By Swetha Sridhar
With the largest adolescent population in the world at 253 million adolescents, one in every five people in India is between the ages of 10 to 19 [i]. It is broadly agreed that this is a critical transitional stage, with major physiological changes such as the attainment of puberty and emotional changes such as the development and exploration of gender and sexual identities and orientations manifesting themselves in the lives of young people. For many adolescents, these changes mark the beginning of a series of complex developmental events. In some contexts, adolescents drop out of school to support domestic responsibilities, join the workforce or marry. Girls who marry early experience a break with their natal families and familiar social networks. Further, they may be subject to the pressures of early fertility, with lifelong consequences. During this phase, adolescent girls are especially exposed to multiple layers of vulnerability due to gendered social norms that impact the way they live their lives, affects their mobility, and limits their decision-making ability. Further, these transitions are embedded within larger structural challenges such as poverty, statelessness, issues of safety and violence and so on.
Support for adolescents during this transition is imperative. However, within global health and social policy, the needs of adolescents are often overlooked [i],[ii]. This neglect has resulted in minimal investments in adolescent-centered programming, lack of social safety support interventions for adolescents compared to other age groups and most importantly, limited robust and credible evidence on adolescents. [iii]
Why must we talk about adolescents?
The adolescent evidence gap has significant implications for health and social programs designed and implemented for adolescents. Studies suggest that adolescents, especially those with the most pressing sexual and reproductive health (SRH) needs may not be reached by interventions as intended by policy-makers and program planners [iv]. For instance, a review of India’s flagship adolescent health program, the Rashtriya Kishor Swasthya Karyakram (RKSK) found that despite efforts being made to encourage adolescents to visit the Adolescent Friendly Health Clinics, unmarried adolescents were reluctant to visit these clinics. This gap in implementation was not identified early on due to a lack of disaggregated data and evidence within adolescent health programming. [v]
Such oversight has significant impacts on India’s development trajectory. Effective and evidence-based adolescent programming has not only the ability to yield a “triple dividend of benefits” [vi], but it also has a cascading impact on education, livelihoods, and an individual’s overall ability to lead full, empowered lives.
In the recent past, India has seen some research attention being paid to adolescents – for instance, the UDAYA study, which is a pioneering study on adolescents in the states of Uttar Pradesh and Bihar and the Performance Monitoring for Action (PMA) project in Rajasthan, which recently expanded its ambit to collect data on adolescent girls. However, despite these gains, there are social, legal and policy barriers that hinder the collection of data, particularly related to unmarried adolescents and their SRH health needs, leaving these needs unaddressed.
Challenges to Evidence Building on Adolescents
The first and perhaps foremost challenge is the lack of universal acceptance of adolescence as a demographic category within India. While, globally, the WHO and UNICEF define adolescents as those between 10 and 19 years of age [vii],[viii], within India, different ministries, departments, and agencies categorize individuals in differing and sometimes overlapping ways [ix]. For instance, even though the Ministry of Health and Family Welfare has adopted the WHO definition, other ministries variously use the categories of children (ages 5 -18) or youth (ages 15 -29). Consequently, even where data are collected and analyzed, comparison is hindered by these differing definitions.
Secondly, collecting evidence on sexual activity amongst adolescents is complicated by the fact that many of the adolescents who are voluntarily sexually active and or have pre-marital sexual activity are below the legal age of consent in India. Under the Protection of Children from Sexual Offences (POCSO) Act, 2012, which is meant to protect children and adolescents below 18 from harm and abuse, any sexual encounter (even if it is consensual) is defined as violence [x]. This criminalization of all sexual expression discourages adolescents from talking about their sexual experiences and needs.
These policy and legal challenges are further reinforced by the far “stickier” challenge of sociocultural dimensions that influence interactions and conversations between researchers and communities as they seek to understand adolescent sexual activity. In general, the social norms that govern adolescent SRH behavior condemn dating and pre-marital sexual activity amongst adolescents. While there is some laxity with regard to men’s sexual behavior [xi],[xii], women’s sexual activity is greatly policed because of the perception of “purity” linked to adolescents, and its association with family honor. Consequently, there is a tendency to deny the occurrence of sexual experiences amongst unmarried adolescent girls – leading to misreporting [xiii], especially amongst adolescent girls, or outright denial [xiv]. On the other hand, given the relative freedom that adolescent boys enjoy, they have been reported to exaggerate sexual encounters, as a result of peer pressure and cultural attitudes around masculinity and sexual activity [xv]. Consequently, it is hard to accurately estimate the actual extent of sexual activity amongst unmarried adolescents.
These norms also influence the ways in which gatekeepers – parents, teachers, and community leaders – who are the first points of contact for researchers on adolescent issues, respond to requests to discuss these “taboo” topics with their adolescent charges. As a result, research on adolescents face unique challenges when it comes to obtaining informed consent [xvi].
Despite the heightened awareness that ensuring sexual and reproductive health and well-being in adolescence plays an essential part in reproductive health and wellbeing in later life, we currently lack the data required to design and implement successful programs. There is a need to expand our understanding of adolescent health and behaviors beyond those of married adolescents. We also urgently need to include adolescents, particularly unmarried adolescents within national and sub-national studies, and ensure the disaggregation of data by age, gender, and socio-economic status. This evidence would enable us to work towards including better inclusion of disadvantaged or marginalized young people in SRH research, particularly those who are out-of-school, economically disadvantaged, migrants, living with disability, and young key populations.
“Swetha Sridhar is a development practitioner committed to ensuring adolescent girls transition into adulthood successfully. Her work focuses on issues of SRHR and adolescence, and it’s linkages to social sector policy in India.”
[i] UNICEF. (n.d.). Adolescent development and participation. UNICEF India. Retrieved July 17, 2021, from https://www.unicef.org/india/what-we-do/adolescent-development-participation
[ii] Molyneux, M. (2020, January 15). Adolescence: policy opportunities and challenges. UNICEF. https://www.unicef-irc.org/article/1955-how-social-protection-can-work-better-for-adolescents.html
[iii] Patton, G. C., Sawyer, S. M., Santelli, J. S., Ross, D. A., Afifi, R., Allen, N. B., Arora, M., Azzopardi, P., Baldwin, W., Bonell, C., Kakuma, R., Kennedy, E., Mahon, J., McGovern, T., Mokdad, A. H., Patel, V., Petroni, S., Reavley, N., Taiwo, K., . . . Viner, R. M. (2016). Our future: a Lancet commission on adolescent health and wellbeing. The Lancet, 387(10036), 2423–2478. https://doi.org/10.1016/s0140-6736(16)00579-1
[iv] Chandra-Mouli, V., Lane, C., & Wong, S. (2015). What Does Not Work in Adolescent Sexual and Reproductive Health: A Review of Evidence on Interventions Commonly Accepted as Best Practices. Global Health, Science and Practice, 10(3), 333–340. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4570008/
[v] Barua, A., Watson, K., Plesons, M., Chandra-Mouli, V., & Sharma, K. (2020). Adolescent health programming in India: a rapid review. Reproductive Health, 17(1). https://doi.org/10.1186/s12978-020-00929-4
[vi] Sheehan, P., Sweeny, K., Rasmussen, B., Wils, A., Friedman, H. S., Mahon, J., Patton, G. C., Sawyer, S. M., Howard, E., Symons, J., Stenberg, K., Chalasani, S., Maharaj, N., Reavley, N., Shi, H., Fridman, M., Welsh, A., Nsofor, E., & Laski, L. (2017). Building the foundations for sustainable development: a case for global investment in the capabilities of adolescents. The Lancet, 390(10104), 1792–1806. https://doi.org/10.1016/s0140-6736(17)30872-3
[vii] WHO. (2014). Health for the World’s Adolescents: A Second Chance in the Second Decade. World Health Organisation. https://apps.who.int/adolescent/second-decade/#
[viii] UNICEF. (2019, October). Adolescents overview. https://data.unicef.org/topic/adolescents/overview/
[ix] Ministry of Youth and Sports Affairs. (2014). National Youth Policy. Government of India. https://yas.nic.in/sites/default/files/National-Youth-Policy-Document.pdf
[x] PLD. (2017). National Consultation on Adolescent Sexuality, Health, and the Law: Mapping Interventions Related Challenges and Strategies. Partners for Law in Development. https://academia.edu/36941131/National_Consultation_on_Adolescent_Sexuality_Health_and_the_Law_Mapping_Interventions_Related_Challenges_and_Strategies_2017_
[xi] Santhya, K., Acharya, R., Jejeebhoy, S. J., & Ram, U. (2011). Timing of first sex before marriage and its correlates: evidence from India. Culture, Health & Sexuality, 13(3), 327–341. https://www.tandfonline.com/doi/abs/10.1080/13691058.2010.534819
[xii] Ghule, M., Balaiah, D., & Joshi, B. (2007). Attitude Towards Premarital Sex among Rural College Youth in Maharashtra, India. Sexuality & Culture, 11(4), 1–17. https://doi.org/10.1007/s12119-007-9006-6
[xiii] Subaiya, L. (2008). Premarital Sex in India: Issues of Class and Gender. Economic and Political Weekly, 43(48), 54–59. https://www.jstor.org/stable/40278237
[xiv] Joshi, B., & Chauhan, S. (2011). Determinants of youth sexual behaviour: program implications for India. Eastern Journal of Medicine, 16, 113–121. https://jag.journalagent.com/ejm/pdfs/EJM_16_2_113_121.pdf
[xv] Jaya, & Hindin, M. J. (2009). Premarital Romantic Partnerships: Attitudes and Sexual Experiences of Youth in Delhi, India. International Perspectives on Sexual and Reproductive Health, 35(2), 97–104. https://www.guttmacher.org/sites/default/files/article_files/3509709.pdf
[xvi] Mehta, S. D., & Seeley, J. (2020). Grand Challenges in Adolescent Sexual and Reproductive Health. Frontiers in Reproductive Health, 2. https://doi.org/10.3389/frph.2020.00002