At the height of the Ebola crisis in Sierra Leone, bodily contact was what people seemed to fear most. Kissing, hugging and shaking hands all became off-limits, especially when greeting strangers.

Yet behind closed doors, where people were increasingly congregating because schools and businesses were closed, we now know something else was going on. Teenage girls were having sex – or being raped – and getting pregnant.

Since 2014, humanitarian organizations have been reporting anecdotally that during the Ebola crisis, girls as young as nine have turned up at health centers pregnant.

“Schools are not functioning, we are idle, that is why men who are older than us keep chasing us,” one teenage girl told researchers for a report on the effects of Ebola, published jointly by Plan International, World Vision and Save the Children. “We have lost concentration and focus on school work, that’s why most of our friends have become pregnant,” another teenage girl said in the same report.

In the study, about 10 percent of children aged seven to 18 said vulnerable girls in their community, especially those who lost relatives to Ebola, were being forced into transactional sex to help pay for food and housing.

A police report obtained by the Sierra Leonean human rights group Humanist Watch Salone also said there were 2,201 reported sexual assaults in 2014, up from 1,485 in 2013.

Sierra Leone already had one of the worst rates of teenage pregnancy in the world. As many as 30 percent of children born each year have teenage mothers, according to government data. Violence is also commonplace, though Sierra Leone sees few rape convictions.

To add to the stigmatization of girls who get pregnant young, the government introduced a highly controversial policy, banning pregnant teenagers from attending school or sitting national exams. The policy, introduced during Ebola, was designed to deter other girls from getting pregnant. However, rights organizations including Amnesty International have slammed it, saying pregnant teenagers have the right to an education.

The outcry led to a bridging program being set up with the support of international donors, including the U.K. government’s department for international development (DFID) and Irish Aid, to enable pregnant teenagers to keep up their schooling. As of March 2016, the ministry of education in Sierra Leone announced 14,000 pregnant girls were now attending the bridging program.

Other organizations are also offering community outreach services and family planning advice to try to address teenage pregnancy.

However, Lisa Denney, Sierra Leone research lead for the Secure Livelihoods Research Consortium at the Overseas Development Institute (ODI), warned that current programs will have a limited impact unless girls are not the only ones targeted to change their behavior. “Girls themselves do not always control the situation,” Denney said. “We also need to deal with the fact men see sex as a currency and think it is OK to constantly proposition young women.”

Denney spent several months researching efforts to reduce teenage pregnancy in Sierra Leone and coauthored a report published this month by the Secure Livelihoods Research Consortium, recommending ways to improve the situation.

She said organizations need to unpack the different reasons girls engage in sex – and adapt their programs accordingly. “If it’s legal consensual sex among teenagers of the same age then it’s a matter of offering family planning promotion because no one is going to stop teenagers having sex once they have started,” she said. “That to me is very different from dealing with a rise in transactional sex and rape.”

Denney says many of the girls interviewed aged between 13 and 18 said Ebola forced some young women to offer sex in exchange for privileges like credit for their phones. They also found themselves vulnerable to sexual assault by strangers or relatives while cooped up indoors trying to avoid contamination.

She said the situation should provide important lessons for future disease outbreaks.

“One of the biggest takeaways from all this research is about using locally respected channels to encourage behavior change. You can issue instructions from the government but until you have local leaders, community elders and secret society chiefs on board, the message will not be taken on.”