Permasalahan Remaja
by. Yudi
[Interaksi Sosial anak remaja dengan lingkungan yang memberikan teguran pada orangtua agar mampu memberikan batasan dalam adopsi isme. Interaksi sosial tersebut tidak terlepas dari peran psikologis anak remaja dalam menghadapi kekerasan verbal yang cenderung memojokkan.]
[Interaksi Sosial anak remaja dengan lingkungan yang memberikan teguran pada orangtua agar mampu memberikan batasan dalam adopsi isme. Interaksi sosial tersebut tidak terlepas dari peran psikologis anak remaja dalam menghadapi kekerasan verbal yang cenderung memojokkan.]
Permasalahan Remaja:
Youth at Risk: Meeting the Sexual Health Needs of Adolescents
Q and A (Questions and Answers) Population Action International Prepared by: Stephanie Koontz and Shanty R. Conly April 1994
Youth at Risk: Meeting the Sexual Health Needs of Adolescents
Q and A (Questions and Answers) Population Action International Prepared by: Stephanie Koontz and Shanty R. Conly April 1994
SUMMARY
à Masa Remaja
à Dimensi Biologis
à Dimensi Kognitif
à Dimensi Moral
à Dimensi Psikologis
à Apa yang harus Aku Pilih?
à Isu-Isu Utama
à Kebutuhan dan Pengalaman
à Mestinya Dilakukan Sesuai Prosedur (catatan untuk orangtua)
à Perilaku Agregasi
à Merespon Emosi
à Strategi Copings
à Mengenal Mekanisme Pertahanan Diri
à Mencemaskan Penampilan
à Masa Remaja
à Dimensi Biologis
à Dimensi Kognitif
à Dimensi Moral
à Dimensi Psikologis
à Apa yang harus Aku Pilih?
à Isu-Isu Utama
à Kebutuhan dan Pengalaman
à Mestinya Dilakukan Sesuai Prosedur (catatan untuk orangtua)
à Perilaku Agregasi
à Merespon Emosi
à Strategi Copings
à Mengenal Mekanisme Pertahanan Diri
à Mencemaskan Penampilan
Bagi sebagian besar orang yang baru beranjak dewasa bahkan yang sudah melewati usia dewasa, remaja adalah waktu yang paling berkesan dalam hidup mereka. Kenangan saat remaja merupakan kenangan yang tidak mudah dilupakan, sebaik atau seburuk apapun saat itu. Sementara itu banyak orangtua yang memiliki anak berusia remaja merasakan bahwa usia remaja adalah saat-saat yang sulit. Alasan kuatnya ialah banyak konflik yang dihadapi oleh orangtua dan remaja itu sendiri.
Banyak orangtua yang tetap menganggap anak remaja kesayangan masih perlu dilindungi dengan ketat sebab di mata orangtua para anak remaja, masih belum siap menghadapi tantangan dunia orang dewasa. Sebaliknya, bagi para remaja, tuntutan personal membawa mereka pada keinginan untuk mencari jati diri yang sesuai guna menciptakan kemandirian dan terbebas dari pengaruh kehidupan orangtua. Keduanya memiliki kesamaan yang jelas sekali, bahwa remaja merupakan tahapan atau tingkatan waktu kritis sebelum menghadapi hidup sebagai orang dewasa.
Bila kita harus mengutip permasalahan-permasalahan yang memang sedang masih menjadi bahan pembicaraan besar bagi setiap negara, diwujudkan melalui tanya jawab di bawah ini. Tidak hanya bagi negara-negara maju, tapi lebih dominan membuat setiap negara harus memikirkan jawabannya. Memang menjadi sangat mengkhawatirkan kepribadian remaja-remaja negara berkembang, ketika generasi yang menjadi kebanggaan negara tersebut tidak memiliki rasa tanggung jawab secara pribadi ataupun secara umum. Dikhawatirkan pula ketidakperdulian terhadap lingkungan sekitar akan semakin membawa kesengsaraan yang semakin meluas. Untuk itu kutipan cerita di bawah ini mudah-mudahan bisa menjadi salah satu gambaran nyata gaya hidup masa kini anak-anak remaja.
SUMMARY
Sex education and contraceptive services for young, unmarried people remain controversial in many societies. Yet the problem of unwanted pregnancy and the AIDS epidemic urgently call for greater openness about adolescent sexuality.
Many young people around the world become sexually active at an early age but most do not use any contraception. The health risks of unprotected sex for adolescents are substantial. Girls in their early, teenage years - whether married or unmarried - have a much higher risk of medical complications or death in pregnancy and childbirth than women in their twenties. Unmarried girls are also at high risk of unsafe, illegal abortion. Adolescent childbearing has significant costs to society, including medical care and girls dropping out of school before completing their education. Meanwhile, the incidence of AIDS and other sexually-transmitted diseases (STDS) among young people is growing.
Addressing the sexual health needs of youth requires a comprehensive approach, beginning with universal and relevant sexuality education-ideally introduced before young people become sexually active. The school systems in most countries, however, have largely failed to meet the sexual health education needs of youth and children. Contrary to popular opinion, sexuality education does not appear to encourage earlier sexual activity; rather, it teachers young people the skills they need to practice safe and responsible sexual behavior and may encourage young teenagers to delay first intercourse until they are older and more mature.
To be effective, sexuality education needs to be directly linked to contraceptive counseling and services. But most family planning and health services-especially government-run programs-have traditionally served married couples and done little to reach young people. In fact, many programs do not serve unmarried young people, either as a matter of explicit policy or for lack of initiative to reach out to youth. Most programs also do not sufficiently emphasize the use of condoms for prevention of STDS. Although the unique outreach, information and counseling needs of youth are best met through specially-designed programs, existing family planning services could do much more to address the needs of young people.
Private organizations, despite their limited resources, have pioneered a variety of strategies for reaching youth, including special reproductive health clinics for young people; community centers which provide contraceptive education and services as part of a broader range of services for youth; and community-level outreach programs in which youth are often involved in educating their peers and in contraceptive distribution. Experience suggests that a combination of these approaches can best reach different groups of youth, including those both in and out of school. The scope of current efforts, however, needs to be significantly expanded.
Finally, efforts are needed to address the social context of adolescent sexuality and childbearing. Broader initiatives, such as expanding education and employment opportunities for girls and eliminating harmful traditional practices like child marriage and female genital mutilation, are also important over the long-term to improving adolescent sexual and reproductive health.
Questions:
Should family planning programs serve unmarried young people? WM sex education and access to contraceptives increase the likelihood that adolescents will be sexually active?
Answers:
Globally, there are about 500 million adolescents aged 15 to 19, most of whom will. Become sexually active before age 20. Young people seldom use contraceptives and are at high risk of pregnancy, AIDS and other sexually diseases (STDs). Yet in most countries, youth are not reached by existing reproductive health services, despite evidence that providing sexuality education and making contraceptives available to young people helps foster more responsible sexual behavior and does not encourage earlier intercourse.
In some developing regions, as in South Asia early marriage is still common and sexual activity before marriage remains relatively rare. In many societies, however, traditional patterns are changing. Young women, especially, are marrying later, and an increasing proportion of adolescents are unmarried. In Bangladesh, the average age of marriage for women has risen from 14 to 18 years since the early 1960s. Because girls are reaching puberty at a younger age, there is a growing gap between the biological ability to have children and the social sanction to do so. Social forces, such as urbanization, changing family structures, and the influence of mass media and peer groups on young people, all contribute to a new cultural context, many aspects of which legitimize sexual activity outside of marriage.
Many sexually active adolescents are older youth who are married or in long-term stable relationships. But many youth begin sexual relations at a very young age. According to recent Kenyan and Ugandn surveys, sexually active youth, on average, had experienced intercourse by age 15 or younger. In the United States, one quarter of 15 year old girls and one-third of 15 year old boys are estimated to have had intercourse, a larger proportion than a decade ago. In nine Latin American and Caribbean countries, roughly one-half to two-thirds of women reported having intercourse before age 20.
Despite the health risks and social problems associated with unprotected sex, youth - particularly younger adolescents - are far less likely than adults to use contraceptives, or to use them consistently and effectively. Contraceptive or to use among both unmarried and married youth is low in developing countries. A recent survey in Costa Rica found that 10 percent of sexually active youth aged 17 and under used contraception at first intercourse, compared to 26 percent of 18 and 19 year olds. In a study in Kenya, 89 percent of sexually active teenagers surveyed had never used any method of contraception. Overall, fewer than 30 percent of married adolescent women in developing countries use contraception, although levels of use range from I percent or even lower in Benin, Nepal and Nigeria, to 40 to 50 percent in Brazil, Jamaica, and Thailand.
Except in some Western European countries, the vast majority of sexually active adolescents lack access to good reproductive health education and services. In many countries, existing services are limited to small-scale pilot programs which reach only a small proportion of all youth. Government support for adolescent programs has been constrained by societal discomfort in acknowledging adolescent sexual activity and by the misconception that access to sexuality education or contraception promotes sexual activity among youth. Recently, however, the World Health Organization (WHO) reviewed 35 studies in several countries, concluding that appropriate sexuality education does not encourage earlier initiation of intercourse but often delays sexual activity and leads to safer sexual practices. The WHO and other studies also show that access to contraceptive services is not associated with earlier sexual activity.
Questions:
How common is the incidence of pregnancy, abortion and childbearing among adolescents?
Answers:
The proportion of women who give birth in their teenage years varies greatly but is often substantial. Over half of all women in many African countries and over a third of women in much of Latin America have their first child before age 20. In the United States, which has the highest rate of teenage pregnancy among more developed countries, roughly 20 percent of women give birth before age 20. Because a high proportion of all adolescent pregnancies are unintended and unwanted, they are often likely to end in abortion, which in many countries is illegal and only available under unsafe conditions.
Worldwide, birthrates for women under age 20 are declining. However, as the population of young adults rapidly increases, the total number of births to adolescent women is growing. Moreover, in many countries births to adolescents account for an increasing proportion of overall births, as fertility rates decline more rapidly among older women. Patterns of adolescent childbearing vary greatly from country to country, even within the same region. In the late 1980s, an estimated 31 percent of young women in Egypt gave birth by age 20, compared to 13 percent of young women in Tunisia.
In some countries such as Botswana and Liberia, premarital births may be culturally accepted as a way for young women to prove their fertility, and a significant proportion of first births occur outside of marriage. Premarital pregnancy is also a common reason for marriage in many countries. Recent surveys of young adults in Latin America and the Caribbean found that from one-fifth to two-thirds of first births to young married adults were conceived before marriage. In an Indonesia survey, one in five married women aged 20 to 24 reported conceiving her first child premaritally. Similarly, at least one in five women aged 20 to 24 in Benin, Cameroon, Cote d'lvoire and Nigeria had conceived premaritally and given birth before age 20.
Regardless of marital status, a high proportion of adolescent pregnancies are unintended. In six African countries, unintended pregnancies range from about 50 to 90 percent of pregnancies in unmarried adolescents and from 25 to 40 percent of pregnancies in married adolescents. In six Latin American and Caribbean countries, between 40 and 50 percent of births to adolescent women are unintended; a somewhat smaller proportion are unintended in three other countries. These data exclude pregnancies ending in abortion and miscarriage.
Globally, abortions among girls aged 15 to 19 are estimated to account for at least 5 million of the roughly 50 million induced abortions that occur each year. Worldwide, over half of women seeking abortion are married with children. But particularly in industrialized countries and in parts of Africa, young unmarried women account for a significant percentage of all abortions. In the United States, 4 out of every 10 teenage pregnancies are terminated, accounting for one fourth of all abortions. Surveys in Brazil also found that over half of young men in two cities and almost one-third of young men in a third city reported being responsible for a pregnancy that had been terminated. In Shanghai, in 1988, the annual abortion rate among 15 to 19 year olds was slightly more than one procedure for every 20 unmarried women.
Questions:
What are the health risks associated with adolescent pregnancy? Answers:
Complications in pregnancy and child birth are greater for adolescent women than for women in their twenties, regardless of marital status. The risk of death, particularly in childbirth, is substantially higher for girls under age 16 and their infants; good prenatal care can significantly decrease these risks. Unsafe abortion-a leading cause of maternal mortality worldwide-is also the cause of a high proportion of maternal deaths among adolescents.
Due to both biological and behavioral factors, early childbearing remains a health risk even when other social and economic factors are taken into consideration. Thus, married adolescents also face significant health risks during pregnancy and childbirth. The younger the adolescent, the higher the risk of complications in childbirth and of maternal or infant death. In a 1974 study in Bangladesh, the risk of dying during pregnancy or childbirth was almost five times higher for girls aged 10 to 14 than for women aged 20 to 24. Young girls are also more likely than most women aged 20 to 34 to develop problems such as anemia and high blood pressure, as well as potentially fatal complications such as toxemia and hemorrhage.
Obstructed labor is another serious and sometimes fatal problem, since the pelvis of many young girls is too narrow for normal delivery. The risk of obstructed labor can be greatly increased by scarring resulting from female genital mutilation (female circumcision), a traditional practice affecting roughly 100 million girls and women, primarily in Africa. Injuries caused by obstructed labor can result in infertility or leakage of urine or fecal matter after delivery. Girls who experience these problems often become social outcasts.
Babies born to young mothers are also at greater risk of premature birth, low birth weight and infant death. A study in Kenya revealed that 40 percent of mothers aged 13 to 14 had babies of low birth weight, compared to 25 percent of 19 year olds. Data from 28 national surveys suggest the relative risk of death for children under five is 64 percent higher for those born to mothers aged 17 or younger, compared to children born to mothers aged 18 to 34 who were not at special risk. The relative risk increased to 130 percent for subsequent births spaced less than two years apart to mothers aged 17 or younger.
Much of the increased risk to young mothers and their infants can be offset by good prenatal care and adequate nutrition during pregnancy. In a hospital-based study of deliveries in Northern Nigeria, the maternal mortality rate for girls aged 14 or younger who had received good prenatal care was 500 deaths per 100,000 live births, compared to 4,200 deaths per 100,000 births for those who did not receive such care. In many countries where access to health services is limited, however, young girls are less likely than older women to seek and receive prenatal care.
Adolescents are believed to account for a significant proportion of worldwide abortion related deaths, estimated at over 100,000 each year. Among women hospitalized for complications of induced abortion, the percentage of patients under age 20 varies widely, from 7 percent in a study in Nepal to between 53 percent (including 20 year olds) and 72 percent in several studies in Nigeria. Younger women are more likely than older women to seek later-term, more risky abortions under unsafe conditions, or to attempt to induce an abortion themselves. Adolescents are thus at special risk of complications of unsafe and incomplete abortion. Aside from death, the long-term consequences may include chronic infection and infertility.
Questions:
What are the economic and social consequences of adolescent pregnancy and early childbearing?
Answers:
Early childbearing limits the educational and employment opportunities of young women and girls, making it more likely that they and their children will be poor. The direct costs to society include subsidies for medical care and poverty assistance for women and their children, where these are made available. Indirect costs include a less educated and thus less productive workforce. High rates of adolescent childbearing also contribute to rapid population growth, which in turn impedes economic and social development.
In many countries, the majority of pregnant girls are either compelled to leave school or drop out due to their need to support themselves. Only a small proportion ever return to school. Studies in Kenya and Tanzania in the 1980s indicated that more than 10 percent of girls leave secondary school each year because of pregnancy. In a survey in Zimbabwe, 90 percent of 14 to 24 year olds who became pregnant in school were forced to drop out, many of them marrying soon after. Pregnancy is reportedly the single most important reason why girls fail to complete secondary school in the Caribbean.
Overall, early childbearing decreases a girl's ability to find paid employment. In Latin America and the Caribbean, teenage mothers appear seven times more likely than older mothers to be poor. In a 1992 Chilean study of women who gave birth as teenagers, the risk of poverty was most strongly associated with low educational status and earning ability, as well as lack of financial support from the child's father. The disadvantage of early motherhood may be overcome when girls have strong family support, high educational aspirations and achievements, and access to economic opportunities. However, in many societies, young unwed mothers are stigmatized and may receive little support from their families. Young unmarried mothers sometimes abandon their children or turn to prostitution to support themselves.
The costs of adolescent pregnancy to society are enormous. In 1990, the U.S. government spent over $25 billion for social and health services and welfare payments to families headed by women who had their first child in their teenage years - an expenditure estimated to be two-thirds higher than if all teenage mothers had delayed childbearing until their twenties. Even in countries which do not provide ser-vices or monetary assistance, greater poverty, combined with lower educational levels and productivity, are important indirect costs to society.
The cost to society also includes health care for pregnant adolescents and their infants including medical care for premature infants and complications of childbirth more likely to occur among adolescents. In 1987, one hospital ward in Northern Nigeria maintained a list of 1,000 girls waiting for surgical repair of vaginal injuries during childbirth. Where adolescents represent a high proportion of hospital admissions for abortion complications and these complications consume a significant share of available funds, adolescent pregnancy also diverts scarce resources from other health problems.
Early childbearing is closely linked to high population growth rates because it shortens the time span between generations and because women who have their first child at a younger age tend to have larger families. In Latin America, women who begin childbearing as teenagers are estimated to have two to three more children than women who delay their first birth until their twenties or later. In South Asia, early marriage and childbearing are closely linked to larger family size and rapid population growth. By contrast, in most East Asian countries, adolescent birthrates are low and average family size is close to or below the two-child population replacement level.
Questions:
To what extent are health problems like AIDS and other sexually transmitted diseases (STDS) associated with adolescent sexual activity?
Answers:
According to WHO, 250 million new cases of STDs occur worldwide each year, the highest rates among 20 to 24 year olds, followed by 15 to 19 year olds. Young people are at high risk of STDs because they may have a series of sexual relationships and are unlikely to use condoms. Moreover, many people with AIDS are infected in their teens. While young men and women are both at risk, the health impact of STDs and the risk of AIDS appear greater for young women.
According to WHO estimates, 1 in 20 teenagers worldwide acquires an STD each year. In Kenya, Nigeria and Sierra Leone, between 16 and 36 percent of youth tested in small-scale studies had one or more STDS. A survey in a Peruvian town found that 23 percent of secondary school males had had an STD. And in the United States, roughly I in 8 teenagers contracts an STD each year.
An important overall risk factor for STDs is having several sex partners or having a partner who has other sex partners. Youth are often at risk because they may have a succession of exclusive but short-term sexual relationships. In many cultures, it is also common for young men to frequent prostitutes - in Brazil, Guatemala and Thailand, for example, a young man's first intercourse is likely to be with a commercial sex worker. Adolescents, particularly girls, are more vulnerable to unsafe sex when they are involved in an unequal relationship, especially with an older partner.
Married adolescent women may have husbands with more than one wife or sex partner. Also at risk are sexually exploited or abused adolescents, including street youth who sell sex for survival. For youth in general, use of drugs and alcohol is also associated with a higher risk of STDs as well as pregnancy.
Use of latex condoms greatly decreases the risk of AIDS and other STDS. However, young people tend not to perceive themselves at risk. Young women in particular may find it difficult to discuss protection with their sexual partners, sometimes even risking violence by suggesting condom use. Anal intercourse, commonly practiced between young men and women in countries like Brazil to avoid pregnancy (as well as between young men), may also promote the spread of AIDS. Worldwide, boys and young men who have sex with other males are at higher risk of STDs for a variety of reasons, including poor access to relevant sexual health information and services resulting from more general societal discrimination.
Although both young men and women are at risk of acquiring STDS, the impact on the health of young women is usually greater. STDs are more easily transmitted to women, are more difficult to diagnose, and result in more serious complications in women. Young women have the added risk that a biologically immature cervix appears more prone to infection. Female genital mutilation can also increase the risk of contracting STDs through bleeding or open infection of scarred areas.
Common STDs can also cause pelvic infection, infertility, a variety of serious pregnancy-related complications, and cervical cancer. For both men and women, infection with an STD appears to increase the risk of acquiring HIV, the virus which causes AIDS, by as much as 10 fold.
Adolescents - especially girls - are at special risk of AIDS. Worldwide, among the 15 million people infected with HIV, rates of infection appear to be highest for women aged 15 to 25 and for males aged 25 to 35. In a study in Rwkita, over 25 percent of pregnant women aged 17 or younger tested positive for HIV. Slowing the spread of AIDS requires changes in the sexual behavior of youth as most transmission is through sexual intercourse and an estimated two-thirds of those who acquire AIDS are infected by age 25.
Questions:
What are the major obstacles to expanding access to sexual health services for youth?
Answers:
In most developing countries, existing laws, policies or practices prohibit or severely restrict access to contraception and abortion for unmarried young people. Most fancily planning programs have done little to reach adolescents. Many programs exclude unmarried youth and health workers often have strong biases against serving them. Moreover, adolescents themselves often have negative perceptions regarding the accessibility and acceptability of existing services.
A study in Asia in the early 1980s found that only two countries- Thailand and Hong Kong-allowed access to contraception without restrictions based on age or marital status. According to a more recent survey of adolescent reproductive health programs in developing countries, many African and Asian programs for young people primarily serve older, married youth, while in Latin America, more programs serve unmarried youth under age 20. Efforts to improve adolescent health are typically developed within the context of health policies for children or adults and are characterized by poor coordination between education, health, and family planning services.
At a practical level, most family planning programs aim to help married couples limit or space births, rather than to help adolescents avoid first pregnancies and STDs. Clinic staff often refuse to provide unmarried or childless adolescents with contraceptives. In a study in the United States, use of services by adolescents depended on three factors: dissemination of information regarding the availability of services, guaranteed confidentiality, and affordability of services. Surveys in several countries indicate that adolescents are often reluctant to use existing services for adults because they are afraid of discovery by family members or other adults they know, or of being reprimanded or turned away by clinic staff. Proximity of services and access to transportation, convenience of clinic hours, and supportiveness of clinic staff are other factors which appear to influence use of family planning services by adolescents.
Young women generally have less access to safe abortion services than older women because they are less likely to know where services are available or to have adequate funds. They may also find it difficult to obtain parental consent where required. Adolescents are also more likely to deny or be unaware of a pregnancy and to delay a decision to have an abortion. However, in some settings adolescents may perceive abortion to be more accessible or acceptable than contraception, even when available under unsafe conditions. Group discussions with youth in Kenya and Nigeria, for example, revealed that they had more positive attitudes and better information about illegal abortion than about contraception.
Questions:
What elements should a comprehensive sexual health policy for adolescents include?
Answers:
Societies need to acknowledge adolescent sexual activity and recognize the special sexual health needs of young people. The key elements of a comprehensive strategy are universal sexuality education, linked to easily accessible and affordable contraceptive and safe abortion services. A truly comprehensive approach should also include broader social initiatives to expand education and employment opportunities for girls and to eliminate traditional practices that harm the health of young women and girls.
Sweden, which has among the most progressive policies in the world on adolescent sexual health, has adopted a comprehensive approach which includes universal sexuality education; special adolescent clinics closely linked to schools; free, widely available and confidential family planning and abortion services; extensive advertising of contraceptives in the media; and widespread availability of condoms. Governmental efforts have emphasized pregnancy and STD prevention, rather than promoting abstinence alone. Although the average age of first intercourse - 16 years - is quite young in Sweden, teenage birth rates are low, at II births per 1,000 women age 15 to 19.
Efforts to prevent early childbearing must also recognize that adolescent sexual activity and pregnancy is closely linked to the extent to which women derive their social status from bearing children and to which young women have alternatives to motherhood. Studies in different regions of the world have shown that girls who aspire to finish secondary school are less likely to become pregnant. In some countries, adolescent girls become pregnant after dropping out of school or terminating their education for other reasons. In sub-Saharan Africa and elsewhere, the nature of economic activity and the extent of women's participation in the labor force are closely linked to the age at which women have their first child.
Recognizing these links between adolescent pregnancy and education and employment opportunities, some private organizations in countries such as India, Mexico and Nigeria have worked to improve girls' self-esteem, delay pregnancy, and promote other opportunities for girls. In other countries, comprehensive efforts to improve adolescent sexual health have included legislation and community education to end traditional practices that are directly or indirectly harmful to the health of young women - such as female genital mutilation and child marriage.
Questions:
What is sexuality education? What should most sexuality education programs seek to achieve?
Answers:
Sexuality education is intended to improve knowledge and understanding of sexual development, human reproduction, and healthy sexual behavior among children and youth. The explicit aim of many sexuality education programs is to help young people practice responsible sexual behavior, including where appropriate, the delay of sexual activity. Programs have also sought to improve communications between youth, their parents and their partners.
Worldwide, youth are often poorly informed about sexuality. In a study in Sri Lanka, one quarter of youth surveyed thought a woman could get pregnant by wearing clothes previously worn by a man. Although many adolescents who use a contraceptive method practice rhythm or withdrawal, in two recent studies in Kenya and Mexico City, the vast majority of young people interviewed could not correctly identify the fertile period in a woman's menstrual cycle. Sexuality education promotes healthy and responsible sexual behavior by providing basic, relevant information, as well as by providing a positive context for youth to discuss the emotional and physical aspects of sexual relationships.
Many sexuality education programs encourage youth to delay first intercourse. However, the results of studies evaluating the success of such programs in delaying sexual activity are mixed. In the United States, programs which only promote abstinence have generally not shown decreased rates of sexual activity, although such programs may be more effective with young adolescents who have not yet had sex. Overall, programs which encourage postponement of sexual activity while also providing information about safer sex and contraception appear to be more effective than those which promote abstinence alone. Sexuality education appears most effective in delaying first intercourse and encouraging contraceptive use among sexually active youth when introduced early, before young people become sexually active.
Some programs seek to help youth discuss sexuality more openly, by using storytelling, drama or role play to help youth communicate their feelings. Research in Africa sponsored by WHO, in which thousands of adolescents were asked to describe a typical first sexual experience, reveals a common experience of poor communication about sexuality between youth and their parents, as well as a lack of mutual discussion between youth in their sexual relation ships. In Ugkita, for example, a survey found that many youth were reluctant to use condoms, apparently because condom use was associated with prostitutes and could be perceived as a lack of respect by young men for their partners.
Sexuality education programs have also sought to promote the idea of responsible parenthood among adolescents. Young men are often neglected by sexuality education and pregnancy prevention programs despite their role in initiating intercourse and their influence on contraceptive use. Some programs have sought to address the issues young men have regarding contraception and to increase their sense of responsibility for pregnancy and fatherhood.
Questions:
What characterizes a successful sexuality education program?
Answers:
Effective sexuality education programs teach practical skills such as sexual negotiation, decision-making and life planning, in addition to providing basic information on human reproduction, contraception, STDs and AIDS. Ideally, such programs are specially designed to respond to adolescents' needs. Many existing programs, however, fall short of these standards.
Traditionally, sex education courses have emphasized reproductive physiology. But teaching practical skills, such as how to negotiate condom use or say 'no" to sex, is also important. Research suggests that knowledge alone is not enough to change sexual behavior - youth must understand the long-term consequences of unsafe practices and feel empowered to practice healthy sexual behavior. A "Life Planning Education" curriculum, developed by the U.S.-based Center for Population Options and adapted for use in a variety of international settings, helps adolescents plan for their futures as well as deal with sexual feelings and behaviors. The curriculum includes topics such as values, goal setting and decision-making, sexuality, contraception, AIDS, parenthood and employment.
More effective programs utilize participatory rather than authoritarian styles of teaching, encouraging discussion rather than moralizing about unmarried sexual activity. They employ teachers specifically trained to work with adolescents on sexuality issues and use educational materials that are culturally and age-appropriate. Peer education programs have been very effective, as trained youth leaders can be influential role models and credible sources of information about sexuality, contraception and other topics. Young people who are HIV-positive or have AIDS are particularly successful at reaching youth with messages about AIDS prevention.
Over the past decade, sex education or family life education programs have been widely introduced in schools around the world and, on a more limited basis, have tried to reach out-of school youth. Unfortunately, the content of many existing sexuality education programs is not relevant to the information needs of young people. Kenya's family life education program avoids words like vagina and uses animal rather than human examples to teach reproductive physiology. Other programs emphasize global demographic problems or caution against premarital sexual activity without providing basic information on practical ways to prevent pregnancy and disease.
Questions:
Do young people have any special needs with regard to contraceptive counseling and services?
Answers:
Adolescents often have special concerns about contraception which need to be addressed by family planning and health workers. Youth may require more extensive counseling than adults before they feel comfortable choosing and using a method. Given the high risk of STDs to adolescents, counseling should emphasize the importance of condoms - used alone or with other methods.
Numerous studies have shown why sexually active adolescents fail to use contraception. Adolescent sexual activity is often unplanned and infrequent - making routine contraceptive use less likely. Moreover, research shows that youth in a number of countries typically feel that planning for sex is bad, since it requires them to acknowledge that they are sexually active in the face of cultural taboos against such activity.
Adolescents may not understand their own personal risk of pregnancy or disease. They often know little about various contraceptive options or find contraceptives too difficult to obtain. Young people may have fears about the health risks of specific contraceptive methods, feel unable to negotiate contraceptive use with their sexual partner, or fear parental discovery and disapproval. In some countries, a significant proportion of married or unmarried youth may also desire pregnancy.
These broad concerns of youth can be addressed through counseling. Youth may want to discuss with trained counselors whether or not to be sexually active, whether they want to use contraception, how their partner feels, and how their parents might react In choosing a contraceptive method, adolescents generally require more information about basic reproductive physiology and contraception than most adults. Counselors also need to be sensitive to the needs of youth who may be engaging in homosexual activity.
With the exception of contraceptive sterilization and IUDS, which are not appropriate options for most youth, most available contraceptive methods are safe and appropriate for adolescents. Oral contraceptives are highly effective in preventing pregnancy and are considered safe for adolescent girls. However, hormonal methods in general do not provide protection against AIDS or most other STDS. Barrier methods, particularly latex condoms, offer adolescents some distinct advantages. Condoms are well suited for infrequent sexual activity and are often less expensive and easier to obtain than other methods. Most importantly, condoms provide a high degree of protection from HIV and many other sexually transmitted infections.
Once a method is chosen, adolescents, like other family planning clients, need to be counseled about possible side effects and appropriate follow-up care. Health workers need to help youth assess their risk of STDs and encourage condom use in addition to other methods, where appropriate. Whatever method is chosen, health personnel should take time to respond to questions and fully explain correct use, to avoid potentially harmful misconceptions. In Mexico City, for example, a survey of young women found that 60 percent incorrectly believed a condom could be used more than once.
Questions:
What types of programs have been effective in addressing the special sexual health needs of adolescents? And what strategies have been successful in reaching out-of-school youth?
Answers:
Different models have been developed AO to provide sexual and reproductive health services to young people. They include clinics which provide reproductive health services only, as well as centers which provide contraceptive services as one element of more comprehensive activities for youth. Programs which provide education and contraceptives at the community level represent yet another model. Special programs have also been developed to reach specific groups, such as married adolescents or street youth.
Special clinics for young people are more common in Western Europe, the United States, and Latin America. School-based clinics typically address a range of student health needs, of which reproductive and sexual health is just one element; contraceptives are often offered on a referral basis only. More specialized reproductive health clinics for adolescents generally provide contraceptive counseling and supplies, and perhaps treatment of STDs and other reproductive tract infections among other services. More recently, special clinics for youth have been established by national family planning associations in several countries in Africa and Asia, including Burkina Faso and Indonesia.
Where special clinics for adolescents have not proved feasible, some existing family planning clinics have introduced separate hours, entrances, or other modifications to make services more acceptable to young people. Hospital-based postpartum and post-abortion programs have also been developed to serve adolescent mothers who want to delay a subsequent pregnancy. These programs have sometimes extended services to other adolescents as well, through word-of-mouth or more formal outreach efforts.
A second model of service delivery has been the multi-service youth center, offering reproductive health services in combination with a broad range of recreation, education or employment-oriented activities. Addressing reproductive health within a more comprehensive program tends to be more socially acceptable, and recreation and other activities often attract young people to the centers. Such centers tend to require more resources, serve small numbers of youth, and focus less on reproductive health. However, successful programs such as CORA (Centro de Orientacion para Adolecentes) in Mexico City and the Women's Centre for pregnant adolescents and young mothers in Kingston, Jamaica, demonstrate the value of a comprehensive approach.
Community-based outreach programs represent a model that generally requires fewer resources. These programs usually include educational activities, and in some cases, contraceptive distribution and clinical referral. Community outreach programs tend to be most effective when youth are involved as peer educators and counselors, as in the Gente joven program in Mexico. Large-scale educational campaigns have also used popular media such as comic books, posters, films, radio and television to communicate important sexual health messages to youth. To be effective, such campaigns also need to inform youth about where to obtain actual services.
Most of these programs can be adapted to serve youth who are both in and out of school. Services aimed at out-of-school youth, however, must be designed to be easily accessible to them and may involve a variety of approaches. In the CORA program in Mexico City, youth leaders are trained in factories as well as schools to be peer educators and distribute barrier methods. Casa de Passagem, an organization working with street girls in Recife, Brazil, provides reproductive and other health services along with income earning opportunities, shelter, and counseling.
Questions:
What do we know about the impact and success of these programs in meeting the sexual health needs of young people? What kinds of programs are most cost effective?
Answers:
Successful programs for adolescents carefully assess and respond to local need; involve youth in various aspects of program planning, implementation and evaluation; and reach out to community leaders and parents for involvement and support. Few programs, especially in developing countries, have been rigorously evaluated for cost-effectiveness and impact. However, experience suggests a combination of specially-targeted approaches may best meet the needs of different groups of youth.
Successful adolescent reproductive health programs are strongly commited to involving young people, using youth on advisory committees in the planning process and as educators, promoters or counselors in program implementation. In Zimbabwe, for example, educational materials for young people were developed following group discussions with youth and a national survey of young adults.
Involving the community - including influential community leaders - improves the likelihood that a project will be effective and sustainable. Parents, other involved community members, and youth themselves can be important sources of support in the controversial area of adolescent reproductive health. Introducing new programs often requires political sensitivity. The MUDAFEM project in Nigeria, for instance, initially limited services to students at the University of Ibadan - with the intention of eventually extending them to younger age groups.
Less tangible factors linked to program success include the quality of relationships program staff-establish with youth. Programs which organize around specific goals and messages may also be more effective at promoting healthy sexual behavior than programs that merely make services available. A recent evaluation of six school-based health clinics in the United States, for example, found that clinics which emphasized the themes of pregnancy and AIDS prevention were more effective at increasing pill and condom use than clinics that only provided services.
Overall, there has been little formal evaluation of adolescent programs, in part, reflecting the resource constraints facing most fledgling programs and the priority such programs have given to direct provision of services. More evaluation is needed to understand which youth these programs are serving and what makes them effective. However, experience suggests that providing services through a variety of different programs may be important.
For example, a study in Monterrey, Mexico, found a community based peer program to be one-third less costly per contraceptive user than a multi-purpose youth center. However, the youth center attracted and served young unmarried girls as well as boys while the community program primarily served boys, suggesting that the two approaches were complementary. Considerations other than cost may, therefore, be important in efforts to make services more widely available to youth.
Sebetulnya, apa yang terjadi hingga akhirnya remaja memiliki dunia sendiri. Mengapa para remaja seringkali merasa tidak dimengerti dan tidak diterima oleh lingkungan sekitarnya? Mengapa remaja seolah-olah memiliki masalah unik dan tidak mudah dipahami, sehingga membuat orang di sekitar menjadi sangat membatasi reaksinya terhadap lingkungan? Sampai kapanpun semua itu akan selalu menjadi pertanyaan-pertanyaan yang bersifat klasik. Didasarkan atas kepercayaan orang-orang terdekat mereka, tentu saja akan memiliki kepuasan tersendiri karena aksen-aksen yang dilontarkan oleh mereka ke dalam lingkungan mendapat dukungan penuh. Artinya, setiap orang punya persepsi yang berbeda-beda di dalam mengartikan pernyataan-pernyataan tersebut, tentu saja tidak hanya sebatas pada pertanyaan-pertanyaan ringan dan berat. Belum tuntas bila tidak dilengkapi dengan jawaban-jawaban yang memberikan pandangan khusus bagi kehidupan pribadi anak remaja. Karena itu penjelasan lebih dalam sepertinya hanyalah ada dalam diri pribadi sebagai orang terdekat dengan mereka. Concernnya ialah kita perduli pada generasi, berarti kita adalah orang yang mampu menemukan jawaban sebenarnya yang memang sangat dibutuhkan.
Kualitas dan kuantitas perhatian sebenarnya tidak selalu membuat anak remaja secara utuh mengharapkannya. Namun kualitas dan kuantitas perhatian saja tidak akan lengkap bila tidak ada pengertian dari orang terdekat dengan mereka. Apalagi ketika usia anak remaja tersebut sudah berada digaris transisi gaya hidup anak remaja masa kini. Apa yang akan dikatakan oleh orangtua bila anak remaja kesayangannya bertingkahlaku diluar kewajaran interaksi sosialnya. Akibat sebagai hasil dari proses adalah akan menjadi beban yang sulit dilepas dari dalam kepala orangtua. Namun, bila adanya keseimbangan antara kualitas, kuantitas perhatian dan pengertian orangtua tidak akan merasa terbebani oleh permasalahan anak remaja kesayagannya terutama antara personal dengan lingkungan.
Sex education and contraceptive services for young, unmarried people remain controversial in many societies. Yet the problem of unwanted pregnancy and the AIDS epidemic urgently call for greater openness about adolescent sexuality.
Many young people around the world become sexually active at an early age but most do not use any contraception. The health risks of unprotected sex for adolescents are substantial. Girls in their early, teenage years - whether married or unmarried - have a much higher risk of medical complications or death in pregnancy and childbirth than women in their twenties. Unmarried girls are also at high risk of unsafe, illegal abortion. Adolescent childbearing has significant costs to society, including medical care and girls dropping out of school before completing their education. Meanwhile, the incidence of AIDS and other sexually-transmitted diseases (STDS) among young people is growing.
Addressing the sexual health needs of youth requires a comprehensive approach, beginning with universal and relevant sexuality education-ideally introduced before young people become sexually active. The school systems in most countries, however, have largely failed to meet the sexual health education needs of youth and children. Contrary to popular opinion, sexuality education does not appear to encourage earlier sexual activity; rather, it teachers young people the skills they need to practice safe and responsible sexual behavior and may encourage young teenagers to delay first intercourse until they are older and more mature.
To be effective, sexuality education needs to be directly linked to contraceptive counseling and services. But most family planning and health services-especially government-run programs-have traditionally served married couples and done little to reach young people. In fact, many programs do not serve unmarried young people, either as a matter of explicit policy or for lack of initiative to reach out to youth. Most programs also do not sufficiently emphasize the use of condoms for prevention of STDS. Although the unique outreach, information and counseling needs of youth are best met through specially-designed programs, existing family planning services could do much more to address the needs of young people.
Private organizations, despite their limited resources, have pioneered a variety of strategies for reaching youth, including special reproductive health clinics for young people; community centers which provide contraceptive education and services as part of a broader range of services for youth; and community-level outreach programs in which youth are often involved in educating their peers and in contraceptive distribution. Experience suggests that a combination of these approaches can best reach different groups of youth, including those both in and out of school. The scope of current efforts, however, needs to be significantly expanded.
Finally, efforts are needed to address the social context of adolescent sexuality and childbearing. Broader initiatives, such as expanding education and employment opportunities for girls and eliminating harmful traditional practices like child marriage and female genital mutilation, are also important over the long-term to improving adolescent sexual and reproductive health.
Questions:
Should family planning programs serve unmarried young people? WM sex education and access to contraceptives increase the likelihood that adolescents will be sexually active?
Answers:
Globally, there are about 500 million adolescents aged 15 to 19, most of whom will. Become sexually active before age 20. Young people seldom use contraceptives and are at high risk of pregnancy, AIDS and other sexually diseases (STDs). Yet in most countries, youth are not reached by existing reproductive health services, despite evidence that providing sexuality education and making contraceptives available to young people helps foster more responsible sexual behavior and does not encourage earlier intercourse.
In some developing regions, as in South Asia early marriage is still common and sexual activity before marriage remains relatively rare. In many societies, however, traditional patterns are changing. Young women, especially, are marrying later, and an increasing proportion of adolescents are unmarried. In Bangladesh, the average age of marriage for women has risen from 14 to 18 years since the early 1960s. Because girls are reaching puberty at a younger age, there is a growing gap between the biological ability to have children and the social sanction to do so. Social forces, such as urbanization, changing family structures, and the influence of mass media and peer groups on young people, all contribute to a new cultural context, many aspects of which legitimize sexual activity outside of marriage.
Many sexually active adolescents are older youth who are married or in long-term stable relationships. But many youth begin sexual relations at a very young age. According to recent Kenyan and Ugandn surveys, sexually active youth, on average, had experienced intercourse by age 15 or younger. In the United States, one quarter of 15 year old girls and one-third of 15 year old boys are estimated to have had intercourse, a larger proportion than a decade ago. In nine Latin American and Caribbean countries, roughly one-half to two-thirds of women reported having intercourse before age 20.
Despite the health risks and social problems associated with unprotected sex, youth - particularly younger adolescents - are far less likely than adults to use contraceptives, or to use them consistently and effectively. Contraceptive or to use among both unmarried and married youth is low in developing countries. A recent survey in Costa Rica found that 10 percent of sexually active youth aged 17 and under used contraception at first intercourse, compared to 26 percent of 18 and 19 year olds. In a study in Kenya, 89 percent of sexually active teenagers surveyed had never used any method of contraception. Overall, fewer than 30 percent of married adolescent women in developing countries use contraception, although levels of use range from I percent or even lower in Benin, Nepal and Nigeria, to 40 to 50 percent in Brazil, Jamaica, and Thailand.
Except in some Western European countries, the vast majority of sexually active adolescents lack access to good reproductive health education and services. In many countries, existing services are limited to small-scale pilot programs which reach only a small proportion of all youth. Government support for adolescent programs has been constrained by societal discomfort in acknowledging adolescent sexual activity and by the misconception that access to sexuality education or contraception promotes sexual activity among youth. Recently, however, the World Health Organization (WHO) reviewed 35 studies in several countries, concluding that appropriate sexuality education does not encourage earlier initiation of intercourse but often delays sexual activity and leads to safer sexual practices. The WHO and other studies also show that access to contraceptive services is not associated with earlier sexual activity.
Questions:
How common is the incidence of pregnancy, abortion and childbearing among adolescents?
Answers:
The proportion of women who give birth in their teenage years varies greatly but is often substantial. Over half of all women in many African countries and over a third of women in much of Latin America have their first child before age 20. In the United States, which has the highest rate of teenage pregnancy among more developed countries, roughly 20 percent of women give birth before age 20. Because a high proportion of all adolescent pregnancies are unintended and unwanted, they are often likely to end in abortion, which in many countries is illegal and only available under unsafe conditions.
Worldwide, birthrates for women under age 20 are declining. However, as the population of young adults rapidly increases, the total number of births to adolescent women is growing. Moreover, in many countries births to adolescents account for an increasing proportion of overall births, as fertility rates decline more rapidly among older women. Patterns of adolescent childbearing vary greatly from country to country, even within the same region. In the late 1980s, an estimated 31 percent of young women in Egypt gave birth by age 20, compared to 13 percent of young women in Tunisia.
In some countries such as Botswana and Liberia, premarital births may be culturally accepted as a way for young women to prove their fertility, and a significant proportion of first births occur outside of marriage. Premarital pregnancy is also a common reason for marriage in many countries. Recent surveys of young adults in Latin America and the Caribbean found that from one-fifth to two-thirds of first births to young married adults were conceived before marriage. In an Indonesia survey, one in five married women aged 20 to 24 reported conceiving her first child premaritally. Similarly, at least one in five women aged 20 to 24 in Benin, Cameroon, Cote d'lvoire and Nigeria had conceived premaritally and given birth before age 20.
Regardless of marital status, a high proportion of adolescent pregnancies are unintended. In six African countries, unintended pregnancies range from about 50 to 90 percent of pregnancies in unmarried adolescents and from 25 to 40 percent of pregnancies in married adolescents. In six Latin American and Caribbean countries, between 40 and 50 percent of births to adolescent women are unintended; a somewhat smaller proportion are unintended in three other countries. These data exclude pregnancies ending in abortion and miscarriage.
Globally, abortions among girls aged 15 to 19 are estimated to account for at least 5 million of the roughly 50 million induced abortions that occur each year. Worldwide, over half of women seeking abortion are married with children. But particularly in industrialized countries and in parts of Africa, young unmarried women account for a significant percentage of all abortions. In the United States, 4 out of every 10 teenage pregnancies are terminated, accounting for one fourth of all abortions. Surveys in Brazil also found that over half of young men in two cities and almost one-third of young men in a third city reported being responsible for a pregnancy that had been terminated. In Shanghai, in 1988, the annual abortion rate among 15 to 19 year olds was slightly more than one procedure for every 20 unmarried women.
Questions:
What are the health risks associated with adolescent pregnancy? Answers:
Complications in pregnancy and child birth are greater for adolescent women than for women in their twenties, regardless of marital status. The risk of death, particularly in childbirth, is substantially higher for girls under age 16 and their infants; good prenatal care can significantly decrease these risks. Unsafe abortion-a leading cause of maternal mortality worldwide-is also the cause of a high proportion of maternal deaths among adolescents.
Due to both biological and behavioral factors, early childbearing remains a health risk even when other social and economic factors are taken into consideration. Thus, married adolescents also face significant health risks during pregnancy and childbirth. The younger the adolescent, the higher the risk of complications in childbirth and of maternal or infant death. In a 1974 study in Bangladesh, the risk of dying during pregnancy or childbirth was almost five times higher for girls aged 10 to 14 than for women aged 20 to 24. Young girls are also more likely than most women aged 20 to 34 to develop problems such as anemia and high blood pressure, as well as potentially fatal complications such as toxemia and hemorrhage.
Obstructed labor is another serious and sometimes fatal problem, since the pelvis of many young girls is too narrow for normal delivery. The risk of obstructed labor can be greatly increased by scarring resulting from female genital mutilation (female circumcision), a traditional practice affecting roughly 100 million girls and women, primarily in Africa. Injuries caused by obstructed labor can result in infertility or leakage of urine or fecal matter after delivery. Girls who experience these problems often become social outcasts.
Babies born to young mothers are also at greater risk of premature birth, low birth weight and infant death. A study in Kenya revealed that 40 percent of mothers aged 13 to 14 had babies of low birth weight, compared to 25 percent of 19 year olds. Data from 28 national surveys suggest the relative risk of death for children under five is 64 percent higher for those born to mothers aged 17 or younger, compared to children born to mothers aged 18 to 34 who were not at special risk. The relative risk increased to 130 percent for subsequent births spaced less than two years apart to mothers aged 17 or younger.
Much of the increased risk to young mothers and their infants can be offset by good prenatal care and adequate nutrition during pregnancy. In a hospital-based study of deliveries in Northern Nigeria, the maternal mortality rate for girls aged 14 or younger who had received good prenatal care was 500 deaths per 100,000 live births, compared to 4,200 deaths per 100,000 births for those who did not receive such care. In many countries where access to health services is limited, however, young girls are less likely than older women to seek and receive prenatal care.
Adolescents are believed to account for a significant proportion of worldwide abortion related deaths, estimated at over 100,000 each year. Among women hospitalized for complications of induced abortion, the percentage of patients under age 20 varies widely, from 7 percent in a study in Nepal to between 53 percent (including 20 year olds) and 72 percent in several studies in Nigeria. Younger women are more likely than older women to seek later-term, more risky abortions under unsafe conditions, or to attempt to induce an abortion themselves. Adolescents are thus at special risk of complications of unsafe and incomplete abortion. Aside from death, the long-term consequences may include chronic infection and infertility.
Questions:
What are the economic and social consequences of adolescent pregnancy and early childbearing?
Answers:
Early childbearing limits the educational and employment opportunities of young women and girls, making it more likely that they and their children will be poor. The direct costs to society include subsidies for medical care and poverty assistance for women and their children, where these are made available. Indirect costs include a less educated and thus less productive workforce. High rates of adolescent childbearing also contribute to rapid population growth, which in turn impedes economic and social development.
In many countries, the majority of pregnant girls are either compelled to leave school or drop out due to their need to support themselves. Only a small proportion ever return to school. Studies in Kenya and Tanzania in the 1980s indicated that more than 10 percent of girls leave secondary school each year because of pregnancy. In a survey in Zimbabwe, 90 percent of 14 to 24 year olds who became pregnant in school were forced to drop out, many of them marrying soon after. Pregnancy is reportedly the single most important reason why girls fail to complete secondary school in the Caribbean.
Overall, early childbearing decreases a girl's ability to find paid employment. In Latin America and the Caribbean, teenage mothers appear seven times more likely than older mothers to be poor. In a 1992 Chilean study of women who gave birth as teenagers, the risk of poverty was most strongly associated with low educational status and earning ability, as well as lack of financial support from the child's father. The disadvantage of early motherhood may be overcome when girls have strong family support, high educational aspirations and achievements, and access to economic opportunities. However, in many societies, young unwed mothers are stigmatized and may receive little support from their families. Young unmarried mothers sometimes abandon their children or turn to prostitution to support themselves.
The costs of adolescent pregnancy to society are enormous. In 1990, the U.S. government spent over $25 billion for social and health services and welfare payments to families headed by women who had their first child in their teenage years - an expenditure estimated to be two-thirds higher than if all teenage mothers had delayed childbearing until their twenties. Even in countries which do not provide ser-vices or monetary assistance, greater poverty, combined with lower educational levels and productivity, are important indirect costs to society.
The cost to society also includes health care for pregnant adolescents and their infants including medical care for premature infants and complications of childbirth more likely to occur among adolescents. In 1987, one hospital ward in Northern Nigeria maintained a list of 1,000 girls waiting for surgical repair of vaginal injuries during childbirth. Where adolescents represent a high proportion of hospital admissions for abortion complications and these complications consume a significant share of available funds, adolescent pregnancy also diverts scarce resources from other health problems.
Early childbearing is closely linked to high population growth rates because it shortens the time span between generations and because women who have their first child at a younger age tend to have larger families. In Latin America, women who begin childbearing as teenagers are estimated to have two to three more children than women who delay their first birth until their twenties or later. In South Asia, early marriage and childbearing are closely linked to larger family size and rapid population growth. By contrast, in most East Asian countries, adolescent birthrates are low and average family size is close to or below the two-child population replacement level.
Questions:
To what extent are health problems like AIDS and other sexually transmitted diseases (STDS) associated with adolescent sexual activity?
Answers:
According to WHO, 250 million new cases of STDs occur worldwide each year, the highest rates among 20 to 24 year olds, followed by 15 to 19 year olds. Young people are at high risk of STDs because they may have a series of sexual relationships and are unlikely to use condoms. Moreover, many people with AIDS are infected in their teens. While young men and women are both at risk, the health impact of STDs and the risk of AIDS appear greater for young women.
According to WHO estimates, 1 in 20 teenagers worldwide acquires an STD each year. In Kenya, Nigeria and Sierra Leone, between 16 and 36 percent of youth tested in small-scale studies had one or more STDS. A survey in a Peruvian town found that 23 percent of secondary school males had had an STD. And in the United States, roughly I in 8 teenagers contracts an STD each year.
An important overall risk factor for STDs is having several sex partners or having a partner who has other sex partners. Youth are often at risk because they may have a succession of exclusive but short-term sexual relationships. In many cultures, it is also common for young men to frequent prostitutes - in Brazil, Guatemala and Thailand, for example, a young man's first intercourse is likely to be with a commercial sex worker. Adolescents, particularly girls, are more vulnerable to unsafe sex when they are involved in an unequal relationship, especially with an older partner.
Married adolescent women may have husbands with more than one wife or sex partner. Also at risk are sexually exploited or abused adolescents, including street youth who sell sex for survival. For youth in general, use of drugs and alcohol is also associated with a higher risk of STDs as well as pregnancy.
Use of latex condoms greatly decreases the risk of AIDS and other STDS. However, young people tend not to perceive themselves at risk. Young women in particular may find it difficult to discuss protection with their sexual partners, sometimes even risking violence by suggesting condom use. Anal intercourse, commonly practiced between young men and women in countries like Brazil to avoid pregnancy (as well as between young men), may also promote the spread of AIDS. Worldwide, boys and young men who have sex with other males are at higher risk of STDs for a variety of reasons, including poor access to relevant sexual health information and services resulting from more general societal discrimination.
Although both young men and women are at risk of acquiring STDS, the impact on the health of young women is usually greater. STDs are more easily transmitted to women, are more difficult to diagnose, and result in more serious complications in women. Young women have the added risk that a biologically immature cervix appears more prone to infection. Female genital mutilation can also increase the risk of contracting STDs through bleeding or open infection of scarred areas.
Common STDs can also cause pelvic infection, infertility, a variety of serious pregnancy-related complications, and cervical cancer. For both men and women, infection with an STD appears to increase the risk of acquiring HIV, the virus which causes AIDS, by as much as 10 fold.
Adolescents - especially girls - are at special risk of AIDS. Worldwide, among the 15 million people infected with HIV, rates of infection appear to be highest for women aged 15 to 25 and for males aged 25 to 35. In a study in Rwkita, over 25 percent of pregnant women aged 17 or younger tested positive for HIV. Slowing the spread of AIDS requires changes in the sexual behavior of youth as most transmission is through sexual intercourse and an estimated two-thirds of those who acquire AIDS are infected by age 25.
Questions:
What are the major obstacles to expanding access to sexual health services for youth?
Answers:
In most developing countries, existing laws, policies or practices prohibit or severely restrict access to contraception and abortion for unmarried young people. Most fancily planning programs have done little to reach adolescents. Many programs exclude unmarried youth and health workers often have strong biases against serving them. Moreover, adolescents themselves often have negative perceptions regarding the accessibility and acceptability of existing services.
A study in Asia in the early 1980s found that only two countries- Thailand and Hong Kong-allowed access to contraception without restrictions based on age or marital status. According to a more recent survey of adolescent reproductive health programs in developing countries, many African and Asian programs for young people primarily serve older, married youth, while in Latin America, more programs serve unmarried youth under age 20. Efforts to improve adolescent health are typically developed within the context of health policies for children or adults and are characterized by poor coordination between education, health, and family planning services.
At a practical level, most family planning programs aim to help married couples limit or space births, rather than to help adolescents avoid first pregnancies and STDs. Clinic staff often refuse to provide unmarried or childless adolescents with contraceptives. In a study in the United States, use of services by adolescents depended on three factors: dissemination of information regarding the availability of services, guaranteed confidentiality, and affordability of services. Surveys in several countries indicate that adolescents are often reluctant to use existing services for adults because they are afraid of discovery by family members or other adults they know, or of being reprimanded or turned away by clinic staff. Proximity of services and access to transportation, convenience of clinic hours, and supportiveness of clinic staff are other factors which appear to influence use of family planning services by adolescents.
Young women generally have less access to safe abortion services than older women because they are less likely to know where services are available or to have adequate funds. They may also find it difficult to obtain parental consent where required. Adolescents are also more likely to deny or be unaware of a pregnancy and to delay a decision to have an abortion. However, in some settings adolescents may perceive abortion to be more accessible or acceptable than contraception, even when available under unsafe conditions. Group discussions with youth in Kenya and Nigeria, for example, revealed that they had more positive attitudes and better information about illegal abortion than about contraception.
Questions:
What elements should a comprehensive sexual health policy for adolescents include?
Answers:
Societies need to acknowledge adolescent sexual activity and recognize the special sexual health needs of young people. The key elements of a comprehensive strategy are universal sexuality education, linked to easily accessible and affordable contraceptive and safe abortion services. A truly comprehensive approach should also include broader social initiatives to expand education and employment opportunities for girls and to eliminate traditional practices that harm the health of young women and girls.
Sweden, which has among the most progressive policies in the world on adolescent sexual health, has adopted a comprehensive approach which includes universal sexuality education; special adolescent clinics closely linked to schools; free, widely available and confidential family planning and abortion services; extensive advertising of contraceptives in the media; and widespread availability of condoms. Governmental efforts have emphasized pregnancy and STD prevention, rather than promoting abstinence alone. Although the average age of first intercourse - 16 years - is quite young in Sweden, teenage birth rates are low, at II births per 1,000 women age 15 to 19.
Efforts to prevent early childbearing must also recognize that adolescent sexual activity and pregnancy is closely linked to the extent to which women derive their social status from bearing children and to which young women have alternatives to motherhood. Studies in different regions of the world have shown that girls who aspire to finish secondary school are less likely to become pregnant. In some countries, adolescent girls become pregnant after dropping out of school or terminating their education for other reasons. In sub-Saharan Africa and elsewhere, the nature of economic activity and the extent of women's participation in the labor force are closely linked to the age at which women have their first child.
Recognizing these links between adolescent pregnancy and education and employment opportunities, some private organizations in countries such as India, Mexico and Nigeria have worked to improve girls' self-esteem, delay pregnancy, and promote other opportunities for girls. In other countries, comprehensive efforts to improve adolescent sexual health have included legislation and community education to end traditional practices that are directly or indirectly harmful to the health of young women - such as female genital mutilation and child marriage.
Questions:
What is sexuality education? What should most sexuality education programs seek to achieve?
Answers:
Sexuality education is intended to improve knowledge and understanding of sexual development, human reproduction, and healthy sexual behavior among children and youth. The explicit aim of many sexuality education programs is to help young people practice responsible sexual behavior, including where appropriate, the delay of sexual activity. Programs have also sought to improve communications between youth, their parents and their partners.
Worldwide, youth are often poorly informed about sexuality. In a study in Sri Lanka, one quarter of youth surveyed thought a woman could get pregnant by wearing clothes previously worn by a man. Although many adolescents who use a contraceptive method practice rhythm or withdrawal, in two recent studies in Kenya and Mexico City, the vast majority of young people interviewed could not correctly identify the fertile period in a woman's menstrual cycle. Sexuality education promotes healthy and responsible sexual behavior by providing basic, relevant information, as well as by providing a positive context for youth to discuss the emotional and physical aspects of sexual relationships.
Many sexuality education programs encourage youth to delay first intercourse. However, the results of studies evaluating the success of such programs in delaying sexual activity are mixed. In the United States, programs which only promote abstinence have generally not shown decreased rates of sexual activity, although such programs may be more effective with young adolescents who have not yet had sex. Overall, programs which encourage postponement of sexual activity while also providing information about safer sex and contraception appear to be more effective than those which promote abstinence alone. Sexuality education appears most effective in delaying first intercourse and encouraging contraceptive use among sexually active youth when introduced early, before young people become sexually active.
Some programs seek to help youth discuss sexuality more openly, by using storytelling, drama or role play to help youth communicate their feelings. Research in Africa sponsored by WHO, in which thousands of adolescents were asked to describe a typical first sexual experience, reveals a common experience of poor communication about sexuality between youth and their parents, as well as a lack of mutual discussion between youth in their sexual relation ships. In Ugkita, for example, a survey found that many youth were reluctant to use condoms, apparently because condom use was associated with prostitutes and could be perceived as a lack of respect by young men for their partners.
Sexuality education programs have also sought to promote the idea of responsible parenthood among adolescents. Young men are often neglected by sexuality education and pregnancy prevention programs despite their role in initiating intercourse and their influence on contraceptive use. Some programs have sought to address the issues young men have regarding contraception and to increase their sense of responsibility for pregnancy and fatherhood.
Questions:
What characterizes a successful sexuality education program?
Answers:
Effective sexuality education programs teach practical skills such as sexual negotiation, decision-making and life planning, in addition to providing basic information on human reproduction, contraception, STDs and AIDS. Ideally, such programs are specially designed to respond to adolescents' needs. Many existing programs, however, fall short of these standards.
Traditionally, sex education courses have emphasized reproductive physiology. But teaching practical skills, such as how to negotiate condom use or say 'no" to sex, is also important. Research suggests that knowledge alone is not enough to change sexual behavior - youth must understand the long-term consequences of unsafe practices and feel empowered to practice healthy sexual behavior. A "Life Planning Education" curriculum, developed by the U.S.-based Center for Population Options and adapted for use in a variety of international settings, helps adolescents plan for their futures as well as deal with sexual feelings and behaviors. The curriculum includes topics such as values, goal setting and decision-making, sexuality, contraception, AIDS, parenthood and employment.
More effective programs utilize participatory rather than authoritarian styles of teaching, encouraging discussion rather than moralizing about unmarried sexual activity. They employ teachers specifically trained to work with adolescents on sexuality issues and use educational materials that are culturally and age-appropriate. Peer education programs have been very effective, as trained youth leaders can be influential role models and credible sources of information about sexuality, contraception and other topics. Young people who are HIV-positive or have AIDS are particularly successful at reaching youth with messages about AIDS prevention.
Over the past decade, sex education or family life education programs have been widely introduced in schools around the world and, on a more limited basis, have tried to reach out-of school youth. Unfortunately, the content of many existing sexuality education programs is not relevant to the information needs of young people. Kenya's family life education program avoids words like vagina and uses animal rather than human examples to teach reproductive physiology. Other programs emphasize global demographic problems or caution against premarital sexual activity without providing basic information on practical ways to prevent pregnancy and disease.
Questions:
Do young people have any special needs with regard to contraceptive counseling and services?
Answers:
Adolescents often have special concerns about contraception which need to be addressed by family planning and health workers. Youth may require more extensive counseling than adults before they feel comfortable choosing and using a method. Given the high risk of STDs to adolescents, counseling should emphasize the importance of condoms - used alone or with other methods.
Numerous studies have shown why sexually active adolescents fail to use contraception. Adolescent sexual activity is often unplanned and infrequent - making routine contraceptive use less likely. Moreover, research shows that youth in a number of countries typically feel that planning for sex is bad, since it requires them to acknowledge that they are sexually active in the face of cultural taboos against such activity.
Adolescents may not understand their own personal risk of pregnancy or disease. They often know little about various contraceptive options or find contraceptives too difficult to obtain. Young people may have fears about the health risks of specific contraceptive methods, feel unable to negotiate contraceptive use with their sexual partner, or fear parental discovery and disapproval. In some countries, a significant proportion of married or unmarried youth may also desire pregnancy.
These broad concerns of youth can be addressed through counseling. Youth may want to discuss with trained counselors whether or not to be sexually active, whether they want to use contraception, how their partner feels, and how their parents might react In choosing a contraceptive method, adolescents generally require more information about basic reproductive physiology and contraception than most adults. Counselors also need to be sensitive to the needs of youth who may be engaging in homosexual activity.
With the exception of contraceptive sterilization and IUDS, which are not appropriate options for most youth, most available contraceptive methods are safe and appropriate for adolescents. Oral contraceptives are highly effective in preventing pregnancy and are considered safe for adolescent girls. However, hormonal methods in general do not provide protection against AIDS or most other STDS. Barrier methods, particularly latex condoms, offer adolescents some distinct advantages. Condoms are well suited for infrequent sexual activity and are often less expensive and easier to obtain than other methods. Most importantly, condoms provide a high degree of protection from HIV and many other sexually transmitted infections.
Once a method is chosen, adolescents, like other family planning clients, need to be counseled about possible side effects and appropriate follow-up care. Health workers need to help youth assess their risk of STDs and encourage condom use in addition to other methods, where appropriate. Whatever method is chosen, health personnel should take time to respond to questions and fully explain correct use, to avoid potentially harmful misconceptions. In Mexico City, for example, a survey of young women found that 60 percent incorrectly believed a condom could be used more than once.
Questions:
What types of programs have been effective in addressing the special sexual health needs of adolescents? And what strategies have been successful in reaching out-of-school youth?
Answers:
Different models have been developed AO to provide sexual and reproductive health services to young people. They include clinics which provide reproductive health services only, as well as centers which provide contraceptive services as one element of more comprehensive activities for youth. Programs which provide education and contraceptives at the community level represent yet another model. Special programs have also been developed to reach specific groups, such as married adolescents or street youth.
Special clinics for young people are more common in Western Europe, the United States, and Latin America. School-based clinics typically address a range of student health needs, of which reproductive and sexual health is just one element; contraceptives are often offered on a referral basis only. More specialized reproductive health clinics for adolescents generally provide contraceptive counseling and supplies, and perhaps treatment of STDs and other reproductive tract infections among other services. More recently, special clinics for youth have been established by national family planning associations in several countries in Africa and Asia, including Burkina Faso and Indonesia.
Where special clinics for adolescents have not proved feasible, some existing family planning clinics have introduced separate hours, entrances, or other modifications to make services more acceptable to young people. Hospital-based postpartum and post-abortion programs have also been developed to serve adolescent mothers who want to delay a subsequent pregnancy. These programs have sometimes extended services to other adolescents as well, through word-of-mouth or more formal outreach efforts.
A second model of service delivery has been the multi-service youth center, offering reproductive health services in combination with a broad range of recreation, education or employment-oriented activities. Addressing reproductive health within a more comprehensive program tends to be more socially acceptable, and recreation and other activities often attract young people to the centers. Such centers tend to require more resources, serve small numbers of youth, and focus less on reproductive health. However, successful programs such as CORA (Centro de Orientacion para Adolecentes) in Mexico City and the Women's Centre for pregnant adolescents and young mothers in Kingston, Jamaica, demonstrate the value of a comprehensive approach.
Community-based outreach programs represent a model that generally requires fewer resources. These programs usually include educational activities, and in some cases, contraceptive distribution and clinical referral. Community outreach programs tend to be most effective when youth are involved as peer educators and counselors, as in the Gente joven program in Mexico. Large-scale educational campaigns have also used popular media such as comic books, posters, films, radio and television to communicate important sexual health messages to youth. To be effective, such campaigns also need to inform youth about where to obtain actual services.
Most of these programs can be adapted to serve youth who are both in and out of school. Services aimed at out-of-school youth, however, must be designed to be easily accessible to them and may involve a variety of approaches. In the CORA program in Mexico City, youth leaders are trained in factories as well as schools to be peer educators and distribute barrier methods. Casa de Passagem, an organization working with street girls in Recife, Brazil, provides reproductive and other health services along with income earning opportunities, shelter, and counseling.
Questions:
What do we know about the impact and success of these programs in meeting the sexual health needs of young people? What kinds of programs are most cost effective?
Answers:
Successful programs for adolescents carefully assess and respond to local need; involve youth in various aspects of program planning, implementation and evaluation; and reach out to community leaders and parents for involvement and support. Few programs, especially in developing countries, have been rigorously evaluated for cost-effectiveness and impact. However, experience suggests a combination of specially-targeted approaches may best meet the needs of different groups of youth.
Successful adolescent reproductive health programs are strongly commited to involving young people, using youth on advisory committees in the planning process and as educators, promoters or counselors in program implementation. In Zimbabwe, for example, educational materials for young people were developed following group discussions with youth and a national survey of young adults.
Involving the community - including influential community leaders - improves the likelihood that a project will be effective and sustainable. Parents, other involved community members, and youth themselves can be important sources of support in the controversial area of adolescent reproductive health. Introducing new programs often requires political sensitivity. The MUDAFEM project in Nigeria, for instance, initially limited services to students at the University of Ibadan - with the intention of eventually extending them to younger age groups.
Less tangible factors linked to program success include the quality of relationships program staff-establish with youth. Programs which organize around specific goals and messages may also be more effective at promoting healthy sexual behavior than programs that merely make services available. A recent evaluation of six school-based health clinics in the United States, for example, found that clinics which emphasized the themes of pregnancy and AIDS prevention were more effective at increasing pill and condom use than clinics that only provided services.
Overall, there has been little formal evaluation of adolescent programs, in part, reflecting the resource constraints facing most fledgling programs and the priority such programs have given to direct provision of services. More evaluation is needed to understand which youth these programs are serving and what makes them effective. However, experience suggests that providing services through a variety of different programs may be important.
For example, a study in Monterrey, Mexico, found a community based peer program to be one-third less costly per contraceptive user than a multi-purpose youth center. However, the youth center attracted and served young unmarried girls as well as boys while the community program primarily served boys, suggesting that the two approaches were complementary. Considerations other than cost may, therefore, be important in efforts to make services more widely available to youth.
Sebetulnya, apa yang terjadi hingga akhirnya remaja memiliki dunia sendiri. Mengapa para remaja seringkali merasa tidak dimengerti dan tidak diterima oleh lingkungan sekitarnya? Mengapa remaja seolah-olah memiliki masalah unik dan tidak mudah dipahami, sehingga membuat orang di sekitar menjadi sangat membatasi reaksinya terhadap lingkungan? Sampai kapanpun semua itu akan selalu menjadi pertanyaan-pertanyaan yang bersifat klasik. Didasarkan atas kepercayaan orang-orang terdekat mereka, tentu saja akan memiliki kepuasan tersendiri karena aksen-aksen yang dilontarkan oleh mereka ke dalam lingkungan mendapat dukungan penuh. Artinya, setiap orang punya persepsi yang berbeda-beda di dalam mengartikan pernyataan-pernyataan tersebut, tentu saja tidak hanya sebatas pada pertanyaan-pertanyaan ringan dan berat. Belum tuntas bila tidak dilengkapi dengan jawaban-jawaban yang memberikan pandangan khusus bagi kehidupan pribadi anak remaja. Karena itu penjelasan lebih dalam sepertinya hanyalah ada dalam diri pribadi sebagai orang terdekat dengan mereka. Concernnya ialah kita perduli pada generasi, berarti kita adalah orang yang mampu menemukan jawaban sebenarnya yang memang sangat dibutuhkan.
Kualitas dan kuantitas perhatian sebenarnya tidak selalu membuat anak remaja secara utuh mengharapkannya. Namun kualitas dan kuantitas perhatian saja tidak akan lengkap bila tidak ada pengertian dari orang terdekat dengan mereka. Apalagi ketika usia anak remaja tersebut sudah berada digaris transisi gaya hidup anak remaja masa kini. Apa yang akan dikatakan oleh orangtua bila anak remaja kesayangannya bertingkahlaku diluar kewajaran interaksi sosialnya. Akibat sebagai hasil dari proses adalah akan menjadi beban yang sulit dilepas dari dalam kepala orangtua. Namun, bila adanya keseimbangan antara kualitas, kuantitas perhatian dan pengertian orangtua tidak akan merasa terbebani oleh permasalahan anak remaja kesayagannya terutama antara personal dengan lingkungan.
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