.

The karaoke session is over, but Koh Kim Phal, who led the session, is still clutching

the microphone. As he speaks his audience listens, sometimes intently and sometimes

with raucous laughter and applause.

Every Thursday afternoon the Reproductive Health Association of Cambodia (RHAC) hosts

a youth activities session at its second Phnom Penh clinic, and 19-year-old Koh Kim

Phal, one of the peer group educators trained by RHAC, frequently leads these sessions.

Phal may not know it, but he is playing a starring role in one scene of a quiet drama

staged to break the silence in Cambodia.

The silence he is breaking enshrouds a long-taboo topic. Not the Khmer Rouge trials

and who will control them. Not rumors about the latest political machinations. The

taboo topic is sex. Not commercial sex, a topic as common in the local newspapers

as the trials and political maneuvers. Youth and sex.

As was the case in countries in the West a little more than a generation ago, traditional

values dictate that unmarried couples simply do not have sexual relationships, particularly

young women who should be virgins when they marry. But traditional values, while

filling as important a role in Cambodia as they do in any culture, can be as fragile

as fairy tales when confronted with the fast-changing facts of modern life.

Young people do have sex in Cambodia. For young men premarital sex is a foregone

conclusion, a rite of passage, most commonly experienced with a commercial sex worker.

An estimated 40 percent of married men visit female sex workers (roughly 50 percent

of whom are HIV positive), and the trend starts early. The age of "coital debut"

is falling for both sexes. While premarital sex is less common for young women, it

is increasing significantly, and young women who marry as virgins often marry men

who have been frequenting brothels prior to their marriage.

"This will kill more Cambodians than the Khmer Rouge did," said Prime Minister

Hun Sen when he addressed the First National Council on AIDS in March.

Cambodia has arguably the most serious HIV/AIDS problem in South-East Asia, exacerbated

by an elevated rate of sexually transmitted diseases. Modern contraceptive methods

are not widely used and not well understood, and the rate of (often unsafe) abortions

is high.

The major factor contributing to the very high maternal mortality rate is septic

abortions.

Young people need the fast-changing facts, the knowledge and skills that will allow

them to make and negotiate intelligent choices about their own sexual lives. "Abstinence

[from sex] has its place," says Geoff Manthey, Country Program Advisor for UNAIDS,

"but you have to give people a range of options. It's the ABCDs of risk reduction:

Abstinence, Be faithful, use Condoms, and Don't share needles."

Why did Koh Kim Phal choose to become a peer group educator? "I wanted to understand

about reproductive health," Phal says, "about sexually transmitted diseases."

The words - "reproductive health" - are vocabulary he learned in a RHAC

training course. What he wanted to learn more about - before he joined the course

- was sex and male-female relationships.

"I used to watch the sex videos," Phal says, "in the coffee shops

in the afternoons, and in the private cinemas in the evenings. I used to go there

often."

Most of the videos were copies of imports from the West. A few were from Asia. Pornography

is a cheap commodity, readily available to any young man in Phnom Penh, and, like

any other culture, Cambodian music and theater is saturated with themes that revolve

around romantic love. But, particularly for young people in Cambodia, advice, support,

suggestions, and open discussion about topics that range from romance and courtship

to sperms, fallopian tubes and orgasms are very rare commodities.

Parents don't discuss these topics. Neither do teachers. Given the social prohibition,

young people often don't talk with one another about these subjects: their culture

has taught them to be shy, self-conscious and embarrassed about topics so taboo that

they are often nameless.

And so young people in Cambodia are left, almost in the dark, or, as the Cambodian

expression goes: like a frog in a well. The frog, from the bottom of the well, sees

only the tiny bit of sky above him and thinks it is the whole world. Young people

have only a little information - frequently misinformation - on which to base decisions

about romantic and sexual relationships, and they are routinely making uninformed

decisions.

Ignorance is bliss, and bliss can be dangerous. Many adult Cambodians believe that

pregnancy is most likely to occur if a woman has sex during menstruation and that

masturbation can damage a young man's brain.

In addition to satisfying his own native curiosity, Phal says, "I like meeting

other young people and talking with them." Peer group educators need to be young

people who "joaljeut" - Khmer for "like" or literally "enter-into-the-heart"

- meeting other young people. They are selected, not because they are good students

(although they often are) but because they are good communicators with natural social

skills.

After a five-day training course, along with approximately 20 other peer group educators,

Phal began to fill his starring role. He simply stood before a classroom full of

students before they had a free class period and offered to talk with them about

the taboo topic. If they wanted to stay and talk, they could. If they didn't, they

could walk out.

With 30 students in the room, about eight walked out, and the rest stayed. Some were

very quiet, especially the girls, but others asked questions and the quiet ones listened

to those who spoke.

They talked about menstruation and other changes in their bodies, about sexually

transmitted diseases, about how to obtain dependable diagnosis and treatment for

gonorrhea, about the taboo questions on their minds.

Over the next four months, Phal conducted 12 group education sessions at his school.

Sometimes the same students returned to new sessions, but many newcomers also joined

each time. Students also approached Phal individually, as he became recognized as

a student with special knowledge who enjoyed sharing it openly with others.

RHAC has trained approximately 250 peer group educators both in-school and out-of-school

in Sihanoukville, Phnom Penh and Battambang. The strategy for the program was based

on a small but comprehensive model launched in Sihanoukville three years ago under

the direction of Hor Phally, a 40-year-old midwife who manages the Adolescent Health

Program. Phally organizes many events that break the silence more publicly: adolescent

quiz shows held on the grounds of schools on a holiday attract over 2,000 students

to a single event and the Khmer media is there to cover the event.

This project is only one among six in Cambodia supported by the UNFPA with funds

from the European Commission. RHAC is working in the four provinces where it currently

has clinics. Health Unlimited is working on broad media activities. Save the Children

is working with marginalized youth in Phnom Penh and Kratie province. Mith Samlanh/Friends

is working with vulnerable youth in the streets and squatter areas of Phnom Penh

and Kampong Cham province. The HIV/AIDS Alliance is working with nine local partner

NGOs in their target areas. CARE is working with RHAC on a factory-based program.

At least once a week, Phal also does some volunteer work in the RHAC clinic: arranging

books in the library, keeping visitor records, typing on a computer, selecting the

karaoke program, and preparing the education sessions with one of the RHAC staff

members.

Today the education program consists of a sheet of paper with a cartoon-like drawing

of a boy and girl sitting together, their backs to the viewer of the drawing as they

gaze out toward the horizon. The boy has his arm around the girl's waist. Each of

the roughly 40 high school students who has joined the session has filled a "thinking

balloon" over the head of the boy or the girl in the drawing with the ideas

that they imagine are going on inside the minds of the girl or boy.

Then they listen as what they have written silently is amplified using a microphone,

by Phal (if they were written by a boy) or by Vanarra, a female member of the Adolescent

Program staff. Sometimes the words they have written are met with raucous laughter

and applause, removing some of the tension around the topic, and sometimes the audience

listens quietly without comment.

The girls sit in a long row along one side of the room, and the boys, who outnumber

the girls, sit in clusters filling the middle of the room and the opposite side.

Phal reads the last of the word balloons and invites an open discussion. Some of

the boys ask many questions and speak often; most of the girls remain silent but

listen intently. The silence is more difficult for them to break - the social barriers

are higher.

Are Phal and other peer group educators like him helping to break the silence? The

statistics for male clinic visits for sexually transmitted diseases tripled during

the most recent six months at the RHAC clinic that hosts the adolescent program in

Phnom Penh. Almost all of them were young men between the ages of 16 and 20. More

and more young women are also coming to the clinic for contraceptives and other services.

Some of them are coming because of the peer group educators, and others are referred

from the other NGO adolescent programs.

These young people are explorers, frogs that have been coaxed up from the bottom

of a well; a few of them are probably croaking down to their fellow frogs who are

still sitting silently in the bottom of the well with only a tiny circle of light

above them.

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