Adolescent sexuality and pregnancy: some reflections from experience. (Youth).

The Casa de la Mujer de la Union in Montevideo, Uruguay, is a non-profit, non-governmental organization. Since November 1987, the Casa de la Mujer has provided a space for women's reflection, training and action, a place where participants can create a new identity as "women" who are subjects of social change. The Casa's goal is to carry out activities and programs that promote women's development at every stage of life, encouraging their participation and equal opportunity in all aspects of social life.

The Casa also carries out specific programs for adolescents and youths, which are the focus of this article:

   the Programa de Atencion Integral
   a la Salud de la Mujer Adolescente
   y Joven (Program for Comprehensive
   Health Care for Young and Adolescent
   Women);

   the Programa de Preparacion Integral
   para la Maternidad-Paternidad
   (Program for the Comprehensive Preparation
   for Maternity and Paternity);

   the Programa de Capacitacion
   Laboral para Jovenes (Work Training
   Program for Youths); and

   the Programa de Reinsercion Social
   y Laboral "En Transito" ("In Transit"
   Social and Work Reinsertion
   Program) for adolescents and youths
   in a situation of social exclusion.

These programs analyze the sexual and reproductive rights of young people and adolescents with an emphasis on prevention, counseling and support regarding sexuality and responsible parenthood, birth control, sexually transmitted diseases, HIV/ AIDS, sex education and counseling.

Some Indicators

According to the 1997 Population and Housing Census, Uruguay's adolescent population (10-19 years of age) consists of approximately 520,000 young people. Of this total, 51% are female and 49% male. Sixteen percent of this population neither works nor attends school. The majority (85%) live in urban or suburban areas. With regard to adolescent Uruguayans' health and sexual and reproductive rights:

* The country has no sex education programs in public schools, nor is there any teacher training for sex education.

* There are no adolescent/youth-oriented government programs or services dealing with sexual and/or reproductive health.

* Thirty percent of births in the Centro Hospitaliario Periera Rossell (Periera Rossell Hospital Center, CHPR)--the most important infant-maternal clinic in the country, which serves the poorer strata of the population--are to women between 12 and 19 years of age. In addition, 27% of these young mothers will have at least one more child before they turn 20.

* Seventeen percent of births nationwide are to women between 10 and 19 years of age.

* Fourteen and a half percent of adolescent women who give birth in CHPR have had no medical examinations during their pregnancy, and 19% had only three or fewer checkups, which is considered poor supervision of pregnancy.

* Women in general, especially the adolescent and youth population, are at high risk for the transmission of HIV/AIDS.

These indicators reveal some of the most relevant factors in this area and demand that we focus on achieving a greater social and political presence for Uruguayan youths and adolescents regarding sexual and reproductive rights.

Clearly, the lack of sex education and counseling places adolescents and youths permanently at risk of developing sexually transmitted diseases and other sexual problems at very early ages, especially girls and young women. These issues are intimately linked to initiating sexual activity at a young age, mostly due to pressure from their partners or peers. As a result, a significant percentage of these relationships end in unwanted pregnancy, complicating the young woman's social and personal development.

Difficulties related to functional literacy, communication problems and low self-esteem are also real obstacles for developing and achieving life goals. This situation is made worse by the lack of dialogue and integration with the adults in their own families or in the community. Adolescents and youths need spaces where they can voice their concerns. They must have specific places for education and prevention that allow them to have access to birth control in order to prevent unwanted or mistimed adolescent pregnancy. They must also receive adequate and understandable information for avoiding sexually transmitted diseases and HIV/AIDS.

In light of all these needs the Casa de la Mujer has designed programs specifically for the youth population and has become a reference center that ensures that the workshops are more than brief moments. On the contrary, the goal is for participants to learn to make independent decisions regarding their bodies and health, enabling them to question culturally assigned roles, know their rights and be protagonists of their own lives and emerge from social exclusion.

Adolescent Sexuality

It is important to note that while men have always begun their sexual lives early on due to the supposed male "need" to express themselves sexually at a young age, today women are having their first sexual experiences at an earlier age than previous generations. Society views it natural and even convenient for male adolescents to begin having sex early, but young women's rights to demand their sexuality is not recognized.

However, curiosity and the desire to know, feel and explore are characteristics of youth and are actively promoted by the media as well. Nonetheless, this thirst for knowledge is fed by scant and incorrect information which implies high risks in terms of young people's reproductive health.

A number of studies point out that young women's motives for initiating sexual activity are primarily related to emotional reasons--to the need to feel loved--and are less often motivated by desire or the search for sexual pleasure. This is not the same with young men who are curious, have sexual desires and look for pleasure.

Other studies have demonstrated the incidence of sexual coercion in young women's first experiences of sex; they are tricked, forced and threatened with violence. This means that, for most young women, sexual initiation can be a experience to which they "consent" but are also "forced."

Group Work

The Programa de Atencion Integral a la Salud de la Mujer Adolescente y Joven (Program for Comprehensive Health Care for Young and Adolescent Women) works with groups of pregnant adolescents and youths who show significant variations in their average profile.

Adolescents

This group includes girls between 15 and 20 years of age.

Most are single. The young women who have partners do not live with them yet, though they plan to do so. The family is generally made up of the mother and the girl's siblings; the father figure is often absent. Very often the girl's mother and/or her sisters have had their first child while single and under age 20. If the girl and her partner do live together, they plan to settle down in the house of a member of their immediate family since the pregnancy is experienced by both the pregnant woman and by her family as a "family" process.

These girls belong to poor socioeconomic sectors. They do not work and dropped out during the first years of high school.

While they state that they do know about contraceptives, they did not use any with their partners.

These young women accept the baby even though the pregnancy was unwanted, which contradicts the fact that they did not take any precautions.

The baby's father is not present. He is excluded from the mother-baby duo.

In terms of their life goals--their future plans with their child, the possibility of economic autonomy, continuing their studies, family planning, etc.--maternity appears as the central focus and overshadows almost all other plans. In cases where they had studied or worked before the pregnancy, the girls voluntarily abandon these activities in order to "protect the child they carry inside."

Youths

This group includes young women between 21 and 29 years of age (average age, 25).

The vast majority have a stable partner; many of them are legally married, living together before the pregnancy, independent from their families of origin.

These young women are from a higher socio-economic level than the adolescents. They generally have a high school or university education or are still studying. Almost all of these women work or study. They continue to do so during their pregnancy and declare their decision to keep working or studying after giving birth.

Some young women in this group did not plan their pregnancy but still accept it, as does their partner. (Most of them did not live with their partners before, but began to do so after the pregnancy.) Other young women planned the pregnancy; some have lost a previous pregnancy; and finally, a few are expecting their second child and state that they had had problems with their previous pregnancy because they were not well prepared.

The partners of these women have an important place in the pregnancy-birth process, usually active participation (such as attending educational workshops and being with the women during the birth).

We have seen that the adolescents and youths who prepare for their pregnancy at the Casa de la Mujer do not always escape the basic problems of most Uruguayan adolescents. For example:

* They do not know their own anatomy and physiology. This often becomes evident when they cannot properly identify their own physical changes or the organs involved in pregnancy and birth.

* They feel ashamed about feeling, touching or showing their body. They feel uncomfortable doing the muscular exercises of the perineum (Kegel exercises).

* They are not used to touching or exploring their bodies. Therefore, they have difficulty undressing in order to massage their breasts, their belly or to listen to the fetus's heart beat.

* The topic of childhood masturbation comes up often, revealing the prejudices, taboos and anxiety surrounding the idea of exploring the pleasure in their own bodies.

The transmission of gender roles to the baby, including those related to sexuality, are also quite significant: Men are "freer" "less controlled" "do not get pregnant." The need to change these roles is never proposed; that is, the women do not think that if they have a girl, they can educate her with different values. The vast majority would prefer to have a son.

Sexuality and Pregnancy

Although both groups of young people show different characteristics in terms of how sexuality is dealt with during pregnancy, we also find some similarities.

In terms of sexual relations, we can see clearly the dissociation of woman-object of desire, on one hand, and mother-saint on the other. Both partners have difficulty in integrating maternity and sexuality. This idea of maternity and sex as opposites stems from the Judeo-Christian culture that separates maternity (pure and immaculate) from sexuality, which is experienced consciously or unconsciously as dirty and sinful.

It is revealing that, in both groups (adolescents and youths) the young women feel unattractive to their partner now that they are pregnant. They say they are "uglier," "fat" and have "little sex." They also stated that their partner "doesn't want anything to do with me," "if I don't start it, nothing will happen, and when I do, not much happens either," "he does it all very fast in order to finish right away." The man seems to fear hurting the baby or having a negative influence on the pregnancy: "He's afraid that something will happen to the baby," or that he might "touch the baby with his penis." These feelings are re-enforced by eventual medical restrictions during the first months of the pregnancy due to the risk of miscarriage. In other cases the man openly declares, "Now I see you as a mother." The fantasy that sexual relations have changed "for good" also appears because, after the baby is born: "It's going to be worse," "I'm afraid that he won't want me anymore," that he "won't see me as a woman now that I am a mother."

In general, sex is associated with vaginal penetration, and all relations must culminate in intercourse. Many women also say that there is less sex play than before the pregnancy. This is clearly visible in adolescents who are unable to identify other forms of pleasure or communication.

In some cases, we find that the young women experience an increase in sexual desire, especially in the youngest group who claim to be "more aroused." They are the ones who "come on" to their partner, yet they feel shame and guilt. Nonetheless, we could also observe that sexual interest in adolescents often decreases in both partners: the women withdraw into themselves as they shift their interests towards the pregnancy as a priority, and the men distance themselves due to their fear of hurting the baby.

As we have already stated, the young women's relationship with their own bodies is often expressed through shame. They are embarrassed to feel, touch or show their bodies. From a more general perspective, we can see how gender roles are communicated to the baby: men are "freer," "less controlled," "do not get pregnant," "don't have to take care of a baby," etc. These social roles are not questioned, nor do the women consider conveying different values to their child.

Maternity is viewed as an inherent aspect of a woman's self-realization. None of the young women propose that a woman can choose not to be a mother. Even in the groups of older women who are continuing to strive for their life goals parallel to motherhood--work, professional careers, studies--maternity is still perceived as a constitutive factor of gender.

Other Spaces for Action-Reflection

The Casa de la Mujer de la Union also has a Programa de Preparacion Integral para la Maternidad-Paternidad (Comprehensive Preparation Program for Maternity and Paternity). This program aims to prepare pregnant women and their partners during the pregnancy so that they may enjoy it as a natural and enriching event. They receive complete information about the process to clear up their doubts, relieve their fears and include them as protagonists of the process.

On the other hand, the Programa de Capacitacion Laboral para Jovenes (Work Training Program for Youths) and the Programa de Reinsercion Social y Laboral "En Transito" ("In Transit" Social and Work Reinsertion Program) for socially excluded adolescents and youths also include workshops for youths of both sexes (between 13 and 24 years of age) on their rights--including sexual and reproductive rights--how to relate among themselves and how to prevent risks to their health.

We have seen that this population is quite ignorant about the body and its functions. Most had their first sexual encounter at a very young age due to pressure from their peers or their partners. In very few cases were these early sexual relations satisfactory. In general, they know about contraceptive methods but not how to avoid pregnancy.

We also observe a high percentage of cervical infections (Human Papilloma Virus, HPV) in the group of young women who come to the Casa de la Mujer for their preventive exams. They often express doubts about sexual relations, saying they have a lack of sexual desire or suffer from dispareunia (pain during intercourse) or other problems. Most have not experienced orgasms because their sexual relations are no more than a few brief caresses followed by penetration. They do not know any other way of having sex. As a result, they often end up rejecting their partner, or accepting sex as one more "job" they must fulfill.

Twenty-five percent of these young women are already mothers and 8% of young men are fathers. Therefore, we consider it fundamental to work with both young women and men about the causes of pregnancy during adolescence, starting from their perspective.

All the groups have noted the following factors:

* lack of or insufficient information;

* irresponsibility, lack of awareness or immaturity;

* early sexual relations are fashionable;

* sexual abuse;

* the initiation of sexual relations at increasingly earlier ages;

* lack of communication within the family: they are afraid to ask or are not given answers;

* permissive and/or authoritarian parents;

* lack of money to buy birth control;

* lack or places to go for information;

* lack of maturity for making decisions;

* not using birth control; and

* the idealization of motherhood.

The young people who have participated in our programs are very spontaneous when relating their experiences related to sexuality and reproduction.

"I wanted to die," said one young woman who became pregnant at 15, "[My first thoughts were] this can't be happening to me. How will I tell my parents? I was sick for days. My boyfriend took it really badly. He thought I had done it on purpose."

"I ended up alone; I never saw him again. Luckily, I have my family," said one young woman who was pregnant at 16. "No one ever told us we could end up pregnant. Of course, we were very young."

Another topic we address is the difficulties that adolescents face when they become pregnant at such an early age.

Difficulties for the young women include:

* discrimination by their friends, in school, in the neighborhood;

* not being prepared to take care of a child;

* limited possibilities for achieving their life plans;

* lack of family support;

* a drastic shift in life stages: they must mature overnight;

* difficult to continue studying, to find work or even to go out and have fun;

* a lot of responsibility but a lack of experience; and

* economic dependence.

Some of these women's impressions:

"I had to leave school, but I could not get a job since everyone required a high school diploma. That is why I am taking this course to get a job."

"I had to leave school. I could not handle how the other students laughed at me."

"Just now I am trying to do something. It was hard for me to start again."

When they accept their responsibility, difficulties for the men include:

* loss of liberty, having to provide economically for a family;

* little experience, lack of preparation;

* a lot of responsibility at a young age; and

* they must abandon their studies and get a job.

Some impressions of these young men:

"I felt very scared. The first thing I said was `It's not mine.'"

"I felt panic. We didn't want a child; we were only having fun."

"No more dancing, or we can only go sometimes. That was difficult for me. I like to go out at night and get together with my friends."

When we asked these men and women if they knew they could get pregnant, they said "Yes." But they thought, "It won't happen to me." They all knew about different methods of contraception but either did not use any or did so occasionally. They did not know why. They also did not know about exams to prevent female genital cancer: "That is for older women," they said.

Carried out over the last few years with mixed groups of adolescents and youths, this study shows us that young people begin their sexual lives with almost no knowledge of their body or sexual development. They do not know that sexual pleasure is part of the experience of each individual. They believe that there is an "ideal form" of sexual expression, yet they still must learn through experience that sexual expressions vary as much as people and their tastes.

Sexual repression is one of the main reasons why young people have difficulty in feeling sexual pleasure. Even though they are exercising their right to have sexual relations, they are doing so with guilt and shame.

Bibliography

Lopez, A., and S. Rostagnol (1999). Las Mujeres y el Estado Uruguayo. Monitoreo de Politicas Publicas Capitulo Salud Reproductiva. Uruguay: Comision Nacional de los Seguimientos de los Compromisos de Beijing.

Lopez, Alejandra (1999). Derechos Sexuales y Reproductivos de las y los Adolescentes. Uruguay.

Londono, Maria Ladi (1994). Etica de la ilegalidad. Cali: Iseder, Feriva.

Deschamps, Jean Pierre (1979). Embarazo y maternidad en la adolescencia. Barcelona: Ed. Herder.

Lutz, Elvira (1992). La adolescente y su derecho al ejercicio de la sexualidad. Uruguay.

Comfort, Alex (1980). El adolescente. Sexualidad, vida y crecimiento. Spain: Ed. Blume.

This article describes the work carried out in the Health Program of the Casa de la Mujer de la Union in Montevideo, Uruguay. Midwife Gilda Vera is cofounder and coordinator of the organization. Social psychologist Ana Travieso and psychologist Beti Jaureguizar work in the Casa's programs, preparing young women and men for childbirth and parenting.