Handbook of Adolescent Gynecology & ARSH (Adolescent Reproductive and Sexual Health) Swati Y Bhave, Ashwini Bhalerao Gandhi
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Introduction

Importance of ARSH1

Swati Y Bhave
 
INTRODUCTION
Adolescents like to experiment and experience new things, which they enjoy as adventures, this is called risk taking behavior. This applies to sex also. A large number of adolescents enter into sexual activity that is either spontaneous or unplanned or under coercion, without having any knowledge whatsoever of the risk of pregnancy and sexually transmitted diseases. This leads to the increasing number of unwanted pregnancies and increasing incidence of sexually transmitted diseases. Due to lack of information and embarrassment adolescents have poor health seeking behavior on issues of reproductive and sexual health ARSH. To prevent this we have to give sexuality education and make ARSH services available and accessible to both married and unmarried adolescents.
The aim of human sexuality education is to provide accurate and correct knowledge about human sexuality and the hidden dangers involved in reckless experimentation. This will help them to take informed and correct decisions at the appropriate time. Most people oppose programs that teach or discuss ARSH as they believe it will lead to promiscuity, though research by WHO has shown that age appropriate sexuality education delays the age of first intercourse, and increases practice of safe sex, reducing the consequences of early and unsafe sex like unwanted pregnancies and sexually transmitted diseases including HIV /AIDS. As health workers we need to increase awareness in the community that sexuality and HIV education programs do not lead to increase in sexual activity.
Most adult are uncomfortable in discussing sexual matters with adolescents, some have religious taboos. As a result most adolescents lack basic reproductive health information, and skills in negotiating sexual relationships, and access to contraception
The International Conference on Population and Development (ICPD) Program of Action in 1994 called for organizations to initiate or strengthen programs to better meet the reproductive health needs of adolescents.
ARSH concerns have been ignored due to social taboo, related to issues of sexuality. This is true even in case of married adolescents Focusing on adolescent reproductive health is both a challenge and an opportunity for health care providers.
 
EARLY MARRIAGE AND EARLY PREGNANCIES
In India, teenage pregnancies are mainly unintended and unwanted, both in and outside wedlock. Girls are married very early inspite of the law. They cannot take a decision for use of 2contraception and are dependent on the male partner and a couple is forced to prove fertility by producing a child in the very first year of marriage.
The census 2001 shows that nearly 20% girls under the age of 15 years are already mothers and there is a high incidence of maternal and fetal morbidity and mortality.
According to NFHS 2, 43% of women are married before they attain 18 years of age and TFR amongst 15-19 years old is 19% of the total fertility.
 
ASSOCIATED RISKS IN TEEN PREGNANCY
Adolescent girls are still growing. Becoming pregnant in this period is like a “child growing in a child”. Early marriage pushes the girls into early child bearing and the associated risks include hemorrhage, anemia, delayed or obstructed labor, low birth weight of the baby, miscarriage, damage to the reproductive tract and in some cases, even death of the mother. More than 70% girls in the age group of 10-19 years suffer from severe or moderate anemia (DLHS-RCH 2004). Female mortality rates are higher as compared to males during 15-24 years.
 
POOR USE OF CONTRACEPTION IN ADOLESCENTS
Among currently married women of 15-19 and 20-24 years age, 5.4 and 16.0 percent respectively ever use a condom. Consistent condom use remains low, only 2.5 in age group 15-19 years and 7.4 percent in age group 20-24 years are currently using condom.
Nearly 27 percent of married female adolescents have reported unmet need for contraception (NFHS-2).
 
UNSAFE ABORTIONS
Unwanted pregnancies lead to the seeking of abortions. Since parental consent is required for unmarried girls under 18 a large number of them resort to unsafe abortions which account for up to 13% of all maternal deaths and 50% of all maternal deaths in the 15-19 age group. Many married women also resort to unsafe abortions for issue of confidentiality: 38-68% of abortion complications are in women under 20 years of age.
 
STDs
Adolescents have a higher risk of sexually transmitted diseases and unwanted pregnancy because of many factors: sex is generally impulsive and unplanned hence protection is rarely used. They have lack of knowledge about contraception and STIs, including HIV They think they are invincible and do not perceive themselves to be at risk. Those that have knowledge find it difficult to have easy access to condoms and other contraceptives. They often have high risk sexual behavior involving multiple partners.
Adolescent girls are at a higher risk of contracting HIV and other sexually transmitted infections due to the immaturity of their reproductive system and also because they are often not in a position to say no to the sexual intercourse that may be inflicted upon them.
More than 35-50% of AIDS cases are occurring in the 15-24 years age group mainly through unprotected sex.
 
POOR EDUCATION STATUS ESPECIALLY IN GIRLS
The age of marriage must be delayed. In early marriages the first conception must be delayed with appropriate use of contraception. To empower women in decision making they have to be literate. Global data has proved that the health statistics improve if women are literate. This is well seen in Kerala state.
But we have a dismal situation of education of adolescents specially of girls in India, 25% of the 15-19 years age group in rural areas and 10% in urban areas are illiterate. Girls account for less than 50% enrollment at all stages of schooling. Enrollment figures are improing but dropout rates are high – 68 percent from class I to X.
3Young people not at school join the workforce at an early age – nearly one out of three adolescents in 10-19 years is working.
 
EXTENDED ADOLESCENCE AND DELAYED MARRIAGES
On one hand we have early marriages and early pregnancies in the rural areas. On the other hand in the urban areas due to higher education there is extended adolescence and very late marriages Majority of girls are getting married after age of 25 years and boys after 30 years due to higher academic persuits. So though the chronological age is higher they still have ongoing adolescent age situation. This long gap between puberty and marriage leads to increasing incidence of premarital sex. Unmarried adolescent boys are far more likely to be sexually active and approve of premarital sexual activity than adolescent girls (Jejeebhoy, 1996). Sexual activity among males was reported at as early as 11 years. For one-third of males, the first sexual partners are sex workers (BSS, 2001, NACO, GOI).
Though we would want them to practice abstinence, it is not possible for many youth to continue doing so and hence we need to empower them to practice safe sex. We need to acknowledge their sexual urges and not remain on high moral grounds. If young couples use effective methods of protection against pregnancy and STIs, and if their decision to enter into a relationship is voluntary, then adverse psychological impact and medical risks are minimized. Adolescents can engage in healthy, fulfilling sexual relationships, and we should not always focus only on the negative outcomes.
 
SEXUAL ABUSE AND RAPE
Most of the rape victims are in the age group of 14-18 years. In 82 percent of rape cases, the victims knew the offenders. Majority of victims did not understand that they are being sexually abused and had no knowledge or skills to protect themselves.
Most adolescents lack the necessary know-ledge of RSH. The information may not be enough to clarify the various doubts they have about sexual activities. Many times information is given without empowering them with skills that help them to take decisions at the proper time and protect themselves.
 
SUBSTANCE ABUSE IN ADOLESCENTS LEADS TO INCREASE IN SEXUAL EXPERIMENTATION AND ADDS TO THE ARSH BURDEN
Drug abuse rate is low in early adolescence and high during late adolescence.
The estimated number of drug abusers in India is around 3 million and that of drug dependents is 0.5 - 0.6 million, more in the North-Eastern states of the country. Most drug users are in the age group 16-35 years. 21 percent of 40,000 male drug users in a household survey were in the age group 12-18 years.
 
DIFFICULTIES IN DELIVERING ARSH SERVICES TO UNMARRIED ADOLESCENTS UNDER 18 YEARS IN A CLINICAL PRACTICE
As per the law in our country the parent or guardian consent is required for medical examination and treatment for children under 18 years. While this does not raise any problem in majority of the medical problems, in fact it is essential and desirable to have parental involvement, this leads to a very tricky situation when an adolescent comes with issues of RSH when the adolescents are very reluctant to have the parents involved.
This puts the practicing clinician in a most difficult position. Obviously the law cannot be broken at the same time as a physician the “best interests of the patient” are ethically important. As we start taking care of adolescents patients in our adolescent friendly centers we will be faced with various dilemmas. If an unmarried girl of 16 comes to the gynecologist for an MTP and does not want parental involvement and will go 4to a quack and undergo a risky unsafe abortion, how does the gynecologists obstetrician help the girl without breaking the law? If an unmarried girl or boy comes for contraception or treatment of STD, how to give these services without informing the parents specially if the parents happen to be your patient as well ! How to ask for a HIV testing without parental consent?
Clinicians need to develop their counseling skills to develop rapport and help the adolescent to confide and seek support and help from the parents, a most difficult situation indeed !In the West in many centers children in chronic disease and terminal illness are allowed to participate in decision making of their treatment protocols. Children from the age of 7 years have cognitive development to understand risk and benefits to be able to make a decision.
As clinicians dealing with adolescents we need to advocate change in laws that will enable us to give RSH services to adolescents without breaking their confidentiality.
 
SUMMARY
As health care professional dealing with adolescent health issues we need to recognize the importance of RSH and help in spreading awareness and doing advocacy for sexuality education in the community and schools. We also need to strengthen our services to deliver to both married and unmarried adolesents.
SUGGESTED READING
  1. Census 2001. Office of the Registrar General India.
  1. CSO. 2002. Women and Men in India.
  1. DLHS-RCH (District Level Health Survey - Reproductive and Child Health), 2002.
  1. DWCD. GOI and UNICEF; NACO and UNICEF, 2001. Knowledge, attitudes and practices of young adults (15-24 years).
  1. International Conference on Population and Development (ICPD). Programme of Action. New York: United Nations Population Division, Department for Economic and Social Information and Policy Analysis (1994).
  1. MICS (Multiple Indicator Survey). 2001.
  1. Ministry of Health and Family Welfare; IIPS and ORC Macro. 2000.
  1. Ministry of Home Affairs, GOI; NNMB (National Nutrition Monitoring Bureau) 2001.
  1. National Family Health Survey 1998-99; 2002-03.
  1. National House Household Survey on Drug Abuse in India.
  1. NCRB (National Crime Records Bureau) 2001.
  1. NSSO (National Sample Survey Organisation) 2001.
  1. 55th Round; SRS (Sample Registration System Statistical Report) 1999. Registrar General, India.
  1. UNODC and Ministry of Social Justice and Empowerment, 2004.