Perspective Chapter: Sexual Health Interventions for Adolescents

Abstract

Comprehensive sexual education emphasizes a holistic approach to human development and sexuality. The goal is to equip adolescents with competencies and values that should enable them to make responsible well-informed decisions about their sexual and social relationships in a world driven by sexual and reproductive health and rights. Sexual education programmes provide mitigating effects on the sustained information adolescents receive from various unsubstantiated sources about their sexuality and gender, which often is contradictory and confusing. It has been widely recognized that sexual education is alone not adequate to empower adolescents for developing positive norms about themselves, relationships, and their sexual health if the component of human rights is overlooked. This chapter hence adopts a rights-based approach to comprehensive sexuality education. Advocacy is on availing opportunities for adolescents to acquire essential life skills and develop positive attitudes and values on their sexuality. The chapter addresses the following contemporary cross cutting issues prevalent among adolescents: Sexual and Reproductive Health and Rights; Sexuality Education; Prevention of sexually transmitted infections; Provision of family planning and prevention of unwanted pregnancies; Prevention of Gender Based Violence. Suggestions on contextualized approaches for effective adolescent sexual education are provided in each section.

1. Introduction

Adolescents and young people have a right to comprehensive sexual and reproductive health services which include the right to sexual knowledge. Consequently, they require comprehensive sexuality education (CSE) to prevent unpredicted and unplanned health outcomes relating to their sexuality. A rights based CSE is recommended for both in and out of school adolescents aged 15–24 years. This enables them to protect and advocate for their health, well-being, and dignity through provision of the necessary toolkit of knowledge, attitudes and skills [1]. Specifically, the initiative aims at empowering this vulnerable population cohort to stand for its sexual and reproductive health and rights (SRHR), and be able to protect itself from any form of abuse, guided by an informed decision mind set. Being a component of basic human rights, SRHR are an important global public health goal that concern adolescents and young people substantially [2]. Fundamentally, adolescents are repeatedly the target of sexual health interventions aimed at avoiding unwanted pregnancies and sexually transmitted infections (STIs) including Human Immunodeficiency virus (HIV) and gender based violence (GBV). These interventions depend on the cultural context, and range from abstinence-only programs to CSE [2].

Adolescents are meant to be the key stakeholders in sexual health education yet, they are rarely consulted when sexual health programmes are developed. Nonetheless, their contributions are crucial to guide relevant and appropriate sexuality education that promotes safer adolescent sexual behaviours [3]. It has been reported that long-term sexuality education programmes result in the reduction of teenage pregnancies and abortions as well as declines in the rates of STIs and HIV infection among young people [4].

The rights-based approach that expands the goals of sexuality education beyond disease and pregnancy prevention is an emerging model for CSE [5, 6]. This approach includes positive sexuality, empowerment, and community engagement. Content related to contextual issues that affect adolescents’ sexual lives including gender and cultural norms, relationship power and sexual orientation should be incorporated into the rights-based approach empowerment programmes [5, 6]. Accessibility of comprehensive sexual and reproductive health services is therefore mandatory for adolescents and young people as a crucial basic human right if universal sexual and reproductive health coverage is to be attained [7].

2. Sexual and reproductive health and rights

Sexual and reproductive health is a state of complete physical, mental and social wellbeing in all matters relating to sexuality and the reproductive system [8]. In addition, individuals need to be empowered on the knowledge of their rights, be enlightened on the services available to them, and helped to overcome individual and societal barriers that prevent them from making informed decisions [9]. This derives from the right individuals have to make decisions governing their body and access services that support that right [10]. It is further asserted that SRHR comprise sexual health, sexual rights, reproductive health, and reproductive rights [10]. These components ought to be reflected in the programming of services and interventions that address individuals’ sexual and reproductive health needs. Furthermore, SRHR focus on pertinent issues that include violence, stigma, and respect for bodily autonomy. These factors have a profound effect on the adolescents’ physical, psychological, emotional and social well-being. Relevant stakeholders therefore need to develop policies, services and programmes that holistically address SRHR issues effectively and equitably. This is grounded on individuals’ rights to decide over their bodies, and to live healthy and productive lives.

Sexual health focuses on counselling, care related to sexuality, sexual identity, and sexual relations. Related services include the prevention and management of STIs and Human Immunodeficiency Virus (HIV), and Human Papillomavirus (HPV) for girl adolescents.

Sexual rights entail the right of all persons to freedom from sexual discrimination, coercion and violence.

Reproductive health promotes delivery of accurate information to all people about their reproductive systems, and awareness creation on the services that support maintenance of reproductive health needs especially among adolescents.

Reproductive rights centre on the recognition of human rights of all people to decide freely and responsibly on the number and timing of their children and the right to attain the highest standard of reproductive health.

Adolescent sexual and reproductive health is related to multiple human rights that include the right to life, health, privacy, education, religion, freedom from torture, and the prohibition of discrimination, all of which need to be supported [1]. The ability of individuals to achieve sexual and reproductive health depends on the realisation of sexual and reproductive rights based on the human rights of all individuals.

Sexual and reproductive health and rights are anchored on four pillars; autonomy, control, respect, and support systems. Related services must fulfil public health and human rights standards in terms of availability, accessibility, acceptability and quality framework of the right to health [10]. Hence, an essential package of sexual and reproductive health interventions for adolescents includes; provision of contraceptive services, prevention and treatment of HIV/AIDS, management of STIs other than HIV, comprehensive sexuality education, safe abortion care, prevention, detection and counselling for GBV, infertility and cervical cancer, and counselling and care for sexual health and well-being.

There is need for SRHR providers to be open minded and play a critical role in shaping attitudes and perspectives of adolescents. This could be a means of challenging and entrenching positive social and gender norms, especially on girls. Meaningful conversations around SRHR need to be normalised in order to keep adolescents well informed, empowered and less vulnerable to STIs, GBV and unintended pregnancies.

Achieving positive outcomes in the area of sexual reproductive health requires huge investment and collaboration among all key stakeholders [11]. Equitable access to good quality SRHR enables bodily autonomy which is a precondition for adolescents’ economic empowerment and their opportunity to contribute actively to democracy, peace and security [12]. The SADC SRHR strategy 2019–2030 emphasises the need for strong political commitment and adequate human and financial resources to support the SRHR initiative. Enablement of all people to exercise their SRHRs and make decisions that govern their bodies free of stigma, discrimination, violence and coercion could thus be assured. The SADC SRHR strategy also supports all the sexual health interventions relating to youths mentioned in preceding sections while advocating for the reduction of intimate partner violence, sexual violence and sexual exploitation to enhance comprehensive SRHR. In addition, midwives need to invest in adolescent health if they are to perform to their full potential [13].

Sexual and reproductive health and rights for all including vulnerable groups like adolescents could be achieved through realisation of the sustainable development goals and universal health coverage. Universal achievement of SRHR takes cognisance of government commitment, human and material resource availability, and collaborative action by various key stakeholders specialising in those areas. Special consideration of these factors could lead to the elimination of sexual and GBV, reduction in teenage pregnancies and STIs, and universal access to comprehensive SRHR services. These rights should be applied to everyone including adolescents, and remain with them throughout life. All rights are equally important since deprivation of one impedes the enjoyment of all the others.

3. Sexuality education

Adolescents’ susceptibility to practicing risky sexual behaviour due to lack of appropriate sexuality education has evolved over time and has since become a global concern [14]. However, despite clear and compelling evidence for the benefits of high-quality, curriculum-based CSE, few adolescents receive preparation for their lives that empowers them to take control and make informed decisions about their sexuality and relationships freely and responsibly [15].

Sexuality education also referred to as CSE [16] is viewed as a rights-based approach that aims to empower young people with the knowledge, skills, attitudes and values they need to determine and enjoy their sexuality; physically and emotionally, individually and in relationships. The concept proposes education beyond information and hence a need to motivate young people to acquire essential life skills and develop positive attitudes [15]. The education should include issues of adolescent sexual development, sexual orientation, sexual behaviours, pregnancy, contraception and related health problems and their complications [17]. Sexuality education for both boys and girls takes place through a potentially wide range of programmes and activities in schools, community settings, religious centres, as well as informally within families, among peers, and through electronic and other media.

Adolescents are the key stakeholders and consumers of CSE because they are at a stage of transitioning from childhood to adulthood. This stage of development is characterised by physiological changes such as sexual maturity and body shape changes, cognitive-complex thinking, social development, and thinking about one’s rights. In addition, menarche and spermarche (first menstruation in females and first sperm emission in males) occur during this period and adolescents become aware of their sexuality. They show personal responsibility and begin to experiment on many things including sexual indulgence at early adolescent stages [18]. Lately, adolescents experience puberty at younger ages than the previous generations due to better health and nutrition. Furthermore, some cultural and religious practices tend to prescribe early childhood marriages without consent of these young people [18].

There are several emerging issues resulting from the changing values/norms of society linked to globalisation. These include; child pornography, prostitution, child sexual abuse and poor parenting, adolescent dating violence, intimate partner violence, body image disorders, rape and abortion, female feticide, psychosexual disorders, homosexuality and masturbation by adolescents [18]. Risky sexual behaviours and lack of knowledge on sexuality-related topics in middle to low income countries are among the leading sexual health problems. These problems are mostly associated with socio-cultural practices that eventually lead to STI and HIV infections, unplanned early pregnancies, and unsafe abortion [19, 20]. Similarly, countries holding conservative attitudes and cultural taboos towards sexuality education have higher incidences of sexually transmitted diseases, teenage pregnancies, child marriages and sexual abuse in their populations [14].

Adolescents need reliable sexuality information that prepares them for safe and life fulfilling skills. This is because at this stage they tend to receive confusing and conflicting information about relationships and sex. When delivered well, CSE enables young people to adopt positive sexual behaviours. These include delaying the age of sexual debut, reducing the frequency of sex and number of sexual partners, and increasing use of contraception especially use of condoms, thereby delaying pregnancy and preventing STIs [21].

Comprehensive sexuality education encourages active participation, which is integral to the empowerment of adolescents, while also helping them to make independent decisions with confidence [21]. In addition, adolescents open up, share their personal experiences and adopt a change of attitudes towards gender and sexuality. Comprehensive sexuality education also helps adolescents to accept who they are, acquire assertiveness and self-esteem skills, confidence when discussing sexuality, and acquisition of self-respect and life skills which enable them to make informed decisions about interpersonal and romantic relations. Overall, CSE motivates young people to access friendly sexual and reproductive health services, gain independence, and acquire sexual rights [20]. Sexual education can also reduce adolescent and youth vulnerabilities to violence by promoting bodily autonomy and integrity, self-confidence and negotiation skills including gender-equitable norms.

Appropriate CSE often leads to better acceptance and appreciation of one’s own body. It eliminates curiosity about their bodies and teaches young children on how to protect themselves from abuse. Furthermore, CSE also helps young people to express love and intimacy in appropriate ways as they interact with all genders in respectful ways [3]. Through CSE, adolescents learn to apply critical thinking skills, effective decision making and effective communication with family, peers and romantic partners. They also learn to take responsibility for own behaviour and tend to enjoy and express one’s sexuality throughout life. Early child pregnancies, child marriages, STIs and HIV and all forms of gender based abuse could thus be reduced [3].

It is recommended that CSE should start in the classroom as an on-going process of acquiring information and cultivating positive attitudes, beliefs, and values [19]. Moreover, the human rights perspective postulates that complete sexuality education must be scientifically and age-appropriate, and recognise peoples’ culture, rights and gender equality [22]. Schools and other educational institutions should scale up access to quality CSE that is culturally appropriate, gender sensitive and evidence-based, and should be inclusive of both in and out of school boys and girls.

There is need to increase access to youth-friendly sexual and reproductive health services. Comprehensive sexual education should therefore be linked to accessible, affordable and effective health services and commodities such as; condoms, contraceptives, HIV counselling and testing, HIV and STI treatment, post-abortion care, safe delivery, prevention of mother-to-child transmission and other related services. Awareness programmes on CSE should be extended to teachers, health care providers, parents, peers, law makers and society at large. The above mentioned cadres are sometimes the perpetrators who tend to promote threatening, unfriendly and inaccessible environments due to inadequate knowledge and conflicting religious-cultural beliefs and legal restrictions [14].

Sexuality education should take place in conducive, non-threatening environments that motivate adolescents to be active participants in the discussions. This could assist them gain confidence to freely open up, develop own body autonomy and make informed decisions regarding rights and wrongs. In addition, teachers and peer educators need to be adequately trained with appropriate knowledge and skills on facilitating sexuality education programmes. Parents and the entire community also need to be equipped with information on parenthood regarding sexuality issues throughout their children’s developmental journey from puberty to adulthood.

4. Prevention of sexually transmitted infections

Sexually transmitted infections are a public health issue of concern. Globally, more than 1 million cases of STIs are acquired every day and about 374 million new cases are recorded every year although there are notable variations in geographic regions and age groups [23]. The burden of STIs is higher in lower and middle income countries with sub-Saharan Africa having the highest number of new cases globally [24]. Adolescents and young adults aged 15–24 make up 25% of sexually active individuals and account for about 50% of new infections [25]. Because adolescents normally face barriers in accessing prevention and management services such as inability to pay, lack of transport and confidential concerns with parents and guardians, they are a particularly high risk group for STIs. Other health behaviours such as high risk for substance abuse, victimisation through violence, poor mental health and suicide related experiences have been shown to co-occur with, and contribute to the risk of HIV and STIs, and unintended pregnancies [26]. Decreased condom use and expanding sexual networks facilitated by dating apps also contribute to high STI rates among adolescents [25].

Adolescents tend to have their first sexual experience whilst still at school where they spend most of their time. Regrettably, the majority of them have their experience of sex education too late [27]. It is for this reason that schools are better placed to deliver CSE to children starting from kindergarten before they are sexually active. This is meant to equip them with the necessary skills to prevent early sexual debut and consequently STIs and unwanted pregnancies.

High quality STI prevention interventions and care include CSE programmes, testing and treatment services, preventive technologies, vaccines and supportive and dignified care [25]. Students need to be given age-specific and accurate information on the prevention, transmission, symptoms and treatment of STIs. Promotion of abstinence to delay sexual debut is one approach that has been promoted to prevent STIs. However, although it is 100% effective in preventing STIs, abstinence has been criticised because it is misaligned with adolescents’ sexual behaviours. Condom use is therefore encouraged as it provides dual protection against STIs and pregnancies. Rights-based approaches are more holistic and provide young people with information that will enable them to cope with sexuality issues including STI prevention.

It is estimated that 258 million adolescents, about 8% of the global youth population, are out of school. Of these, 60 million are primary school going age or less [27]. Research has shown that out of school adolescents are more likely to initiate sex early and marry at a young age, usually to elderly men. Their risk of exposure to STIs is therefore high. Consequently, CSE should also be provided to out of school adolescents to equip them with life skills for the prevention of negative sexual and reproductive health outcomes. A significant increase in adolescent pregnancies was reported at the height of the COVID-19 lockdowns [28]. This suggests that young people who were previously at school, and who may have received school based CSE practised unsafe sex and got pregnant. Moreover, these adolescents were exposed to the risk of getting STIs. Evidently, sex education on its own is not very effective in preventing STIs and has to be linked to service provision like access to condoms and confidential counselling and treatment.

Parents should be actively involved in sex education programmes to reinforce the information their children already have. A compressive sex education includes gender components which empower young people to negotiate safer sex and avoid STIs. Rights based approaches also enable stigmatised disabled and Lesbians, Gay, Bisexual, Transgender, and questioning + (LGBTQ+) adolescents to access STI preventive services and treatment [25]. These stigmatised groups derive less satisfaction from their sexuality education than their peers and this is an area which needs to be strengthened.

5. Provision of family planning and prevention of unwanted pregnancies

Unintended pregnancy among adolescents represents an important public health challenge in both high-income and middle and low-income countries [29]. Globally, contraceptive use among adolescents remains consistently low [30]. This is attributed to lack of access to information and health services related to sex which consequently increase the risk of unsafe abortions and carrying unwanted pregnancies [31]. The capacity of adolescents to engage in early sexual activity has evolved over time and presents challenges to policy makers [32]. Increasing contraception among adolescents is therefore important for the prevention of adverse health outcomes such as maternal mortality, obstructed labour and obstetric fistula as well as negative socio-economic outcomes including reduced opportunities for education and employment [30]. On the contrary, increased access to family planning services results in adolescents’ ability to delay parenthood and enjoy improved health and educational outcomes.

Other provider, individual, health system and societal barriers to the use of contraceptives by adolescents have been observed in different settings. These include; poor contraceptive knowledge among adolescents, inadequate training of health workers in the provision of adolescent sexual health services, weak input of reproductive health information in educational institutions, religious factors, and access of reproductive sexual health services being considered a taboo in some cultures which do not expect that age group to use contraception [33].

There is need to increase awareness and knowledge of family planning methods among adolescents. This calls for the education of community members towards remodelling use of family planning services among sexually active adolescents. This may be more beneficial towards the prevention of unintended pregnancies. In some settings, efforts to increase education and access to voluntary contraception were thwarted by the emergence of the COVID-19 pandemic in 2020. This resulted in further exacerbation of risk vulnerabilities because of the associated restrictions which included difficulties in accessing transportation, closure of health facilities, and mobile clinics, and community-based interventions including supply delays for contraceptives [34].

The reversal of the gains on contraceptive education of adolescents need to be revamped and intensified for sustained empowerment on the prevention of unplanned and unwanted pregnancies by adolescents. Several recommendations for family planning education and prevention of unwanted pregnancy can be proffered including health education of adolescents on contraceptives in conjunction with skills-building and improving contraceptives accessibility. Furthermore, all stakeholders should support young people to navigate through adolescence with adequate knowledge, skills and services to facilitate good decisions regarding their sexuality. This could be done through provision of CSE, strengthening education on communication between parents and adolescent children, and empowering youths for sexuality decisions. Reinforcing peer education strategies in health facilities and community setups could facilitate increased knowledge and consequently, adolescents could gain confidence and upgrade their rights-based approach to sexuality education.

6. Prevention of gender-based violence

Gender-based violence refers to harmful acts directed at an individual based on their gender. It is rooted in gender inequality, the abuse of power, and harmful norms which include sexual, physical, mental and economic harm inflicted in public or in private [35]. Gender-based violence also includes threats of violence, coercion and manipulation and can take many forms such as intimate partner violence, sexual violence, child marriage and female genital mutilation, with young people considered a high risk group [36]. Lesbians, Gay, Bisexual, Transgender, and questioning+ youth and young women with disabilities are also at increased risk of experiencing GBV [37].

Gender-based violence is a global pandemic and one of the most prevalent human rights violations in the world with serious health and security impacts for those affected [35]. When a woman has been subjected to GBV, she suffers short and long-term consequences such as injuries, unintended pregnancies, sexually transmitted infections and gynaecological disorders, as well as anxiety, depression, post-traumatic stress disorder and self-harm in some instances [38]. Almost one in every three women, or approximately 736 million women worldwide, have been subjected to intimate partner violence, non-partner sexual violence or both at least once in their lifetime [38]. Although the majority of GBV victims are women and girls and a majority of policymakers focus on them, it is important to recognise that men and boys can also experience GBV [35].

Effective prevention programming is a key component of a comprehensive strategy to reduce GBV. The best approach is implementing primary prevention programmes that address the underlying attitudes, norms, and behaviours that support GBV. Preventive measures from 25 years of GBV programme development and evaluation have been suggested as follows [37]:

Educational programmes for youths in primary and secondary schools: Bullying and teen dating violence should be addressed as these could be risk factors for GBV later in life. In collaboration with community structures, students should be educated on the consequences of abusive behaviour and encouraged to keep within safe spaces to reduce the risk for GBV. Awareness on abusive behaviours and the associated mitigatory measures need to be created through delivery of a curriculum on dating violence, sexual harassment, and promoting healthy personal boundaries. This strategy is meant to reduce dating violence and sexual harassment among adolescents and encourage school authorities to maintain surveillance on unsafe areas.

Programmes for tertiary students: The focus is on changing sexual violence norms and promotion of positive social interactions among youth to enhance taking action against peer violence. The programmes should engage both males and females to inculcate the capability and responsibility to recognise and intervene before, during, and after violence has occurred. This inclusivity is meant to remove the focus on males being the potential perpetrators and females the victims. Although the programmes are delivered to tertiary students, the long term effect would be on all population groups including adolescents.

Selective prevention: These are school based programmes delivered to adolescents at risk of experiencing GBV. They are supplementary to the universal prevention strategies. Individuals for the interventions are identified on the basis of their risk factors such as race, class, ability, sexual orientation, and a family background of violence and substance abuse.

Programmes for boys and men: Gender-based violence awareness raising and engagement activities among this group are premised on the fact that most GBV is perpetrated by males. Interventions should hence target males’ unique role as potential perpetrators and bystanders.

Evidence from the aforementioned interventions suggest that that there is merit in programmes that target attitudes, develop skills, and are comprehensive in nature [37].

Since GBV is saliently promoted through socio-cultural practices entrenched within some settings, it is crucial for programming to create partnerships with the influential community leaders in addressing it. Such partnerships could achieve a change in the mindset of communities that practice harmful social and gender norms which perpetuate gender inequality. Using CSE as a primary prevention strategy to end GBV could help adolescents to nurture positive gender-equitable attitudes and values, which are linked to reduced violence and healthier, equitable and non-violent relationships [38]. This early intervention could have a long-lasting impact across the lives of both men and women including adolescents. There is therefore a need to advocate for, and develop policies that advance gender equality and social protection, including the elimination of all forms of GBV and discrimination against adolescents.

7. Conclusion

Comprehensive Sexuality Education is pivotal to addressing the health and well-being of adolescents. Application of a personalised learning approach provides age-appropriate and progressive education on sexual and reproductive health and rights, relationships, sexuality, contraception, and prevention of ill health. Opportunity to address sexuality with a positive approach, emphasising values such as respect, inclusion, equality, empathy, responsibility and mutuality are also enhanced. The impact is greater if school-based programmes are complementary to sexual education by families, teachers and community youth centres for out of school adolescents. Additionally, providing youth-friendly services at health and associated institutions enhances CSE for improved adolescent sexuality outcomes.