Promoting adolescent sexual and reproductive health from a democratic perspective. (Youth).

Each year about 15 million adolescents aged 15-19 years give birth, as many as 4 million obtain an abortion, and up to 100 million become infected with a curable sexually transmitted disease. (1) In addition, two million adolescents are forced into prostitution. (2)

Of the 6 billion people living on this planet, one billion are adolescents: 85% of these young people live in developing countries, and a significant number are already sexually active.

In Latin America, adolescents' sexual and reproductive health is now being perceived as an important concern. Only a few decades ago, it was considered natural and even desirable for young women to become pregnant before age 20, as long as they were married. Young men were expected to become sexually active as they entered adolescence, regardless of the possible risks. It did not even matter with whom they were having sex, as long as it was a woman.

Today, there is general agreement, among those responsible for the public policy and the region's social plans and programs, that--due to reasons of health, economics and psychological maturity--it is preferable to have children after age 20, regardless of one's marital status. As a result, any pregnancy before age 20 is considered an early pregnancy.

The way in which issues related to early pregnancy and the increased rates of adolescent pregnancy in several countries of our region and specifically in Venezuela are raised is quite revealing. Generally, early pregnancy is treated almost exclusively as the girls' problem. But there are few studies and little discussion about the other, necessary protagonist in pregnancy: men.

Indeed, we cannot even say boys, although we are certain that members of the male sex are responsible. Who are they? How old are they? Under what circumstances were they involved in the pregnancy? A chauvinistic perspective of this phenomenon continues to prevail. At heart, the problem is reduced to the belief that young women should resist men's seduction and not give in to sexual relations.

Secondly, it is amazing that other problems affecting the adolescent population of our countries to a similar degree--as revealed by alarming figures on abortion, sexually transmitted diseases and sexual abuse--are topics of secondary importance in relation to early pregnancy. I believe that this is not by chance. In general, it is difficult for us to accept that many young people have active sex lives, even outside of marriage. In particular, we refuse to see this reality when talking about girls because it still seems normal and even desirable for boys to start having sex at a young age. And no matter how serious abortion, STDs or sexual abuse are, they can always be hidden.

The high rates of adolescent pregnancies clearly reveal facts that we individually and collectively deny. We must treat this problem with haste because its root continues to be moral prejudice.

I also feel we should reexamine the objective of preventing early pregnancy or adolescent pregnancy, as is so often proposed in public policy and by NGOs. Let's reflect upon this a little: rather than making decisions for adolescent women and men--even when they seem to be the best decisions to us--we should be giving young people the opportunity to make their own decisions. If we believe that if adolescents--just as anyone else in the population--have the preparation, information and services that they need, then these young people (just like adults) naturally will tend to make decisions that will improve their quality of life. Therefore, the objective should not be the prevention of adolescent pregnancy but rather the promotion of adolescent sexual and reproductive health. This is what women have struggled for so long: the right to choose. If we are merely trying to prevent adolescent pregnancies, we might as well invest our efforts in the development of a vaccine.

It may be hard to accept that adolescent women and men have sexual and reproductive rights. Indeed, it has taken two centuries for young people to be accepted as citizens and subjects, not objects, of law. It will be even more difficult for them to be accepted as sexual beings. Those of us who believe in adolescents' sexual and reproductive rights face the challenge of asserting that young people have the right to:

* decide freely and responsibly the number and spacing of their children and to have the information and the means to do so;

* obtain sexual and reproductive health as an integral part of general health throughout the life cycle;

* make decisions free from discrimination, coercion or violence;

* receive honest, scientific and timely education for the full and responsible exercise of sexuality; and

* enjoy equality between women and men so that they may be able to make responsible and conscientious decisions that guarantee their quality of life and the equitable distribution of the commitments derived from the exercise of gender roles, sexuality and reproduction, free from discrimination.

Ideological resistance to this issue is strong and quite understandable. The belief that adults know what is best for young people and that we can use any means necessary--including physical violence--if it is for their own good is deeply rooted in our subconscious. This same conviction leads political leaders to take control of countries by force, for the good of the people. The idea that someone else needs for us to organize their life because they are too young or too ignorant gives us a great feeling of power.

Some readers--especially mothers, fathers or even teachers--may be thinking, you mean we should let young people do what ever they want with their sexuality? Undeniably, as adults we have the obligation to ensure the well-being of our children, but we should also accept that this well-being includes the ability to incorporate ethical and moral criteria in their decisions, especially those related to the exercise of their sexuality.

In my opinion, the difference lies in how we expect the young subject to structure these moral and ethical criteria. The research of Piaget and Kohlberg shows how children develop from moral heteronomy to moral autonomy. (3) In other words, control exercised by others becomes self-control. For example, deciding not to throw trash on the floor because the teacher will punish me is quite different from deciding not to do it because the school belongs to everyone and needs to be kept clean. In the first case, the motivation of the behavior is fear, and the objective is behavioral and emotional adaptation to moral standards; in the second case, the motivation is the collective good as a form of personal realization.

This issue of moral heteronomy and moral autonomy leads us to two important observations. First, sexuality appears to be the only area of life in which parents and teachers agree that the less informed or trained people are, the better their chances of making the right decisions. In all other aspects of life, we are sure that the sooner and better prepared we are, the greater our chances of being successful. We would never think of waiting until our child had decided to study engineering to teach her how to count.

Despite this peculiar attitude, it seems our adolescents have been making decisions about their sexuality for quite some time, whether we like it or not. In Venezuela, for example, 60% of all young people become sexually active before age 20. (4) Society's refusal to accept young women's and men's right to adequate reproductive health information and services has only increased their risk. In our country, only 20% of all sexually-active young people of either sex use any contraceptive method. (5)

At the beginning of this article, I acknowledged that the recognition of the situation of adolescent women's and men's sexual and reproductive health as a public health concern is in itself a step forward. I also stressed the need to look beyond the problem of adolescent pregnancy, which is only one important aspect of young people's sexual and reproductive health, and I pointed out some of the chauvinistic biases that persist in the analysis of the problem of early pregnancy.

I would also like to address the reigning consensus regarding young people's sexuality that identifies education as the best strategy for confronting these concerns. When we try to come to an agreement on what sort of education, and where, how and when to carry it out, we come up against a wide range of diverse and often contradictory criteria. Proposals for sex education, including contents, strategies, materials and organizational structure, are not free from the influence of society's dominant ideologies and power relations. As result, educational proposals are not neutral, technical issues. According to Aller, sex education can be classified according to the following schools or tendencies: (6)

* Those who consider sexuality to be a sinful aspect of life, only redeemed by its reproductive function within marriage, propose sex education whose fundamental principle is prohibition, the "don't" principle: Don't ask, don't do it, don't enjoy it, don't discover it. This school of thought forms part of the moralist tendency. Its goal is the preservation and defense of dogmatically established values, such as virginity, chastity and "purity." The educational strategies and methodological proposals are: the imposition of models of behavior that they themselves have established as sane and healthy, with no possibility of discussion or questioning, and the exaggeration of the risks of sexual relations in order to terrorize young people. This tendency is sponsored by some sectors of the Catholic church and the so-called pro-life groups.

* The biological tendency includes those who address sex as an exclusively biological component, fundamentally linked to the reproductive process. They believe that the differences between women and men, be they psychological or social, are determine by biological factors alone. They define the sex organs as mere reproductive organs that condition all expressions of sexuality in the different aspects of individual and social life. This conception of sex education is what we generally find in formal education.

* The mechanical perspective reduces sexual activity and sexuality education to a series of mechanisms and techniques that supposedly lead to a full and enjoyable experience of sexuality. Some trends in sexology and some writers of manuals or "cookbooks" for enjoying a "healthy" sex life adopt this focus.

* The pathological tendency focuses on the problematic aspects of sexuality, including health concerns, psychological problems and social ills. This perspective views these pathological aspects as inherent to sexuality and totally independent from society. This view is also strongly linked to the moralist perspective as they both they cast aspersions on sexual pleasure.

* The concept of consciousness-raising through dialogue proposes using critical analysis to raise levels of awareness in order to contribute to a full, enjoyable and responsible exercise of sexuality. This perspective is based on the belief that sexuality is more than genital contact and that it has repercussions in many different areas of human life, from the most intimate and private sphere to the most public and social.

Those of us who participated in formulating the concept of sexual and reproductive health in the International Conference on Population and Development in Cairo belong to this final classification. We strive to achieve the rights established in the ICPD Programme of Action.

AVESA, the Asociacion Venezolana para una Educacion Sexual Alternativa (Venezuelan Association for Alternative Sex Education) has been developing programs to promote adolescent sexual and reproductive health from a perspective of reflection and critical awareness in order to encourage the healthy, enjoyable and responsible exercise of sexuality, based on citizenship, democracy and adolescent women's and men's rights. Our work has proved this to be the most effective and respectful way of transforming young people's difficult realities and assuring their right to enjoy: "... a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters related to the reproductive system and to its functions and processes."

Being Autonomous

I exercise my ability to make decisions--to be autonomous--when I agree to have sexual relations or I when decide not to become sexually active yet.

I know that young women are becoming sexually active at an earlier age, but each one of us has to examine our inner thoughts and feelings and ask ourselves:

- Do I really want to do this? Or am I confusing love and desire?

- Are my friends or my boyfriend putting pressure on me?

- Do I know how to protect myself from unwanted pregnancy?

- Is it too early for me?

- Do I want to satisfy my own desires, or am I looking for acceptance?

- Do I want to sleep with him in order to keep him?

- Am I doing it because I'm afraid?

- Or because I want to rebel?

In any case, I should always think first about what I want and not confuse my desire with worrying about satisfying someone else's desire or any other social pressures.

Deciding to become sexually active demands autonomy: I, myself, decide, without pressure from other people; self-awareness: I know myself and what to do for myself; and self-esteem: I know that I count and that I do not have to give in to pressure from others.

Source: "Hablemos entre nosotras. Cartilla de Educacion Sexual NO Sexista para mujeres adolescentes." Fundacion Dialogo Mujer, Colombia, 1994.

Notes

(1.) "Adolescent Reproductive Health: Making a Difference" (1998). In Out Look, vol. 16, no. 3., December.

(2.) AVESA (1998). Sexualidad Adolescente en Cifras. Caracas: AVESA.

(3.) As cited in Rios Cabrera, Pablo (1999). La Aventura de Aprender. Cognitus: C.A. Caracas, p. 6

(4.) AVESA (1998). Sexualidad Adolescente en Cifras. Caracas: AVESA

(5.) Idem.

(6.) Aller, Luis M. (1992). Pedagogia de la Sexualidad Humana. Conference proceedings from the Congreso Iberoamericano de Educacion Sexual, Jorge Paniagua, ed., Medellin, pp. 55-63.

The author is the General Coordinator of the Asociacion Venezolana para una Educacion Sexual Alternativa (AVESA, Venezuelan Association for Alternative Sex Education).