Exposure to risk often longer now.

As girls begin to initiate sexual activity earlier and marry later in many countries, they are exposed longer than ever to the risk of unplanned pregnancy and sexually transmitted infections (STIs). (1) Given the public health consequences of this increasing vulnerability, many experts say reproductive health programs should make adolescents' needs a priority.

Data on 10- to 19-year-olds in developing countries are not reliable enough to draw firm conclusions about trends in their sexual behavior before marriage. (2) But Demographic and Health Survey results show an increasing gap between age at first sexual intercourse and age at first marriage in 32 of 37 countries surveyed in every region of the developing world, suggesting that premarital sex is rising throughout sub-Saharan Africa and in most countries of other regions. (3) In the United States, the gap between sexual initiation and marriage widened by almost 30 percent during the 1980s. (4) Women in the United States now typically begin sexual activity about seven years before marriage and are sexually active for almost one quarter of their reproductive lives before giving birth. (5)

Beginning sex at earlier ages increases the risk of STIs for young women and men because the longer a person is sexually active before marriage, the more partners he or she is likely to have. (6) Marrying later can open educational and vocational opportunities to young women, (7) but later marriage combined with increasing premarital sex among adolescents puts them at greater risk of unplanned pregnancies, unsafe abortions, and STIs, including HIV. (8)

Sexually active adolescents' risk of pregnancy and STIs is already high. They are less likely than adults to use condoms and other contraceptives and more likely to experience contraceptive failures. (9) (They are also more likely to resort to unsafe abortion if they decide to terminate unplanned pregnancies. (10)) Adolescent girls are at greater risk for STIs than older women because of specific biological characteristics that make them more susceptible to such infections and because they are less likely to be able to refuse unwanted or coercive sex or to negotiate condom use. (11)

SERVING ADOLESCENTS WITH DIFFERING NEEDS

Most people worldwide have their first sexual experiences--which can have lifelong effects on their sexual and reproductive health--before reaching age 20. (12) Dr. Malcolm Potts, FHI president emeritus and Bixby Professor at the University of California, Berkeley, USA, and his colleagues write that the earliest stages of men's and women's reproductive lives are so important for public health that countries with scarce medical resources should devote most of those resources to protecting young people's sexual and reproductive health. They propose that public reproductive health programs focus on providing education, counseling, and other services to adolescents and young adults at two distinct stages of their reproductive lives: when they are not yet sexually active, and when they are sexually active but do not yet wish to have children. Meanwhile, social marketing programs and private providers would be expected to meet the needs of most women at two other stages of their reproductive lives: when they plan to have a child or more children, and while they are fertile but do not want more children. (13)

Just as adults' priorities for contraception and STI protection change over the course of their reproductive lives, young people's reproductive health needs differ as they move through adolescence. Ten-year-olds need information about the changes they will face with the onset of puberty, while older adolescents may need protection against unplanned pregnancy and STIs.

Recognizing that adolescents are not a homogeneous group, Jane Hughes of the New-York based Population Council and Dr. Anne McCauley of the Washington-based International Center for Research on Women have suggested tailoring programs to meet the needs of young people with three different kinds of experiences: those who are not yet sexually active, those who are sexually active and have experienced no unhealthy consequences of their sexual activity, and those whose sexual experiences have resulted in unhealthy consequences, such as abortion complications or STIs. Noting that most providers primarily serve young people in the latter group, Hughes and Dr. McCauley point to the need to put more emphasis on reproductive health education, counseling, and services for adolescents in the first two groups. (14) This approach is supported by research that shows that family life education and other programs to prevent teenage pregnancy and STIs are most effective when they reach young people before they are sexually active. (15)

REFERENCES

(1.) Mensch B, Bruce J, Greene M. The Uncharted Passage: Girls' Adolescence in the Developing World. New York: Population Council, 1998.

(2.) Mensch.

(3.) Blanc AK, Way AA. Sexual behavior and contraceptive knowledge and use among adolescents in developing countries. Stud Fam Plann 1998;29(2):106-16.

(4.) Forrest JD, Cates W. Stages of women's reproductive life: impact on contraceptive choice. In Hazeltine FP, LaGuardia K, eds. Opportunities in Contraception: Research and Development. Washington: American Association for the Advancement of Science, 1993.

(5.) Forrest JD. Timing of reproductive life stages. Obstet Gynecol 1993;82(1):105-11.

(6.) Alan Guttmacher Institute. Into a New World: Young Women's Sexual and Reproductive Lives. New York: Alan Guttmacher Institute, 1998.

(7.) Singh S. Adolescent childbearing in developing countries: a global review. Stud Fam Plann 1998;29(2):117-36.

(8.) Population Reference Bureau. The World's Youth 2000. Washington: Population Reference Bureau, 2000.

(9.) Blanc.

(10.) Ipas. Children, Youth and Unsafe Abortion. Chapel Hill, NC: Ipas, 2001. Available: http://www.ipas.org/arch/pdf/FACTunsafeab%20.pdf.

(11.) Alan Guttmacher Institute.

(12.) Mensch.

(13.) Potts M, Rooks J, Holt BY. How to improve family planning and save lives using a stage-of-life approach. Int Fam Plann Perspect 1998;24(4):195-97.

(14.) Hughes J, McCauley AP. Improving the fit: adolescents' needs and future programs for sexual and reproductive health in developing countries. Stud Fam Plann 1998;29(2):233-45.

(15.) Frost JJ, Forrest JD. Understanding the impact of effective teenage pregnancy prevention programs. Fam Plann Perspect 1995;27(5):188-95; Grunseit A, Kippax S, Aggleton P, et al. Sexuality education and young people's sexual behavior: a review of studies. J Adol Res 1997;12(4):421-53; Kirby D. School-based programs to reduce sexual risk-taking behaviors. J School Health 1992;62(7):280-87; Stanton B, Li X, Kahihuata J. Increased protected sex and abstinence among Namibian youth following a HIV risk-reduction intervention: a randomized, longitudinal study. AIDS 1998;12(18):2473-80.