The unintended consequences of sex education: an ethnography of a development intervention in Latin America

Abstract

This paper is an ethnography of a four-year, multi-disciplinary adolescent sexual and reproductive health intervention in Bolivia, Nicaragua and Ecuador. An important goal of the intervention – and of the larger global field of adolescent sexual and reproductive health – is to create more open parent-to-teen communication. This paper analyzes the project's efforts to foster such communication and how social actors variously interpreted, responded to, and repurposed the intervention's language and practices. While the intervention emphasized the goal of ‘open communication,’ its participants more often used the term ‘confianza’ (trust). This norm was defined in ways that might – or might not – include revealing information about sexual activity. Questioning public health assumptions about parent–teen communication on sex, in and of itself, is key to healthy sexual behavior, the paper explores a pragmatics of communication on sex that includes silence, implied expectations, gendered conflicts, and temporally delayed knowledge.

Keywords:

• adolescent sexual and reproductive health
• parent–adolescent communication
• open communication
• anthropology of development
• Latin America

Introduction

There is by now an extensive anthropological critique of the international development project, focusing on large infrastructure projects, the de-politicizing effects of development, the creation of neo-colonial relationships, and much else (Escobar 1995; Ferguson 1994, 1997). We also see the increasing use of anthropological concepts and research methods in development work itself (Rossi 2004; Sillitoe 2007; Mosse 2013). This phenomenon is particularly visible in the field of global health where anthropologists have often been employed to understand the ‘cultural barriers’ to good healthcare delivery or to act as ‘mediators’ between healthcare institutions and communities (Scheper-Hughes 1990). The use of anthropological research in development is itself controversial and has raised the question of whether such research simply serves as a ‘rubber stamp’ for top-down interventions, or whether it has much effect at all (Mosse 2005, 2013; Maternowska 2006; Pandian 2008; Gupta 2012). What has been less studied, however, is how such anthropology works on the ground. How do the various social actors interpret and ‘use’ development interventions?

This paper is an anthropological ‘meta-study’ – an ethnography of a multi-disciplinary health intervention that included ethnographic fieldwork. Its focus is a four-year, international project on adolescent sexual and reproductive health carried out in Cochabamba, Bolivia, Managua, Nicaragua, and Cuenca, Ecuador. ‘Community-Embedded Reproductive Health Care for Adolescents’ (CERCA) was conducted with European Commission funding, bringing together public health professionals, obstetrician-gynecologists, epidemiologists, economists, psychologists, statisticians, peer educators and anthropologists from Europe, North America and South America. The intervention embraced current ‘progressive’ ideas, ranging from the standard global health emphasis on healthcare rights and local capacity building to the use of anthropological fieldwork and the need to identify and respond to ‘community’ needs (Decat et al. 2013).

The rationale to include anthropologists, as in many other development projects, was to study such community needs as well as the wider socio-cultural context shaping healthcare decisions. A key part of this context was communication between parents and teens. One of the CERCA project's guiding premises was that unilateral public health policies are not enough to improve adolescent sexual and reproductive health in the global South (Decat et al. 2013). Instead it aimed to take comprehensive actions targeting multiple ‘levels’: clinics and communities, behaviors and beliefs, individual adolescents, and crucially, families. Reflecting priorities first defined by the International Conference on Population and Development 20 years ago, parents were seen as key agents of change (UN 1995, 49–51).

Open communication with parents might seem to be a self-evident ‘good’ since adolescents need sexual education from elders in order to access contraception or resist peer or partner pressures to have sex before they feel ready. In the US, the dominant public health narrative of the past two decades has linked actions to improve ‘open communication’ between parents and teens to positive adolescent health outcomes (Miller et al. 1998; Whitaker et al. 1999; Jaccard, Dodge, and Dittus 2002; Hutchinson et al. 2003; Martino et al. 2008). Outside the US, the global field of adolescent and reproductive sexual health has also viewed – although less prominently – improved family communication as an important goal in health interventions (Liposvek et al. 2002; Rani, Figueroa, and Ainsle 2003; Amoran and Fawole 2008; Crichton, Ibisomi, and Obeng Gyimah 2012; Harrison 2008; Bochow 2012; Gallegos et al. 2007; Atienzo et al. 2011; Caal et al. 2013). Wight and Fullerton (2013), however, have pointed to the considerable difficulties in measuring ‘open communication’ between parents and teens. In a more anthropological vein, Hardon and Posel (2012) discuss the moral dimension of pressures to be ‘open’ in health communication: ‘“Speaking is healing” is the confessional imperative that juxtaposes secrecy to truth telling.’ To not be open implies withholding the truth, a moral act. Hardon and Posel argue that this normative understanding informs many public health interventions today. And while the goal of open communication reflects laudable public health goals of combating stigma surrounding sexually transmitted diseases, it can paradoxically blind us to the social utility of secrecy: ‘What we reveal and what we withhold are sites of negotiation, integral to the ways in which we inhabit the social world’ (Hardon and Posel 2012).

In this paper we analyze the CERCA project's efforts to foster open communication between parents and teens and how social actors interpreted, responded to, and sometimes repurposed the intervention's language and practices. While direct verbal communication may be the most obvious way to communicate knowledge of sex, it is far from the only way. Instead, we found distinct and sometimes conflicting social uses of this knowledge, for example knowledge that was shared, withheld, or saved for later use. While the CERCA project and public health discourse emphasized the goal of ‘open communication,’ the people targeted by the project more often used the term confianza (trust). The norm of confianza was defined in ways that might – or might not – include revealing information about sexual activity.

There were also important affective aspects of communication – shameful, shaming, or empowering – that subtly shaped efforts to achieve the moral norm of ‘openness.’ Whether or not teens claimed to have ‘good’, ‘bad’, plenty or no communication with adults, they were also exposed to the morality tales, gossip, family histories, half-whispered scandals, and contradictory messages about sex that adults speak. For adults, communication on sex was not a straightforward transmission of facts about contraception, but entailed a navigation of intergenerational conflicts and threats to their children's public reputation.

The intervention, including its anthropological component, was circumscribed by existing social relations but also created spaces for new dynamics to emerge. Different actors used the intervention for their own ends, only some of which dovetailed with the original public health aims. For example, participants used intervention spaces to shame a ‘lying’ husband, to share knowledge that should nevertheless not be ‘acted upon,’ or to find out who a son or daughter was dating. Other adults, while acknowledging the intervention's importance, insisted it was a ‘woman's thing’ or ‘for gays.’ Silence, shame, or simple lack of interest in speaking about sexual and reproductive health not only signified an absence of ‘open communication,’ but were themselves highly expressive of larger social contradictions and struggles to define moral norms.

Research methods and sites

This paper draws on fieldwork primarily conducted in Cuenca (Nelson, 10 months total during the project's pre-intervention and intervention stages, between January 2011 and March 2013), shorter periods of intensive research in Managua and Cochabamba (Nelson, one month in each, January and February 2013), and rolling peer discussion groups (five rounds in total, Nelson in all countries, Rodriguez in Nicaragua, Ballesteros in Bolivia, between March 2012 and March 2013). Fieldwork in all three cities during the intervention period consisted of in-depth semi-structured and unstructured interviews with adult and youth participants of CERCA, and with non-participants living in target communities (37 in Cuenca, 20 in Managua, 14 in Cochabamba); participant ethnographic research with young people and parents of young people (Nelson, 35 peer-conducted interviews) using modified ‘PEER’ methods (Price and Hawkins 2002); observation of intervention activities (school-based and clinic-based workshops, health fairs, movie forums, public outreach events); peer group discussions (18 in Cuenca, 13 in Cochabamba, 15 in Nicaragua); and two documentary films (Nelson and Howitt 2013). The majority of in-depth interviews and peer-group discussions were transcribed in their original Spanish. The transcripts were subjected to holistic content analysis where key themes were identified and triangulated with field notes and observations.

Intervention activities varied by city but included outreach campaigns, sex education workshops in schools, free text-message and Internet hotlines, ‘adolescent-friendly communication’ training for health providers, and mobile health clinics and condom dispensaries. The project also had a major focus on research, including ‘deliverables’ such as international journal publications (for example this paper). Anthropological research also aimed to create new spaces for dialogue. Regular discussion groups were organized in each site, held separately with teens and parents. The groups were named comités comunitarios to reinforce the premise that discussions would function as non-hierarchical spaces in which all participants (facilitators included) held equally valid knowledge (Harrison 2008; Bohmer and Kirumira 2000). These ‘community committees,’ it was hoped, would reveal the barriers to more open communication between teens and parents, as well as provide a space where they could discuss solutions.

‘Open communication’ or ‘confianza’? Interference and overlap between two moral norms

An important premise of the intervention strategy – anchored in the vast global literature on the importance of teen–parent communication to sexual and reproductive health – was that it would foster ‘open communication’ where it had previously not existed. But in all three sites, young people as well as parents much more commonly referred to ‘confianza’ – having it (tenemos confianza) or lacking it (falta de confianza). There is a subtle difference between the terms confianza and ‘open communication.’ Confianza implies mutual trust and intimacy, but unlike open communication, does not necessarily entail a relationship where sex is talked about openly. In fact, the moral norm of open communication at times came into direct conflict with the moral norm of confianza.

It was the last peer discussion group in Cuenca, Ecuador, after almost three years of research. The young men and women, and one of the mothers, were by then well known to the ethnographer. Bruno, Julio*, Virginia*, Wilson, Bryan, Oscar, Laura and Ana Lucía had variously participated as peer researchers, peer group discussants, focus group discussants, interviewees and documentary film collaborators. Beyond their research participation, all but two were on posters promoting the project, which dotted the local health center and high school corridors: ‘Quererse mutuamente es protegerse sanamente’ (To love each other is to protect each other's health). During this period, some of the original peer group had graduated from high school, and were now outside the intervention's target population. Romances between participants had bloomed and withered, certain exes had been exiled. This small group of teenagers had at length analyzed, debated and dramatized love, sex, jealousy, gossip, peer pressures – and family pressures. So it was a surprise when Julio entered what was intended to be a ‘peer space’ accompanied by his mother.

Julio sat slumped, arms crossed and silent next to his mother. After some 20 minutes of listening to the teenagers critique the lack of trust between adults and young people, his mother raised her hand:

I have a question for you who are so linked to this issue of sexuality. Does it seem right (conveniente) to you that a young man or woman, at an early age, is advised to have sexual relations?

The ethnographer knew Julio had a serious girlfriend, for she had seen them holding hands and cuddling. Now his friends looked at him with a mix of embarrassment and concern as he sank deeper into his chair. In a place where people talked about ‘sexual relations’ in code in a lyrical southern Sierras Spanish that circled and whirled and steered clear of vulgaridades, her directness came as a shock. Put on the spot, the ethnographer stumbled out a non-committal response, ‘It is not a question of convenience or right, but just a matter of fact that lots of young cuencanos are already sexually active.’

His mother conceded, ‘We can't put a knife to their back saying they can't do it.’ She turned to Julio, ‘This is my son. To motivate my son I have told him, “saying to someone ‘I love you’ doesn't mean that you are kissing in the street. I will beat you (te pego) if I see you kissing in public”.’ A debate ensued. Bruno countered that his grandfather was pleased that CERCA had given his grandson knowledge on how to use condoms. In response, Julio's mother claimed, ‘If I ask my son with whom he has the most trust (confianza) he will say his mom.’ For her, having confianza did not mean the ability of a teen to ask for contraceptive knowledge without fear of consequences or a parent's ability to provide information about contraceptives; it signified the strength and intimacy of the mother–son bond.

In the days that followed, the grandmother of Julio's good friend Virginia* told the story of when Julio had

arrived crying here one day, saying ‘I’m going to die’ because he had asked his mom ‘how old does a person have to be to have sex?’ And his mom grabbed a stick and beat him. The poor boy didn't know where to go so he came here.

In a separate conversation, a health professional involved in the project offered the unsolicited information that Julio had already come to the clinic, having text-messaged the free CERCA hotline to get emergency contraception for his girlfriend.

While the CERCA intervention sought to build confianza – usually interpreted as ‘open communication’ – between adolescents and parents, the ethnographic research process itself became a venue for a diverse set of social actors to contest the meanings and uses of confianza. For Julio's mother, confianza appeared to be the unquestioned basis of their close relationship and was not threatened by her ruling out any discussion of sex. For Virginia's grandmother, it meant providing young people with a place where sex could be discussed openly and without punishment. For Bruno (Julio's friend and peer), it meant adult family members supporting young people to learn about modern contraceptive methods. For the health professional, it meant adolescent-friendly contraception services that young people could use privately. For the ethnographer, it meant creating enough trust between those targeted by the intervention and those running it to be able to talk openly about sensitive subjects.

The moment Julio's mother walked into the ‘peer’ space, different interpretations of confianza came to a head. The intervention did not simply ‘reveal’ a pre-existing intergenerational conflict or a ‘cultural barrier’ (i.e. a beating) to open communication; the intervention also created new ‘temporary socialities.’ As Bochow (2012: S18) notes, conversations about ‘love and sexuality are in themselves social acts that create a momentary, spontaneous sense of “being together”.’ Within the context of a health intervention dedicated to making sexuality a topic of familial conversation, this ‘being together’ was not spontaneous. Instead, multiple interpretations of the project's call for more open talk about sexuality constituted social forms of communication in and of themselves.

In the final period of fieldwork, the lead ethnographer brought together adults and adolescents (sometimes related, sometimes not) in joint discussion groups (they had previously been kept separate). The decision to do so was made partly because peer group discussants had, in anonymous ‘comments slips,’ asked for the chance to have facilitated conversations with adults. In the course of one workshop in Managua, discussants spoke about the differences between ‘mandar’ (to order around) and ‘dialogar’ (to discuss). Several of the mothers, having themselves gotten pregnant in adolescence, argued that knowing who their daughters were with made it possible to give ‘buen consejo’ (good advice) to prevent them from making the same ‘mistakes.’ But the young women complained that their mothers boss them around and nose around in their private lives (entrometerse en la vida privada). In a one-on-one interview the next day, one teenager said that a parent who gets ‘up in your business’ by asking direct questions about sexual intimacy is, despite speaking openly, displaying a lack of trust (no confían en vos). Here again, ‘open communication’ means something quite different from confianza.

The complexities of confianza were reiterated by young people across the CERCA research sites. When asked how they talk about sex and sexuality with parents or significant adults, the initial answers fell into two categories. Either they claimed that ‘no hay confianza’ (there's no trust) or, conversely, ‘tenemos confianza’ (we have trust). These same claims were contradicted within the same interview as well as in instances where we had ongoing conversations and contact over the life of the project. Those who reported a lack of confianza would nonetheless demonstrate detailed awareness of their family's rules and expectations regarding who they should, or would be allowed to be romantically partnered with, when and in what context they would be allowed to begin having sex, etc. And those who claimed they did have confianza could nevertheless speak of precise boundaries to communication, which aspects of their sexual lives must be hidden, and which questions could not be asked.

Sexual knowledge in conflict

The different interpretations of ‘open communication’ and ‘confianza’ do not simply reflect a translational discrepancy between public health discourse and everyday language. They instead point to larger power dynamics and changing moral and sexual norms that circumscribe what can be spoken and what must be silenced in parent-adolescent talk and within extended families. Some teens, as we have seen, contested their parents’ ‘prying’ by complaining that such behavior reflected a lack of confianza. On the other hand, some parents understood the project as justifying a return to the socio-sexual practices of previous generations where adolescent partnerships would be subjected to family approval. In one instance, Patricio, the father of a seventeen-year old girl who had participated in the peer discussion groups, said:

If I am honest and sincere, the project has already given a result, because my daughter has a boyfriend and given the way things are these days I didn't even realize it. And some days ago the boy came to the house to talk to us. Why? So that we could give permission for her to go out with him … something very few young people do these days. And this is really great, doctor, if I’m not mistaken.

Other adults reiterated this father's praise of the workshops on open communication as a means to enhance parental control over adolescent relationships. In both Managua and Cuenca, adult project participants interpreted the emphasis on open communication as a license to encourage their children to make public relationships that might otherwise have been kept hidden. But as the story of Julio's mother illustrates, parental encouragement to bring a boyfriend or girlfriend forward for familial judgment did not entail approval of public displays of affection, nor did it equal a green light for the initiation of sexual relations. Patricio explained: ‘You can't just let them run wild (dejarlas sueltas), saying you can do whatever you want, or go out with whomever you want at any hour of the day.’

Parental involvement in teen partner choice was asserted in the idiom of confianza, but spoke to issues that went beyond the focus on the parent–child dyad that is the norm in North American adolescent sexual and reproductive health programs. Young people spoke of receiving conflicting advice from older relatives, for example aunts versus mothers versus cousins, or uncles versus brothers versus fathers. Having confianza with young people was also important to some family members because they believed it was their duty to assess the socioeconomic status and seriousness of a young relative's potential partner – for example, through a face-to-face meeting.

Parental judgments also reflected each region's racial and economic hierarchies. For example, in Cuenca status is often judged according to perceived distance from a state of indigenousness, which in turn indexes both ‘race’ and class background (see Weismantel 2001). In the outer barrios of Managua, parents were more concerned by a young person's perceived proximity to ‘the street’ as a place of gang violence, sexual promiscuity and drug use. The monitoring of teens’ reputations was not exclusively a parental concern. In many Cochabamban and Cuencan families, one or both parents were migrant laborers and the duty and right to protect young people and monitor their activities were distributed across extended family networks. Communication on sex thus went far beyond the transmission of information about contraception or the presence or absence of parent–teen trust, but was shaped by the local semiotics of appearance, status hierarchies, and the making and unmaking of (especially female) ‘reputation.’

The wrong amount of sex and involvement with the wrong partner were frequently the subject of morality tales, scandals and gossip (chisme or chuchicheo). Both young people and adult participants in all three countries used pejoratives to describe (perceived) sexually active young women (‘roses without petals’ and ‘ball warmers’) and sexually non-active young men (‘mama's boys’ and ‘future priests’). As one young cuencana explained, ‘I’ve got to watch myself so I don't end up in the mouths of others.’ Anthropologists (Gluckman 1963; Merry 1984) have argued that gossip should not be seen as a degraded form of speech but as a dynamic act of meaning-making (White 2000, 30) and constitutive of power relations within communities (Besnier 2009). Bochow points out that for young people in Kumasi, Ghana, speech is ‘an act of proper social conduct’ (Bochow 2012, S17). In the CERCA intervention, gossip functioned as a parallel form of communication to that prescribed for health service provider interactions (client confidentiality) and the open communication demanded of parents (talk about sex openly) and adolescents (make relationships and sexual status public).

Some parents actively supported the project's goal of enabling teens to acquire knowledge about contraception and/or sexually transmitted diseases, but also insisted that such knowledge should not be ‘used’ but ‘saved’ for later. Ashcraft (2006) argues that while ‘the discourse of readiness’ is widespread in the field of adolescent sexual and reproductive health, it can ignore the relational context of readiness that not only depends on the teen's self-perceived emotional state. One mother and nurse discussed how she instructed her teenage daughter:

You can have [sexual relations] when you desire them, when you want them, but right now you have to prevent it from happening. And she knows the methods. I show them to her: this is a carton of pills, this is a copper T, this is a condom.

This mother's ostensible openness about sexual health is a complex form of communication where health- and rights-oriented sex talk mingles with subtle assertions of parental control. The daughter's ‘desires’ are seemingly validated yet she is also instructed not to have desires ‘right now.’

While in some instances adults ‘hijacked’ the norm of open communication to support the goal of enforcing parental control, in others adults claimed the norm of openness for entirely different purposes. In the third meeting of an adult peer discussion group held on the outskirts of Cuenca, three mothers of adolescent children and one grandmother (Beatriz*) and grandfather (Carlos*) sat down to talk. The discussion centered on participants’ understandings of the challenges young people face, and that they as adults have faced, in achieving a healthy sexual life.

‘I think,’ said Beatriz*, ‘that young people, well nobody, really, is being truthful, especially men. “I’m like this, I’m like that” and it's not the case. It is all a lie.’ It quickly transpired that Beatriz was using statements in the questionnaire about consent and honesty with partners to publically accuse her husband, Carlos, of infidelities. In attempting to divert the discussion back to adolescent concerns, the facilitator (Nelson) was blocked by Carlos, Beatriz, and a third member of the peer group, Marcia:

C: Figuring out what you want and don't want should be a mutual agreement between both people…

B: It's not true. [Men] should be honest and true. Say, ‘Listen, I don't love you.’ They shouldn't lie! No lying!

Marcia: They’re machistas. It's not that they don't know what they want, they are machistas. There are even old men who are dishonest.

Here, the imperative of ‘open communication’ central to the project became a platform on which Blanca could publically, and with the support of female peers, demand the truth about her husband's sexual improprieties. Similarly, Carlos used the language of the questionnaire to defend his reputation, only to be put back in his place by Marcia's accusations of machismo.

This exchange points to the subtle ways in which ‘open communication’ – as well as the talk and practices of the intervention and wider project of adolescent sexual and reproductive health – become gendered. For Julio's mother, talking about sexual and reproductive health was itself sexual or sexualizing. For some adult men, such talk was seen as feminizing and counter to ‘healthy’ (in the sense of normal) male sexual behavior. Miguel*, 15, from Managua, an active participant in the community committees, was reluctant to share how his older cousins talked to him about sex, except to say that it was ‘vulgar’ and that they had explicitly counselled him not to use condoms. He provided an example instead from his friend's father, who had been asked to participate in CERCA activities:

My dad's friend says, ‘No way man, I’m not going to talk with you all. I’m not going to talk about this with you all…it's a woman's thing, a gay thing,’ he says, ‘Talking about sexuality, this and that, it's for gays and women. You all are crazy [vos sos loco].’

The idea that the CERCA project and its attendant research was ‘for gays and women’ was reiterated by other men. These views reflected perhaps the relative absence of male adults at parent-targeted activities (high school-based workshops, community outreach activities, health fairs). But they also pointed to a more widespread ‘gendering’ not just of sex talk, but of the very field of adolescent sexual and reproductive health. Adult men who did participate in the project shared stories of male relatives and neighbors who disagreed with the project's aims. Wives also told of husbands who claimed ‘we women are learning things we shouldn't be learning about’ or gave examples of fatherly and grandfatherly relationship advice counter to that given by wives, sisters and aunts.

In a small group discussion with three young men in Cochabamba (aged 15–16) in the final months of the intervention, one joked:

Young Man: My mom always tells me, ever since I told her I had a girlfriend, ‘You have to take care of her, you have to respect her, you shouldn't be doing this, you have to behave yourself, it's not like being around your [male] friends.’ But my mom and dad have different opinions, because my dad is always saying something else.

[The group laughs]

I: What does he say? You won't offend me because I’ve heard it all.

YM: ‘Have a bunch! You can do it!’ My dad was like, ‘I was a big stud, I had lots [of women]’ and I believe him because my mom told me, ‘Your dad had loads [of women] and of all of them he chose me.’

The contradictory messages that this young man received from his parents were not due to a lack of ‘open communication’ or trust. On the contrary, both mother and father were speaking freely, revealing their own sexual histories. The machista attitudes of adult men might be considered by some public health campaigns as a ‘cultural barrier’ to reducing teen pregnancy. Yet sexual double standards for boys and girls were not limited to the ‘community’ but were also found among health providers and within more elite circles, for example when a male doctor expressed the opinion that ‘libertine’ sexual behavior was passed from mother to daughter, or a municipal representative spoke at a CERCA event about the ‘natural sexual passivity’ of young women and the sexual dominance of young men. Nor was there consensus in the ‘community’ as to what constituted normal or good behavior for male and female teens. Some young men were critical of what they called the machista attitudes of the adult men in their lives. Others requested discussions of gay rights, abortion rights and the porn industry, showing themselves to be more ‘open’ in talking about sex than many adults, including some health providers who had decided that these issues were beyond the project's concerns.

Conclusion

Questioning public health assumptions that open parent–teen communication on sex, in and of itself, is key to healthy sexual behavior, we explored a pragmatics of communication that included silences, evasions, implied expectations, temporally delayed knowledge, and gendered conflicts. The paper began by highlighting differences in how teens and adults interpreted confianza. These differences had significant effects on the intervention and have implications for the wider field of health promotion.

For one, the goal of creating a ‘community-embedded’ intervention was potentially undermined by community members having different understandings of what can and should be said about sex. Some parents, such as Julio's mother, thought the intervention encouraged not (only) talk about sex, but also inappropriate sex itself. Another way of putting this would be to say that, for her, talking about sex was already a kind of sex. Julio's mother's views might seem common-sensical to sociolinguists interested in the performative effects of language. For her, knowledge about sex naturally comes from having sex. In a sense, the intervention seems to reverse this ‘natural’ sequence of cause and effect: it says knowledge of sex should come before sex itself (to make sure it's done right, at the right time, with the right person). From her point of view, the intervention's view of sex – as well as ‘communication’ – might have seemed naïve (or cynical), i.e. the assumption that language about sex can be safely quarantined from the activity itself. In this particular instance, Julio's mother happened to be right: Julio was asking questions about sex because in fact he was already having sex. She was also right that his sexual activity was linked to the intervention because he had gone there to obtain emergency contraception.

However, it would be mistaken to say that the intervention simply tried to impose a ‘progressive’ or global health norm of open communication about sex on a community norm of confianza (regardless of whether one would view this as a valid goal). While there were some instances of open conflict among project participants, often more subtle forms of persuasion were used – which depended as much on silence, evasion and implied threats as it did on ‘open communication.’ As Rossi (2004, 556) argues, power struggles in the arena of international development are ‘founded less on direct confrontation than on a kind of semiotic proselytism that appears in continuous negotiations over meanings and attempts to enroll others in one's interpretations of specific circumstances.’ Parents and teens were not neatly divided along generational lines; there were important differences among parents and grandparents as well as among teens. Social actors also ‘used’ the intervention for different purposes – to expose infidelities, to gain access to contraception, or to resist or reinforce parental influence over young peoples’ relationships.

The different ways social actors interpreted and used the intervention point to more than a problem of ‘translating’ between global public health and local norms – a problem that, say, an anthropologist could help resolve by providing a better translation. Rather, they also demonstrate the pragmatic, affective and performative aspects of language often missed in health promotion. Speech does not just convey useful information – on contraception, for example. It also constitutes and is made by social bonds. It incites, shames, and restrains. Speech in turn is restrained by social contradictions and double binds that cannot be directly ‘named.’ Summing up the polyphonic voices heard during the community committees would lead to several contradictory statements, such as: ‘Teens have too much knowledge of sex; teens don't have enough knowledge of sex.’ ‘Teens should have knowledge of sex, but not yet.’ ‘Girls should not allow themselves to be “damaged” by having sex; boys should have a bunch now or else won't become men.’ It is unlikely that these contradictions are the result of a lack of ‘open communication.’ On the contrary, they are a highly expressive form of communication. They ‘say’ what can be difficult to say directly: what is at stake in sex, power struggles, and conflicts in moral norms. This is not to say that change is not possible, but to question the paradigm that makes ‘more communication’ the antidote to the constructed problem of ‘no communication.’

Project participants’ communication practices reflected larger conflicts over socio-sexual norms: family-sanctioned adolescent relationships or adolescent freedom to choose partners; public displays of affection by young unmarried couples or tight restrictions on bodily contact; communication on sex as inciting sexual practice or communication on sex as delaying sexual practice. Fostering ‘open communication’ brought some of these tensions to light, but it also underlined the difficulty of resolving them through more, or more open, communication. While the intervention did not always have the effects that public health planners had planned, neither was it ineffective. Various social actors – including the project staff – often effectively used its language and practices for different aims, demonstrating the polyphonic nature of the community.

Notes on contributors

EN led the design, implementation and analysis of the qualitative research discussed in this paper, with intellectual contributions from AE. The paper was drafted by EN and AE. MB, OR and DE assisted in conducting research and commented on the manuscript. EN will act as guarantor of the paper. All authors approved the final manuscript.

Acknowledgements

This paper is an output from project ‘Community-embedded reproductive health care for adolescents in Latin America’ (GA241615) funded by the European Commission FP7 Programme. The International Centre for Reproductive Health (ICRH) coordinates the research consortium, led by Peter Decat and Sara de Meyer. The authors assume full responsibility of the paper and the European Commission is not responsible for the content. The authors gratefully acknowledge Peter Decat, Sara De Meyer, Marie Jose Sarmiento, Lina Jaruseviciene, Miguel Orozco, Zoyla Segura, Joel Medina, Anna Gorter, Bernardo Vega, Arturo Quishpe, Marcia Ibarra, Kathya Cordova, Arnold Cordova, Freddy Cordova, the teams of ICAS, CIES, SG, UvA and UC, and Marleen Temmerman for their contributions to the design and implementation of the CERCA research intervention.

This study was conducted in compliance with the Helsinki Declaration on Ethical Principles for Medical Research Involving Human Subjects and is approved by the Bioethics Committee of Ghent University, Belgium (Belgian Registration number of the study: B670201111575).

This work was supported by the European Commission FP7 Program under grant (GA241615), ‘Community-embedded reproductive health care for adolescents in Latin America.’ This document is an output of the CERCA project, coordinated by the International Centre for Reproductive Health (ICRH) in Ghent. The authors declare no competing interests.

The authors would like to thank the Center for Social Science and Global Health for funding the open access version of this article.

Notes

1. The ‘*’ indicates that we have changed the informant's name to protect anonymity. In all other instances the researchers adhere to the expressed desire of informants to use their real first and/or full names.

2. All direct quotes in this paper are from digital recordings transcribed in the original Spanish (by native speakers) and then translated into English by the lead author. Original Spanish excerpts are available upon request.