Hello, hello, Parents of Ubusha. Welcome to the dual podcast-article series in which we have a
sit down with experts on sexual and reproductive health. In this series our experts share
reliable, accurate and scientifically-based information in an easy to understand way so you can
support your adolescent on their journey to good choices about their health.
In this episode we speak to Dr. Elona Toska, from the University of Cape Town. Dr. Elona
Toska is an adolescent health and well-being expert and emerging leader in adolescent and
HIV/AIDS research. She holds an MSc and DPhil from the University of Oxford (UO) in Evidence Based Social Intervention. She is the Director and Chief Research Officer of the Adolescent
Accelerators Research Hub at the Centre for Social Science Research at the University of Cape
Town (UCT).

We would like to thank Dr Toska for generously sharing insights on adolescents. We hope
parents, guardians and community members listening are now better equipped to support
them through this crazy thing called life. Do enjoy.
Q & A*
Who are adolescents, and how can we understand the ways in which they make choices
regarding their sexual and reproductive health?
It is a time of incredible change in our bodies, in our minds and in how we position ourselves in society.
[It is also a time of change in] how we interact with our parents. It’s a process of kind of creating more
and more independence and in some ways rejecting, not in a bad way, but kind of saying [to the parent]
‘I don’t need you as much as before’. So this transition is difficult, but also [comes with] trying new
things and the phrase of learning by doing cannot be truer in adolescence because our brains at that
time [are] developing. Think of it as a tree in the spring: there’s new branches and leaves everywhere.
It’s a phase, and it hopefully continues for the rest of our lives, truly driven by our bodies so there’s not,
you know, malicious intent to wake up and be risky. But [what is there] is [the] intent inside the brain to
try new things and learn by doing. The community [becomes important] and sometimes [that is] kind of
against who we’ve been as a child, [but it is] a way of being your new [self].

Does some of this exploration and sense of adventure show up in the sexual and reproductive area of
their lives as well?
Yes. Sexual reproductive health does not start in adolescence. It is a taboo topic, but actually we are
born with bodies that have some physical pathways, patterns in our organs and hormones. And there
are big hormonal changes in adolescence starting with puberty, and they result in both physical changes
but also emotional changes. So the moodiness we often think about [when thinking about] adolescence
or the risk-taking, [or] the sleeping late in the morning. These are all linked to that physical change. But
that physical change doesn’t appear like with a button the day you turn 10. Actually many young people
will have already felt changes in their bodies before adolescence but we don’t label them or we don’t
talk about them.

[During adolescence you also] realize that you want to be friends with someone, maybe more than
friends. And this is all quite new, right? Who you socialize with is determined totally by your parents and
the caregivers and the community [earlier in your life then] suddenly you are free to talk to [others],
meet someone elsewhere, have play a new game etc. [This is all] it’s linked to that exploration, but it’s
also linked to learning how to be a human and form relationships which can be physical as well. They
can be emotional, they can be purely physical, they can be a combination of both.

You mention that the physical aspects of ones being does not emerge at puberty or at adolescence,
and yet there’s a taboo around it. Why might that be? Why is so much attention given to it around
that age group?
As a parent, I can acknowledge that it’s very hard to [see your child grow up]. You’ve had this little
human for, like, several years. You’re doing your best to keep them alive and safe from hurting
themselves and feed them well and vaccinate them and worry when they are sick or not sleeping. And
then that time goes fast. And then there you are trying to get them through school, teach them how to
dress themselves and pack. And then that time also goes [by fast]. And suddenly there’s this new topic
that you weren’t ready [for], and they’re moving at the speed of light and you feel stuck sometimes.
It’s not only about sex, it’s about everything. It’s about whether a mother has her period and if a father
can talk about morning erections, for example.

There’s lots of things that happen in our bodies that grown-ups shy away from [and hid from] our
children because they were so little. But they in the meantime have more curiosity and interests and
that is a part that catches us by surprise. I’d say as parents [we don’t have] easy available spaces for
most of us to practice talking about it [these things]. It’s not easy to say “hey, Vanessa, my son and
daughter said this yesterday. What do you do when that happens or how do I respond if my son says
that, you know, making a baby requires a penis in vagina, and he heard that at school?. Or he heard
something that’s not true at school.” We’re often caught by surprise because we’re not initiating all the
learning and the conversations anymore – children or adolescents are bringing up these topics or
sometimes learning and discussing them separately [from the parents]. We’re not on top of it anymore.
We don’t have full knowledge and control over their lives. And it’s very difficult.

It seems the conversation is not just about sex then – it is about looking at the holistic being.
Yes, and it is in the context of keeping [the adolescent] safe. There is this need for independence. And
that does come with these barriers also in between. But it is important to remember that our job of
keeping our young people safe does not end just because they’re pushing us away a little bit.
They still need us; we all need it. I still need to be safe in my support group [even] in my ripe age of 3
decades of experience, so there’s no reason our young people don’t need that. But it is harder to
provide [safety]. So to think about coming always from a space of “I care for you, I want to keep you
safe, let me know how and if I can do it”, and realizing that you won’t be the sole source of that [safety
and protection] anymore as they grow older [is necessary]. There’s other sources [from where] they’re
getting support. Sometimes [they will get] less support, so they’ll get hurt. [For instance] not using
condoms, maybe having a sugar daddy or blesser or having multiple girlfriends or boyfriends. But those
are the contexts of what we as parents are. The way I think about it is I want to keep my children safe
while they’ll do these things, and be there in case they need me.

What would you say we need to understand in terms of how young adolescents make decisions?
That’s a big question. How we discuss this in the research world is that a young persons, but really even
from childhood, do not make their decisions based just on their individual factors. Think of it as circles – the person in the center and there’s factors linked to them. Some of it is biological. Sometimes there are
factors linked to puberty. There may be in some cases living with HIV, which brings in some biological
results and how they grow.

Then there’s the family space where there’s a lot about, as I said earlier, on interaction with your
caregiver. And there’s a lot of research on dimensions of parenting or caregiving. It doesn’t have to be
the biological parent but the adult who is your adult or adults. It could be on armed or grandma or a or a
grandfather or a single parent. There are multiple dimensions of the relationship with the child and
talking about sex and relationships is only one of them.

We also think that if adolescents are factually informed, they will suddenly make good decisions. The
best way we summarize this in our research to date and our knowledge and maybe many parents will
realize this, is knowledge is necessary but not sufficient. You can have knowledge, but it doesn’t
translate in perfect actions. When it comes to knowledge and facts and information, young people,
children, everyone will absorb what they’re ready mentally to absorb cognitively. So we could tell them
this perfect curriculum of information but if they only absorb the pieces that they can handle
[cognitively]. Assuming that having talked once about something [therefore] they now know it is not
right. And just because they are 17 [years old] doesn’t mean that they took it all in, for example.
The third I think in terms of this kind of knowledge [has to do with being] responsive. Imagine me being
like “hey, today we’re going to talk about periods” [ to someone who hasn’t] had theirs. Because your
brain is not ready or, you know, that’s what you think, [it won’t stick]. But then another day [they may]
see something happen at school or with friends and [they] will come [to you to talk about it]. That’s
where the responsiveness comes in. It will be important to have a space where you could ask that
question so that the grown-ups or the peers, if it’s a peer support program, can provide that
information. So it’s kind of a pull and push. We’re pushing information onto a young person and pulling
[by] being enabling them to drive the conversation – we need both.

Then there’s the parenting, communication dimension. What has emerged from research in South Africa
and other places is what we call parental monitoring. Imagine a skyscraper and you’re like painting or
building it. You need scaffolding to kind of hold it. [It is being able to answer questions like] “Do you
know where your adolescent is going at night? Do you know when they leave the house where they’re
going? Do you know who their friends are? Do they come back at a certain time every day, like knowing
where they are so that you can kind of hold them?” That’s monitoring or supervision and I think having
positive supervision is quite important. That’s throughout their lives.

Then there’s the positive parenting element, which is about praise. Now it’s not all about saying you’re
the most beautiful child in the world, even though I say that all the time to my children; it’s about saying
seeing them, like, truly seeing them and saying “I really loved how you looked after your sister earlier
today or thank you so much for cleaning up after yourself”. And I know that when we’re busy and
stressed out as parents, it’s the last thing that comes to your mind. And you don’t have to do it 45 times
a day. But I think helping each other feel seen and modeling that with our young people helps. It helps
them feel important and valued.

Another dimension is being very good about not having harsh discipline. There is extremely strong
evidence that beating a child or emotional abuse, calling them names, shouting at them is associated
with violent perpetration later on in life and risk-taking [behavior]. So [minimizing] exposure to early
childhood violence, and I know we don’t intend to make it violent, but it is to them, whether it’s at
school or home, is really one of the things that we can do to help set up a safer relationship with our
adolescent. There are ways of having good discipline and good discipline is about setting boundaries and
being clear about consequences and following through with them.

And then the other thing that’s maybe hard to do is just spend time with your children and it can be 5
minutes. Maybe it’s doing a quick phone game on your phone. It’s watching something on TV, talking
about it. It doesn’t have to be 5 hours of walking around the neighborhood and chitchatting. It is about
key elements of that relationship that can keep them safe.

From the research, what do we know about the ways in which parents communicate or relate to their
child or their growing adolescent and the impact that has on the choices that they make, the
behaviors they exhibit and propensity for high risk taking?
So what I’ve been trying to say is that young people feel kind of compelled to take risks, and we may
define risk very differently amongst different individuals. And it doesn’t mean that they should not be
punished for it. That’s one of the first things, right. So it’s not about telling them the right thing to do. It’s
also how we react.

[Being] clear about how we respond to risk taking is important and one of the important things is to
acknowledge that something has happened, not to shy away from it. There’s a lot of inner work that a
parent or caregiver has to do when you respond to them becoming their own person and taking risks.
But in a lot of our, particularly in some of our communities where we do research and work, there’s a lot
of shaming of the parent when the child does something wrong. And of course there is something there
because as we just discussed how one is in the home shapes who you are as a child.
But there’s also other influences that a parent can’t always control. So how we respond in those cases is
important, and being aware that there is this inner work we are doing as parents. So it’s about us as
well. But it’s not about us to fix it. What we want to do is provide the young person the space to talk
about it and retrace their behavior in the future. It’s very hard work, I want to acknowledge this.

How can a parent respond to the following example: An adolescent asking “What negatives are there
if I use a condom, but I still have multiple sexual partners”.
First of all, to have a young person say that to the parent is probably quite unusual, right? I would
suspect that most parents wouldn’t know it, but maybe they noticed something or something comes up
in the space and I think it’s important to sync around the patterns through which these are happening
and that there are what we call gender norms. There is a really amazing book called Becoming Men by
Malusi Langa, who works with young men in Alex for a long period, and he talks about the pressure of
being a young man who has many sexual partners and how this a kind of showing off, but it’s also
extremely stressful for these young men because they feel that that’s the only way that they will be
valued – by being able to show that they can manage multiple girlfriends and please them sexually and
romantically. This is not a conversation that parents would have with their young men, for example. But
if it does come up, one of the things that one could say is, “gosh, isn’t it hard work to do this with all of
them? Are you OK? Do you know their HIV status. Have you been checked?”

I know this is hard to do, but kind [express that] I’m worried about you. It’s hard to do. My first reaction
is also like “please stop doing what you’re doing” but actually that doesn’t help. They’re not going to
stop it because what has led to those spaces is not so obvious, and they didn’t wake up in the morning
necessarily saying today I’m going to be a have multiple concurrent sexual partners.
It is a bit challenging because maybe for a period in their lives they will have multiple sexual partners. So
then the question is, how can we keep them safe in those relationships? [The parent can ask
themselves] “Can I help them have an identity that doesn’t depend on having multiple sexual partners to
prove their worth or prove their value in society?” How we promote safe sex in those practices is an
important way to support them. Maybe slowly [they will] stop doing it is but it’s not going to happen by
just telling them “Don’t do it” ; and it’s certainly not going to happen by ignoring it.

How can parents initiate a conversation with my adolescent about their sexual and reproductive
health?
I think being available when someone gives you cues. May the adolescent will never come to the parent
and say “tell me about how to use a condom”. That’s actually quite unlikely to happen to be honest. It’s
not bad. I think one of the ways to be responsive is to be aware of cues, [for example] maybe you’re
watching a movie together and something happens, you can use it as an opening, as an opportunity to
say “Oh gosh, you know, they could have used the condom, gosh no one in my time used condoms. We
didn’t even talk about them with our parents. But I saw some at the clinic recently, so I picked them up
and I put them in the space. If you want to use them, they’re there”. So something like that kind of
normalizes that conversation.

We have a lot of good data from South Africa and other countries that staying in school as long as
possible, is highly protective. We [can think of] school as a social vaccine. A lot of young people struggle
in school and drop out, then it kind of sets off a cascade of challenging issues in part because they’re
searching for meaning outside of who they are, in part because being out of school means we have
more available time. You’re where no one can look after you, et cetera. So if there’s ways to support
your young person, even if they’re struggling in school, remaining in school in the safeway that is quite
important.

And then we have emerging data that where young women report not having enough food at home,
there’s links more directly to higher rates of transactional sex and sex with an older partner. Now we all
have heard stories of blessers and young women wanting extensions [therefore getting into these] really
sexual relationships. I’m not saying they never happened, but when we look at large survey data, hunger
at home or not [having] enough food to eat is a very strong factor associated with later sexual risk.
Early sexual debut is also associated with later sexual risk. So once you start risk early, it continues. You
may sit there and say, “gosh, but it’s already happened. What do I do?” Well, if you know about it, you
can kind of help mitigate a bit, soften the potential risk by helping the [young woman] get on
contraception or get those condoms and bring them at home for a young man. At least then they know
that there is a space where they can access some of the supportive services for young women who
become pregnant. It’s quite important to support them to return to school.

Part of the issue is the stigma around early motherhood. And I wanted to bring this up specifically
because we’ve put a lot of effort in prevention, but much of it is around talking. Even though there’s lots
of social issues, family and community which are drivers of early pregnancy, we seem to forget about
the young mother once she’s had a child. I think it’s just quite important to realize and remember they
did not get pregnant by themselves. Now, this isn’t about blaming the father. Tracking down the father,
forcing them to pay maintenance or negotiating inhlawulo. All of those have their own practices of how
they happen. It is also about recognizing that there is a lot at stake with a young woman for her life and
future, but also that of the child. And acknowledging that there may have been good and bad reasons
why this pregnancy happened, but it doesn’t end there, we need to actually support them, and it’s a
large cohort of them.

One of the last factors that’s quite important for us and I don’t know how parents can do this, but the
healthcare providers, nurses and counselors and doctors and pharmacists, the guard at the door of a
clinic, at the gate of a clinic [and so on, are] parents themselves. We don’t enter these facilities or
schools as teachers or maybe police officers, maybe community health workers or social workers – many
of us do not enter our workspaces and suddenly become a new person. So, we often treat adolescents
and young people in these spaces, but the impact is particularly great in facilities and health facilities, in
the same way that we treat adolescents at home which means often with avoidance of the topic. [There
is imposing of the idea that] “
if you do these three things, you’ll be the perfect woman or the perfect man” or through shaming like
“you missed your appointment or you’re late, go to the back of the queue”.

Now I also haven’t been treated so great sometimes in my life, we all have had those cases. But as an
adult person, the impact on me is different. I can handle it. I have self-confidence etc. But a young
person, the impact of being treated that way in a public space like a facility where it’s taken a huge
amount of emotional effort to show up to access the service, has a great impact. So this is another space
where interactions with adults are quite important. It’s not just about the parent at home, it’s also about
the relationships with teachers at school and healthcare providers.

It seems when care is prioritized, you get more from the parent-child relationship than you do from
shaming, guilting and embarrassing them. Is that what we’re seeing very clearly in the data?
Yeah, I mean the data we see is that physical hitting by parents or caregivers and calling names,
shouting, belittling, which we call home violence is associated with later risk-taking in life. It is often
when there is good parental supervision, monitoring and positive parenting that the praising makes a
difference to soften the blow, so to speak.

Similar with being exposed to violence at schools or being hit with a ruler or a belt, [this] is also very
strongly associated with risk-taking, but also, for example taking antiretrovirals in young people living
with HIV. This is particularly true in early adolescence, where you’re still very connected to the adult
relationships and then the third element is in facilities. We have both qualitative and quantitative data
[which] very strongly associates how you feel [about experiences at health] facility with [likelihood] of
taking your medication if you’re living with HIV.
Contraception use in young women and young mothers specifically and reduced condom use are linked
to experiences at facilities.

What or who do we refer to when we speak of young mothers?
The official definition of an adolescent mother is someone who had their first child before the age of 20.
Teenage Moms, adolescent mums. But in many ways, it’s about how ready and supported you are near
early motherhood, so you could be 20 or 21 and still not feel ready or be in a safe relationship. But in
our work with over 1000 young mothers and their children in the Eastern Cape it is with young women
who had their first child before they were 20.

I want to say this, just because something that one doesn’t want [to happen] did happen, doesn’t mean
that actually they are a rebel or a rule breaker because I don’t have the data and we don’t have the data,
but it’s actually extremely hard to make condoms available in schools because those parents who are
often in school governing bodies or other people in the community find it very difficult to imagine that
young people need condoms.

So it’s quite important to support people to think through that assumption and work backwards. For
example, the LO curriculum is very detailed and it would make both of us blush; they’re learning this at
age 11. The same parents are also teachers so often the quality of what [adolescents are] being taught
in school makes people are embarrassed so they either don’t [teach] it at all or they do it in a minimal
way. It is difficult to teach rowdy teenagers such a topic, so we’re part of the research questions that we
have is, “should it be a mobile phone app? Should it be a game?” Can it truly be learned in a classroom
setting through an adult [given] that [there is a] power dynamic [and] at the same time, they’re also
learning and exposed to phone and other devices and cyber.

Do male adolescence differ in terms of how they negotiate and navigate sexual freedom and
boundaries compared to female adolescence?
In general the development of gender identity starts early on, but it really flourishes and settles in
adolescents and young adulthood. And it is about biology, obviously, but it’s also about socializing. So
we definitely socialize young men and young women differently, and therefore the way that they
engage with relationships is different. Now, this varies, in urban/ rural settings [and] sometimes other
layers, such as culture, family traditions, etc.
I would hesitate to make blanket statements, but
whatever we observe in the broader society of how men behave, it’s already starting in young, young
men – adolescent boys – and what we think of young women is also being kind of initiated in [early].
One of the things that struck me in the research that I’ve been looking at [is that] for young men there is
increased pressure to perform the toxic masculinity narrative and hegemonic masculinity. Parents may
have heard these words, but it means that there is only one way to be a man.
And that one way sort of scripted somewhere, everyone seems to knows what it means, but it’s kind of
the little bit different in everyone’s minds.

In the effort to become a real man, young man will then do a lot of things that they think are part of this.
They’ll judge each other. It can involve having sexual conquests [and] having multiple sexual partners.
But at the core, those have spent time talking to young men realize that [young men] are unsure how to
express their love, and they do not want to be valued for their money or their sexual prowess. So to
support young men, [we need] to think about relationships more broadly and how they show their care;
it can be material support, but it can also be emotional support.

And so to break some of these provider loves patterns, [which is what it is called because] you [are]
loved because you’re the provider, [we must acknowledge that] some parts of our societies are very
gender fluid and the future generations are going to be more and more so. But what we also model as
care-givers and communities also shapes these expectations and then they translate in how people have
sex. But sex is the last thing. In some ways it’s everything else around that makes the opportunities or
choices available to them.

You mentioned some of the drivers for young women dating older men, are young men dating up as
well or are they kind of staying with the same age group? Do we know anything about that?
A lot of our research on this topic has come from the world of HIV and what we have realized there is
that young women, not all, are having relationships with older men. It’s not a huge proportion, but it’s
sufficient to feed into this cycle of HIV transmission and acquisition, which is what we’re trying to
interrupt through that work. But they also are having relationships with their peers, even if not
concurrent. So obviously those young men then are part of that relationship. [There are] relationships in
schools. The issue with older men, it’s not the age. I would hesitate to judge every young woman who
has a relationship or a sexual or romantic, or both, with someone purely on the age difference. The main
issue [with age] is the power inequality. It’s whether the exchange or gifts brings up the lack of condom
use or inability to negotiate contraception or feeling unsafe. Depending financially on that partner,
which can lead to spaces of violence, emotional or physical, [is why this is a point worry]. It may happen
with young men [too], but I think the power dynamic there would be different because the norms
around the young men are different. It’s tricky for young woman to then also negotiate consent [when
these differences are in place].

Then I’ve been speaking a in terms of heterosexual [sexual relationships], so I should apologize for my
heteronormativity. The prior conversation about exploration would apply to all kinds of sexual
exploration and there’s a much larger proportion of young people in Generation Alpha and Z as the
current children and adolescents are [referred too], are going to have the highest proportion of
exploring of relationships, not just in terms of gender identity, but also sexual orientation. So keeping an
open mind around that is going to be another challenge for us as parents.

Do you have top three myths or untruths about sexual reproductive health and regarding adolescence
that you think absolutely must be debunked?
1) That young women are getting pregnant to get the Child Support grant. There is huge qualitative
and quantitative data [indicating] that is not true.
2) That sexual risk-taking, drinking or drugs [are] forms of delinquency only.
3) That shaming, blaming and hitting are the answer to forcing good behavior. –

*This dialogue is based on the transcript of the interview with Dr. Toska conducted on April 14th, 2023. The text has been edited and adapted according to length specifications, for increased readability and coherence from the original audio-visual recording. The full audio recording is available on the Ubusha Bami podcast, available on all streaming networks.

References:

1. Image – https://pin.it/H65jtoB