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

HIV Prevention in Early Adolescence and Beyond

Sexual desires, attitudes, opportunities and behaviors among young people are influenced by a multi-layered and gendered mix of individual, situational, and contextual factors (Dixon-Mueller 1993; Marston and King 2006; Obermeyer 2005; UNAIDS 1999). In every society, some subgroups of young adolescents living in the path of STIs/HIV are in greater jeopardy than others. Girls and boys sold into the sex trades or living on the streets; schoolgirls who exchange sex with strangers or "sugar daddies" for money or other gifts; daughters forced into early marriage with older husbands; boys and girls living with violence in their families or communities; and young orphans, refugees or displaced are especially at risk (Bruce and Joyce 2006; Global Health Council 2007; Luke 2003; UNICEF et al. 2002). In addition to these special groups, however, virtually all populations of 10-14-year-olds are vulnerable to the possibility of sexual exploitation and abuse (and, in some cases, to becoming perpetrators) and/or to deliberate or unwitting but "voluntary" sexual risk-taking. Similarly, virtually all lack the comprehensive knowledge, skills and support services they need to ensure that their sexual transitions are informed, safe and voluntary, both for themselves and their partners. At least three types of policy and programmatic initiatives are needed.

Filling the Knowledge Gap

Even in countries where most young people are aware of HIV/AIDS, they often have little idea of exactly how it is transmitted or how to avoid becoming infected and few have typically heard of other STIs (Alan Guttmacher Institute 2006; Bankole et al. 2007; Dehne and Riedner 2005; Matasha et al. 1998; Ross et al. 2006; Singh et al. 2005; Temin et al. 1999; Vuttanont et al. 2006). Young adolescents, in particular, are very unlikely to recognize the symptoms of the most common viral and bacterial STIs; to know that some infections (especially among girls) may be asymptomatic; to know that infections can be passed to the mouth and rectum (and by men or boys to boys) as well as to the genitals; to know that they must be medically diagnosed; and to know where to go for STI/HIV counseling, testing, or treatment. Similar knowledge gaps appear with respect to pregnancy prevention and safe and unsafe sexual practices, among many other topics.

International agreements such as those adopted at the International Conference on Population and Development (1994), the Fourth World Conference on Women (1995) and the UN Special Session on the Rights of the Child (2002) affirm that governments are responsible for ensuring that children and adolescents acquire the knowledge and skills they need to deal "positively and responsibly" with their sexuality. Moreover, effective HIV/AIDS prevention "requires States to refrain from censoring, withholding or intentionally misrepresenting health-related information, including sexual education and information,... consistent with their obligations to ensure the [child's] right to life, survival and development" (UN Committee on the Rights of the Child 2003:6).

Comprehensive, rights-based sexuality education for young adolescents that is reinforced by community-based youth programs, popular media (radio, television, magazines) and the Internet is urgently needed in all countries. Educational initiatives clearly need to start young (in primary school); to be realistic, interactive and sustained; to teach practical value-identification and negotiating skills; and, where possible, to reach adolescents with "straight talk" about their bodies and their sexual rights and obligations before they drop out of school -- if they are attending at all -- and before they become sexually active, by any definition (Adamchak et al. 2007; Rogow and Haberland 2005; Ross et al. 2006; Singh et al. 2005; Speizer et al. 2003; UNICEF et al. 2002; Vuttanont et al. 2006).

Filling the Service Gap

Investments are required to upgrade the quantity, quality, accessibility and acceptability of sexual and reproductive health services for young male and female adolescents. Although the need is great in all countries, it is most urgent in settings of high STI/HIV prevalence (especially among young adult populations ages 15-24) and/or where significant numbers of young male or female adolescents have already been initiated into penetrative sex or are about to become so, "ready or not." Early clinical interventions are essential in areas such as counseling and treatment for girls and boys who are victims of sexual abuse and violence; contraceptive advice and services; condom distribution to those who are sexually active; safe abortion and pregnancy and delivery care for young pregnant girls, married or unmarried; and confidential counseling, testing, and treatment of STIs/HIV. Young girls entering arranged marriages have special sexual and reproductive health needs, including premarital STI/HIV testing of their prospective husbands to avoid early and unknowing exposure to HIV (WHO 2006).

International organizations concerned with young people's sexual and reproductive health and rights have long been advocating for school- and community-based adolescent-friendly sites and services (Dehne and Riedner 2005; WHO 2003, 2004). Despite United Nations agreements that adolescents have a right to receive confidential, non-judgmental and non-discriminatory services that respect their privacy, health systems typically fall far short of providing them. The service gap is due to shortages of resources or appropriate facilities; lack of specialized provider training; the reluctance of providers to serve young male and female clients (especially without parental consent) or those who are unmarried; and/or legal or administrative restrictions on their doing so (Cook and Dickens 2000; Dehne and Riedner 2005; Eggleston et al. 1999; Ringheim 2007). As is the case for sexuality education, advocacy efforts can endorse the provision of comprehensive services to younger as well as older adolescents as both a necessary, pragmatic public health measure and as a human right.

Filling the Sexual Rights Gap

Young adolescents have the right to remain HIV-negative; to be free of all unwanted sexual acts and relationships; and to learn how to make voluntary, informed and safe sexual choices. Policies and programs are needed to reduce sexual harassment, violence, and abuse of children and of young female and male adolescents within families, schools and communities (Jejeebhoy et al. 2005; Mgalla et al. 1998; Mirsky 2003) and to eliminate the forced marriage of young girls (International Center for Research on Women 2005; International Planned Parenthood Federation et al. 2006). Adolescents and adults who engage in any form of sexual violence or abuse require counseling and appropriate legal and social deterrents, as do adult males who have sex with underage girls or boys. HIV prevention efforts must challenge ideologies and practices of male sexual entitlement while promoting the empowerment of girls to control their bodies and their lives.

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