Starting Young: Sexual Initiation and HIV Prevention in Early Adolescence

Ruth Dixon-Mueller

Disclosures

AIDS and Behavior. 2009;13(1):100-109. 

In This Article

The Evidence: Heterosexual Intercourse at Age 14 or Younger

Except for girls who are already married or cohabiting, the sexual activity of adolescents who have had vaginal intercourse at least once before their 15th birthdays tends to be infrequent and sporadic (Juarez and Castro Mart\0xEDn 2006; Singh et al. 2000). Nevertheless, the risks of STI/HIV transmission per sexual act are escalated among 10-14-year-old girls because of the immaturity of the reproductive tract, higher levels of sexual coercion, and the infrequent use of condoms, as mentioned earlier. That the partners of under-age girls in most developing countries tend to be considerably older, on average, and to have had more extensive sexual histories, also increases girl's vulnerability to STIs/HIV as compared with boys the same age (Clark 2004; Clark et al. 2006; Luke 2003). Among the 68% of female primary school students age 12 and over in Mwanza, Tanzania who said they were sexually experienced, for example, almost half had had sex with adults, including teachers, relatives and strangers; one-third said they had had an STI; and fewer than one in three had ever used a condom (Matasha et al. 1998:575).

Demographic and Health Surveys (DHSs) reveal striking variations across countries in the percentages of male and female respondents aged 15-19 who say they first had sexual intercourse when they were 14 or younger ( Table 1 ). Contrasts are particularly sharp within Sub-Saharan Africa: 48% of 15-19-year-old Gabonese boys claim they had sex before age 15 compared with virtually none in Eritrea; 30% of girls in Niger compared with only 3% in Rwanda. Boys are far more likely than girls to initiate intercourse early in Gabon, Zambia, Kenya and Namibia, whereas the reverse is true in Mali, Niger, Nigeria, the CAR and other countries in the region, particularly where girls are married young. Early female sexual initiation in countries where high proportions of males in the pool of potential partners aged 15-24 are HIV-positive (e.g., estimates of 5% or more in Table 1 ) places girls at especially high risk.

In North Africa, the Middle East, and South and Southeast Asia, sexual initiation before age 15 is rare among both boys and girls-typically well under 5%-except in Nepal, Bangladesh, India, and Pakistan where substantial numbers of girls are still married at puberty. HIV prevalence among young people is also fairly low in these regions, at least at the national level. In contrast, in Latin America and the Caribbean, where HIV has gained a foothold (1% or more) among young people in several countries, 15-34% of boys aged 15-19 in the countries shown here say they had intercourse at 14 or younger and 5-13% of girls. Nationally representative surveys of 13-15-year-old students in selected African and Latin American countries shown in Table 2 , although not exactly comparable, also reveal high levels of early sexual initiation as well as multiple partnerships among boys (20-45% have had intercourse) and, to a lesser extent, girls (7-29%) (WHO 2007). In developed countries, school-based surveys of 15-year-olds in 2002 found that one-quarter of both boys and girls in Canada and the United States had had intercourse at least once, compared with 17-47% of boys and 3-40% of girls in 23 European countries (Godeau et al. 2008:67; Mosher et al. 2005:21-22).

National-level data mask important variations within countries as well as patterns of very early sexual initiation among some populations (Bruce and Joyce 2006). A country-wide survey of girls in grades 5-7 in Tanzania found that one-quarter of those age 13 and younger were sexually active, for example, and one-half of those aged 14 and 15; early initiation was more common among urban than rural girls (Mgalla et al. 1998). In Benin City, Nigeria, young people in focus groups said that girls commonly started having sexual intercourse at 11-13 compared with 14-15 for boys (Temin et al. 1999). About 40% of all male students aged 10-18 surveyed in the Caribbean region and 9% of females said they had intercourse at age 12 or younger; among those who had had intercourse, one-half of the boys and one-quarter of the girls said they were 10 or younger when they first had sex (Halc\0xF3n et al. 2003). In comparison, 12% of boys and 7% of girls reported having sex at 13 or younger in a 1997 U.S. survey of 12-14-year-olds, with black students most likely and non-Hispanic white students least likely to do so (Albert et al. 2003:20-21).

In the more culturally conservative countries within the sub-Saharan and South Asian regions, girls' sexual initiation at age 14 or younger occurs almost exclusively within arranged marriages. Elsewhere, the proportions of young girls for whom intercourse is initiated outside of marriage (or, in the case of Latin America and the Caribbean, outside of informal cohabiting unions) are substantial (FI-FM in Table 1 ). Young sexually active unmarried girls are not necessarily exposed to higher risks of STIs/HIV than their married or cohabiting age-mates, however. On average, they have intercourse far less frequently; are more likely to use protection against STIs/HIV and pregnancy (even if rarely); and have partners who are less likely to be HIV-positive than the often much older and sometimes polygamous husbands of very young brides (Clark 2004; Clark et al. 2006; Glynn et al. 2001).

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