The international community has repeatedly agreed to meet young people’s developmental needs, including those relating to sexual and reproductive health. Yet young people often have little or no access to the information and services they need to make healthy, informed decisions about their sexual and reproductive lives.
Why is good sexual and reproductive health so important for young people today?
The social and developmental consequences of sexual and reproductive decisions are far-reaching. Health, education, interpersonal relations and preparation for the world of work are closely connected. An unintended pregnancy can irrevocably disrupt a young girl’s life, precluding further schooling and training. Contracting HIV in an unprotected sexual encounter can bring a young person’s prospects for a healthy and productive future to an end.
Young people have a right to the information and services they need to make healthy decisions about their lives. Since the International Conference on Population and Development in 1994, the international community has consistently reaffirmed the right of young people to age-appropriate reproductive health information and services that safeguard their rights to privacy, confidentiality, respect and informed consent. The international community also has reaffirmed that the rights and responsibilities of parents to provide guidance in such matters should not prevent young people from having access to the information and services they need to enjoy good reproductive health.
Good sexual and reproductive health is crucial to national development. The challenges of preparing the next generation for adult roles are remarkably similar across both developed and developing country settings. Almost half of the world’s 6.4 billion people are under age 25, more than 1 billion of them between 10 and 19. Countries that fail to provide boys and girls with the means to remain healthy and in school will not benefit as fully from other investments they make in young people. In addition to the impact on individual health and welfare, the decisions these young people make about the timing and number of their children will have long-lasting consequences for population growth.
What is the reality of young people’s sexual and reproductive lives today?
Most people today become sexually active during their teenage years. A recent study of teenagers in Cameroon revealed that two-thirds of young people have sex by the age of 16, and more than half of them don’t use condoms. A 2004 World Health Organization report also cites increased premarital sex among Asian youth. Almost 25 percent of Filipinos aged 15 to 24 are engaged in premarital sex, 70 percent of them do not use contraceptives. In sub-Saharan Africa, more than 50 percent of girls have sex before age 19, as do three-quarters or more of teenage girls in industrialized countries.
Young people rarely have access to detailed and accurate information about sexuality and reproduction. As a result, they often are ill-prepared for sexual relations or unable to protect themselves from unintended pregnancy and sexually transmitted infections (STIs). In Botswana, where more than one-third of the population is HIV-positive and almost all young people are at least aware of the virus, nearly two-thirds of girls still have misconceptions about transmission. Among married Ethiopian girls aged 15 to 19, only one-third knows that condoms can protect against HIV/AIDS. Prevention-oriented programs should make a special effort to reach young people, both in and out of school, with sexual and reproductive health information and services.
Worldwide, more than 10 million young people aged 15 to 24 have HIV or AIDS. Every year, almost half of all new HIV infections and at least one-third of all new STIs occur among people under age 25. Of the 14,000 new HIV infections acquired per day in 2003, almost 6,000 occurred among young people aged 15 to 24, the majority of them women. In the United States, young people 15 to 19 years old have higher rates of STIs than any other age group. Young people tend to consider themselves invulnerable to risk, even in countries where HIV is widespread, and the unplanned and sometimes secretive nature of their sexual encounters makes protecting themselves difficult. Yet the immature reproductive tracts of young people make them more susceptible than adults to acquiring HIV/AIDS and other STIs.
Girls are more vulnerable to reproductive health problems than boys for biological and social reasons, and often have little say over the conditions of their sexual relations and childbearing. A study in South Africa revealed that teen girls were more likely to become infected with STIs than were boys, largely because they were involved with older men who were more likely to have been exposed to a virus. In Western Kenya, nearly 25 percent of girls aged 15 to 19 are HIV-positive, compared with only 4 percent of boys the same age.
Faced with an unintended pregnancy, a teenager often will resort to self-induced abortion or the services of an untrained provider. Fully one-quarter of unsafe abortions take place among girls aged 15 to 19 every year.
Schooling and reproductive behavior are closely linked. Education is associated with differences in adolescent childbearing throughout the world. The proportion of women who have their first child before age 19 ranges from 5 percent or less in developed countries such as Denmark, to more than 50 percent in developing countries such as Niger. Surveys reveal that girls with secondary education are between three and 13 times less likely to become early mothers, and young girls who give birth are far less likely to complete high school than their childless peers.
Adults who are traditional sources of information on sexual and reproductive matters are increasingly unavailable to young people or are unfamiliar with current threats to reproductive health. Urbanization, evolution of family structures away from the extended family and toward the nuclear family, and other social and economic changes have had an effect on the systems that traditionally prepare young people for future reproductive roles. The epidemic of STIs, including HIV/AIDS, adds to the challenge of providing sufficient information to young people about threats to their sexual and reproductive health.
How has the international community agreed to support the reproductive health of young people?
The 1994 International Conference on Population and Development (ICPD) articulated a broad, rights-based commitment to sexual and reproductive health for everyone, including youth. The ICPD Programme of Action refers to the need for parents and other adults to provide guidance and to respect the rights of young people to information and services. It calls on governments to overcome barriers to reproductive health care for young people and encourages health care providers to be open to young clients. Explicit objectives were to encourage “responsible and healthy reproductive and sexual behaviour, including voluntary abstinence,” among young people and to reduce adolescent pregnancy.
The sexual and reproductive health of youth is a key issue in 2004 as governments reconvene for the 10-year review of ICPD. Representatives of 179 countries agreed to objectives set forth in the original ICPD Programme of Action, but since 1994, many of those countries have addressed youth reproductive health inconsistently or not at all. Countries that have effectively addressed the issue have treated it as an urgent matter of public health rather than an issue of morality.
What strategies will help ensure good sexual and reproductive health among young people?
Leadership from the very top is key to addressing young people’s sexual and reproductive health needs. In places as diverse as Uganda and the Netherlands, the government has waded fearlessly into the territory of youth reproductive health because it has so clearly understood the public health mandate for doing so. In Uganda, where HIV infection rates peaked in the 1990s, the president’s outspokenness made it possible to communicate information about the causes and prevention of AIDS through a broad range of channels — television, political leaders, religious centers, schools and others. In the Netherlands, ongoing collaboration between the government and the media helps educate the population and has dramatically reduced adolescent pregnancy, abortion and STIs.
Successful reproductive health policies and programs cut across sectors. While useful policies and programs exist in various sectors, they often are undermined by a lack of coordination. In Chile, however, the government works with the education system to help pregnant girls and young mothers continue their education, providing them with schooling, job training, child care and nutrition.
Sexuality education and services in schools reach millions of students. Since a large number of young people attend school in most parts of the world, integrating sexuality education into school curricula is an important strategy. Studies have shown that fears of sex education contributing to earlier and less thoughtful sexual activity are misplaced. In the Netherlands, for example, sex education is universal, public messages about sexuality are widespread, and access to services is viewed as a basic human right. Adolescents begin sexual activity later, have fewer partners and are far better prepared for sex than their U.S. counterparts, as shown by low rates of unintended pregnancy, abortion and STI transmission.
Sex education and services through the public health system also can reach out-of-school youth and integrate young people into a system they will use as adults. In places where school attendance rates are low, governments need to find alternative routes for communicating health information to young people. Bangladesh, India and Taiwan have reached young people by using mass media campaigns that emphasize the importance of contraceptive options and delaying first births, the benefits of a small family and the necessity of immunizations. Health services for youth should not only address the medical aspects of reproductive health, but also relationships and values. Peer educators may complement clinical efforts by providing young people with someone to talk to, and act as a link to sources of information and services.
Youth-friendly services are needed to reach young people with information and treatment.In clinics, as in schools, special training is needed for adult health care providers, who often impose their values on young clients or are insufficiently sensitive or supportive. In one positive example, the Mexican government has been sensitizing health workers to young people’s needs not only for information and services, but also for privacy and understanding.
Recruiting non-governmental organizations (NGOs) to support and expand on sexual and reproductive health initiatives is critical. In countries where the government welcomes a strong role for civil society in national debate and programmatic work, NGOs have played a vitalizing role in work on youth reproductive health. In both Senegal and Mali, NGOs have been actively involved in combating female genital mutilation. In Senegal, community involvement has brought about the end of the practice in a number of villages and led to its legal prohibition nationwide in 1999. Responding to the needs of young people is not the responsibility of government alone; communities, parents, churches and civil society need to join in with efforts to reach them.
Gender inequities that expose young people to sexual and reproductive risk must be addressed and eliminated wherever possible. Girls experience sexual coercion, risky pregnancy, botched abortion and STIs in large part because of gender inequities that condition their sexual encounters. Boys, often urged into experimentation by peers and elders, tend to have distorted views of gender relations or fail to act on their own aspirations for equal, richer relationships with girls. In either scenario, they end up taking dangerous sexual risks. The most effective sexual and reproductive health programs challenge the pervasive male notions of sexuality and gender relations that rob both boys and girls of their health, their future and the opportunity for genuine intimacy with others.
Specific goals, including funding objectives, should be set in the pursuit of youth reproductive health. Aiming high is especially important when the objective is to benefit one-half of the world’s people and those who literally will inherit the earth. Young people are dependent on the accountability of adult policymakers, program directors, clinicians, teachers and parents. To safeguard the future of young people everywhere is to safeguard the future of humanity itself.