Contraception in adolescence: a review. 1. Psychosocial aspects.

Bulletin ofthe World Health Organization, 62 (1): 151-162 (1984) i World Health Organization 1984 Contraception in adolescence: a review 1. Psychosocial aspects* ADELE D. HOFMANN' Use of contraception among adolescents, particularly those who are unmarried, is significantly different from that among older couples, and is influenced by educational, developmental, social, and psychological factors. Even when family planning services are available and teenagers are properly educated, compliance tends to be poor. Contributory factors to poor contraceptive use include: services not attuned to adolescent needs; lack of guaranteed confidentiality; unsuitable methods of contraception; little psychological support; immaturity of cognitive thought processes in the adolescent with an inability to appreciate long-term consequences of current acts; and a developmental tendency to take risks coupled with a denial of the possibility ofpregnancy. A particularly significant finding is the importance ofpsychological conflict associated with sexual activity and contraception. The adolescent suffers less anxiety by denying the risk ofpregnancy than by taking responsibility for it through conscious, consistent contra- ception. The emotional costs of admitting the possibility ofpregnancy are unacceptably high in terms ofpersonal devaluation, guilt, and risk of rejection by the partner. Family planning programmes for unmarried adolescents should include clinic sessions exclusively for young people, after school hours; they should guarantee privacy and confidentiality, and should accept the adolescent in a non-judgemental manner. Examin- ations should be carried out in such a way as to minimize embarrassment, and thorough counselling should be available to enable the adolescent to choose a suitable method. Frequent follow-up visits should be arranged, and particular attention should be given to identifying and relieving conflict. Broad social policy can also influence adolescent contraceptive behaviour. Sex education in schools and through the media has significantly improved levels of contra- ceptive use among teenagers. There is no evidence that such initiatives promote premarital sexual activity. Over the last decade, a great deal of new infor- mation about contraception has emerged, with direct and indirect implications for young people. This paper reviews the current trends in adolescent sexual behaviour and the psychosocial aspects of family planning for this group. Part 2, which will be published in a later issue of the Bulletin, will examine biomedical aspects of the various contraceptive methods. * Part 2 of this review, covering biomedical aspects of contra- ception in adolescence, will be published in a later issue of the Bulletin. ' Adjunct Professor of Pediatrics, Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA 90024, USA. BACKGROUND Current trends in adolescent fertility rates show marked intercountry variability (1 ).' However, in all regions, sexually active adolescents are less influenced by family planning initiatives than any other age group, and often these initiatives have no effect at all (2). Adolescent fertility The problems associated with adolescent fertility a DE GUZMAN, E. A. Adolescent fertility and its demographic and social implications. Presented at the FPOP Zamboanga Chapter Symposium on Adolescent Fertility, Zamboanga City, Philippines, 24 September 1978. 4389 -151- 152 A. D. HOFMANN are nowadays compounded by early menarche and fecundity among females. In developed countries, the age of onset of menstruation has decreased by about four months per decade over much of this century, presumably as a result of improved nutrition and health (recent trends, however, suggest that there is an irreducible minimum age of about 12-13 years) (3). The average age of menarche is now 14-15 years in rural developing regions and 12.5-13.5 years in urban areas throughout the world (4, 26). Less is known about spermarche in males, although visible signs of puberty are occurring at an in- creasingly earlier age. Bhargava et al. (5) noted the initiation of genital enlargement in middle and upper class Indian boys at 10.7 ± 2.1 years. A somewhat later median age of 11.9 ± 2.2 years has been found among North American males (6), the disparity per- haps reflecting climatic as well as genetic differences. Richardson & Short (7) detected the first appearance of sperm in morning urine in a group of British schoolboys at a mean age of 13.3 years and suggested that this finding was coincident with spermarche. At the same time, 80% of the boys showed no evidence of facial or axillary hair or voice changes, implying that spermarche occurs early in puberty. Similar studies by Hirsch et al. (8) in Israeli males noted the first appear- ance of urinary sperm at a somewhat later mean age of 14.5 years. Risks of adolescent childbearing Childbearing in the adolescent years imposes significantly greater health risks on both mother and infant than pregnancy at age 20-25 years (9, 10). While optimal nutrition and prenatal care can reduce or even eliminate these hazards (11, 12), except possibly in females under the age of 16 years (13, 14), this is an unrealized ideal throughout much of the world. Pregnant teenagers continue to be particularly vulnerable to anaemia, toxaemia, prolonged labour, and delivery by Caesarean section in both developed and developing countries. Adolescents who bear children are also often sub- ject to high social costs, losing the opportunity to complete their education, to secure job training and work, to gain economic security for themselves and their families, and more broadly, to improve the quality of their lives. Recognition of the manifold benefits of deferred childbearing to both the indi- vidual and the community is reflected in government policies and social trends towards later marriage, in both developing and developed countries (15, 16). Premarital pregnancy Despite the evident benefits, an older age of marriage is not without its costs. The combination of early menarche and deferred marriage has produced a significant increase in the number of out-of-wedlock pregnancies occurring among teenagers in both devel- oping and developed countries (9, 10, 17-20).b The most vulnerable young people appear to be those exposed to urbanization, industrialization, expanded educational and employment opportunities (par- ticularly for young women), Western media influ- ence, and adolescent peer group pressures (21-24).C The consequences of premarital conception include forced early marriage (25), greater demands for abor- tion, and a rising incidence of out-of-wedlock births (26-28). While premarital coitus and pregnancy may be acceptable in some cultures, often leading to societally acceptable consensual family formation,d premarital virginity - at least for girls - is a much more widespread tradition. Under these circum- stances, the unmarried pregnant adolescent is likely to deny or hide her condition and significantly delay antenatal care, thus placing her health at even greater risk. Primary pregnancy prevention among unmarried young people should be of widespread concern. It is important to develop an understanding of contem- porary adolescent sexual behaviour and patterns of contraceptive use. Programmes are needed, not only to reinforce abstinence as an option, but also to pro- vide suitable family planning services to those in need. PREMARITAL SEXUAL BEHAVIOUR Knowledge about the extent of premarital coitus among young people is limited and comes primarily from surveys in Europe and North America, with only a handful of reports from developing countries (Table 1). The limitations of the sampling techniques used in some studies, the empirical nature of others, and the inherent unreliability of self-reported be- haviour inevitably restrict the applicability of these data to all adolescents. However, even with these con- straints, the evidence strongly suggests that a substan- tial proportion of unmarried young people in many countries are sexually active. This direct evidence is further supported by reports of increasing numbers of premarital teenage pregnancies. It is important to note, however, that the coital behaviour of adolescent girls is seldom promiscuous in the epidemiological sense. The majority of young women have a single partner throughout their teenage b Conclusions and recommendations ofthe strategy consultation on adolescent fertility, Washington, DC, 13-14 April, 1977. (Avail- able from the Population Institute, 110 Maryland Ave., NE, Washington, DC 20002, USA.) ' Final report of the Working Group on Adolescent Fertility Management, Manila, Philippines, WHO Regional Office for the Western Pacific, 1980. d See footnote a, page 15 1. PSYCHOSOCIAL ASPECTS OF CONTRACEPTION IN ADOLESCENCE Table 1. Proportion of adolescent population reported to have experienced premarital coitus Sexually experienced (%) Age range Country Source Sample (years) Both sexes Males Females WHO Regional Office for the Western Pacific, 1980a Husslein, 1977 (39) Hutchinson, 1978 (40) WHO Regional Office for Europe, 1 980b Sigush & Schmidt, 1973 (36) Frydman, 1978 (41) Lancet et al., 1978 (42) Asayama, 1976 (43) WHO Regional Office for the Western Pacific, 1980a Gachuci 1974 (46) WHO Regional Office for the Western Pacific, 1980a Owuamanum, 1982 (24) Foss, 1978 (44) Student surveys 516 students Random sample of 1 500 adolescents General estimate 600 students General estimate National survey of 4976 students Random survey of 5000 students Student surveys Male students Student survey 240 high school students 355 adolescents 15-16 By age 20 15-17 By age 16 By age 19 By age 18 By age 16 By age 17 14-19 16-21 47 58 47 25 20 - 50 - 50 33 - 35 30 35 - - 42 11 - 15 7 By age 15 By age 19 12-2 1 12-14 14-19 By age 19; Christians Non-Christians - 80 - 17 4 - 10 2 - 68 43 57 - - 72 - - Sweden Lewin, 1980 (45) United States Zelnick & Kantner of America 1977 (29) 181 students National survey of 4000 females Median age, 16 39 15-19 White females Black females - - 31 - - 63 a Final report of the Working Group on Adolescent Fertility Management. Manila, Philippines, WHO Regional Office for the Western Pacific, 1980. b Research needs and approaches in adolescent reproductive health in developing countries of the WHO European region. Copenhagen, WHO Regional Office for Europe, 1981. years in a monogamous relationship (29). While serial monogamy is not uncommon (i.e., a sequence of several relationships, but only one at a time), rel- atively few adolescent girls have more than two or three partners prior to marriage (30-33). Most perceive sexual intercourse to be an expression of love and commitment or a response to a longing for affection and intimacy (34, 35). Few young women indulge in hedonistic promiscuity (36-38). 153 Australia Austria England Europe (9 countries) Federal Republic of Germany France Israel Japan Kenya Republic of Korea Nigeria Norway A. D. HOFMANN OR 00 0 Do CV) C > ),- 05 (VC'D o 0~C '.,.' 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The most notable feature of contraceptive be- haviour in adolescence is its inconsistency. A minority of teenagers employ any method at their coital debut and subsequent use is unpredictable and erratic at best (Table 2). Even if family planning services are easily available in the community, a delay of six months or more before seeking such help is common; pregnancy or a pregnancy "scare" is a frequent precipitant (47). In the USA, half of all unplanned teenage pregnancies occur during the first six months of coital activity. One-fifth of all sexually active 15-19-year-olds and two-fifths of those aged 15 years or under conceive within six months of their coital debut; 1 in 10 con- ceives within the first month (56). The most signifi- cant contributing factor is inadequate protection. Fertility is not necessarily diminished in the early post- menarcheal phase. Among 120 Turkish primiparous adolescents, none of whom had used contraceptives, 21 7o became pregnant within the first 2-8 cycles after menarche and 25% within the first 8-14 months.e There is no support for the contention that formal sex education or contraceptive availability leads to an increase in the number of girls deciding to be sexually active. The first coital episode is usually a spon- taneous event with both partners disavowing any con- scious responsibility or advance intent. Few adoles- cents engage in prior discussions or give serious thought to their personal contraceptive needs. Fewer than 5% have ever attended a family planning clinic (20, 29, 47, 49). Furthermore, there is no increase in the number of partners or promotion of promiscuity once family planning services have been sought out (54). On the contrary, such a step usually indicates an increase in commitment to one partner. Factors affecting contraceptive use In seeking reasons for poor contraceptive use, even when services or non-prescriptive supplies are readily available, initial inquiries looked at the most obvious barrier, absence of accurate knowledge. Many studies have reported a significant degree of misinformation about contraception and fertility among adolescents. Much of what young people learn is from unreliable sources - peers, hearsay, magazines, and television. ' Research needs and approaches in adolescent reproductive health in developing countries of the WHO European Region. Copenhagen, WHO Regional Office for Europe, 1981. Most adolescents feel that their parents do not pro- vide them with adequate sex education. School sex- education programmes are also viewed as falling far short of ideal (9, 35, 51, 57, 58)/ Thus, a substantial number of girls believe themselves too young to become pregnant, have inaccurate knowledge about the timing of ovulation (yet often rely on the "rhythm" method for protection), or have a variety of other misconceptions leading to gross mis- apprehension of their pregnancy risk (19, 55, 59-64). However, inadequate knowledge is only one, rel- atively minor, factor in what is now recognized to be an extremely complex behaviour pattern. Even with accurate information and readily available services, many adolescents continue to be inconsistent in their use of contraception (65-69). Table 3 lists the many factors that have been identified as significant barriers to effective use of contraception. Some of these factors, however, are in dispute. Not all investigators have found significant socioecon- omic differences between effective and ineffective users (30, 47, 62). Two reports failed to confirm an association between poor use of contraceptives and conflict with parents (63, 77). Such inconsistency, however, is not surprising when one considers that determinants of sexual and contraceptive behaviour will inevitably differ among different groups, or even from one adolescent to another, according to the collective impact of individual, family, social, and cultural characteristics. Whatever influences may operate in a given situ- ation, the role of conflict is central - conflict within the adolescent herself, or between her attitudes and those of her parents, partner, or peers, or in the contravention of the norms of society. Luker has examined the impact of such conflict on the "cost- benefit" ratio of using effective contraception from the perspective of the adolescent (86). Possible "costs" include acknowledgement of sexual activity, having to plan ahead when not committed to coital be- haviour and possibly not intending to have coitus again, taking the initiative in a relationship in which the idealized feminine role is one of passivity, thereby risking devaluation and rejection by the partner, or being perceived as promiscuous if coitus is prepared for in advance. Other potentially unacceptable costs include: the risk of discovery of contraceptive sup- plies, and hence of sexual behaviour, by parents, and possible retribution; logistical problems in obtaining contraceptives when needed, but not planning ahead; and exposure to the medical hazards associated with the pill or intrauterine device. For many adolescents, the costs entailed in contraceptive use are more impor- tant than the risk of pregnancy, which is often seen as f PALAN, V. T. A study of the knowledge, attitudes and beliefs of Malaysian youths on social and biological development. Presented at the Workshop on Family Life Education, Malaysia, 16 June 1979. PSYCHOSOCIAL ASPECTS OF CONTRACEPTION IN ADOLESCENCE 159 relatively remote because of cognitive immaturity and defensive denial. An unconscious wish to be pregnant is far less common than has previously been thought (82). Adolescent coital and contraceptive behaviour should be seen in developmental terms. Teenagers simply cannot be evaluated by the same standards as adults. Cognitive immaturity makes it difficult for young adolescents to perceive the future conse- quences of their current acts, to appreciate fully long- term cause and effect relationships, or to make logical decisions when reasoning involves abstract concepts, values, and principles (87). The ability to anticipate, plan and prepare ahead for the possibility of coitus requires a degree of cognitive development that teen- agers simply do not have, particularly when reasoned thinking is compromised by heavy psychological "costs". Cobliner (60) found that young adolescents tend to avoid taking steps to obtain contraception because of a probabilistic thinking pattern and the failure consciously to acknowledge the risk of pregnancy. Elkind (80, 88) calls this perception of invulner- ability the "personal fable" and sees it as intimately linked with the egocentric state of early adolescent psychosocial development, a stage dominated by the search for sexual identity. Not only does the adoles- cent believe he or she is immune to risk but also that everyone else shares his or her particular beliefs, feel- ings and thoughts. These beliefs tend to be rigid, stereotypic, and traditional, particularly in relation to sex-role behaviour and perception of right and wrong. It is not until the mid-teens or later that this rigidity in thinking gives way to a more flexible acceptance of alternative views and individual differ- ences.8 The development of the capacity to think rationally and realistically is a relatively late adoles- cent event. This developmental progression offers an explanation of why young teenagers in particular tend to be inconsistent in their use of contraception, unless their needs are met within a context that reduces "costs" and provides continuing close support. FAMILY PLANNING PROGRAMMES FOR ADOLESCENTS Recent experience with family planning pro- grammes specifically aimed at young people indicates that a high level of contraceptive compliance and a significant reduction in unintended pregnancies can be achieved. One North American high school with a health clinic on the premises and vigorous outreach among the students achieved a remarkable 400o reduction in pregnancies over 3 years (89). Expansion I See footnotef, page 158. of family planning services for adolescents in theUSA has been credited with preventing nearly one million unplanned births and 1.4 million abortions over the last decade, with the prevention of 417 000 teenage pregnancies in 1979 alone (90). Programme compo- nents that have been identified as important to success with adolescents (91, 92) are given in Table 4. Psychological cost barriers can also be reduced if policy leaders are willing to deal openly and honestly with adolescent sexuality. The use of the media and mandatory sex education programmes in schools (52) has resulted in significantly better rates of consistent protection (primarily with the condom) than those that prevail in the absence of discussion (44). This is not, however, a widely accepted approach (58). It is worth restating that there is no evidence that sex edu- cation programmes encourage adolescents to be sexually active. Factors relating to broad societal change and shifting sexual values are much more significant. Indeed, one might argue that effective sex education programmes in schools, combining factual information with clarification of values and pro- motion of decision-making skills, will enable teen- agers to make more reasoned choices with regard to their sexual activity. Table 4. Factors contributing to successful family plan- ning programmes for adolescents Dissemination of knowledge about the availability of services. Convenient location of services, without risk of public disclosure on entering or leaving the premises. Guaranteed confidentiality and protection of privacy throughout. Afternoon clinic hours at times when adolescents are not required at school or expected home. Brief admission procedure, with a minimum of "red tape". Appointment for services within one week of initial contact. Services free or at nominal cost. Positive staff attitude, with close attention to reducing embarrassment and enabling adolescents to acknowledge that contraception is both necessary and permissible if they have decided to be sexually active. Personalized, friendly counselling. Choice of method based on the adolescent's own preferences and patterns of sexual behaviour, in addition to medical considerations. Instruction in a back-up method in case of discontinuation of primary method. Frequent follow-up visits. 160 A. D. HOFMANN In conclusion, contraception requires a different approach for unmarried adolescents than for married adults. To assume that sexually active young people will be just as motivated to control fertility as are older individuals, is unrealistic. Success will only be achieved when the special requirements of young people are catered for in family planning programmes specifically attuned to their needs. RESUME CONTRACEPTION CHEZ LES ADOLESCENTS: UNE REVUE. 1. PROBLEMES PSYCHOSOCIAUX Les adolescents, en particulier les adolescents celibataires, utilisent les contraceptifs d'une maniere assez differente de celle des couples plus ages, et ils sont influences en cela par leur education et leur niveau de developpement, ainsi que par des facteurs sociaux et psychiques. Meme lorsqu'il existe des services de planification familiale et que les moins de vingt ans ont e correctement eduques, les consignes de securite en la matiere ne sont guere observees. Parmi les causes de ce phenomene, on peut citer les suivantes: services mal accordes avec les besoins des adolescents; absence de garantie que le caractere confidentiel des consultations sera respecte; methodes de contraception mal adaptees; soutien psychologique insuffisant; immaturite de l'adolescent, qui n'est pas capable d'evaluer les consequences a long terme de ses actes immediats; tendance caracteristique de cet age a prendre des risques et a nier l'eventualite d'une grossesse. Ce qu'on pu constater de plus significatif, c'est l'impor- tance du conflit psychologique lie a l'activite sexuelle et a la contraception. L'adolescent est moins angoisse lorsqu'il nie le risque de grossesse que lorsqu'il assume ses responsa- bilites en pratiquant consciemment et systematiquement la contraception. Ce qu'il en cofite, sur le plan affectif, d'ad- mettre la possibilite d'une grossesse depasse les limites de l'admissible. Les programmes de planification familiale a l'intention des adolescents celibataires devraient comporter des consul- tations reservees exclusivement aux jeunes, apres les heures de classe; ces programmes devraient garantir le respect du caractere prive et confidentiel de la consultation, et l'ado- lescent devrait etre accueilli de telle maniere qu'il ne se sente pas juge. Les examens devraient etre effectues de maniere a embarrasser le moins possible l'adolescent, qui devrait en outre beneficier de conseils detailles afin qu'il puisse choisir lui-meme une methode appropriee et acceptable. Il faut pr& voir de frequentes visites medicales de contr6le et s'em- ployer particulirement a determiner la nature des conflits et a leur porter remede. L'ensemble de la politique sociale peut egalement in- fluencer le comportement de l'adolescent a l'egard de la contraception. Dans les pays oui l'ducation sexuelle figure aux programmes scolaires et est diffusee par les medias, les moins de vingt ans utilisent nettement plus les moyens contraceptifs. Rien ne tend a prouver que ces initiatives favorisent l'activite sexuelle preconjugale. REFERENCES 1. DARABI, K. F. ET AL. A perspective on adolescent fer- tility in developing countries. Studies in family plan- ning, 10: 300-303 (1979). 2. BRACKETT, J. W. & RAVENHOLT, R. T. 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