Young Adolescents' Sexual and Reproductive Health and Rights: Sub-Saharan 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 sub-Saharan Africa and globally.* We define all boys and girls between the ages of 10 and 14 as young adolescents.

Sub-Saharan Africa has been the subject of many generalizations, but in reality is marked by extreme contrasts in adolescents’ sexual, marital, and reproductive behaviors. Differences are based on religious, racial, and ethnic identities and on contrasting colonial and post-colonial histories, political and socioeconomic conditions, and kinship systems. More is known about adolescents’ sexual and reproductive behaviors in this region than in other parts of the developing world, due in part to the high rates of fertility and HIV/AIDS among young people (especially young women) in some areas.^2-5

SEXUAL INITIATION
Patterns of early intercourse, marriage, and childbearing vary significantly across sub-Saharan Africa.

• Proportions of girls ages 15 – 19 who report having intercourse before their 15^th birthdays range from only 3% in Zimbabwe and Rwanda to 27% in Guinea and 30% in Niger (see table).
  
• Very high proportions of boys report heterosexual intercourse before age 15 in some countries (48% in Gabon), and almost none in others (2% in Mauritania).
  
• In most countries in the region, a substantial proportion of girls who report having intercourse before age 15 were not married at sexual initiation. In contrast, intercourse for girls 14 or younger is linked with early arranged marriage in countries like Niger, Chad, Mauritania, and Ethiopia.

• Despite declines in early marriage regionally,^6,7 at least one in six girls still marries or enters a consensual union before age 15 in seven countries (see table).
• Virtually all sexual activities among boys before age 15 are premarital. African men typically do not marry until their mid to late 20s or early 30s, whereas their brides are much younger.^6,7
  
• Fewer than 7% of girls had children before age 15 in any country. Pregnancy-related risks of complications and death are high, however, because access to skilled birth attendants and safe abortions is limited.⁸
  
• Early sexual initiation is often forced, for girls and for boys. In some countries, approximately 25% of girls and young women report coerced first sex, which is associated with subsequent episodes of forced and unprotected sex, and higher probabilities of unintended pregnancies and STIs—including HIV/AIDS.^9-12
  
• Boys may be perpetrators as well as victims of sexual coercion, even in early adolescence. In Kenya, boys who had been coerced into first sex were more likely to admit having persuaded or forced others to have sex against their will.¹³
  
• A survey of primary school students ages 12 and over in Mwanza, Tanzania, found that 80% of boys and 68% of girls are “sexually experienced.” Although about half of boys and girls said that their first sexual act was vaginal intercourse, 40% reported oral sex and 10% anal intercourse as their first sexual experience.¹⁴
  
• Orphans and vulnerable children may be especially likely to engage in early sexual activity, due in part to lack of social and economic support. One South African study found that 23% of orphans had sex by age 13, compared with 15% of non-orphans.¹⁵

WHAT DO YOUNG ADOLESCENTS KNOW?^†
Despite very high levels of early sexual activity and/or HIV/AIDS prevalence in some countries in sub-Saharan Africa, young people often do not know how to protect themselves and their partners.¹⁶ This trend has been exacerbated in recent years by policies and programs emphasizing abstinence-until-marriage approaches rather than comprehensive sexuality education.

• In Burkina Faso, Ghana, Malawi, and Uganda, fewer than one-fifth of 12 – 14-year-old boys and girls have detailed knowledge about HIV and pregnancy prevention.¹⁷ Whereas 41% of girls have received family life or sex education in school in Ghana, only 10% have done so in Burkina Faso.¹⁷
  
• Even where adolescents have heard of HIV/AIDS, fewer have accurate knowledge of other STIs. In Ghana, for example, only 25% of 12 – 14-year-old boys and girls have heard of STIs apart from HIV/AIDS.¹⁸
  
• In Benin City, Nigeria, although most secondary school students are familiar with several STIs, most believe it is sex with “strangers” that puts them at risk. Many believe that STIs are an inevitable consequence of having sex.¹⁹
  
• Throughout sub-Saharan Africa, adolescents are largely uninformed about STI symptoms and effective treatments. Some self-medicate with over-the-counter drugs or remedies from traditional vendors.²⁰

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.²¹ 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.

In many countries of sub-Saharan Africa, the genital mutilation of girls during childhood or adolescence requires a strong policy and program response to eliminate the practice.

Sexuality education: School-based and out-of-school sex and family life education programs, including peer education components, are urgently needed across the region.^14,16 Maximizing the potential reach of comprehensive, rights-based sexuality education in primary and middle schools will require overcoming obstacles to school attendance—including discrimination against girls—in many countries (see table).⁶ School curricula have been introduced in Cameroun and Nigeria,²² among other countries, but opposition from conservative religious groups has been very strong.  Various school-based programs have been evaluated in Kenya, Nigeria, Uganda, Tanzania, and other countries for their impact on knowledge and behaviors, but many are targeted at older students and are of short duration.^23-25

Sexual and reproductive health services: Non-governmental organizations (NGOs) have established adolescent-friendly reproductive health services in local sites in countries including Uganda, Tanzania, and Zambia, typically targeted to reach male and female 10 – 24-year-olds with sexual and reproductive health information and services, improve access, and train providers.²³ Even in countries where such clinics and services are offered by NGOs or the public sector, coverage tends to be limited and the breadth and quality of care uneven.²⁰ Younger as well as older adolescents need access to STI/HIV counseling and testing; counseling and treatment related to sexual coercion and violence; contraceptive services and supplies; prenatal and delivery care; and safe, early, and accessible abortion services to prevent avoidable complications and deaths. Increased investment in the quality and infrastructure of sexual and reproductive health services throughout the region is critical to young adolescents’ present and future well-being.

Other approaches: Community-based programs for younger and older adolescents have been instituted in Botswana, Cameroun, Guinea, Kenya, South Africa, and Zimbabwe, among other countries. These typically incorporate mass media campaigns for safe sex, social marketing of male and female condoms, peer counseling on sexual and reproductive health, and entertainment such as TV or radio shows, dramas, and recreational activities.^24,25 Some programs in Nigeria specifically challenge ideologies and practices of male privilege and sexual entitlement, and empower girls to make free and informed decisions about their own bodies and their lives—including resisting female genital mutilation.²⁶

*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.

†Data on older adolescents 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 reviewer Shehu Idris (International Centre for Reproductive Health and Sexual Rights, Nigeria).

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

3. Shelley Clark.  2004.  "Early marriage and HIV risks in Sub-Saharan Africa."  Studies in Family Planning 35(3):149-160.

4. Laurie Schwab Zabin and Karungari Kiragu.  1998.  "Health consequences of adolescent sexuality and fertility behavior in Sub-Saharan Africa."  Studies in Family Planning 29(2):210-232.

5. Nancy Luke.  2003.  "Age and economic asymmetries in the sexual relationships of adolescent girls in Sub-Saharan Africa."  Studies in Family Planning 34(2):67-86.

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

7. United Nations, Dept. of Economic and Social Affairs.  2004.  World Population Monitoring 2002.  Reproductive rights and reproductive health: selected aspects.  New York: United Nations: Table A.1.

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

9. Annabel S. Erulkar.  2004.  "The experience of sexual coercion among young people in Kenya."  International Family Planning Perspectives 30(4):182-189.

10. 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: World Health Organization.

11. Michael A. Koenig, Iryana Zablotska, Tom Lutalo et al.  2004.  "Coerced first intercourse and reproductive health among adolescent women in Rakai, Uganda."  International Family Planning Perspectives 30(4):156-163.

12. Pranitha Maharaj and Chantal Munthree. 2007. "Coerced first sexual intercourse and selected reproductive health outcomes among young women in Kwazulu-Natal, South Africa." Journal of Biosocial Science 39(2): 231-244.

13. Carolyn Njue, Ian Askew and Jance Chege.  2005.  "Non-consensual sexual experiences of young people in Kenya: boys as perpetrators and victims," pp. 139-157 in Shireen J. Jejeebhoy, Iqbal Shah and Shyam Thapa (eds)., Sex Without Consent: Young People in Developing Countries.  London and New York: Zed Books.

14. E. Matasha et al. 1998.  "Sexual and reproductive health among primary and secondary school pupils in Mwanza, Tanzania: need for intervention."  AIDS CARE 10 (5):571-582.

15. Tonya R. Thurman, Lisanne Brown, Linda Richter, Pranitha Maharaj, and Robert Magnani. 2006. "Sexual Risk Behavior among South African Adolescents: Is Orphan Status a Factor?" AIDS Behavior; 10: 627-635.

16. Susheela Singh, Akinrinola Bankole and Vanessa Woog.  2005.  "Evaluating the need for sex education in developing countries: sexual behaviour, knowledge of preventing sexually transmitted infections/HIV and unplanned pregnancy."  Sex Education 5(4):307-331.

17. Akinrinola Bankole, Ann Biddlecom, Georges Guiella, Susheela Singh and Eliya Zulu.  2007.  "Sexual behavior, knowledge and information sources of very young adolescents in Sub-Saharan Africa," African Journal of Reproductive Health, to be published December 2007.

18. Kofi Awusabo-Asare, Ann Biddlecom, Akwasi Kumi-Kyereme and Kate Patterson.  2006.  Adolescent Sexual and Reproductive Health in Ghana: Results from the 2004 National Survey of Adolescents.  Occasional Report No. 22.  New York: Alan Guttmacher Institute.

19. Miriam J. Temin et al.  1999.  "Perceptions of sexual behavior and knowledge aobut sexually transmitted diseases among adolescents in Benin City, Nigeria."  International Family Planning Perspectives 25(4):186-190 & 195.

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

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

22. Andrea Irvin.  2000.  Taking Steps of Courage: Teaching Adolescents about Sexuality and Gender in Nigeria and Cameroun.  New York: International Women's Health Coalition.

23. David A. Ross, Bruce Dick and Jane Ferguson (eds.).  Preventing HIV/AIDS in Young People: A Systematic Review of the Evidence from Developing Countries.  Geneva: World Health Organization.

24. Ilene S. Speizer, Robert J. Magnani, and Charlotte E. Colvin.  2003.  "The effectiveness of adolescent reproductive health interventions in developing countries: a review of the evidence."  Journal of Adolescent Health 33(5):324-348.

25. Sue Alford, Nicole Cheetham, and Debra Hauser.  2005.  Science & Success in Developing Countries: Holistic Programs that Work to Prevent Teen Pregnancy, HIV & Sexually Transmitted Infections.  Washington DC: Advocates for Youth.

26. Francoise Girard.  2003.  "My Father Didn't Think This Way': Nigerian Boys Contemplate Gender Equality.  Quality/Calidad/Qualité No. 4.  New York: The Population Council.