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By Usha Rai A drop-in sexual-health centre in New Delhi and an adolescence sex education programme for class 10 students in rural and urban Haryana clearly demonstrate the benefits of sexuality education and counseling for youth
Five years of research and intervention on the myths and misconceptions about reproductive and sexual orientation and needs of adolescents has revealed that it is possible to change public perceptions and break taboos on sex and sexuality. For this study-cum-intervention, called ‘Young People’s Health and Development—a Reproductive and Sexual Health-Centred Action Approach, 2003-2008’, MAMTA-Health Institute for Mother and Child partnered the Swedish Association for Sexuality Education (Rfsu). Marie Andersson, programme director of Rfsu, says it took 50 years for the Swedish public to accept the need for sexuality education. However, by 1955, sexuality studies were mainstreamed in the school education programme. The average youth in Sweden gets sexually active between the ages of 15 and 16, so it is important for them to be aware of the risks involved and the precautions available. “India should benefit from the experience of Sweden and not wait for 50 years to introduce adolescence sexual education,” she says. In the first phase of the India study, 32 villages of Rewari district of Haryana, 31 villages in Varanasi district of Uttar Pradesh and four urban slums of Koramangala in the city of Bangalore in Karnataka, were selected for work on key health needs associated with puberty such as menstruation and personal hygiene. It was found that lack of precise information and incomplete knowledge associated with puberty and sexual reproductive health (SRH) makes young people inquisitive and vulnerable to risk-taking behaviour. Simultaneously, MAMTA worked towards building the capacities of a network of 134 NGOs in seven states to understand and take action on reproductive sexual health in terms of early marriage and early pregnancy and unwanted pregnancies. They were also able to address the vulnerability of young people to HIV infections. Sexuality education was seen as a ‘preventive tool’. This network of NGOs is called SRIJAN (Sexual Reproductive Initiative for Joint Action Network). A friend in need MAMTA’s initiative for adolescents is called Friends, a youth-friendly health centre in the heart of a resettlement colony, Tigri, in the capital, New Delhi. Friends was set up in February 2006 to address the needs of young people, particularly unmarried ones, who avoid public reproductive health services believing that the services are not intended for them for a variety of reasons: the staff will be judgmental, concern over privacy, fear that parents might learn of the visit and embarrassment at requiring such services. Moreover, in most reproductive health programmes accessed by young married men and women, little consideration is given to their biological development and emotional immaturity at the adolescent stage. It was therefore felt that specialised approaches must be established to attract young clients, taking into account their specific needs. The drop-in health centre, appropriately called Friends, was developed by MAMTA with young people coming on board to design the clinic’s services – its logo, its name, the ambience of the waiting room, the kind of posters and books they would like there and the clinic’s timings. Young women emphasised the need for a female doctor and counsellor and separate clinic timings for men and women. The men stressed the need for a young doctor who would be more like a friend. All these preferences were integrated into the centre’s design. Friends has developed as a place where young people can seek information, advice or contraceptives. And its usefulness has been clearly demonstrated. Of the 315 unmarried clients who visited the centre between February 2006 and December 2008, 27% had a friend of the opposite sex and 11% had experienced sexual intercourse. The 50,000 inhabitants of Tigri are largely migrants from Rajasthan, Uttar Pradesh and Bihar who work as labourers, hawkers, daily wage earners and grade 4 office employees. Adding to the health vulnerability of the population is widespread alcoholism, gender inequity, poor education, various forms of substance abuse, and gambling. Till the end of 2008, 688 young people had visited Friends 1,791 times. The most frequent visitors were unmarried adolescents between 15 and 19 years. Most people came with general health complaints. A staggering 84% were anaemic. Over 72% of the men too were anaemic. Nutritional deficiency was also high – 64% were underweight with a body mass index of less than 18.5%. With 12% males and 11% females having symptoms of sexually transmitted infections, a good professional health service like this one was clearly required. Nearly 10% were physically abused and 5% sexually abused. Twenty-four per cent of the young people were suffering from depression and the counselling service was therefore very helpful. The Tigri project has three components: a youth-friendly health centre providing clinical and information services, outreach activities to raise awareness about sexual and reproductive health issues, and research activities to determine what services young people want. MAMTA is now working towards integrating the youth-friendly services into the public health system. Reaching out to schools The Haryana study on adolescence education was equally significant. Four years of sustained effort at imparting adolescence education to 5,000 school children in rural and urban Haryana has changed the children’s knowledge as well as attitude on issues like unwanted pregnancies, sexually transmitted infections (STIs), HIV and AIDS, sexual abuse, violence, and equity in decision-making powers of girls and boys. The school-based Adolescent Education Programme (AEP) was conducted by MAMTA in four schools, two girls’ schools and two boys’ schools, in urban Rewari and rural Bawal. The programme was endorsed by the district education officers, school principals, parents, teachers and students. Regular feedback and consultation over three years helped the MAMTA team address various challenges including opposition from school teachers. In the first phase in 2004-2005, the adolescence education framework was developed for classes 8, 9 and 10 based on an assessment of the knowledge and need of the students. In the second phase, from 2005 to 2008, a specific programme was developed and delivered incrementally by a group of trainers from outside the school system. At the end of each year, tests were conducted to assess the students’ knowledge, attitude and practice, and the curriculum was revised accordingly for the subsequent year. To study the impact of the intervention, a comparison was made between students of class 10, who had been through the AEP, and class 11 students of the same school who had not been through it. Outcomes of the programme The change in the attitude of girls towards various issues concerning adolescence growth and maturity was more significant than that of the young boys. Boys and girls who had been through the programme were able to identify and reject common misconceptions about nocturnal emissions and masturbation (such as, it leads to impotency, causes sexual dysfunction, deformity of sexual organs and weakness). The class 10 students were able to correctly identify all four or at least three of the symptoms of sexually transmitted infections (STI) compared to class 11 students who had not been through the programme. A significantly higher percentage was also able to reject myths related to HIV transmission as compared to their seniors who had not been through the AEP. Girls in class 10 were able to understand that the oral pill did not protect them from STIs and HIV. The AEP was also empowering for girls. A little over 91% of the girls in the rural schools and 95% in the urban ones felt the decision to have a baby should be made by both partners in a marriage. There was also a significant change in the attitude and understanding of decision-making in a relationship. The question the students who had been through AEP had to answer was ‘do men take better decisions than women’. This would lead to greater equity and understanding in a marriage as well as a change in the male psyche and understanding of the abilities of women. A significant number of class 10 students who had been through AEP knew how to use a condom properly and a significant number of girls said they would ‘decline to have sex without a condom’. Sex without a condom was rejected by 77% of rural girls who had been through AEP as compared to a little over 5% of their seniors in rural schools who had not been through AEP. At the end of three years’ intervention, 80% of boys and 89% of girls in rural schools and 69% of boys and 31% of girls in urban schools agreed that a girl can suggest the use of a condom to her boyfriend. It was agreed that a boy could suggest the use of a condom to his girlfriend. A significant percentage of class 10 girls from rural areas who had been through AEP said they would ‘oppose then and there’ sexual abuse, while the girls from urban schools said they would not only oppose it but would confide to a trusted elder. ‘Is it all right to have pre-marital sex?’ At the end of three years, more girls in the intervention group said it was fine to have sexual relations before marriage. However, more boys in the intervention group disagreed than those who had not been through AEP. Between 40% and 46% of boys in urban and rural schools respectively who had been through AEP reported that they had been through a sexual experience (had intercourse). Six to 10% of girls in rural and urban schools reported sexual experience. However, in terms of numbers they were very small. Forty to 68% of boys and girls said they would like to have adolescence education taught by school teachers but not their class teachers. School authorities unanimously endorsed the need for a school-based AEP though there was some scepticism about the capacity of teachers to run this programme and some reservation about whether there should be discussion about issues like condoms and abstinence versus safe sex. Based on the study, MAMTA has concluded that AEP should be sustained over a period of three years or more so that there is optimum exposure of all students to the issues and an opportunity to discuss related matters with trust and confidence. Currently, such programmes are not a part of the curriculum. MAMTA advocates devoting at least 16 hours a year to AEP. The sustainability of the programme would depend on teachers taking ownership of the programme. While students are open to adolescence education, teachers have expressed their inability to deliver the curriculum. MAMTA has suggested that books or manuals with basic non-negotiable curriculum be developed with key messages. (Usha Rai is a senior development journalist based in New Delhi) InfoChange News & Features, April 2009
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