|Adolescent Sexuality and the HIV Epidemic (UNDP, 1999, 24 p.)|
Approximately one-third of the world's population is between 10-24 years of age, and four out of five young people live in developing countries, a figure which is expected to increase to 87% by the year 2020 (Friedman, 1993; Ainsworth and Over, 1997). In many countries the majority of young people are sexually experienced by the age of 20 and premarital sex is common among 15-19 year-olds. For example in recent surveys it was found that 73% of young men and 28% of young women in this age group in Rio de Janeiro reported having had premarital sex, compared with 59% and 12% respectively in Quito, and 31% and 47% respectively in Ghana (Population Council, 1996)
Sexually transmitted infections (STIs) including HIV are most common among young people aged 15-24 and it has been estimated that half of all HIV infections worldwide have occurred among people aged under 25 years (World Health Organisation, 1995). In some developing countries, up to 60% of all new HIV infections occur among 15-24 year-olds. Yet, vulnerability to STIs including HIV is systematically patterned so as to render some young people more likely to become infected than others. Gender, socio-economic status, sexuality and age are important factors structuring such vulnerability. Unequal power relations between women and men, for example, may render young women especially vulnerable to coerced or unwanted sex, and can also influence the capacity of young women to influence when, where and how sexual relations occur (Rivers & Aggleton, 1998).
The consequences of HIV/AIDS can be far-reaching for young people. Not only does HIV disease have terrible consequences for the individual, causing serious illness and eventual death, it has the potential to trigger negative social reactions. Across the world, people with HIV/AIDS routinely experience discrimination, stigmatization and ostracization (Auer, 1996; Malcolm et al, 1998). Children and young people who are orphaned by the epidemic, and who themselves may be infected, are sometimes left without the support of adults (Levine, Michaels & Back, 1996). For women and adolescent girls, the consequence of AIDS can be particularly dire. There is strong evidence, for example, that in some countries women may be 'blamed' for HIV disease even in circumstances where they have been infected by remaining faithful to their husband or other male partner (Bharat & Aggleton, in press). There is also evidence to suggest that women are less likely to receive the kind of care and support made available to male household members (Warwick et al., 1998). Moreover, where the male head of household has died there may be loss of social support for young women, ostracization from the community, and lack of legal protection to inherit land and property. Some young women may find themselves unwelcome in the extended family and may even be coerced into sex work (Levine, Michaels & Back, 1996).
Given the significant number of young people living in developing countries seriously affected by the epidemic, it is crucial that work is undertaken to ensure that they are able to protect themselves. This involves providing them with access to information and resources, as well as promoting a climate which is understanding of young people and their sexual and reproductive health needs. In recognition of the enhanced risks faced by young people, UNAIDS and its cosponsoring organisations including UNDP, has identified young people as a key group for HIV-related prevention activities. World AIDS Day 1998 gives special emphasis to this fact in its identification of young people as a key group with which to work.
Epidemiological studies across the developing world show that young people are not equally affected by HIV/AIDS. Rather, those who are most socially and economically disadvantaged are at highest risk (Elford, 1997). The risk of HIV infection for young people in developing countries is increased by socio-cultural, political and economic forces such as poverty, migration, war and civil disturbance (Sweat and Denison 1995). Young people may also face the increased risks of HIV infection by virtue of their social position, unequal life chances, rigid and stereotypical gender roles, and poor access to education and health services.
Major changes over the last few decades have affected the sexual and reproductive health of young people in developing countries. Rapid urbanisation and rural-urban migration has meant that greater numbers of young people are living in precarious and impoverished conditions. Traditional, multi-generational extended families have been increasingly replaced by nuclear families, lone-parent families and, in some cases, the complete absence of parents (Fuglesang, 1997). There are increasing pressures on young people to be sexually active and, in the case of boys, to have had several different partners (Rivers & Aggleton, 1998). Evidence from a variety of countries suggests that the age at which young people become sexually active may be falling (Fee & Yousef, 1993). Certainly young people become sexually active at an early age in many countries. In Uganda, for example, almost 50 per cent of young men and nearly 40 per cent of young women recently surveyed reported having had sex by the age of fifteen years (Konde-Lule et al, 1997). In Dar es Salaam, Tanzania 60 per cent of 14 year-old boys and 35 per cent of girls have reported that they are sexually active (Fuglesang, 1997). In a recent Brazilian school-based study, 36% of females reported having had intercourse by the age of 13 (Weiss, Whelan & Gupta, 1996). In parts of the world such as India where there is sparse evidence about sexual activity among young people and it is widely assumed that sexual initiation takes place within the context of marriage, recent studies show that approximately one in four unmarried adolescent boys report that they are sexually experienced (Jejeebhoy, 1998).
In both developed and developing countries, there are a number of obstacles which make it difficult for young people to protect their sexual and reproductive health.
Young people often have less access to information, services and resources than those who are older (Friedman, 1993; Aggleton and Rivers, 1999). Health services are rarely designed specifically to meet their needs, and health workers only occasionally receive specialist training in issues pertinent to adolescent sexual health (Friedman, 1993; Zeiaya et al, 1997, World Health Organisation, 1998). It is perhaps not surprising therefore that there are particularly low levels of health seeking behaviour among young people. For example, even where they are able to recognise signs and symptoms of STDs, young people recently interviewed in Tanzania indicated that they were hesitant to go to public clinics or hospitals, but were more likely to treat themselves with over-the-counter medicines (Fuglesang, 1997). Similarly, young people in a variety of contexts have reported that access to contraception and condoms is difficult (e.g. Zeiaya et al, 1997). Most importantly, legislation and policies which prevent sex education taking place, or which restrict its contents, prevent many young women and men from maximising their sexual and reproductive health.
One of the most important reasons why young people are denied adequate access to information, sexual health services and protective resources such as condoms, derives from the stereotypical and often contradictory ways in which they are viewed. It is popularly believed that all young people are risk-taking pleasure seekers who live only for the present. Such views tend to be reinforced by the uncritical use of the term adolescent (with its connotations of 'storm and stress') in the specialist psychological and public health literatures. This term tends not only to homogenise and pathologise our understanding of young people and their needs, it encourages us to view young people as possessing a series of 'deficits' (in knowledge, attitudes and skills) which need to be remedied by adults and the interventions they make (Aggleton & Warwick, 1997).
Hoffman & Futterman (1996) have commented that adults often hold ambivalent attitudes towards young people, viewing them simultaneously as '... small adults and as immature inexperienced and untrustworthy children' (ibid, p.236). Many adults also have difficulty acknowledging adolescents as sexual beings, and therefore adolescent sexuality is viewed as something which must be controlled and restrained. These stereotypes have also informed much HIV-related research and practice with young people. Warwick and Aggleton (1990), for example, have described the central images to be found in the literature on young people and AIDS. These include the 'unknowledgeable or ill informed adolescent', the 'high-risk adolescent', the 'adolescent who is unduly conforming to peer pressures', and the 'tragic but innocent adolescent' who inadvertently becomes infected by HIV.
These powerful images and assumptions influence policy and practice in relation to young people and their sexual health. Some adults believe that young people are of their nature sexually promiscuous and that giving them information about sex will make young people more sexually active (Friedman, 1993). As a result, sex education in schools either does not take place or promotes only certain risk reduction measures (most usually abstinence). Yet there is now clear evidence that well-designed programs of sex education, which include messages about safer sex as well as those about abstinence, may delay the onset of sexual activity, and reduce the number of sexual partners, and increase contraceptive use among those who are already sexually active (Grunseit et al, 1997; Grunseit, 1997).
While formal health education programs have been influenced by stereotypical attitudes about young people's sexuality, parents and families across a wide variety of cultures have also sought to deny young people information about sex and reproduction. In countries as different as India and Nicaragua, parents and children report that they do not talk to each other about sex (George & Jaswal, 1995; Zeiaya et al, 1997). Often parents and family members do this in the belief that they are 'protecting ' young people from information which they believe may lead to sexual experimentation. However, evidence suggests that young people who openly communicate about sexual matters with their parents, especially mothers, are less likely to be sexually active or (if girls) become pregnant before marriage (Gupta, Weiss and Mane, 1996).
While young people have been commonly stereotyped as uniformly hedonistic and irresponsible, they are in fact a remarkably heterogeneous group. Their experiences vary widely according to cultural background, gender, sexuality and socio-economic status among other variables. While some young people may take risks, the majority are at least as responsible as their parents, and some may be even more so. Moreover, it is important to recognise that in many developing countries, the onset of pubertv signals greater economic and family responsibility rather than increased pleasure-seeking and risk taking (Aggleton & Rivers, 1998). That said, there are a number of structural as well as individual factors which may heighten young people's vulnerability to HIV and AIDS.