The crucial years [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • DECEMBER 1976 • USA $1 the crucial years I WORLD HEALTH ADOLESCENCE the crucial years he health-related problems of adolescents are far from being a new development. Yet only in recent years have they really caught the imagination of health policy makers and the public in general, and at last a widespread concern for such prob- lems is taking root. By the same token, and indeed perhaps because interest has been relatively slow in developing, it is only now that a real understanding is emerging of the extremely complex nature of adolescence. Regardless of how one wishes to define adolescence— and of course in different social and cultural environments there is a tenden- cy to see this age period differently—the problem is a cultural one and calls for attention. Why has this problem been so late in attracting attention? In the first place adolescents have, by definition, survived what in most areas of the world is a most critical health period of life, name- ly early childhood. Because of this and because mortality rates during the ado- lescent years are not particularly high, it has been widely assumed that this popu- lation group is a healthy one, free from the problems with which health per- sonnel usually concern themselves. Today, however, we are faced with a situation which prompts a second and far more critical appraisal. Certain marked changes in the socioeconomic levels of most countries have produced what is now a relatively well document- ed secular trend towards earlier matura- tion. The growth spurt, it is clear, tends to occur somewhat earlier in life. For girls this means an earlier menarche, an earlier vulnerability to pregnancy and thus an earlier exposure to the possibili- t1 The older generations have a duty to ensure that the young people of today and tomorrow enjoy a sound and healthy life. Already very clearly citizens of today, adolescents also represent the adult society of tomorrow. (Photo WHO/J. Mohr) ty of the various social implications that reproductive life necessarily represents. For both males and females, moreover, the general tendency towards an in- creased height and weight gain in the early teens means that physiologically and anatomically the adolescent is a somewhat different figure than he or she was some 50 years ago. At the same time, the environment in which the adolescent is asked to func- tion has undergone and continues to undergo some of the most dramatic changes that have been experienced in history. Unless we place the adolescent in this context, unless we try to under- stand the relationship between the adolescent and the different social, eco- nomic and technological forces that impinge on his or her immediate being, then we shall be unable to understand the nature of his or her problems or to find solutions to such problems. When we look at the special health problems of the young, the mortality rates for accidents, the problem of sex- ually transmitted diseases, and the various nutritional, psychological, recreational and health service needs of the adolescent, it must not be forgotten that all these are intimately related to the fundamental, social and cultural context in which the adolescent lives. Not the least of the difficulties in the way of solving such problems is the fact that what is true for the so-called deve- loped or highly industrialized countries of the world is not necessarily true for those areas that are still growing throughout the transitional period of industrialization. We must ask ourselves how the young people of today and tomorrow are to be assured of a sound and healthy life. When all is said and done, we should not forget that adolescents—who in many parts of the world constitute a majority of the population today—represent the adult society of tomorrow. ■ THE LIAGATINE Of THE WORLD HEALTH ORGANIZATION DECO., it :3A. 51 Cover: WHO photo by P. Ahnasy Contents Adolescence: the crucial years 3 That awkward age by 0. Jeanneret . Becoming mature by B. & D. Hamburg 12 Olga Korbut—Olympic superstar 18 Sex education: lowering the taboos by M. Hulten . 22 Search for identity by M. Carballo 26 WHO News in Brief 30 World Health Day stamps 1976 31 World Health appears in Arabic, English, French, German, Persian, Por- tuguese, Russian and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. that awkward age Until the present "epidemic" of drug abuse and pill-taking, the health authorities have never had to include the health problems of adolescents among their priorities by Olivier Jeanneret I n the industrialized countries at least, anyone who looks around at the adolescents of 1976 cannot fail to be struck by their air of vitality and health. It is true that some of them are not to be met with in the street : the handicapped, the chronically sick who are confined to hospital or secluded at home, those on the margins of society, whether drug-dependent or otherwise. But the others—secondary schoolchildren, apprentices or young employees—are on the whole very un- likely to attract special attention from their teachers, foremen or bosses by the frequency of their illnesses or their sick- ly state of health. True, not all of them are always cheerful, with a perpetual smile on their lips. A few may even stump about, gloomy and glum, stoop- ing as if they were Atlas, carrying all the weight of the world on their shoulders. In this, they hardly differ from us adults; many of our faces too reflect our cares and preoccupations even in the street. One index of this very satisfactory state of health—if an indirect one—can be found by looking into the youngsters' sporting activities. A study made a few years ago in Geneva by the University Institute of Social and Preventive Medi- cine, with the support of the Health Service of Youth, found that among a sample of 443 adolescents aged between 17 and 18 some 78 per cent of boys and 56 per cent of the girls practised one or more sport all year round. Among these, 68 and 42 per cent respectively kept in regular training. Without claim- ing to draw any general conclusion from these findings, one can at least use them to knock a hole in the wide- spread—and perhaps prejudiced view that young citizens of that age are becoming less and less physically active. As for the health authorities at least until the recent "epidemic" of drug abuse and pill-taking—they have never had to include the health problems of adolescents among their priorities. As usual, whatever measures they take are based on statistics of mortality and morbidity. In terms of mortality, adolescents aged from 15 to 19 in the developed world share with children of school age the privilege of having the lowest rates; they are less, for example, than those for infants aged 1 to 4 years. In France, between 1950 and 1970, they ranged from 93 to 119 per 100,000 for boys, and from 43 to 89 per 100,000 for girls. The risk of dying is therefore between one and two per 1,000 each year. The higher risk for boys, already apparent in infancy, goes on increasing with age; between 15 and 19 years the mortality rate is already two or three times higher for boys than for girls, according to a study made by the National Institute of Health and Medical Research in Paris. The principal cause is the risk of accidents of all kinds. In Switzerland, for instance, the point has been reached where the male mortality rate from accidents alone exceeds the total female rate among adolescents and young adults (age groups 15 to 19 and 20 to 24). In the United Kingdom in 1971, Logan and Ashley attributed six male deaths in ten to accidents compared with three female deaths in ten in these two age groups. The vogue for mopeds and motor- cycles plays a major role in the evolution of these mortality rates. In the same country, the authors noted with satisfac- tion that this type of accident had been reduced by a half in the course of a decade. In 1963, Lee found that each year a young motorcyclist had one chance in 50 of being killed or seriously injured while riding this type of vehicle. From then on, the risks concern more powerful vehicles, whether with two or four wheels. A long way behind accidents, two other causes of death vie for second place among the 15 to 19 age group : the first, less amenable to prevention than to medical treatment—leukaemia and malignant tumours; the second, more amenable to prevention and not at all to treatment suicide. Among other causes, infections, and particularly tuberculosis, have happily lost their former preponderance. All told, if mortality is a safe indica- tion, it still ought not to be considered as an adequate one from the public health point of view. One has only to think of the high proportion of non- fatal accidents, of unsuccessful suicide attempts, or of tumours and leukaemia A picture of health. Despite the view prevail- > ing among some older citizens, it seems that more and more young girls and boys now take up one or more sport and practise it all the year round. ( Photo J. Mohr ©) 4

cases successfully treated. Hence the interest in morbidity statistics, much more difficult to collect and therefore less reliable, but allowing us a closer look at realities. Systematic, long-term or periodic surveys help us to determine the pre- valence among this age group of anoma- lies of the sense organs, for instance, or of illnesses resulting in permanent hand- icap (cerebral, osteo-muscular, cardiac, digestive, and so forth). Similarly the average number of days' absence from school or work can be recorded and this figure broken down according to sex, colour of skin, town dwellers or country dwellers. Even if these data are taken from a representative sampling of a whole country's population, their prac- tical interest is often limited by the fact that the special peculiarities of the high- risk groups are not easily distinguished. Hence the special interest of studies which deal with such groups, whether they are the children of migrant workers or of underprivileged minorities. Ann F. Brunswick and Eric Josephson (1972) interviewed and examined, over the space of four and a half years, 752 young blacks aged between 12 and 17, constituting a representative sample from homes in Harlem, New York. Table I shows the prevalence of the various complaints mentioned by or observed in the age group 12 to 15, in decreasing order of frequency. Not only is it an impressive list, but it includes a highly disturbing number of complaints. It should be mentioned in passing that this survey considerably exceeds its terms of reference and ex- tends to the attitudes and behaviour of young people in the field of health. What stands out in the context of needs not being met is the fact that on average "for every health problem (observed by a physician) which was already being dealt with or treated, there were eight others which required medical atten- tion". Other classical sources of morbidity data are hospitalization statistics, out- patient departments, the surgeries of practising physicians and preventive medical services (at school or at work). The first three mentioned have the major drawback of only reflecting demand—and it is well known how much this may differ from real needs. As for statistics from the preventive medical services, they are usually limited to showing the prevalence of data determined in the course of routine medical checks, which depend not only on the validity and sensitivity of the techniques employed, and the pre- determined specificity of the complaint, but also on the list of ailments to be reported. Thus visible ailments (acne, obesity), rare disorders (spinal curva- ture, urinary infections) or diseases which are on the wane (tuberculosis) figure more often on this list than the more frequent but highly subjective complaints such as headaches, stomach ache, fatigue or depressed moods. For the adolescent, the impact of all these on his capacity to work and his enjoyment of leisure activities is much greater than is generally supposed. Fatigue Let us now look more closely at a symptom (fatigue) and a sign (heart murmur) which are characteristic of adolescence. Among young people at work or 6 TABLE I Major health problems in order of frequency (except dental problems) reported in interviews and observed in examinations among adoles- cents in Harlem, New York (A.F. Brunswick and E. Josephson, 1972) Black Youth 12-15 Years Reported in Interviews* Observed in Examinations** Trouble seeing: reported by one in four; girls more than boys. Frequent colds: reported by one in five; girls more than boys. Repeated headaches: reported by nearly one in five; no sex difference. Nervous or emotional problems: re- ported by one in six; girls more than boys. Stomach pains: reported by one in six; girls more than boys. Skin problems: reported by one in seven; girls four times as often as boys. Pains in legs and/or arms: reported by one in seven; no sex difference. 8 Speech problems: reported by one in eight; no sex difference. Repeated sore throats: reported by one in eight; girls more than boys. Repeated nose bleeds: reported by one in ten; no sex difference. Long-lasting cough: reported by one in ten; no sex difference. 12 Asthma or wheezing: reported by one in ten; no sex difference. 13 Vomiting: reported by one in ten; girls more than boys. Vision and eye problems: observed in one in five; no sex difference. Upper respiratory tract disorders: ob- served in one in six; no sex difference. Heart or blood pressure problems: ob- served in one in six; no sex difference. Skin and complexion problems: ob- served among ten per cent; girls twice as often as boys. Nervous and emotional problems: ob- served in one in twelve; girls more than boys. Nutritional problems, chiefly obesity: observed in seven per cent; no sex difference. Neuromuscular or musculoskeletal dis- orders: observed among seven per cent; no sex difference. Lung and bronchial disorders: observ- ed among five per cent; no sex difference. Blood problems, chiefly anaemia: ob- served in four per cent; girls twice as often as boys. Urinary problems: observed in four per cent; girls three times as often as boys. Speech problems: observed in three per cent; no sex difference. * Refers to period of one year prior to interview. Since girls reported more problems than did boys, they tend to exceed boys on any one condition. Listed here are health problems reported in their interviews by at least 10 per cent of the black youth 12-15 years of age. — Health problems physicians noted for at least three per cent of the examined 12-15 year olds. that awkward age A disturbing number of health complaints were brought to light by a survey taken a few years ago among young blacks living in Harlem. For every problem observed by the doctor, there appeared to be eight others crying out for medical attention. The adjoin- ing table lists the leading complaints reported in interviews and observed during medical examinations in the course of the survey. (Photo If 1/0/C. Blackwell) engaged in a strenuous sport, both local muscular fatigue and cardio-respiratory fatigue may be observed. The former will appear mostly in connection with static effort linked either with specific muscular activity (carrying, holding, squeezing) or else with retaining a cer- tain position for a long time (standing, bending or squatting). The latter is accompanied by rapid breathing (polypnea) and even difficulty in breath- ing (dyspnea), chest pains, stitch, an accelerated pulse and a drop in arterial pressure. Both require a cessation of effort in order to bring about recovery. The appearance of either can be signifi- cantly delayed by keeping in training. Sensory fatigue may provoke some peculiar symptoms but does not assume any special characteristic in adolescents compared to adults. On the other hand, general fatigue is probably one of the commonest com- plaints among adolescents, whether they are employed, undergoing apprentice- ship, still at school or even unemployed. Defined by J. Forssmann and G. Copee as "a subjective phenomenon stemming not from a single sensation so much as from a group of sensations, whose in- terpretation varies from one individual to another and according to circum- stance", fatigue acts as a kind of warn- ing signal to prevent the build-up of more serious trouble. Sometimes indica- ting its presence by a feeling of weak- ness and sleepiness, sometimes on the contrary by insomnia, irritability, gener- al muscular stiffness, digestive troubles or breathlessness after the least effort, it rapidly affects attentiveness, judgment, decision-taking and output. At work, this may lead to mistakes and the risk of accidents. It is hardly surprising that the adolescent often complains of fatigue : "growing pains," regular or occasional bursts of intense physical activity (es- pecially among boys), the strains of apprenticeship, overwork at school, lack of sleep—and all too often among girls the rigours of a slimming diet —all these factors help to provoke the indications of fatigue which are so com- mon during this particularly delicate stage of human life. And yet the same adoles- cent whom one sees slumped in an arm- chair can be found within the hour, in fine form, in the stadium, the gymnasium or the dancehall, or playing at the pinball tables. So what happened? Some pass- ing interest has stimulated and motivat- ed him anew, so that all hii fatigue symptoms miraculously disappear. Can one say those symptoms were imagi- nary? Everything leads us to believe that they were not. They relate both to the adolescent's activity and physiological potential, and to the fickleness of that complex and little understood phenomenon—fatigue. Heart murmurs Suppose we make a quite routine auscultation of an adolescent's heart. This investigation needs to be inter- preted very carefully and circumspectly because there are two possibilities of error : either an apparently innocent murmur could actually be caused by a pulmonary stenosis, "a hole in the heart", or an interventricular irregulari- ty of pathological significance; or else a murmur could be suspected of indicat- ing a pathological disorder when in fact it is harmless. If the first mistake ap- pears to be rare, but should be regarded as serious, the second—the result of 7 trying too hard to avoid the first—may have disturbing psychological conse- quences, especially among adolescents. Already anxious about his own physi- cal normality, the adolescent tends to read a meaning into every word and even every facial expression of the ex- amining physician. Being advised to consult a specialist can worry him even more than his parents, no matter how much one may try to soothe and ex- plain. Fortunately, in the great majority of cases the specialist so consulted can in good conscience reassure everyone and ensure that his patient with the quite innocent heart murmur is not subjected to any unnecessary ban on physical activity. This underlines the importance of ensuring that: all clinical examinations of adoles- cents (whether at school, at work or in the armed forces) should be carried out under the best technical and profes- sional conditions; any anomalies observed previously, such as heart murmurs, should be known to the examining physician, ei- ther from a personal medical dossier accompanying the patient, from the patient himself or his parents, or in the last resort from an informal contact with the patient's usual doctor; in case of doubt, particularly during a medical check-up required before be- ing accepted for a job, an adolescent should not be transferred to some easier post when he is really physically sound and without any significant heart defect, lest he spend the rest of his life as a hypochondriac. No survey of the physical health of adolescents would be complete without a discussion of the two potential conse- quences of their sexual relationships: sexually transmitted diseases and ado- lescent pregnancy. STD will be dealt with only briefly here, since an entire issue of World Health was devoted to this theme in May 1975 (as well as a further article in last month's issue). Pregnancy—a perfect example of a genuine health problem in the absence of any disease—will be dealt with at greater length. In the United States, gonorrhoea heads the list of notifiable diseases and syphilis comes in fourth place. Out of an estimated total of 2.5 million cases in that country in 1972 (a total between three and nine times greater than the number of declared cases), 1.6 million concerned persons aged under 25. In fact the recent growth in the numbers of adolescents infected exceeds the total of all other age groups. In many other countries at the same economic level, the situation is just as disturbing. We will not go into the whole story of the socio-economic, socio-cultural, psycho-social and biological factors which may explain the recrudescence of these diseases, particularly that of gonorrhoea. If adolescents appear to be at particularly high risk, this is simply because a certain ill-defined proportion of them occasionally or regularly change their sexual partners; in addition they are often ill -informed about the risk and little inclined to seek early treatment. Several researchers for instance have reported that, by all accounts, some adolescent girls believe that the oral contraceptives they take will protect them from venereal disease as well as from pregnancy. Gallagher reports that efforts started in the United States to set up special consulting-rooms dealing with these infections have not met with much success. In fact it appears that youngsters prefer to go to a doctor they trust or to a non-specialized consulting- room for adolescents. There is still debate about the preven- tive measures which deserve first priori- ty for this prime "target group". Sex instruction given to children at primary and secondary schools seems to leave few traces when a "high-risk situation" —such as the choice of partners—arises. In any conversation between a physician and a supposedly sexually active adoles- cent, for whatever purpose, the former is rarely inclined to take the initiative in talking to the latter about the two troublesome and unwanted consequences of that activity. Because of the high prevalence of gonococci lying dormant and undetected in women, a biological check during all gynaecological exa- minations is recommended, at least in the United States, and especially in the case of adolescent girls who fre- quently change their sexual partners. The superficial and fleeting nature of sexual relations among certain groups of ado- lescents, especially those who frequently that awkward age <A leading cause of Mortality among today's youngsters is the traffic accident, for which the well-established vogue for mopeds and motor- cycles is largely to blame. The mortality rate for boys in such accidents is much higher than that ..for girls. Happily there are signs in some parts of the world that this particular problem may be beginning to recede. In the light of all the stresses at work onl> the teenager, „small wonder that he or she complains frequently of fatigue. Yet the youngster observed slumped in apathy and weariness is Often to be seen within the hour in fine form on the dance floor or at the sports stadium. (Photos J. Mohr ©) more from one place to another, makes it even more difficult to track down and treat their contacts, an essential task if the present epidemic of gonorrhoea is to be checked. All this helps to explain the interest shown by Member States of WHO in the technical discussions on STD which took place concurrently with the 1975 World Health Assembly in Geneva. These discussions had been prepared by a multidisciplinary working group comprising specialists in these diseases, sociologists, psychologists and health educators. For adolescents, the fundamental dilemma is to know whether or not they are to conduct their sexual lives without health worries. Today we have moved far away from the belief that masturba- tion might have dire effects on health, but it must be admitted that sexual promiscuity carries all the more risks when the partners are numerous and are only casual acquaintances. In this re- spect it is apparent that, even if young people are tending to renounce marriage or put it off till later, they are more and more inclined to live with steady partners, even within so called "communes". One the other hand, professional prost- itution on the classic pattern has given way to the easy availability of amateur partners—of either sex—whether paid or not. It is so difficult to ensure that the health controls which many coun- tries apply to prostitutes also reach these "amateurs" that a serious danger arises of a further spread of these diseases. The rapid increase in the problem of adolescent pregnancy in most industria- lized countries since the 1950s and its repercussions on the entire life of the adolescent girl (not to mention that of those around her) has started off a whole literature of its own and deserves a separate article. But let us try to pick out the essential factors. "Among those adolescents who do become pregnant, some will already be married or preparing for marriage; oth- ers will be precipitated into marriage. Of those who remain single, some will seek a legal or illegal abortion; others will become unmarried mothers or surrender their children for adoption" (wHo, Technical Report Series, No. 583, 1975). Briefly stated, these are the alterna- tives. Let us first look at the numerical scale of this phenomenon as reported in several countries. Every year in the United States: about 600,000 girls aged under 20 become mothers, and one third of these are aged under 18; this means that one child in four is born to a mother aged under 20; in New York this proportion is as high as one in three; each year in the State of Georgia, one in a 100 of girls aged 10 to 15 has a baby, and almost one in two of those aged between 15 and 19. Up to 1955 in the United Kingdom, 150 to 200 births each year were to girls aged under 15; this number had ex- ceeded 1,000 by 1966 and stood at 1,267 in 1971, four years after the liberaliza- tion of the abortion laws. In France, in round figures, "60,000 children each year are born to mothers aged under 20, that is, seven per cent of all births. Some 10,000 of these are born to mothers aged 17 or under, including about 3,000 to mothers aged 16 and below. Adolescent girls aged between 10 and 16 are responsible for 3.5 per thousand of all births, that is, for one child in 300" (J. P. Deschamps, 1976). So much for total births. But how do these figures break down according to the mother's marital status and what proportion of pregnancies have been interrupted? In the United Kingdom in 1971, four years after the easing of the abortion laws, 610 out of 1,000 con- ceptions among unmarried girls aged under 15 ended in legal abortion; the remaining 390 were recorded as illegiti- mate births. In most of the countries where easier abortion laws do not yet exist, the hidden total of clandestine abortions does not allow such a breakdown to be made. The United Kingdom also records the interval between marriages and births and publishes these figures. There is a great difference between the figures for all mothers aged under 20 and those for girls aged 15 and under. As age increases (Table II), the propor- tion of legitimate and legitimized births, i.e. preceded or followed by the mar- riage of the biological parents, increases compared with illegitimate births and terminated pregnancies. As for the in- verse proportion of conceptions before and after marriage according to age, this is hardly surprising since the number of marriages contracted by adolescent girls obviously increases with age. No less important and disturbing than this quantitative aspect, we have to bear in mind the qualitative aspect un- derlying the alternatives stated above; behind the bald statement quoted from the WHO document there lies a whole series of fearful choices for the adoles- cent girl: whether or not to embark on a career of heterosexual activity; if so, when and in what circumstances—in the lasting delirium of a grand passion or in the vapours of alcohol after a hectic party; or if not, how to resist the pres- sures of teasing (and possibly envious) comrades, the demands of boys or men, or the permissive atmosphere of con- temporary urban society; whether or not to increase the rela- tionships and/or the number of part- ners, with a consequent risk in the second case of adding to the risk of infection; whether to worry about the risk of pregnancy and to obtain the best pos- sible means to prevent it, or not to worry and to do nothing about it. The most recent British figures show a cer- tain proportion of the "sexually active" who only rarely take sensible precau- tions (wHo, 1975); in the event that pregnancy is sus- pected, whether to put off indefinitely any medical or biological confirmation or to face up to the reality as quickly as possible, however catastrophic that real- ity might be; once pregnancy is confirmed, wheth- er to lock up the secret and conceal the "accident" for as long as possible or to seek early advice, help and support from wherever it is certain to be forthcoming. According to Deschamps, "the pregnant adolescent girl is psychologically and socially alone in assuming her role of mother"; when the pregnancy is conceded as an unforeseen mishap during a stable relationship with a loving partner who is also valuable as a confidant, whether to discuss with him the best steps to take, or to leave him under one pretext or another—a simple enough solution in the absence of marital ties; — finally, when the outcome of the pregnancy, for one reason on another, is the birth of a healthy but illegitimate baby, whether to keep it despite all the obstacles which society in most coun- tries still puts in the road for the unmar- ried mother, or to resign oneself to having it adopted. Such a separation can be a rending experience for an adolescent mother uncertain of the fate and future happiness of the child she will never see again. This simple enumeration shows clear- ly what degree of maturity each of these alternative choices demands; in other TABLE II Proportion of legitimate and legitimized births per 1,000 conceptions according to age of mother; United Kingdom, 1971 (adapted from J.P. Deschamps, 1976) Mother's age Number of conceptions Legitimate or legitimized births Child conceived after marriage Child conceived before marriage Total 16 17 18 19 1,000 1,000 1,000 1,000 24 107 246 431 228 407 393 288 252 514 639 719 10 that awkward age Young girls today, like those pictured on these pages, generally present an appearance of blooming health. But in the domain of sexual relationships, a whole series of fearful choices may lie before the growing girl. Whatever choice she makes demands a high degree of maturity, and the risks of making an error of judgement are all the greater if she is at a younger age, or is less knowledge- able about sexual matters. ( Photos J. Mohr, Len Sirman © ) words, the degree to which the adoles- cent girl risks making errors of judg- ment, and all the more so if she is younger (and therefore in principle more impressionable), less knowledge- able (particularly if she has been less well informed at school), and if she comes from a socio-cultural background which leaves the hazards of sexual life to chance. Is real life as easy to pigeon-hole as that? Of course not. Many writers have tried to classify matters in this way, especially in the field of psychology. But the resulting picture, however alluring it may seem at first glance, can never take into account all the multiplicity and diversity of the factors involved. It is precisely this multiplicity and diversity of factors, and the complexity of personal relationships, that can make the question of such preventive mea- sures as contraception so delicate. This is a further source of concern for the health professional, who has to weigh up the respective advantages and disadvantages not only of the means of contraception and abortion but also of the consequences of pregnancy and birth on the health of the young girl and, in the latter case, of the baby. Space is lacking to draw up a complete balance-sheet on the basis of all the available data. Simplifying considerably, one can sum up the present trend of thought as follows : Contraception: Noting first that con- tinence remains the best method from all points of view, let us consider the existing hormonal preparations. These are doubly inconvenient for the young- est of sexually active girls, since they interfere with the development of the endocrine process, and have to be taken with infallible regularity. Hence the in- terest in mechanical techniques, notably the inter-uterine devices such as the loop or coil, which adapt themselves to the shape of the uterus, are fitted by a doc- tor and demand no further initiative on the part of the wearer. Legalized induced abortion: The risk of immediate complications seems to be higher for some than for others (J. L. Rauh and others; Deschamps), while the medium- and long-term complica- tions are hard to evaluate, particularly if one includes the psychological aspects. Pregnancy carried to full term: It must be conceded that various complications are more likely up to the age of 16 than after that age (WHO, 1975); however, it is still very difficult to deal separately with biological and medical factors on the one hand and psycho-social and socio-economic factors on the other in assessing the risks above the age of 16. To sum up, as regards both sexually transmitted diseases and pregnancy, adolescents pay the price for two para- doxes. Firstly, the length of exposure to these two risks increases as biological factors make puberty start earlier and social factors retard the end of adoles-• cence. Secondly, the present attitude of soci- ety is anything but logical: it appears to be rather more permissive about early sexual relationships, but rather more repressive about their possible conse- quences. Would it be more logical for society to become more restrictive too in respect of adolescent sexual rela- tionships? In fact today's legislation, a fairly faithful indicator of attitudes at the national level, suggests that quite the opposite is happening: legalization of abortion in many countries encourages the view that society is extending its permissiveness to one particular conse- quence of sexual relations—adolescent pregnancy. As for the other conse- quence, surely it is time to abandon the term "venereal" as a symptom of the trivialization of the diseases which have carried that name for centuries. From now on, it is time for the health professionals to show sufficient imagina- tion and initiative to ensure that ado- lescents prefer contraception to abor- tion; and it is up to medical science to discover vaccines against syphilis and gonorrhoea and thus make a significant contribution towards the battle to con- trol these diseases. ■ 11 he onset of adolescence is a critical period of biological and psychological change for the individual. For many, it involves a drastic change in social environment. These years are highly formative for health-relevant behaviour patterns such as the smoking of cigarettes, the use of alcohol or other drugs, the driving of automobiles, habits of food intake and exercise, and patterns of human rela- tionship. The onset of adolescence is triggered by events in the brain. Information is transmitted from the brain to the pitu- itary gland, and pituitary hormones then stimulate the secretion of sex hormones which have important effects on various tissues of the body, including the brain. These hormonal changes are probably related to concomitant changes in sex- ual, aggressive, and emotional behaviour. It is remarkable that so little psycho- biological evidence is available on such relations, but much new information may be expected in the years ahead. Recent studies of monkeys and apes reveal striking changes in behaviour during adolescence. In their natural habitats, adolescent males are the most active, exploratory, and aggressive indi- viduals. In many primate species, there are sex differences in behaviour from early life, the males being more aggres- sive and in adolescence these differences are accentuated. But the biological changes of human puberty occur in a social environment very different from the circumstances in which our species evolved. The human environment has been transformed since the industrial revolution, largely in the twentieth century. So the old biology is set in a new context. The transformation of modern times is nowhere more vivid than in the United States where industrialization, urbanization, complex technology, pro- longed education, geographic mobility, and cultural heterogeneity are such strik- ing characteristics. While these and other social changes provide stimulating opportunities in adolescence, they also pose difficult problems. There are more teenagers in the United States today than ever before in the history of the country. In 1969 there were an estimated 18.6 million persons aged between 15 and 19 years. This was 5.6 million more than in 1949, and represents an increase of almost 50 per cent. The recent growth in the adoles- cent population is even more impressive when we realize that, from 1930 to 1958, the 15-19 year old sector of the popula- tion had stayed within the limits of 10 and 12.5 million. The sharp increase reflects the post-war "baby boom" of the 1950s. According to current projec- tions, this trend of an increasing ado- lescent population will continue but at a slower pace. becoming mature The advantages of the technological society appear to have seen attained at a high cost for the acolescent population. For them, drastic change has introduced complications in human relationships and personal security—a fact which presents a serious challenge to modern societies BY BEATRIX AND DAVID HAVBURG 12 In many developing nations, a similar sudden sharp rise in the adolescent population is probable or is already occurring. In these instances, the youth explosion is due to the striking decreases in infant and child mortality as a result of improved public health measures, nutrition, and health care. The fact, therefore, of sheer numbers causes us to pay attention to the adolescent segment of the population, and these adolescents are a potent factor affecting every seg- ment of society. Youth rebellion was a prominent theme of the 1960s throughout the world. In the 1970s public opinion polls consistently reveal that, for a majority of American people, problems of youth are viewed with serious concern. Such concern now centres on teen-age alcohol- ism, drug abuse, runaways, rejection of schooling, and sharp increases in deaths due to accidents and suicide. At present automobile accidents are the leading Youth rebellion and protest have become prominent features of recent decades. More than ever before, young people are question- ing the values of their elders—often with some justice. ( Photo Len Sirman ©) cause of death in adolescence and sui- cide is second. Because of the tendency toward under-reporting of suicide, a substantial number of the listed acci- dents are also probably suicide. The problems are appearing at younger and younger ages. Some of the most poignant examples of disturbed, deviant and self-destructive behaviour occur in the junior high school age population, aged 11 to 15. During Senate hearings in 1972 on the Runaway Youth Act, it was estimated that at least one million young people run away from home each year in the US. The Center for the Study of Social Behavior undertook a systematic survey for the National Institute on Alcohol Abuse and Alcoholism (NIAAA), on the drinking behaviour of adolescents. This report in 1975 states that 74 per cent of the adolescent population have had some experience with drinking alcohol. Most of this is exploratory, but the frequency of adolescent drunkenness is three or four times greater than of adult drinkers. Heavy drinking is defined by the survey as drinking at least once a week and five to 12 drinks per occasion. In reporting negative aspects of drink- ing, 17 per cent of the youths men- tioned difficulties with friends, and 10 per cent cited criticism from girlfriends or boyfriends as a result of their drink- ing. Trouble with police was men- tioned by 7 per cent and trouble with school personnel by 5 per cent; 40 per cent of the students reported drinking in cars while 16 per cent reported driving after significant alcohol intake; and 35 per cent of the students said they some- times drink alone. 13 As in other studies, this national survey indicates that boys drink with greater frequency and in greater quanti- ties than girls. However, there appears to be a noticeable shift toward more adolescent girls drinking alcoholic beverages than in previous samples. The quantity and frequency of alco- hol consumption increases with age. A dramatic shift between abstainer and drinker occurs from age 13-17. It should be noted that these data do not include high school dropouts, and studies indicate the dropout population has a higher proportion of drinkers than the in-school population. The level of alcohol consumption by teenagers is probably underestimated for this reason. Suicide rates of adolescents are in- creasing each year in the United States. The 1974 figures show a remarkable upsurge in the 15-24 age group, where there was a 90 per cent increase over the rate of one decade ago. The 10 to 14 year age group showed a considerable increase in the same decade. In the past ten years, there has also been a sharp rise in juvenile crime. The severity of the offences are greater and the age of the offenders is younger than ever. In New York City, for example, crimes by youthful offenders have increased by 70 per cent in the past five years. A break- down shows that murder by juveniles has tripled and rapes are twice as pre- valent. A study of the delinquents in New York indicated that most of them were either educationally retarded, emotionally disturbed or both. The Department of Youth Services' budget has increased by 70 per cent in the past five years but workable solutions to the problems are still elusive. Facilities are inadequate and attempts at treatment programmes have not been notably successful, while recidivism rates are high. The fact that accidents and suicide rank as number one and number two in the leading causes of death in the ado- lescent population partly reflects the great strides in conquering infectious disease. A major challenge of adolescent health now is that adolescents are to a large extent agents of their own destruc- tion, in behaviour associated with acci- dents, suicide, alcohol and drug abuse. Such behaviour also has a high cost for society, both in economic and other terms. Heavy cigarette smoking on a long- term basis increases the risks of a vari- ety of serious diseases, including cancer of the lung and bladder, emphysema, bronchitis, and coronary artery disease. In view of the seriousness of smoking as 14 a public health problem, the importance of preventive approaches aimed at dis- couraging young people from making an enduring commitment to cigarette smoking is of immediate importance. Although recent statistical findings indi- cate a slight decrease in the proportion of adults who smoke in the US, smok- ing behaviour among teenagers, espe- cially adolescent girls, has increased substantially within the past seven years. Public health campaigns designed to discourage the practice, such as anti- smoking media messages and school presentations, have so far had little effect on preventing the initiation and continuation of cigarette smoking in adolescents. However, much more could be done in this direction. Adolescence is the crucial time for the formation of smoking habits; 60 to 75 per cent of the 45 million adult smokers in the US began cigarette smoking by age 18. The proportion of teenagers who smoke cigarettes regularly has increased from 12 per cent in 1968 to 16 per cent in 1974. This increase has taken place almost exclusively among females. It is reasonable to expect adolescents to continue to experiment with smoking as long as cigarettes are readily available and widely used. Therefore, the focus of prevention should perhaps be directed toward discouraging regular cigarette smoking rather than preventing ex- perimentation with cigarettes. Studies indicate that young people have received sufficient information to be know- ledgeable about the health hazards of cigarettes. But for many this is not yet personally meaningful and in any event, the risks are deferred until later years. Research in health education is needed to determine how understanding can change attitudes and affect beha- viour. Within the adult population, there are indications that the social climate concerning cigarette smoking has become less favourable. If this trend continues, the adult-sanctioned and .1 All the world loves a lover; a young couple exchange a fond kiss in a suburban street. All the same, for adolescents in particular, dras- tic changes within the technological society of today have introduced complications in human relationships and personal security. ( Photo WHO /E. Mandelmann) Indoor football and slot-machines have a par-D ticular fascination for young people, to whom they may offer an escape from the feeling of alienation fostered by the dehumanized urban environment. (Photo Len Sirman © ) Left: Heavy cigarette smoking increases the risks of a variety of serious diseases. Public health campaigns have so far had little effect on the smoking habits of adolescents. (Photo WHO/E. Mandelmann) Above: The influence of television on con- temporary youth has been exerted all through their lives, and has played an important background role in shaping their attitudes, values and behaviour. ( Photo WHO/P. Almasy) Right: A survey made in the USA last year showed that 74 per cent of the adolescent population had had some experience with drinking alcohol, and the frequency of ado- lescent drunkenness was three or 'bur times greater than that of adult drinkers. (Photo WHO/E. Mandelmann) socially reinforced elements of smoking behaviour will lose considerable strength. This trend bodes well for future prevention of heavy smoking in adolescence, since a change in the smo- king patterns of the parents has a great influence upon the adolescent in the formation of smoking habits. There are still some persons who believe that turmoil in' adolescence is inevitable for everyone. However, in- creasing evidence from careful studies has shown that this picture is over- drawn. While emotional distress is common and difficulties abound, only a modest proportion of adolescents in the general population become psychotic or otherwise seriously disturbed. Adolescence is the transitional period between childhood and the assumption of adult roles and responsibilities. In all cultures, the definition of adolescence bears some relationship to the biological changes of puberty. In some instances, puberty rites mark a dramatic shift from child to adult status. When this occurs it is usually in a stable, non-industrial society where much of childhood has been spent in explicit observation of and preparation for highly visible adult roles. In most cultures there is usually an interim status in which pubertal and post-pubertal young persons are main- tained in interim roles for varying periods of time before being accorded full adult prerogatives and responsibili- ties. The most highly industrialized countries have the longest adolescent phase. In the United States, for exam- ple, adolescence, on average, encom- passes a 12 year span of time, from about 11 years of age to mid-twenties. In complex, technological societies, the adult work roles are much less visible and accessible than in simpler societies. Contemporary rapid social change has been widely considered to be an important contributing factor to the problems of youth in modern societies. The fact of change has been constant in man's history but the rate of change has been rapidly accelerating. This rate phenomenon is highly pertinent to one's perception of change and ability to cope. We have moved from rates of change on an evolutionary scale of mil- lions of years to the spread of agricul- ture in thousands of years, to changes of the Industrial Revolution which took a couple of hundred years, and now in the "post-industrial" society sweeping changes seem to be occurring from one generation to the next. In the twentieth century, advances in technology have played an important role in initiating social changes. Under the stress of change, the coping styles of individuals in a society reflect the pat- terns of socialization which charac- terized their upbringing. Socialization is typically viewed as the shaping of the behaviours of children by parents and other significant adults. It is also true, however, that the behaviours and values of young persons are reflected back to parents and significant adults and, in turn, can play a significant role in shaping the behaviour of the adults. 16 One of the effects of industrialization has been geographic mobility and, therefore, the loss of regular contact with the large extended family and net- work of friends and neighbours. In the US, the small nuclear family is typically now to be found in an urban or sub- urban setting. Neither of these contexts in any way duplicates the richness of the social network of the stable small towns of earlier generations. In cities, there are large numbers of impersonal contacts with strangers, perhaps fostering a sense of alienation. Urban children have less than optimal access to the supports, models and constraints of meaningful personal adult models. The role of tele- vision and of age-segregaged peer groups in filling this vacuum has been highly significant. The influence of TV on contemporary youth has been exerted throughout the entire course of their lives and has played an important background role in shaping their attitudes, values and behaviours. It has diluted the parental influence in shaping values by replacing their filtered information which reflected a particular cultural perspective. In this way, TV opens up the possibility for transmission of culture between diverse groups. It elevates some persons to hero status while at the same time, with a relentless focus on the novel and the sensational, it can promote cynicism and the undermining of positively- valued figures with whom youth can identify. TV has also fostered a shrunk- en globe and may facilitate a one-world perspective. The role of TV in promoting violence in the USA has been under scrutiny by the Office of the Surgeon General, and an extensive report has been issued. The findings implicate the viewing of televi- sion violence by children as a contribu- ting factor to violence in society. The experimental evidence shows that vio- lence on television can induce imitative behaviour on the part of children. In summary, the advantages of the technological society appear to have been attained at a high cost for the adolescent population. For them, dras- tic change has introduced complications in human relationships and personal security. This presents a serious chal- lenge to modern societies. Most efforts at remedying the serious problems of youth have been largely unsuccessful. As in the conquest of many epidemic medical diseases, preventative measures offer the most hopeful approach. There have been promising ap- proaches through the careful study of tasks and challenges of specific adoles- cent phases. Information gained in this way can be utilized to teach appropriate coping skills to adolescents. Other pro- mising approaches have to do with eff- orts to provide meaningful work partici- pation for adolescents even while they are still in compulsory schooling ages. Finally, deeper understanding of adolescent problems in rapidly changing societies can permit us to take more compassionate account of the poignant dilemmas of this great transitional era. ■ 17 olympic super-star Few adolescents have to face the thrills and the pitfalls of being a star. This fate befell Olga Korbut at the age of 17, when she became almost overnight the darling of the spectators during the Vunich Olympic Games in 1972. The young Soviet gymnast was interviewed for World Health by V. Suponyev WH: Olga, as one of the Soviet Union's leading gymnasts, you must spend a great deal of time practising in the gymnasium. What effect has sport had on your studies? OLGA : To start with, let me mention its negative influence. Students who prac- tise sport lead a hard life and the sport- ing calendar shows no mercy towards us. Examinations draw closer, yet we have to set off for a competition held somewhere far away. Everybody else is enjoying the school holidays, while I have two training sessions every day, with no relaxation in sight. But obviously it would not be fair to take me as an example in judging the effect of sport on a college student's studies. After all, the status of a member of an Olympic team is quite different, and demands are made not only by the college teachers but also by sports managers, all of whom have to be taken into account. But many of my college friends have taken up different sports, and as far as they are concerned it is evident that sport is of great help to them. They rarely fall sick, which means that they do not miss any lessons, and as a rule they are cheerful and hard- working. In general, scientific research has shown that the regular change from mental to physical activity is an excel- lent form of relaxation and a means of heightening one's working capacity. What is there to say about myself? I am majoring in history at the Grodno teachers' training school. It goes without saying that I had more chances to see different places than my college friends. They know the Tower of Lon- don only from drawings and photos, whereas I can clearly visualize it, having been there myself. They can only read about America today but I have been there more than once. This is an advan- tage that I owe to sport. It is difficult to overestimate the value of this trend for my future profession. WH: What effect did gymnastics have on your physical and ethical development? OLGA : I think it is hardly fair to single out gymnastics and better to consider sport in general. As regards physical development, sport has undoubtedly given me agility, stamina and strength, and has helped to build up my will- power and character. I am not only thinking of competitions, when everyone can clearly see the clash of personalities. One's staying-power is also developed during training. Some- times one is fatigued or perhaps apathe- tic, and overcoming this is like gaining small victories over oneself—this is something that will always come in handy in life. As gymnasts we have to keep our weight down, and to limit ourselves in many ways. Almost every- thing in life turns into a test of charac- ter. One has to learn to take calmly both victories and defeats, and to take a critical approach to every action. But these are the sort of things that are necessary in everyday life, aren't they? WH : Which gymnastics events do you consider specially beneficial for one's health and which may be dangerous? OLGA : Your question reminds me of something that happened three years ago. A few shortsighted people in the International Gymnastics Federation put a veto on some of the exercises and movements devised by my coach Renald Knysh as part of my programme. To all intents and purposes, this was an at- tempt to stop progress in gymnastics. Competent specialists from different countries, the general public and sport fans all came to my defence. And the veto was revoked. Later events confirmed that we were right. The movements that had been considered unconventional and were thought by some people to be extremely dangerous during the Munich Olympics are now denionstrated by many gym- nasts from different countries without any risk to their health. Nothing in gymnastics that I know of can pose any real danger. But there is one indispensable condition: nobody should overestimate their capabilities or try something which is still beyond them. For instance, if a novice suddenly tackles a double somersault, the results could be quite unpleasant. But this is Youth, charm and agility. This is how mil- I> lions of spectators and television viewers remember Olympic gold-medallist Olga Kor- but—not only at the Munich Games in 1972 but at dozens of other international athletics meetings. (Photo Keystone-Press) 18

like putting a man who has never seen a plane before at the controls: a catas- trophe would be inevitable. The selection of exercises and movements is determined by the level of training. Of course, it is difficult to avoid injuries, but what causes injuries is not the risk inherent in the move- ments themselves but the gymnast not being sufficiently fit, making technical mistakes and lacking self-confidence. Sometimes injuries are caused by un- foreseeable accidents, but never by the difficulty of our programmes. As far as health is concerned, regular participation in any sport is beneficial, though I would personally give first place to gymnastics. WH : What distinction do you see between ordinary sports activities and the devel- opment of the qualities required for international contests? OLGA : There are many differences, of course. First and foremost, the psycho- logical tension involved is not to be compared. It you take up sport for health and personal pleasure, you are responsible only to yourself. But when you enter the international arena, you assume a responsibility towards your team mates, your fellow-compatriots and your country. Then there is a big difference in the demands made on one's fitness. Nobody can enter for any major meeting like the European and world championships or the Olympic Games without being in tip-top form. You have to keep on making progress all the time, making the programme ever more intricate and not repeating something that people are familiar with. All this, quite naturally, requires strenuous work. WH : Did sport influence your choice of a profession? OLGA : That is a difficult question. Per- haps it had no effect at all. History was something that always interested me, and I became even more absorbed in it after seeing a little of the world. WH : What qualities do you feel gymnas- tics have developed in you? OLGA : Primarily a sense of team spirit and sociability. Individualists have a hard time in sport, and do not enjoy life to the full, in my view. Olympic gym- nastics today start with team competi- tion, and the same is true in world championships. There is no doubt about 20 "To be quite frank, one sometimes gets weary of being always in the public eye—sometimes your biggest wish is for solitude." Olga's graceful finish to her exercise on the bars won her tumultuous applause and the coveted gold medal. But she admits that, at the age of 17, she was still a schoolgirl and all this publicity demanded far more than a child's attitude. (Photo Novosti) <For this youthful sports team, the tug-of-war is an occasion for high-spirited fun. High performance sporting events for youngsters scarcely in their teens can be more serious affairs, and demand a deep sense of responsi- bility. But it is important to avoid depriving such youngsters of the joys of childhood, warns Olga Korbut. (Photo WHO/E. Mandelmann) that. First, you have to do all in your power for the team, and only after that should you worry about personal success. If you notice, gymnasts always show particular self-control and effort in team competitions, where the slight- est mistake can affect the success of the entire group. Looking back on the road I covered in sport, there were quite a number of successes and setbacks. But as far as my happiest moments are concerned, they were bound up with the victories scored by the Soviet team at the Munich Olympics and at the world cham- pionships in Varna, and with the two- fold victory of the picked Byelorussian squad at the Spartakiads of Soviet Nations. I happened to take part in them and shared the delight felt by all my team mates. As for sociability, it goes without saying that gymnastics are conducive to its development. We meet many fine people at the contests: rival gymnasts, coaches and just sport fans. But to be quite frank, one sometimes gets weary of being always in the public eye, of endless and sometimes indiscreet ques- tioning by interviewers and of relentless autograph hunters. Sometimes your biggest wish is for solitude—to go somewhere where no one knows you and bothers you. WH : To what degree did sport help to develop your maturity? OLGA : That is a far from simple ques- tion to answer. It should be viewed, I believe, first of all from the moral and psychological standpoint. At the age of 15, I won the national title in one of the gymnastic events, and at 17 I took part in the Olympic Games. In fact, I was still a schoolgirl, and all this demanded far more than a child's atti- tude—it required a deep sense of re- sponsibility. Possibly I matured earlier than girls of my own age. Now girls and boys are coming into big-time sport at an even earlier age. The USSR national gymnastics team, for instance, has in its ranks Masha Filatova and Natasha Shaposhnikova, both of whom are only 12. The same is true in swimming, figure skating, and many other sports. This seems to be the trend of our times, and nothing can be done about it. The girls and boys who appear in high performance sporting events at an early age will also have to mature faster. But at the same time an effort has to be made to avoid depriving them of the joys of childhood; the process of mental maturity should not be a pain for them. This problem has to be solved by coaches, teachers and sport organizers. I think it is a hard problem, but it is one that can be solved. ■ 21 y old friend twisted his beard while talking to me. He smiled, however, when telling me that ever since his early puberty he had been looking forward to the period of adolescence—those peaceful years of emotional and social merging into adulthood. Now, in his late thirties, he thought he ought to have woken up one morning with the deep satisfaction of being able to cope with adult life. But that was not the case. In particular he had had difficulties in orientating him- self as regards sex. I realized that he felt very lonely about this matter, that he had not earlier been able to talk to any- body about these feelings. I understood he had approached me because he knew I had spent some ten years providing sex education to teenagers in Swedish schools. We started a discussion about the likely reasons for the difficulties he had mentioned, and what might have been done to make life easier for him during that period. We put forward many ques- tions and reached some conclusions. We started with the way he was twisting his beard: the embarrassment, the taboo. The word taboo, originating from the language of Polynesians and other peo- ples of the Southern Pacific, literally means separated or set apart as sacred or unclean, forbidden to general use, placed under prohibition or ban. Ap- parently sex is a matter of taboo in large areas of the world, although there are exceptions. There are indeed societies where sex is looked upon as a subject to be freely taught to the young by the more experienced adults; but these are in the minority. On the other hand it may be enlightening to contemplate how it would be to live in a minority society, where some other primary concern of life, like eating, was set apart—where you could not talk freely about it, where you would have to feel ashamed if any- body caught sight of you while eating, where the techniques of how to prepare food would be secrets... We did not manage to reach a satis- factory answer as to why sex is generally tabooed, but turned to analyse what it meant to people in our own society. Besides being noted for its economi- cally and educationally high standard of living—one of the highest among the Western industrialized countries Sweden is world famous for being the archetypal society of sexual liberation. The implications of this, however, have been widely misunderstood. First of all the sexual taboos may be different, but they are certainly not diminished to anything near the extent that is general- Add ly believed. Secondly, the rapid change of outlook on this subject during a short period of time has generated deep con- tradictions among different groups of people within the society. There is a far wider variation in attitudes than is un- derstood abroad. Many people still con- sider sex so sacred that it should not be contemplated except in utmost privacy within the firm confines of life-long lasting marriage. Sex is a subject that is not supposed to be talked about at all. If you do, you are "unclean". Perhaps more important is the fact that almost all children are totally ignorant of their parents' sex life, and most parents would indeed be extremely upset and ashamed if a child should unexpectedly become a witness of intercourse. Most teenagers even tend to deny the possibil- ity that their parents still may engage in any sort of sexual practice. The parents of others yes, but their own—no. In theory yes, but in practice no. In other words, their parents are sacred and should not be suspected of being "un- clean". Many schoolchildren are aware of the fact that their parents may not agree with them being exposed to obligatory sex education in the schools. In fact, most teachers seem to find sex education a very difficult task, and many prefer to SEX EDUCATIO\ lowering the taboos Why do we put so much effort into teaching, for instance, the history of religion, while totally neglecting the historical evolution of human sex? by Mai Hulten 22 A first love affair? Even young Scandinavians —who are widely believed to be the best- informed youngsters in sex matters feel inhibited about discussing sex in mixed com- pany. (Photo WHO/E. Mandelmann) restrict their presentation to apparently neutral biological data. As a broad generalization it is pro- bably safe to say that the majority of teenagers, even in Sweden, lack the opportunity freely and sincerely to dis- cuss the subject of sex with any adults. If given the chance to discuss sex a group of Swedish teenagers may have great initial difficulties in starting to put any questions forward at all. The inten- sity of the silence may be immense, particularly if both girls and boys are present. Mixing the two might turn out to be so inhibiting that it would be wiser to discuss the subject separately, at least for a start. However, once the discus- sion has commenced, it usually becomes most lively. What then are the major questions? The most common types are the self-orientated ones: what do I do in order to achieve the type of love rela- tionship I want? What do I really want? What is true love? What does it really imply? What type and degree of genero- sity? How important is it to be faithful? In essence, which moral attitudes should I myself adopt? Questions like "How old do you feel one should be to have intercourse?" or "At what age may one start to practise petting?" reflect a search for new rules to replace those existing at a time when the answer would consistently be—"not until you marry". Much time is usually devoted to an analysis of double-standards, i.e. the contradictory application of different rules for girls and for boys. Many adolescents seem to start to gain some theoretical insight into this, but virtually nobody can cope with it in practice. Girls (and women) are afraid of show- ing affection, of taking the initiative, because of the dangers this might in- volve—the danger of being turned down, or that the boy might be put off instead of appreciating the honesty of her approach. The initiative is left with the boys (and men), irrespective of whether they want to take it or not. These rules are firmly accepted in soci- ety; thus at parties boys are almost invariably supposed to invite the girls to dance, and it would be considered ultra- feminist for the girls to take the in- itiative. It might be acceptable for a girl to ask a boy to take her out, but with the sex act it is a different matter. In accepting intercourse she must consider the possibility that she might be con- demned not only by other people, but also by the boy himself. A boy, on the other hand, may find himself engaged in trying to convince a girl to accept his sexual approach and eventually practise intercourse, only to realize later that his efforts were futile in the sense that he might not be able to continue to appreciate and love her, since she is no longer worth his love. He actually wants her to be sacred, and disapproves of her becoming "unclean". He may have a vague feeling of cheat- ing, which might not reach the level of consciousness that would prevent him from repeating the mistake. Some boys also fail to see that they are using their seducing capacity as a measure of maleness. They become girl hunters. This is often condemned, but rarely seriously discussed as a problem, which might be solved by gaining in- sight into the forces behind the practice. The most common mistake seems to be the failure to understand that these boys are in essence unhappy, and are des- perately trying to cope with the futile demands imposed upon them by the attitudes of the community. Some questions, of great concern to an earlier generation, are today much 23 ' ' - lowering the taboos Even school teachers find sex education a difficult task, and many prefer to restrict their presentation to rather neutral biological data. In general, it remains true that the majority of teenagers lack the opportunity freely and sincerely to discuss the subject of sex with any adults. Practically nothing is taught about the task of parenthood. ( Photos WHO/ P. Almasy and M. Jacot) more rarely asked. The one about mas- turbation might serve as an example. Many young people seem to have reached a less dramatic attitude towards masturbation. They are not burdened by any strong feelings of guilt, nor worried whether the practice might be harmful. Admittedly there are exceptions to this. On the other hand, some questions are seldom put forward because of diffi- culties in overcoming the barriers of embarrassment and shyness. For in- stance, many youngsters are deeply concerned whether they are physically normal or not. About one third of all boys do have some breast development at puberty, which is often a source of much unnecessary worry, since they do not dare to ask anybody about it. These youngsters unfortunately lack detailed knowledge about normal variations in development at puberty. The same ap- plies to many girls awaiting their first menstrual period or believing their breasts are underdeveloped. Young girls share a great reluctance to face a gynae- cological visit. Their theoretical know- ledge of contraceptives or venereal dis- eases may generally be fairly advanced, but they find personal questions about these subjects too intimate to be put forward. Many boys, too, worry about the size of their penis. They do not dare ask whether this might have anything to do with sexual performance or a mea- sure of their potency. In many countries, boys and girls at school have the opportunity to receive sex education directly from teachers and occasionally from school nurses. As already mentioned, this is primarily offered within a biological framework, and mainly deals with conception, pregnancy, childbirth, con- traception, induced abortion, venereal diseases and sexual minorities. Some biologically and sociologically impor- tant subjects like spontaneous abortions and infertility seem to have escaped attention. Until recently, comparatively little time has been spent on imparting knowledge about sex life in general, and with few exceptions practically nothing is taught about the task of parenthood. During recent years some sex educa- tors have advocated that young people should have the opportunity to receive much more detailed information than that included in the obligatory school education programmes. However, this new trend has been limited by its over- emphasis of sexual technology, primari- ly based on some sex research data from USA. A few Youth Sex Guidance Cen- tres seem to have gained a deeper in- sight into the need for a more integrated outlook on sex education, including tact- ful talks about psychological factors. Good and informative books on sex- ology are generally available. Access to them, however, requires the initiative of a selective search in bookstores or libraries. On the the other hand, the general interest in sex matters is reflect- ed not only by a large direct outflow of articles on the subject in many news- papers and magazines, as well as in film, radio and television programmes, but also indirectly by the element of sex built into commercial advertizing. The message of the latter—that your likeli- hood of becoming appreciated, respect- ed, loved is dependent on the extent to which you can conform to a narrow standard of beauty, emphasized or changed by some superficial attribute like clothing or cosmetics—is easily swallowed by the still insecure adoles- cent trying to orientate himself or herself in a complex society with confu- sing sexual and moral attitudes. However, many young people seem to have started to get a clear insight into this, and to be reacting against it. The content of any sex education programme must of course be adjusted to the particular sociological environ- ment. Vague though this statement might appear at first sight, it calls for a great effort to provide enough know- ledge to enable the students to put the sexual attitudes and rules of their own society into a historical and sociological framework. Why do we put so much effort into teaching, for instance, the his- tory of religion, while totally neglecting the historical evolution of human sex? More meaningful knowledge of human sexology may meanwhile be gained from serious research projects. Thus, according to the investigations by Kinsey, Masters and Johnson in the United States a high proportion of women experience difficulties in achiev- ing orgasm by normal intercourse. As a geneticist I wonder whether this might not be due to the fact that there is no need for a female to obtain orgasm in order to produce children. An inter- disciplinary approach to such problems might well be fruitful not only for the specialists but for the whole field of sex education for the adolescent. ■ 25 search for identity It is hardly surprising that a generation gap has emerged to underline how marginal the adolescent is to the core of society, or that adolescence tencs to be seen by many as a problem age BY VA\UEL CARBALLO arely, if indeed ever at all, has the subject of adolescence cap- tured the attention and concern of the public as it has in recent years. From being a topic that received little more than passing academic in- terest for so long, adolescence has now come to be viewed as a major issue for health and social policy, a life phase preg- nant with doubts for parents, teachers, legislators and adolescents themselves. No simple answers are forthcoming to account for the change in attitude that has occurred, but some general state- ments can be made concerning the nature of the world in which the ado- lescent functions and the roles that he or she is expected to play in it. These may begin to form a background against which a perspective on the issue can be developed. The first consideration of course is that adolescence must be seen as some- thing of a social artefact; that is to say, adolescence—like the notion of middle age or old age—is a concept built up of social expectations that are themselves premised on a host of values, traditions and factors that change with time, cul- ture and economics. Thus while we may acknowledge that writings as far back as those of the early Greek thinkers were already reflecting observations made on the bodily and intellectual changes that characterize this age period, it is not clear whether the concept of adolescence as we now think of it has been common to all historical periods and societies. There is good reason to believe that at times and in certain social climates, there has been little occasion or need felt for such a concept; the passage from childhood to adulthood in these settings has been marked by little more than perfunctory recognition of a new status in the adult world. Some societies on the other hand have evolved quite complex and socially meaningful rituals to sup- port and denote this passage from child to adult and, through intricately pre- pared initiation ceremonies, have tended to ensure that the transition is not without widely shared knowledge about the implications and obligations for both individual and society. Thus when we use the term adoles- cence it must be with the implicit un- derstanding that what we are referring to is a general rather than a specific period in the life of the child and that while there are, inevitably, many com- mon features that transcend cultural boundaries, there will occasionally be quite significant variations. Some of these will inevitably arise between what are commonly termed the industrialized or developed social systems and those that are still going through the process of change to industrialization. Within countries they may even be predicated upon such geographical factors as urban versus rural location. Despite these qualifications, however, there are some basic facts which are common to the adolescent period irre- spective of setting, and these go far towards setting the scene for the way in which adolescents view their social world and how, in turn, it responds to them. Maturation and development, for example, is universal in all adolescents and follows a reasonably common pathway. The rapid onset of growth and sexual development has often been de- scribed and there is little need to pursue it here other than to point out that there is now a marked tendency for this onset to occur earlier in life and for the in- creases in body weight and height that are classic features of the adolescent period to be greater now than they were some 50 years ago. Similarly, sexual maturity—the capacity for reproduc- tion—is also likely to be achieved earlier in the contemporary world than was previously the case. The significance of these facts, then, is that we now not only have the sudden dramatic and somewhat psychologically jolting growth spurt with all its potential implications of embarrassment, awk- wardness and fear, but that it occurs among younger children than was pre- viously the case. The consequent emo- tional and intellectual needs that auto- matically arise do so at times when the immediate social environment family and school may be unprepared or ill- equipped to deal with them. The second general consideration concerns identity and the fact that adolescents, like anyone else, gain their perception of themselves from their en- vironment. Their guidelines are what others tell them, how others react to their impulses. treat them, or help them in adjusting to new needs. Per- haps more so than with any other The burdens of social responsibility increase I> steadily during adolescence—that critical stage in life when a young person seeks to establish who he or she is, what types of friendship to form, how to face the future. (Photo J. Mohr ( 0 ) 26

period in the life cycle, however, the search for identity during adolescence is a critical activity. It is critical not only because it marks a radically new phase in the relationship to the outside world and the first marked transition to a new social age, but also because it takes place against a background of the dra- matic and often difficult physiological and intellectual changes that first mark adolescence. Parent-child relationships begin to change, and responsibility for well- being, for extra-familial associations, begins to lie more with the adolescent than it did at any earlier stage in his life. In this process of transfer of responsibil- ity the adolescent must seek to establish who he or she is, what types of friend- ships will be developed and what type of orientation will be made to the future. These are not decisions that are easily made; more so than anyone else, the adolescent depends for guidance upon the range of personality and behaviour models around him. Traditionally many of these would have been provided by the family, and there would have been an element of control exerted by the family in direct- ing the adolescent to one or another model according to social or group needs prevalent at that time. In the contemporary world, however, the fami- ly has had to relinquish much of the responsibility for "socializing" and guid- ing youth and much of the task has been delegated to formal education. But educational systems have unfortunately often tended to reflect ideal or theoreti- cal approaches, and have not always shown an ability to include social educa- tion in the curricula or to relate their training role to the contemporary set- ting. The fact that so few educational programmes are currently equipped to deal with the reproductive or sexual needs of adolescents is a case in point which by now has been substantially documented and which highlights the information vacuum confronting many young adolescents. In the absence of what are considered to be adequate and easily accessible guidelines, adolescents necessarily seek alternatives. If the family is unable to provide what are felt to be appropriate indicators or if it is unable to present advice with the certainty and emotional support or reinforcement required to make that advice palatable, or if there are no other effective resources, then youngsters will turn to other channels or create new ones. In developing societies particularly the role of the adolescent is changing markedly not only with respect to family, but also to education and occu- pation. A growing demographic and political force, the adolescent generation is coming of age in an environment that is dominated by the social and cultural upheaval implicit in urbanization and the development of industrially or tech- nologically oriented social systems. In many of these countries the adolescent population is coming to constitute the base of the demographic shift from rural to urban life and is being thrust into the relative independence that comes with labour- or education-selective migra- tion. At ages and in situations where they can find little guidance other than that which is available from their peers and the media, they are being compelled to innovate and experiment. One of the most effective influences in this process throughout the con- temporary world has proved to be the somewhat ill-defined but never- theless ubiquitous culture of youth. Built up and disseminated through a sophisticated network of mass media technology, and revolving around what have become internationally acceptable symbols of music, dress and personali- ties, it has become probably one of the most dominant forces in the "socializa- tion" of adolescents. It has provided, in a non-formal way, the type of ideologi- cal framework that generations use in order to distinguish themselves from previous and subsequent age-groups. And in the sense that this media-precipi- tated or media-facilitated culture has provided the sense of an integrated group in which all adolescents can par- ticipate, it has, to a great extent, created a "community" to replace the diminish- ing role of the extended family and the collective values and relations existing be- fore rapid transport and socially encour- aged mobility became so dominant. The media, meanwhile, have tended to further this conceptual mobility and through radio, cinema and television provide the adolescent with a much 28 search for identity <Pop-music is today a recognisable part of the culture of youth. Revolving around what have become internationally acceptable symbols of music, dress and personalities, this cult of youth has become one of the most dominant ,forces in determining the adolescent's social role. ( Photo J. Mohr © ) Girl sorters at work in a large spinning mill. Cy Young women today are increasingly entering the wage-earning labour force and are freeing themselves from the traditional bonds of arranged marriages and maldependence. Marriage itself is no longer viewed—as it used to be as necessarily an institution for sex and reproduction. (Photo ILO) wider range of behaviour patterns, values and beliefs to choose from than was ever possible in previous genera- tions. Some of these alternatives may support the values proposed or present- ed in the home environment. Others inevitably invite doubts if not direct contradictions. Such in the strength of the media and such the contemporary role of the family that the adolescent is increasingly sensitized to the ambiguities and ill-defined aspects of the social world in which he functions. Formal education, the emphasis placed on full-time schooling, and thus the institutionalization of student life, has, in an odd way, also contributed to this. For in isolating or segregating the adolescent from the adult occupational world for long periods of time, it has admitted if not in fact promoted the student to the position of evaluator and critic of the adult world in which his own value is so unclear. This is not to suggest that in previous historical periods the person whom we now term the adolescent automatically slotted into the adult world with all its hierarchies and complexities, but it is important that in traditional societies the value of youth, their energy, their productivity is clear and is directed and is acknowledged by both family and community. Modern society, on the other hand, often seems strangely unsure as to where the adolescent should be in the social hierarchy. It simply orientates him towards a postponement of work and marriage, offering in their place the goal that more education for longer periods of time will ultimately bring about greater rewards. Earlier maturing, more intellectually aware young people, are thus systematically placed in a type of abeyance and in a sense denied active participation in the adult society towards which they are, at the same time, expected to direct their respect. A further point is that as a result of the greater mobility of people and their broader spheres of interaction and con- tact, and partly because of the fewer informal controls that might otherwise be provided through the extended fami- ly and the family-based community, values concerning sexual life and family life also appear to be changing. For the adolescent seeking to identify and grasp specific values relating to sexual beha- viour and family responsibilities, the picture may not be as clear today as it was 50 or even 20 years ago. Even for adults the situation is fluid and new types of relationships are being ex- plored. Divorce, for instance, is more common and is seen as an easy and acceptable way of dealing with unsatis- factory relationships; marriage is no longer viewed as necessarily an institu- tion for sex and reproduction as it was, while few of the economic constraints that previously prompted the need for and maintenance of marriage are as domi- nant as before. Women are increasingly entering the wage-earning labour force and are freer of the traditional bonds to matrimony and male-dependence. Finally, one must take into account the potential that an increasing adoles- cent population presents for economic marketing and political mobilization. Almost inevitably, the adolescent has become a prime target for both activities and in so doing has also been given a status which at first glance is often mis- leadingly high. For when put to the test this special status proves not to be so clear and the discrepancy again tends to accentuate the gap between expressed ideals and social realities a fact that has contributed in no small way to the conflict between older adolescents and what they interpret as an authority structure whose concepts appear to them to be decades out of date. It is not altogether surprising then, given these factors, that a so-called generation gap should have emerged to further emphasize the marginality of the adolescent from the core of the social framework or that adolescence shows an inclination, albeit an unnecessary one, to become a problem period of growth. It is, after all, this fact that has contrib- uted to adolescence attracting the atten- tion and concern that it has today. But it is perhaps ironic that—in an age when so much is known about the needs of human beings with respect to personal and social life—more is not actually done to structure the context in which adolescents function in such a way that meaning and identity would be easier to define and, once defined, would show more consistency with the society concerned. ■ 29 from mother to baby Research workers in the WHO Oncho- cerciasis control programme in Africa have established that the microfilarie in the systems of pregnant mothers suffering from onchocerciasis ("river blindness") can be transmitted to the unborn baby. The investigation fol- lowed discovery in Ghana of the presence of the parasite (Onchocerca volvulus mi- crofilarie) in new-born babies. Ten of the 34 pregnant women in the Bawku Hospital, in northern Ghana, in- cluded in the study, were found to be affected with onchocerciasis. The 35 ba- bies born—one was a twin delivery—were examined within an hour of their birth. Three of the 11 babies born to the oncho- cerciasis sufferers were found to be carrying the parasites. Their mothers had been the most heavily infected in the group. too many drugs? Today's highly competitive drug market offers thousands of medi- caments, in many cases variants of the same substance under different brand names. Tetracycline, for instance, an antibiotic in wide use, is sold under at least 125 brand names. Is there a way to avoid the heavy expenditure this pro - liferation of drugs involves, particularly for many developing countries who must import all the drugs their health services need? A first step in this direc- tion has been taken by WHO with the drawing up of a tentative list of 150 active substances of proven efficacy and safety in the treatment of common symptoms and diseases. The list—to be finalized in consultation with a wide range of experts and leading world insti- tutions—will offer health ministries a basic tool in shaping their drug policies, formulating national lists of essential drugs, avoiding wastage, and ensuring that only drugs which will be of max- imum value to them are imported. against diarrhoea A mixture of specified quantities of salts and glucose dissolved in drinking water, which has proved highly effective in the treatment of cholera and other acute diarrhoeas, will be produced and promoted by UNICEF under the name "Oral Rehydration Salts" or "ORS", and not "Oralyte" as it was originally named. The name "Oralyte" is being dropped owing to certain legal problems in registering it as a trade mark. WHO is promoting the technique of oral rehy- dration as a simple and effective tool against acute diarrhoeas, which can be used in health care programmes by auxiliary health workers or even by mothers (see World Health, July 1976, page 30). Dr David Morley, of the Insti- tute of Child Health, University of London, has said : "I would like to suggest. . . that WHO . . . put their next major drive (after smallpox) into oral rehydration . . . This could do more to relieve the suffering of small children than most of the other possible pro- grammes." rabies surveillance Information on rabies in Europe— outbreaks among wild or domestic ani- mals, cases of human rabies and treat- ment of persons exposed to the infec- tion, and control measures taken by the national veterinary services—is being collected under a European Rabies Surveillance System recently set up by WHO. A key element in the system is the WHO Collaborating Centre for Rabies Surveillance and Research created with- in the Federal Research Institution for Animal Virus Diseases, in Tubingen, Federal Republic of Germany. All the information received will be placed in a computer data bank, evaluated from time to time, and the results transmitted to the interested governments and insti- tutions. Wildlife rabies in Europe, parti- cularly in foxes, is estimated to have been advancing in a general westward direction at the rate of 40 to 50 kilo- metres a year. It poses a serious problem owing to the inherent difficulties in planning control measures in the wild. ■ Keeping an eye on foxes.. . (Photo WHO/E. Schwab) CORRECTION In the October issue of World Health the headline on the article from WHO's Western Pacific Region should have read ''TB in Papua New Guinea" instead of "TB in New Guinea". New Guinea is the geographic name of the entire island comprising West Irian, which forms part of Indonesia, and Papua New Guinea, which became an independent state in September 1975. The article in question dealt only with Papua New Guinea as is of course, made clear in the text. The Editor regrets this error. 30 ip,L,1 4( World Health Day Stamps, 1976 Foresight prevents blindness. Tara 1976✓ 6R. IRAN Lhlfr The message of World Health Day, 7 April 1976, that Foresight Pre- vents Blindness, was brought home to millions around the world through the medium of special postage stamp issues. Here we reproduce just a selection of the "blindness" stamps which have so far reached WHO headquarters in Geneva. EGYPT ,,,,,,.. 20M 1976 .S.• PREVENTION OF BI NONFSS EVOIHEr PREYENIR IA MITE 4[HEIE.! -TIE* 191 6 ZIEd '1=1 20 Authors of the month Professor 0. JEANNERET is Director of the Institute of Social and Preven- tive Medicine at the University of Geneva. Dr B. A. HAMBURG is Associate Professor of Psychiatry and Behavio- ral Science, Stanford University School of Medicine, and Dr D. A. HAMBURG is President of the Insti- tute of Medicine, the National Academy of Sciences, Washington DC. Mr M. SUPONYEV is a correspondent of the Soviet news agency Novosti. Dr M. HUT:FEN is Director of the Regional Cytogenetics Laboratory, East Birmingham Hospital, England. Dr M. CARBALLO is a member of the unit of Maternal and Child Health, Division of Family Health, at WHO headquarters in Geneva. WORLD HEALTH for reacers everywhere ORDER FORM Please enter my subscription to "World Health" as follows: US$' Sw.fr. One year 10 25.— Two years 18. 45. ' Three years 24.— 60. One year : Two years: Three years: I enclose cheque/postal order in the amount of Name: Street: City: Country: *or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland Growing up can be a serious matter. See page 12. (Photo WHO/J. Mohr) e s R ea n ie s S. A. L au sa n ne Pr in te d in Sw itz er la n d