Within the rights approach, the capability of girls to exercise their sexual and reproductive freedom is strongly linked to their entitlement to a system of sexual and reproductive health protection that ensures both an array of relevant services and a healthy environment [21, 41–43]. Providers and policy makers' repertoires do not neutrally describe what goes on regarding girls' sexual and reproductive health, but in fact have implications and consequences for the way they approach those girls and the actions they take to deal with adolescent pregnancies and adolescents' sexual and reproductive health [32, 39, 40]. In this study those repertoires were dictating the array of sexual and reproductive health services that would be available for girls in Orellana and the way they were delivered. To some extent they also influenced girls' sexual and reproductive freedom, and the social determinants of sexual and reproductive health beyond the provision of health care.
The "sex is not for fun" repertoire could be perceived as a starting point for stressing the urgency for implementing sexual and reproductive health services for adolescents. Since adolescents' reproductive and sexual health and rights have not been high in the public policy agenda of many Latin American countries [25, 30], stressing the harmful, and preventable, consequences of sexual risk-taking for adolescents and the society as a whole, could be an argument for addressing the lack of interest in this issue. Providers' acknowledgement that girls should be entitled to a network of reproductive and sexual health services (that included access to sexual and reproductive education and information) could create an opportunity for strengthening sex education programs in Orellana. However, the "sex is not for fun" repertoire might also shape those services in a way that constrains girls access to "relevant" information: contradictory messages regarding contraceptive use might discourage girls from using them; providers' difficulties with managing selected sexuality issues might lead to incomplete or misleading sex education programs; services that do not take into account issues of gender inequality or gender-based violence and sexual violence might fail to fulfill the reproductive and sexual health needs of girls. This way of providing biased information does not seem to be the best, since several studies show that the greater impact on adolescents' sexual behavior comes from comprehensive information on sexuality and not from abstinence-only education [44–47].
The network of reproductive and sexual health services that the gendered sexuality and motherhood repertoire constructed was one oriented towards girls and women, thus reinforcing the idea that reproductive matters were exclusively women's/girls' responsibility. Moreover, since girls were not expected to be interested in sex, but in reproduction, issues regarding sexuality might not be addressed as importantly as issues regarding contraceptive use and maternal and child health. As a consequence, girls might end up being entitled to health services that reinforce their responsibility regarding pregnancy - including pregnancy prevention- and motherhood, and deny girls' right to be sexually active and well-informed and protected. This "mother-nization" of reproductive services for girls has also been described by Varea in a study in Quito's Isidro Ayora Maternity .
Providers acknowledged that illegal and unsafe abortions were common among adolescents, and that pregnancy due to sexual abuse was common. However, abortion had no place within the array of services girls' should be entitled to in Orellana. Pregnant adolescents were persuaded to accept, love the fetus and make sacrifices for its wellbeing, even when pregnancy was the product of unwanted sexual intercourse or rape.
The array of services that girls were entitled to also left out the provision of support for child-raising, such as childcare services, maternity leave, and measures to ensure paternal compliance with their economic responsibilities; those were not available within the array of services under the state's responsibility, but remained the individual's - mainly the woman's-responsibility.
If we conceptualize freedom not just as individual liberty, but as the actual capability to make choices, then it does not only depend on the existence of a network of policies and laws, but also on the degree of implementation and the impact those policies have on individuals' capability to exercise their rights. Both the "sex is not for fun" repertoire and the "gendered sexuality and parenthood" repertoire curtailed girls' freedom to exercise safe sex by displaying a normative code that disapproved of sexual intercourse for girls before they established a formal relationship, did not straightforwardly encourage girls to use contraceptives, and reinforced submissive, dependent, and obedient attitudes. This normative code is produced and reproduced by the machismo-marianismo system that emphasizes men's dominance while encourages women's submission, chastity, and self-sacrifice [32, 49–51]. This normative system, alongside Ecuador's Penal Code - in Ecuador abortion is legally permitted only when the life and health of the mother are at risk and when pregnancy is due to rape of a mentally disabled woman- curtailed girls' freedom to decide upon the continuation or termination of their pregnancies, by stressing motherhood as women's natural responsibility.
The "professionalizing adolescent pregnancies" repertoire also greatly influenced the way sexual and reproductive health services were provided. Even if providers were truly well-intentioned, the way they approached adolescent girls -and boys- could be constructed as paternalistic and patronizing: girls were not really heard but advised, confidentiality could not be ensured and professionals assumed they had the right to decide what was best for the patient. Those attitudes of health providers have been found to be ineffective for reproductive and sexual health promotion, and contribute to further disempowering girls. Instead, the encounter between the provider and the girl could be reconstructed differently, as an opportunity for helping girls gain agency and freedom towards their sexual and reproductive life [29, 31, 52–54].
Since adolescence was viewed by professionals as an underdeveloped stage, youth participation in decision making in this area was largely non-existent. However, dissident voices were also present: some of the youngest policy makers who participated in our study had a critical view regarding youth participation, asking for youth involvement at all levels of the decision making process. This could be an encouraging sign in Orellana, since evidence from other settings has established that youth participation in developing policies and programs addressing their needs is effective in implementing more meaningful interventions, and it is also a basic principle of the rights' approach to sexual and reproductive health [24, 25, 27]. The hierarchical division of expertise left out, (or at least almost left out), issues and providers working in gender-based violence. As many studies show, sexual abuse and intimate-partner violence are vital problems limiting girls' freedom to enjoy sexual and reproductive rights and any system of health protection should take them into account as central features [24–26, 28, 33, 48].
The idealization of institutions such as marriage and family might also constrain girls' freedom to exercise their sexual and reproductive rights, by overseeing girls' vulnerability to sexual abuse, violence and other violations of rights of girls living within those "safe" institutions [55–57]. "Familism", a cultural value typical in Latino societies that "weights on the interdependence among nuclear and extended family members for support, emotional connectedness, familial honor, loyalty, and solidarity" (Munoz-Laboy, p. 773) , could have positive consequences in the way of acknowledging the important role of families influence on girls' sexuality and sexual behavior. It could have a positive impact on promoting healthy behavior, but it might also foster very restrictive norms for controlling girls' sexual freedom, especially when embedded within the machismo-marianismo system [32, 58].
Providers' and policy makers' repertoires determined the areas that the array of sexual and reproductive health services should include, leaving out the ones more prone to cause conflict and opposition, such as gender equality, abortion provision and welfare services for pregnant adolescents. In that way, sexual and reproductive services for adolescents could have more chance of being implemented, but it raised questions regarding how adequately such services would address adolescents' sexual and reproductive needs. Moreover, even in the areas that were part of this narrowed array of services, patronizing and hierarchical attitudes might further diminish the positive impact of the provided services.
In this study, issues related to gender relations were preeminent. Women's subordination is a crucial social determinant of poor sexual and reproductive health [19, 20, 59, 60]. Institutional gender regimes interact with the wider gender order, and could reinforce gender based inequities or contribute to challenge and resistance . The present study evidenced that, in Orellana, gender regimes of reproductive and sexual health services mainly reinforced girls' subordination, although attempts to resist and challenge were also present. On the one hand, services were provided in a hierarchical way that reinforced young girls' disempowered position and devalued their knowledge and experiences. Policies that did not take into account young single women's needs for economic support and child-care further constrained their possibilities of being independent. On the other hand, the fact that some providers challenged the discriminatory gender regimes of their own institutions, acknowledged the problem of sexual and intimate partner violence within marriages and families, and struggled to ensure adolescents' participation, established opportunities for making this rigid gender and generational order more prone to change.
This article opens the discussion regarding how policies and services might best contribute towards the realization of adolescents' sexual and reproductive rights. Girls' reproductive and sexual freedom could be enhanced by the provision of adequate, unbiased information and services -especially regarding contraceptives- that comply with the standards of availability, accessibility, acceptability, good quality, relevance and equity. The repertoires emerging from this article also point to the relevance of critically questioning the consequences of moralistic attitudes that stigmatize girls' sexual activity and focus on the prevention of girls having sexual intercourse, instead of the prevention of unprotected, coerced, uninformed, and unpleasant sexual activity. It would be interesting to explore mechanisms to reconstruct masculinity and parenthood in a more constructive way, and to foster men's/boys' responsibility towards their offspring. Services might play an important role in achieving that if policy makers conceive boys and men, not only as a menace but as an opportunity for improving girls' -and their own- reproductive and sexual health. At the same time, it appears important to reconstruct motherhood not as a woman's destiny, but as a choice, and such a shift would be more likely to occur by having an open debate regarding abortion and the state's responsibility for the provision of welfare services; thereby ensuring that girls can cope with maternity without sacrificing other aspects of their lives-such as education, independence, employment and leisure.
Main limitations and measures to enhance trustworthiness
Measures were taken in order to strengthen trustworthiness . Regarding credibility - how well the findings had captured the reality being explored - since the first author was living in the area where the research was going on, credibility was enhanced by prolonged engagement in the area and persistent observation. The risk of naivety was minimized by discussion with the other researchers who were not familiar with the setting. The fact that the first author was both an insider (through her daily work in Orellana), and outsider (through her role as researcher), may have influenced the results. On the one side it helped to gain access to participants, on the other side participants' opinions may have been influenced by social desirability bias. Since the first author was also European, the risk of ethnocentrism also has to be taken into account. Credibility was also enhanced by informal debriefing with colleagues and triangulation of researchers. Referent checking was done through informal discussions with providers who were not involved in the study, and by presenting and discussing preliminary results in a workshop with Orellana's service providers and policy makers. In order to stay closer to the text, the original Spanish version was used for coding, and translation into English only took place after repertoires emerged.
Transferability-analytical generalizability - was enhanced by purposely selecting participants based on their ability to contribute to the study question. An effort was made to contextualize the results, so that readers could better evaluate the applicability of the results to other areas. In fact, even if the study is based on a very concrete setting, the results may reflect not only the discourses of Orellana's service providers and policy makers, but also the general discourse of professional stakeholders involved in adolescents' sexual and reproductive health.
Dependability-the ability to respond to issues emerging from the data - was enhanced by following an emergent design, i.e. the interview guides incorporated issues emerging from previous interviews.
Regarding neutrality, we did not claim to be neutral as researchers as in a positivistic paradigm, but in accordance with Lincoln & Guba, we sought neutrality of the data . The researchers' position influenced the research topic and the rights approach, and may have influenced the results. However, in order to avoid biases and stay neutral to data we used the method of "bracketing" , which here meant not excluding contradictory findings and not going in-depth into existing theories until we had analyzed the data.