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Generation Sex

One billion young people today are maturing emotionally, connecting socially and exploring their sexuality. To help them avoid risky behaviors, researchers first have to understand them.

by Mary Beth Regan

Around the globe, more than 1 billion young people, ages 15 to 24, are making the often-difficult transition to adulthood. They are changing physically, maturing emotionally, connecting socially and having sex with each other. But the consequences aren't as simple as they may once have been. The global economy is changing, and in most countries, young people need higher education to keep pace economically. As a result, the age of marriage is drifting upward. More adolescents are finding themselves exploring their sexuality outside of marriage, resulting in more out-of-wedlock pregnancies and births.

The public health toll is staggering: One in every 10 births worldwide is to a teen mom; at least one in 10 abortions worldwide is performed on young women ages 15 to 19. And every day, 500,000 young people are infected with a sexually transmitted infection (STI). A March 2008 study reported that one in four girls and young women, ages 14 to 19, in the U.S. has at least one of four common STIs—and nearly half of African-American females in the study have one of the STIs. Worldwide, more than 10 million people, ages 15 to 24, are infected with the HIV virus, many of them in Africa, according to UNICEF.

"In some ways, we are fighting biology," says Robert Wm. Blum, MD, PhD, MPH, the William H. Gates Sr. Professor and Chair of Population, Family and Reproductive Health (PFRH). "The social norms are changing. Historically, marriage and puberty would coincide. But as the age of marriage goes up, there's a greater period between fertility and marriage. So we are seeing this clash around the globe ... and a lot of countries are wrestling with it."

At the Bloomberg School, researchers are making strides toward understanding adolescent sexual behavior—and using that newfound knowledge to design programs aimed at helping teens make healthier decisions about their sexual lives.

Across countries, across cultures, a pattern is emerging, as researchers work to tease out "protective measures" that help teens avoid risky behaviors, such as drinking, taking drugs and having unprotected sex. The three leading factors to emerge: a connection to a caring adult, an interest in school and a stable community.

"We are starting to see a whole set of risk and protective factors in a kid's life," Blum says. "If some of these protective factors are in place, kids do better. ... They contracept, they delay first sex, and they are less likely to get into a whole slew of other problems as well."

Understanding Teens

Freya Sonenstein, PhD, director of the Bloomberg School's Center for Adolescent Health, has been working in this field since the late 1970s. Her groundbreaking work, the National Survey of Adolescent Males, was the nation's first comprehensive look at adolescent male sexuality (see sidebar). This year, surveyors begin a fourth round of interviews with the first boys, surveyed initially in 1988, now in their mid-30s. Based on the data, Sonenstein has seen a change in positive male behavior. "There's been a decrease in the level of sexual experience and an increase in age of first intercourse," says Sonenstein. "Boys have been delaying first sex and the percentage using condoms all the time has gone up."

Researchers Michelle Hindin, PhD '98, MHS '90, and Ushma Upadhyay, PhD '06, have turned their attention overseas. Hindin, a PFRH associate professor, is looking at the specific behaviors, within a specific culture, that lead to first sexual experiences. Since 2001, Hindin has worked with data from over 2,000 mothers and their children in Cebu, Philippines. Nearly all are Catholic. By age 18, 31 percent of boys and 20 percent of girls reported having premarital sex—low percentages compared to other nations.

Hindin's data show: Boys who progress to physical relationships earlier (holding hands, kissing) have sex earlier, whereas girls who progress to emotional attachments earlier (dating and emotional relationships) have sex earlier than female counterparts who don't have the same emotional relationships. Also, if mothers report equitable decision-making styles at home, sons report delaying first sex. If mothers report that they have high-status houses, daughters report holding off on first sex.

Another Bloomberg School researcher, Kathleen M. Roche, PhD '98, MSW, has spent a decade looking at U.S. parenting styles and how they affect adolescent behaviors, including early sex. Much of her work has focused on families living in low-income urban neighborhoods. Over the course of several peer-reviewed papers, she has pieced together recurring themes. First, there's some indication that uninvolved, ineffective parenting carries steeper penalties for young people in more dangerous neighborhoods. Second, there is considerable variability even within low-income neighborhoods. "There's a growing body of evidence to suggest that the stakes are even greater when families are faced with more risks," says Roche, a PFRH assistant professor.

And teens who fare best are those who perceive that the parent, or other concerned adult, genuinely cares about them and wants to provide them with a better future.

Helping Teens

Building on such findings, Bloomberg School researchers are designing and putting into place intervention strategies in Baltimore that they hope to duplicate around the globe. They are in the right city: While Baltimore has seen dramatic declines in teen births, down from rates as high as 191.3 per 1,000 births in the 1960s, the city still remains on par with less developed countries. In 2006, for example, the incidence of adolescent births in the city to girls ages 15 to 19 was 66.9 per 1,000 live births, or about the same rate as in Paraguay.

Since 2006, Clea McNeely, DrPH, and Beth Marshall, MPH '03, have been evaluating a promising program called the Turning the Corner Achievement Program, targeted at middle school students. Working with the Eddie C. and C. Sylvia Brown Family Foundation and the Living Classrooms Program, McNeely, a PFRH assistant professor, and Marshall, a senior research program coordinator, have augmented middle school classrooms at a local charter school with "fellows" (college graduates or mid-career professionals) who work with students' families and provide academic enrichment and after-school activities.

Preliminary data indicate these charter school students, with additional attention and mentoring from fellows, perceive themselves to be in a better situation than students in other schools. Interestingly, this perception may translate into less risk-seeking behavior, Marshall says. Fewer students engaged in early sexual initiation or sexual intercourse, preliminary data show, when compared to similar students in other schools. One explanation: These students experience the protective measures of strong adults, schools and communities. "They start to expand their opportunities and possibilities," she says.

Another group of teens appearing to fare well are those serving on the School's Center for Adolescent Health's Youth Advisory Committee (YAC). These high school students from schools across Baltimore meet weekly to discuss issues and participate in enrichment activities aimed at bringing the perspective of youth to the community, policymakers and researchers. Two recent graduates—Ikia Means and Quinta Ocain, both 18 and from East Baltimore—are linked by determination, good choices and hope for the future. Both are determined to defy the statistics that mark their home turf. Means wants to be a doctor; Ocain wants to become a sports medicine therapist. Both say they want to take their message of making good choices to others.

"Some kids just aren't getting enough attention," says Means, who doesn't speak often to her own mother, but who was raised by a loving grandmother. "Most of them find love in someone of the opposite sex. They just get caught up in each other. ... And it's because they aren't getting enough attention from their parents. They are going to do whatever they are into—computers, or driving motorcycles, or drugs or having sex."

Means is now working for the Annie E. Casey Foundation, a Baltimore-based non-profit dedicated to families and children—a plum job she credits to her involvement in the Youth Advisory Committee. "The program opened doors for me," she says. "The YAC director was like a best friend. ... She was a mentor. We talked about everything."

Means and Ocain say younger teens need to know that pregnancy is not fun and that it could hamper a girl's ability to go to school or get a job. "College is a permanent fixture now. You have to go," says Ocain, who plans to transfer from community college to Morgan State University, where she will study on scholarship. " ... 'Cause these days, a McDonald's job? Nobody can live off that really."

The two young women recently helped Bloomberg School researchers and city health officials with material for a program called CONTAC-U (Connecting with Teens About Contraceptive Use), which will use a 21st-century approach to retaining clients at a clinic in West Baltimore. The clinic, on an empty lot next to boarded-up buildings, provides information and contraception to young people. The only problem: Many of them walk through the door once, but then never return. Preliminary data show that over one year, the clinic retains only half its initial visitors.

What's the best way to keep them connected, keep them contracepting and keep them coming back? Kathleen M. Cardona, DrPH '05, MPH '97, has designed a hip, teen-friendly approach. Beginning this spring, she and her team hope to enroll as many as 500 girls in a program that will use cell phone messages, text messages, email and the Web to communicate with them. For example, young women who choose to take birth control pills may receive daily inspirational text messages, with a gentle reminder to take them. "We need to meet teens where they are," says Cardona, an assistant scientist with the Center for Adolescent Health. "Kids aren't going to come into a clinic and pick up brochures to get their information these days."

Media expert Dina L.G. Borzekowski, EdD, EdM, MA, agrees. Teens spend many hours each day in front of screens, she says, and it's critical to meet them on their home turf if you want to give them good information. Borzekowski, a Health, Behavior and Society assistant professor who works in the U.S., Africa and Asia, says she sees huge possibilities for such an intervention strategy around the globe—especially in China and Africa, where many teens have Internet access or cell phones.

Researchers find encouragement in the latest trends as they piece together new insights into adolescent sexual behavior and design intervention strategies that are having an impact. "The kids seem to be moving in the right direction," Sonenstein says.

Blum agrees. "For every failed program there are successful, evidence-based programs that work. We have a lot left to learn, but now it's a matter of political will," he says. "We need to stop investing in programs that have been shown to fail and start investing in those evidence-based programs that work."