"Boys Should Have the Courage to Ask a Girl Out": Gender Norms in Early Adolescent Romantic Relationships

The link between early adolescents' gender discrimination and gender attitudes about peers: Does gender similarity matter?

Gender is one of the most salient social identities, particularly during early adolescence. However, factors related to adolescents' gender attitudes remain underexamined. We examined links between adolescents' gender discrimination, felt-gender similarity, and intergroup gender attitudes. Participants were 270 adolescents in the United States (Mage = 12.95 years, SD = 1.33; 47.4% adolescent girls; 63.7% White, 12.2% Latinx, 10.7% Black, 4.1% Asian, 5.6% multiracial, and 3% indigenous). Path analyses showed that gender discrimination negatively predicted adolescents' attitudes towards own- and other-gender peers. Felt own-gender similarity positively predicted own-gender attitudes as expected, but other-gender similarity did not predict other-gender attitudes. Further, own- and other-gender similarity did not interact to predict adolescents' gender attitudes. However, adolescents' attitudes towards other-gender peers were more negatively impacted by gender discrimination for those who felt highly similar to own-gender peers than for those with average or low own-gender similarity. Findings inform potential strategies to improve adolescents' gender attitudes.

Gender Norms and Culture in Asian-Canadian Adolescent Boys’ Anticipating Dating Relationships

Adolescent romantic experiences can have profound developmental significance and may be predictive of future romantic relationships. Despite such potential significance, little is known about the challenges that confront teenage boys when navigating dating relationships. The present study sought to understand how masculine gender norms influence boys’ attitudes and behaviors and the influence of cultural expectations as they anticipate prospective dating relationships. Focus-group discussions were held with adolescent boys ( N = 23), ranging in age from 14 to 18 years, from a multicultural Canadian city. Grounded Theory methodology was used to analyze discussion responses. The Central Category of the grounded theory was Anticipating Getting Experience in Dating, while communicating and benefiting from relationships were subcategories. Masculine Gender Norms arose as the major Contextual Category. The findings demonstrate how these boys attempted to maintain a socially approved masculine status while coincidingly struggling with confidence and the demands of this status. Contextual factors involving peer expectations, social/digital media culture, multicultural context and parents’ expectations additionally contribute to their navigational struggles. Implications for boys’ relational development, in light of masculine gender norms, are addressed. Interventions are suggested to support boys in their development of confidence in romantic communications.

The Relational Nature of Gender, the Pervasiveness of Heteronormative Sexual Scripts, and the Impact on Sexual Pleasure

This study examined how gender shapes sexual interactions and pleasure outcomes. We highlight varying expectations people have in regard to sex by combining questions about orgasm frequency and sexual pleasure. Our analysis was driven from a sample of 907 survey responses from cis women, cis men, trans women, trans men, non-binary, and intersex millennial respondents, 324 of which had gender-diverse sexual histories. The findings built upon previous literature about the orgasm gap by including those with underrepresented gender identities and expanding our conceptualization of gender's role in the gap beyond gender identity. Qualitative results indicated that individuals change their behavior based on their partner's gender and follow strong gendered scripts. Participants also relied upon heteronormative scripts and cis normative roles to set their interactions for the sexual encounter. Our findings support previous research on how gender identity impacts pleasure outcomes and has implications for how we might make gender progress in the arena of sexuality.

"Such conversations are not had in the families": a qualitative study of the determinants of young adolescents' access to sexual and reproductive health and rights information in Rwanda

Background

Access to sexual and reproductive health and rights (SRHR) information during adolescence has become a global concern. This study explored factors that enable or prevent young adolescents from accessing to SRHR information from the perspective of the key informants in Rwanda.

Methods

We conducted a qualitative study using semi-structured interviews with 16 purposively selected key informants from public and private institutions in Rwanda. This selection was based on their positions and expertise in delivering SRHR information to adolescents. The interview guide questions were designed based on the social-ecological theoretical framework of adolescent health. The interview transcripts were recorded, transcribed, translated and thematically analysed in Nvivo 11.

Results

The study reflected that multiple enablers and barriers at the individual, relationship, community and societal levels determined young adolescents’ access to SRHR information. These determinants include information-seeking behaviour and age of starting sexuality education at the individual level; and parents’ limited communication with young adolescents due to taboos, lack of skills, limited parental availability, beliefs, lack of appropriate language and peer norms at the relationships level. Enablers and barriers at the community level were the diversity of SRHR sources, the scope of sexuality education programmes, and cultural and religious beliefs. Finally, the perceived enablers and barriers at the societal level consisted of inadequate resources, inappropriate SRHR policy-making processes and unfriendly SRHR laws.

Conclusion

Enabling access to SRHR information requires addressing multiple factors within the social-ecological environment of young adolescents. Addressing these factors may facilitate improved access to SRHR information for this age group.

Why do young people engage in dating relationships during early adolescence? An inter-generational qualitative analysis from Blantyre, Malawi

Engagement in dating relationships plays an important role in the health trajectories of young people, particularly during the early adolescent period between ages 10-14. Yet little is known about such relationships among youth in low resource contexts. This study sought to contribute to the literature on this topic by exploring reasons why school-going young people aged 12-14 years engage in dating relationships in Blantyre, Malawi. A thematic analysis was used to code and analyse in-depth interview data from 23 young people and 19 caregivers. Against the backdrop of growing sexual desires and feelings of attraction, participants stressed harassment from boys and coercion from older men, peer pressure, social status attainment, financial deprivation and encouragement during initiation ceremonies as reasons for engaging in dating relationships. Girls were found to be subject to multiple power dynamics-including gender power relations, as well as power dynamics within same-gender peer groups-that influenced their sex and relationship involvement. These findings carry implications for the design and timing of sexual and reproductive health youth programmes in Sub-Saharan Africa and emphasise the need for multi-level interventions to address the multiple influences in young people's dating lives.

Conceptualisations of masculinity and sexual development among boys and young men in Korogocho slum in Kenya

Youth and adolescence are times when young men negotiate their identity in relation to social and cultural expectations of being a man, with enduring implications for sexual health and wellbeing. This study explored how boys aged 10-14 years living in Korogocho slum in Nairobi, Kenya conceptualised masculinity, their perceptions of how masculinities are performed, and the linkage between conceptualisations of masculinity and sexual development. Three bases of gender socialisation were identified: (1) verbal messaging (mainly from parents and teachers); (2) observing the behaviours of older men in the community; and (3) information received from mainstream and social media. Masculinity conceptualisations focussed on financial stability, family life and responsibility, physical attributes, character and religion. Two contrasting portrayals of masculinity emerged in the form of idealised and dominant masculinities. A close linkage was found between masculinity conceptualisations and sexual development. Findings are important for programmes that aim to transform harmful gender norms and signal the need for longitudinal research exploring how gender beliefs may change over time.

Influence of beliefs about romantic love on the justification of abusive behaviors among early adolescents

INTRODUCTION

Romantic experiences during adolescence have an important influence on functioning later in life. Romantic love has been associated with the acceptance of abusive behaviors. This study examined the relationship between myths of romantic love and the perceived severity of different types of abusive behaviors, as well as the influence of gender.

METHODS

The sample comprised 448 Spanish adolescents (M = 12.92 years old; SD = 0.85), of which 50.3% were male and 49.7% were female. Participants were evaluated in the school setting. The Perception of Abuse Scale and the Myths, Fallacies, and Misconceptions about Romantic Love Scale were administered.

RESULTS

Statistically significant negative associations between the myths of romantic love and the perceived severity of abusive behaviors were found. Myths regarding possession, dedication, and exclusivity were associated with a lower perceived severity of abusive behaviors in adolescent males. Myths regarding the omnipotence of love were associated with a lower perceived severity of abusive behaviors in adolescent females. Believing in jealousy as a demonstration of love (myth of jealousy) and in the need to establish a steady union when you love someone (marriage myth) explained a lower perceived severity of abusive behaviors in regression models. However, being female and having these beliefs explained a higher perceived severity of abusive behaviors.

CONCLUSIONS

The myths of romantic love are already present during early adolescence. These beliefs are implicated in the construction of gender inequality and difficulties in the identification of dating abuse behavior severity. A gendered perspective is necessary to understand this issue. Early intervention strategies should address the cognitive and emotional components of intimate relationships.

Understanding the Relationship Between Adverse Childhood Experiences, Peer-Violence Perpetration, and Gender Norms Among Very Young Adolescents in Indonesia: A Cross-Sectional Study

PURPOSE

This study assesses the role of gender norms on the relationship between adverse childhood experiences (ACEs) and peer-violence perpetration among very young adolescents in three urban poor cities of Indonesia.

METHODS

A cross-sectional study was conducted in Bandar Lampung, Denpasar, and Semarang in Indonesia. A total of 2,974 participants (boys: 44.79%, girls: 55.21%) between 10 and 14 years were included in the analysis. Logistic regression, mediation, and moderation analyses were conducted stratified by sex.

RESULTS

Risk factors of peer-violence perpetration among boys and girls included three (boys: adjusted odds ratio [aOR] 2.51, 95% confidence interval [CI] 1.32-4.75; girls: aOR 1.82, 95% CI .95-3.52) and four or more (boys: aOR 6.75, 95% CI 3.86-11.80; girls: aOR 5.37, 95% CI 3.07-9.37) history of ACE. Risk factors of peer-violence perpetration among boys included having inequitable sexual double standard (SDS) indices (aOR 1.46, 95% CI 1.09-1.95). SDS measures the perception boys are rewarded for romantic relationship engagement, whereas girls are stigmatized or disadvantaged for the experience. Other risk factors included lifetime tobacco use among boys and girls and lifetime alcohol use among boys. Protective factors included parental closeness among girls.

CONCLUSIONS

Based on the research in three Indonesian communities, this study demonstrates that boys are disproportionately exposed to adversities including history of ACE, inequitable SDS, lifetime alcohol use and tobacco use in comparison to girls. Programs targeting ACE and gender norms which engage boys, girls, and families are more likely to be successful in reducing peer-violence perpetration and promoting gender equitable norms.

Healthy Romantic Relationships: Attitudes and Perceptions of College Students

Sexual assault (SA) is a serious issue affecting college students in romantic relationships. Having strong understandings of what constitutes healthy romantic relationships (HRR) can protect students by allowing them to better recognize SA and other problematic behaviors in relationships. However, little research has explored how students conceptualize HRR. Utilizing qualitative thematic analysis, this study analyzed data from individual and focus-group interviews from a sample of 45 students at a southwestern university in the United States. Findings indicated that students understood HRR to be characterized by direct communication, respect, and mutual satisfaction. However, their experiences showed that these ideals were not always achieved. This discrepancy may be explained by the influence of social norms, particularly around sexual behavior and gender role expectations. Implications and recommendations for social workers/counseling professionals are discussed.

Longitudinal Trajectories of Physical Intimate Partner Violence Among Adolescent Girls in Rural South Africa: Findings From HPTN 068

PURPOSE

Little is known about temporal patterns of physical intimate partner violence (PIPV) among South African adolescent girls. We sought to identify and describe PIPV risk trajectories and related correlates in this population.

METHODS

Our analytical cohort came from the HPTN 068 Cash Transfer Trial in Mpumalanga Province, South Africa. Cohort members were eighth and ninth graders (median age 14 years) who enrolled in 2011 and had three to four annual, self-reported PIPV measurements. We used group-based trajectory models to identify groups of girls with similar longitudinal patterns of PIPV risk over 4 years and potential correlates of group membership.

RESULTS

We identified two trajectory groups (n = 907): a higher-risk group (~52.8% of the cohort) with predicted PIPV probabilities of 13.5%-41.1% over time and a lower-risk group (~47.2% of the cohort) with predicted probabilities of 2.3%-10.3%. Baseline correlates of higher-risk group membership were ever having had sex (adjusted odds ratio [aOR]: 4.42, 95% confidence interval [CI]: 1.56-12.57), borrowing money (aOR: 1.95, 95% CI: 1.01-3.79), and older age (aOR per 1-year increase: 1.39, 95% CI: 1.11-1.73), while being in the 068 intervention arm (aOR: .29, 95% CI: .17-.51) and supporting more gender-equitable norms (aOR per 1-unit score increase: .89, 95% CI: .81-.97) were inversely associated.

CONCLUSIONS

A high proportion of adolescent girls experience sustained PIPV risk in rural South Africa, suggesting a need for interventions in late primary school that encourage gender-equitable norms, healthy relationships, and safe ways to earn income during adolescence.

Adolescents living with HIV, complex needs and resilience in Blantyre, Malawi

BACKGROUND

Adolescents living with HIV (ALHIV) in Malawi experience multiple challenges associated with their illness and various social, environmental, economic and cultural factors. In exploring their various medical concerns and social vulnerabilities, we consider the role of multiple services in creating a pathway for resilience.

METHODS

Multiple methods and case studies allowed for triangulation of evidence and provided a holistic understanding of resilience among adolescents with complex needs. The research methods included: (1) a survey to identify examples of young people with complex needs, (2) qualitative interviews and field notes to further explore these needs, (3) patient files and health passports to identify clinical challenges, and (4) ecomapping exercises to personalize cases and identify resilience-enabling resources and supports. We present four case studies to highlight the complex experiences and access to services of ALHIV, and to illustrate their growing power and decision-making capacity over time.

RESULTS

Adversity experienced by ALHIV varied by gender, family situation, years of schooling, and use of teen-clubs for support. The two female adolescents emphasised their need to be accepted and how this impacted sexuality and reproduction. The two males illustrated how ideas of masculinity influenced their sexual practice and involvement with health services and the correctional justice system. Multiple risks (alcohol use, sexual activities) and complex needs (belonging, having a purpose in life/productive activities, autonomy, desire for offspring) influence pathways to resilience. ALHIV were able to strengthen their own wellbeing by resisting negative behaviours and peer pressure and caregiver interactions through 'strategic silence'.

CONCLUSION

ALHIV experienced self-transformation as a result of taking ART, with fewer severe episodes of illness and distressing skin conditions. Continuous engagement at the teen-club clinic transformed both productive activities and social relationships among ALHIV as they set life goals, gained a sense of empowerment, requested SRH services, and formed intimate relationships. These transformative opportunities allowed them to learn ways of minimizing risk of reinfection and violence, and of navigating health worker-caregiver-adolescent interactions.

Parent-child sexual and reproductive health communication among very young adolescents in Korogocho informal settlement in Nairobi, Kenya

Background

Parents are an important source of sexual and reproductive health (SRH) information for very young adolescents and are likely to have a significant influence on adolescents’ sexual attitudes, values, and risk-related beliefs. This study explored the nature and content of parent-child communication about SRH issues.

Methods

Thirty-two parents and 30 adolescent boys and girls aged between 11 and 13 years participated in narrative interviews in a resource-poor urban setting in Nairobi, Kenya. Interviews were audio-recorded, transcribed, translated into English, and uploaded on Atlas.ti software for coding and analysis.

Results

Findings from the study show gender differences in parent-child communication. More girls than boys reported that they had talked with their parents about romantic relationships. Four approaches—no communication, fear-based communication, supportive communication, and involving an external person were used by parents in SRH communication. Parents hostile attitudes towards romantic relationships during adolescence discouraged adolescents from disclosing their relationship status. While communication did occur, it was mainly reactive, one-sided, and authoritarian, often initiated by parents.

Conclusions

Parents need to be empowered with adequate and factual SRH information and effective communication strategies to enhance communication with very young adolescents. There is a need for further research to identify the most effective parent-child communication approaches to improve SRH outcomes among adolescents.

Gender norms about romantic relationships and sexual experiences among very young male adolescents in Korogocho slum in Kenya

Objectives

To investigate the association between gender norms about romantic relationships and sexual experiences of very young male adolescents (VYMA) living in Korogocho slum in Nairobi, Kenya.

Methods

We used cross-sectional data from a sample of 426 VYMA living in Korogocho slum. We conducted an exploratory factor analysis and confirmatory factor analysis to, respectively, explore and validate the factor structure underlying gender norms scale items. We used structural equation modelling to assess the association between gender norms and sexual experiences of VYMA.

Results

We found high endorsement of heteronormative beliefs about romantic relationships and low endorsement of sexual double standards. Sexual experience was associated with low endorsement of heteronormative beliefs, being pre-pubertal, school absenteeism and being below recommended grade for age. Sharing a sleeping room with more than two people, been born outside Nairobi, and living in households headed by older persons lowered the likelihood of sexual experience.

Conclusions

Our findings underscore the need for further research to understand how gender norms evolve as young boys transition through adolescence to adulthood and how these changes impact on sexual behaviors

Electronic supplementary material

The online version of this article (10.1007/s00038-020-01364-9) contains supplementary material, which is available to authorized users.

The Influence of Schooling on the Stability and Mutability of Gender Attitudes: Findings From a Longitudinal Study of Adolescent Girls in Zambia

PURPOSE

Inequitable gender norms are thought to harm lifelong health and well-being. We explore the process of gender attitude change and the role of schooling in shifting or reinforcing gender norms among adolescent girls in Zambia.

METHODS

We used longitudinal data collected from unmarried, vulnerable girls (aged 10-19 years) as part of the Adolescent Girls Empowerment Program. We conducted random effects multinomial logistic regression to determine whether schooling-related factors were associated with shifts in adolescent girls' gender attitudes across three survey rounds and explored whether these relationships varied by age.

RESULTS

Mean gender attitude scores at the aggregate level remained stable over time among rural girls and improved slightly for urban girls. At the individual level, about half the girls had relatively unchanged scores, whereas the other half shifted to higher or lower scores between rounds. Rural and urban girls currently attending school were more likely to have relatively stable equitable attitudes than stable, inequitable attitudes, or attitudes that shifted to inequitable. Educational attainment was not associated with shifts in gender attitudes among rural girls. Urban girls with higher educational attainment were more likely to have relatively stable equitable attitudes than stable, inequitable attitudes, or attitudes that shifted to inequitable or more equitable.

CONCLUSIONS

Patterns of gender attitude stability and change differed more for urban girls than rural girls and varied by age and schooling-related factors. In general, schooling appears to be an institutional lever that holds promise for shifting gender attitudes toward greater equality. Our study highlights the importance of looking longitudinally at the effects of social context and reinforces calls for targeted, context-specific interventions for this age group.

Gender norms and health: insights from global survey data

Despite global commitments to achieving gender equality and improving health and wellbeing for all, quantitative data and methods to precisely estimate the effect of gender norms on health inequities are underdeveloped. Nonetheless, existing global, national, and subnational data provide some key opportunities for testing associations between gender norms and health. Using innovative approaches to analysing proxies for gender norms, we generated evidence that gender norms impact the health of women and men across life stages, health sectors, and world regions. Six case studies showed that: (1) gender norms are complex and can intersect with other social factors to impact health over the life course; (2) early gender-normative influences by parents and peers can have multiple and differing health consequences for girls and boys; (3) non-conformity with, and transgression of, gender norms can be harmful to health, particularly when they trigger negative sanctions; and (4) the impact of gender norms on health can be context-specific, demanding care when designing effective gender-transformative health policies and programmes. Limitations of survey-based data are described that resulted in missed opportunities for investigating certain populations and domains. Recommendations for optimising and advancing research on the health impacts of gender norms are made.

'Inexperienced'? Patterns in romantic and sexual experiences among urban poor early adolescents in Nairobi, Kenya

The need for early prevention approaches to improve young people's sexual and reproductive health is gaining attention, yet little is known about the sexual experiences of early adolescents aged 10-14 years. Drawing on cross-sectional survey data collected from 365 early adolescents in a Nairobi slum, we used latent class analysis to identify subgroups based on self-reported awareness about sex and involvement in romantic and sexual activities. Multivariate regression models were fitted to examine the characteristics of each subgroup. Results revealed three subgroups: Involved (12%, high probability of being aware of sex and to have engaged in romantic/sexual activities); Observant (48%, high awareness but little own experience); and Naïve (40%, little awareness or personal experience). Being in the Involved group was associated with older age, having commenced puberty/orphanhood, and living in the least poor households. Findings suggest that while most early adolescents in this setting have not initiated romantic and sexual activities, there are distinct subgroups of who would not be captured by looking only at the prevalence of sexual intercourse. Understanding the characteristics and needs of specific subgroups may help to strengthen efforts to improve young people's sexual and reproductive health in urban poor environments.

Measuring gender norms about relationships in early adolescence: Results from the global early adolescent study

Introduction

Gender norms are increasingly recognized as drivers of health and wellbeing. While early adolescence constitutes a critical window of development, there is limited understanding about how adolescents perceive gender relations across different cultural settings. This study used a mixed-method approach, grounded in the voices of young people around the world, to construct and test a cross-cultural scale assessing the perceptions of gender norms regulating romantic relationships between boys and girls in early adolescence.

Methods

The study draws on the Global Early Adolescent study (GEAS), a study focusing on gender norms and health related outcomes over the course of adolescence in urban poor settings worldwide. In-depth interviews were first conducted among approximately 200 adolescents between 10–14 years in seven sites across 4 continents to identify common scripts guiding romantic relations in early adolescence. These scripts were then transformed into a multidimensional scale. The scale was tested among 120 adolescents in each of 14 GEAS sites, followed by a second pilot among 75 adolescents in six sites. We evaluated the psychometric criteria of each sub-scale using principal component analysis, and parallel analysis, followed by exploratory factor analysis to guide the selection of a more parsimonious set of items.

Results

Results suggested a two-factor structure, consisting of an “adolescent romantic expectations” subscale and a “Sexual Double Standard” subscale. Both subscales yielded high internal validity in each site, with polychoric Cronbach alpha values above 0.70 with the exception of Kinshasa for the adolescent romantic expectations scale (0.64) and Hanoi for the sexual double standard scale (0.61).

Conclusion

This study reveals common perceptions of gendered norms about romantic engagement in early adolescence, normative for both sexes, but socially valued for boys while devaluated for girls. The findings illustrate that social hierarchies of power in romantic relationships form early in adolescence, regardless of cultural setting.

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Gender norms about romantic relationships prevail across diverse cultures.

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New cross-cultural scales measure early adolescents’ perceptions of gender norms;

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Adolescent romantic relations are viewed as normative but damaging for girls;

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Even before sexual activity, adolescents understand societal expectations about relationships;

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Social hierarchies of power in relationships form in early adolescence.

Updates on adolescent dating and sexual violence prevention and intervention

PURPOSE OF REVIEW

Dating and sexual violence victimization are not uncommon in early adolescence and increase in prevalence throughout adolescence into young adulthood with profound health and social consequences. Greater attention to what works in prevention is needed to inform current policies and practices.

RECENT FINDINGS

Adolescent dating violence (ADV) and sexual violence victimization, including cyber dating abuse, are highly prevalent among adolescents. Studies have found sex category differences, with adolescent girls reporting more victimization than boys, particularly sexual violence. Sexual and gender minority youth also experience a higher prevalence of violence victimization than their heterosexual counterparts. Studies on risk factors include examinations of childhood adversities, exposure to sexually explicit material and substance use as well as the role of gender inequitable attitudes on violence perpetration. Recent prevention research includes examining the impact of bystander interventions and transforming gender norms.

SUMMARY

Recent ADV/ sexual violence research highlights both prevalence and modifiable risk and protective factors that may help reduce such violence. Practitioners caring for youth should consider ADV/ sexual violence when seeing patients (including those struggling with substance use and other behaviours that contribute to poor health) and not simply rely on screening tools to identify those suffering from ADV/ sexual violence.

Evaluating the impact of the DREAMS partnership to reduce HIV incidence among adolescent girls and young women in four settings: a study protocol

Background

HIV risk remains unacceptably high among adolescent girls and young women (AGYW) in southern and eastern Africa, reflecting structural and social inequities that drive new infections. In 2015, PEPFAR (the United States President’s Emergency Plan for AIDS Relief) with private-sector partners launched the DREAMS Partnership, an ambitious package of interventions in 10 sub-Saharan African countries. DREAMS aims to reduce HIV incidence by 40% among AGYW over two years by addressing multiple causes of AGYW vulnerability. This protocol outlines an impact evaluation of DREAMS in four settings.

Methods

To achieve an impact evaluation that is credible and timely, we describe a mix of methods that build on longitudinal data available in existing surveillance sites prior to DREAMS roll-out. In three long-running surveillance sites (in rural and urban Kenya and rural South Africa), the evaluation will measure: (1) population-level changes over time in HIV incidence and socio-economic, behavioural and health outcomes among AGYW and young men (before, during, after DREAMS); and (2) causal pathways linking uptake of DREAMS interventions to ‘mediators’ of change such as empowerment, through to behavioural and health outcomes, using nested cohort studies with samples of ~ 1000–1500 AGYW selected randomly from the general population and followed for two years. In Zimbabwe, where DREAMS includes an offer of pre-exposure HIV prophylaxis (PrEP), cohorts of young women who sell sex will be followed for two years to measure the impact of ‘DREAMS+PrEP’ on HIV incidence among young women at highest risk of HIV. In all four settings, process evaluation and qualitative studies will monitor the delivery and context of DREAMS implementation. The primary evaluation outcome is HIV incidence, and secondary outcomes include indicators of sexual behavior change, and social and biological protection.

Discussion

DREAMS is, to date, the most ambitious effort to scale-up combinations or ‘packages’ of multi-sectoral interventions for HIV prevention. Evidence of its effectiveness in reducing HIV incidence among AGYW, and demonstrating which aspects of the lives of AGYW were changed, will offer valuable lessons for replication.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5789-7) contains supplementary material, which is available to authorized users.

"Girls Have More Challenges; They Need to Be Locked Up": A Qualitative Study of Gender Norms and the Sexuality of Young Adolescents in Uganda

Unequal power and gender norms expose adolescent girls to higher risks of HIV, early marriages, pregnancies and coerced sex. In Uganda, almost half of the girls below the age of 18 are already married or pregnant, which poses a danger to the lives of young girls. This study explores the social construction of gender norms from early childhood, and how it influences adolescents' agency. Contrary to the mainstream theory of agency, which focuses on the ability to make informed choices, adolescents' agency appears constrained by context-specific obstacles. This study adopted qualitative research approaches involving 132 participants. Of these, 44 were in-depth interviews and 11 were focus group discussions, parcelled out into separate groups of adolescents (12-14 years), teachers, and parents (n = 88), in Western Uganda. Data were analysed manually using open and axial codes, and conclusions were inductive. Results show that gender norms are established early in life, and have a very substantial impact on the agency of young adolescents. There were stereotypical gender norms depicting boys as sexually active and girls as restrained; girls' movements were restricted; their sexual agency constrained; and prevention of pregnancy was perceived as a girl's responsibility. Programs targeting behavioural change need to begin early in the lives of young children. They should target teachers and parents about the values of gender equality and strengthen the legal system to create an enabling environment to address the health and wellbeing of adolescents.