Young Adolescents' Sexual and Reproductive Health and Rights: South and Southeast Asia

International agreements affirm that adolescents have a right to age-appropriate sexual and reproductive health information, education, and services that enable them to deal in a positive and responsible way 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 South and Southeast Asia as well as globally.* We define all boys and girls between the ages of 10 and 14 as young adolescents.

The countries of South and Southeast Asia encompass a richly layered mix of cultures, religions, languages, racial and ethnic groups, and economic and political systems. Although South and Southeast Asia are very different settings with regard to many aspects of adolescent sexual and reproductive health, there are also important commonalities. Most young adolescents throughout the region have little if any accurate information about their bodies and their sexual and reproductive health.² Known or suspected sexual contact of any kind by unmarried girls and women in some parts of South and Southeast Asia may result in personal censure, loss of family honor, or forced marriage.

SEXUAL INITIATION
Premarital sexual intercourse remains generally taboo, meaning that timing of first intercourse is often assumed to correspond with marriage and that direct evidence on premarital sexual relations is scarce.

• In South Asia, 26% of all Bangladeshi girls ages 15 – 19 were married at age 14 or younger compared with 14% in India, 9% in Nepal, and 7% in Pakistan (see table). Arranged marriages of girls before age 15 do appear to be declining in these countries.³
  
• In Bangladesh and India, 6% and 2% of all girls ages 15 – 19 became mothers at age 14 or younger, most without the help of a skilled birth assistant.⁴ Maternal and newborn deaths and complications for these girls are common.
  
• In Nepal, 20% of all 15 – 19-year-old boys say they had heterosexual intercourse before age 15, often with sex workers, compared with very low proportions elsewhere.⁵ Although evidence is scarce, ethnographic studies suggest that some boys in India, Bangladesh, and other South Asian countries engage in same-sex intercourse during adolescence.^6,7

• In Southeast Asia, very few girls ages 15 – 19 were married or say they had intercourse before age 15—from 3% in Indonesia to virtually none in Vietnam—and almost no girls had babies this young.
  
• In a survey of unmarried adolescents ages 15 – 19 throughout Vietnam, only 14% of boys and 19% of girls report ever having a girlfriend or boyfriend. Norms of sexual purity remain strong, resulting in very low reported levels of premarital sex before age 18 and virtually none before age 15.⁸
  
• In a metropolitan region of the Philippines, adolescents begin dating in groups at ages 13 – 16. Romantic relationships and physical intimacy are postponed to later adolescence: at ages 17 – 19, 30% of boys and 20% of girls report having intercourse, and higher proportions report engaging in kissing, petting, and other intimacies.⁹
  
• Among vocational students ages 15 – 21 in northern Thailand, approximately 2% of girls and 15% of boys report having sexual intercourse before age 15 and about 30% and 40%, respectively, by age 18.¹⁰ Early sexual initiation is associated with other risk-taking behaviors among both male and female students.
  
• In India, more than one-quarter of women in one sample who had been sexually abused were exposed to the abuse between the ages of 9 and 12. Half were abused by more than one person and almost all were abused repeatedly.¹¹ Similar patterns of incest and sexual abuse are reported throughout the literature, but it is challenging to provide representative data because of the hidden nature of the practice.
  
• Throughout South and Southeast Asia, girls from poor families are susceptible to being recruited or sold into prostitution by their families, which places them at high risk of HIV and other sexually transmitted infections (STIs).^12-16 Boys are also vulnerable: in Sri Lanka, for example, a majority of child prostitutes are boys.¹⁷

WHAT DO YOUNG ADOLESCENTS KNOW?^†
Sexual and reproductive health information, education, and services for adolescents are viewed as unnecessary or even morally dangerous throughout much of South and Southeast Asia.² Widespread sexual taboos and the high value on premarital virginity, especially for girls and young women, means that little if any information is passed on from mothers to daughters until “needed.” Boys may also be uninformed.

• Young brides in India are often shocked and frightened by their (sometimes forced) sexual initiation on their wedding night because they lack even the most basic knowledge of sexual relations.¹⁸
  
• A sample of young adults ages 18 – 25 in Pakistan reported that the information they received about puberty and sexual development when they were younger often led to confusion and stress. Young women learned most from female family members; young men from friends, family members, religious sources, magazines, and films. Some young women said they had no information about sexual relations prior to their marriage.¹⁹
  
• In Bangladesh, adolescents ages 12 and over enrolled in a non-governmental    reproductive health program were eager for information about their bodies, romantic relationships, sex, pregnancy, family planning, and STIs.²⁰ Much of what the boys already knew came from pornographic videos which they secretly watched with friends.
  
• In Bangladesh, India, and Indonesia, only 5% of married girls ages 15 – 19 know without prompting that condoms prevent HIV, and only 9% in the Philippines. In contrast, 24% of married girls ages 15 – 19 in Nepal and 65% of married boys know this. Far higher proportions of all 15 – 19-year-olds in Cambodia and Vietnam know that condoms prevent HIV, although many need prompting.²¹

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.²² 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.

Policies and programs to eliminate the marriages of girls 14 and younger and to promote delayed marriage and informed consent among older adolescents are urgently needed. 

Sexuality education: High proportions of 10 – 14-year-olds are currently attending school in most countries in the region (see table). Providing sex education in schools will require overcoming entrenched cultural conservatism and securing parental and community support at state and local levels. In India, in 2007, several states banned sex education, in spite of a national HIV/AIDS policy that supports such programs for young people.²³

Sexual and reproductive health services: Awareness-raising is required among public health providers and non-governmental organizations (NGOs) of the need for special clinics or programs for adolescents, especially where premarital sex is increasing.²⁴ Laws prohibiting the provision of family planning services to unmarried adolescents should be eliminated in Indonesia, Vietnam, and wherever else they exist. Health care providers need to be trained to work with young adolescents and to be sensitive to the possibilities of incest and sexual abuse of both boys and girls. In countries where a substantial number of girls marry and give birth at 14 or younger, special efforts are needed to ensure that secluded, newly married girls obtain contraception for birth spacing and good prenatal care, and that their deliveries are assisted by trained birth attendants prepared to deal with emergencies such as hemorrhage and obstructed labor.

Other approaches: Some NGO programs and special government projects across the region (especially UNFPA-supported) are developing innovative methods of reaching young adolescents with accurate and nonjudgmental sexual and reproductive health information—such as media sources, out-of-school programs, and the Internet. These and other approaches need to be evaluated with respect to their impact on the sexual and reproductive health and rights of young adolescents and their potential for adaptation in other settings.

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. S. Bott, S.J. Jeejebhoy, I. Shah and C. Puri (eds.).  2003.  Towards Adulthood: Exploring the Sexual and Reproductive Health of Adolescents in Asia.  Geneva: World Health Organization.

3. Cynthia B. Lloyd (ed.)  2005.  Growing Up Global: The Changing Transitions to Adulthood in Developing Countries.  Washington DC: National Academies Press:453-67.

4. World Health Organization (WHO).  2006.  Skilled attendant at birth 2006 updates.  Dept. of Reproductive Health and Research Factsheet.  Geneva: WHO.

5. AnnDenise Brown, Shireen J. Jejeebhoy, Iqbal Shah and Kathryn M. Yount.  2001.  Sexual Relations among Young People in Developing Countries: Evidence from WHO Case Studies. Geneva: WHO:13.

6. Hamkhothang Lhungdim and Ravi K. Verma.  2005.  "Risk-taking and sexual behaviours of the unmarried male youth in rural India." Paper delivered at the IUSSP International Population Conference, Tours, France, July 18-23: http://iussp2005.princeton.edu/programSummary.aspx, Session 7.

7. Radhika Chandiramani.  1998.  "Talking about sex," Reproductive Health Matters 6(12):76-86.

8. Barbara S. Mensch, Wesley H. Clark and Dang Nguyen Anh.  2003.  "Adolescents in Vietnam: looking beyond reproductive health," Studies in Family Planning 34(4):249-262.

9. Ushma D. Upadhyay, Michelle J. Hindin and Socorro Gultiano.  2006.  "Before first sex: gender differences in emotional relationships and physical behaviors among adolescents in the Philippines."  International Family Planning Perspectives 32(3):110-119.

10. Alice Liu, Peter Kilmarx, Richard A. Jenkins et al.  2006.  "Sexual initiation, substance use, and sexual behavior and knowledge among vocational students in Northern Thailand."  International Family Planning Perspectives 32(3):126-135.

11. Anuja Gupta and Ashwini Ailawadi.  2005.  "Childhood and adolescent sexual abuse and incest: experiences of women survivors in India," pp. 171-185 in Shireen J. Jeejebhoy, Iqbal Shah and Shayam Thapa (eds.), Sex Without Consent: Young People in Developing Countries.  London: Zed Books.

12. Brian W. Willis and Barry S. Levy. 2002. "Child prostitution: global health burden, research needs, and interventions," Lancet 359: 1417-1422.

13. United Nations Children's Fund (UNICEF). 2007. "The State of the World's Children 2007." New York: UNICEF.

14. United Nations. 2000. "Sexually Abused and Sexually Exploited Children and Youth in Vietnam." New York: United Nations.

15. Kamalesh Sarkar, Baishali Bal, Rita Mukherjee, Malay Kumar Saha, Sekhar Chakraborty, Swapan Kumar Niyogi, Sujit Kumar Bhattacharya. 2006. "Young age is a risk factor for HIV among female sex workers-An experience from India." Journal of Infection 53: 255-259.

16. Jay G. Silverman, Michele R. Decker, Jhumka Gupta et al. 2007. "HIV Prevalence and Predictors of Infection in Sex-Trafficked Nepalese Girls and Women." Journal of  the American Medical Association 298 (5): 536-542.

17. UNICEF, UNAIDS, WHO.  2002.  Young People and HIV/AIDS: Opportunity in Crisis.  New York: UNICEF.

18. K. G. Santhya and Shireen J. Jejeebhoy.  2005.  "Young women's experiences of forced sex within marriage: evidence from India," pp. 59-73 in Jeejebhoy et al (see note 11).

19. Monique Hennink, Imran N. Rana and Robina Iqbal.  2005.  "Knowledge of personal and sexual development amongst young people in Pakistan," Culture, Health and Sexuality 7(4):319-332.

20. Sabina Faiz Rashid.  2003.  "Communicating with adolescents about sex education: experiences from BRAC, Bangladesh," in Bott et al (see note 2).

21. Demographic and Health Surveys, HIV/AIDS Survey Indicators Database, http://www.measuredhs.com (accessed 22 Aug. 2007)

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

23. "Sex education creates storm in AIDS-stricken India," Reuters, July 14, 2007.

24. Karl L. Dehne and Gabriele Riedner.  2005.  Sexually Transmitted Infections Among Adolescents: The Need for Adequate Health Services.  Geneva: World Health Organization:25-38.

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