Talking about Life, Love and Sexuality

More than 1.3 billion people -- one in five people alive today -- are adolescents aged 10 to 19.^[1] About 85 per cent of them live in developing countries.

Young people represent an enormous potential resource for most developing countries. Their educational achievement, the skills they develop and the decisions they make about sexual behaviour and childbearing have profound effects, not only on their own lives, but on the lives of generations to come.

Poor sexual and reproductive health outcomes, which are often linked with poverty, can often be traced to the adolescent years, when most people become sexually active. Key risk factors include early sexual initiation, substance abuse, depression and ignorance about contraception.^[2] Lack of of power leaves adolescent girls vulnerable to sexual coercion.

Adolescents, even married ones, and especially girls, often have little or no access to reliable information and services, or the economic and social power, to protect themselves against unintended consequences of sexual relations.

Adult discomfort with adolescent sexuality is a major obstacle to providing young people with the information and services they are entitled to. The result can be lost potential and opportunities, unwanted children, illness, or even death.

Investments in young people’s development, including education, livelihoods, financial literacy, and health, are among the most cost-effective expenditures in terms of the societal and economic returns. Yet often adolescents are often neglected countries’ development agendas.

Contents

• Get the Facts
  
  • Adolescent Pregnancy
  • Child Marriage
  • Sexually Transmitted Infections and Young People
• What Needs to Be Done
  • The ICPD and the Millennium Development Goals

Get the Facts

• Half of the world’s people are under 25. In all regions, the time between puberty and marriage is increasing.
   
• In developing countries, most sexually active adolescent girls are married.^[3]
   
• Adolescents’ capacities, needs and opportunities vary, often dramatically, by age, gender, schooling, economic and marital status, region and area (urban, rural, migratory) of residence and birth, and cultural affiliation.^[4] Effective programming needs to address their different needs and circumstances.
   
• Many countries have laws that prohibit people under 18 from accessing reproductive health services without parental consent, effectively denying access to many sexually active young people.
   
• Gender inequalities limit the ability of young women, especially those who are married, to say no to sex or negotiate condom use.
   
• Rigorous review of more than 60 studies from developing countries demonstrates that sexual and reproductive health education does not increase premarital sex or lower the age of sexual debut.^[5]

Adolescent Pregnancy

• About 16 million adolescent girls aged 15-19 give birth each year, accounting for more than 10 per cent of all births worldwide.^[6]
   
• Adolescent pregnancy is correlated with low education levels for girls.
   
• At least 2.5 million adolescent pregnancies every year lead to unsafe abortions.^[7]
   
• Compared to adults, adolescents are more likely to delay abortion, resort to unskilled persons to perform it, use dangerous methods and present late when complications arise.
   
• Complications from unsafe abortion are the leading cause of death among teenagers in many countries in southern and eastern Africa and Latin America.
   
• In low- and middle-income countries, almost 10 per cent of girls become mothers by age 16 years, with the highest rates in sub-Saharan Africa and south-central and south-eastern Asia.^[8]
   
• Adolescent pregnancy is dangerous: Though mothers aged 10 to 19 account for 11 per cent of all births worldwide, they bear 23 per cent of the overall burden of disease due to pregnancy and childbirth.
   
• Girls between the ages of 10 and 14 are five times more likely to die in pregnancy or childbirth than women aged 20 to 24. Girls aged 15 to 19 are twice as likely to die. The vast majority of these deaths take place within marriage.^[9]
   
• Sixty-five per cent of all cases of obstetric fistula occur in girls under the age of 18.^[10]
   
• Other problems related to adolescent pregnancies include anaemia, postpartum haemorrhage and mental disorders, such as depression.^[11]
   
• Adolescent pregnancy is dangerous for the child as well: stillbirths and death in the first week of life are 50 per cent higher among babies born to mothers younger than 20 than among mothers aged 20 to 29, and rates of premature birth, low birth weight, and asphyxia are higher among children born to mothers under 18.
   
• Contraceptive use by sexually active teenage women ranges from 2 per cent in Niger, Rwanda and Senegal to less than 11 per cent throughout Latin America and the Caribbean, and 34 per cent in Indonesia. It rises to 92 per cent in Great Britain.^[12]
   
• Half of all adolescent births occur in just countries: Bangladesh, Brazil, the Democratic Republic of the Congo, Ethiopia, India, Nigeria and the United States.^[13]

Child Marriage

• Although most countries have declared the minimum legal age of marriage to be 18, some 10 million teenage girls marry every year.
   
• In places where child marriage is practiced, girls rarely have any say in when and whom they marry.^[14]
   
• Worldwide, more than 50 million adolescent girls aged 15–19 are married, some with little understanding of sex or reproduction.
   
• Early and arranged marriage perpetuates the low status of women by disrupting schooling and limiting economic opportunity.
   
• Young married girls are often under extreme pressure to prove their fertility.^[15]
   
• Most married adolescents will not complete secondary education, and many will become pregnant before their bodies are mature enough to safely deliver a child.
   
• Married adolescents often face greater reproductive health risks than unmarried adolescents. Research conducted in Kenya and Zambia shows that young married girls are more likely to be HIV-positive than their unmarried peers because they have sex more often, use condoms less often, are unable to refuse sex, and have partners who are more likely to be HIV-positive.^[16]
   
• While child marriage has decreased globally over the last 30 years, it remains common in rural areas and among the poorest of the poor. Impoverished parents often give up their daughters for economic reasons, or believe that child marriage will protect their daughters and family status.^[17]
   
• Child marriage is most common in sub-Saharan Africa and South Asia (where 42 and 48 per cent of girls, respectively, marry before age 18).^[18]
   
• Married girls are at higher risk than women who marry later for sexual and domestic violence at the hands of their husbands, and more likely to believe that a husband might sometimes be justified in beating his wife.^[19]

Sexually Transmitted Infections and Young People

• Each year at least 111 million new cases of curable STIs occur among young people.^[20]
   
• Most adolescents do not have access to acceptable STI services.^[21]
   
• There are more than 30 bacterial, viral and parasitic transmitted infections, in addition to the more well known ones such as gonorrhea, chlamydia, syphilis, human papilloma virus (HPV), and hepatitis B and HIV. Untreated, these infections can have serious consequences, especially for women and their children. HPV, for example, can lead to cervical cancer, which is often deadly. Others multiply the risk of HIV transmission during sex.
   
• Adolescent girls are at higher risk from STIs than boys because they reach puberty earlier, have older partners more often, and are physiologically more vulnerable to infection.
   
• An estimated 5.4 million youth are living with HIV -- the majority live in East and Southern Africa.^[22]
   
• Three out of four HIV infections are sexually transmitted.
   
• Survey data from sixty-four countries indicate that only 40 per cent of males and 38 per cent of females aged 15 to 24 had accurate and comprehensive knowledge about HIV and its prevention.^[23] This falls far short of the global goal of ‘ensuring comprehensive HIV knowledge in 95 per cent of young people by 2010.
   
• Young women, who are more vulnerable to the HIV epidemic than men, comprise 57 per cent of all young people with HIV. In sub-Saharan Africa, 3.2 million young people are living with HIV and three young women are infected for every young man (in some countries the ratio is 6 to 1.^[24]
   
• Research in Uganda reveals that young people living with HIV are often discriminated against by sexual and reproductive health service providers. Sixty per cent of those living with HIV reported that they had not disclosed their status to their sexual partners; 39 per cent were in relationships with a sexual partner who did not have HIV. Many did not know how to disclose their status to their partners.^[25]

What Needs to Be Done

• Each country needs to develop a package of youth services based on the local context.
   
• Adolescents need support in building up their social, economic and psychological resources so they have the power to make their own choices about sex and reproduction.
   
• Ensure age-appropriate sexual and reproductive health education aimed at building life skills. Include very young adolescents (10-14), who no longer qualify for many programmes aimed at children, are often neglected in programming and policy. Reaching out to young girls is an especially powerful strategy.
   
• Provide all young people with access to comprehensive and culturally appropriate sexual and reproductive health education in schools. Programmes should offer accurate, comprehensive information while building communication and other life skills.
   
• Different approaches, including peer outreach, pop culture and on-the-job programmes, are needed to reach out-of-school youth.
   
• Information is an important first step, but young people also need help in developing life skills and access to youth-friendly sexual and reproductive health services and supplies.
   
• Advocate for laws to protect adolescents, especially those who are most vulnerable (including migrants, street children, sex workers, refugees and victims of violence) from sexual exploitation.
   
• Involve young people in programming decisions. Their contributions will make programmes more successful.
   
• Girls’ education must be a priority: limited education is closely associated with early childbearing and sexually transmitted infection. Higher education levels for girls are correlated to later marriage and childbearing and lower rates of HIV in most countries.^[26]
   
• Educate families and communities about the value of girls’ education and the risks of child marriage to family health and opportunity.
   
• Address gender inequalities that leave girls vulnerable to pregnancy and HIV infection because they cannot negotiate safe sex as equals in a relationship.
   
• Ensure that married adolescents are not left out when programming for sexual and reproductive health information and services.
   
• Protect the health of pregnant adolescent girls (including support for safe delivery, infant feeding and care following delivery, education and counselling and contraceptive services to plan subsequent unintended early pregnancies and post-abortion care).
   
• Empower young people with education, financial literacy and livelihood skills and resources that build their self-esteem and allow them to make a decent living. Adolescent girls, in particular, may need negotiation skills to help them delay sexual initiation, reject unwanted advances and avoid sexually transmitted infection.
   
• Humanitarian interventions should address the fact that sexual and reproductive health risks faced by adolescents are multiplied in conflict and post-conflict settings. Drop-in centres and other supportive facilities where young refugees can freely access health information and services areimportant. Adolescents without parents or guardians, especially girls, should be protected. The reproductive health needs of young people cannot be met by the health sector alone. The involvement of community leaders, media, religious leaders, the private sector, and schools are critical.
   
• Young people are more connected than ever before by a mass media Pop music, TV, radio, social networking, mobile phones and the Internet and these can be powerful and cost-effective communications channels for imparting knowledge to young people and inspiring them to positive aspirations, values and attitudes.
   
• Development data should be disaggregated by age and sex to better inform strategies and approaches.

The ICPD and the Millennium Development Goals

At the 1994 International Conference on Population and Development (ICPD), the Programme of Action signed by 189 countries called for: the protection and promotion of the rights of adolescents to reproductive health education, information and care and a reduction in sexually transmitted infections and pregnancy among adolescents. It called upon governments and NGOs to meet the special needs of adolescents and establish appropriate programmes to respond to those needs. Fifteen years later, with a much larger population of youth, the ICPD commitments to them are more important than ever.

Addressing the needs of adolescents, especially those of girls, is critical to the achievement of every one of the Millennium Development Goals. Education is not only a goal in itself (MDG2) but fundamental to eradicating poverty and hunger (MDG1). Education and health care for young people are essential to reduce child and infant mortality and HIV infection (MDG4, MDG5, MDG6). And the promotion of gender equality and empowerment of women (MDG3) has to start with the young.

References

1. UNICEF, Adolescence: The big picture, updated 19 March 2009, accessed 10 June 2009 at http://www.unicef.org/adolescence/index_bigpicture.html
2. International Federation of Obstetricians and Gynecologists, Adolescent Sexual and Reproductive Health. Draft Final Report, March 2009.
3. DHS Adolescent Data Guides, UNFPA 2009
4. This diversity is captured by recent DHS Adolescent Data Guides from 50 countries.
5. Kirby, D., Obasi, A., Laris, B. 2006. The Effectiveness of Sex Education and HIV Interventions in Schools in Developing Countries: A Systematic Review of the Evidence from Developing Countries, Geneva: World Health Review.
6. World Health Organization, Why is giving special attention to adolescents important for achieving Millennium Development Goal 5?, Fact Sheet WHO/MPS/08.14, 2008, accessed at http://www.who.int/making_pregnancy_safer/events/2008/mdg5/adolescent_preg.pdf
7. WHO Fact Sheet, 2008. Op cit
8. WHO 2008 Fact Sheet http://www.who.int/making_pregnancy_safer/events/2008/mdg5/adolescent_preg.pdf
9. United Nations. 2001. We the Children: End-Decade Reviewof the Follow-up to the World Summit for Children: Report of the Secretary-General (A/S-27/3).
10. World Health Organization, Why is giving special attention to adolescents important for achieving Millennium Development Goal 5?, Fact Sheet WHO/MPS/08.14, 2008, accessed at http://www.who.int/making_pregnancy_safer/events/2008/mdg5/adolescent_preg.pdf
11. WHO Fact Sheet, 2008 Op cit
12. International Federation of Obstetricians and Gynecologists, Adolescent Sexual and Reproductive Health. Draft Final Report, March 2009.
13. WHO 2008 Fact Sheet op cit
14. International Women’s Health Coalition http://www.iwhc.org/index.php
15. Girls Count: Center for International Development, 2008. www.cgdev.org/files/15154_file_GirlsCount.pdf
16. International Center for Research on Women: Too Young to Wed: The Lives, Rights and Health of Young Married Girls, 2003 http://www.icrw.org/docs/tooyoungtowed_1003.pdf?bcsi_scan_232E6C93C4B63649=0&bcsi_scan_filename=tooyoungtowed_1003.pdf
17. UNFPA, State of the World Population 2005.
18. UNICEF. 2005. Early Marriage: A Harmful Traditional Practice.
19. Jenson, R. and R. Thornton. 2003. ‘Early female marriage in the developing world', Gender and Development, Vol. 11, no. 2 pp. 9-19.
20. IPPF, 2006.
21. International Federation of Obstetricians and Gynecologists, Adolescent Sexual and Reproductive Health. Draft Final Report, March 2009.
22. UNAIDS, 2008 Report on the Global AIDS Epidemic.
23. UNAIDS, 2008 Report on the Global AIDS Epidemic.
24. UNAIDS, 2008 Report on the Global AIDS Epidemic.
25. Birungi, H., Mugisha, J.F. and Nyombi, J.K. 2007. Sexuality of young people perinatally infected with HIV: A neglected element in HIV/AIDS Programming in Uganda. Exchange on HIV/AIDS, sexuality and gender. Nairobi: Population Council.
26. World Health Organization, Why is giving special attention to adolescents important for achieving Millennium Development Goal 5?, Fact Sheet WHO/MPS/08.14, 2008, accessed at http://www.who.int/making_pregnancy_safer/events/2008/mdg5/adolescent_preg.pdf