AIDS Behav (2009) 13:100–109
DOI 10.1007/s10461-008-9376-2
ORIGINAL PAPER
Starting Young: Sexual Initiation and HIV Prevention
in Early Adolescence
Ruth Dixon-Mueller
Published online: 4 April 2008

Springer Science+Business Media, LLC 2008
Abstract The rising numbers of new HIV infections
among young people ages 15–24 in many developing
countries, especially among young women, signal an
urgent need to identify and respond programmatically to
behaviors and situations that contribute to the spread of
HIV and other sexually transmitted infections in early
adolescence. Quantitative and qualitative studies of the
sexual knowledge and practices of adolescents age 14 and
younger reveal that substantial numbers of boys and girls in
many countries engage in unprotected heterosexual vaginal
intercourse––by choice or coercion––before their 15th
birthdays. Early initiation into male–male or male–female
oral and/or anal sex is also documented in some popula-
tions. Educational, health, and social programs must reach
10–14-year-olds as well as older adolescents with the
information, skills, services, and supplies (condoms, con-
traceptives) they need to negotiate their own protection
from unwanted and/or unsafe sexual practices and to
respect the rights of others.
Keywords HIV prevention
Adolescents

Sexual behavior
Risk factors
Africa
Asia

Latin America
The development of cognitive, emotional, and social
capacities during early adolescence and the emergence of
sexual feelings and curiosity occur at a time of intense
R. Dixon-Mueller (&)
Apartado 110-4100, Grecia, Costa Rica
e-mail: dixonmueller@yahoo.com
R. Dixon-Mueller
Population and Reproductive Health, International Women’s
Health Coalition, New York, USA
123
socialization into gendered sexual attitudes and behaviors
(Barker 2000; Breinbauer and Maddaleno 2005; Patton and
Viner 2007). By the time of their 15th birthdays, a sub-
stantial number of boys and girls in some developing
countries have already engaged in risky sexual activities,
including but not limited to unprotected heterosexual
vaginal intercourse. Learning what 10–14–year-olds know,
feel, believe, and do (or are encouraged or forced to do)
with respect to their bodies and their sexuality is crucial for
designing realistic HIV prevention programs that respond
to their needs and protect their sexual health and rights.
The Strategic Value of Investing in 10–14-Year-Olds
The benefits of investing in the health and development of
very young adolescents have been stressed in a number of
documents (e.g., Bruce and Joyce 2006; Chong et al. 2006;
Lloyd 2005; UNICEF et al. 2002). Relatively little is
known about the sexual and reproductive knowledge,
attitudes, and practices of young adolescents, however, or
about the prevalence of HIV and other sexually transmitted
infections (STIs) within this age group. Behavioral data are
often reported for 15–19-year-olds, while estimates of HIV
prevalence among young people typically refer to ages
15–24. Yet, 10–14-year-old boys and (especially) girls in
many developing countries—particularly those who live in
communities where epidemics are generalized among
young people—are at considerable risk of acquiring STIs,
including HIV, as soon as they become sexually active
(Global Health Council 2007; UNICEF et al. 2002).
Early, unprotected sexual initiation can trigger a suc-
cession of harmful physical, emotional and social outcomes,
especially for girls (Brown et al. 2001; Jejeebhoy et al.
2005; Zabin and Kiragu 1998). The physiological
AIDS Behav (2009) 13:100–109
vulnerability that places adult women at higher risk than
men of acquiring STIs/HIV from an infected partner during
a single act of vaginal intercourse is heightened among
young adolescent girls, especially when intercourse is ini-
tiated before menarche or soon after (Duncan et al. 1990;
Glynn et al. 2001). In addition, younger adolescents are
more likely than older adolescents to report that their sexual
initiation was involuntary or coerced, and girls are far more
likely to say so (including young brides in forced marriages)
than boys (Alan Guttmacher Institute 2006; Brown et al.
2001; Jejeebhoy et al. 2005; Matasha et al. 1998; WHO
2005). In provincial Tanzania, 43% of girls whose sexual
initiation took place at age 14 or younger said they were
forced, compared with 18% who first had intercourse at ages
15–17 and 12% at age 18 and over; comparable figures for
Peru are 41, 28 and 17%; Bangladesh, 36, 28 and 21%; and
Thailand, 20, 7 and 4% (WHO 2005:14). Forced intercourse
is associated with abrasion, tearing, and bleeding of the
immature vagina or rectum; non-use of protection; and other
characteristics such as alcohol or drug use; multiple part-
nerships; repeated episodes of abuse; and heightened
probabilities of being infected with STIs/HIV (Jejeebhoy
et al. 2005; Jewkes et al. 2006).
Young adolescents who have consensual sex with age-
mates or older partners are also in jeopardy, however.
Compared with older teens, they are less likely to have the
foresight, skills, cognitive maturity, information and sup-
plies they need for their or and their partners’ protection
from pregnancy and STIs/HIV (Bankole et al. 2007; Blanc
and Way 1998; Breinbauer and Maddaleno 2005; Eggle-
ston et al. 1999; Patton and Viner 2007). Among sexually
active boys in low-income neighborhoods of Recife, Bra-
zil, for example, only 11% of 13–15-year-olds regularly
used contraceptives with their casual or steady partners
compared with 45% of 18–19-year-olds (Juarez and Castro
Martı́n 2006:65). Research is needed in a variety of
socioeconomic and geographical settings to identify key
points of intervention aimed at preventing the initiation of
(and vulnerability to) unsafe behaviors among young
female and male adolescents; reducing their harmful
effects; and promoting healthy sexual choices.
Approaches to Interviewing Young Adolescents
About Sex
Interviewing 10–14 or 12–14-year-olds about sexual topics
poses many challenges (Bankole et al. 2007; Chong et al.
2006; Eggelston et al. 2000; Helitzer et al. 1994). Parents,
teachers and community or state representatives may
strongly oppose such inquiries. Ethical standards in most
cases require permission from parents or guardians as well
as from young people themselves, yet some will withhold
101
their consent, thus biasing the results. Terms used in
questionnaires or interviews, such as sexual intercourse,
anal or oral sex, or even masturbation may not be under-
stood by some young respondents––if such questions are
asked at all––yet explicit descriptions can be shocking.
(Investigators may be unaware of the local names for these
and other practices, of course.) Behaviors that are consid-
ered shameful or taboo are likely to be underreported while
those viewed as ‘‘masculine’’ are often exaggerated by
boys, thus making gender contrasts appear sharper than
they are.
Some of these difficulties can be overcome by adapting
questions to local cultural contexts and to respondents’
personal situations (Marston and King 2006; Obermeyer
2005), although such adjustments hinder cross-cultural
comparability. To avoid questioning young adolescents
directly, older teenagers can be asked about their sexual
experiences when they were younger and the age at which
particular events first occurred (Albert et al. 2003; Chong
et al. 2006). Younger boys and girls can be asked indi-
vidually or in focus groups about their perceptions of their
peers’ or best friends’ behaviors rather than their own
knowledge or experiences (Bankole et al. 2007; Gueye
et al. 2001; Temin et al. 1999). Different modes of inter-
viewing, the use of self-administered questionnaires
(pencil-and-paper or computer), and other approaches such
as thematic word sorting can be tested to see what works
best for particular topics and groups (Mensch et al. 2003;
Plummer et al. 2004; Ramakrishna et al. 2003), recogniz-
ing that diverse approaches are bound to elicit different
results in different contexts.
The World Health Organization (WHO) has produced
sample core instruments for surveys, in-depth interviews,
and focus group discussions on sexual topics designed for
young people who have reached puberty but are not yet
married or living with a sexual partner (Cleland et al.
2003). The standard WHO questionnaire, which can be
adapted to a variety of settings, asks male and female
adolescents about their main sources of information on
puberty, sex, and reproduction; their knowledge of sexual
and reproductive health issues; dating relationships and
types of sexual partnerships; experiences of heterosexual
and homosexual intimacies and sexual intercourse;
knowledge and use of condoms and contraception; and
sexual outcomes such as STIs, pregnancy and abortion. The
Pan American Health Organization (PAHO) has also cre-
ated questionnaires for male adolescents (Lundgren 2000).
Unlike the 2002 U.S. National Survey of Family Growth
which contains very explicit questions on penetrative sexual
practices for 15–24-year-olds (Mosher et al. 2005:9), nei-
ther the WHO nor the PAHO protocols contains a clear line
of inquiry about insertive and receptive oral or anal inter-
course in male–male or male–female sexual encounters.
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102 AIDS Behav (2009) 13:100–109

This gap is especially problematic given the hypothesis in Table 1 Percentages of male and female 15–19-year-olds who had
intercourse before age 15, of females married, and of 15–24-year-olds
the PAHO report that a ‘‘significant percentage of adoles- estimated to be HIV-positivea
cents (in Latin America and the Caribbean) engage in
Intercourse \ 15 Married \ 15 HIV+
(heterosexual) anal sex in order to prevent pregnancy and 15–24
preserve a young woman’s virginity’’ and the recommen- Male Fem. Fem. FI–FM Male Fem.
dation of further research on this topic (Lundgren 2000:37).
Western Africa
2001 Benin 23.8 16.0 5.0 +11.0 1.0 3.8
2005 Guinea 17.9 19.7 12.2 +7.5 – –
The Evidence: Heterosexual Intercourse at Age 14
1999 Cote d’Ivoire 13.8 22.1 7.4 +14.7 2.9 8.4
or Younger 2001 Mali 10.6 26.0 19.4 +6.6 1.3 2.1
1998 Niger 10.0 29.8 27.3 +2.5 – –
Except for girls who are already married or cohabiting, the 2003 Nigeria 7.9 20.3 16.1 +4.2 3.0 5.8
sexual activity of adolescents who have had vaginal 2003 Burkina Faso 4.7 7.3 4.2 +3.1 4.0 9.8
intercourse at least once before their 15th birthdays tends to 2003 Ghana 3.9 7.4 2.5 +4.9 1.4 3.0
be infrequent and sporadic (Juarez and Castro Martı́n 2006; 1998 Togo – 20.4 3.8 +16.6 2.0 5.9
Singh et al. 2000). Nevertheless, the risks of STI/HIV 1997 Senegal – 9.6 8.2 +1.4 0.2 0.5
transmission per sexual act are escalated among 10–14- Median 10.3 20.0 7.8 +5.4 1.7 4.8
Central Africa
year-old girls because of the immaturity of the reproductive
2000 Gabon 48.1 23.8 6.6 +7.2 – –
tract, higher levels of sexual coercion, and the infrequent
2005 Congo 25.3 23.5 3.7 +19.8 3.2 7.8
use of condoms, as mentioned earlier. That the partners of 1995 C. Af .Rep. 16.0 24.6 16.1 +8.5 5.9 13.5
under-age girls in most developing countries tend to be 2004 Cameroon 11.5 18.0 11.2 +6.8 5.4 12.6
considerably older, on average, and to have had more 2004 Chad 10.7 19.0 17.9 +1.1 2.4 4.3
extensive sexual histories, also increases girl’s vulnerabil- Median 16.0 23.5 11.2 +7.2 4.3 10.2
ity to STIs/HIV as compared with boys the same age (Clark Eastern Africa
2004; Clark et al. 2006; Luke 2003). Among the 68% 2002 Zambia 39.3 17.5 4.9 +12.6 8.1 20.9
of female primary school students age 12 and over in 2003 Kenya 30.9 14.5 3.5 +11.0 6.0 15.6
2003 Mozambique 23.5 27.7 14.0 +13.7 6.1 14.7
Mwanza, Tanzania who said they were sexually experi-
2004 Malawi 18.0 14.1 6.2 +7.9 6.4 14.9
enced, for example, almost half had had sex with adults,
2001 Uganda 15.5 14.2 6.8 +7.4 2.0 4.6
including teachers, relatives and strangers; one-third said 2005 Rwanda 15.3 5.2 0.2 +5.0 4.9 11.2
they had had an STI; and fewer than one in three had ever 2004 Tanzania 13.0 11.4 4.6 +6.8 3.6 8.1
used a condom (Matasha et al. 1998:575). 2004 Madagascar 7.7 16.0 8.8 +7.2 0.1 0.2
Demographic and Health Surveys (DHSs) reveal strik- 1999 Zimbabwe 6.3 3.2 1.7 +1.5 12.4 33.0
ing variations across countries in the percentages of male 2001 Mauritius 2.1 13.2 13.4 -0.2 – –
and female respondents aged 15–19 who say they first 2005 Ethiopia 1.7 11.1 12.7 -1.6 4.4 7.8
had sexual intercourse when they were 14 or younger 2000 Eritrea 0.0 8.8 8.5 +0.3 2.8 4.3
(Table 1). Contrasts are particularly sharp within Sub- 1990 Sudan – [4.9] 4.9 0.0 (est.) 1.0 3.1
Median 14.2 13.2 6.2 +7.2 4.6 9.6
Saharan Africa: 48% of 15–19-year-old Gabonese boys
Southern Africa
claim they had sex before age 15 compared with virtually
2000 Namibia 31.3 9.8 1.7 +8.1 11.1 23.8
none in Eritrea; 30% of girls in Niger compared with only 2004 Lesotho 17.6 6.9 1.4 +4.5 17.4 38.1
3% in Rwanda. Boys are far more likely than girls to ini- 1998 South Africa – 8.5 0.4 +8.1 10.7 25.7
tiate intercourse early in Gabon, Zambia, Kenya and Median 24.2 8.5 1.4 +8.1 11.1 25.7
Namibia, whereas the reverse is true in Mali, Niger, North Africa and Middle East
Nigeria, the CAR and other countries in the region, par- 2000 Armenia 1.3 0.6 0.6 0.0 0.2 \0.1
ticularly where girls are married young. Early female 1998 Turkey 0.0 [2.3] 2.3 0.0 (est.) – –
sexual initiation in countries where high proportions of 2004 Morocco – [1.6] 1.6 0.0 (est.) – –
2000 Egypt – [1.3] 1.3 0.0 (est.) – –
males in the pool of potential partners aged 15–24 are HIV-
2002 Jordan – [0.6] 0.6 0.0 (est.) – –
positive (e.g., estimates of 5% or more in Table 1) places
Median 1.2 1.3 1.3 0.0 – –
girls at especially high risk. South Asia
In North Africa, the Middle East, and South and 2001 Nepal 20.0 8.8 9.1 -0.3 0.3 0.3
Southeast Asia, sexual initiation before age 15 is rare 2004 Bangladesh – [26.3] 26.3 0.0 (est.) \0.1 \0.1
among both boys and girls––typically well under 5%–– 1999 India – [14.3] 14.3 0.0 (est.) 0.3 \0.1
except in Nepal, Bangladesh, India, and Pakistan where 1991 Pakistan – [7.3] 7.3 0.0 (est.) \0.1 \0.1
substantial numbers of girls are still married at puberty. Median – 11.6 11.6 0.0 0.1 \0.1

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AIDS Behav (2009) 13:100–109 103

Table 1 continued and 3–40% of girls in 23 European countries (Godeau et al.

Intercourse \ 15 Married \ 15 HIV+ 2008:67; Mosher et al. 2005:21–22).
15–24 National-level data mask important variations within
Male Fem. Fem. FI–FM Male Fem. countries as well as patterns of very early sexual initiation
among some populations (Bruce and Joyce 2006). A
Southeast Asia
country-wide survey of girls in grades 5–7 in Tanzania
2003 Philippines 2.8 1.4 1.2 +0.2 \0.1 \0.1
2003 Indonesia 0.0 2.8 2.8 0.0 \0.1 \0.1
found that one-quarter of those age 13 and younger were
2000 Cambodia – 1.0 1.1 -0.1 1.0 2.5 sexually active, for example, and one-half of those aged 14
2002 Vietnam – [0.3] 0.3 0.0 (est.) 0.3 0.2 and 15; early initiation was more common among urban
Median 1.4 1.2 1.2 0.0 0.1 0.1 than rural girls (Mgalla et al. 1998). In Benin City, Nigeria,
Central America and Caribbean young people in focus groups said that girls commonly
2001 Nicaragua 34.5b 10.9 9.4 +1.5 0.2 0.1 started having sexual intercourse at 11–13 compared with
2000 Haiti 28.3 12.0 4.7 +7.3 4.1 5.0 14–15 for boys (Temin et al. 1999). About 40% of all male
1999 Guatemala 27.9b 8.3 6.8 +1.5 0.9 0.8 students aged 10–18 surveyed in the Caribbean region and
2005 Honduras 26.5b 8.6 7.0 +1.6 1.2 1.5
9% of females said they had intercourse at age 12 or
2002 Dom. Rep. 16.4 12.8 10.4 +2.4 2.2 2.8
younger; among those who had had intercourse, one-half of
Median 27.9 10.9 7.0 +1.6 1.2 1.5
South America
the boys and one-quarter of the girls said they were 10 or
1996 Brazil 34.1 11.5 4.3 +7.2 0.6 0.5 younger when they first had sex (Halcón et al. 2003). In
2003 Bolivia 15.3 6.2 2.4 +3.8 0.1 \0.1 comparison, 12% of boys and 7% of girls reported having
2000 Peru 15.3 5.1 2.1 +3.0 0.4 0.2 sex at 13 or younger in a 1997 U.S. survey of 12–14-year-
2005 Colombia – 13.7 4.5 +9.2 0.9 0.2 olds, with black students most likely and non-Hispanic
1990 Paraguay – 5.5 2.7 +2.8 – – white students least likely to do so (Albert et al. 2003:
Median 15.3c 6.2 2.7 +3.8 0.5 0.2 20–21).
a
Countries are listed in descending order within regions according to the In the more culturally conservative countries within the
percentages of males reporting heterosexual intercourse before age 15.
Figures in [] are estimated from % married because questions on age at
sub-Saharan and South Asian regions, girls’ sexual initia-
first intercourse were not asked in the survey tion at age 14 or younger occurs almost exclusively within
b
Data are not available for males from DHS surveys; figures shown here arranged marriages. Elsewhere, the proportions of young
are males ages 20–24 who had intercourse before age 15 from non-DHS
surveys. Corresponding figures for females from these surveys are 14.3% girls for whom intercourse is initiated outside of marriage
in Nicaragua (2001), 12.2% in Guatemala (2002) and 14.0% in Honduras (or, in the case of Latin America and the Caribbean, outside
(2001) (Guttmacher Institute 2007: Cuadro 1)
c
of informal cohabiting unions) are substantial (FI–FM in
Table 2 shows much higher proportions sexually active of 13–15-year-
old male students in Guyana, Venezuela and Uruguay Table 1). Young sexually active unmarried girls are not
Sources: Percentages having intercourse and of girls married before age necessarily exposed to higher risks of STIs/HIV than their
15 are from ORC Macro, Demographic and Health Surveys (DHS), married or cohabiting age-mates, however. On average,
Statcompiler, http://www.measuredhs.com, accessed 13 October 2007.
Percentages of young adults 15–24 living with HIV are midpoints of high they have intercourse far less frequently; are more likely to
and low estimates for 2001 from UNICEF et al. (2002:38–45) use protection against STIs/HIV and pregnancy (even if
rarely); and have partners who are less likely to be HIV-
positive than the often much older and sometimes polyg-
HIV prevalence among young people is also fairly low in amous husbands of very young brides (Clark 2004; Clark
these regions, at least at the national level. In contrast, in et al. 2006; Glynn et al. 2001).
Latin America and the Caribbean, where HIV has gained a
foothold (1% or more) among young people in several
countries, 15–34% of boys aged 15–19 in the countries What’s Missing: Evidence on Other Risky Sexual
shown here say they had intercourse at 14 or younger and Behaviors
5–13% of girls. Nationally representative surveys of 13–
15-year-old students in selected African and Latin Ameri- Many young adolescents who say they have ‘‘never had
can countries shown in Table 2, although not exactly sex’’ are engaging in unprotected oral or anal sexual
comparable, also reveal high levels of early sexual initia- activities. Questions remain unasked not only because they
tion as well as multiple partnerships among boys (20–45% are controversial, but also because researchers and
have had intercourse) and, to a lesser extent, girls (7–29%) respondents may assume that ‘‘sexual activity’’ and even
(WHO 2007). In developed countries, school-based sur- ‘‘heterosexual intercourse’’ refer only to penile–vaginal
veys of 15-year-olds in 2002 found that one-quarter of both penetration. When the relevant questions are asked, a quite
boys and girls in Canada and the United States had had different picture emerges. Among primary school students
intercourse at least once, compared with 17–47% of boys aged 12 and over in the Mwanza region of Tanzania who

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104 AIDS Behav (2009) 13:100–109

Table 2 Percentages of male and female 13–15-year-old students who have had sexual intercourse and more than one partner, national student
health surveysa
Ever had intercourse Two+ partners HIV+ 15–24
Male Fem. Male Fem. Male Fem.

Western Africa
2005 Senegal 34.5 8.1 21.2 4.1 0.2 0.5
Eastern Africa
2004 Zambia 45.2 29.1 26.0 23.3 8.1 20.9
2003 Kenya 45.1 23.3 – – 6.0 15.6
(3 regions) 53.5– 27.1– – – – –
35.4 14.9 – – – –
2003 Uganda 29.4 14.0 16.1 6.2 2.0 4.6
Rural 35.2 14.3 18.5 7.2 – –
Urban 25.0 13.8 14.3 5.5 – –
2003 Zimbabwe – – – – 12.4 33.0
Manicaland 28.0 9.6 22.2 8.6 – –
Harare City 17.5 3.9 9.9 1.7 – –
2006 Tanzania – – – – 3.6 8.1
Dar Es Salaam 14.9 3.8 10.9 2.8 – –
Southern Africa
2004 Namibia 37.9 18.8 20.4 8.9 11.1 24.2
2005 Botswana 26.9 10.3 15.5 5.8 16.1 37.5
2003 Swaziland 19.9 6.7 12.4 3.0 15.2 39.5
South America
2004 Guyana 37.3 10.7 27.8 3.7 3.2 4.0
2003 Venezuela – – – – – –
Barinas State 37.3 5.1 21.1 2.5 – –
Lara State 29.9 4.4 16.6 1.0 – –
2006 Uruguay 35.6 15.9 24.2 5.5 0.5 0.2
Other 39.9 18.2 28.3 5.6 – –
Montevideo 30.9 12.6 19.7 5.4 – –
2005 Chile – – – – 0.4 0.2
(4 regions) 20.8– 15.4– 12.4– 4.3– – –
14.8 5.6 7.1 1.4 – –
a
Countries are listed in descending order within regions according to percentages of males reporting that they have had heterosexual intercourse.
Percentages having two or more partners refer to all students, not just those who have had intercourse. WHO-sponsored student health surveys
were also conducted in China, the Philippines, and six North African and Middle Eastern countries but did not include the questions on sexual
intercourse
Sources: Percentages who have had sexual intercourse and number of lifetime partners are from Global School-Based Student Health Survey
Factsheets (WHO 2007). Percentages of young adults 15–24 living with HIV are midpoints of high and low estimates for 2001 from UNICEF
et al. 2002:38–45)

said they were ‘‘sexually experienced’’ (four-fifths of all
boys and two-thirds of all girls), half of both sexes said that
their first sexual act was vaginal intercourse; 40% said it
was oral-genital contact (presumably fellatio); and almost
10% said it was anal intercourse (Matasha et al. 1998:575).
Ethnographic accounts from Tanzania, India, Bangla-
desh, Mexico, and other settings portray a variety of sexual
‘‘games’’ in which boys engage as a form of male bonding
that include anal penetration of younger or ‘‘effeminate’’
boys, group masturbation, and other activities (Barker
2000; Szasz 1998). Whether anal penetration is viewed as
‘‘sex’’ or ‘‘play’’ (or, alternatively, as male ritual, bullying
or violence expressed in a sexual manner) is not always
clear, however. Nor is the distinction between heterosex-
uality and homosexuality, the latter representing a
disdained social category that most boys will reject even as
they pleasure themselves with boys or are used as sexual
outlets by other boys or men (Barker 2000; Brody and

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AIDS Behav (2009) 13:100–109
Potterat 2003; Rajani and Kudrati 1996). Boys living on the
streets of Mwanza, Tanzania, and Bangalore, India,
described repeated acts of anal rape by older boys or men
enforcing their power (Rajani and Kudrati 1996; Rama-
krishna et al. 2003). Apart from these resented acts, most
street boys participated in initiation rites that involved the
group rape of new boys; anal penetration of unwilling
‘‘sleepmates’’ to release sexual tension; and more consen-
sual ‘‘comfort sex’’ with special friends until they acquired
female partners (and sometimes afterwards as well).
Young male adolescents’ experiences as active or
receptive partners in anal intercourse and what it means to
them have not been well studied in general populations.
Yet such information is imperative for understanding
potential male–male and male–female STI/HIV transmis-
sion routes during these vulnerable years. Given the very
high risks of STIs/HIV for the receptive partner in unpro-
tected anal intercourse if the insertive partner is infected,
younger boys who are penetrated by older boys or men are
particularly susceptible. In addition, forced anal penetra-
tion and other forms of violence and abuse can trigger a
sequence by which young male victims subsequently act
out the same behaviors with their male or female partners
(Jewkes et al. 2006; Population Council 2004). Girls, too,
may be subjected to anal penetration during episodes of
sexual abuse or rape, or, willingly or not, by boyfriends,
‘‘sugar daddies,’’ or as young brides. Although heterosex-
ual anal intercourse is said to be not uncommon in
countries such as Brazil, Puerto Rico, Peru, India and South
Africa (Brody and Potterat 2003; Caceres et al. 1997;
Halperin 1999; Lundgren 2000; Verma and Collumbien
2004), the practice remains largely uninvestigated among
young people in developing countries. In the United States,
4.6% of all 15-year-old boys interviewed in the 2002
National Survey of Family Growth and 2.4% of girls said
they had ever had anal intercourse with an opposite-sex
partner; by age 19, 15.3% and 18.6% had done so (Mosher
et al. 2005:21–22).
Surveys that refer to ‘‘oral sex’’ rarely ask boys whether
they had fellatio only with girls or were insertive or receptive
partners with other boys or men. Again, whereas evidence
from developing countries is scarce (the Mwanza school
survey reported above is one exception), U.S. studies have
found up to one-third of 14–15-year-old male and female
students admitting they have engaged in fellatio (Halpern-
Felsher et al. 2005; Remez 2000; Schuster et al. 1996). In
the 2002 National Survey of Family Growth, 30% of
15-year-old boys said they had ever ‘‘received’’ oral sex
from females and 18% of 15-year-old girls had ever ‘‘given’’
oral sex to males (Mosher et al. 2005:21–22). To the extent
that teenagers in these and other studies view fellatio as ‘‘not
really sex’’ (e.g., see Kaufman and Stavrou 2004 on South
Africa), risks to the receptive boy or girl—although low per
105
sexual act—may be compounded by its higher frequency
compared with vaginal intercourse in some populations and
by the greater likelihood that fellatio is performed with
multiple casual partners.
HIV Prevention in Early Adolescence and Beyond
Sexual desires, attitudes, opportunities and behaviors
among young people are influenced by a multi-layered and
gendered mix of individual, situational, and contextual
factors (Dixon-Mueller 1993; Marston and King 2006;
Obermeyer 2005; UNAIDS 1999). In every society, some
subgroups of young adolescents living in the path of STIs/
HIV are in greater jeopardy than others. Girls and boys sold
into the sex trades or living on the streets; schoolgirls who
exchange sex with strangers or ‘‘sugar daddies’’ for money
or other gifts; daughters forced into early marriage with
older husbands; boys and girls living with violence in their
families or communities; and young orphans, refugees or
displaced are especially at risk (Bruce and Joyce 2006;
Global Health Council 2007; Luke 2003; UNICEF et al.
2002). In addition to these special groups, however, vir-
tually all populations of 10–14-year-olds are vulnerable to
the possibility of sexual exploitation and abuse (and, in
some cases, to becoming perpetrators) and/or to deliberate
or unwitting but ‘‘voluntary’’ sexual risk-taking. Similarly,
virtually all lack the comprehensive knowledge, skills and
support services they need to ensure that their sexual
transitions are informed, safe and voluntary, both for
themselves and their partners. At least three types of policy
and programmatic initiatives are needed.
Filling the Knowledge Gap
Even in countries where most young people are aware of
HIV/AIDS, they often have little idea of exactly how it is
transmitted or how to avoid becoming infected and few
have typically heard of other STIs (Alan Guttmacher
Institute 2006; Bankole et al. 2007; Dehne and Riedner
2005; Matasha et al. 1998; Ross et al. 2006; Singh et al.
2005; Temin et al. 1999; Vuttanont et al. 2006). Young
adolescents, in particular, are very unlikely to recognize the
symptoms of the most common viral and bacterial STIs; to
know that some infections (especially among girls) may be
asymptomatic; to know that infections can be passed to the
mouth and rectum (and by men or boys to boys) as well as
to the genitals; to know that they must be medically
diagnosed; and to know where to go for STI/HIV coun-
seling, testing, or treatment. Similar knowledge gaps
appear with respect to pregnancy prevention and safe and
unsafe sexual practices, among many other topics.
123
106
International agreements such as those adopted at the
International Conference on Population and Development
(1994), the Fourth World Conference on Women (1995)
and the UN Special Session on the Rights of the Child
(2002) affirm that governments are responsible for ensuring
that children and adolescents acquire the knowledge and
skills they need to deal ‘‘positively and responsibly’’ with
their sexuality. Moreover, effective HIV/AIDS prevention
‘‘requires States to refrain from censoring, withholding or
intentionally misrepresenting health-related information,
including sexual education and information, …consistent
with their obligations to ensure the [child’s] right to life,
survival and development’’ (UN Committee on the Rights
of the Child 2003:6).
Comprehensive, rights-based sexuality education for
young adolescents that is reinforced by community-based
youth programs, popular media (radio, television, maga-
zines) and the Internet is urgently needed in all countries.
Educational initiatives clearly need to start young (in pri-
mary school); to be realistic, interactive and sustained; to
teach practical value-identification and negotiating skills;
and, where possible, to reach adolescents with ‘‘straight
talk’’ about their bodies and their sexual rights and obliga-
tions before they drop out of school—if they are attending at
all—and before they become sexually active, by any defi-
nition (Adamchak et al. 2007; Rogow and Haberland 2005;
Ross et al. 2006; Singh et al. 2005; Speizer et al. 2003;
UNICEF et al. 2002; Vuttanont et al. 2006).
Filling the Service Gap
Investments are required to upgrade the quantity, quality,
accessibility and acceptability of sexual and reproductive
health services for young male and female adolescents.
Although the need is great in all countries, it is most urgent
in settings of high STI/HIV prevalence (especially among
young adult populations ages 15–24) and/or where signif-
icant numbers of young male or female adolescents have
already been initiated into penetrative sex or are about to
become so, ‘‘ready or not.’’ Early clinical interventions are
essential in areas such as counseling and treatment for girls
and boys who are victims of sexual abuse and violence;
contraceptive advice and services; condom distribution to
those who are sexually active; safe abortion and pregnancy
and delivery care for young pregnant girls, married or
unmarried; and confidential counseling, testing, and
treatment of STIs/HIV. Young girls entering arranged
marriages have special sexual and reproductive health
needs, including premarital STI/HIV testing of their pro-
spective husbands to avoid early and unknowing exposure
to HIV (WHO 2006).
International organizations concerned with young peo-
ple’s sexual and reproductive health and rights have long
123
AIDS Behav (2009) 13:100–109
been advocating for school- and community-based ado-
lescent-friendly sites and services (Dehne and Riedner
2005; WHO 2003, 2004). Despite United Nations agree-
ments that adolescents have a right to receive confidential,
non-judgmental and non-discriminatory services that
respect their privacy, health systems typically fall far short
of providing them. The service gap is due to shortages of
resources or appropriate facilities; lack of specialized
provider training; the reluctance of providers to serve
young male and female clients (especially without parental
consent) or those who are unmarried; and/or legal or
administrative restrictions on their doing so (Cook and
Dickens 2000; Dehne and Riedner 2005; Eggleston et al.
1999; Ringheim 2007). As is the case for sexuality edu-
cation, advocacy efforts can endorse the provision of
comprehensive services to younger as well as older ado-
lescents as both a necessary, pragmatic public health
measure and as a human right.
Filling the Sexual Rights Gap
Young adolescents have the right to remain HIV-negative;
to be free of all unwanted sexual acts and relationships; and
to learn how to make voluntary, informed and safe sexual
choices. Policies and programs are needed to reduce sexual
harassment, violence, and abuse of children and of young
female and male adolescents within families, schools and
communities (Jejeebhoy et al. 2005; Mgalla et al. 1998;
Mirsky 2003) and to eliminate the forced marriage of
young girls (International Center for Research on Women
2005; International Planned Parenthood Federation et al.
2006). Adolescents and adults who engage in any form of
sexual violence or abuse require counseling and appropri-
ate legal and social deterrents, as do adult males who have
sex with underage girls or boys. HIV prevention efforts
must challenge ideologies and practices of male sexual
entitlement while promoting the empowerment of girls to
control their bodies and their lives.
Discussion
Boys and girls ages 10–14 constitute a key target group for
the investment of global and national AIDS prevention
resources. By choice, persuasion or coercion, a substantial
minority of young adolescents in many countries has
unprotected vaginal, oral or anal sex with peers or older
partners before they turn 15. Research on this under-studied
age group is urgently needed to provide the evidence base
for instituting effective HIV prevention programs and
policies early in the life course.
In their recommendations for monitoring sexual
behavior and HIV risks in general populations, Cleland
AIDS Behav (2009) 13:100–109
et al. (2004:ii3) advise against lowering the 15–24 age
boundaries to include 10–14-year-olds on two grounds:
first, that young adolescents’ reports of their sexual
behavior are particularly unreliable; second, that HIV
prevalence in this age group is typically very low. These
grounds could also be used to justify monitoring young
adolescents, however. The unreliability factor derives from
gender- and culture-specific social pressures and/or inter-
nalized norms that contribute to boys’ and girls’ tendencies
to embellish, conceal, or otherwise misreport certain sexual
experiences, and from their sometimes limited under-
standing of the questions asked. Yet, the analysis of such
tendencies is itself highly relevant to HIV prevention
efforts. Similarly, the low HIV prevalence factor does not
deny that many boys and girls aged 14 or younger have
already initiated sexual practices that put them and/or their
partners at substantial risk, now or in the future, and that
some will already be infected. Others will have already
acquired STIs, such as the one-third of sexually experi-
enced primary-school girls who reported having had
symptoms in the Tanzanian study noted earlier, and are
prime candidates for early HIV infections. Routine epide-
miological monitoring of STIs/HIV among young
adolescents—at least among 12–14-year-olds—as well as
behavioral monitoring of their knowledge, attitudes, pen-
etrative and non-penetrative sexual practices, partnerships,
protective behaviors, and positive and negative sexual
experiences would form a useful basis for the design of
initiatives to reverse the rising rates of HIV infection
among 15–24-year-olds that are so commonly reported.
Acknowledgement Research for this paper was supported by the
International Women’s Health Coalition, New York.
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