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Beyond bonus or bomb: upholding the sexual and reproductive health of young people.

Abstract: Described as a blessing or a curse, a bonus or a bomb, the youthful population boom in the global South is thought to be the catalyst of present and future social change on a massive scale. These binary understandings of youth are popular among proponents of development programs aimed at young people, including for family planning. But dualistic, numbers-based theories oversimplify a much more complex picture. They narrow our perceptions of young populations and, when lacking more detailed understanding based in youth experience, have the potential to constrict sexual and reproductive health and rights. Instead, youth-friendly, inclusive sexual and reproductive health policy should build from young peoples' visions and diverse realities.

Keywords: young people, sexual and reproductive health and rights, youth bulge, demographic dividend

Resume

Decrite comme une benediction ou une malediction, un cadeau ou une bombe, l'explosion de la population jeune dans les pays du Sud est consideree comme le catalyseur du changement social present et futur sur une echelle massive. Ces conceptions binaires de la jeunesse sont populaires parmi les promoteurs de programmes de developpement destines aux jeunes, notamment la planification familiale. Mais les theories dualistes, fondees sur des chiffres, simplifient excessivement un tableau beaucoup plus complexe. Elles reduisent nos interpretations des populations jeunes et, lorsqu'il leur manque une comprehension plus detaillee fondee sur l'experience des jeunes, elles ont le potentiel d'inhiber la sante et les droits sexuels et genesiques. Au contraire, une politique de sante sexuelle et genesique integratrice et axee sur les jeunes devrait etre fondee sur les idees des jeunes et leurs realites diverses.

Resumen

Descrito como una bendicion o una maldicion, una ventaja o una bomba, el boom de la poblacion juvenil en el Sur mundial es considerado como catalizador de actuales y futuros cambios sociales en gran escala. Esta vision dicotoma de la juventud es popular entre defensores de programas de desarrollo dirigidos a personas jovenes, incluidos los programas de planificacion familiar. Pero las teorias dualistas, basadas en cifras, simplifican excesivamente una situacion mucho mas compleja. Limitan nuestras percepciones de las poblaciones de jovenes y, cuando carecen de un mejor entendimiento basado en la experiencia juvenil, tienen el potencial de restringir la salud y los derechos sexuales y reproductivos. En cambio, las politicas inclusivas y amigables a la juventud referentes a la salud sexual y reproductiva deben basarse en las visiones y diversas realidades de las personas jovenes.

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The youthful population boom in the global South is thought to be the catalyst of present and future social change on a massive scale. For many, the size of the youth population alone makes it a formidable force in global politics, economics, and international development. Held against a background of supposedly peaceful population ageing and potential economic stagnation in the global North, the youthful population is presented as both the key to positive future growth for global South nations and equally, as potentially explosive.

Political scientist Henrik Urdal describes large youth populations as a "blessing or a curse". (1) Former World Bank Chief Economist Justin Yifu Lin asks if they are a "demographic dividend or demographic bomb in developing countries". (2) Journalist Winsley Masese questions whether Kenya's youth are a "demographic time bomb or blessing". (3) These comments are illustrative of an international, wider conversation among many development policy-makers, scholars, and media commentators about the potential of the youthful population boom. The dualistic terms they use reflect two popular theories about young people. The "demographic dividend" concept suggests that large youth populations provide a "window of opportunity" for economic growth and development, while the "youth bulge" theory predicts that they are prone to violence and unrest. The two theories are gendered. The demographic dividend theory emphasizes the role of empowered young women, while the youth bulge theory characterizes young men as prone to violence.

As above, the theories are often used as mutually reinforcing arguments. They function like two sides of the same coin. For many analysts, the side of the coin that faces up--bonus or bomb--depends on the role of family planning in successfully lowering birth rates, along with other interventions to support youth achievement, such as education, employment, and civic participation. A demographic dividend can degenerate into a violent youth bulge and conversely, a youth bulge can be redeemed as an economic bonus given the right opening. USAID Deputy Administrator Donald Steinberg's comment on a Rio+20 plenary is an example of this thinking:

"The youth bulge are the young people we didn't reach, the demographic dividend will be the ones we reached." (4)

This binary framework for understanding large youthful populations is found in development policy. For instance, the online forum for civil society input on the post-2015 development agenda includes a discussion on "high population growth, including the issue of the youth bulge and the demographic window of opportunity." As part of this theme one of the forum moderators, demographer John Bongaarts of the Population Council, makes the case for family planning for young people, along with socio-economic development and education for girls to support fertility decline. (5) As with this post-2015 consultation, the youth bulge and demographic dividend concepts are often used to inform family planning policy. However, use of one theory does not automatically evoke the other, and they are often used separately. For instance, the IPPF briefing paper Family Planning and the Demographic Dividend advocates government- and donor-facilitated fertility decline in places like Thailand through provision of voluntary family planning, and improved child survival and women's empowerment strategies. The paper does not refer to the youth bulge theory or to the potential of youth violence due to high numbers. (6)

I agree that providing young people with access to family planning, in the context of comprehensive and quality sexual and reproductive health, is an important policy priority. I also agree that demographic information about youthful population size is one of many essential inputs to inform appropriate policy. At the same time, I argue that numbers-driven theories, like the demographic dividend and youth bulge theories, oversimplify a much more complex picture and provide problematic rationales for family planning. They narrow our perceptions of young populations and, when lacking more detailed understanding based in youth experience, have the potential to constrict sexual and reproductive health policy and impact the type and quality of family planning available. This is true both generally, and for policy aimed specifically at young people. Creative policymaking and thinking are required to provide sexual and reproductive health policy that is responsive to the full spectrum of needs of the global population, build on the gains of ICPD, and uphold rights. Sexual and reproductive health provision should be available to people of all ages who require it, including adolescents and young people.

In this paper, I analyse the popular "youth bulge" and "demographic dividend" theories and look at how international agencies and governments have adopted them as the basis for policy addressing young people. Despite their popularity, I argue that the theories mischaracterize young people and offer limited insight into their complex identities and realities. Because of this these theories are likely to result in policies and services that do not accurately respond to young peoples' needs. In particular, the theories argue for lowering birth rates as a cornerstone of family planning policy, advocacy and provision, as a way to address global problems. They overemphasize contraception as a technical solution to resolving larger economic and social issues. * Access to contraception is an essential part of sexual and reproductive health provision and an important aspect of women's empowerment. At the same time, any policy that instrumentalizes contraception as a means to achieve national and international goals has the potential to undermine rights.

I argue for inclusive and nuanced understandings of young people, generated largely by youth advocates and their allies, which promote a rights-based approach to sexual and reproductive health. Young advocates' quality work provides a starting point for youth-friendly policies and services that meaningfully include young people. Their visions for sexual and reproductive health services break down walls that have too long divided sexual and reproductive health from HIV services and provide models for inclusive service provision.

Young people: carrying the future?

Current demographic trends show both population growth and decline in different parts of the world. Global population growth rates have slowed significantly since the 1960s, and total fertility rates have fallen. Although family size is getting smaller, with an estimated global total fertility rate (TFR) of 2.53 children per woman, 33 countries in sub-Saharan Africa have a TFR over four. Nevertheless, fertility rates are declining in these countries as well, particularly in urban areas. In other countries, especially in East Asia and Eastern Europe, fertility rates have fallen well below the replacement level of roughly 2.1 children per woman so that population is declining. Between 2005-2010, the 75 countries with below-replacement fertility made up 48% of the world's population. (8)

Trends in fertility rates contribute to the global distribution of ageing and youthful populations.

Population ageing, when the number of older people in the population increases and the number of young decreases, is occurring throughout the world. It is most concentrated in the global North, e.g. Japan, Russia, and Italy, where the number of older people exceeds the number of those less than 15 years of age. The UN's World Population Prospects: the 2012 Revision, reports that by 2050 there will be close to double the number of older people (aged over 60) than children in developed countries. (8) The diminishing numbers of youth in the global North have contributed to concerns about how to keep ageing nations' economies robust, given the fall in numbers of working age adults, and also how to meet the health care and other needs of older populations. (9) At the same time, ageing in "shrinking Europe" has led to considerable anxiety about the changing face and race of nations as young people migrate to them in search of opportunity. Young migrants' potential to contribute to nations and communities with ageing populations are sometimes eclipsed by nationalist fears and racist prejudices. (10)

In contrast, children and young people are the majority of the population in parts of the global South, with 1.7 billion children under age 15 and 1.1 billion young people ages 15-24, (8) who make up the largest global cohort in history. The largest youthful populations proportionately are in countries that are the least developed, including Niger, Mali, Zambia and Somalia, (8) which also have the highest population growth rates. Fertility rates in these countries are still relatively high in relation to mortality rates (including child mortality), particularly in southern Africa. This creates "population momentum," where youth cohorts in their reproductive years contribute to population growth rates both in their countries and globally. The Revision estimates that the present world population of about 7.2 billion will reach 8.1 billion in 2025, 9.6 billion in 2050, and 10.9 billion by 2100. *a

In large part because of their potential fertility, young people in the global South are credited with determining the future--not only of population growth rates, but the collective future of the planet. For example, a 2013 UNFPA poster urges us to "Keep the promise of the ICPD alive by delivering on its unfinished agenda. The stakes have never been higher." Calling for increasing sexual and reproductive health access, it goes on to say that as 1.8 billion people enter their childbearing years, their reproductive decisions and access to services will decide: "Whether our population continues to grow rapidly, outstripping our ability to feed and care for all, or whether growth slows down and eventually stabilizes, depends on the choices they make--and the ones we help them carry out." (11)

UNFPA is a strong advocate for sexual and reproductive health and rights for young people, and the mixed messages in this poster do not reflect their larger strategy. This poster, however, does send mixed messages. On the one hand, it is supportive of young people's sexual and reproductive health needs, ([dagger]) and on the other it equates their fertility and reproductive decisions with potential resource scarcity, hunger and instability. This is a familiar positioning of women's fertility as the source of global problems which has been fruitfully critiqued by feminist thinkers in the international women's health movement. (7,13,14) It is an imprecise equation that misrepresents the complicated political and economic reasons for hunger and resource scarcity, and creates pressure to lower population growth rates as if that alone would address them.

The issues of large youthful populations, population growth and development, young people's needs and rights, and appropriate policy interventions are complex and important. Equally important are the ideas we use to understand young people and to shape policy.

Two sides of the same coin: the youth bulge and demographic dividend theories Youth bulge theory

Despite their compatibility, the youth bulge and demographic dividend theories have different origins and aims. The youth bulge theory was first developed as a US intelligence tool, intended to help military analysts identify international security issues caused by large populations of youth, particularly young men. (15) In contrast, the demographic dividend theory is an economic rationale to bolster investment in international family planning and economic labour market flexibility. (16)

Geographers Gary Fuller and Forrest Pitts define a youth bulge as when young people aged 15-19 and 20-24 make up 20% or more of a country's adult population. (17) *b In the 1990s, the US Central Intelligence Agency funded Fuller to develop the theory, which is considered to be the outcome of a cumulative body of scholarship on youth, political unrest, and state breakdown by scholars, including Flerbert Moller, (18) Jack A Goldstone, (19) and later, Richard Cincotta. (20) Political scientist Flenrik Urdal further developed the theory, and published policy-oriented papers with the World Bank and the UN's Population Division, as well as in academic journals. (21,22)

These scholars believe youth bulges increase unrest at a variety of levels and intensities in parts of Africa, the Middle East and parts of Asia and South America. They argue that youth bulges correlate with political crises, like revolutions; (19) riots, insurgency and coalitional aggression; (23) a significant increase in armed conflicts; (22) and revolutions leading to the installation of dictatorships. (24) Most of the theory's proponents agree that youth bulge violence is not inevitable, but is the combination of population stress and lack of employment, resources, and education for young people. As such, states can mitigate or harness the impact of bulges through providing increased educational and employment opportunities.

While some versions of the youth bulge theory are more nuanced and provide a rationale for supportive youth policy, in general the concept is problematic. It predicts youth-driven, population-based violence as the norm. Mitigation of youth violence is the exception, only in cases of strategic government intervention. Even if political and economic conditions lessen the threat of the youth bulge in the moment, the theory maintains that the potential for future violence is present as long as the population boom is young.

Men are the primary subjects of the youth bulge theory. For instance, Urdal states: "Generally, it has been observed that young males are the main protagonists of criminal as well as political violence." (1) Barker and Ricardo suggest that sweeping statements such as Urdal's do little towards identifying the minority of men who perpetrate violence, but instead, "create self-fulfilling prophecies and strip young men of their individuality and subjectivity, and fail to explore the plurality of young men's experiences". (25) However, the generalized assertion that young men are violent, especially in large numbers, spurs negative media images. Accompanied by a "youth heatmap of the world" and pictures of Yemeni young men shouting, for example, an article in the Guardian, a UK newspaper, discusses youth bulge violence. (26) Likewise, a Daily News and Analysis India article, "The dark side of the demographic dividend", warns of youth male violence and terrorism. (27) In these and similar articles, the youth bulge is personified in negative, racialized and gendered terms as an angry, young brown man from Africa, the Middle East, or parts of Asia or Latin America, often marked as a terrorist. This stereotype is an example of what anthropologist Nancy Scheper-Hughes calls "dangerous discourses" that overpredict individual acts of youth violence, even as they downplay the role of other forms of violence and structural inequalities that contribute to youth poverty and powerlessness. (28)

Because it promotes the idea that young men are a potential threat, even in instances where egregious stereotypes are not employed or endorsed, some have challenged the youth bulge theory as a rationale for youth-oriented policy and programming. USAID Deputy Administrator Donald Steinberg rejects the notion that members of the youth bulge are a "volatile, dangerous and purposeless group, ready to join the next warlord able to offer them a siren song of empowerment", and argues that we should instead consider young people as "individuals who are trying to find their way in life, who want to be full contributors to their families, their societies, and the world...." (29) Likewise a 2009 report prepared for the UK Department for International Development's Equity and Rights Team looks at the limits of the theory in framing youth policy and concludes:

"It is important that youth are not generally viewed as a security "threat". The majority of young people do not get involved in violence, and governments need to acknowledge the huge potential of youth to contribute to peacebuilding and development and promote policies of inclusion and development rather than containment." (30) Others use the idea of young men as a threat to promote an urgent rationale for increased youth-focused policies and services, including family planning. With their influential report, The Security Demographic: Population and Civil Conflict after the Cold War, Cincotta, Engelman and Anastasion seek to reach "military, diplomatic, and intelligence communities," as well as traditional service providers and international agencies in order to make a case for family planning based on "relationships between population dynamics and armed conflict". They argue that family planning is a key tool for averting present and future youth bulge violence. (20) Based on this assertion, in 2005 the US Council for Foreign Relations argued for continued US commitment to international family planning assistance because of the potential for youth bulge unrest in African countries such as Ethiopia and Niger. (31) Likewise, international relations scholar Jennifer Dabb Sciubba's The Future Faces of War recommends family planning as a strategic US military intervention to address demographic insecurity, alongside the empowerment of women. (32) To my knowledge, these troubling policy prescriptions have at least not yet resulted in direct programming.

More recently, the African Development Bank held a 2013 policy meeting on how to "capture the demographic dividend in Africa" which included a look at how family planning can reduce the impact of the youth bulge. At the meeting, demographer Jean-Pierre Guengant, Director of Research at the Institut de Recherche pour le Developpment, argued: "The biggest problem of the next 20 years, will be to fulfill the aspirations of this youth bulge." In order to provide them with education and health supports, "it is necessary to stabilize the number of births--preferably reduce fertility--through increased contraceptive methods". (33)

Like Guengant, many who use the "youth bulge" to argue for increased family planning employ the term to refer to a large youthful population, without explicitly evoking youth violence or suggesting military intervention. Instead, they argue that family planning and lowered birth rates are a necessary precursor to development. These arguments are more akin to the rationales for family planning to create a demographic dividend.

Demographic dividend theory

The demographic dividend theory is the flip side of the youth bulge theory. It is an economic rationale that suggests than when the number of working age adults in a population is larger than the number of dependent seniors and children, there is a "window of opportunity" wherein the adults' productivity and consumption levels can rise and the economy can benefit. (34) Cuaresma, Lutz and Sanderson see Bloom and Williamson's 1998 analysis of age structure and economic growth in Asia as the origin of the theory, and review other demographic dividend models. (35) Economists David Bloom and David Canning have further developed the theory, including in a 2003 report with Jaypee Sevila, published by the Rand Corporation, a US research group, (34) and a paper positing a positive correlation between reduced fertility, increased female labor force productivity and per capita income, written with peers. (36)

East Asia is often cited as an example of a region where demographic dividend activity directly contributed to economic growth. The success of the East Asian demographic dividend is attributed to population size and distribution, and also to government support services. These include health care, increased access to education, and economic policies that support open trade. (34) The East Asian example of demographic dividend achievement is often contrasted to sub-Saharan Africa, where demographers conjecture that slowed demographic transition and high fertility rates have stalled economic growth. (37) In response to these and similar analyses of African demographics and economic stagnation, pursuit of African demographic dividends and lower fertility rates has become a policy priority. For instance, at the 2013 high-level Ministerial meeting at the 3rd International Conference on Family Planning, discussion centered on how to use family planning to generate an African demographic dividend that would help African nations to enjoy the "accelerated economic growth that can result from a rapid decline in a country's fertility rate, coupled with smart investments in health, education and job creation". (38)

Scholars position youth-specific, government services as necessary to support, and benefit from, a demographic dividend. As with the youth bulge theory, most demographic dividend proponents emphasize that the impacts of large youthful populations are not automatic, but are dependent on appropriate national policies. For instance, Dramani and Ndiaye suggest that for Senegal to benefit from the country's youthful population, the government must introduce reforms that support improved worker productivity and increased job opportunities. (39)

Family planning is seen as the key government priority to reduce fertility and create the right age structure to achieve a dividend. Proponents of the theory assert that population policy is a key tool to achieving this age structure because it influences when a demographic transition will take place. *c Bloom, Canning and Sevilla, (34) as well as Guengant and May, (37) suggest that rapid fertility decline has the potential to be a catalyst of steeper economic growth.

Gender equality is also seen as a determinant of dividend success, and empowerment of women is a stated goal in many demographic dividend policy prescriptions. For instance, a 2013 IPPF briefing paper shows positive images of young women with the goal to "empower women to make autonomous decisions about family planning by tackling economic, social, cultural, political and geographic barriers" in order to achieve a demographic dividend. (6) In keeping with this focus on women and empowerment, the face of the demographic dividend, particularly in development literature, is of young women. Images like these are far more positive than those of the youth bulge's "angry young man". At the same time, such images are also open to criticism. Gender scholar Kalpana Wilson suggests that many images of women in development literature problematically depict women as the objects of development. (40) Wilson's comments suggest that images of young women as the face of the demographic dividend occupy a highly politicized terrain and can potentially project multiple meanings, even as they are intended as positive.

Notably, while there is a substantial body of work on the demographic dividend, there are far fewer critiques, particularly from feminist perspectives. This is a gap in the literature. Some critiques build on the concept, even as they offer a different read on it. For instance, Cuaresma, Lutz and Sanderson argue that the gains from the demographic dividend should be attributed not to demographics but to increased educational attainment. (35) Mishra suggests that infrastructure investments are the key to dividend success in India. (41)

Critical inquiry into the theory and its policy impacts could interrogate a number of issues. First, the theory's emphasis on reducing fertility for economic gain is a problematic policy prescription, in that it could lead to quantitative targets for family planning and lead to limited contraceptive options, and undermine broader sexual and reproductive health and rights goals. This is not an automatic outcome of all policy based in the demographic dividend theory, especially given that there are versions of the theory that de-emphasize the role of fertility reduction. However, diminishment of family planning options is a possible outcome when national population reduction goals determine policy. This is particularly true when policy and programs do not reflect the ICPD Programme of Action.

For example, a troubling family planning prescription emerged at a national conference on the potential and risks of young people in Pakistan: a demographer presenting at the meeting recommended that "fertility must continue to decline" for economic growth, public health, and to lessen population stress on resources. In his view, Pakistan should "eliminate" pregnancies in women under the age of 18 and over the age of 34, while reducing fertility in women between the ages of 20 and 34. (42) Such a prescription would sharply determine, if not also curtail, women's sexual and reproductive freedom and access to services. These could include access to a range of contraceptive options and to safe, legal abortion, as well as antenatal care for those with wanted pregnancies.

The mindset that says family planning is the key to development has contributed to the current push for use of hormonal and long-acting contraceptives in sub-Saharan Africa and South Asia by international agencies and donors. For instance, at the 2012 London Summit on Family Planning, the Bill & Melinda Gates Foundation, along with partners USAID, UK Department for International Development, UNFPA, pharmaceutical company Pfizer, and the US non-profit PATH rolled out a new collaboration which aims to "reach" three million women in sub-Saharan Africa and South Asia in three years with 12 million doses of Depo-Provera. (43) This promotion is problematic when long-term methods are to be disseminated without adequate attention to health and safety concerns, as well as access to regular health care, a range of other contraceptive options and safe abortion. (44) It could also undermine the positive work being done by these agencies to advance a broader sexual and reproductive health and rights agenda.

In sum, the demographic dividend and youth bulge theories both provide problematic rationales for family planning aimed at young people. Both focus on lowering fertility rates--the one for economic growth and the other for violence mitigation--and emphasize reducing numbers. There is a definite trend towards narrowing contraceptive options to those considered most effective for reducing fertility rates, overturning decades of evidence that the wider the range of options, the more likely people are to find a method that suits them. The theories also offer limited understanding of young people, and particularly in the case of the youth bulge, promote a damaging stereotype of young men. In order to maintain a range of quality family planning options in the context of comprehensive sexual and reproductive health needs, a different approach is needed, one that builds from the perspectives of young people.

Beyond bonus and bomb

Young activists and allies in international networks and organizations, such as those in the Youth Coalition, (45) rally round the right to good quality, youth-friendly sexual and reproductive health services, as part of comprehensive health care that is available across a wide range of settings and responds to the diversity that exists in the youth population. Policies for sexual and reproductive health for young people should build from their vision and realities. Given the popularity of international agencies' youth coalitions, and the number of young people's advocacy networks and organizations, there is much to draw from.

Implementing this vision means expanding sexual and reproductive health beyond a contraceptive dissemination agenda that is focused on lowering fertility rates, but does support access to contraception and safe abortion. It requires not only listening to young people, but also anticipating that they have multiple, intersectional identities. *d Youth-led consultations and initiatives offer insight into the scope of young peoples' experiences and the age-specific biases young people with HIV can face, as the ATHENA Network and the Global Youth Coalition on HIV/ AIDS found when they consulted over 800 young people from every global region:

"Young people living with and affected by HIV, especially young women living with HIV, young people who engage in sex work, young men who have sex with men, young transgender people, and young people who use drugs, among others, are often unable to access sexual and reproductive health services, including family planning, without facing stigma and discrimination based on age, gender, HIV status and sexual orientation, as well as attitudes and norms around 'appropriate' sexual behaviour." (47)

Acknowledging the range of genders and sexualities among young people can lead to a transformative integration of services and dislodge the assumption that pregnancy prevention and fertility control are the sole goal. At the same time, breaking down and refuting gender stereotypes (like that of the angry young man or young women as the objects of development) has the potential to make services open and appropriate for users of all genders.

Young activists demand sexual and reproductive health and services as a right, free from discrimination and coercion. Young peoples' recommendations for comprehensive care include: access to a full range of contraceptives, access to safe, legal abortion and emergency contraception; HIV testing, treatment and support; sexuality education that acknowledges a breadth of sexual orientations and expressions; and education around gender-based violence, including violence against women and/or because of sexual orientation or gender identity. (45,47,48)

Link Up calls for combined services that are "delivered by knowledgeable, ethical and supportive health care providers". (47) This is essential for reaching young people who are affected by HIV, particularly those who are frequently barred from accessing services and support because of their age and because of punitive laws that criminalize sex work, men who have sex with men, young people who use drugs, and young LGBTQI people. A 2013 assessment of issues faced by HIV positive adolescents (aged 10-19) living in the Asia-Pacific region underscored the importance of addressing the "anxiety, fear and complex emotions some adolescents living with HIV face around sexuality and their reproductive options through counseling, peer support, and role model programs". (48)

These insights open possibilities for connecting young people and their allies across borders, in part because the recommendations for policy and service approaches are based in community assessments of young people's needs, rather than international population agendas. Young advocates are already active both locally and globally.

Increased collaboration with them could help refine and strengthen local efforts. Finally, youth-friendly, inclusive and comprehensive sexual and reproductive health approaches can and should inform those for other age groups to create a transformative approach to sexual and reproductive health and rights for all ages.

[ILLUSTRATION OMITTED]

Doi: 10.1016/S0968-8080(14)43765-0

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Anne Hendrixson

Assistant Director, Population and Development Program, Hampshire College, Amherst, MA, USA.

Correspondence: alhCLPP@hampshire.edu

* For example, see Lisa Ann Richey's analysis of how family planning programs in Tanzania aimed to address economic and political development problems in Population Politics and Development. (7)

*a This median estimate assumes that countries with higher TFR will experience a decline in fertility rates, while countries with a TFR lower than two will experience an increase in fertility rates. (8)

([dagger]) See, for instance, UNFPA's 2014 Framework of Actions for the follow-up to the Programme of Action of the International Conference on Population and Development for an in-depth discussion of their approach to meeting the sexual and reproductive health needs of young people in the global South. (12)

*b The youth bulge literature most often refers to a "large" or "disproportionate" cohort of young people, because the precise ratio of youth to adults needed to create a "bulge" is a matter of debate, and there is not a standard definition or calculation.

*c Demographic transition refers to a shift in population dynamics from high death and birth rates to low death and birth rates. During this transition, there is often a boom in the population before fertility rates fall.

*d See Nancy Lesko's 2001 Act Your Age! A Cultural Construction of Adolescence for an alternative theoretical understanding of young people based in feminist thinking and building from critiques of imperialism and colonialism. (46)
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