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UNDP/UNFPA/WHO/World Bank Special Programme of Research,
Development and Research Training in Human Reproduction
Sexual relations among
young people in developing countries:
evidence from WHO case studies
AnnDenise Brown, Shireen J. Jejeebhoy, Iqbal Shah, Kathryn M. Yount
Department of Reproductive Health and Research
Family and Community Health
World Health Organization
Geneva
WHO/RHR/01.8
Distribution: GENERAL
WHO/RHR/01.8
© World Health Organization 2001
This document is not a formal publication of the World Health Organization (WHO),
and all rights are reserved by the Organization. The document may, however, be freely
reviewed, abstracted, reproduced or translated in part or in whole, but not for sale or in
conjunction with commercial purposes.
The authors are responsible for the views expressed in this document.
Copies of this document are available on request from:
Department of Reproductive Health and Research
World Health Organization
1211 Geneva 27
Switzerland
Fax: 41-22-7914171
E-mail: rhrpublications@who.int
Contents
Executive summary ................................................................................................... 1
Introduction ............................................................................................................. 3
Background .................................................................................................... 3
The context of sexual relationships among young people ........................................ 6
Sexual debut .................................................................................................. 6
Nature of sexual partnerships ....................................................................... 10
Sexual coercion ............................................................................................ 16
Consequences of unsafe sexual activity ................................................................. 21
Sexually transmitted infections ...................................................................... 21
Unwanted pregnancy .................................................................................... 21
Abortion ....................................................................................................... 23
Family Support following an unplanned pregnancy ....................................... 27
Informed choices among youth: the content and sources of information ................ 29
Common misperceptions .............................................................................. 29
Sources of information ................................................................................. 33
Gender imbalances influencing risky sexual behaviour ............................................ 37
Summary and recommendations ............................................................................ 43
Programmatic recommendations ................................................................... 43
Research recommendations .......................................................................... 45
References ............................................................................................................. 48
Annex 1: Summary description of the studies ........................................................ 51
Acknowledgements
A grant from the Population Council’s FRONTIERS Project supported the work on this over-
view and is gratefully acknowledged. The authors would like to thank Ms. Nicky Sabatini-Fox
and Mr. Mark Nunn for their assistance in preparing the document.
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 1
EXECUTIVE SUMMARY
Since the late 1980s, the UNDP/UNFPA/WHO/World Bank Special Programme of Research,
Development and Research Training in Human Reproduction (“the Programme”) has supported a
number of social science research initiatives on under-investigated areas of sexual and reproductive
health care. Four of these initiatives—on the dynamics of contraceptive use, the determinants and
consequences of induced abortion, sexual behaviour, and the role of men—also covered the needs
and perceptions of young people.
These four initiatives comprised 146 research projects and, of these, 34 studies in 20 countries in
Africa, Asia, and Latin America addressed young people, including adolescents (aged 10–19 years)
and youth (aged 15–24 years). Fieldwork for these case studies was conducted chiefly between
1992 and 1996. A summary review of the studies is now available from the Programme.
The studies cover a variety of sociocultural settings. In some, premarital sexual activity is taboo,
using contraception is forbidden among unmarried youth, and abortion is viewed as the only solution
to premarital pregnancy among adolescents. In others, premarital pregnancy may be condoned and
childbearing among unmarried women is not unknown.
Most studies focus on unmarried youth. However, some focus on special groups such as pregnant
young women or those who have terminated a pregnancy, young reproductive health seekers in
general, or young clients of services for sexually transmitted infections (STIs).
Many common themes emerge from these studies. In every setting, sexual activity begins during
adolescence among many young people. Much of this activity is risky—contraceptive use is often
erratic, and unwanted pregnancy and unsafe abortions are observed in many settings. Sexual
relations may be forced. There are wide gender-based differences in sexual conduct, and in the
ability to negotiate sexual activity and contraceptive use. Despite this, relatively few young people
think they are at risk of disease or unwanted pregnancy. Awareness of safe sex practices seems to
be superficial, and misinformation regarding the risks and consequences of unsafe sex is wide-
spread.
This paper reviews these and other findings, discusses their implications for policies and pro-
grammes, and highlights research gaps. For the sake of consistency, the term “youth” is used to
refer to young people of all ages between 10 and 24.
A number of recommendations are offered on the basis of the summary review of these case
studies. These include programmatic recommendations to build negotiation skills, dispel misconcep-
tions, counter sexual violence, involve young people in programme design, tailor fertility regulation
services to meet young people’s needs, and communicate the message that every unprotected
sexual act risks disease and unwanted pregnancy.
The review suggests a need for more in-depth behavioural research on the perspectives and experi-
ences of youth in different settings. It points to the need to study positive outcomes, in addition to
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
2
risk assessment, and stresses that research should explore the ways in which gender roles and
power imbalances affect life skills among youth and how social constraints make young women
particularly vulnerable and unlikely to exercise choices relating to their sexual and reproductive
lives. Research is also needed to document how young women can exercise greater autonomy.
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 3
INTRODUCTION
Since the late 1980s, the UNDP/UNFPA/WHO/World Bank Special Programme of Research,
Development and Research Training in Human Reproduction (“the Programme”) has launched a
number of social science research initiatives to improve knowledge of under-investigated but
crucial areas of sexual and reproductive health. Adolescents and youth have not always been the
primary focus of these initiatives, nor have data always been gathered with the intention of analys-
ing the perspectives and behaviours of young people. Nevertheless, several Programme-supported
case studies under research initiatives relating to the dynamics of contraceptive use (1988), the
determinants and consequences of induced abortion (1989–90), sexual behaviour (1991–92), and
the role of men in reproductive health (1995–96) extended their investigations to explore the needs
and perspectives of young people. Despite the diversity of study designs and varying degrees of
emphasis on young people, many themes emerge from this body of research which shed light on
young people’s extent of involvement in, and patterns of, sexual and reproductive behaviour. The
objective of this paper is to review and document the findings emerging from these studies, and,
thereby, to highlight the sexual and reproductive health situation of young people.
Background
Under the above-mentioned four initiatives, 146 research projects were supported in 21 developing
countries. Of these, 34 studies in 20 developing countries in Africa, Asia, and Latin America ad-
dressed young people, including adolescents (aged 10–19) and youth (aged 15–24). Fieldwork
relating to these case studies was largely conducted between 1992 and 1996. Several case studies
focused specifically on adolescents or youth. Others covered subjects of a wider age range, but
were designed to present findings independently on the sexual and reproductive behaviour of youth.
All these studies were conceived and implemented by scientists from developing countries applying
research questions and protocols appropriate to their own context. As a result, studies include a
broad range of designs and methodologies.
It is important to note that the studies included in this paper were not nationally representative.
Almost all were case studies and their findings were not intended to be generalised to the country or
region in which they were conducted. Also, the distribution of included countries is not representa-
tive of developing countries more generally. To a considerable extent, the distribution of countries
represented here reflects the fact that studies dealing with highly sensitive issues are more culturally
acceptable in some settings than in others. Finally, it must be noted that the Programme was able to
support only a small proportion of the large number of proposals submitted under the above initia-
tives.
Annex 1 lists all the case studies included in this paper, providing information on: study site and
populations; composition of the sample in terms of age, sex, and marital status; and sample size and
design.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
4
The studies included here cover a large number of sociocultural settings, with wide disparities in the
context of the sexual and reproductive behaviour of young people. In some settings, for example,
premarital sexual activity is considered taboo, using contraception is forbidden among unmarried
youth, and abortion is viewed as the only solution to premarital pregnancy among adolescents (as
evident from, for example, case studies in Hanoi and Ho Chi Minh City, Viet Nam, and sites in
Seoul, Kyongbuk, and Kyongnam in the Republic of Korea). In others, premarital pregnancy is
more likely to be condoned, and childbearing among unmarried women not unknown (as evident
from case studies in Cuba, for example).
The samples of subjects in the studies varied. The majority of studies address the perspectives and
behaviours of females and males, and most focused on the subpopulation of unmarried youth.
However, some case studies focused on special groups, such as pregnant young women or those
who had terminated a pregnancy, young reproductive health seekers in general, or young clients of
services dealing with sexually transmitted infections (STIs). The age ranges also varied. The
majority of studies encompassed the 15–24 year-old population––i.e. youth—but some include
younger adolescents (typically aged 13 onwards). Other studies include subjects of a wider age
range, but contained separate analyses of the youth populations which are presented in this paper.
For convenience, the authors used the term youth to refer to samples that spanned adolescence
(10–19 years of age) and youth (15–24 years of age). For the most part, as described in Annex 1,
samples were drawn from among educational institutions, health facilities, workplaces, and,
occasionally from meeting places. A few studies drew their samples from household surveys.
Methodologies employed in the studies also varied. While the majority of case studies reported on
the findings of a survey, several of them combined qualitative methods (focus group discussions or
in-depth interviews) with a quantitative survey, and a few were exclusively qualitative. Studies
employing a survey were about equally divided between those that opted for face-to-face inter-
views and those that employed self-administered questionnaires (one study contained both).
Many common themes emerge from these studies, in spite of their substantive or methodological
differences. In every setting, sexual activity appears to begin during adolescence among a substan-
tial proportion of youth. Much of this activity is risky; the practice of contraception and condom use
is often erratic, and unwanted pregnancy and unsafe abortions are observed in many settings.
Sexual relations are not always consensual: force and coercion are far from unknown. While young
people tend to be generally well informed, they have only patchy in-depth knowledge of issues
related to sexuality. Moreover, expressed norms often conflict with behaviour. Lastly, there are
wide gender-based differences in sexual conduct, and in the ability to negotiate sexual activity and
contraceptive use.
This paper reviews these and other findings, discusses their implications for policies and pro-
grammes, and highlight research gaps. Subsequent sections are organised as follows. Section 2
describes the context of relationships among youth, notably the formation of partnerships, the
magnitude of sexual activity, and the extent to which sexual activity is safe and consensual. Section
3 discusses the adverse health consequences of risky sexual behaviours, including STIs, unwanted
pregnancy, and abortion. Section 4 focuses on the extent to which youth are fully informed of
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 5
healthy sexual practices, and the sources of their information. Section 5 highlights the enormous
gender imbalances that persist in sexual attitudes and decision-making among youth. Section 6
summarises the main findings and recommendations that emerge for programmes and research.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
6
THE CONTEXT OF SEXUAL RELATIONSHIPS
AMONG YOUNG PEOPLE
The case studies suggest that a considerable proportion of adolescents and youth engage in pre-
marital sexual activities that tend to be unsafe. These include: having multiple partners, contact with
sex workers, and erratic use of contraceptives. Furthermore, for a considerable minority of young
people sexual debut and sexual activity are not consensual.
Each study took care to ensure the privacy and anonymity of its respondents. In many studies, for
example, questionnaires, or at least the most sensitive questions, were self-administered; in all, study
participants were reassured by the research team of the confidentiality of their responses. Despite
these efforts, comparisons between females and males, and across regions are difficult to draw
because of prevailing cultural norms and gender-related double standards. Many authors have
commented, for example, on the tendency for young males to over-report, and young females to
under-report, their sexual experiences. Likewise, there may also be a greater tendency to withhold
information on sexual activity among youth in highly conservative settings in which taboos prohibit-
ing premarital sexual activity are strictly observed––e.g. parts of Asia––than in others where
premarital sexual activity is more likely to be condoned or accepted. Hence, while gender- and
culture-specific disparities observed in this section are clear, the magnitude of these disparities is
uncertain.
Studies shed light on a host of issues relating to young people’s sexual relationships, from their
dating behaviours to sexual activity status to coerced
sexual experiences and consistent use of contraception.
These aspects of the sexual behaviours of youth are
reported in this section.
Sexual debut
As age at marriage rises, opportunities increase for premarital friendships, dating, and more serious
partnerships between young males and females. A few case studies have explored the dating
patterns of youth, and findings suggest considerable cultural variation. Among college students in
Dumaguete City, Philippines (Cadelina, 1998), for example, dating is practised by large proportions
of youth, although not on a regular basis. Popular locations for meeting dates, as reported by about
half of all respondents, include movie houses, discotheques, pubs or karaoke bars. Dating does not
involve sexual intercourse for the majority of youth: 22% of those who date in Dumaguete City (9%
and 41% of females and males, respectively) report that dating usually includes sexual intercourse,
although 24% of both females and males report heavy petting.
Among young college students in Hanoi and Ho Chi Minh City, Viet Nam, too, the practice of dating
and having a close relationship (nguo yeu, literally “being a lover”, usually without sexual relations)
is common: 47% of young males and 39% of young females in this study report such a relationship
· “Dating” connotes many
activities for young people.
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 7
(Vu Quy Nhan, 1996). Typically, however, dating comprises chatting (88% females, 73% males);
and for smaller numbers of others, it reportedly includes hand-holding (8% and 17%, respectively),
kissing (3% and 5%) and petting (1% and 5%), but rarely intercourse (0.1% and 1%).
A few case studies explored how aspects of the home environment relate to dating and sexual
behaviour. A case study of adolescents in secondary school and those out of school in three Peru-
vian cities, Lima, Cusco, and Iquitos (Alarcon and
Gonzales, 1996) found that parental permission is usually
sought before young people date: for example, of the 28–
36% of males and 20–32% of females who report fre-
quent socialising, up to half of all males and a quarter of all
females report that they go out even without permission.
Table 1 shows the percentage of youth reporting sexual intercourse and age at debut (where avail-
able) as found in the case studies focusing on a cross-section of currently unmarried youth, as well
as among special populations (youth who are about to be married, seeking health care services, and
so on). Although the case studies were not designed to be similar, questions relating to sexual
activity and age at debut were largely similar across the studies. Results are presented by region.
Several interesting findings emerge which contradict the impression that prevails in many settings
that few unmarried young people are sexually active.
For females, premarital sexual activity varies widely across regions; within each region, however,
rates reported in various case studies are remarkably similar. For example: rates of sexual activity
are concentrated in the 2%–11% range in various settings in Asia; 12%–25% in various settings in
Latin America; and 45%–52% in settings in Sub-Saharan Africa. Of interest is the exceptionally
high rate reported among a sample of about-to-be-married Chinese women in Shanghai who re-
ceived their “obligatory” health examination prior to marriage (Gao, 1998). When marriage is
imminent, premarital sex seems to occur among the majority of women, even in conservative
settings.
The case studies suggest that among males, typically, between one-third and half are sexually
experienced. However, there is considerably more variation than is observed among young females,
both across and within regions. For example, on the low side, 15% of college students in Hanoi and
Ho Chi Minh City (Viet Nam) and 24% of schoolgoing males in Kwangju metropolitan area (Re-
public of Korea)––both in Asia––report premarital sexual activity. At the other end of the spectrum,
there is less regional variation, with highs in the range of 66%–75% reported in all three regions.
Premarital sexual activity is more prevalent among males than among females, although some of
this difference may be attributable to over-reporting among males, and under-reporting among
females. Gender disparities—perhaps somewhat overestimated as a result of cultural norms—are
widest in Asia, where reported rates are at least five times as high among males as among females.
In the Latin American case studies, too, rates are up to twice as high among males as among
females. In the single African case study where sex-specific data are available, the disparity is
much narrower.
· Young males are consider-
ably more likely to be sexu-
ally experienced than are
young females.
Table 1. Premarital sexual activity among youth, 1990s.
Site/country Sample Age
Range
% sexually
experienced Age at sexual debut
(mean or median) Source
Female Male Female Male
Botswana
Phikwe, Mahalapye,
Kang
In- and out-of-school females 13–19 45 Ns1Na2Na Kgosidintsi, 1997
Nigeria
Ilorin University students 15–24 52 73 193173Araoye, 1995
Uganda
Kampala Secondary school students414–17 455
(both sexes) 155
(both sexes) Mathias, 1993
China
Shanghai About-to-be married females visiting clinics
for required physical examination 18–29 69 Ns 21–233Ns Gao, 1998
Korea, Republic of
Export Promotion
Zones
Females working in free trade zone,
unmarried, residing in dormitories, attending
public information programmes
19–29 30 Ns 18–205Ns Kwon Tai-Hwan
et al., 1994
Korea, Republic of
Kwangju Secondary school students 16–21 11 24 183183Gayun, 1996
Korea, Republic of
Seoul Unmarried university students;
Industrial workers 15–29 Ns 36
78 Ns 205
20–215Jong Kwon Lim
et al., 1995
Nepal
Border towns Male residents
Non-residents 18–24 Ns 54
40 Ns 185
175Tamang, 1999
Philippines
Dumaguete City College students 18–24 10 50 183173Cadelina, 1998
Thailand
North and North-
east
Rural household survey 15–24 2 51 185165Isarabhakdi, 1995
Thailand
Bangkok Females, school-going and factory workers 15–19 3 Ns 185Ns Soonthorndhada
A, 1994
Thailand
Chiang Mai Factory workers, married and unmarried 13-25
(unmarried) 675 18
3163Rugpao, 1997
Viet Nam
Hanoi, Ho Chi Minh
City
College students 17–24 2 15 203203Vu Quy Nhan,
1996
Argentina
Federal Capital,
Chubut
Adolescents at public hospitals for
reproductive health services 13–19 44 52 31% at <16 35% at < 16 Pantelides, 1991
Argentina
Buenos Aires Students in final three years of secondary
school 13–19 25 55 20% by age
16547% by age
165Mendez Ribas
et al, 1995
Argentina
Buenos Aires Secondary school students 13–19 23646425% at <15 57% at <15 Kornblit, 1993
Peru
Lima Youth attending night school (2%
males/females married) 10–24 25 66 22% at <15 30% at <15 Villanueva, 1992
Site/country Sample Age
Range
% sexually
experienced Age at sexual debut
(mean or median) Source
Female Male Female Male
Peru
Lima, Cusco,
Iquitos
Secondary school students and out-of-school
adolescents 13–19 12–23742–55815–16514–155Alarcon and
Gonzales, 1996
Peru
San Martin de
Porres
Females attending one night school 10–19 20 Ns 20% at <15 Ns Rodriguez-Lay,
1997
Peru
Lambayeque Household survey in 14 districts 12–19 13 36 Na Na Caceres, 1995
1 Not studied.
2 Not available.
3 Mean value.
4 Females and males combined.
5 Median value.
6 Estimated from report that percentage for overall sample was 34% but male rates were twice those of females.
7 Lima: 23%; Cusco: 12%; Iquitos: 21%.
8 Lima: 43%; Cusco: 42%; Iquitos: 55%.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
10
· Age at sexual debut is
lower among males than
among females.
· Sexual debut most fre-
quently occurs in the home.
· Young males are more
likely than females to report
multiple sexual partners.
Given its association with risk behaviours, age at sexual
debut is presented. The case studies reveal varying ages:
however, it is in Latin America that age at debut appears
notably earlier than in the other two regions. The case
studies report that between 20% and 25% of females
attending night schools in Lima, Peru (Villanueva, 1992)
and San Martin de Porres, Peru (Rodriguez-Lay, 1997), and secondary school in Buenos Aires,
Argentina (Kornblit, 1993) reported sexual debut by age 15, as did 30% of males in high schools in
Lima, and 57% of males in secondary schools in Buenos Aires. In the case studies in Africa and
Asia, typically median ages at debut are 18–20 years among females, and Table 1 gives means15–
20 years among males.
The case studies suggest that where sexual activity
occurs, it occurs, especially at initiation, within the home of
one of the partners. The home was the location of sexual
debut among students in Dumaguete City, Philippines
(Cadelina, 1998), as well as for the overwhelming majority (92%) of young, about-to-be-married
women in Shanghai, China (Gao, 1998). So too in the case study in Lambayeque, Peru (Caceres,
1995), almost half (48%) of sexually active youth reported that sexual initiation had occurred in the
home of one of the partners. Other studies point out, however, that this practice is far more com-
mon among sexually active females than males. For example, among secondary school students in
Buenos Aires, Argentina (Mendez Ribas et al., 1995), females are far more likely to report sexual
relations in the home (76%) than are males (42%). Among college students in Hanoi and Ho Chi
Minh City, Viet Nam, too, sexual activity typically occurs in the home of a partner among two-thirds
of females (63%) and about two-fifths of males (38%) (Vu Quy Nhan, 1996).
Nature of sexual partnerships
Multiple partner relationships were explored in a number
of case studies, but findings may not be comparable
because of variation in reference periods, from twelve
months preceding the survey in a few studies, to lifetime
measures in the majority. Nevertheless, findings summa-
rised in Table 2 suggest that large percentages of sexually
active youth have engaged in sexual relations with more than one partner. There is, however,
considerable inter-study and gender disparity: proportions who have ever experienced sexual
activity with more than one partner ranged from about one in five among sexually active male
college students in Dumaguete City in the Philippines to about three-quarters of young sexually
active males attending health services in Buenos Aires, Argentina (Pantelides, 1991). Of the four
case studies reporting multiple partners among sexually active youth in the recent past (last six or
twelve months), rates range from 25% to 27% in the last 12 months among young men in the border
towns of Nepal (Tamang, 1999) to 69% in the same reference period among younger university
students in Ilorin, Nigeria; number of partners reported by these young men ranged from two to 20
(Araoye, 1996).
Table 2. Multiple partners reported by sexually active youth: percentage reporting two or more partners.
Country Sample Reference Period Age range % reporting 2 or more partners Source
Female Male
Nigeria
Ilorin University students 12 months 15–24 15.9169.82Araoye, 1995
Uganda
Kampala Secondary school students312 months
Lifetime 14–17 9.9
14 Mathias, 1993
Korea, Republic of
Kwangju Students in Classes 9-12 Lifetime 16–21 33 68 Gayun ,1996
Nepal
Border towns Border town residents
Non-residents 12 months
12 months 18–24 Ns4 27
25 Tamang, 1999
Philippines
Dumaguete City College students Lifetime 18–24 19 19 Cadelina, 1998
Thailand
Rural North/Northeast5Rural household survey 12 months 15–24 06317Isarabhakdi, 1995
Argentina
Federal Capital,Chubut Adolescents at public hospitals for
reproductive health services Lifetime 13–19 31 76 Pantelides, 1991
Argentina
Buenos Aires Students in final 3 years of secondary
school Lifetime 13–19 36 72 Mendez Ribas
et al., 1995
Argentina
Buenos Aires Secondary school students 6 months 13–19 15 43 Kornblit, 1993
Peru
Lima Students in night school (2% males and
females married) Lifetime 10–24 8 42 Villanueva, 1992
Peru
Lima, Cusco, Iquitos Secondary schools students and out of
school adolescents Lifetime 12–19 20–36844–659Alarcon and
Gonzales, 1996
1 Up to 3 partners; 12% females report engaging in casual sex.
2 Up to 20 partners; 49% males report engaging in casual sex.
3 Female and male responses combined.
4 Not studied.
5 Refers to percentages reporting sexual relations with casual partners: male: 71%; females: 0%.
6 No females reported engaging in casual sex.
7 71% males reported engaging in casual sex.
8 Lima: 24%; Cusco: 20%; Iquitos: 36%.
9 Lima: 53%; Cusco: 44%; Iquitos: 65%.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
12
Corresponding rates among females are uniformly lower. Lifetime rates range from 8% among
students in night schools in Lima, Peru (Villanueva, 1992) to 36% of secondary school students in
Buenos Aires, Argentina (Mendez-Ribas et al., 1995). For females, only three case studies meas-
ured the number of partners in the recent past: not a single rural female in the North and North-east
of Thailand reported multiple partners in the previous 12 months (Isarabhakdi, 1995). In contrast,
15% of university students in Ilorin, Nigeria reported 2–3 partners in the preceding 12 months
(Araoye, 1996). Likewise, 15% of secondary students in Buenos Aires, Argentina reported two or
more partners in the six months preceding the survey (Kornblit, 1993). Clearly, gender disparities
are wide, with one notable exception. About as many female as male college students in
Dumaguete City, Philippines, have engaged in sexual relations with multiple partners (Cadelina,
1998).
The nature of partnerships at sexual debut and at the time of each study differed markedly between
females and males (Table 3). Over 80% of females in six of the eight studies with data available,
tended to have experienced sexual intercourse with a
steady boyfriend, with marriage in mind. In contrast, far
fewer sexually experienced males initiated sexual activity
with a steady girlfriend, and over one-third in most studies
reported debut with a sex worker. Alarmingly, as many as
82% of young men visiting border towns of Nepal report
recent relations with a sex worker (Tamang, 1999).
Among young males, where multiple partners are cited, a combination of girlfriend/regular partner
and a casual partner (usually a sex worker) is not unusual. A study among rural adolescents in
North and North-east Thailand observed that among sexually active men, 16% reported engaging in
sexual activity with their regular partner as well as with a sex worker, “friend” and/or “loose girl” in
the twelve months preceding the survey (Isarabhakdi, 1995).
Few studies explicitly inquired about homosexual experi-
ence. Those that did are highly selective of region (Latin
America), sex (males), and special populations (STI clinic
attendees). No attempt was made, in any of the studies, to
probe for homosexual behaviour, and results, in some
cases, may well be underestimates. Results from three case studies in Peru reported rates ranging
from 2%––among school-aged adolescents in Lima, Cusco, and Iquitos (Alarcon and Gonzales,
1996, ages 13–19) and a sample of youth outpatients at general medicine services in urban Chile
(Kleincsek, 1994)––through 10% among males in night schools in metropolitan Lima (Villanueva,
1992, ages 10–24) to 13% among literate males in Lambayeque (Caceres, 1995, ages 12–19). In
Asian case studies, a homosexual experience was reported by 6% of university males in
Dumaguete City, Philippines (Cadelina, 1998), and 10% of STI clinic attendees in New Delhi, India
(Grover, 1995).
Two of the case studies inquired about homosexual relations among females: among urban school-
aged adolescents aged 13–19 years in Lima, Cusco and Iquitos, Peru, only 1% reported a homo-
· Young females are more
likely than males to report
sexual intercourse with a
steady partner.
· Homosexual experiences
are not unknown.
Table 3. Sexual partner, at debut or currently.
Female Male
Country Sample Age
Range Friend or
casual contact
at sexual debut
or currently
%
Fiancé/
boyfriend
contact at
sexual debut or
currently
%
Sex worker/
partner at
sexual debut
or currently
%
Friend, or
casual contact
at sexual debut
or currently
%
Fiancé/
girlfriend
contact at
sexual debut or
currently
%
Source
Nigeria
Ilorin University students 15–24 12 85 23 49 31 Araoye, 1995
Korea, Republic of
Export Promotion
Zones
Females in manufacturing
sector, residing in dormitories 19–29 27 73 Ns1Ns Ns Kwon Tai-Hwan et al.,
1994
Korea, Republic of
Seoul Unmarried university students 15–29 Ns Ns 43 11 46 Jong Kwon Lim et al.,
1995
Nepal
Border towns Male residents
Male non-residents2<25
<25 Ns
Ns Ns
Ns 33
82 62
18 3Tamang, 1999
Philippines
Dumaguete City College students 18–24 17 65 17 19 58 Cadelina, 1998
Thailand
North/North-east Rural household survey 15–24 0 100 46 24 30 Isarabhakdi, 1995
Thailand
Chiang Mai Factory workers, married and
unmarried 13–25 6 94 50 37 13 Rugpao, 1997
Viet Nam
Hanoi and Ho Chi
Minh City
College students 17–24 0 100 34 3 63 Vu Quy Nhan, 1996
Argentina
Buenos Aires Students in final 3 years of
secondary school 13–19 2 97 42 11 47 Mendez Ribas et al.,
1995
Peru
Lima, Cusco, Iquitos Secondary school students and
out-of-school adolescents 13.19 Na4Na 19-55 Na Na5Alarcon and Gonzales,
1996
Peru
San Martin de
Porres
Females attending one night
school 10–19 Na 87 Ns Ns Ns Rodriguez-Lay, 1997
1 Not studied.
2 Casual relations.
3 Included with casual contact.
4 Not available
5 8–12% engaged in sex with sex worker and partner at the same time.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
14
sexual experience (Alarcon and Gonzales, 1996); however among a sample of college students in
Dumaguete City, Philippines, 14% reported that their first sexual experience had been with a part-
ner of the same sex (Cadelina, 1998).
Several of the case studies––largely those in Asia––document associations between the consump-
tion of alcohol and risky sexual behaviour among young men (casual and sex worker contacts).
These studies suggest that young people recognise that alcohol reduces social and sexual inhibitions,
and reduces concern about disease prevention and safe
sexual behaviour. For example, large percentages of
female and male university students in Hanoi and Ho Chi
Minh City were of the opinion that alcohol “facilitates”
casual sex (62% and 70%, respectively). In the case study
of the risk behaviour of young men in border towns in
Nepal, researchers found that resident young men who reported alcohol consumption had almost
four times higher odds of having casual sex than young men who did not consume alcohol. Similar
associations were observed in case studies in Thailand among rural males in the North and North-
east (Isarabhakdi, 1995), and urban factory workers in Chiang Mai (Rugpao, 1997), as well as
university students in and around Seoul, Republic of Korea (Jong Kwon Lim et al., 1995). Among
the latter (Republic of Korea), the frequency of alcohol consumption was positively associated with
the number of sexual partners a respondent reported. Among rural men in North and North-east
Thailand, similarly, 59% reported that alcohol consumption typically preceded sexual relations with
sex workers (Isarabhakdi, 1995); among male Korean university students, the corresponding figure
was 80% (Jong Kwon Lim et al., 1995); furthermore, in this study, 79% of college students who
had experienced an STI indicated that they had probably obtained the infection when engaging in
sexual relations after having consumed alcohol.
Case studies report that, between 30% and 90% of males
and between 12% and 90% of females practised some
form of contraception during their first sexual experience
(Table 4). Although the in-school and university students
were more likely than others to have practised contracep-
tion at debut, the practice is not universal, even among
them.
Gaps remain between ever-use and consistent use of
contraceptives (Table 5): for example, while 69% of both female and male college students in the
case study in Dumaguete City, Philippines, had ever used contraceptives, only 53% of males and
56% of females claimed to practise contraception regu-
larly. In Lambayeque, Peru, contraceptive use by youth
was similarly inconsistent––while 45% of all males and
32% of all females had ever used a method, only 13% and
10%, respectively, professed regular use, and only 11%
and 4%, respectively, had used a condom in their last three
sexual contacts. The leading reason for inconsistency of
· Alcohol consumption is
linked to unprotected sex.
· The use of contraceptives
at sexual debut is infrequent,
with females consistently less
likely to report practice than
males.
· Contraceptive use is typi-
cally irregular, and very few
youth report consistent and
correct use of contraceptives.
Table 4. Contraceptive practice at sexual debut, and methods used by adolescents practising contraception
Country Sample Ages Contraceptive use Methods used: condom Method used:
natural methods1Sources
Female Male Female Male Female Male
China
Shanghai About-to-be married females visiting clinics for
required physical examination 15–29 22 Ns243 Ns 40 Ns Gao, 1998
Korea, Republic of
Export promotion
zones
Females in manufacturing sector, residing in
dormitories 19–29 8 Ns Na Ns3Na Ns Kwon Tai-Hwan et al.,
1994
Korea, Republic of
Seoul Unmarried male university students 15–29 Ns 314Ns 71 Ns Na Jong Kwon Lim et al.,
1995
Philippines
Dumaguete City University students 18–24 59 51 25529675 71 Cadelina, 1998
Thailand
Chiang Mai Factory workers, married and unmarried 13–25 Na 387Ns Na Ns Na Rugpao, 1997
Thailand
North/North-east Rural household survey 15–24 2 of 11 7081 of 2 77 1 of 2 4 Isarabhakdi, 1995
Viet Nam
Hanoi, Ho Chi Minh
City
College students 17–24 32 28 14 52 86 48 Vu Quy Nhan, 1996
Argentina
Buenos Aires Students in final 3 years of secondary school 13–19 9098910 73 89 39 16 Mendez Ribas et al.,
1995
Cuba
Havana, Matanzas,
Pinar del Rio
Females attending 4 hospitals for pregnancy
termination or delivery 12–19 20 Ns Na Ns Na Ns Lopez et al., 1997
Mexico
Mexico City Low-income adolescents at Obstetric and
Gynaecology Clinic of a public hospital, ever
pregnant, ever terminated a pregnancy
<20 2 Na Na Ns Ns Ns Ehrenfeld, 1994
Peru
Lima, Cusco, Iquitos Secondary school students and out-of-school
adolescents 13–19 17–4511 Na Na Na 32–4412 Na Alarcon and Gonzales,
1996
1 Includes withdrawal and rhythm.
2 Not studied.
3 Not available
4 31% with girlfriend ; 33% with casual friend; 37% (35% condom) with sex worker.
5 Includes 10% reporting use of condoms and natural methods simultaneously.
6 Includes 8% reporting use of condoms and natural methods simultaneously.
7 % practising contraception at debut was 54% if partner was sex worker and 20% otherwise.
8 % practising contraception at debut was 76% if partner was sex worker; 38% if casual sex partner; 34% if partner was girlfriend.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
16
· Sexually active youth ex-
press a preference for tradi-
tional methods, such as
withdrawal and rhythm.
· Coercive sexual relations
are not uncommon, especially
among young females.
use was a dislike of the method: 49% males and 37% of females attributed non-use to dislike; and
18 of males and 14% females attributed non-use to their partner’s dislike (Caceres, 1995). A case
study from Mexico of ever-pregnant adolescent females reported that sexual activity was largely
spontaneous and without contraception: “When you’re in that boat, you don’t think… We’ll
worry later”, was a typical response (Ehrenfeld, 1994; 1999).
Condom use is particularly erratic. Even though it seems to be a widely-held belief that condoms
were not to be used in regular partnerships or marriage (for example the case studies of: youth in a
barrio in Buenos Aires, Argentina, by Gogna, et al., 1996; university students in Seoul, Republic of
Korea, Jong Kwon Lim et al., 1995; and adolescent factory workers in Chiang Mai, Thailand,
Rugpao, 1997), there is little indication that condoms are regularly used even in contacts with casual
partners or sex workers. In the case study in Lambayeque, Peru, for example, in their relations
with sex workers, only 21% of all males report consistent condom use, while 41% have never used
a condom (Caceres, 1995). Among young factory workers in Chiang Mai, Thailand (Rugpao, 1997),
23% and 16% of males report no or inconsistent condom use in their relations with sex workers
who they visited “regularly” and those who were more “temporary”, respectively; 57% reported
non-use or inconsistent use when the partners were “promiscuous girls”.
A few studies point to inconsistent condom use despite relatively high levels of condom awareness.
Among college students in Ilorin, Nigeria, for example, although over 90% were aware of con-
doms, only 19% and 43% of sexually active females and males, respectively, made use of them.
Among females attending night schools in San Martin de Porres, Peru (Rodriguez-Lay, 1997), while
23% were aware of condoms, under 1% had used them. Evidence from the case study among
schoolgoing adolescent females in Selibe Phikwe,
Mahalapye and Kang in Botswana suggests that, although
out-of-school adolescent females were more likely ever to
have practised contraception than in-school females, those
still in school were more regular users (Kgosidintsi, 1997).
Choice of method reflects a general and heavy reliance on
natural methods. Withdrawal and rhythm are frequently
reported: for example, in the case study of university students in Dumaguete City, Philippines, cited
above, about half the users practised natural methods; among female industrial zone workers in
Seoul, Kyongbuk, and Kyongnam, Republic of Korea, over half; and among university students in
Ilorin, Nigeria, 44% and 27% of females and males, respectively.
Sexual coercion
Given the sensitive nature of the topic, non-consensual
sexual activity is difficult to research. The topic is espe-
cially sensitive among youth, the age group in which
coercion is perhaps most likely to occur. Although force
and sexual coercion were not the sole topics of any of the
studies reviewed in this article, a few studies exploring
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 17
sexual behaviour or the context of abortion were able to raise the issues, at least indirectly. Studies
have employed different ways of assessing coercion—in some, force was defined as any sexual
activity that was not consensual; in certain others, a considerable age difference between partners
was regarded as an indirect indicator of coercion, and in yet others it was defined more directly and
narrowly as rape or sex with “sugar daddies” (males, usually substantially older than their partner,
who exchange money and/or gifts for sex).
Thirteen studies included in this review documented the extent to which sexual debut—or more
recent sexual activity—was forced. Nine studies drew their samples from among students and out-
of-school youth, factory workers, health centre clients, and, in one case, households. In the remain-
ing four, the samples consisted of pregnant adolescents, adolescents who had undergone an induced
abortion, or recent mothers (Mpangile et al., 1992; 1999; Bautista, 1989; Ehrenfeld, 1994; Austin,
1996). Their findings, presented in Table 6, clearly dispel the notion that sexual activity among youth,
especially young females, is entirely consensual.
Although there is considerable variation, in the majority of case studies, between 5% and 15% of
young females report a forced or coerced sexual experience. In several case studies, the figure is
higher: 21% among in- and out-of-school adolescents in Selibe Phikwe, Mahalapye and Kang,
Botswana (Kgosidintsi, 1997), 20% among secondary school students in Lima, Cusco and Iquitos,
Peru (Alarcon and Gonzales, 1996), and 41% among young females attending urban night study
centres in Lima, Peru (Villanueva, 1992). Among females working in an export zone in Republic of
Korea, 9% reported that sexual debut had been forced by factory supervisors or colleagues (Kwon
Tai-Hwan et al., 1994). In a case study in Manila, Philippines, 6% of unwed mothers report that
pregnancy resulted from rape, and another 7% that it resulted from sex in exchange for money to
support a drug habit (Bautista, 1989). Among rural adolescent females in North and North-east
Thailand, three of 11 sexually active females report that their sexual debut was a result of force or
pressure from their partner (Isarabhakdi, 1995).
The “sugar daddy” phenomenon is cited in a number of studies as a reason for having sex against
one’s will. About one in five school-going and out-of-school adolescent females in Selibe Phikwe,
Mahalapye, and Kang, Botswana, for example, report that it is difficult to refuse sex when money
and gifts are offered. In this sample, girls as young as 13 reported having engaged in sex with
“sugar daddies” (Kgosidintsi, 1997). Another case study in a hospital setting in Dar-es-Salaam,
United Republic of Tanzania, reports that 28% of young women suffering post-abortion complica-
tions were made pregnant by men who were about 25 years older than them, evidence that the
authors link to a coercive relationship (Mpangile et al., 1992; 1999). Studies report that perpetrators
were often authority figures––work place supervisors (Republic of Korea), “sugar daddies,” and
older male teachers, policemen, priests, and relatives (Botswana, United Republic of Tanzania).
Sexual coercion is also experienced by males. Fewer case studies have explored coercive relation-
ships among males than among females (five compared to 13); these studies suggest that under 7%
of young males have experienced non-consensual sexual debut. In Dumaguete City, Philippines, a
few (under 1%) report the phenomenon of “sugar mommies” (Cadelina, 1998).
Table 5. Current contraceptive practice.
Country Sample Age
range % practising any
contraception % practising contraception by method1% practising contraception
regularly Source
Female Male Female:
Condom Female:
Natural
method
Male:
Condom Male: Natural
method Female Male
Botswana
Selibe Phikwe,
Mahalapye,
Kang
In- and out-of-school
females 13–19 Na2Ns2333Na Ns Na 66 Ns Kgosidintsi, 1997
Kenya
Nairobi
Homa Bay
Secondary school
students 12-21
Urban
Rural Na Na 16
57 Ns 35
73 Ns 10
39 20
57
Nyamongo, 1995
Nigeria
Ilorin University students 15–24 81472519 44 43 27 31 76 Araoye, 1996
Uganda
Kampala Secondary school
students614–17 52 Ns Ns Ns Ns Ns Ns Mathias, 1993
China
Shanghai and
two rural
counties
Pregnant women
attending facility for
pre-marital
examination or for
abortion
18–24 277Ns 13 Na Ns Ns 6 Ns Wang, 1997
Korea,
Republic of
Export
Promotion
Zone
Females in
manufacturing
sector, residing in
dormitories
18–29 218Ns 25 12 Ns Ns Na Ns Kwon Tai-Hwan
et al., 1994
Korea,
Republic of
Seoul
Male university
students 15–29 Ns Na Ns Ns 359Na Ns Na Jong Kwon Lim
et al., 1995
Nepal
Border towns Residents
Non-residents10 <25 Ns Na Na Ns 60
76 Ns Ns 41
43 Tamang, 1999
Philippines
Dumaguete
City
College students 18–24 69 69 3211 37 3412 35 56 53 Cadelina, 1998
Viet Nam
Hanoi, Ho Chi
Minh City
College students 17–24 1 9 Na Na Na Na Na Na Vu Quy Nhan,
1996
Argentina
Buenos Aires Students in final 3
years of secondary
school
13–19 97 96 90 58 93 42 62 79 Mendez et al.,
1995
Chile Urban, four regions <2013 Na Na 23 Na 23 2-6 12 Kleincsek, 1994
Peru
Lima, Cusco, Secondary school
students and out-of- 13–19 22–53 30–41 14–40 4–11 23 2-6 Na Na Alarcon and
Gonzales, 1996
Country Sample Age
range % practising any
contraception % practising contraception by method1% practising contraception
regularly Source
Female Male Female:
Condom Female:
Natural
method
Male:
Condom Male: Natural
method Female Male
Iquitos school adolescents
Peru
San Martin de
Porres
Youths attending
night school 10–24 814 37 0 4 30 6 Na Na Villanueva, 1992
Peru
Lambayeque Household survey in
14 districts 12–19 32 45 415 Na 111Na 10 13 Caceres, 1995
1 Natural methods include withdrawal and rhythm.
2 Na = not available. Ns = Not studied.
3 Higher among out-of-school 53% compared to 25% among in-school adolescents; but more regular use (76%) among in-school users as compared to 58% among out-of-school users.
4 Females: Other methods: OC 11%; other 3%; % users among those ever engaged in sex work: 39%; those ever engaged in casual sex: 30%; and with regular partner 37%.
5 Males: other methods: OC 17%; other 12%; used with sex worker 86%; casual partner 81%.
6 Females and males combined.
7 Includes use of oral contraceptives, 8%; IUD, 1%; other methods, 5%.
8 Includes use of oral contraceptives, 13%; other methods, 1%.
9 With sex workers 48%; with girlfriend 26%; with casual partner 23%.
10 Casual sexual relations only.
11 Includes 15% females who report condom use combined with natural methods.
12 Includes 19% males who report condom use combined with natural methods.
13 The study referred to the population 15–40 but results presented here refer to youth only; figures for females and males combined.
14 All used oral pills or IUDs.
15 Used condom at least once during the last three sexual encounters.
Table 6. Experience of sexual coercion
Country Sample Ages Question posed % coerced
Females Males
Source
Botswana
Selibe
Phikwe,
Mahalapye,
Kang
In- and-out-of-school
females 13–19 Ever forced to have
sex 21
in school: 20
out-of-school: 26
Ns1Kgosidintsi,
1997
Tanzania,
United
Republic of
Dar Es-
Salaam
Women admitted to
hospitals for post-
abortion complications
14–19 Partner at time
respondent became
pregnant aged 45 or
older
28 Ns Mpangile
et al., 1992,
1999
Korea,
Republic of
Export
promotion
zones
Females in
manufacturing sector,
residing in dormitories
19–29 Partner at sexual
debut2Colleague: 9
Other: 3 Ns Kwon Tai-
Hwan et al.,
1994
Philippines
Manila First-time mothers,
married and unmarried 15–24 Reason for pregnancy Rape: 6
“Seduced” while on
drugs: 7
Ns Bautista, 1989
Philippines
Dumaguete
City
College students 15–24 First sexual partner Rape: 2
Sugar daddy: 3
For cash or other
gain: 10
"Sugar mommy":
<1 Cadelina,
1998
Thailand
North/North-
east
Rural household survey 15–24 Reason respondent
engaged in sex first
time: forced/
pressured including by
partner
(27)3Forced/
pressured by
partner: 10
Isarabhakdi,
1995
Argentina
Federal
Capital and
Chubut
Adolescents at public
hospitals for
reproductive health
services
13–19 Reason respondent
engaged in sex first
time: “violation”
5 0 Pantelides,
1991
Argentina
Buenos
Aires
Students in final 3 years
of secondary school 14–20 Reason respondent
engaged in sex first
time: “violation”
Rape: 2
Insistence of
partner: 3
Rape: 0
Insistence of
partner: 3
Mendez Ribas
et al., 1995
Mexico
Mexico City Low-income adolescents
at Ob/Gyn clinic of
public hospital, ever
pregnant, ever
terminated a pregnancy
<20 FGD4Experience of rape
discussed by at
least one participant
Ns Ehrenfeld,
1994
Panama
Metropolitan
and San
Miguelito
health
region
Females, first time
pregnant, attending
antenatal care services
<20 Pregnancy resulted
from rape 1
Aged under 17: 3 Ns Austin, 1996
Peru
Lima,
Cusco,
Iquitos
Secondary school
students and out-of-
school adolescents
13–19 Sexual debut was
forced 2–20 3–7 Alarcon and
Gonzales,
1996
Peru
San Martin
de Porres
Females attending night
schools 10–19 Sexual debut was
forced 18 Ns Rodriguez-
Lay, 1997
Peru
Lima Youth attending night
schools 10–24 Sexual debut was
forced 41 2 Villanueva,
1992
1 Not studied.
2 Many women reported that their sexual debut had been forced by supervisors or colleagues in the factory.
3 Small sample: N=3 of 11 sexually experienced females.
4 Focus group discussion
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 21
CONSEQUENCES OF UNSAFE SEXUAL ACTIVITY
Sexually transmitted infections
Few studies have explored sexually transmitted infections
(STIs) among youth. What is of interest among the eight
case studies that did so is that their samples are drawn
from the population at large––educational institutions,
factories, and communities––rather than from among
high-risk populations per se. Results presented in Table 7
confirm that typically, somewhat larger proportions of young men than young women have experi-
enced symptoms of a sexually transmitted infection. Only one study (university students in Ilorin,
Nigeria), however, explored treatment-seeking behaviours. In this study, 10% of female university
students had experienced abnormal vaginal discharge, and 4% sores: of these, although the large
majority (89%) did indeed obtain treatment, about one-third of these students reported self-medica-
tion. In contrast, all males who experienced symptoms sought care, and relatively few (17%)
attempted self-medication (Araoye, 1996).
Unwanted pregnancy
A substantial minority of sexually active unmarried young
women experience pregnancy, which is typically both
unplanned and unwanted. In the community-based studies
that explored unwanted pregnancy, between 10% and
40% of young unmarried females reported having experi-
enced an unwanted pregnancy (Table 8). On the high side, among females about to be married in
Shanghai, for example, 40% admitted experiencing an unwanted pregnancy (Gao, 1998); in export
zones in the Republic of Korea, unmarried factory workers report similar rates (37%, Kwon Tai-
Hwan et al., 1994); in sites in Botswana, 42% of out-of-school adolescent females had experienced
a pregnancy (Kgosidintsi, 1997); and in Buenos Aires, Argentina, 27% of adolescent women seek-
ing health care had experienced an unwanted pregnancy (Pantelides, 1991).
In general, it appears that youth attending school or university are less likely to experience an
unwanted pregnancy than are those drawn from the general population––usually under 10% in
studies in every region (see for example, case studies in Argentina, Botswana, Nigeria, Peru,
Philippines, Uganda and Viet Nam). For example, among students in the final three years of sec-
ondary school in Buenos Aires, Argentina, 3% of all females report a pregnancy, while 2% of males
report making a partner pregnant. This finding is consistent with other findings from the same study,
suggesting more consistently safe sexual behaviour, including higher rates of contraception and a
higher incidence of planned as opposed to spontaneous sexual activity (Mendez Ribas et al., 1995).
Delays in recognising or admitting the pregnancy are observed among ever-pregnant adolescents at
a public hospital in Mexico City (Ehrenfeld, 1994; 1999), for example, the first skipped period was
· Substantial minorities of
youth have experienced
symptoms of sexually trans-
mitted infection.
· Considerable percentages
of young females (10%–40%)
report unwanted pregnancy.
Table 7. Experience of sexually transmitted infections.
Site/
country Sample Age range % ever experienced a symptom of
a sexually transmitted infection Source
Female Male
Botswana
Selibe Phikwe,
Mahalapye, Kang
In- and out-of-school
youth 13–19 61Ns2Kgosidintsi, 1997
Nigeria
Ilorin University students 15–24 Discharge: 10
Sores: 43Gonorrhoea: 9
Syphilis: 5
Chancroid: 2
Araoye, 1996
Korea, Republic
of
Export Promotion
Zones
Females in
manufacturing sector,
residing in dormitories
19–29 7 Ns Kwon Tai-Hwan
et al, 1994
Korea, Republic
of
Seoul
Unmarried male
university students 15–29 Ns 84Jong Kwon Lim
et al., 1995
Philippines
Dumaguete City College students 18–24 35106Cadelina, 1998
Thailand
North and North-
east
Rural household
survey 15–24 3 12 Isarabhakdi, 1995
Thailand
Chiang Mai Factory workers,
married and unmarried 13–25
(unmarried) 1738Rugpao, 1997
Argentina
Buenos Aires Students in final 3
years of secondary
school
13–19 79Na10 Mendez Ribas
et al., 1995
Peru
Lima, Cusco,
Iquitos
Secondary school
students and out-of-
school adolescents
12–19 5–1411 3–812 Alarcon and
Gonzales, 1996
1 Were treated for an STI symptom.
2 Ns = Not studied.
3 89% report receiving treatment; 30% report self-medication.
4 Including 3% who had experienced gonorrhoea.
5 Of those who responded; Including those who did not respond, 2%.
6 Of those who responded; Including those who did not respond, 6%.
7 % reporting symptoms of: Dysuria: 28; Itching: 35; Ulcer: 1.
8 % reporting symptoms of: Dysuria:19; Itching: 15; Ulcer: 11; Gonorrhoea: 6; Pus from urethra: 6.
9 Asked only of adolescent females who ever visited gynaecologist, 7% of sexually initiated report visiting gynaecologist for STI
symptom; actual number with symptoms may be higher.
10 Not available.
11 Lima: 14; Cusco:8; Iquitos: 5.
12 Lima: 8; Cusco: 5; Iquitos: 3.
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 23
typically considered a delay; the second an irregularity; and it was often only in the third month of
pregnancy that adolescents acknowledged the fact that they were pregnant. Many attempted
abortions notwithstanding; of these, most did so unsuccessfully.
Young females may be reluctant to disclose the experience of an unwanted pregnancy, and hence
the rates reported in Table 8 might well be underestimates of the actual numbers. A case study in
Selibe Phikwe, Mahalapye and Kang, in Botswana, underscores this possibility. This study inquired
about the experience of pregnancy among both respondents themselves and their peers, and results
suggest that while 18% reported the experience of at least one pregnancy, almost three in four
report pregnancy among a peer (Kgosidintsi, 1997).
Only one study addresses the consequences of unwed motherhood on young women’s lives. This
study, conducted in Manila, Philippines (Bautista, 1989) reports generally negative consequences:
social ostracism, threat of poverty and economic dependence, and fear of remaining single. Mother-
hood involved considerable personal cost to young women in this study: it disrupted work (27%),
schooling (13%), and parental financial support (9%).
Abortion
Data on levels of induced abortion in developing countries
are notoriously difficult to gather, either because abortion
is restricted or because the issue is too sensitive. Even so,
among young females reporting a pregnancy, the over-
whelming majority––in almost every case study in every
region––opted for abortion. In case studies conducted in
settings where abortion is not restricted, such as China, Republic of Korea, and Viet Nam, for
instance, well over 85% of ever-pregnant respondents had opted for abortion.
Even where the practise of abortion is restricted, however, large percentages of pregnant young
females opted for abortion: college students in Ilorin, Nigeria (76%), and school-going and out-of-
school adolescents in Lima, Cusco, and Iquitos, Peru (49%–86%, Alarcon and Gonzales, 1996), for
example. The two case studies in Argentina suggest somewhat different conclusions. In one, the
majority of ever-pregnant young females seeking health care in hospitals in the Federal Capital and
Chubut districts chose to carry the pregnancy to term (62%), and another 14% were pregnant at
the time of interview (Pantelides, 1991). In a second, all four of the ever-pregnant secondary school
students in Buenos Aires opted for abortion (Mendez Ribas et al., 1995), suggesting perhaps that
this better-educated group (or their families) had greater access to private abortion services than
the general population.
Where abortion is legally restricted, this fact is not universally known by youth. For example, case
studies in Lima, Cusco and Iquitos, Peru (Alarcon and Gonzales, 1996) report that 25%–35% of
males and 26%–36% of females were unaware of the restrictions on abortion. A qualitative case
study of pregnant adolescents in Mexico City (Ehrenfeld, 1994; 1999), some of whom underwent
abortion, revealed a similar lack of awareness of the legal situation.
· Induced abortion is widely
used by pregnant young
women, even in settings
where it is restricted.
Table 8. Consequences of unsafe sex: unplanned pregnancy.
Country Sample Ages Question
posed
ever-
pregnant
among
sexually
experienced
%
delivering
of ever-
pregnant
%
experiencing
1 or more
abortions
among ever-
pregnant
%
males
reporting
an
unplanned
pregnancy
%
Source
Botswana
Selibe Phikwe,
Mahalapye,
Kang
In- and-out of-
school females 13–19 Ever been
pregnant1
In-school
Out-of-school
18
8
42
Na2Na Ns3Kgosidintsi,
1997
Nigeria
Ilorin University
students 15–24 Ever been
pregnant; any
partner ever
been pregnant
91676
4135Araoye, 1995
Uganda
Kampala Secondary
school students 14–17 Ever been
pregnant 26(25)7(75)8Na Mathias, 1993
China
Shanghai About-to-be-
married females
visiting clinics for
required
physical
examination
<21 to
>26 Ever been
pregnant 40 Na 90 Ns Gao, 1998
Korea,
Republic of
Export
Promotion
Zone
Females in
manufacturing
sector, residing
in dormitories
<19–29 Ever been
pregnant 37 1298810 Ns Kwon Tai-
Hwan et al.,
1994
Korea,
Republic of
Kwangju
Secondary
school students 15–22 Ever had a
friend who
was pregnant
21 Na Na Na Gayun, 1996
Korea,
Republic of
Seoul
Male university
students 14–24 Ever made a
female partner
pregnant
Ns 9 11 9112 11 Jong Kwon
Lim et al.,
1995
Philippines
Dumaguete
City
College students 15–24 Ever been
pregnant; any
partner ever
been pregnant
6 Na Na Na Cadelina,
1998
Viet Nam
Hanoi, Ho Chi
Minh City
College students 17–24 Ever been
pregnant; any
partner ever
been pregnant
1113 0 100 814 Vu Quy Nhan,
1996
Argentina
Federal
Capital,
Chubut
Adolescents at
public hospitals
for reproductive
health services
13–19 Ever been
pregnant 27 6215 24 8 Pantelides,
1991
Argentina
Buenos Aires Students in final
3 years of
secondary
school
14–20 Ever been
pregnant or
partner ever
been pregnant
3(0)
16 (100) 17 218 Mendez Ribas
et al., 1995
Peru
Lima Youth attending
night school 10–24 Ever been
pregnant,
partner ever
been pregnant
24 54 3819 920 Villanueva,
1992
Peru
Lima, Cusco,
Iquitos
Secondary
school students,
out-of-school
adolescents
13–19 Ever been
pregnant,
partner ever
been pregnant
8–2221 40–9322 50–8623 3–524 Alarcon and
Gonzales,
1996
Peru
San Martin de
Porres
Females
attending night
schools
10–19 Ever been
pregnant 463
25 3826 Ns Rodriguez-
Lay, 1997
1 Botswana: 72% report a friend who experienced an unwanted pregnancy (Kgosidintsi, 1997).
2 Not available.
3 Not studied.
4 49% reported a miscarriage.
5 Of these pregnancies, 69% were reportedly aborted, 17% ended in a live birth, 2% ended in a miscarriage and in
the remaining 12% of cases the male partner was unaware of the oucome.
6 4 of 200.
7 Small numbers: 1 of 4.
8 Small numbers, 3 of 4.
9 Small numbers, 5 of 43.
10 Small numbers,38 of 43.
11 Small numbers,1 of 11.
12 Small numbers,10 of 11.
13 Small numbers,2 of 19.
14 Small numbers,9 of 118.
15 Another 14% currently pregnant.
16 Small numbers: 0 of 4.
17 Small numbers: 4 of 4.
18 N=5; 3 of 5 males report that pregnancy was terminated.
19 Another 8% report a miscarriage.
20 Partners of 35% males reporting an unplanned pregnancy underwent abortion, 9% miscarriage.
21 Lima, 8%; Cusco, 12%; Iquitos, 22%.
22 Lima, 93%; Cusco, 40%; Iquitos, 53%.
23 Lima, 86%; Cusco, 50%; Iquitos, 47%.
24 33–65% of partners experiencing an unwanted pregnancy underwent abortion; 33–53% continued the pregnancy.
25 Small numbers, 5 of 8.
26 Small numbers, 3 of 8.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
26
· Pregnant young women use
many different methods to
induce abortion and multiple
abortions are not unknown.
· Post-abortion complications
are reported frequently.
Contraceptive experience of abortion-seekers suggests that practice tends to be irregular, or incor-
rect, and the method of choice is largely traditional. Among young women working in an export
promotion zone in the Republic of Korea, almost two-thirds of women who had experienced an
abortion also reported use of withdrawal or the rhythm method (Kwon Tai-Hwan, et al., 1994).
Incorrect use of contraceptives compounded the vulnerability of young women. For example, in the
case studies of export zone workers in the Republic of Korea (Kwon Tai-Hwan, et al., 1994) and
abortion seekers in Dar-es-Salaam, United Republic of Tanzania (Mpangile, et al., 1992), abortion
seekers reported incorrect use of contraceptive methods, such as, for example, sharing oral contra-
ceptives with friends, or taking them just before or after intercourse. Abortion-seekers in Dar-es-
Salaam, United Republic of Tanzania (Mpangile, et al., 1992) and those with unwanted pregnancies
in Manila, Philippines (Bautista, 1989) reported limited overall knowledge of contraception. In the
Dar-es-Salaam case study, 88% of adolescents experiencing post-abortion complications lacked
complete information concerning contraception. This study also shows that adolescents seeking
abortion are considerably more likely than older women to report that their partner at the time of
pregnancy was a casual contact (40% compared to 25% and 14% among women aged 20–24 and
30–34, respectively).
Among pregnant adolescents observed at a public hospital in Mexico City (Ehrenfeld, 1994; 1999),
72% of young women who had an unwanted pregnancy
that was ultimately carried to full term reported an aver-
age of 2.3 unsuccessful attempts at abortion. For the
members of the group who did abort the pregnancy, one to
four abortion attempts were made before success. Many
of these attempts were self-induced, involving typically
“strong injections” of unknown drugs and consumption of
infusions of various types.
Though numbers are small, several case studies point
to the experience of multiple abortions among young females. For example, two of four ever-
pregnant secondary school adolescents in a case study in Kampala, Uganda (Mathias, 1993),
reported more than one abortion, as did 13% of ever-pregnant young women working in an export
promotion zone in the Republic of Korea (Kwon Tai-Hwan, et al., 1994), and over 20% of women
who had experienced an unwanted pregnancy in sites in Cuba (Lopez, 1997; 1999). Finally, a case
study of adolescents with abortion complications drawn from three hospitals in Santiago, Chile
(Molino and Toldeo Dreves, 1997) reports that 23% of abortion-seeking respondents had experi-
enced at least one previous abortion.
Again, despite small numbers, the evidence suggests that
complications may be more prevalent among adolescent
abortion-seekers than among adults. In settings in which
clandestine abortions were sought (e.g. in Mexico, United
Republic of Tanzania), complications were particularly prevalent. In the case study in Dar-es-
Salaam, United Republic of Tanzania, almost two-thirds of all females suffering from abortion
complications were in the 15–24 age group. In a case study of secondary school students in Kam-
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 27
pala, Uganda (Mathias, 1993), of the three abortion seekers, one had suffered serious complica-
tions. Even in settings where abortion is legally available, shame and lack of knowledge may com-
bine to constrain young women from seeking timely and safe abortions––for example, almost two in
five (38-39%) abortion-seekers working in an export promotion zone in the Republic of Korea
reported post-abortion complications (Kwon Tai-Hwan et al., 1994).
Case studies of pregnant adolescents in Mexico City
(Ehrenfeld, 1994; 1999) and Santiago, Chile (Molino and
Toldeo Dreves, 1997) highlight the considerable guilt
experienced by adolescents who have experienced abor-
tion. The case study in Mexico points out that guilt stems
not only from the act of abortion itself but also from
having engaged in sexual relations and having “failed” as a “real” woman by opting for abortion.
And the case study in Santiago reports a high incidence of depression among pregnant adolescents
who opted for abortion.
Family support following an unplanned pregnancy
Two studies discuss perceptions and experiences of family
support and findings diverge considerably. A rare look at
family reactions to premarital pregnancy comes from a
study of about-to-be-married ever-pregnant Chinese
women in Shanghai: in this study (Gao, 1998), only 13%
reported parents who reacted “sympathetically” to their
pregnancies, while others reported such reactions as
indifference (40%), surprise (31%) and anger (11%).
Neither partners nor friends were much more supportive––only 18%–21% were reportedly “sym-
pathetic” (Gao, 1998). Among pregnant adolescents in hospital settings in Cuba (Lopez, 1997;
1999), in contrast, parents are reportedly extremely supportive, and 80% were reported to have
assisted their young daughters in continuing their education or bringing up their children.
A few studies have explored perceptions of family support in case of unwanted pregnancy. In the
Sichuan province of China, a study of abortion-seekers observes that while almost all had discussed
the choice of abortion with their partners, almost two-fifths (38%) perceived a lack of support from
family members, and were too shy to inform their family of their sexual activity. Among pregnant
young women working in an export promotion zone in the Republic of Korea, only a third had
consulted parents or relatives and even fewer (11%) had consulted the male partner (Kwon Tai-
Hwan, et al., 1994). And among adolescents attending night school in Lima, Peru, 6% of pregnant
adolescents (and 13% of their partners) had consulted their parents (Villanueva, 1992).
The lack of family support operates also at a different level. The case study in Mexico City of
adolescents who had experienced a pregnancy reports that decision-making regarding abortion
sometimes excluded the pregnant adolescent herself. In this study, mothers and partners were the
two categories of people most likely to be consulted by the pregnant woman, and several reported
· The experience of abortion
is associated with consider-
able guilt.
· Experiences and percep-
tions of family support follow-
ing an unplanned pregnancy
vary.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
28
being “forced” by one or the other to attempt abortion. Friends of either sex were notably absent
from the decision-making process (Ehrenfeld, 1994; 1999).
The lack of family support can also limit access to resources needed for a safe abortion. In the case
study in Mexico City (Ehrenfeld, 1994; 1999), several pregnant adolescents who would have pre-
ferred abortion carried on the pregnancy for want of financial resources and a reluctance to
approach families for financial help.
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 29
INFORMED CHOICES AMONG YOUTH: THE
CONTENT AND SOURCES OF INFORMATION
The case studies examined, to some degree, the levels of sexual and reproductive knowledge of
youth, and the sources of that knowledge. Some case studies went beyond simple inquiries about
awareness (generally the ability to name or list contraceptive methods or diseases) to inquiring
about common misconceptions or more in-depth knowledge. Results suggest that, while youth are
generally well informed, in-depth knowledge of sexual health issues tends to be quite patchy, and
misconceptions concerning safe practices are quite widespread. Sources of information, moreover,
tend to be largely informal. This section highlights common misconceptions expressed by youth
regarding safe sexual practices, and sources of sexual health information reported by youth.
Common misperceptions
Messages generally conveyed to youth in information and education programmes tend to be largely
scientific and technical. These messages do not, however, reflect the questions and doubts that
young people have concerning healthy sexual practices. As a result, a range of misperceptions
continues to exist, side-by-side with sound general infor-
mation on disease and contraception. These mispercep-
tions may well have contributed to the risky behaviours
described above.
Knowledge of conception and the fertile period was
generally poor among young people, both female and
male; and, interestingly, among educated as well as
uneducated youth. A case study of pregnant adolescents in Mexico City goes so far as to report that
“the vagina seemed not to exist for many” (Ehrenfeld, 1994; 1999). As Table 9 shows, substantial
percentages of youth believe that sexual debut or occasional sex carries no risk of pregnancy, and
this misperception is held among both females and males. Misconceptions extend to the other
extreme as well. In a case study of youth in 13 provinces of Indonesia, for example, 9–13% of
males and 6–7% of females believe that pregnancy can occur through physical embrace
(Wirakartakusumah, 1997).
Condoms are widely known among youth, and generally
outrank such other commonly-known contraceptive
methods as the pill, the intrauterine device (IUD), with-
drawal and rhythm. Despite this awareness, mispercep-
tions appear to dissuade youth from using condoms. Studies from Africa discuss these mispercep-
tions in detail. A study of secondary school students in Nairobi and Homa Bay, Kenya, reports that
awareness of condoms was not an issue––most young people were aware of its role in preventing
HIV transmission, and could name several brands. This awareness was, however, countered by
considerable mistrust of the condom: “scientifically the virus HIV is very small such that it can
· “A woman cannot become
pregnant at first intercourse
or with occasional sexual
relations.”
· “Condoms are unsafe.”
Table 9. Percentage of females and males believing that a woman cannot become pregnant at
first sex or if one has sex only occasionally.
Site/country Sample Age range Female Male Source
Uganda
Kampala Secondary school students 14–17 421Mathias, 1993
China
Shanghai About-to-be-married females
visiting clinics for required physical
examination
15–29 28 Ns2Gao, 1998
Argentina
Buenos Aires Secondary school students 13–19 16 19 Mendez Ribas et al.,
1995
Peru
Lima Youth attending night school (98%
unmarried) 10–24 62 3522Villanueva, 1992
Peru
Lima, Cusco,
Iquitos
Secondary school students and
out-of-school adolescents 12–19 43–60442–665Alarcon and
Gonzales, 1996
1 Combined for females and males; 20% agree; 22% don’t know.
2 Not studied.
3 Among females, 22% agree and 40% don’t know; among males, 24% agree, and 28% don’t know.
4 Female: Lima, 43; Cusco, 54; Iquitos, 60.
5 Male: Lima: 42; Cusco, 58; Iquitos, 66.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
30
go through the pores in a condom hence not safe”; condoms “burst during use”; and “it is
risky because it can remain in the vagina” were commonly voiced concerns, such that only 35%
of urban females and males, and 56% of rural ones expressed confidence in the effectiveness of
condoms (Nyamongo, 1995). University students in Ilorin, Nigeria, were equally concerned: some
17% of males and 24% of females reported that condoms “can climb into womb”. And in a case
study of adolescent females in Selibe Phikwe, Mahalapye and Kang in Botswana, 76% of in-school
and out-of-school adolescents argued that condoms often slid off (Kgosidintsi, 1997).
A number of case studies explore levels of awareness
of STI/HIV transmission. Although a general aware-
ness of HIV and AIDS (the latter in particular) was
considerable, more in-depth knowledge of the major
modes of transmission was limited. For example, over
80% of respondents in case studies in selected sites in China, Guatemala, Indonesia, Kenya, Ni-
geria, Peru and Thailand were aware of AIDS; but useful, working knowledge of modes of trans-
mission was reported in very few studies—the only positive exceptions appearing to be about-to-be
married young women in Shanghai, China (Gao, 1998) and students and factory workers in Bang-
kok, Thailand (Soonthorndhada, 1994), where 90% and 95%, respectively, were knowledgeable
about modes of transmission.
One common and very dangerous misconception relates to the asymptomatic nature of STIs and
HIV. In case studies in a range of settings, youth were confident that an infected person would
reveal some outward evidence of their condition. A view expressed by young people in a low-
income urban area in Argentina reflected the belief that individuals who are HIV-positive are
· “You can tell when a person
is infected with STD or HIV.”
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 31
emaciated: “ She is very thin, surely because she is a
carrier.” (Gogna et al., 1996). Only 5% of males in the
case study of university students in Ilorin, Nigeria, and 7–
12% of students in case studies in Hanoi and Ho Chi Minh
City, Viet Nam were aware of the asymptomatic nature of
STIs/HIV (Araoye, 1995; Vu Quy Nhun, 1996). In one
case study alone, conducted among rural youth in North and North-east Thailand (Isarabhakdi,
1995), did the majority of respondents—81% of males and 86% of females—recognise the asymp-
tomatic nature of STIs/HIV.
Another dangerous misunderstanding revealed in case studies is the belief that, rather like many
other viral infections, STI symptoms go away of their own accord. Some 22% of secondary stu-
dents in Kampala, Uganda (Mathias, 1993), and 7% and 12% of male and female college students
in Hanoi and Ho Chi Minh City, Viet Nam (Vu Quy Nhan, 1996) believed that such was the case.
Another misperception is that women are responsible for
transmitting STIs and HIV. In a case study of youth
residing in an urban barrio in Buenos Aires, Argentina, for
example (Gogna et al., 1996), respondents suggested that
the male was more vulnerable to AIDS than the female
because the female could infect him without becoming sick herself: “… the contamination affects
me and kills me more quickly than her, because she already has all the defences, I think…
and so I die quicker...” and “The man is weaker than the woman. The women are stronger in
sexual things”. Young men in this study also suggested that the absence of personal hygiene
among “dirty women” was a factor contributing greatly to disease transmission, notably: “... they
don’t wash and they do it again and again..., there comes a time when the girl begins to rot”.
In the same study, respondents perceived menstrual blood as a potent source of STI/HIV transmis-
sion; whereas semen, in contrast, represented vitality, and as such was not considered to be an
infectious or potentially harmful agent. Menstrual blood was regarded as highly dangerous by
young men: “ Many people can become sick, infected by the menstrual blood of the woman…
it is stronger than the semen of the man and can infect the man” .
In a few case studies, large percentages of youth stated that STIs/HIV could be prevented by good
personal hygiene—19% of female university students in Ilorin, Nigeria (Araoye, 1995); 30% of
youth in sites in Chile (Kleincsek, 1994); and 44% and 50% of young men and women in sites in
Guatemala (Mendez, 1994). In the same vein, 65% of male Korean university students in Seoul
report that urination after sex gets rid of any infection that
might have been transmitted (Jong Kwon Lim et al.,
1995).
Young people also report that “medicines” and the use of
antibiotics after sex can prevent infection with HIV. This
was reported by 7% and 5% of Nigerian college-going
· “STIs/HIV can be pre-
vented by good personal
hygiene, and AIDS cured by
medication.”
· “Symptoms of sexually
transmitted diseases go away
on their own.”
· “Women are responsible
for transmitting STIs/HIV.”
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
32
males and females, respectively, in Ilorin (Araoye, 1996); 40% of Korean college-going males in
Seoul (Jong Kwon Lim et al., 1995); 28% and 15%, respectively, of young Thai male and female
factory workers in Chiang Mai (Rugpao, 1997); and 20% of adolescent females in Lambayeque
Department, Peru (Caceres, 1995).
A number of young people report a certain fatalism about
contracting STIs and HIV, believing that these infections
can be transmitted through such everyday contact as the
sharing of glasses or eating utensils, the use of the same
toilet as an infected person, poor personal hygiene and
mosquito bites.
Eating and drinking with the same utensils as an infected person was indicated as a means of
transmission in several case studies: by 37% of young people in 13 provinces in Indonesia
(Wirakartakusumah, 1997), 56% of college-going males in Seoul, Republic of Korea (Jong Kwon
Lim et al., 1995), 70% of about-to-be-married women in Shanghai, China (Gao, 1998), and 82% of
young men already infected with an STI and attending a clinic in New Delhi, India (Grover, 1995).
Using the same toilet as an infected person is also described as a source of transmission: this
belief was held by 4% and 6% of college-going males and females, respectively, in Hanoi and
Ho Chi Minh City, Viet Nam (Vu Quy Nhan, 1996); 13% of youth in sites in Chile (Kleincsek et al.,
1994); 26% of factory workers in North and North-east Thailand (Rugpao, 1997); and 56% of
college-going males in Seoul, Republic of Korea (Jong Kwon Lim et al., 1995).
Mosquito bites are another oft-mentioned source of transmission: 12% of male and 20% of female
college students in Hanoi and Ho Chi Minh City, Viet Nam; 25%-28% of night school students in
Lima and San Martin de Porres, Peru (Villanueva, 1992; Rodriguez-Lay, 1997); and as many as two
in five (38%-44%) females in three settings in Guatemala (Mendez, 1994).
Youth in other case studies maintain that infection is transmitted through kissing (Gao, 1998, about-
to-be-married women in Shanghai, China, 44%), touch (Grover, 1995, male patients attending an
STI clinic in New Delhi, India, 78%), and even being in the same room as an infected person
(Wirakartakusumah, 1997, youth from 13 Indonesian provinces, 24% and 28% of females and
males, respectively).
Young people tend to distance themselves from perceiving personal risk, and are reluctant to accept
that their behaviours might be risky for a range of reasons. A number of case studies highlight the
extent to which young people underestimate the risks they face; in general, case studies suggest
that between one in three and one in five youth consider
themselves at any risk. In the border towns of Nepal,
although 52% of men residing in border towns and 38% of
those visiting these towns did not use condoms in their last
sexual contact with a non-regular partner, only 11% and
24%, respectively, considered themselves at risk of
· “It can’t happen to me.”
· “There’s nothing I can do
about it.”
· “STIs/HIV are transmitted
through everyday activity.”
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 33
contracting AIDS (Tamang, 1999). A similar situation was observed in a case study of university
students in Ilorin, Nigeria (Araoye, 1995), where only a minority of sexually active males (21%) and
females (38%), classified as being at high risk for AIDS, perceived themselves to be in any danger
of acquiring HIV. In a case study in Chile (Kleincsek, 1994) also, while fewer than 20% of sexually
active youth used condoms regularly, only 29% perceived themselves to be at risk. Among young
factory workers in Chiang Mai, Thailand, those engaging in risky behaviours were only moderately
more likely to perceive themselves to be at risk than were those practising safer sex measures: 14%
compared to 9% (Rugpao, 1997). Even in a STI outpatient clinic in New Delhi, India (Grover,
1995), only one quarter of young men questioned recognised themselves to be at risk of acquiring
HIV.
Reasons for this vary. One apparent factor is the way in which they perceive their relationships:
many young people express trust in the monogamous nature of the relationship and fidelity of their
partner, and display this trust in their beliefs concerning the partner’s infection status and loyalty to
the relationship. Another misperception is that sex worker contacts are safe, because sex workers
are regularly monitored for infection. For example, in a case study of men in the border towns of
Nepal, young men engaging in casual sex reported that if one chooses one’s casual sex partners
carefully, condoms are unnecessary: As I have sex with clean or disease-free women, there is no
need to use condoms…I take precautions by being selective about my partners” (22-year-old
lorry driver, Tamang, 1999). In addition, it is apparent that many young people consider that HIV is
only a serious risk for members of special groups, sex workers and drug addicts, for instance. In a
case study conducted among urban barrio residents in Buenos Aires, Argentina, for example, young
people argued that the HIV virus is transmitted through the saliva of homosexuals or when several
persons shared a marijuana cigarette, thereby distancing themselves from any fear of risk (Gogna et
al., 1996).
And finally, young people display a fatalistic outlook concerning their chances of contracting infec-
tion. In a focus group discussion, youth from low-income urban areas in Buenos Aires, Argentina,
expressed a sense of resignation and personal vulnerability: “I think that one is not going to be
very careful for themselves all their lives”. Similarly, young men in the border towns of Nepal
argued that consistent condom use is impossible, citing the concern that condoms interfere with
pleasure “unless your semen does not come out, we do not enjoy.” (23 year old); an 18-year-old
student observed that it is difficult in practice to interrupt the sexual act: “the brain does not work
while enjoying…” (Tamang, 1999).
Sources of information
Studies reiterate the fact that information on sexuality, conception, pregnancy, contraception, and
disease is rarely imparted by teachers or health professionals. Moreover, parents are frequently not
the primary source of information. Ranking high as main sources of information are friends and the
media. This can have disastrous consequences: a study of first-time mothers in Manila, Philippines,
reports that 28% learned about sex from the man who made them pregnant. A further 32% gar-
nered their knowledge from friends, and another 13% from the media (Bautista, 1989).
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
34
Case studies in several settings suggest that peers remain
the main source of information on sexuality. Among
secondary school students in Nairobi and Homa Bay,
Kenya, 35% of females and 51% of males reported
frequent discussions of sexual matters with their peers
(Nyamongo, 1995). Among college students in Hanoi and
Ho Chi Minh City, Viet Nam, over 90% of youth report that they are most comfortable discussing
sexual and reproductive health with peers of their own sex, while far fewer report discussion with
their parents (Vu Quy Nhan, 1996). In a case study in 13 provinces of Indonesia
(Wirakartakusumah, 1997), peers outrank parents as the main source of information on sexual
matters for both females and males: 74% of males and 65% of females obtain their information
from their peers, compared to 13% and 23% of males and females, respectively, who report parents
as their source of information. Also, 47% of males and 44% of females name teachers as their
main source of information. Only in case studies in Peru of in- and out-of-school adolescents in
Lima, Cusco, and Iquitos (Alarcon and Gonzales, 1996); and night school students in Lima
(Villanueva, 1992), are both peers and parents cited as main sources of information on sexuality.
Even so, young females are more likely to obtain their information from the family––usually the
mother––than are young males. In case studies in some Asian settings, for example, while peers are
the preferred source of information, females are far more likely than males to discuss sexual and
reproductive health issues with their parents, usually mothers. Among college students in Hanoi and
Ho Chi Minh City, Viet Nam, while 70% of females discuss these issues with one of their parents,
only 49% of males do so. In contrast, males are more likely than females to discuss their sexual and
reproductive health needs with outsiders such as colleagues, pharmacists, medical practitioners, and
Youth Union members (Vu Quy Nhan, 1996). In a case
study in 13 provinces of Indonesia (Wirakartakusumah,
1997), while peers, and even teachers, outrank parents as
the main source of information about sex for young
people, females are more likely than males to rely on their
parents (23% versus 13%), somewhat less likely to rely on
peers (65% versus 74%), and about as likely to rely on
teachers (44% versus 47%).
Case studies in Latin America support these findings. In the case study of school-going and out-of-
school adolescents in Lima, Cusco, and Iquitos, Peru (Alarcon and Gonzales, 1996), females are
more likely than males to report parents as their main source of information on sexuality (43–58%
compared to 33–41%), and are correspondingly less likely to get their information from peers (16–
18% compared to 23–26%). Among night school students in Lima, Peru (Villanueva, 1992) too,
mothers were reported as one of the sources of informa-
tion on sexuality by 23% of females compared to 4% of
males, and fathers by 8% and 14%, respectively; in
contrast, males were more likely to report consultation
with friends (32% compared to 21%) and of books (16%
compared to 8%). Among adolescents attending health
· Youth prefer different
sources of information for
different aspects of sexual
health.
· Youth are interested in
learning more about sexual
health.
· Peers are a major source
of information on sexuality for
many youth.
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 35
services in Federal Capital and Chubut, Argentina, similarly, while almost half of all females discuss
sexuality with their parents, only one in three males report the same (Pantelides, 1991).
It is very likely that youth prefer to obtain information on different aspects of sexuality and safe sex
behaviours from different sources. One case study (Mendez Ribas, et al., 1995) of adolescents in
secondary schools in Buenos Aires, Argentina, reveals, for example, that mothers are the main
source of information for their daughters on topics of menstruation (84%) and the risk of pregnancy
(65%); although the mothers remain important sources of other information, adolescent females are
more likely to consult peers on other topics, such as sexual relations, contraception and ejaculation.
Males, in contrast, obtained information from their fathers, but equally, on almost every topic, from
their peers, the school and the media.
In some settings, the mass media are the predominant source of information on HIV/AIDS,
though—interestingly—this is not necessarily the case regarding other aspects of sexual health. For
example, among young females in several sites in Guatemala (Mendez, 1994), Chile (Kleincsek,
1994) and adolescent factory workers in Chiang Mai, Thailand (Rugpao, 1997), the vast majority––
over 70%—obtained HIV/AIDS information from television and radio; in contrast, only 25% of
youth in the Chilean case study obtained information about other STIs from these media. This trend
is in part testimony to the public education and information campaigns that have been implemented
in these and other study sites.
Health care providers were rarely cited as a major source of information. The one exception was a
study of secondary school students in Kampala, Uganda, in which about 50% reported that their
sources of information were teachers (50%) or health providers (49%).
A few case studies––in Argentina, Kenya, Peru and the Philippines—explored young people’s
impressions of sex education in schools. The majority of respondents (over 50% in most cases)
rated the information provided by schools as inadequate. Several expressed the view that, where
sex education was imparted, teachers focused on discouraging students from sexual activity without
pointing out dangers or explaining and teaching safe sex behaviour. One student made the com-
plaint: “The Ministry of Education is afraid to face the fact…students are engaging in sex.
They are not advising the students on the dangers of sex. They leave the whole issue to
parents, who in most cases shy off.” (Kenya, Nyamongo, 1995).
Generally, young people in these studies argued for a much more explicit focus on sexuality in the
school curriculum. A clear desire exists among youth for diverse, wide-ranging information and
counselling on sex-related issues. In a case study of secondary school students in Kampala, Uganda
(Mathias, 1993), for example, between half and three-quarters of all respondents requested further
information on a vast range of topics encompassing: the prevention of pregnancy and disease; the
use of contraceptive methods; friendship; dating; and human reproduction. Surprisingly, the large
majority expressed a preference towards health providers, rather than teachers or parents, as
information sources. Among university students in Dumaguete City, Philippines, (a large number of
whom classified themselves as Catholic and/or attended Catholic educational institutions, 86%
favoured the establishment of sex education programmes at school level. Among those who did not,
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
36
leading reasons included the views that sex education was “irrelevant”, would “corrupt the minds of
students,” and was “against religion” (Cadelina, 1998). Likewise, large proportions of about-to-be-
married Chinese women in Shanghai (Wang, 1996) articulated a strong need for information on
contraception (76%) and STIs (41%) among youth, and for more accessible, free contraceptive
services (45%). In a case study in Seoul, Republic of Korea, a majority of male university students
recognised a need for more information on sexual health (65%) and counselling (34%), (Jong Kwon
Lim et al., 1995).
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 37
GENDER IMBALANCES INFLUENCING RISKY
SEXUAL BEHAVIOUR
The case studies included in this paper point to a number of gender imbalances that underscore
stereotypical perceptions of the sexual/reproductive roles of young females and males. An illuminat-
ing example of such differences comes from a case study of secondary school students in Buenos
Aires, Argentina (Mendez Ribas et al.,1995) which identifies three characteristic patterns of sexual
debut. Each pattern is clearly much more highly preferred either by females or by males.
One pattern, reflecting a committed relationship, was experienced by 48% of all youth (of whom the
majority––just under two-thirds of the 48%––were female). In this category, sexual debut occurred
in a committed relationship, at ages 16–18, with the intention of strengthening the relationship. This
debut occurred in the home of one of the partners, and the immediate main reactions were pain and
fear of pregnancy. The decision to have sex was made jointly by the couple, and some method of
contraception––usually withdrawal––was used.
The other two patterns were more likely to characterise males than females. The first, labelled
“impulsive,” covered 26% of the sample, of which 99% were males. This group was characterised
by early debut (15 or younger), motivated by “physical need”, curiosity, or peer pressure; and the
partner at debut was usually a sex worker (for males). The decision to have sex was made either
alone or among peers, and initiation typically occurred in a hotel or brothel. The predominant
immediate reactions were anxiety and fear of AIDS. If any method of contraception was used, it
was usually a condom. The second pattern typical of males was labelled “occasional”, comprising
26% of youth, of whom 79% were male. In this group, sexual debut occurred with a friend or
casual acquaintance (usually sexually experienced). Age at initiation in this group varied as did the
location of first sex—from the home of one of the partners, to the beach, or in a car. Initiation was
usually spontaneous and, typically, sex occurred without contraception; the typical reactions were
confusion and a fear of being discovered.
While this typology is not intended for generalisation, it does highlight major differences in the
attitude and behaviour of young males and females that are evident, to some degree, in all settings,
and can be adapted in other settings as well. Likewise a number of case studies in diverse settings
highlight the extent to which the context defining the formation of sexual partnerships between
young people is gender-specific.
A number of case studies highlight continuing, widespread,
gender-specific attitudes to premarital sexual activity.
Generally, males continue to be more likely to consider
premarital sexual activity to be acceptable than are
females; and, furthermore, both females and males con-
sider premarital sex to be more acceptable for males than
for females.
· Young people themselves
appear to condone, or even
encourage, premarital sexual
relations for males, but not for
females.
O c c a s i o n a l P a p e r 4
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38
As seen in Table 10, these double standards are particularly evident in case studies in Asia, but can
be seen in case studies in Latin America as well. For example, among rural youth in North and
North-east Thailand, 46% of females and 32% of males hold the view that men should be virgins at
marriage; in the case of females, however, these figures increase to 71% and 63%, respectively
(Isarabhakdi, 1995). In a case study of college students in Hanoi and Ho Chi Minh City, Viet Nam,
while 8% of females agree that casual sex can be fun, almost two in five males (37%) state this
opinion (Vu Quy Nhan, 1996). Among youth attending night school in Lima, Peru, 49% of females
and 68% of males agree that males should gain sexual experience prior to marriage; yet 73% of
females and 59% of males hold the view that females must be virgins at marriage (Villanueva,
1992).
Exceptions do emerge. Among secondary school students in Kampala, Uganda (Mathias, 1993) and
in Buenos Aires, Argentina (Kornblit, 1993), large majorities of males and females––over 70% in
Uganda, and some 75–85% in Argentina––agreed that
premarital sexual activity was “normal” for both females
and males.
The case studies suggest that young females and males
accept––and in many case justify—sexual double stand-
ards and the constraints imposed on the sexual behaviour
of women. Males, for example, are widely perceived to need sexual experience and a variety of
partners; women are not. One case study among adolescents attending reproductive health services
in two hospitals in Argentina reports the widespread belief that male “sexual urges” are uncontrolla-
ble, and consequently explain the greater “need” that men have for casual sexual relations
(Pantelides, 1991). Adolescent schoolgirls and factory workers in Bangkok, Thailand, concur,
believing that “all men are just like that. I think they have a lot of sex urge” (Soonthorndhada,
1994). And university students in a case study in Dumaguete City, Philippines, argued that “men
should have experience…women do not need experience,” and justify this with the view that “if
a man does not get quite a lot of experience before marriage he’ll want even more after….
Women are more idealistic than men” (Cadelina, 1998).
Correspondingly, findings imply that young females recognise the ways in which these double
standards constrain the behaviour of females relative to that of males. Adolescent female factory
workers and students in Bangkok, Thailand, for example, recognise that: “We cannot do whatever
we want, roaming, smoking, drinking….”; “we are brought up this way”; “it’s social expec-
tations, they will look down on you if you go loose”; “men can go anywhere, do whatever
they like, even trying sex….”; and “no-one wants a woman who has had sexual experience”
(Soonthorndhada, 1994). Similarly, low-income young women in Buenos Aires, Argentina, argue
that “the man can go with many women and not lose his reputation, but if the woman does the
same thing with men, they will always say bad things about her” (Gogna et al., 1996). And
young women in this study recognise their limited options relative to young men. When asked,
young women considered the roles of men far preferable to their own, citing the greater freedom
and independence of males as reasons: “The life of a man is easier, they come and go as they
please, however many times. The woman has to stay home and care for the children.”
· Gender-based double
standards are often consid-
ered socially justifiable.
Table 10. Attitudes to premarital sex.
Female respondents Male respondents
Site/country Sample Age
range Question wording Attitudes of
males to
premarital
sex
Attitudes of
females to
premarital
sex
Attitudes of
males to
premarital
sex
Attitudes of
females to
premarital
sex
Source
Uganda
Kampala Secondary school students114–17 Should not have sex before
marriage 73 78 73 78 Mathias, 1993
Korea, Republic of
Export Promotion
Zone
Females in manufacturing
sector, residing in
dormitories
19–29 It must be forbidden until
marriage Na261 3Ns4Ns Kwon Tai-Hwan et al.,
1994
Korea, Republic of
Seoul Unmarried male university
students 15–29 Chastity should be kept at all
costs Ns Ns 16 29 Jong Kwon Lim et al.,
1995
Philippines
Dumaguete City College students 18–24 Not all right 73 92 42 71 Cadelina, 1998
Thailand
North and North-east Rural household survey 15–24 Should be virgin at marriage 46 71 32 63 Isarabhakdi, 1995
Thailand
Bangkok Females, school-going and
factory workers515–19 Agree that single <19 should
not have sex 43 86 Ns Ns Soonthorndhada A,
1994
Thailand
Chiang Mai Factory workers, married
and unmarried 13–25 Premarital sex not
acceptable 46 85 2 50 Rugpao, 1997
Viet Nam
Hanoi, Ho Chi Minh City College students 17–24 Sex should only take place
in marriage
Sex okay if couple is
engaged
Casual sex can be fun
Na 98
8
8
74
43
37
Na Vu Quy Nhan, 1996
Argentina
Buenos Aires Secondary school students613–19 Should be virgin at marriage 16 25 16 25 Kornblit, 1993
Peru
Lima Youth attending night school
(2% m/f married) 10–24 Males should gain sexual
experience before marriage
Woman must be virgin at
marriage
49
73
Na
NA
68
59
Na
Na
Villanueva, 1992
Peru
Lima, Cusco, Iquitos Secondary school students
and out-of-school
adolescents
12–19 Should not have relations
before marriage751–52 37–43 31–35 24–28 Alarcon and Gonzales,
1996
1 Percentages of overall sample, i.e. male and female respondents combined.
2 Na = not available.
3 May be tolerated if marriage is promised: 20%.
4 Ns = not studied.
5 Rough, based on responses on scale ranging from 1 (strongly disagree) to 5 (strongly agree) : mean values are 2.13 and 4.30, respectively.
6 Percentages of overall sample, i.e. male and female respondents combined.
7 Range over three settings: Lima, Cusco, Iquitos.
O c c a s i o n a l P a p e r 4
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· Young people’s motives for
engaging in sexual activity
differ widely.
Results from several case studies indicate that males and
females engage in sexual relations with very different
motives. Two case studies, one among rural adolescents in
North and North-east Thailand (Isarabhakdi, 1995), and a
second among secondary school adolescents in Buenos
Aires, Argentina (Mendez Ribas et al., 1995) highlight
these disparities.
As seen in Table 11, for females, the leading reasons expressed by females for having sex were
love and the desire to strengthen a committed relationship. Reasons commonly given included the
desire to express or prove love, the need to strengthen the relationship, and a wish to “share” (see
for example, Argentina, Pantelides, 1991, Mendez Ribas, et al., 1995; Thailand, Isarabhakdi, 1995).
Although a large number of males also expressed a similar position, leading motives among them
also included curiosity, “physical need” and peer pressure.
Motives can also be gleaned from responses of females and males to questions concerning deci-
sion-making on sexual debut and relations. For example, the majority (53%) of females in secondary
school in Buenos Aires, Argentina (Mendez Ribas, et al., 1995) reported that decisions on the timing
of sexual debut were made jointly with their partners, suggestive of perceptions of a stable relation-
ship; only 7% reported making the decision on their own. Males, in contrast, reported a different
decision-making scenario: while 22% reported joint decision-making, an additional 18% reported
making decisions on their own, and 22% reported making the decision along with their peers (no
females reported this).
Table 11
Table 11. Percentage distribution of main reason(s) given for engaging in sexual
activity: Argentina and Thailand.
Reason given Argentina1
Buenos Aires
Secondary school students
Ages 13-19
Thailand2
Rural north and north-east
Household sample
Ages 15-24
Females Males Females Males
Love 68 19 55 43
Partner “insisted” 18 11 - -
Curious 2 15 36 87
“Physical need” 7 45 9 66
Peer pressure 0 7 9 40
Force/rape 2 0 27 10
Forced by partner 3 3 - -
Spontaneous - - 46 37
1 Mendez Ribas et al., 1995.
2 Isarabhakdi, 1995.
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 41
A third study, among adolescents attending public hospitals for reproductive health services in two
sites of Argentina (Pantelides, 1991), also highlights differences in the reactions of males and
females to sexual relations. In this study, males tended to report “satisfaction” and a sense of
“winning”; while females seem much more likely to experience a sense of “sharing” or “feeling
good with their partner”.
Case studies suggest that fears of losing their partner,
incurring his anger, or jeopardising the relationship appear
to be important factors inhibiting young females from
exercising choice in the timing of sexual activity or negoti-
ating contraceptive or condom use. In the case study of
female students and factory workers in Bangkok, Thai-
land, adolescents state the belief that “women have less
power to bargain, they think that if they have sex with their boyfriends they will get them
forever and that is a big mistake. Men never want only one, they want more and more”
(Soonthorndhada, 1994). In a similar vein, the case study in Mexico (Ehrenfeld, 1994; 1999) reports
that a majority of ever-pregnant adolescents, including both those who chose to continue pregnan-
cies and those who did not, reported that sexual activity was initiated through subtle pressure and
promises of a permanent relationship by the partner.
Young females face the same dilemmas when negotiating contraceptive or condom use. In the case
study in three sites in Botswana (Kgosidintsi, 1997) women reported an inability to negotiate con-
dom use, for fear of incurring their partner’s anger and/or risking the continuation of the relation-
ship. One-third of adolescent, schoolgoing and out-of-school females responded that they were not
confident that they could decline sex if their partner refused to use a condom; and another 5%
reported that they would certainly have sex anyway in order to maintain the relationship. And in a
case study of young women working in export promotion zones in the Republic of Korea (Kwon
Tai-Hwan, et al., 1994), unmarried females were reluctant to insist on using condoms, for fear that
they would be labelled “bad quality girls” with “loose morals”.
Even after the experience of an unwanted pregnancy, young
females in a case study in Mexico City, Mexico, continued
to leave contraceptive decisions to the male partner––“he
looks after me” was a typical justification. Even those who
chose to undergo an abortion without informing their part-
ners were not necessarily exercising informed choice––
they did so out of the fear that, “I was going to lose my
boyfriend,” or that “he would abandon me” (Ehrenfeld, 1994; 1999).
Efforts to adhere to behavioural double standards make young unmarried women fear disclosure of
their sexual activity, and can inhibit them from seeking contraception. In the case study of pregnant
young women in Shanghai, China (Wang, 1996), in which 27% had ever used a contraceptive, and
16% had ever used one with any regularity, a leading reason for non-use was fear or embarrass-
ment (30%); in contrast, only 9% cited poor access to supplies. The case study of students and
· Fear of losing the partner
prevents young females from
making informed choices
about sexual relations.
· Fear of disclosure com-
pounds the reluctance of
sexually active young females
to seek contraception.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
42
· Despite constraints, some
young females appear to be
refusing sex without con-
doms.
factory workers in Bangkok, Thailand (Soonthorndhada,
1994), reports that pharmacies and department stores
were the preferred sources of contraceptive supplies,
because of the privacy and anonymity these sources
enabled.
There is, however, emerging evidence of an increasing
ability among females to say “no” to unprotected sex. In the case study of schoolgoing and out-of-
school females in sites in Botswana, for example, over two in five report that they would refuse sex
without contraception. Similarly, in a qualitative study in Argentina (Gogna et al., 1996), responses
included: “as much as I would like children or the pleasure of being with him… how it is today
is that I have to put myself first… use the condom or, if not, nothing will happen”; and “he
can go wherever he wants (to sleep), as long as he uses a condom and does not bring any
disease home to me”.
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 43
SUMMARY AND RECOMMENDATIONS
Despite the non-representative nature of the studies and wide disparities between cultural settings
represented, this review suggests clear global trends in the sexual and reproductive health situation
of youth.
The picture that emerges suggests that risky sexual behaviour is typical of substantial proportions of
young people in every setting studied. Multiple partners, irregular use of condoms and other contra-
ceptives, unwanted pregnancies, the frequent occurrence of unsafe abortions, and the experience of
being forced or coerced into having sex are not uncommon.
Despite such behaviour, relatively few young people consider themselves to be at risk of disease or
unwanted pregnancy. Awareness of safe sex practices seems to be superficial, and misinformation
regarding the risks of unsafe sex and its consequences is widespread.
Above all, these case studies suggest that gender inequalities are already present in adolescence.
Double standards regarding the acceptability of male and female premarital sexual behaviour are
evident in the attitudes and behaviour of youth in all settings; and the vulnerability of young females,
already a matter for concern, is exacerbated by these unequal values.
There are, finally, hints of a shift towards greater informed choice and powers of negotiation among
young females, and towards more consistent condom use among youth generally. These conclusions
are tentatively drawn from qualitative studies, and have not been substantiated by large-scale
representative samples.
Programmatic recommendations
Findings from these case studies stress the global need for: adolescent- and youth-friendly sexual
and reproductive health services; counselling on sexuality,
pregnancy, post-abortion issues and family planning; and
sex education programmes that are age-appropriate and
sensitively imparted. Several additional programme recom-
mendations stand out from this review.
The case studies have pointed to the constraints that youth, particularly young females, face in
exerting informed choice and in acquiring family planning services and information. Findings high-
light: (i) the difficulties that young females have in refusing sex or insisting on condom use with their
partners, and their general tendency to acquiesce to the authority of their partners in matters of
sexual initiation, contraceptive use, the decision to become pregnant and/or whether or not to have
an abortion; (ii) the inhibitions that young males face in exerting informed choice about contracep-
tion, when faced by peer and social pressures that strongly encourage sexual activity; (iii) the
· Build life skills among
youth.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
44
difficulties young females face in countering threats of sexual coercion and force; and (iv) the
reluctance of young people to seek appropriate and timely care for sexual and reproductive health
needs.
These findings point to a general need—especially among
young females—to build negotiation skills that will enable
safe and informed choices.
As explained, gender-based double standards are wide-
spread; and there is a general need for parents, educa-
tional institutions and community institutions to address and
correct them.
The case studies have documented the prevalence of sexual coercion and force against females in
various settings, and against males in some settings. Sexual coercion is frequently perpetrated by
adults. Findings such as these bring into question current intervention strategies that assume that
sexual activity is voluntary. Programmes are needed that
inform youth and adults about the threat of sexual vio-
lence, and that empower youth to protect themselves
from, and take appropriate actions against, the perpetra-
tors of sexual violence.
While young people may be aware of sexual and reproductive risks in general, their information is
incomplete and they hold a number of misconceptions that are rarely addressed in health pro-
grammes. Risk behaviours are practised partly as a result of such mistaken beliefs as, for instance,
that STIs can be prevented by good personal hygiene, or that women cannot become pregnant at
first sex. There is a great need, therefore, to understand common misperceptions in different set-
tings and to provide not only basic information on STIs and contraception, but also information that
attempts specifically to dispel existing misconceptions.
In particular, the message needs to be clearly imparted that every sexual act risks disease and
unwanted pregnancy.
This review suggests that young females and males have
different preferences for information sources, with fe-
males tending to prefer family sources, and males tending
to prefer the mass media. There is also some indication
that youth prefer to be informed about different aspects of
sexual and reproductive health in different ways. These
preferences need to be accommodated.
Parents have a considerable role to play in assuring that
their children lead healthy sexual and reproductive lives; yet parents are inhibited, for many reasons,
in assuming this role. In some cases, parents assume that their children are unlikely to engage in
sexual relations or are not mature enough to need relevant knowledge; and in other cases, parents
· Address double standards
and gender disparities.
· Raise awareness of sexual
force and coercion, and equip
youth to counter them.
· Dispel myths and miscon-
ceptions.
· Provide information
through media acceptable to
youth.
· Involve parents in commu-
nicating information on safe
sex behaviour.
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 45
may assume that these information needs are better met in school. Nonetheless, studies have
suggested that, especially among young females, the actual and preferred sources of information on
many dimensions of sexuality are parents, and particularly mothers. Parents in many settings are
not, however, prepared to respond to this need.
Furthermore, the case studies have suggested that sexual debut frequently occurs in the home,
spontaneously (this is particularly true for females), when parents are absent: finding such as these
need to be transmitted to parents, and efforts must be made to involve mothers and fathers to deal
realistically with the sexual affairs of their adolescent
children.
Young males and females have quite different preferences
concerning sources of information; and also have obvious
misconceptions, concerning various and diverse issues of
sexuality, that need to be addressed. Misconceptions can
and do spread (as is clear from the fact that many young
people cite their peers as major sources of information).
Such findings point to the need to involve youth in the
design and implementation of programmes to raise aware-
ness of risk and safe sex behaviours. Furthermore, the
preferences and perceptions of youth need to be incorpo-
rated into every such programme.
The case studies have suggested that fear of disclosure prevents many young people—again,
particularly females—from seeking appropriate and timely care for a variety of sexual and repro-
ductive health needs. In some settings, a major reason for unprotected sexual activity is fear of
disclosure while seeking contraceptives; in others, abortion is delayed till the second trimester or
sought from unqualified providers because of a similar fear. There is a need to tailor family plan-
ning services and delivery mechanisms such that they inspire trust among young people concerning
issues of confidentiality. At the same time, providers should be trained to respect the right of youth
to privacy and confidentiality.
Research recommendations
Gaps in our understanding of the sexual and reproductive health of young people continue to be
numerous and wideranging. The case studies have clearly shown that: young people are not a
homogeneous group; their sexual and reproductive health situation varies even over a couple of
years of age; the consequences of ill-health are manifested in different ways; and the needs and
perspectives of youth vary by age. They have also highlighted the extent to which gender relations
tend to be unbalanced among young people, and the severe way in which such imbalances affect
not only the reproductive and sexual health of young females but also their ability to make choices
that affect it.
This review suggests a need for more in-depth community- and facility-based behavioural research
· Involve youth in pro-
grammes aimed at imparting
information and developing
educational strategies.
· Promote access to confiden-
tial and private sexual and
reproductive health care
services.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
46
that focuses on the perspectives and experiences of youth
in different settings. Central among themes deserving
investigation are the vulnerability of young people to
sexual and reproductive ill-health, the community and
social forces and gender imbalances that limit their
choices, and the influence of the former on the latter.
Following is a summary of priority research needs.
Much of our research has tended to focus on risk behav-
iours and their determinants. Yet, findings have pointed to
such desirable positive outcomes as gender-balanced relationships, behaviour that demonstrates
sophisticated negotiation skills, the making of informed sexual and reproductive choices, and prompt
and appropriate health-care seeking. There is a need for small, in-depth studies: to determine the
characteristics of, and circumstances surrounding, such examples of positive deviance; and to
identify and analyse the strategies used successfully by the young people concerned.
Research is needed that explores the ways in which gender roles/expectations and power imbal-
ances in family structures limit or affect life skills among youth. More specifically, research is
needed to examine ways in which social constraints make young women particularly vulnerable and
unlikely to exert choices relating to their sexual and reproductive lives—whether concerning the
prevention of risk behaviour, the timing of marriage, or choices regarding motherhood. Of interest
in many settings is research that explores the constraints that married adolescent and young women
face in accessing information and services, in influencing decisions about fertility, contraception,
morbidity and sexual relations, and in remaining free from disease, violence and unwanted preg-
nancy. Research is also needed to identify circumstances under which adolescent and young
women may be able to exercise greater autonomy in these matters.
The patterns of formation and conduct of sexual partner-
ships among young people remain an important, unex-
plored area of research. Questions that need attention
include: What are the nature and duration of different
types of partnerships? Do females and males have differ-
ent perceptions or expectations of relationships? How do
females and males perceive sexual responsibility or
“appropriate” behaviour within relationships? How do
expectations of a relationship influence decisions to
practice contraception or safe sex? And to what extent,
and by whom, are choices exercised regarding sexual
behaviour and the avoidance of disease and unwanted
pregnancy?
Despite increasing levels of sexual activity and the corre-
sponding increase in the risk of contracting STIs, the issue
· Investigate the determi-
nants of positive behaviours
and outcomes.
· Investigate the gender
roles and life skills that affect
the health situation of young
women.
· Explore premarital sexual
behaviour, the ways in which
sexual partnerships are
formed among youth, and the
respective social meanings
that females and males at-
tribute to relationships.
· Investigate the ways in
which sexually active youth
deal with the dual risks of
unwanted pregnancy and
sexually transmitted infec-
tions.
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 47
of dual protection among youth has rarely been addressed.
Research is needed that: (i) ascertains the opinions of
sexually active youth about the risks they face concerning
unwanted pregnancy and HIV/STIs; and (ii) explores the
ways in which young people cope with these risks, and the
constraints they face in changing behaviours.
Young people, especially females, are observed to be particularly vulnerable to sexual coercion and
violence. Sometimes this coercion clearly involves the use of force, at other times it is more subtle
and involves economic or psychological manipulation. A considerable amount of further research is
needed that sensitively explores the levels, patterns, nature and extent of sexual coercion and
violence. Another question that must be answered is that of how the presence or threat of violence/
coercion limits the ability of young women to negotiate
safe sex and/or contraception, their ability to make repro-
ductive choices, and their ability generally to influence
their own reproductive and sexual health.
Research is needed that explores the use of reproductive
health services by youth, and the sociocultural and pro-
gramme-related constraints they face in doing so. Guide-
lines need to be developed on ways of overcoming the common fear of disclosure, and the way in
which to design and implement appropriate and acceptable mechanisms for the provision of effec-
tive sexual and reproductive health care to youth.
This is a daunting agenda. Securing informed health choices for young people entails changes in
multiple sectors: the family, society and health and educational systems. It requires a rethinking of
what programmes offer, who programmes are directed to and how programmes are delivered. It
requires an acceptance of changing norms and the provision of an environment that will support
young people to make healthy and informed choices.
· Explore the issues of
sexual coercion, force and
violence, concerning both
married and unmarried youth.
· Investigate young people’s
access to health care, and the
constraints they face in the
pursuit of good health.
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
48
REFERENCES
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adolescents in the cities of Lima, Cusco and Iquitos. Lima, Peru, Cayetano Heredia Peruvian
University (unpublished final report submitted to the Programme in December, 1996).
2. Araoye M. Sexual behaviour patterns and contraceptive choice, Nigeria. Ilorin, Nigeria,
University of Ilorin Teaching Hospital (unpublished final report submitted to the Programme in May,
1995).
3. Austin KL. Some psychosocial characteristics that play an important role in adolescent
pregnancies in the Metropolitan and San Miguelito health regions of the Republic of
Panama. Panama City, Panama, Center for Research in Human Reproduction, Ministry of Health
(unpublished final report submitted to the Programme in June, 1996).
4. Bautista PF. Young unwed mothers: medical, psychosocial and demographic implications.
Quezon City, Philippines, Management Communication Systems (unpublished final report submitted
to the Programme in June 1989).
5. Caceres S. Sexual behaviour of adolescents at Department of Lambayeque and risk of
sexually transmitted disease/HIV infection. Chiclayo, Peru, Faculty of Health Sciences, Univer-
sity of Chiclayo (unpublished final report submitted to the Programme in February, 1995).
6. Cadelina C. Sexual behaviour and level of awareness of STDs: a survey among college
students. Dumaguete City, Philippines, Department of Sociology/Anthropology, Silliman University
(unpublished final report submitted to the Programme in August, 1998).
7. Ehrenfeld N. Female adolescents at the crossroads: sexuality, contraception and abortion
in Mexico. Mexico City, Mexico, Dr Manuel Gen Gonzalez General Hospital (unpublished final
report submitted to the Programme in October, 1994).
8. Ehrenfeld N. Female adolescents at the crossroads: sexuality, contraception and abortion in Mexico.
In: Mundigo A, Indriso C, eds. Abortion in the developing world. London, Zed Books, 1999: 368–386.
9. Gao E. Study on the needs and unmet needs for reproductive health care among unmarried
women in Shanghai. Shanghai, People’s Republic of China, Shanghai Institute of Planned Parent-
hood Research (unpublished final report submitted to the Programme in March, 1998).
10. Gayun Y. Determinants of sexual behaviour and gender power relations among Korean
adolescents. Kwangiu, Republic of Korea, Chonnam National University (unpublished final report
submitted to the Programme in January, 1996).
11. Gogna M, Pantelides EA, Ramos, Silvina E. Cultural and psychosocial factors affecting
prevention and treatment of STDs: power, affection and pleasure in the negotiations between
the genders, Argentina. Buenos Aires, Argentina, Centre for Population Studies (unpublished final
report submitted to the Programme in May, 1996).
12. Grover V. Sex behaviour and risk perception among men attending an STD clinic in the
capital city of India. New Delhi, India, University College of Medical Sciences and GTB Hospital
(unpublished final report submitted to the Programme in May, 1995).
O c c a s i o n a l P a p e r 4
Evidence from WHO Case Studies 49
13. Isarabhakdi P. Determinants of sexual behaviour that influence the risk of pregnancy and
disease among rural Thai young adults. Nakorn Pathom, Thailand, Institute for Population and
Social Research (unpublished final report submitted to the Programme in November, 1995).
14. Jong Kwon Lim, Han Hyong Kim, Hye Ryun Kim, Dong Hyon Chang, Joo Hyung Kim, Sexual
behaviour and contraceptive use of Korean young men. Seoul, Republic of Korea, Korean
Institute for Health and Social Affairs (unpublished final report submitted to the Programme in
February, 1995).
15. Kgosidintsi N. Sexual behaviour and risk of HIV infection among adolescent females in
Botswana. Gaborone, Botswana, National Institute of Development, Research and Documentation
(unpublished final report submitted to the Programme in October, 1997).
16. Kleincsek MM. People identifying AIDS and STDs as problems leading to sexual behav-
iour changes. Santiago, Chile, Educacion para el Mejoramiento de la Calidad de Vida (unpublished
final report submitted to the Programme in September, 1994).
17. Kornblit AL. Sexual models among young and adults: convergences and divergences,
Argentina. Buenos Aires, Argentina, Faculty of Social Sciences, University of Buenos Aires
(unpublished final report submitted to the Programme in October, 1993).
18. Kwon Tai-Hwan, Jun Kwang Hee, Cho Sung-nam. Sexuality, contraception and abortion among
unmarried adolescents and young adults: the case of Korea. In: Mundigo A, Indriso C, eds. Abor-
tion in the developing world. London, Zed Books, 1999: 346-367.
19. Kwon Tai-Hwan, Jun Kwang, Cho Sung-nam. Sexuality, contraception and abortion among
unmarried adolescents and young adults: the case of Korea. Seoul, Republic of Korea, College of
Social Sciences, Seoul National University (unpublished final report submitted to the Programme in
December, 1994).
20. Lopez MM, Madan LF, Perez CR. Pregnancy in adolescents. Havana, Cuba, National Centre
for Sex Education (unpublished final report submitted to the Programme in October, 1997).
21. Luo Lin, Wu Shi-zhong, Chen Xiao-qing, Lin Min-xiang. Induced abortion among women in
Sichuan Province, China: a survey. Chengdu, People’s Republic of China, Sichuan Family
Planning Research Institute (unpublished final report submitted to the Programme in October 1995).
22. Luo Lin, Wu Shi-zhong, Chen Xiao-qing, Li Min-xiang. Induced abortion among unmarried
women in Sichuan Province, China: a Survey”. In: Mundigo A, Indriso C, eds. Abortion in the
developing world. London, Zed Books, 1999: 337–345.
23. Mathias A. A study of reproductive knowledge, sexual attitudes and behaviour among
secondary school students in urban Kampala, Uganda: KAP study, sexual knowledge,
beliefs, practices. Kampala, Uganda, Makerere University (unpublished final report submitted to
the Programme in December, 1993).
24. Mendez DA. Knowledge, beliefs, attitudes and behaviour of the female adolescents at
high risk of HIV or other venereal diseases in Guatemala. Guatemala City, Guatemala, Univer-
sity of Valle de Guatemala (unpublished final report submitted to the Programme in September,
1994).
25. Mendez Ribas JM, Necchi S, Schufer M. Risk awareness and sexual protection: perceptions
and behaviour among a sexually active population, Argentina. Buenos Aires, Argentina,
Hospital Clinic, University of Buenos Aires (unpublished final report submitted to the Programme in
May, 1995).
O c c a s i o n a l P a p e r 4
Sexual Relations Among Youth in Developing Countries:
50
26. Mpangile GS, Leshabari MT, Kihwele DJ. Induced abortion in Dar es Salaam, United
Republic of Tanzania. Dar-es-Salaam, United Republic of Tanzania, Uzazi Na Malezi Bora United
Republic of Tanzania (UMATI) (unpublished final report submitted to the Programme in October,
1992).
27. Mpangile GS, Leshabari MT, Kihwele DJ. Induced abortion in Dar-es-Salaam, United Republic
of Tanzania: the plight of adolescents. In: Mundigo A, Indriso C, eds. Abortion in the developing
world. London, Zed Books, 1999: 387–403.
28. Nyamongo I. Investigation into condom acceptability, sexual behaviour and attitudes
about HIV infection and AIDS among adolescent students in Kenya. Nairobi, Kenya, Institute
of African Studies, University of Nairobi (unpublished final report submitted to the Programme in
January, 1995).
29. Pantelides E. 1. Knowing the fertility situation of adolescents in Argentina, quantifying the
phenomenon and describing its characteristics 2. Exploring the network/complex of factors
that determine whether an adolescent will be a father or a mother, Argentina. Buenos Aires,
Argentina, Centre for Population Studies (unpublished two-part final report submitted to the
Programme in June, 1991).
30. Rodriguez-Lay G. Research about acceptability and effectiveness of family planning
services for young people who belong to an educative system. Lima, Peru, Institute for Popula-
tion Studies (unpublished final report submitted to the Programme in December, 1997).
31. Rugpao S. Sexual behaviour in adolescent factory workers. Chiang Mai, Thailand, Chiang
Mai University (unpublished final report submitted to the Programme in March, 1997).
32. Soonthorndhada A. Adolescent sexual attitudes and behaviour and contraceptive use of
late female adolescents in Bangkok: a comparative study of students and factory workers.
Nakorn Pathom, Thailand, Institute for Population and Social Research, Mahidol University (unpub-
lished final report submitted to the Programme in December, 1994).
33. Tamang A. Sexual risk behaviour and risk perception of HIV-AIDS transmission among
men in border towns of Nepal. Kathmandu, Nepal, Centre for Research on Environmental Health
and Population Activities (unpublished final report submitted to the Programme in March, 1999).
34. Villanueva M. Pregnancy and reproductive health in students that attend night school.
Lima, Peru, Cayetano Heredia Peruvian University, Institute for Population Studies (unpublished
final report submitted to the Programme in June, 1992).
35. Vu Quy Nhan. Survey on young adults’ reproductive behaviour: KAP study. Hanoi, Viet
Nam, National Committee on Population and Family Planning (unpublished final report submitted to
the Programme in January, 1996).
36.Wang J. The resolution of pre-marital pregnancy in Shanghai, China. Shanghai, People’s
Republic of China, Institute of Population Research, Fudan University (unpublished final report
submitted to the Programme in January 1997).
37. Wirakartakusumah D. Indonesian teenage reproductive health. Jakarta, Indonesia, University
of Indonesia (unpublished final report submitted to the Programme in January, 1997).
38. Toleo Dreves, Virginia and Ramiro Molina, Carlos. Mental health profile in adolescents with
interruption of their pregnancy with induced abortion, Santiago, Chile, Escuele de Salud
Publica, Psiquiatra Infanto Juvenil Centro de Medecina Reproductiva y Desarollo Integral del
Adolescente (CEMERA), Universidade de Chile (unpublished final report submitted to the
Programme in January 1997).
Annex 1. Summary description of the studies
Sample characteristics Sample size
Country Study population Sample
drawn
from
Age
range Married
(M) or
unmarried
(U)
Sex Total
sample % <25
years Female Male Design Author
Africa
Botswana In-school and out-of-school adolescents,
Selibe Phikwe, Mahalapye, Kang
Purposive, systematic sampling of
students from enrolment lists
Schools 13–19 U F 1366 100 1366 - Survey,
SAQ1Kgosidintsi, N.
(1997)
Kenya Secondary school students from eight
purposively selected secondary schools in
Nairobi (urban) and Homa Bay (rural)
district (girls only, boys only and a mixed
school) Forms 1–4.
Students randomly selected through
enrolment registers of each Form.
Schools 12–21 U F &
M375 100 166 209 Survey,
SAQ, and
free listing
Nyamongo, I.
(1995)
Nigeria University students, Ilorin, Kwara State
purposively selected university;
systematic random sample of students.
University 15–24 U F &
M1000 100 500 500 Survey,
½ SAQ
½ FTFI2
Araoye, M.
(1996)
Tanzania,
United
Republic of
Women admitted to four public hospitals
in Dar-es-Salaam with abortion
complications.
All women hospitalized.
Hospitals 14–49 M & U F 455 62 282 - Survey,
FTFI, IDI3Mpangile, G.S.
et al.,
(1992)
Uganda
Americas
Secondary (high) school adolescents from
10 schools in urban Kampala.
Stratified random sample of students from
10 randomly selected schools.
Schools 14–17 U F &
M400 100 200 200 Survey,
FTFI Mathias, A.
(1993)
Argentina Adolescents attending two public
hospitals for adolescent reproductive
health services for the first time, one each
in Federal Capital and Chubut.
Random selection of adolescents at two
purposively selected facilities.
Hospitals 13–19 U F &
M373 100 134 239 Survey,
FTFI Pantelides, E.
(1991)
Sample characteristics Sample size
Country Study population Sample
drawn
from
Age
range Married
(M) or
unmarried
(U)
Sex Total
sample % <25
years Female Male Design Author
Argentina Four public, secondary municipal schools
in the Buenos Aires city area.
Random selection of students from
classes 1–3 and 4–6 of 4 randomly
selected schools.
Schools 13–19 U F &
M395 100 217 178 Survey,
SAQ Kornblit, A.L.
(1993)
Argentina San Fernando, barrio of Buenos Aires
Purposive sample. Barrio and
participants 18–25 U & M F &
M50 100 24 54 FGDs4 and
IDIs5Gogna, M. et
al.,
(1996)
Argentina Adolescents attending final 3 years of
secondary schools of different types,
public, adolescents attending private,
religious, non-religious, boys only, girls
only and mixed schools in Buenos Aires.
Random selection of 30 adolescents per
class drawn from stratified sample of
schools.
Schools 14–20 U F &
M952 100 420 532 Survey,
SAQ Mendez Ribas,
J.M.
et a.,
(1995)
Chile Urban-based group attending general
medicine and other departments and
special programmes of hospital centre in
four regions of Chile.
Purposive selection.
Hospitals 15–40 M & U F &
M1209 45 616 593 Survey,
SAQ, semi-
structured
survey
Kleincsek, M.
et al.,
(1994)
Chile Adolescents with abortion complications
and those deciding to carry their
pregnancies to full term, attending three
hospitals in Santiago, Chile (and followed
up at months 6 and 12).
Purposively selected facilities; all
adolescents entering for post abortion
complications and a matched control
group of adolescents attending facilities
for delivery.
Hospitals <19 M & U F 680 100 680 - Survey,
FTFI Molina, R. et
al.,
(1997)
Sample characteristics Sample size
Country Study population Sample
drawn
from
Age
range Married
(M) or
unmarried
(U)
Sex Total
sample % <25
years Female Male Design Author
Cuba Adolescents attending four hospitals in
Havana, Pinar del Rio, Matanzas for
pregnancy termination or delivery
Purposively selected facilities; all
adolescents entering in May–Aug 1994.
Hospitals 12–19 M & U F 801 100 801 - Survey,
FTFI Lopez, M.M. et
al.,
(1997)
Guatemala Target populations: purposively drawn
sites.
1. Urban group living in city slums,
uprooted migrants.
2. Rural group from 3 large towns with
Indian and Hispanic components.
3. Transient group from 5 localities with
heavy tourism, truck movement, harbours,
ports, bars and houses of prostitution,
varying in size and level of urbanization
Purposive selection of sites, respondents
randomly selected.
Household,
or meeting
places
13–20 M & U F 758 100 758 - Survey,
FTFI Mendez D.A.
(1994)
Mexico Low-income clients at the Obstetrics and
Gynaecology Clinic of a public hospital,
Mexico City.
Quota sample of pregnant adolescent
females.
Hospital <20 M & U F 72 100 72 - FGDs, &
IDIs Ehrenfeld, N.
(1994)
Panama Adolescents pregnant for the first time,
attending antenatal care services in 8
health centres of the Metropolitan and
San Miguelito health regions.
Purposive selection of facilities; all
adolescents.
Health
centres <20 M & U F 424 100 424 - Survey,
FTFI Austin, K.L.
(1996)
Sample characteristics Sample size
Country Study population Sample
drawn
from
Age
range Married
(M) or
unmarried
(U)
Sex Total
sample % <25
years Female Male Design Author
Peru Adolescents from 14
districts/conglomerates in the Dept. of
Lambayeque.
Random selection of one district in each
of 14 clusters; systematic random sample
of households in each district.
Households 12–19 Not
reported F &
M1803 100 909 894 Survey,
SAQ Caceres, S.
(1995)
Peru Students in 7 purposively selected night
study centres in Metropolitan Lima
Stratified random sample.
Night study
centres 10–24 M & U F &
M1150 100 764 386 Survey,
SAQ Villanueva, M.
(1992)
Peru Students attending one night school
(educational night centre), San Martin de
Porres.
All female students at one purposively
selected night school.
Night
school 10–19 M & U F 228 100 228 - Survey,
FTFI Rodriguez-
Lay, G.
(1997)
Peru Urban adolescent students of secondary,
public and private schools, and out-of-
school youth, Lima, Cusco, Iquitos
Cities purposively selected; stratified
random sample of in-school students;
purposive selection of out-of-school
adolescents.
Schools,
homes 13–19 U F &
M5202 100 2537 2665 Survey,
FTFI Alarcon, I. et
al.,
(1996)
Asia
China Women visiting MCH centres for the
required premarital examination,
Shanghai 3 urban districts and 2 rural
counties.
Purposively selected sites; women
randomly selected.
MCH
centres <21
>26 U F 2580 87 2245 - Survey
FTFI,
FGDs6
Gao Ersheng
(1998)
Sample characteristics Sample size
Country Study population Sample
drawn
from
Age
range Married
(M) or
unmarried
(U)
Sex Total
sample % <25
years Female Male Design Author
China Pregnant rural and urban women,
presenting for premarital examination or
for abortion, 2 districts in urban Shanghai
and 2 rural counties.
Purposively selected sites.
Health
facilities 17–25 U F 1111 100 1111 - Survey,
FTFI Wang Jufen
(1996)
China Abortion seekers in first trimester of
pregnancy. Sites in six rural counties of
Sichuan province. Prospective follow-up
on days 15, 90 and 180 at purposively
selected hospitals/family planning clinics.
Hospitals or
family
planning
clinics
18–40 U F 457 93 457 - Survey,
FTFI Luo L, et.al.,
(1995)
India Randomly selected from outpatient STD
clinic at a university-affiliated hospital in
New Delhi.
Purposive selection of clinic; random
selection of clients.
Clinic 15–40 M & U M 397 45 - 179 Survey,
FTFI Grover,V.
(1995)
Indonesia Respondents were randomly selected
from 13 provinces, (N Sumatra, W
Sumatra, S Sumatra, Lampung, Greater
Jakarta, West Java, Central Java,
Yogyakarta, East Java, Bali, West Nusa
Teggara, Kalimantan, S Sulawesi).
Representative sample. Provinces
purposively selected based on sampling
structure of 1993 National Economic and
Social Survey. Households randomly
selected in each survey region.
Households 15–24 U F &
M2994 100 1378 1616 Survey,
SAQ Wirakartakusu
mah, D.
(1997)
Sample characteristics Sample size
Country Study population Sample
drawn
from
Age
range Married
(M) or
unmarried
(U)
Sex Total
sample % <25
years Female Male Design Author
Korea,
Republic of Single women in dormitories in three
export zones who agreed to attend an
educational programme (other groups
also studied, not reported here), Kuro
(Seoul), Kumi (Kyongbuk), Masan-
Ch’angwon (Kyongnam).
Purposive selection of dormitories.
Dormitories <19–
29 U F 326 91 326 - Survey,
FTFI Kwon Tai-
Hwan et al.,
(1994)
Korea,
Republic of University students from four universities,
living in and around Seoul.
Two-stage systematic sampling of
universities, stratification by grade, 30
students per grade.
Universities 14–29 U M 1103 80 - 875 Survey,
SAQ Jong Kwon
Lim, et al.,
(1995)
Korea,
Republic of School students (from 9th grade in school
to seniors in college) in Kwangju
metropolitan, and surrounding rural areas
Purposive sample of school students.
Schools 15–22 U F &
M849 100 400 449 Survey,
SAQ Gayun, Y.
(1996)
Nepal Recruited from five border towns along
the Indian–Nepal border (resident and
non-resident).
Cluster sampling to identify resident men;
purposive sampling by occupation for
non-resident men.
Household,
places of
work or
meeting
places
18–40 M & U M 800 41 - 326 Survey,
FTFI, IDI Tamang, A.
(1999)
Philippines First-time mothers, married and
unmarried, Metro Manila.
Purposive sample of sites.
NGOs for
unwed
mothers;
maternity
hospitals
for married
15–24 M & U F 200 100 200 - Survey,
FTFI, IDI Bautista, P.F.
(1989)
Philippines College students, Dumaguete City
Systematic random sampling of students. Colleges 15–24 U F &
M1196 100 503 693 Survey,
SAQ Cadelina, C.
(1998)
Sample characteristics Sample size
Country Study population Sample
drawn
from
Age
range Married
(M) or
unmarried
(U)
Sex Total
sample % <25
years Female Male Design Author
Thailand Female factory workers and students,
Bangkok.
Twelve randomly selected schools and 18
randomly selected garment factories.
Schools
and
factories
15–19 U F 500 100 500 - Survey
FTFI, FGDs Soonthorndha
da, A.
(1994)
Thailand Young factory workers from 50
purposeively selected factories in Chiang
Mai, participants randomly selected.
Purposively selected factories.
Factories 13–25 M & U F &
M1210 100 609 601 Survey,
FTFI Rugpao, S.
(1997)
Thailand Adolescents from rural areas of six
provinces in north and north-east
Thailand, study sites purposively selected,
participants randomly.
Households 15–24 M & U F &
M1228 100 605 623 Survey,
SAQ, FGDs Isarabhakdi, P.
(1995)
Viet Nam College students from eight university
campuses in Hanoi and Ho Chi Minh City;
Random selection of 4 institutions each in
Hanoi and Ho Chi Minh City, random
selection of students.
Universities 17–24 U F &
M1603 100 803 800 Survey,
FTFI Vu Quy Nhan
(1996)
1 SAQ: Self-administered questionnaire.
2 FTFI: Face-to-face interview.
3 IDI: In-depth interview .
4 FGD: Focus group discussion.
.
