Usha Rai : The benefits of sex education and counselling

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)