Reproductive Health Awareness Through The Life Cycle - Birth To Adolescence

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Chapter 8 RHA through the Life Cycle: Birth through Adolescence
We cannot waste our precious children. Not another one, not another day. It is long past time for us to act on their behalf.
NELSON MANDELA AND GRAA MACHEL
Table of Contents Chapter 8

Reproductive Health Awareness: A Wellness, Self-Care Approach RHA through the Life Cycle: Birth through Adolescence
Chapter 8 RHA through the Life Cycle: Birth through Adolescence Introducing Chapter Eight ........................................................................................................8-5 Training Schedule for the Sample RHA Training..............................................................8-13 Objectives...........................................................................................................................8-14 Sample Lesson Plan for Session 8......................................................................................8-15 Important Terms .................................................................................................................8-16 Activities and Handouts for the Sample Lesson Plan ..........................................................8-19 What Did I Learn When I Was Young? .............................................................................8-20 RHA Themes for Youth .....................................................................................................8-27 HomeworkTalking with Young People..........................................................................8-31 Alternate Activities and Handouts .........................................................................................8-34 RHA, Gender, and Self-Esteem .........................................................................................8-35 Puberty................................................................................................................................8-42 Effective Communication in Response to Pressure ...........................................................8-51 Body Image, Sexuality, and the Media...............................................................................8-56 Adolescent Panel ................................................................................................................8-60 Resources ...............................................................................................................................8-62
Related Activities in Other Chapters Color My World Purple .....................................................................................................2-26 Boys and Girls at Play ........................................................................................................2-28 Menstrual Cycle Flash Cards..............................................................................................3-42 Reproductive System Silhouettes .......................................................................................3-68 STI Handshake ...................................................................................................................4-51 HIV/AIDS: What is True? What is False? .........................................................................4-60 Red Light, Green Light, Identification of Risk...................................................................5-17 The Three Circles: Personal Sexuality Standards ..............................................................5-20 8-2
Reproductive Health Awareness
Reproductive Organ Talk ...................................................................................................5-35 Assertive Communication ..................................................................................................6-40 Basic Facts about Family Planning Methods ...................................................................10-41
RHA through the Life Cycle: Birth through Adolescence
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Key Questions What do young children and adolescents need to

know about reproductive health awareness?
What attitudes and skills should they develop in

order to follow good reproductive health practices from an early age?
How can people help children and adolescents

develop these skills?
ntroducing Chapter Eight
Reproductive Health Awareness (RHA) is important throughout the life spanfrom infancy to old age. There are two chapters on RHA through the life span in the manual. This chapter focuses on RHA issues and themes to consider when working with young people, from birth through adolescence. The next chapter focuses on RHA concepts and approaches that are more relevant to fertile adults and the aging population.
From Birth to Adolescence

From the moment we are born we begin to express our own health needscrying when we are hungry or uncomfortable and sleeping when tired. Soon we begin to make eye contact and can smile or make cooing sounds when interacting with a caring adult. As toddlers we already recognize differences between boys and girls and begin learning about the gender roles prevalent in our family and community. As very young children we watch and learn from parents and other family members as they teach us basic self-care skills like hand washing, teeth brushing, and wearing warm clothes in cold weather.
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From birth to adolescence a young person goes from being totally dependent on his or her parents to developing increasing autonomy regarding decision making and actions that can greatly affect his or her present and future reproductive health. It is important to provide children and adolescents with needed information before they experience various aspects of sexuality (Irvin, 2000). The World Health Organization has defined sexual health as (WHO, 1975) the integration of the physical, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching, and that enhance personality, communication, and love To develop and maintain good sexual and reproductive health, young people need to learn about human development, relationships, values, sexual behavior, and healthy practices. They also need to recognize gender and power dynamics, as well as the social and cultural influences that may affect their sexual expression. Both boys and girls need to be included in efforts to increase reproductive health awareness and self-care practices.
The RHA Approach for Young People

The following are key RHA questions that children and adolescents may reflect on. These questions point to important RHA concepts and skills that young people need to develop.
Body Awareness and Self-Care

How does my body work? How do I take good care of my body, including my reproductive health? How do people of the other sex take good care of their reproductive health? What self-care practices should I follow? What might I observe about my body now, and in the next few years? What physical changes are normal and healthy? What changes might signal a problem, and the need to tell a caring adult or seek services?
Gender
8-6 How are girls and boys different? How are they the same? How do I see my role as a girl or boy in our community? Based on gender, how are boys and girls treated differently? In what ways does different treatment benefit boys? Girls? In what ways does different treatment limit or harm girls? Boys? What can we do so that both girls and boys can live healthier lives?
Sexuality
What makes me feel good and gives me pleasure? What are some of the joys of sexuality? In what ways is it okay for others to touch me (When? Where? How? Who is allowed to touch me?) What type of touching is not okay, for my particular age? How should I respond if someone touches me (or tries to) in a way I am uncomfortable with? How old should I be before entering a committed relationship? When should a person start having sexual relations? How does a sexually active person protect himself or herself from pregnancy and infections? Are there traditions or practices in our community that are harmful to my sexual development and overall reproductive health? How do I avoid harmful practices?
Interpersonal Communication
How do I communicate my health needs, desires, and concerns to others? How can I advocate for my own health? For the health of others? Do I pressure others to follow unhealthy behaviors? What can I do to resist pressure from others to follow unhealthy behaviors? How do I avoid unwanted sexual relations? If I become sexually active, how do I avoid practices that put me at risk of getting pregnant (or getting a girl pregnant?) How do I avoid getting an infection that can be transmitted during sex? How would I begin to talk about whether to have sexual relations with someone? How would I communicate about preventing pregnancy and sexually transmitted infections? If I am concerned about my health, or afraid in any way, whom can I talk with? Where can I go for help?
In thinking about these and other RHA questions, young people need to develop the knowledge, attitudes, and skills necessary to protect their reproductive health. They need to be able to advocate for their own health, as well as respect and support the health needs of others. Many of the topics presented in the other chapters of this manual, including gender awareness, fertility awareness, STI prevention, family planning, safe motherhood, assertive communication and negotiation, sexuality, etc., can be applied to adolescents and children who will soon become
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adolescents. See the previous chapters in the manual and the list of resources at the end of each chapter for more information on these topics. The key is to present educational messages to young people in a way that is developmentally appropriate, culturally sensitive, and shows awareness of the moral values of the individual and his or her family. Programs and organizations use different age ranges when speaking about the needs of children of different ages. For the purpose of this manual, however, we have grouped young people in the following ways: 1) infants to toddlers (0 to 3 years); 2) young children (4 to 9 years); and 3) adolescents to young adults (10 to 24 years). The terms youth, young adult, young people, and adolescents have been used interchangeably. When providing education and counseling to young people, providers will often find a wide range of differences among children who are more or less the same age. With this in mind, providers should select the approach, the content, and level of detail that is developmentally appropriate for a particular child or adolescent, considering the behaviors and experiences this person has had so far, and not just her or his chronological age
Parents as Sexuality Educators

Sexuality education begins in the home where parents and caregivers are the primary sexuality educators of their children. Whether their opinions are spoken or unspoken, some aspect of a parents perceptions and beliefs about sexuality are communicated to their children in the home. Strong family bonds can also benefit young adults faced with decisions about whether to begin sexual activity at a young age. In a recent study in Peru, adolescent boys and girls who felt important to, or connected with their families, were less likely to have sex. (Magnani et al., 1999) Although parents have the opportunity to provide information and guidance regarding sexual and reproductive health within the context of their own values and beliefs, many feel unprepared or uncomfortable with how and when to provide what information to their children.
Parents may feel unprepared to talk with their children about sexual and reproductive health 8-8
Often parents can benefit greatly from parenting skills training in this area. Some parenting tips for talking with their children on this subject are
Begin early and provide information that is developmentally appropriate Find teachable moments (an every day experience, comment or question can that
leads you into a relevant discussion about topics pertaining to sexual and reproductive health)
Know that it is OK to feel uncomfortable Be askable Listen carefully, hear the questions beneath the actual question that is asked Share your feelings, beliefs, and values in addition to information Include the joys of sexuality Tell your child you care about their happiness and wellbeing Be aware of what is taught in your community by teachers, religious instructors, the
media, etc. (Sexuality Information and Education Council of the United States 2000) Providers can offer parenting classes to help parents develop the skills they need to better prepare their children to adopt healthy practices.
Reproductive Health Education, Counseling, and Services for Youth

Parents and community members may fear that education about reproductive and sexual health might lead youth to become sexually active at an earlier age. However, research in this area has shown that this is not the case. In fact, effective programs have provided information and skillbuilding opportunities that have helped young people resist pressures to become sexually active at a young age. Programs have also succeeded in increasing the likelihood that those who do become sexually active protect themselves against STIs and pregnancy. Many parents, educators, administrators and others are rightfully concerned about how reproductive health information is presented to children. Building community and parental support is important to the success of reproductive health programs for youth. The following framework for programming for adolescent health is from a joint WHO/UNFPA/UNICEF study group.
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Framework for Programming for Adolescent Health Keys to Success Major Interventions Settings
Put youth at the center Address multiple health

problems
Create safe and supportive

environments
Home School Health center Work place Street Community organizations Residential center Media/entertainment Political and legislative
systems
Provide information Build Skills Provide counseling Improve health services
Build and link existing

interventions in various settings
Combine interventions Respect cultural diversity Strengthen program

management
Encourage positive adult

attitudes and behaviors
Source: Adapted from Framework for country programming for adolescent health in Action for adolescent health: Towards a common agenda: Recommendations from a joint WHO/UNFPA/UNICEF study group by WHO/UNFPA/UNICEF. 1997. Geneva: Author.
Learning about reproductive and sexual health can be a lifelong process that ideally builds on the foundation and training young people receive in their family environment. In addition to parents, trained service providers can be very instrumental in helping young people develop the skills they need to foster good reproductive health practices throughout their lives.
Reproductive Health Curricula for Youth

Many international programs incorporate a life-skills approach to reproductive and sexual health education for youth. This approach is very interactive and experiential. It helps young people develop skills beyond reproductive health to deal effectively with the demands and challenges of everyday life. The life-skills approach has five foundational skill areas. These include: 1) decision-making and problem solving; 2) creative thinking and critical thinking; 3) communication and interpersonal skills; 4) self-awareness and empathy; and 5) coping with emotions and coping with stress. (Moya, n.d.) Research to identify successful adolescent pregnancy prevention and STI reduction curricula in the United States shows that successful programs have all ten of the following characteristics (Kirby, 1997)
Focus on reducing a small number of sexual behaviors Are based on theoretical approaches to modifying social behavior
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Give a clear message Provide basic information Address social pressures on sexual behavior Model and practice communication, negotiation, and refusal skills Employ a variety of teaching methods Incorporate goals, teaching methods, and materials appropriate to the students Last a sufficient length of time Provide training for teachers and peer educators
An effective reproductive and sexual health curriculum includes a variety of educational activities that increase knowledge about sexuality, address emotional and attitudinal aspects of sexuality, and develop specific behaviors and skills needed to negotiate sexual health and pleasure in a way that is safe and responsible.
In This Chapter
This chapter does not provide a comprehensive curriculum for training providers about youth from birth to adolescents. Instead, it suggests different ways to address this topic with a RHA approach and provides a few key examples and themes to think about when designing your own training. The activities in the sample lesson plan address
Personal reflections and experiences during youth Recommendations for educating youth about sexual and reproductive health RHA topics for youth in the areas of body awareness and self-care, gender, sexuality
and interpersonal communication
Discussing self-care practices with young people

The activities in this chapter were designed for training providers. However, the activities can be easily adapted and then used directly with young people. For ideas on how to modify these activities for a pre-adolescent or adolescent audience, see the tools for trainers at the end of each activity. In addition, see the resource list for more information on comprehensive sexual and reproductive health curricula and recommended approaches for youth.
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Many of the activities can be adapted and used directly with young people
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Reproductive Health Awareness: A Wellness, Self-Care Approach Training Schedule for the Sample RHA Training
Schedule Day One (Chapter 1) Introduction Pretest Reproductive Health Awareness: An Overview Session (Chapter 2) Gender: Implications for Health Session (Chapter 3) Body Awareness and Self-Care: Focus on Fertility Session (Chapter 4) Body Awareness and Self-Care Practices Session 4 3 BREAK (Chapter 8) RHA through the Life Cycle: Birth through Adolescence 8 Assign Any Homework (Chapter 12) RHA and the Community: A Focus on Safe Motherhood 12 (Chapter 14) Evaluation Posttest Presentation of Certificates 16 2 LUNCH (Chapter 7) Interpersonal Communication: Skills for Providers 7 (Chapter 11) Creating Change: Achieving Healthy Behaviors 11 (Chapter 13) Implementing the RHA Approach, continued 15 1* BREAK (Chapter 6) Interpersonal Communication: Talking with My Partner 6 (Chapter 10) Family Planning and the RHA Approach 10 (Chapter 13) Implementing the RHA Approach, continued 14 Day Two (Chapter 5) Sexuality: Healthy Expression Throughout Life Day Three (Chapter 9) RHA Through the Life Cycle: Fertile and Aging Adults Day Four (Chapter 13) Implementing the RHA Approach Review Any Homework Assignments
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* Bold numbers refer to the number of each 90-minute session for this sample training.
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bjectives
By the end of this session, participants will be able to
Identify reproductive health messages they received and experiences they had during
their own childhood
List and describe RHA issues and topics important to children of all ages, especially
in the areas of body awareness and self-care, gender, sexuality, and interpersonal communication
Discuss a self-care practice with a child or adolescent
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RHA through the Life Cycle: Birth to Adolescence Sample Lesson Plan for Session 8
Time
35 to 45 minutes
Sample Lesson Plan
Content
What Did I Learn When I Was Young? Personal reflections Recommendations for educating youth
Methodology
Trainer reads a series of questions and participants document personal experiences. They discuss conclusions, lessons learned, and recommendations for educating youth.
Materials
- List of discussion questions - Handout: Reflections on Ages 0 to 24 - Large pieces of paper and marking pens
Evaluation
On a handout participants identify and document reproductive health messages they did and did not receive during their youth. They list recommendations for educating young people.
45 to 60 minutes
RHA Themes for Youth Body awareness and self-care Gender Sexuality Interpersonal communication
- Large pieces of Participants form small paper, tape, and groups, one for each marking pens RHA pillar. They note RHA themes appropriate - Sample RHA for youth and present themes or topics this to the large group. A comprehensive list of RHA themes or topics is documented. For homework, participants discuss a self-care practice with a child or adolescent - Handouts Remembering Self-Care Practices
Participants identify and describe RHA themes or topics appropriate for youth in their area.
10 minutes
Homework Talking with Young People Discussing selfcare practices
Participants complete the homework assignment and describe their teaching experience the following day.
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Important Terms
Abstinence
Some people define abstinence as refraining from vaginal or anal intercourse. Others have a more broad definition that may range from not having any genital contact with another person to avoiding all sexual behavior all together, including masturbation. Primary abstinence refers to someone who has not had a sexual experience with another person. Secondary abstinence refers to a person who is sexually experienced but chooses not to engage in sexual activities during some time of their lives (Hatcher, et al. 1998). The time during which young people pass from being a child to being an adult. In this manual we use the terms youth, young adult, young people and adolescents interchangeably when referring to individuals who are 10 to 24 years of age. Different programs and institutions consider different age ranges when referring to adolescents. When comparing early, middle and late adolescence, young people experience a pattern of physical and psychosocial developmental changes during each of these three different phases. Young people may go through these changes at different rates.
Adolescence
Assertive Communication Attitudes about Health Body Image Counselor
Expressing yourself with confidence and conviction, even when challenged or under pressure to change your mind. Feelings or emotions a person has about health or the behaviors related to health. A persons perceptions or feelings about her or his own body. Someone who helps another person work through a problem, often emotional in nature, by listening empathetically and assisting the person to find solutions (Irvin, 2000). A person who helps to develop the knowledge, attitudes, skills, and character of another person through teaching (Irvin, 2000). A coming-of-age ritual in some countries that involves the cutting and removal of a girls external genital organs (e.g., clitoris) or the partial or total removal of external genital structures (labia minora, labia majora), sometimes including stitching and narrowing of the vaginal opening. Also called female circumcision or female genital mutilation (EngenderHealth, 2002). The reproductive organs. A state of mind in which a person trusts or has confidence in a health concept or behavior.
Educator
Female Genital Cutting (FCG)
Genitals Health Belief 8-16
A process by which people exchange information and emotions. We communicate in many different ways including verbal language, body language, and written words. From birth to adolescence we develop many of our communication styles. The interactive process of teaching and learning, which focuses on acquiring knowledge, attitudes, and skills that support behaviors that enable young people to take greater responsibility for their own lives by making healthy life choices, gaining greater resistance to negative pressures, and for minimizing harmful behaviors (UNICEF, 2001). The surgical removal of the retractable skin (foreskin) covering the glans penis. A girls first menstrual period. Includes radio, internet, television, newspapers, magazines, billboards, posters, pamphlets, and other forms of mass communication to the public. Includes eating and drinking healthy foods on a regular basis. To have proper nutrition a person needs to have sufficient quantities of food, and the right types of food for optimal growth and development. Friends or acquaintances of approximately the same age. Programs that feature people educating or promoting services among their peers (people of the same age, economic background and educational level). Youth peer educators can provide educational activities, act as role models, participate in all aspects of the project cycle (i.e., planning, design, implementation, monitoring and evaluation), provide referrals to health services and carry out social marketing activities for reproductive health and family planning commodities. Emotional or mental force from people belonging to the same social group (i.e., age, grade or status) to act or behave in a manner similar to themselves. Peer pressure has a great influence on adolescent behavior and reflects young peoples desire to fit in and be accepted by others. (Reproductive Health Outlook, 1997-2003) A time when the bodies of boys and girls go through many changes. During puberty a young girl becomes physically able to become pregnant and a young boy becomes physically able to father a child. In addition to changes in the reproductive system, boys and girls also experience changes in the way they think, feel and relate to others. Puberty marks the passage from childhood to adulthood.
Life Skills Approach
Male Circumcision
Menarche Media
Nutrition
Peers Peer Education
Peer Pressure
Puberty
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Self-Esteem
The way people feel about themselves. People with strong self-esteem feel satisfaction, even when theyre not doing something to make themselves feel good. People with strong self-esteem frequently feel the following feelings in many different circumstances: 1) sense of connection; 2) sense of uniqueness; 3) sense of power; and 4) sense of models for making sense of the world. (Bean, 1992) When a sexual activity is used to harm another person physically or psychologically. Sexual abuse occurs when one person does not consent to sexual activity. Any sexual relationship with a child (consenting or not) is sexual abuse. A lifelong process that begins at birth. It covers a range of topics including human development, relationships, values, and sexual behavior in an effort to provide young people with the knowledge and skills they need to make informed and responsible decisions about their health and lives. (SIECUS, 2001) This is when semen leaves the boys body while he is sleeping.
Sexual Abuse
Sexuality Education
Wet Dream or Nocturnal Emission Values
Principles or qualities that are intrinsically valuable and desirable. People may have different values. Our families, the culture we are raised in, our personal experiences, age, and other influences help to shape our values.
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Activities and Handouts for the Sample Lesson Plan
What Did I Learn When I Was Young? RHA Themes for Youth HomeworkTalking with Young People
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A
Time
ctivity What Did I Learn When I Was Young?

By the end of the activity, participants will be able to
Objective
Identify reproductive health messages they received and experiences

they had during their childhood
Describe how these messages and experiences may have influenced

their plans for the future
List recommendations for educating young people about reproductive

health 35 to 45 minutes Before conducting this activity review the list of questions in tools for trainers How Old Were You When. You may use these questions during the activity or create your own list of questions, tailored to your group. Copy the handout Reflections on Ages 0 to 24Birth through Young Adulthood. In addition, you may want to distribute the Important Terms on page 8-16. You will also need large pieces of paper and colorful marking pens. 1. Invite participants to think about their lives from birth to adolescence. Distribute the handout Reflections on Ages 0 to 24Birth through Young Adulthood. 2. Tell participants you will ask them a series of questions. (A sample list of questions is provided in the tools for trainers for this activity.) After each question, they are to circle the age on the handout when they experienced the event in question, and then draw an arrow pointing to the number and write a brief answer to the question. For example, if you ask, How old were you when you first observed a difference between boys and girls? Some participants would circle age two on the handout, draw an arrow to the number 2, and then write a personal note that briefly answers this question, linking the arrow with their brief note. (See the example on the handout.) Participants may place their answers wherever they will fit on the page. Tell participants to keep a separate list of any items or topics mentioned that they never experienced between ages 0 and 24. They can note these items in the space at the bottom of the handout.
Preparation
Directions
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3. Let participants know that this is a personal reflection. They will not need to share their specific answers with the group. Instead, they are to pay attention to themes that emerge which shed light on the RHA educational needs of youth. They should share only the insights or experiences they feel comfortable sharing. 4. Read the list of questions, pausing after each question so participants can record their answers on the handout. 5. Once all the questions have been asked and answered, ask participants to review their responses and think about the reproductive health messages they learned, their experiences, and the choices they made during their youth. You may ask questions like the following. How did your experience (what you learned and what you didnt learn) affect you? Your reproductive health? What reproductive health messages did you receive when you were a child? An adolescent? What additional information, attitudes, skills, and services would you have benefited from in your early childhood? Your adolescent years? Based on your experience, what recommendations do you have for educating children and adolescents about reproductive health? Record the main points on large pieces of paper and tape them to the wall.
Wrap-up
Close with points like the following.
Often parents, other caregivers, and service providers feel

uncomfortable and unprepared to talk with children about reproductive health issues.
Children and adolescents need age-appropriate information about

sexual and reproductive health as they grow up. They also need to know where to get additional information and services.
Providers can conduct parenting classes to help parents and other

caregivers become more effective sexuality educators of their children.
Providers who work directly with young people can share important
information, foster supportive values and attitudes, and help young people develop the skills they need to live healthier lives.
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Evaluation
Participants will document the reproductive health messages they received and personal experiences they had during their childhood on the handout Reflections on Ages 0 to 24. In the large group they will describe how these experiences may have influenced their plans for the future and list recommendations for educating young people about reproductive health. Participant ability to do this will be assessed by the trainer during the classroom discussion.
Note to Trainers
A modification of this activity can be used with adolescents or children who will soon be adolescents. Rather than reflect on the past, the young people are to think about their future and the plans they have for school, family and relationships, work, and fun. To do this, first ask the young people to draw a straight line and number it from the age they are today to age 90. Each number on the line represents a birthday. Next, invite the young people to think about the major things they would like to accomplish in their lives, and when they would like to accomplish them. Tell them to note each future plan, just above the year they would like the event to take place. For example: {graduate from school}{marry} . . . . . . . . . . . . . . . . . . . . . . . . \/ . . . . . . . . . \/ . . . . . . . age 11 12 13 14 15 16 17 18 19 20 21 22 23 {1st child}{2nd child} etc. . . . . \/ . . . . . \/ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . age 24 25 26 27 28 29 30 31 32 33 34 35 In small groups ask the adolescents to share their goals and life plans and describe the steps they need to take to reach their goals. Then, tell participants to imagine that they just had a baby, or contracted a STI, including HIV/AIDS. Ask the small group to discuss how this would effect their lives now, and in the future. Invite a representative of each small group to present a summary of their discussion to the entire class. Then, discuss what young people can do in order to accomplish their plans for the future.
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Helping young people develop the skills they need to achieve their future plans
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How Old Were You When?

Sample Questions
Tools for Trainers
To the Trainer: You may wish to select just some of these questions, since there are many sample questions on this list. How old were you when 1. You first observed a difference between boys and girls? 2. You noticed your genitals? 3. You learned how to say no to something you did not want? 4. You first asked someone to hold you? 5. A grown-up told you that others should not see or touch your genital area? 6. You learned where babies came from? 7. You learned that boys were treated differently from girls? 8. You knew that animals mated and had offspring? 9. You learned about sexual intercourse? 10. You learned that girls menstruate? 11. You learned that boys have wet dreams? 12. You learned from a grown-up that young people should not smoke or take drugs? 13. You learned from a grown up about the changes of puberty? 14. You first experienced menstruation or a nocturnal emission? 15. You learned what it means to be homosexual? 16. You learned how old a person should be when they got married? 17. You learned whether it was okay to have a sexual relationship outside of marriage?
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How Old Were You When? continued 18. You learned from a grown-up how to avoid unwanted pregnancy? 19. You learned from a grown-up how to avoid getting a sexually transmitted infection? 20. You were circumcised? 21. You explored your genitals for pleasure? 22. You recognized sexual messages from the media? 23. You were first kissed romantically, or first kissed someone romantically? 24. Stopped going to school? 25. You got married? 26. You first had sexual intercourse? 27. You first got pregnant? (Or got someone pregnant?) 28. You first got a sexually transmitted disease? 29. You first went to a provider for reproductive health services? 30. You learned whether older people should stop having sexual relations?
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Reflections on Ages 0 to 24
Birth through Young Adulthood
Handout
1 (2) 3 8-26
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
I never:
A
Time
ctivity RHA Themes for Youth

By the end of this activity, participants will be able to
Objectives
List the four pillars of RHA Identify and describe RHA themes or topics appropriate for children
and adolescents in the areas of body awareness and self-care, gender, sexuality, and interpersonal communication 45 to 60 minutes For this activity you will need large pieces of paper, tape and colorful marking pens. You may also wish to review the tools for trainers, RHA Themes for Youth. This activity builds on the previous activity, What Did I Learn When I Was Young? Participants and trainers should review the conclusions of the previous activity and have easy access to the handout Reflections on Ages 0 through 24, which was completed during the previous activity.
Preparation
Directions
1. Ask participants to list the four pillars of RHA. Review the importance of each pillar. (If needed see chapter 1 for a review of the four pillars.) 2. Divide participants into four groups. Each group will concentrate on a different RHA pillar Body awareness and self-care Gender Sexuality Interpersonal communication
3. Give each group a large piece of paper and colorful marking pens. Ask the group to discuss and list youth-appropriate RHA themes or topics relevant to their particular pillar. (The list may be very general, like the example in tools for trainers, or quite lengthy with many sub-topics included.) 4. Invite a representative from each group to present their conclusions. After the presentation, ask the person to tape his or her large piece of paper with the groups list to the wall for all to see.
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5. Then, elicit from the large group any additional RHA themes for youth that are appropriate to this specific pillar and add them to list. 6. Invite participants to share how they might incorporate these RHA themes into the work they will do with young children or adolescents.
Wrap-up
At the end of the activity, conclude with the following points.
The RHA approach provides a framework for education, training and

service delivery. It reminds us that issues regarding reproductive and sexual health are important and relevant throughout the life span, from birth to very old age.
There are many ways to provide education with a RHA approach.

Much will depend on the age and experience of the individual, the setting, the time available, and the background and training of the provider.
Education about reproductive and sexual health does not lead youth to
become sexually active at an earlier age.
Instead, effective programs can provide information and skill building

opportunities for how to postpone sexual involvement, and help young people resist pressures to become sexually active at a young age.
Effective programs can also help sexually active youth reduce risky
behaviors and protect themselves more frequently against STIs and unintended pregnancy.
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Evaluation
Select participants will correctly list the four RHA pillars during the large group discussion. Or, all participants will write the names of the four pillars on a piece of paper. During each small group discussion and presentation of a pillar, RHA themes appropriate for youth will be identified and described. Participant ability to do this will be assessed by the trainer during the classroom discussion.
Note to Trainers
When conducting this activity you may wish to focus on a particular age range, for example, young adolescents ages 10 through 14. Or, you may ask participants to place the letter C next to themes most relevant for young children and an A next to themes more appropriate for adolescents. The themes may be very general, like those listed in the tools for trainers, or very specific and detailed. When working with a group of trainers or educators you may also want to analyze the lists and determine the knowledge, attitudes, and skills that young people should acquire with regard to each topic or theme on the list. After the class is over you may wish to create a handout similar to the tools for trainers that accompanies this activity, RHA Themes for Youth. However, the handout you create should also reflect the conclusions of each small group.
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Sample RHA Themes for Youth

Body Awareness and Self-Care Gender
Tools for Trainers
Current gender roles (benefits and limitations) Body image and self-esteem Reproductive and sexual health messages girls Normal growth and development (including and boys receive changes during puberty) Dealing with social and environmental pressures Fertility awareness or realities Prevention practices (nutrition, hygiene, exercise, Dealing with power dynamics within the abstinence, family planning, safer sex practices, relationship avoiding unsafe abortion, avoiding drugs, alcohol and tobacco, etc.) Building empathy Self-observation (checking breast or testicular Rights, responsibilities, respect, and caring self-exam; checking skin changes, rashes, Values and decision-making infections; checking other body changes, Life skills and reproductive life plan monitoring emotions and feelings, etc.) Gender equity opportunities (future work, roles Early detection (noticing physical changes as in marriage, family relationships, health well as stress, depression, thoughts of harming care, etc.) oneself, etc.) Visions for the future Self-referral (telling a parent or caring adult, seeking services)
Sexuality
Sexuality as a positive, joyful expression of oneself Range of acceptable sexual behavior Knowing what is right for you, at what age, under which circumstances Acceptance of own standards, knowing that what is right for you may not match the standards of peers Acceptance of the personal standards of others, not forcing or coercing someone to engage in sexual practices they are not comfortable with Benefits of delaying the age of marriage and the birth of your first child Risks and consequences of unintended pregnancy and STIs including HIV/AIDS Common sexual problems Harmful traditional practices (FGC, use of herbs to dry the vagina, etc.) Sexual abuse and family violence
Important relationships (parents, family, friends, romantic interest, providers, others) Dating Communicating health needs, desires, and concerns to others (body language, listening skills, assertive communication, negotiation, refusal skills, etc.) Advocating healthy practices Coping with pressures to follow unhealthy behaviors (avoiding risks of STIs, unwanted sex, unintended pregnancy, drugs, etc.) Influences of media and the culture on sexual behavior and reproductive health
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A
Time
ctivity HomeworkTalking with Young People

By completing the homework assignment, participants will be able to
Objective
Discuss a self-care practice with a child or adolescent

You will need about 10 minutes to describe the homework assignment. Remember to schedule an additional 30 minutes the following day to discuss the homework experience and share lessons learned. You may wish to make copies of the handout Remembering Self-Care Practices. 1. Invite participants to think about a self-care practice they could discuss with a young child or adolescent. Brainstorm possible ideas like For a young child: hand washing, tooth brushing, caution with strangers, care when crossing a street For a young adolescent: good hygiene, self-care related to changes of puberty, avoiding risky behaviors, refusal skills, communicating values and beliefs about sexual intimacy For an older adolescent: sexual decision-making, responding to unwanted, sexual advances, pregnancy prevention, STI protection, etc.
Preparation Directions
2. Before talking with the child or adolescent, ask participants to think about how they will bring up the topic, what they will say, what values and beliefs they want to convey, whether there are skills they can practice together with the young person, and any other important points to consider. 3. Ask participants to also consider how to evaluate learning. One way to do this with young children is to ask them to draw a picture of what they learned. See the handout for this activity. 4. On the following day ask participants to share their experience with the class and discuss any lessons learned. Discuss options for follow-up discussions with youth on the topics presented.
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Wrap-up
After explaining the homework, close with points like the following.
When providing sexual and reproductive health education to young

people it is important to provide information that is developmentally appropriate at a time and in a way that is meaningful to the young person. Often a topic is addressed in different ways at different ages.
By paying close attention to young people and listening carefully, we

can often find teachable moments.
A song, event, television program, or question a young person asks

may trigger these moments. Teachable moments can provide an opening into meaningful conversations and powerful educational experiences about reproductive health and self-care.
Evaluation
Based on each participants report of their experience, the trainer assesses whether all participants completed the assignment.
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Remembering Self-Care Practices
Handout
One way to help young children think about and remember a self-care practice is to ask them to draw picture of what they learned. Below is a drawing by a 6-year-old girl, Devon Yee.
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Alternate Activities and Handouts
RHA, Gender, and Self-Esteem Puberty Effective Communication in Response to Pressure Body Image, Sexuality, and the Media Adolescent Panel
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ctivity RHA, Gender, and Self-Esteem

Objective
Define self-esteem Describe how gender stereotypes can influence a persons self-esteem List characteristics of young people with strong self-esteem Describe how parents and providers can help children and young
adults develop and strengthen their self-esteem
Preparation
Prior to conducting this activity review information on self-esteem, including the tools for trainers Reproductive Health Awareness and Self-Esteem for Children. Reflect on the role of self-esteem and self-care practices for children in the participants community. You will need large pieces of paper and colorful marking pens for this activity. You may also wish to copy the handout Self-esteem and Reproductive Health Awareness. 1. Invite participants to define self-esteem in their own words. Describe the four elements of self-esteem. See the tools for trainers for more information on the concept. Distribute the handout Self-esteem and Reproductive Health Awareness, if appropriate. 2. Invite participants to form small groups of four to five participants. Ask all participants to think about children or adolescents of a particular age range. Tell half of the small groups to focus on boys and the other half to focus on girls. 3. In the small group ask participants to consider the four elements of selfesteem and discuss the answers to the questions below. What influences might cause a child to have a low self-esteem? How might gender stereotypes influence a young persons self-esteem? What are the characteristics of a child or adolescent of this age who has strong self-esteem? What is this child like? How does he or she feel on a regular basis? What factors appear to enhance the childs self-esteem?
Directions
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How might a persons self-esteem be associated with his or her ability to adopt self-care practices?
4. Ask a representative of each group to present a summary of their discussion to the large group. Compare the gender perspective of the groups that discussed girls with the groups that discussed boys of the same age range. 5. Brainstorm ways that parents and providers can help children and young adults develop and strengthen their self-esteem. Record responses and conclusions on large pieces of paper.
Wrap-up
At the end of the activity, conclude with the following points.
Each person is unique and special, just the way he or she is. However,
some young people may not feel that way on a regular basis.
Having strong self-esteem may help some young people avoid some of
the pressures to engage in risky behaviors. (Magnani et al., 1999)
Parents and providers can be instrumental in helping young people

develop and strengthen their self-esteem.
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Evaluation
During the small group discussion and class presentation, participants define self-esteem, describe how gender stereotypes can influence a persons selfesteem, and list characteristics of young people with strong self-esteem. In the large group they list how parents and providers can help children and young adults develop and strengthen their self-esteem. Participant ability to do this will be assessed by the trainer during the classroom discussion.
Family members can create a home environment that helps young people develop a healthy self-esteem
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Reproductive Health Awareness and Self-Esteem for Children

Elements of Self-Esteem Sense of Connection:
Ability to relate effectively and comfortably to people, places, and things
Tools for Trainers
Characteristics of Children with Strong Self-Esteem

Have a sense of belonging to someone (family, friends, community, etc.) Feel comfortable with and connected to their own bodies. Trust their bodies will work well. Are able to have healthy relationships with parents, siblings, friends, teachers, and others. Communicate well with others.
Ways to Help Strengthen Self-Esteem in Children

Create a consistent environment of warmth, affection, good communication, and satisfying relationships. Help children overcome any deep emotional losses. Reach out when it is not expected (through speaking, touch, gestures, smiles, notes etc.) without requiring a response. Teach children to be aware of their bodies, including sensations of good health and illness. Model and teach children good communication skills. Help children see and understand what makes them unique and special. Teach children the wide range of normal changes as their bodies grow and develop. Provide children with a variety of opportunities to communicate and express themselves in many different ways. Do not shame or ridicule children for touching and exploring the body. This is normal at every age.
Sense of Uniqueness:
Respect for ones own special characteristics
Respect and appreciate themselves and their bodies as they are. Value their own special characteristics and differences. Are able to express themselves in their own unique way.
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Reproductive Health Awareness and Self-Esteem for Children, continued Elements of Self-Esteem Sense of Power:
Ability to have control over ones own life

Intend to do the things that keep their bodies healthy, despite pressures they may experience. Believe they can do what they set out to do, such as practice healthy behaviors. Feel others cannot make them do things that will harm their bodies. Are able to use the skills they have to do things well, like avoid health risks, monitor and observe their own bodies, detect a possible health problem and seek resources, if needed. Feel comfortable about acquiring new skills, including ways to maintain or improve health. Feel comfortable when they have a responsibility to fulfill such as not causing others to become ill or injured.

Provide an environment of physical and emotional safety. Encourage children to use what they know and do well. Affirm their successes. Teach children useful skills, like how to observe and care for their bodies and communicate effectively to protect their health. Provide opportunities for decisionmaking. Encourage children to make all of the decisions they are capable of making. Help children set limits regarding what they will not do to others and not let others do to them. Help children acquire better control over their feelings and physical bodies through movement, sports, exercise, dance, and other means.
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Reproductive Health Awareness and Self-Esteem for Children, continued Elements of Self-Esteem Sense of Models and Mentors:
Sense of order and purpose in ones life

Know people they feel are worthy of being emulated. Have consistent values and beliefs guiding and directing their actions. Feel a sense of purpose and direction. Are able to make sense of whats going on in their lives and of the circumstances in which they find themselves. Have a sense of order and process, enabling them to organize their environment to accomplish tasks.

Expose children to positive adult role models who are able to relate their experiences of success to children. Talk about and act consistently regarding values, beliefs, and standards. This includes issues regarding sexuality, reproduction, body awareness and self-care. Provide an orderly environment and have children participate through regular duties and responsibilities. Encourage children to solve problems and figure things out on their own as much as possible. Model, repeat, and acknowledge acceptable behaviors, norms, and standards.
Source: Adapted from Bean, 1992
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Self-Esteem and Reproductive Health Awareness
Handout
Self-esteem is confidence and satisfaction with oneself. Young people with strong selfesteem feel satisfaction even when they are not doing something to make themselves feel good. Self-esteem has to do with the way people generally feel about themselves. According to Bean (1992), people with strong self-esteem often have the following feelings in many different circumstances and with a great deal of intensity
Sense of connectionAbility to relate effectively and comfortably to people,

places, and things
Sense of uniquenessRespect for ones own special characteristics Sense of powerAbility to have control over ones own life Sense of modelsAbility to refer to human, philosophical and operational
models to help make sense of the world Gender stereotypes can have a negative influence on a persons self-esteem. For example, if the family or culture places a high value on strong, aggressive, and tough males, then a physically small and shy boy may develop a low regard for his own special and unique characteristics. If a highly intelligent girl is told that boys do not like smart girls she may decide not to study, or may leave school at an early age, to relate more comfortably to those around her. Children and young adults with strong self-esteem may be more empowered to advocate for their own reproductive health needs and to follow healthy practices. In a recent study in Peru (Magnani et al., 1999), youth of both sexes who felt important to or connected with their families were less likely to have sex. In the same study, high self-esteem was an indication of delayed sexual activity among girls, although for boys the effects of selfesteem were mixed. Parents and providers can learn techniques for working with young people in ways that support the development of strong self-esteem.
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A
Time
ctivity Puberty
Objective
Describe three physical changes boys experience during adolescence Describe three physical changes girls experience during adolescence Describe three other changes young people may experience during
early, middle, and late adolescence (e.g. changes in thinking abilities, emotions, relationships with others, etc.) One hour or more Review adolescent reproductive growth and development. See the tools for trainers following this activity and the resource list at the end of the chapter for more information. See chapter 3 for detailed information on male and female reproductive anatomy and physiology as well as fertility awareness information. If appropriate, make copies of the handouts on puberty and distribute them as references at the end of the activity. 1. Divide participants into three small groups and give each group a large piece of paper and colorful marking pens. Assign each group a different stage of adolescent developmentearly, middle, or late adolescence. 2. Invite participants to focus on the particular stage of adolescence assigned to them (early, middle or late). They may want to reflect on their own adolescence as well as the adolescent years of their children during this phase (if applicable). Then, in the small group ask them to discuss and record what they remember about their assigned stage of adolescent development in terms of Growth and physical changes Cognition (thinking abilities, awareness, judgment, concerns) Emotions (feelings) Relationships with others (peers, parents, siblings, teachers, opposite sex, etc.)
Preparation
Directions
3. Remind participants that they do not need to disclose any personal information they are uncomfortable talking about. They may speak in generalities, if they prefer. 8-42
4. Ask a representative of each small group to summarize their discussion for the large group. 5. Provide additional information about growth and development trends for early, middle and late adolescence to complement what is presented by the small groups. (See the tools for trainers following this activity description.) Correct any misinformation and summarize key points regarding the growth and development of adolescents. 6. Review the changes of puberty as described in the handouts for this activityPhysical Changes Girls May Notice During Puberty and Physical Changes Boys May Notice During Puberty.
Wrap-up
Close the activity with the following points.
During the passage from childhood to adulthood, young people

experience major changes in all levels of their lives.
Three important themes apparent during this transition include the

challenges that youth face in exploring and establishing their identity, independence, and intimacy.
Young people move through the changes or stages of adolescence

(early, middle, and late) at different rates. Although two young people may be the same age, one may exhibit signs of growth of early adolescence and the other may appear to be experiencing many of the characteristics of middle adolescence.
Rather than focus on the specific age of an adolescent, it is most

appropriate for providers to consider where that young person appears to be in terms of her or his behavior, physical development, cognitive abilities, emotional maturity, etc., and then plan appropriate counseling, services, and interventions, as indicated.
It is important that young people learn about the changes of puberty for
both boys and girls before they occur. This way they will know what to expect, understand what it means to them, and be better prepared to protect their reproductive health.
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Adolescents grow and change at different rates
Evaluation
During the small group discussion and class presentation participants list and describe some of the changes of puberty that occur during early, middle, and late adolescence. However, to better test participant knowledge regarding the main concepts presented during this activity, the trainer should make up a written or oral test for participants to complete after this activity. (See the tools for trainers for this activity for key points to be included in the test.)
Note to Trainers
Providers may wish to review the Tanner Stages of Adolescent Development (Iannelli, 2003). The Tanner model describes the usual progression of physical changes from preadolescence to adulthood by identifying and describing typical physical changes (e.g., changes in the penis, testes, and pubic hair for boys and changes in the breasts and pubic hair for girls) at five different stages of development. It is important to remember that there is much variation in the normal progression through these stages since development is influenced by the unique characteristics of the individual adolescent, his or her nationality and ethnicity, and other factors.
Source: Part of this activity was adapted from Monesterio, 1998
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Adolescent Reproductive Growth and Development

Puberty
Tools for Trainers
Puberty is a time when the bodies of boys and girls go through many changes. They become taller and bigger, their genitals develop and mature, and many grow body hair. During puberty a young girl becomes physically able to get pregnant and a young boy becomes physically able to father a child. Puberty usually begins around ages 10 to 12 and ends when the persons body is physically mature, around ages 16 to 18 or older. Typically, girls begin puberty about 2 years before boys. They also reach their full height about 2 years before boys. However, by the time puberty is complete, young men are often taller and weigh more than young women of the same racial and ethnic background.
Hormones
Substances in the body called hormones trigger the changes of puberty. As a girl enters puberty, the hormone estrogen influences many of the physical changes she will notice. For a boy testosterone influences many of the physical changes he will notice. Changes in these and other hormones cause physical changes in the body as well as emotional changes. During puberty adolescents may be happy one moment and then suddenly very sad or upset. They also become more aware of their bodies and sexual feelings increase.
Physical Changes in Girls

As a girl enters puberty, she may notice many physical changes. Her breasts start to grow and hair begins to grow on her genitals. Often girls grow taller and bigger quickly. This is called a growth spurt. During puberty a girls hips widen and hair grows under her armpits. There is also a change in sweat and odor. Some girls notice acne or pimples, especially on their faces or backs. Most girls have their first menstrual period about 1 to 2 years after beginning puberty. This signals the time when a girl can become pregnant. Although many girls have irregular menstrual cycles, they can still become pregnant if they have sex. A girl can become pregnant the first time she has sex.
Physical Changes in Boys

There are many physical changes boys may notice during puberty. Their shoulders and chest broaden. Boys usually have a growth spurt. The penis and scrotum grows. Hair begins to grow on the genitals, on the chest, and under the armpits. The sound of the voice gets lower. Boys may also notice they have pimples as well as a change in sweat and odor.
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Adolescent Reproductive Growth and Development, continued During puberty, boys become able to ejaculate. This is when sperm and seminal fluid leave the penis. If a boy ejaculates inside a girls vagina, the sperm in his semen can cause her to become pregnant. Sometimes a boy will ejaculate while he is sleeping. This is called a wet dream or nocturnal emission. It is very normal.
The Process of Change

It takes several years for boys and girls to go through puberty. While all boys and girls experience puberty, it is different for each person. Some start puberty at a younger age than their peers. Others begin puberty later. For some young people, their bodies change very quickly. Others experience the changes more slowly. It is normal for adolescents to develop and change at different rates. It helps boys and girls to talk about the changes of puberty with others. An important question many early adolescents have is Am I normal? A trusted adult or health worker can answer questions and reassure young people if they are concerned about normal changes.
Other Trends
In general, young women begin their first menstruation at an earlier age than they did decades ago. In many countries they are also marrying at a later age than they did in the past. For these and other reasons, there are many sexually active adolescents of childbearing age at risk of pregnancy, unsafe abortion, and STIs, including HIV. Although married adolescents may not face the same family conflicts and social stigma as unmarried youth that are sexually active, they are still at risk for the complications of STIs and the health risks of early pregnancy. A goal of RHA for adolescents is to help young people develop the knowledge, attitudes, and skills they need to keep themselves as healthy as possible during their passage from childhood to adulthood, while making good decisions for themselves. To support this goal, programs need to address more than a young persons individual acquisition of knowledge, attitudes, and skills. It is also important to assess the many influences of the environment where young people are raised and identify key factors that are associated with adolescent behavior and reproductive health risk-taking. These may include region of residence, economic position of the family, family structure, communication with parents, working for pay, peer behaviors, self-esteem, and other factors.
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Observing Changes During Adolescence

Physical Changes Thinking and Awareness Preoccupation and concern about body changes (Am I normal?) Concrete thinking, focused on what is happening here and now Limited abstract thinking Conformity to group norms Increased ability to think abstractly and perceive the consequences of actions and behaviors Risk behaviors more prevalent Increasing interest in sexual matters Greater awareness of own sexual orientation Concern with social and political issues Emotions Changes in emotions, mood swings, expressed anger Day dreaming Emotionally not prepared for parenthood
Tools for Trainers
Relationships with Others Seeking independence, yet still wanting attachment to parents Close relationships with peers Idealized friendship with peers and public figures Conflict with parents regarding control Acceptance by peers very important Influenced by peer behaviors
Early Adolescence*
Growth spurt For girls, breast development, pubic hair, first menstruation and other changes For boys, penis and testes development, pubic hair, nocturnal emission and other changes Becoming physically able to conceive or father a child Growth slows in girls Sexual development well established
Middle Adolescence
Selfabsorbed, may withdraw Introspective May feel in love with one person for a while, and then in love with another May explore fantasies
* Age ranges for early, middle, and late adolescence have not been included in this table because young people pass through the different stages of adolescence at different ages. It is more appropriate to pay attention to a young persons current behavior than try to predict a stage of development based on his or her age. However, an estimate of age ranges for early adolescence would likely include 11 to 14 year olds, for middle adolescence the range would likely include 14 to 17 year olds, and for late adolescence, 17 to 20 year olds. As young people move through adolescence to adulthood they increase their ability to establish independence, identity, and intimacy. RHA through the Life Cycle: Birth through Adolescence
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Observing Changes During Adolescence, continued
Physical Changes
Thinking and Awareness Abstract thinking well established Greater ability to plan and foresee consequences Body image and gender roles well established May experience uncertainty about sexuality, future relationships, and work possibilities
Emotions More stable expression of emotions, including dealing with anger
Relationships with Others Greater independence from parents Peer influence lessens More ready for a committed and stable, intimate relationship
Late Adolescence
Physically mature, adult appearance Reproductive system fully developed
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Physical Changes Girls May Notice during Puberty
Handout
BreastsBudding breasts are one of the first changes. A girl may notice small, tender lumps under one or both nipples that will get bigger over the next few years. One breast may develop faster than the other, although they usually even out by the time her breasts are fully developed. HairShortly after breast development begins, soft pubic hair starts to grow. It becomes thicker and curlier later, often about 6 to12 months before first menstruation. Hair also begins to grow under the armpits. Body shapeA girls hips get wider and her waist narrows, taking on the more curvy shape of a woman. Her body begins to build up fat in the legs, buttocks, and abdomen, which is normal. Body sizeGirls begin growing quickly once puberty begins. Often hands, feet, arms, and legs grow more quickly than the rest of the body. Girls may feel clumsier than usual during this time. Growing usually slows down in middle adolescence and is completed by late adolescence. SkinSince glands are growing, a girl may notice that she sweats more and her skin may become oilier. Most girls experience acne or pimples, even when they wash and clean their skin regularly. Acne may be mild to severe for some girls. Cervical secretionsChanges in cervical secretions occur before first menstruation. Girls may notice a change in vaginal sensation and secretions on their undergarments. MenstruationGirls typically menstruate about a year after the peak of their growth spurt in height. Most girls get their periods between 9 and 16 years of age. At first some girls have periods that seem to have no schedule. Then their periods become more regular.
Source: Adapted from the American Academy of Pediatrics, 2002
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Changes Boys May Notice during Puberty
Handout
Body sizeBoys begin growing quickly once puberty begins. They may grow three to five inches in one year. Often hands, feet, arms, and legs grow more quickly than the rest of the body. Boys may feel clumsier than usual during this time. Body shapeBoys get taller, their shoulders become broader and they gain weight. Many boys notice a swelling under their nipples. This is usually temporary and does not mean they are growing breasts. Testicles and scrotumWith the beginning of puberty the testicles and scrotum get bigger. The skin of the scrotum darkens and wrinkles and the testes begin to make sperm. SkinSince glands are growing, a boy may notice that he sweats more and his skin may become oilier. Most boys experience acne or pimples, even when they wash and clean their skin regularly. Acne may be mild to severe for some boys. HairLong strands of hair first appear at the base of the penis. After first ejaculation the hair becomes more course and curly. Hair also grows in the armpits. For some boys hair may grow on the chest and back during puberty or some years later. Some men do not have chest hair. Usually facial hair starts to grow around the time hair grows in the armpits. It appears first on the upper lip, then the upper part of the cheeks, and lastly the beard. Some young men develop a lot of facial and body hair while others do not. Voice Before the first ejaculation, some early voice changes occur. But the tone of the voice deepens later, after the body has grown quickly and after hair has started to grow in the armpits. Ejaculation About a year after the testicles begin to grow, a boy has his first ejaculation. His penis also enlarges around this time. Sometimes boys unexpectedly have erections, for no apparent reason. Ejaculation can happen while sleeping. This is called a nocturnal emission or wet dream and is normal.
Adapted from the American Academy of Pediatrics (2002)
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ctivity Effective Communication in Response to Pressure

Objective
Demonstrate what to say if someone is pressuring them to act in a way

that is not in their best interest
Preparation
Review information on assertive communication techniques. See page 6-43 for an example of these techniques and the resource list at the end of this chapter. Prepare pressure statement cards. These are statements people commonly use to convince others to act in a way that is not in their best interest. Write a different statement on each card. Make enough cards for each participant to have at least one card. You may use the pressure statements suggested in the tools for trainers or create your own. You may want to use statements young people will commonly hear or use other statements, more appropriate to the particular participants in your class.
Time Directions
45 minutes or more 1. Introduce the activity with a brief discussion about our right to protect our own health and wellbeing from a very young age. Include concepts like: 1) each person has the right to protect her or his own reproductive health; and 2) sometimes friends or peers may encourage us to take health risks or to do things that are against our beliefs and values. 2. Ask participants to list some of the unhealthy behaviors young people may be pressured to engage in (for example, leave the market with a stranger who offers candy, smoke cigarettes, use drugs or alcohol, engage in undesired sexual behavior, fail to use protection against pregnancy or a STI, etc.). Tell participants to think about what they would say if someone encouraged or pressured them to engage in activities that are not in their best interest. Next, explain how participants will practice ways to respond to pressure statements. 3. Ask participants to stand in two lines, facing one another. Each person in the first line will have a card with a pressure statement to read. The person across from them (in the second line) will respond to the statement in a way they would if they really cared about that person and yet needed to communicate assertively what was in their best interest.
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For example, the first person in line one reads his or her pressure statement card. It may say something like, Everyone has smoked marijuana. Its nothing, why are you holding back? Then, the first person in line two will make up an effective response like, It doesnt matter why Im holding back. If you really cared about me, you wouldnt pressure me like this. Youd respect my feelings. 4. After the first statement and response, ask these two people to go to the end of their respective lines. Invite the next two people in line to read the statement and respond verbally to the pressure. Continue until each person has had an opportunity to participate. 5. Then, give each person in line two a pressure statement card and ask those in line one to now respond verbally in a way that affirms what is in their best interest. Continue until all participants have had the opportunity to both read a pressure statement and respond to one. 6. Invite participants to share their experiences and perceptions of the activity. Possible discussion questions are listed below. How did it feel to read the pressure statements? How effective do you think the responses were? Do you have any suggestions? In our culture how does gender influence the way we pressure others to follow unhealthy behaviors or respond to these pressures? How do we find and exercise the power to follow healthy practices?
7. Discuss how important it is to teach young children and adolescents ways to respond to pressures they may encounter to engage in unhealthy behaviors. Invite participants to share ideas for helping young people develop and practice effective communication skills.
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Peer pressure to engage in unhealthy behaviors may be very convincing
Wrap-up
Close the session with the following points.
Some people find it hard to know what to say if someone is pressuring

them, especially if that person is someone they care about or someone they want to like them.
To develop effective communication skills, it helps young people to

think about and practice what they might do or say when pressured to engage in unhealthy behaviors. Then, should the situation arise, they may be better prepared to respond in a way that is in their best interest.
We all have the right to protect our reproductive health and the right to
advocate for our own health and wellbeing.
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Evaluation
During the activity the trainer will assess participants ability to demonstrate what to say if someone is pressuring them to act in a way that is not in their best interest. Fellow participants may also provide feedback and suggestions for improving effective communication. If appropriate, participants may conduct an activity like this with young people and be assessed by a trainer or supervisor.
Note to Trainers
You can easily modify this activity for use with young children or adolescents. You may ask the young people to make up their own pressure statements, and use their statements rather than the examples in tools for trainers. This way the pressure statements will be more realistic and relevant to the group. When using this activity with young people, also talk about other ways to avoid the pressures to engage in unhealthy behavior. This includes avoiding people and places that encourage risky behaviors, refusing to talk about it any more, walking away, telling a trusted adult, etc. Consider that in some situations (like sexual abuse or domestic violence) assertive communication may not be a safe option. See the activity Assertive Communication pages 6-40 through 6-46 for more information.
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Sample Pressure Statements

To the Trainer: Write a separate statement on each card. You may use these statements or create your own.
Tools for Trainers
Pressures to have sex Everyone we know is having sex, why are you holding back? If you dont have sex with your boyfriend (girlfriend), I think
youll lose him (her).
Lets go back to my house; no one is home right now. I think you really want to have sex. Youre just shy. Now youve got me all excited. We have to have sex. Dont you want to see what its like? If you dont do it, someone else will. If you loved me you would.
Pressures to smoke, use drugs, or alcohol Dont you think it looks cool when people smoke? Alcohol isnt bad for you. If it were, it would be illegal for
everyone.
Try some. Itll relax you. Youre always so uptight. Just try it once. I think youll like it. Arent you curious about how this will make you feel? Dont worry, nobody can get addicted the first time.
Pressures to not use condoms or other family planning methods With condoms it just doesnt feel the same. Do you think I have some disease? When people use condoms its because someone has been
sleeping around. Is that why you want to use them?
If you (I) get pregnant well get married. Anyway, Ive heard that condoms dont work that well. So,
why use them?
You cant get pregnant the first time. You wont get pregnant. We hardly ever do it.
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A
Time
ctivity Body Image, Sexuality, and the Media

By the end of this activity, participants will be able to
Objective
Compare the image they have of themselves as a young person with

the way young people are portrayed in their community and the media today
Describe how cultural norms and the media might influence a persons
perception of her or his own body, expression of sexuality, and selfcare practices 1 hour or more You will need a piece of blank paper for each participant and colorful marking pens or crayons for drawing pictures. You will also need a large piece of paper for each small group and a variety of materials for making a collage. These materials may include popular magazines, posters, colorful paper, ribbon, glue, scissors, newspapers, etc. Read the tools for trainers and think about the role of providers in your group in supporting strong self-esteem in children. 1. Tell participants to think back and remember the person they were at a particular age in their childhood (You, the trainer, select the age range depending upon your focus for this activity.) Invite participants to think about how they saw themselves physically, the way they looked, dressed, felt, and what they were typically doing. 2. Ask participants to quickly draw a picture of themselves as young people of this age. They may attempt to make a life-like drawing or do a cartoon figure with symbols. As they draw ask participants to reflect on their perceptions of their bodies at this age. 3. Invite participants to form small groups with about four to five people each. In the small group they may share their drawings and briefly describe how they perceived themselves at the specified age. 4. Give each small group a poster-size piece of paper. The members of each group will make one collage that illustrates how children (or adolescents) of this age are portrayed in the media today. Tell participants to think about how youth are portrayed in magazines, on television, on the radio, in popular songs, on commercials and billboards (e.g., smoking is appealing, fancy cars and alcohol attract pretty girls, sexually active partners seldom get STIs on television, etc.) The collage should reflect what people this 8-56
Preparation
Directions
age look like now in the media, how they dress, how they appear to feel, their expression of sexuality, and what they are typically doing. 5. Ask a representative from each group to present their collage. They will describe the images portrayed by the media and compare this to the original pictures of how the members of the group remembered themselves at this age. They may then tape the poster along with the individual drawings to the wall. 6. In the large group summarize the key themes that emerge. Compare the image participants had of themselves with the images of young adults they see in the media today. The following are possible discussion questions. How could the way the media portrays youth influence how a young person might feel about her or his body? How might a persons image of her or his body influence how well the person follows self-care practices? How is sex used to sell products, entertain viewers, etc? What other social pressures encourage young people to engage in risky behaviors? How can you help young people develop and maintain a positive body image? How would you address social pressures on sexual behavior when working with young people?
Wrap-up
The media typically portrays a romanticized or sensational image of

peoples lives. The amount of sex and violence is often exaggerated and unrealistic.
The media can influence how young people think and act. They may
worry about what is normal or wish they were different than the way they are. They may be more inclined to follow behaviors (e.g., smoking, unprotected sex, fast and reckless driving, etc.) that put their health at risk.
Helping children and adolescents value, appreciate, and take care of

their bodies is an important part of reproductive health awareness for youth.
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Evaluation
During the small group discussion and class presentation participants describe how the image they have of themselves in their youth compares with the way young people are portrayed in their community and the media today. In the large group they list how cultural norms and media might influence a persons perception of his or her own body, self-esteem, and expression of sexuality, and self-care practices. During the classroom discussion the trainer will assess participant awareness of these issues.
Note to Trainers
This activity can be easily modified and used with adolescents or children who will soon be adolescents. Ask the young people to draw a picture of how they see themselves today and then make a collage of the way young people their age are portrayed in the media. Then, ask them to reflect on how these media images might affect their perceptions about themselves and what they consider to be normal and desirable. Invite young people to critique the media and its potential impact on them. Ask the young people to think of ways to deal with this and other social pressures on their lives.
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Sexuality and the Media
Tools for Trainers
The media can have a powerful influence on a young persons attitudes, values, and beliefs about sex. With increasing exposure to television, music, advertising, and the Internet, young people are often exposed to a wide range of sexual messages, many of which are very explicit and often unrealistic or misleading. For example, the average American adolescent will view almost 14,000 sexual references per year, yet only 165 of these references deal with birth control, self-control, abstinence, the risk of pregnancy, or the risk of STIs (American Academy of Pediatrics, 2001)
The following are suggestions for presenting responsible sexual content in television, films, and music. (Advocates for Youths Media Project, n.d.)
Recognize sex as a healthy and natural part of life. Include healthy parent and child conversations about sex. Demonstrate that not only the young, unmarried, and beautiful have sexual
relationships.
Show that not all affection and touching must culminate in sex. Portray couples having sexual relationships with feelings of affection, love, and
respect for one another.
Discuss or show the consequences of unprotected sex. Recognize and respect the ability to say no. Dont use miscarriage as a dramatic convenience for resolving an unwanted
pregnancy.
Indicate that the use of family planning and STI protection is a normal part of a sexual
relationship.
Avoid associating violence with sex or love. If rape is depicted, show it as a crime of violence, not one of passion.
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ctivity Adolescent Panel

Objective
Discuss insights and lessons learned through listening to young people

as they share their personal stories and describe their experiences
Preparation
Recruit adolescents for a panel discussion. Select three to four young people who have dealt with some of the challenges common to youth in your area. Adolescent experiences may include unintended pregnancy, HIV, violence, homelessness, etc. Talk with these adolescents before the training and ask them to be prepared to tell their story. They will be asked to talk about the difficulties they have faced, how they have coped, and the lessons they have learned. Tell the adolescents that the participants will want to ask them questions about their experiences and hear about the advice they may have for providers who work with youth. After the activity, debrief with the panel members and thank them again for their participation. 1 hour or more 1. Introduce the panel and thank them for coming to talk with the class. Ask each adolescent to take a few minutes to tell their story, the challenges they faced, the lessons they learned and anything that helped or would have helped them better cope with the challenges. 2. Provide an opportunity for participants to ask questions one at a time. During the question and answer time you may need to direct the group and help filter any questions that may seem inappropriate or too personal for a young person to answer. Possible questions to ask the panel are listed below. What are the biggest problems or difficulties that you face as a young adult? (School, pregnancy, drugs, violence, etc.) What are your friends concerned about? What are some of the reasons why young people become pregnant or find themselves at risk of getting a STI? What would help young people better protect themselves from pregnancy or a STI, including HIV?
Time Directions
8-60
What would you say to other young adults about sex, sexuality, and reproductive health? How can adults be helpful? What can they say or do? Are there certain things that adults shouldnt do or say? If you were planning a program for your friends, to help them learn about reproductive health awareness and self-care practices, what would that program be like?
3. Ask the panel to close with any additional suggestions or recommendations as to how the participants can better provide counseling, education, and services to adolescents like them. 4. Thank the panel for their time and insights. 5. After the adolescents have left, spend some time discussing the common themes that surfaced and what participants learned from the experience. Discuss ways to include youth in the planning, development, implementation, and evaluation of programs and services for young people.
Wrap-up
We can learn a lot about how to work with young people by listening
carefully to young people themselves.
Many international organizations attribute the success of their youth

programs to the meaningful involvement of youth in all aspects of programming (Senderowitz, 1998).
Young people have been involved in programs in a variety of ways

including planning, recruitment, outreach, peer education, clinic work, and evaluation.
Evaluation
This activity should raise awareness around the resourcefulness of young people and the benefits of including them in program activities. Based on the discussion participants have after the adolescent panel has departed, the trainer will assess whether participants discussed insights and lessons learned after listening to the adolescent panelists.
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Resources
Reference List
Advocates for Youth Media Project. (n.d.) Recommendations for presenting responsible sexual content in television, films, and music. Washington DC: Advocates for Youth. American Academy of Pediatrics. (2002). Puberty information for boys and girls [Public information brochure]. Retrieved April 18, 2002, from http://www.aap.org/family/puberty.htm American Academy of Pediatrics. (2001). Sexuality, contraception, and the media. Pediatrics 107, 191-194. Retrieved July 1, 2002, from http://www.aap.org/policy/re0038.html Bean, R. (1992). The four conditions of self-esteem (2nd ed.). Santa Cruz, CA: ETR Associates. Monasterio, E. (1998). Counseling teens: Are we effective? [Provider training]. Oakland: Center for Health Training. Centre for Development and Population Activities (CEDPA). (1998). Choosing a future! Issues and options for adolescent boy. Washington, DC: Author. EngenderHealth. (2002). Sexuality and sexual health: Online minicourse. Retrieved May 5, 2002, from http://www.engenderhealth.org/res/onc/sexuality/index.html Hatcher, R., Trussell, J., Stewart, F., Cates, W., Stewart, G., Guest, F., et al. (1998). Contraceptive technology (17th rev. ed.). New York: Ardent Media. Iannelli, V. (2003). Tanner stages. Retrieved January 9, 2003, from www.pediatrics.about.com/library/bltannerstages.htm Irvin, A. (2000). Taking steps of courage: Teaching adolescents about sexuality and gender in Nigeria and Cameroun. New York: International Womens Health Coalition. Kirby, D. (1997). No easy answers: Research findings on programs to reduce teen pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy. Kirby, D. (n.d.) Effective curricula and their common characteristics. Retrieved April 5, 2002, from http://www.etr.org/recapp/programs/effectiveprograms/.htm Magnani, R., Seiber, E., Zelinski Gutierrez, E., & Vereau, D. (1999). Correlates of sexual activity and condom use among secondary school students in urban Peru. Washington, DC: FOCUS on Young Adults, Pathfinder International. Moya, C. (n.d.). Life skills approaches to improve young adult reproductive health. FOCUS YARH Briefs, 2, Retrieved April 29, 2000, from http://www.pathfind.org/pubs/YARH%20Briefs/bri2fin.pdf 8-62
Newton, N. (2000). Lessons learned from SEATs experience: Applying best practices to youth reproductive health. Arlington, VA: John Snow (JSI)/ Family Planning Service Expansion and Technical Support (SEATS). Reproductive Health Outlook. (1997-2003). Glossary. Retrieved March 19, 2003 from http://www.rho.org/html/glossary.html Senderowitz, J. (1998). Involving youth in reproductive health projects. Washington, DC: Focus on Young Adults. Sexuality Information and Education Council of the United States (SIECUS). (2001) For parents and other adults. Retrieved May 10, from http://www.siecus.org/parent/index.html Sexuality Information and Education Council of the United States (SIECUS). (2000). Families are Talking. Vol. 1, No. 1 [pamphlet], Retrieved May 6, 2002, from http://www.siecus.org/pubs/families/Families_Newsletter.pdf United Nations International Childrens Emergency Fund (UNICEF). (2001). What is the life skills approach? Retrieved March 3, 2003, from http://www.unicef.org/teachers/lifeskil.htm WHO/UNFPA/UNICEF. (1997). Framework for country programming for adolescent health. In Action for adolescent health: Towards a common agenda. [Recommendations from a joint WHO/UNFPA/UNICEF study group.] Geneva, Switzerland: Author.
Other Resources
Aguilar Gil, J., Botello, L., & Aumack Yee, K. (1998). Juntos planeamos el futuro. Hablemos de la autoconciencia de la salud sexual y reproductiva [Together we plan the future: Talking about Reproductive Health Awareness]. Mexico City, Mexico: MEXFAM. Barth, R. (1996). Reducing the risk: Building skills to prevent pregnancy, STD & HIV. Santa Cruz, CA: ETR Associates. CEMOPLAF (1997). Autocuidado de la fertilidad y sexualidad par adolescentes medios: Manual para el facilitador reproductiva [Reproductive and sexual health awareness and selfcare: Manual for reproductive health facilitators]. Quito, Ecuador: Author. Hedgepeth, E., & Helmich, J. (1996). Teaching about sexuality and HIV: Principles and methods for effective education. New York: New York University Press. Howard, M., & Mitchell, M., (1993). Postponing sexual involvement: An educational series for young teens. Atlanta, GA: Emory/Grady Teen Services Program, Grady Memorial Hospital. Huggins, K. (1995). The nursing mothers companion (3rd ed.). Boston: Harvard Common.
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Hunter-Geboy, Carol, (1995). Life planning education: A youth development project. Washington, DC: Advocates for Youth. Knebel, E. (2002). My changing body: Fertility awareness for young people. Washington, DC: Institute for Reproductive Health and Family Health International. Kilbourne-Brook, M. (1998). Adolescent reproductive health: Making a difference. Outlook,. 16, 3, Washington DC: PATH. Madaras, L. (1993). My body myself for girls, New York: Newmarket Press. National Guidelines Task Force. (1996) Guidelines for comprehensive sexuality education, kindergarten-12th grade. New York: SIECUS. Office of Family Planning, State of California, Department of Health Services. (1996). TeenSMART: Enhanced counseling guidelines, Sacramento, CA: Author. Queenan, J. & Queenan C. (1992). A new life: pregnancy, birth, and your childs first yearA comprehensive guide. London, England: Marshall Cavendish Books. Saavedra, D. (1993). My body myself for boys. New York: Newmarket Press. Senderowitz, J. (1999). Making reproductive health services youth friendly. Washington, DC: FOCUS on Young Adults. Singer, M.I., Singer, L.T. & Anglin, T.M. (Eds.). (1993). Handbook for screening adolescents at psychosocial risk. New York: Lexington Books. Wilson, P. (1992). When Im grown. Washington, DC: Advocates for Youth. World Health Organization (WHO) Global Programme on AIDS and United Nations Educational, Scientific and Cultural Organization (UNESCO). (1994). School health education to prevent AIDS and STD: A resource package for curriculum planners. Geneva, Switzerland: World Health Organization. Zilbergeld, B. (1999). The new male sexuality. New York: Bantam Books.
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Headquartered in Washington, DC, CEDPA is an international nonprofit organization that seeks to empower women at all levels of society to be full partners in development. Founded in 1975, CEDPA supports programs and training in leadership, capacity building, advocacy, governance and civil society, youth participation and reproductive health. The Enabling Change for Women's Reproductive Health (ENABLE) project works to strengthen women's capabilities for informed and autonomous decision making to prevent unintended pregnancy and improve reproductive health. Initiated in 1998, ENABLE seeks to increase the capacity of non-governmental organization (NGO) networks to expand reproductive health services and to promote a supportive environment for women's decision making.
ENABLE is funded by the Office of Population and Reproductive Health, Bureau for Global Health, U.S. Agency for International Development, under the terms of Cooperative Agreement No. HRN-A-00-98-00009-00.
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Reproductive Health Awareness Through The Life Cycle - Birth To Adolescence

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Chapter 8 RHA through the Life Cycle: Birth through Adolescence

Table of Contents Chapter 8

RHA through the Life Cycle: Birth through Adolescence

RHA through the Life Cycle: Birth through Adolescence

Key Questions What do young children and adolescents need to

What attitudes and skills should they develop in

How can people help children and adolescents

ntroducing Chapter Eight

From Birth to Adolescence

RHA through the Life Cycle: Birth through Adolescence

The RHA Approach for Young People

Body Awareness and Self-Care