Young Adolescents' Sexual and Reproductive Health and Rights: Middle East and North Africa

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International agreements affirm that adolescents have a right to age-appropriate sexual and reproductive health information, education, and services that enable them to deal positively and responsibly with their sexuality.¹ Programs and policies are typically designed for older adolescents, however. This brief—part of the International Women’s Health Coalition’s series on young adolescents—uses evidence on their sexual and reproductive knowledge and behaviors to argue for more responsive policies and programs in the Middle East and North Africa, and globally.* We define all boys and girls between the ages of 10 and 14 as young adolescents.

Despite their geographical spread and diverse politics, countries in this region share certain characteristics that shape the sexual and reproductive behavior of adolescents. Populations are predominantly Muslim, and while some countries are governed by fundamentalist regimes that limit girls’ mobility, dress, and comportment, others are more liberal. Premarital sex is generally taboo, especially for women, and may even be punishable by imprisonment or other harsh penalties. Although many parents still choose a marital partner for their daughter or (less so) son, in some settings parents increasingly agree that their daughter—usually in her twenties when she marries—should make the final decision.^2,3 Although still at low levels, HIV/AIDS appears to be spreading in the region, fuelled in large part by increases in injecting drug use, commercial sex work, and sex with multiple partners.^4-6

SEXUAL INITIATION
Data on initiation of sexual intercourse and frequency of premarital sexual activity are almost non-existent for countries in this region, or are underestimates. Women (and most men) are assumed to have their first sexual intercourse at marriage; the virginity of the bride reflects on the honor of her family and entire kin group.

• Among girls ages 15 – 19 in the region, very few were married and thus sexually initiated before their 15^th birthdays, ranging from only 6% (Yemen) and 5% (Sudan) to virtually none in the other countries for which data are available (see table). From 14% to 48% of young women ages 20-24 were married before their 18^th birthday, however.⁷
  
• Fewer than 1% of 15 – 19-year-old unmarried girls in Armenia report having had intercourse in the past year.⁷ Questions about premarital sex were not asked in the other countries.

• Almost no 15 – 19-year-old boys in Armenia and Turkey say they had heterosexual sex with girls before age 15, the only two countries in which this question was asked. By contrast, in Armenia, 13% of boys 15 – 19 report having premarital sex in the past year, among whom two-fifths had multiple partners and only half used condoms.⁷
  
• A survey of boys ages 15 – 18 in Tehran, Iran found that 28% report having sexual contact with girls or women (some by age 12), even in this highly restrictive environment where non-marital sex is illegal.⁸ There are also signs that same-sex relations among young boys in Iran are common.⁶
  
• Childbearing occurs almost entirely within marriage and is thus rare before age 15. From 5% (Jordan) to 25% (Yemen) of young women ages 20 – 24 had at least one child before age 18, however.⁷
  
• The legal minimum age for marriage without   parental consent is 15 years for girls in Yemen, Turkey, and Morocco, 16 in Egypt, and higher in other countries in the region.² Requirements of the bride’s or groom’s consent to marriage are often waived for “customary” or “religious” reasons, thus violating their right to marry only with their free and full consent.⁹

WHAT DO YOUNG ADOLESCENTS KNOW?†
Although norms of patriarchy, family honor, male power and privilege, and female sexual purity are changing in some countries, they still generally restrict young people’s access to sexual and reproductive health information, education, and services.¹⁰

• As Egyptian girls reach puberty, they are given little if any information about sexuality and reproduction. Mothers fear telling their daughters things that might “open their eyes prematurely” and prefer to give information only “when necessary,” e.g., at first menstruation or just before their wedding night.¹¹
  
• Iranian boys ages 15 – 18 in one study were able to answer an average of only one of three questions correctly about when a woman can get pregnant; three of 10 questions naming contraceptive methods; four of nine questions about HIV, sexually transmitted infections (STIs) and their symptoms; and 1.5 of three questions about condom use.⁸
  
• In Armenia, almost half of boys ages 15 –19 and one-third of girls know that HIV can be prevented by having only one uninfected sexual partner and by using a condom.¹² In Palestine, only 6% of married girls ages 15 – 19 know this.¹³
  
• Young people in Egypt, Jordan, Libya, Morocco, Oman, Sudan, and United Arab Emirates perceive marriage and proper hygiene to be methods of prevention against STIs.¹⁴ In Tunisia, Algeria, and Syria, very few young adults have heard of STIs such as gonorrhea or syphilis.¹⁰
  
• Half of Tunisian males ages 17 – 24 and 70% of females believe that using contraceptives can be dangerous to health.¹⁴

POLICY AND PROGRAM RESPONSES
Evidence shows that withholding information and services from young people only increases the likelihood that if and when sexual initiation occurs, it will be unprotected.¹⁵  Young people require not only basic information about their bodies, preventing HIV/STIs and pregnancy, but also programs that address gender equality, empowerment, rights and responsibilities, and sexual and reproductive negotiation and decision-making. The meaningful participation of adolescents in the design of programs, laws, and policies that affect their sexual and reproductive lives should be guaranteed.

Sexuality education: The potential for reaching young adolescents in schools varies substantially along with rates of school attendance across the region (see table). Discrimination against girls in schooling is still striking in some countries, including Yemen, where 73% of boys are enrolled but only 32% of girls.¹⁶ Sex education curricula are rare in the region due to political and religious opposition, and sexual and reproductive health topics are often skipped because teachers are unprepared or embarrassed to teach them.¹⁷ Although Algeria, Iran, Morocco, Tunisia, and Bahrain have included a human reproduction and health education module in their national school curricula, courses are aimed at high school and university students.¹⁰

Sexual and reproductive health services: Services for unmarried adolescents are virtually non-existent throughout the region.^10,17 Tunisia and Iran have initiated adolescent health clinics that are open to unmarried young people, however, as well as school health clinics.^6,18 Due to government resistance in this region, the private and non-governmental sector may initially be the most effective intervention point and source of financial and infrastructural support. Those health centers which do exist must be prepared to address the specific health needs of young adolescents.

Other interventions: Out-of-school programs can make a difference in conservative environments if they are designed to provide young adolescents with functional literacy training, life skills, sexual and reproductive health information, and related short programs that enhance students’ awareness, physical security, confidence, and assertiveness. In rural upper Egypt, for example, the Ishraq (“enlightenment”) program for 11 – 15-year-old girls who are not in school also works with boys and community leaders to change attitudes and traditional practices that discriminate against girls and negatively affect their sexual and reproductive health and rights.¹⁹ There are signs that more young people in parts of the region access information in innovative ways, including internet sites and hotlines.¹⁸ Utilizing these approaches and other media, including television, to provide necessary information to young people should be explored.

Sexual and reproductive rights of women and girls are of particular concern in this region, as customary practices such as virginity tests, female genital mutilation (FGM), forced marriages, so-called “honor crimes,” and sexual harassment, rape, and sexual abuse and incest continue to be ignored or even legitimized in some areas.²⁰ For example, despite campaigns against the practice, 99% of 15 – 19-year-old Egyptian girls interviewed in the 2000 Demographic and Health Survey had undergone genital cutting (median age at time of procedure was 10 years).⁷ A fundamental transformation of socioeconomic, cultural, and political conditions through legal, educational, and other means can help ensure that young adolescent girls and boys make safe, informed, and voluntary transitions in their sexual and reproductive lives.

*There is little evidence on the sexual and reproductive knowledge and behavior of 10 – 14-year-olds. Except where noted, this brief is largely based on reports by15 – 19-year-olds of their knowledge and behaviors before age 15, drawn from available Demographic and Health Surveys in the region. This region extends across northern Africa from Morocco in the west to Egypt and Sudan in the east, and across the Middle East from the Mediterranean and Gulf countries to Iraq and Iran.

† Data on older adolescents and young adults are used here, based on the assumption that 10-14-year-olds would know even less about sex and reproduction than their older counterparts.

Acknowledgments
We are grateful to reviewers Yara Jarallah (Member, Youth Coalition for Sexual and Reproductive Rights, Palestine) and Pardis Mahdavi (Assistant Professor, Department of Anthropology, Pomona College).

References

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1. Paragraphs on adolescence in the Plan of Action of the International Conference on Population and Development, Cairo, 1994 and the five-year review by the United Nations General Assembly; and the Platform for Action of the Fourth World Conference on Women, Beijing, 1995 and the five-year review by the United Nations General Assembly.

2. Cynthia B. Lloyd (ed.). 2005. Growing Up Global: The Changing Transitions to Adulthood in Developing Countries. Washington DC: National Academies Press.

3. Hoda Rashad, Magued Osman and Farzaneh Roudi-Fahimi. 2005. Marriage in the Arab World. MENA Policy Briefs. Washington, DC: Population Reference Bureau.

4. Farzeneh Roudi-Fahimi. 2007. Time to Intervene: Preventing the Spread of HIV/AIDS in the Middle East and North Africa. MENA Policy Brief. Washington DC: Population Reference Bureau.

5. UNAIDS & World Health Organization (WHO). 2006. UNAIDS & WHO AIDS Epidemic Update. Geneva: UNAIDS & WHO.

6. Pardis Mahdavi. 2007. "Passionate uprisings: Young people, sexuality, and politics in post-revolutionary Iran." Culture, Health, and Sexuality, 9(5): 445-457.

7. Demographic and Health Surveys, http://www.measuredhs.com, Statcompiler.

8. M. N. R. Mohammadi et al. 2006. "Reproductive knowledge, attitudes and behavior among adolescent males in Tehran, Iran," International Family Planning Perspectives, 32(1):35-44.

9. Angela Melchiorre. 2004. At What Age are School Children Employed, Married and Taken to Court?  (2nd. ed.)  Copenhagen: The Right to Education Project. http://www.right-to-education.org, accessed May 2005. (See country -specific reports, e.g., Lebanon)

10. Jocelyn DeJong, Bonnie Shepard, Farzaneh Roudi-Fahimi and Lori Ashford. 2007. Young People's Sexual and Reproductive Health in the Middle East and North Africa. MENA Policy Brief. Washington DC: Population Reference Bureau.

11. Aida Seif el Dawla, Amal Abdel Hadi and Nadia Abdel Wahab. 1996. "Women's wits over men's: trade-offs and strategic accommodations in Egyptian women's reproductive lives," pp. 69-107 in Rosalind P. Petchesky and Karen Judd, eds., Negotiating Reproductive Rights: Women's Perspectives Across Countries and Cultures. London and New York: Zed Books.

12. Demographic and Health Surveys, http://www.measuredhs.com, HIV/AIDS Survey Indicator Database.

13. Palestine Central Bureau of Statistics (PCBS). 2000, Health Survey in the West Bank and Gaza Strip. Ramallah: PCBS.

14. Rima Afifi Soweid and, Talar Manayan. 2004. Inventory of Knowledge Attitude and Behavior Studies Related to Sexual and Reproductive Health of Young Persons in the Arab States and Needs Assessments Related to Research and Inventory for Sexual and Reproductive Health of Young Persons in the Arab States. Beirut: UNFPA and the American University of Beirut.

15. Douglas Kirby, National Campaign to Prevent Teen Pregnancy, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, 2001, http://www.teenpregnancy.org.

16. UNESCO Institute for Statistics. 2004. Global Education Digest 2004: Comparing Education Statistics Across the World. Montreal: UNESCO Institute for Statistics: Table 5.

17. K. L. Dehne and G. Riedner. 2005. Sexually Transmitted Infections Among Adolescents: The Need for Adequate Health Services. Geneva: World Health Organization.

18. Jocelyn DeJong and Golda El-Khoury. 2006. "Reproductive health of Arab young people." British Medical Journal 333: 849-851.

19. Martha Brady, Abeer Salem and Nadia Zibani. 2005. "Bringing new opportunities to adolescent girls in socially conservative settings: The Ishraq program in rural Upper Egypt." Transitions to Adulthood Brief. No. 12. New York: Population Council.

20. Women for Women's Human Rights. 2006. "Women and Sexuality in Muslim Societies."  http://www.wwhr.org.

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