Health and medicine course

1. Youth Sexual and Reproductive Health
Half of the world’s population is younger than 25 years old and 9 out of 10
young people live in developing countries. These young people face
profound challenges, such as high rates of early marriage, unintended
pregnancy, HIV and other sexually transmitted infections, and maternal
mortality and morbidity.
This course has two main goals. The first is to provide an introduction to
key sexual and reproductive health issues of youth, including the
relationship between gender norms and health. The second is to present
an overview of the best programmatic approaches for improving young
people’s sexual and reproductive health.
Objective
By the end of this course, the learner will be able to:
 Recognize the unique physical, psychological, and social characteristics of
young people
 Describe the sexual and reproductive health needs of young people
 Recognize the ways in which gender norms affect the sexual and
reproductive health outcomes of youth and learn how programs can
address gender inequality
 Understand why young people require special attention to achieve
positive sexual and reproductive health outcomes
 Identify programmatic initiatives and approaches that improve the sexual
and reproductive health of young people
Demographics and Definitions
Young people are a great resource for families, communities, and societies.

2. Today, there are 1.8 billion people between the ages of 10 and 24
- the largest generation in history to transition into adulthood. In
many countries, young people make up half the population. Nearly
90% of the world's young people live in developing countries.
In many countries, birth rates are falling as contraceptive use increases.
Falling birth rates mean that a country has a smaller population of people
at young, dependent ages and a larger population of working age adults
(ages 15-64).
A large workforce with fewer children to support creates a window of
opportunity - also known as "demographic dividend" or a "demographic
bonus." Wise governments will invest in measures to support the health
and development of youth - especially since even as birth rates are falling,
the total number of youth will increase by over 70 million by 2025.
Source: Nugent 2005
Highlight
This course uses the United Nations definitions of young
people, adolescents, and youth.
 For information on health and development of youth, see the world
development report 2007 Development and the Next Generation PDF(link
is external)(link will open new window).
 For data on world population, click here(link is external)(link will
open new window).
 For demographic information on youth ages 15-24, see The DHS
Program - Youth Corner Main Page(link is external)(link will
open new window).
Highlight
“Having a lot of young adults is good for any country if its economy is
thriving, but if jobs are in short supply it can lead to frustration and
violence."
"An abundance of young people is like gearing on a balance sheet: it
makes good situations better and bad ones worse.”

3. Source: The Economist Dec 3, 2011
A Time of Transition
Adolescence is a time of transition that is
marked by many physical, psychological, and social milestones including:
 Menstruation in girls; semenarche in boys
 Physical changes in their bodies and brains
 Changes in perceptions of themselves and others
 Development of personal values that are influenced by gender norms and
guide behavior
 Sexual initiation
 Transition from classroom to workplace
 Transition to economic independence from elders and a separate
household
 Transition to adult roles and responsibilities, many of which are shaped by
gender and gender norms
The pace of this transition varies among individuals and cultures. A
common starting point is the onset of puberty. The age of puberty onset
has been falling globally for both boys and girls. Girls now enter puberty
between the ages of 8 and 13 and reach their first menstruation several
years later. Boys enter puberty between the ages of 9 and 14 and reach
semenarche between 11 and 15.
Adolescence marks a critical time of development for young people—
including intense physical, hormonal, cognitive, and social changes, and

4. the formation of one's identity separate from parents. Young people are
acquiring information, developing attitudes, and experimenting with
relationships and behaviors that will affect their present and future well-
being.
As young people begin to consider the future, they may still not be aware
of or understand all of the consequences of their behavior. They may lack
the information and self-confidence to make informed and independent
decisions. They may not accurately perceive their risk of illness or death.
Their behavior and decisions, including whether or not to have sex, are
influenced by their peers, and their sexual encounters are often unplanned
and unprotected.
Did you know?
The World Health Organization (WHO)(link is external)(link will
open new window) estimates that about two-thirds of premature deaths
in adults are related to early adoption of harmful behaviors initiated in
adolescence — such as unprotected sex, violence, smoking, or substance
use.
Highlight
The choices and decisions adolescents make today have long-term
repercussions. During adolescence, health and social behaviors are
established for life; thus, adolescence provides an opportunity for
addressing both sexual and reproductive health and gender issues.
Adolescence and Gender Norms
Both boys and girls are learning what it means to be a man or a woman in
their culture. These gender norms are likely to influence their behaviors
and health for decades to come.
Gender norms for females in many cultures include:
 Submissiveness
 Deference to male authority

5.  Dependence
 Virginity until marriage
 Faithfulness in relationships, including marriage
Gender norms for men, in contrast, are built around power and control,
independence and not showing emotions (other than anger). These norms
include:
 Risk-taking
 Using violence to resolve conflict
 Early sexual activity
 Having multiple sexual partners
The different gender norms for women and men limits young people's
control over their sexual and reproductive lives, their ability to receive an
education, their economic security, and their overall health and well-
being. However, around the world, millions of young people are
working to challenge harmful gender norms. Many believe in
gender equality and are helping to bring about positive change.
Changing World

6. Today's generation of young people is the largest in history. In
2013, young people ages 10-24 accounted for an estimated 25% of the
total population. Their decisions and behaviors will affect the world's social,
environmental, and economic well-being for generations. If young people
are provided with the appropriate skills and opportunities, they can be
catalysts for positive, sustainable change.
Unfortunately, young people’s access to resources varies greatly, which
affects their quality of life. Of the 1.8 billion young people living today:
 approximately 122 million are illiterate,
 66 million are unemployed, and
 millions more are underemployed.
Young women in very low-income countries are less likely to be enrolled in
school and more likely to be illiterate than their male counterparts, and
young women all over the world are less likely to be employed than young
men.
For boys in many societies, the definition of manhood is closely tied to
employment. Where poverty and unemployment are high, lack of earning
opportunities has a profound negative effect on men's sense of self. Young
men who are unemployed and underemployed feel a loss of power and
identity and are at an increased risk of perpetrating intimate partner
violence, abusing alcohol, and engaging in other risky behaviors.
In many societies, girls' limited access to earning opportunities further
exacerbates their dependence on men for economic support, increasing
their vulnerability to child marriage, early sexual initiation, cross-
generational and transactional sex, unsafe working conditions, and other
forms of exploitation.
Many young people have limited or no opportunity to participate in their
communities or the political process. This is especially true for young
women because family responsibilities and lower access to education and

7. other resources limit their ability to contribute to or benefit from the social
and political structures they live within.
Child marriage is a global problem. In South Asia and parts of Africa, nearly
half of young women marry before the age of 18. Over the next 10 years,
100 million girls will marry before their 18th birthday. Child marriage is
linked to early childbearing; as many as 90% of adolescent pregnancies
occur within marriage.
In some countries, laws against child marriage and increased access to
family planning information and services allow more young people —
particularly young women — to remain and succeed in school and the
workplace as contributors to and consumers of local and global economies.
Technology further improves the ability of young people to network,
mobilize, and participate in social change and political decision making.
As the number of young people increases, young people urgently need
access to quality education, vocation and life skills, and a range of health
services. Cultural and social norms need to change so that youth with
support from adults and decision makers can establish healthy behaviors
while young, creating a solid foundation for a healthy and productive
future.
Sources: PRB 2013; Barker 2005; Correia 2006; UNESCO Institute for
Statistics 2012; International Labor Office 2012; UNFPA 2012; UNFPA
2013; WHO 2009; World Bank 2012
Highlight
During a town hall meeting with Tunisian youth, Secretary of State Hillary
Rodham Clinton said:
“[T]here are underlying dynamics that are affecting young people
everywhere – changes in demographics and technology, economics and
politics that are bringing together this unique moment in history. Young
people are at the heart of today’s great strategic opportunities
and challenges, from rebuilding the global economy to combating
violent extremism to building sustainable democracies." - Secretary
of State Hillary Rodham Clinton, “Youth Rising,” Tunisia, February 25, 2012

8. An Opportunity to Address Gender Norms
During adolescence, young people may begin to form romantic and sexual
relationships. These relationships are influenced by society and gender
norms. Harmful gender norms can undermine healthy relationships and can
affect young people’s reproductive and sexual health. These norms often
lead to an expectation that a woman should not refuse sex, even if her
partner will not use a condom, or the expectation that men prove their
masculinity by having sex with many women.
Not all gender norms are harmful, and even harmful norms can be
changed to create positive health outcomes. For example, community level
discussions examining gender norms can help change the definition of a
“real man” to include the responsibility to use one’s strength to prevent
and not instigate violence.
Youth programs that consider and address gender norms and related
barriers to participation are better able to fully engage their desired
participants. For example, programs that want to attract vulnerable girls,
such as out-of-school girls or adolescent mothers, may want to consider
those barriers that may limit their participation — such as availability of
transport or their physical safety. When programs do not consider these
issues, it is only the less vulnerable young men and women who may be
able to attend.
Youth are receptive to conversations about gender equality. The concept of
justice is often highly important to young people, and they may not have

9. yet fully embraced the gender roles expected of adults. These factors allow
them to more easily reflect critically on gender norms in their communities.
Programs that incorporate gender strategies that allow for examination of
gender roles, norms and expectations, especially in relationships, have
achieved increased contraceptive use, increased use of health services,
improved health knowledge, and increased communication about family
planning.
Throughout this course, gender implications for sexual and reproductive
health issues, as well as programs to address these issues, will be
described. Basic gender terms that will be used throughout the course
are defined here:
 Sex
 Gender
 Gender norms
 Gender equality
 Gender integration
Additional Reading
There are many resources for understanding and addressing the issues
around gender inequality generally and for youth specifically:
 USAID Gender and Sexual and Reproductive Health 101(link will
open new window) course
 USAID’s Gender Equality and Female Empowerment Policy(link is
external)(link will open new window)
 USAID’s Interagency Youth Working Group’s gender page(link is
external)(link will open new window)
 Interagency Gender Working Group’s Gender and Health Toolkit, section
on adolescents and youth
Young Women and Harmful Gender Norms

10. Young women are disproportionately burdened by poor sexual and
reproductive health outcomes around the world in part because of harmful
gender norms. Young women have less power, status, and prestige than
young men and are therefore less able to access or advocate for what they
need.
Young women who are most vulnerable include those who are:
 Married or at risk of marriage and under the age of 18
 Living in rural communities
 Not in school or living with their parents
 Very young (ages 10 to 14) not in school or living with their parents
Gender inequality is especially important during adolescence because this is
a time when many young women become marginalized in their
communities. They may be forced to drop out of school, expected to do
more work in the home, or forced into marriage. They often experience
less freedom of movement and are socially isolated. They are more
vulnerable to gender-based violence, unprotected sex — often
forced, coerced, or transactional — and the associated unplanned
pregnancies and infections (STI and HIV) that can result.
Sources: Bruce 2006; Engebretsen 2012; International Center for Research
on Women 2007; Plan International 2012; United Nations Interagency Task
Force on Adolescent Girls ND

11. Did you know?
The World Health Organization states, “Gender inequities are pervasive in
all societies. Gender biases in power, resources, entitlements, norms, and
values and in the organization of services are unfair. They are also
ineffective and inefficient. Gender inequities damage the health of millions
of girls and women.”
Source: WGEKN 2007
Highlight
Examples of programs that empower girls and young women and reports
on gender inequality as it affects these populations can be found on the
Interagency Youth Working Group’s (IYWG) Adolescent Girls(link is
external)(link will open new window) page.
Young Men and Harmful Gender Norms
Because gender inequality disproportionately
affects young women, most programming to address harmful gender
norms focuses on empowering young women and girls. However, rigid and
unequal gender norms also hurt young men.
Young men who are most vulnerable include:
 Young men who identify as gay, bisexual, transgender or queer
 Young men who are unemployed
 Those who are out of school or engage in child labor
 Those who have been victims of violence as children

12. Gender norms pressure young men to act in ways that can harm their
health in order to prove their manliness. Young men are more likely to
initiate first sex at a younger age than young women, generally have more
sexual partnerships in their lifetime and are more likely to have multiple
concurrent partnerships — all increasing the risk of STIs, including HIV,
and unplanned pregnancy for young men and women. Harmful
constructions of masculinity put men at an increased risk for other
negative health outcomes too, such as alcohol-related injury and suicide.
Violence is the leading cause of death for young men.
Rigid gender norms are also closely linked with homophobia — or
the fear of homosexuality. Men who do not display the expected masculine
characteristics often experience violence and discrimination because it is
believed that these young men are homosexual. A lack of stereotypically
masculine characteristics, however, is not necessarily related to one’s
sexual orientation.
Allowing or encouraging discrimination against young men who are or are
believed to be homosexual hurts youth programs. Some young people will
feel unsafe in the program. Others, out of fear of being accused of
homosexuality, may act according to harmful norms of masculinity — such
as being violent, having many sexual partners, or not respecting women —
to prove their manhood. Promoting a culture of acceptance and respect for
all people encourages positive and healthy behaviors.
Engaging men and boys to examine harmful gender norms is
essential to improving the sexual and reproductive health of both
adolescent boys and girls. Transforming the understanding of
masculinity is vital for creating and sustaining change. Even when
young men are not the targeted beneficiaries of a program that seeks to
address gender inequality, they should be considered when designing
programs.
Sources: Correia and Bannon 2006; Plan International 2011
Highlight
Homophobia is a challenge for all programs. UNESCO’s report Education
Sector Responses to Homophobic Bullying (link is external)(link will

13. open new window)provides information on how the education sector
addresses this challenge.
The IYWG’s Adolescent Boys(link is external)(link will open new
window) page provides descriptions of and links to tools and reports that
address the impact of harmful gender norms on males and male
engagement in programs.
Did you know?
Programs addressing gender inequalities often focus on increasing
opportunities for young women, but few promote corresponding change for
boys. In some areas of the world, gender norms can increase inequality for
young men. For example, in sub-Saharan Africa, female adolescents are
more likely to be out of school. But research suggests that in some areas
of the world, such as Latin America and the Caribbean, pressures to find
work mean that young men are more likely to be out of school than young
women.
Source: UNESCO 2012
Reproductive Health of Young People Matters
Unprotected sexual activity
can result in unplanned or unwanted early pregnancy, unsafe abortion,
and sexually transmitted infections (STIs), including HIV.
Unintended pregnancy

14. Sixteen million adolescent girls ages 15 to 19 give birth each year. This
accounts for approximately 11% of all births worldwide. Nearly all births to
adolescents (95%) occur in developing countries. Pregnancy is the
leading cause of death among young women in developing
countries, and an estimated 90% occur among married
adolescents. Maternal mortality risk is approximately 28% higher for
women under 18 than for women over 18.
Unintended or mistimed pregnancy creates physical, psychological, and
social risks for many adolescent girls. An unmarried girl who becomes
pregnant often drops out of school, which limits her ability to be self-
sufficient. Repeat pregnancies occur frequently among young mothers; in
the U.S., repeat pregnancies occur among 35% of adolescents pregnant in
the past two years. Furthermore, a mutli-country study conducted in South
Asia found that married adolescents are at the greatest risk of rapid repeat
pregnancies. If girls become pregnant before age 18, or if they are unable
to space subsequent pregnancies by at least three years, both they and
their babies face health risks. Many girls report not wanting to
become pregnant, but the level of unmet need for contraception
among young people is more than twice that of adults. Between 2.2
and 4 million adolescent girls obtain an abortion each year, the majority of
which are expected to be unsafe. For example, 59% of all unsafe abortions
in Africa are estimated to be among young women under age 25.
Sexually transmitted infections
Over one-third of new STIs occur among young people. Sexually
transmitted infections lead to other health problems, including infertility
and HIV. More than 10 million young people between the ages of 15 and
24 are living with HIV. Nearly half of all new infections each year occur
among young people. In areas with high HIV prevalence and limited access
to antiretroviral therapy (ART), AIDS is a significant cause of death among
youth.

15. HIV/AIDS
Adolescent girls are particularly vulnerable to HIV infection; females
make up more than 60% of all young people living with HIV. In
some settings, young married girls (ages 15 to 19) have been shown to
have higher rates of HIV infection than sexually active unmarried youth of
the same ages. Married adolescent females have little to no decision-
making power related to condom use or sexual activity. In developing
countries, 80% of unprotected sex among adolescent girls occurs within
marriage.
Risky sexual behaviors such as early initiation of sexual activity, multiple
sexual partnerships, cross-generational sex, and inconsistent or incorrect
use of condoms and contraceptives increase young people's risk of STIs,
HIV, and early or unintended pregnancy. Appropriate sexual
and reproductive health information, life skills training, and health services
can help youth to make healthy choices. People who provide these services
should consider many factors, including young people’s age, gender,
marital status, parenting status, level of education, where they live, and
overall socioeconomic status. Parents, spouses, in-laws, community
members, and decision makers are also important in establishing
supportive environments for healthy decision making.
Sources: Baldwin and Edelman 2013; Blanc et al. 2013; Ramos 2011;
Baldwin & Edelman 2013; WHO 2006; WHO 2004; Warriner & Shah 2006;
UNICEF 2011; IWHC 2008; Clark et al. 2006
Highlight
Risks to youth are documented in a WHO technical report on birth
spacing(link is external)(link will open new window).
Information on maternal mortality and morbidity can be found here(link is
external)(link will open new window).