Comprehensive Sexual Education
FIGIJ Advocacy Statement in Support of Comprehensive Sexuality Education
Comprehensive sexuality education (CSE) is a vital component in the development of child and adolescent sexual and reproductive health, important attributes for both the individual and their community. CSE is defined by the World Health Organization (WHO) as a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality. CSE aims to equip children and young people with knowledge, skills, attitudes and values that will empower them to develop respectful social and sexual relationships that will promote their health, well-being, human rights and dignity.
The United Nations 2030 Sustainable Development Goals (SDGs) delineate both universal human rights as well as goals for progress. The SDGs support CSE as a human right for health and wellness as well as for quality education, “every individual has the right to health and well-being in all aspects of their sexuality, their body and their reproductive choices. These rights are agreed upon in international law. FIGIJ, the International Federation of Pediatric Adolescent Gynecology, is strongly advocating for the widespread implementation of CSE as a basic human right proven to improve health outcomes for children and adolescents. We are gynecologists, pediatricians, adolescent medicine specialists, and other providers whose professions are dedicated to promoting and protecting the sexual and reproductive health of children and adolescents. FIGIJ recognizes the evidence and unequivocally supports CSE.
The Content and Value of CSE
The United Nations and the WHO have published International Technical Guidance that outlines the main domains of CSE which include:
- Values, Rights Culture and Sexuality
- Understanding Gender
- Violence and staying safe.
- Skills for health and well-being.
- Human body and development
- Sexuality and behaviors
- Sexual and reproductive health
These domains have age-based education objectives that can be tailored to meet the sociocultural environment. Topics covered by CSE, which can also be called life skills, family life education and a variety of other names, include but are not limited to, families and relationships; respect, equity and diversity, consent and bodily autonomy; positive sexuality; anatomy, puberty and menstruation; contraception and pregnancy; stigma and discrimination based on sexual orientation and gender identity; and sexually transmitted infections, including HIV.
When CSE has been implemented, it has been shown to:
- Decrease intimate partner and dating violence.
- Decrease childhood sexual abuse and increase disclosure of abuse events.
- Reduce bullying and violence based on gender and sexual orientation through reduction in stigma.
- Delay initiation of sexual activity
- Decrease the frequency of sexual intercourse.
- Decreased number of sexual partners
- Reduce risk-taking in sexual activities.
- Increase use of condoms
- Increase use of contraception
CSE: Threats and Misconceptions
Several misconceptions have been raised towards CSE. These erroneous predictions include that CSE will lead to early sexual initiation; will deprive children of their innocence by introducing sexuality early in school education; will erode culture, religion, or family values; will provide information about sex that might be appropriate for adolescents but not for young children; will diminish the role of parents in providing sexuality education; and will make teachers provide education in areas they are not comfortable.
On the contrary, in countries in which CSE curricula has been introduced, it has been proven to delay sexual debut and have overall positive influence on sexual health and well-being of adolescents and young people. CSE should be age-appropriate and curricula should be developed in a carefully planned process from the beginning of formal schooling. With an emphasis on positive values and relationships, considering the key values relevant to cultures or religions and the communities context, CSE programs are meant to work in partnership with parents involving and supporting them. Most teachers and educators have the skills to provide information and identify their students’ needs and concerns; they can be trained in CSE content and are not expected to be experts on sexuality. The role of CSE is to complement the efforts of parents, not to exclude their invaluable participation. Consistently, parents globally have broadly supported the provision of CSE.
FIGIJ Advocates for the following calls for action:
In recognition of CSE as an essential intervention to improve child and adolescent health and well-being, FIGIJ urges the following calls to action:
1. To governments, community, educators should:
a. Develop coalitions of stakeholders in communities including parents, community religious and government leaders, health care providers, educators and youth to support culturally sensitive CSE implementation and counter campaigns of misinformation and misconceptions about CSE.
b. Demonstrate broad support for the adoption of the WHO Technical Guidance as a resource for the CSE curriculum
c. Provide financial and resource support from the health care sector for CSE. As with childhood immunization, CSE is an essential health need of children and adolescents that requires support and implementation from the health and education sectors.
d. Engage meaningfully and partner with young people in creation and implementation of CSE curricula
2. That health care providers should:
a. Advocate for support of implementation of CSE.
b. Include CSE in medical school and allied health curricula.
c. Be consistent in our own practice with the principles and education found in CSE.
Angela Aguilar, Philippines
Anastasia Vatopoulou ,Greece
Clara Di Nunzio, Argentina
Daniela Ivanova Panova, North Macedonia
Ellen Rome, USA
Judith Simms-Cendan, USA
Michalina Drejza, Poland / United Kingdom
Yasmin Jayasinghe, Australia
FIGIJ Advocacy Statement: The Need for Safe Abortion Access for Adolescents
FIGIJ advocates for global unrestricted access to abortion for adolescents.
Introduction and purpose: demographics of Global Abortion Access for Adolescents
WHO estimated in 2019 that adolescents aged 15–19 years in low- and middle-income countries (LMICs) had an estimated 21 million pregnancies each year, of which approximately 50% were unintended. In many countries unsafe abortion is the leading cause of death in women (maternal mortality and also contributing to morbidity). In global crises, such as war or pandemics (i.e. COVID-19 or Ebola virus), girls are particularly vulnerable to sexual abuse, often resulting in unintended pregnancies and/or early marriage. Even in high income countries, access to abortion is not distributed equitably, with low-income communities having less access to abortion services.
Access to safe and legal abortion is an important, essential component of healthcare, especially for adolescents who have a higher percentage of unintended pregnancies and higher maternal morbidity and mortality, a worldwide public health problem.
In some countries abortion is completely restricted for all women. Restrictive regulations on abortions specifically targeting adolescents, even in countries where abortion is legal, include waiting periods, requirement for parental notification and/or consent, and restriction on travel across borders for accessing abortion services. FIGIJ supports the WHO 2022 Abortion Care Guidelines recommendation for decriminalization of abortion services.
Restricting abortion for adolescents leads to:
- Increased risk of distress and shame in adolescents who seek abortion services.
- Lack of robust systems for objective data collection and analysis about numbers of girls seeking abortions leading to knowledge gaps in sexual and reproductive medicine.
- Rise in maternal morbidity and mortality in vulnerable adolescents.
- Loss of trust in healthcare systems.
- Seeking of abortion services through unsafe channels
- Missed opportunities to access patients to prevent subsequent unintended pregnancy.
Restricting abortion leads to negative effects for healthcare providers, including:
- Reconsideration or refusal of evidence-based safe abortion services according to international guidelines.
- Fear of legal consequences of providing abortion health services.
Safe versus unsafe abortions: A matter of access
Both medical and surgical abortions are a crucial part of healthcare and performed in the clinical setting are safer than pregnancy, with the risk of death in childbirth greater than 10-fold more than with abortion. The risk of complications from legal abortion performed by a provider is extremely low, and contrary to myths does not affect future fertility or increase risk of cancer.
Historically, globally 45% of abortions occurred outside the healthcare setting and the majority in low and middle income countries (LMIC). Many women and girls with unintended pregnancies face barriers to attaining safe, timely, affordable, geographically reachable, respectful and non-discriminatory abortion care, so as a consequence they often resort to home remedies and unskilled providers to obtain an abortion resulting in unsafe abortion practices. Data show that restriction access to abortion does not prevent people from seeking abortion, it simply makes it more deadly. In order to access safe abortion young women need to face and manage stigma, lack of confidentiality and overcome significant systemic, social and cultural barriers. The need for parental consent, providers’ bias and the mere recognition of young people as sexual beings prevent youth from accessing sexual and reproductive health services they need and deserve.
Echoing the WHO, FIGIJ supports broad access for medical abortion for all adolescents as it is safe, private, cost-effective and limits the need for transportation for clinic visits.
FIGIJ advocates for the full spectrum of comprehensive reproductive care for adolescents including contraception, emergency contraception, sexual education and abortion services.
- Providing women and girls with comprehensive sexuality education, accurate family planning and contraception information and services, and access to quality abortion care.
- Providing appropriate method mix for abortion (self-managed abortion, medical and surgical abortion) to all patients based on values and preferences of women and girls and the available resources.
- Training health professionals to provide safe and quality abortion care services with an appropriate understanding and interpretation of the laws and policies that regulate this practice.
- Staffing of health professionals offering abortion care within reach of patients.
- Supporting and protecting health professionals and patients against stigmatization.
- Recognition that pregnancy can occur due to violence and/or coercion and would necessitate appropriate safeguarding measures.
Postabortion care should include full contraceptive access, reproductive health counseling as well as nonjudgmental mental health support. Please see FIGIJ advocacy states “LARC’s access to prevent teenage pregnancy“ and “Mental health in children and adolescents from a PAG perspective “.
Human rights – including sexual and reproductive – should be respected, protected, and promoted by professional societies. Progressive legislation decriminalizing abortion upholds adolescent’s sexual and reproductive health.
Call for action
● FIGIJ supports access for adolescents to comprehensive sexuality and reproductive health education and the full range of contraceptive options, including emergency contraception to reduce unplanned pregnancy.
● FIGIJ supports legal and safe access to the full range of abortion services as a part of comprehensive medical care.
● FIGIJ supports a full decriminalization of abortion as recommended by the WHO.
● FIGIJ supports removing abortion restrictions specifically aimed at adolescents including third party authorization and/or parental notification and parental consent laws.
Mariela Orti, Argentina
Evelien Roos, the Netherlands
Anastasia Vatopoulou , Greece
Michalina Drejza, Poland/United Kingdom Clara Di Nunzio, Argentina
Judith Simms-Cendan, USA
FIGIJ Statement Adolescent: A call to minimize the risk of adolescent pregnancy through education and contraceptive access
Adolescent pregnancy, according to the World Health Organization (WHO) is pregnancy occurring in women under the age of 20 years. When a girl becomes pregnant during adolescence, her present and future changes radically. Adolescent pregnancy is a serious health risk relevant to all social classes, all economic levels and all cultures, yet profoundly affects adolescents living in low and middle income countries (LMICs). Every year, an estimated 21 million girls aged 15–19 years living in LMICs become pregnant, approximately 12 million girls between 15-19 years give birth. Just under 1 million girls under the age of 15 years give birth every year in LMICs. Pregnancy and childbirth among early adolescents in particular results in serious harm to the health of the affected dyad. Even for the older adolescent, girls aged 15 to 19 years, it is the second leading cause of maternal mortality globally.
Risk factors for Adolescents Becoming Pregnant
Adolescents who have low self esteem, a lower level of education and socioeconomic status (poverty), who lack family or social support and who live in communities without any institutional social support are especially vulnerable to becoming pregnant at a young age. Many girls experience considerable pressure to marry and become mothers while they are still children themselves, and this varies by culture and region. As a result, child marriage is a main contributing factor for adolescent pregnancy. The United Nations and WHO have estimated that 9 out of 10 births to girls between 15-19 years occur within marriage. Child marriage, according to UNICEF, affects girls disproportionately,and increases the personal risk of violence, exploitation, abuse, and adolescent pregnancy.
Adolescent Pregnancy Affects the Health and Welfare of Both Mother and Child
As gynecologists who care for adolescents, FIGIJ members recognize that girls especially below the age of 15 have much higher rates of maternal morbidity and mortality than older women as their body is not physically ready for the physiologic effects of pregnancy. Adverse maternal outcomes of pregnancy in this age group include obstructed labor, obstetric fistula, placental abruption, hypertensive (preeclampsia/eclampsia) and hemorrhagic complications, infection, and even death. Perinatal complications affecting the baby include prematurity, low birth weight and fetal death in utero. Pregnant teens with no support from their family are at risk of not accessing prenatal care and higher rates of depression and anxiety. While some adolescents see a rise in social standing and increased access to medical care, for many others the impact is much more adverse including denial of education, social ostracism, susceptibility to intimate partner violence, and economic hardship for her and her offspring.
Adolescent Pregnancy Prevention Requires Broad Efforts
Prevention of adolescent pregnancy requires comprehensive sexual health education and accessibility of services. Adolescents who may want to avoid pregnancies may not be able to do so due to knowledge gaps and misconceptions on where to obtain contraceptive methods and how to use them. Age-appropriate reproductive health education has been found to be effective. Targeting at-risk adolescents and providing individualized care were also effective. Improvement in health care and psychosocial support to pregnant adolescents prevents adverse outcomes for both the mother and the neonate. Governments must improve literacy of girls, improve legislation with regard to banning child marriage and addressing sexual violence and make laws to prioritize national support adolescent pregnancy.
Adolescents face barriers to accessing contraception including restrictive laws and policies regarding provision of contraceptive based on age or marital status, health worker bias and/or lack of willingness to acknowledge adolescents’ sexual health needs, and adolescents’ own inability to access contraceptives because of knowledge, transportation, and financial constraints. Effective interventions are available to prevent adolescent pregnancy and mitigate the effect of pregnancy on the young. However, many intervention programs do not include married girls, nor very young adolescents aged 10-14 years. Providing support especially to socioeconomically disadvantaged communities to keep the children in school and to provide access to health services is key to decreasing the incidence of adolescent pregnancies. Adolescents who become pregnant should be free from stigmatization and be permitted to continue their education. Programs caring for adolescents during their pregnancy and postpartum should support their emotional, medical and educational needs in a positive way, avoiding blame and shaming of young mothers.
FIGIJ calls for a holistic approach to respond to this problem (see Figure 1 below). Preventing adolescent pregnancies requires analysis of unique factors that place the child at risk. Family and community resources should be mobilized with both policy and material support of national governments and other influential sectors worldwide to recognize this burden and to reduce its impact on adolescent health.
Call for action
FIGIJ supports comprehensive sexual and reproductive health education.
FIGIJ advocates for access to youth-friendly health services including affordable and safe contraception, such as emergency contraception and LARCs. See FIGIJ Statement: A Call to Increase Access to LARC’s for Prevention of Adolescent Pregnancy.
FIGIJ supports development of comprehensive programs from communities and institutions for both prenatal and postpartum care, education and socioeconomic support to optimize adolescent health and wellbeing during and after pregnancy.
Angela Aguilar, Philippines Anastasia Vatopoulou, Greece Evelien Roos, the Netherlands
A Call to Increase Access to LARC’s for Prevention of Adolescent Pregnancy
Long Acting Reversible Contraception (LARCs) methods, methods which have more than a year of duration of efficacy, include copper intrauterine devices (IUDs), levonorgestrel IUD ́s and etonogestrel subdermal implants. These are highly effective and safe for use in adolescents and should be offered as first-line contraception. There is no evidence showing an increased risk of complications when using IUDs/implants in adolescents. Additionally, hormonal LARCs have numerous noncontraceptive benefits including reduction of menstrual pain and bleeding.
Adolescent pregnancy rates have declined in the past decade for a combination of reasons, including the increased access to and use of LARCs, but adolescent pregnancy remains disproportionately prevalent in women with low socioeconomic status (SES) compared to those with higher SES in high and middle income countries. (See the FIGIJ Preventing the Risks of Adolescent Pregnancy Statement). With postpartum LARCs use, the rate of repeat adolescent pregnancy decreases and the time interval to subsequent pregnancy increases. Despite the strong encouragement for their use, LARCs are not yet the most chosen methods due to various barriers including education of patients, families and providers as well as accessibility and affordability of these methods.
Improving education, access and use of LARCs
Dispelling Misconceptions of Providers and Patients
A misconception that IUD use increases the risk of pelvic inflammatory disease and impairs future fertility limits its uptake globally. An abundance of data with the levonorgestrel and copper IUDs confirms when placed according to guidelines infection risk is not increased. Adolescents who are at high risk for sexually transmitted infections should be screened either prior to or at the time insertion and treated if needed. Dual method of contraception use including condoms with LARCs or short acting contraception (SARC) such as oral contraceptives is recommended universally for adolescents and prevents sexually transmitted infections in at risk youth.
According to the UN Report on Contraceptive Use by Method in 2019, LARCS are used 13 times more by married than unmarried women (IUD 151 v 8 million, Implant 18 v 5 million). Both the WHO and the US-CDC-MEC state that IUD use in nulliparous adolescents under the age of 20 has benefits that outweigh the risks.
Misconceptions amongst parents and adolescents include that IUDs are not highly efficient at preventing pregnancy, and that they are not safe methods in younger women. Social media is filled with videos and posts regarding pain with IUD insertion, IUD expulsion and other complications, yet it is known that these complications are rare. These very compelling personal statements do not represent the general experience and safety; they induce fear and create negative perceptions about these methods. Improving education about the benefits of LARCS, as well as accurate information about the complications, should be provided widely on platforms most accessible to the young patients who need this information.
Improving access and affordability
Globally, there remains a lack of skilled providers in IUD and implant insertion and removal. Providing training opportunities for midwives, birth attendants and others who provide women’s health care will improve their skills and increase their capacity to provide care. Supplies of LARCs to underserved and rural areas should be increased concurrently with training of providers
The up-front costs of IUDs and implants, while expensive compared to SARCs, are actually economical because of their long duration of use and the higher comparable efficacy in prevention of pregnancy. This makes them a cost effective choice for countries and insurance carriers, but unless there is support at the individual level, barriers will remain for patients unable to afford the upfront cost.
Same day insertion will increase accessibility to patients who may be unable to return for multiple provider visits, either because of family, education or job responsibilities, or due to cost of travel.
As long as pregnancy can be excluded, a LARC method can be placed at any time during the menstrual cycle. The copper IUD can also be used as an emergency contraceptive method.
Globally there are widespread cultural or religious beliefs that act as barriers to LARC, including fear that increasing teen contraception will increase sexual promiscuity among adolescents. Establishing dialogues with communities regarding adolescent sexuality and safe relationships, while maintaining respect for cultural norms is important for developing trusting relationships between providers, patients and families.
Removing barriers of access to and correcting misperceptions about LARCs is cost effective, is safe and can reduce adolescent pregnancy and its medical and psychosocial sequela.
Call for action
FIGIJ advocates for broad education on LARCs for reproductive health providers and the public.
Providers, professional societies as well as governments are encouraged to provide factual information on LARCS and other forms of contraception through social media platforms to adolescents.
FIGIJ endorses free provision of contraception, including LARCS for adolescents and encourages both government and the insurance industry to support this initiative.
Mariela Orti, Argentina
Angela Aguilar, Philippines
Judy Simms-Cedan, United States of America Clara Di Nunzio, Argentina
The global prevalence of eating disorders (EDs) has doubled in the last decade from 3.5% to 7.8%, and 40% of these disorders are seen in those aged between 15-19 years. Amongst adolescents an ED is one of the most common chronic illnesses. EDs can have significant consequences, leading to impaired physical health, quality of life, and disruption of psychosocial functioning of adolescent patients and their families. They are, however, treatable conditions, and early recognition enables better outcomes. This statement focuses on the gynecologic consequences of EDs that result in under- and overnutrition.
The most common EDs are anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED). EDs are not the result of an individual’s choice but rather a result of interaction between genetic and environmental factors at critical time points in development. Adolescents, particularly girls, are increasingly conscious of their body and this has a bearing on their diet. Transgender youths are vulnerable to EDs resulting from having a body image that is not compatible with their gender identity, with an up to 2-4 fold increased prevalence of these disorders compared to cis-gendered youths. In the adolescent gynaecology setting, EDs may present with weight loss, menstrual disturbances, unexplained growth or pubertal delay, restrictive or abnormal eating behaviours, over exercising or recurrent vomiting. Although formal diagnosis and treatment of EDs are outside the scope of practice for pediatric and adolescent gynecologists, it is critical that providers are comfortable in recognising and screening for EDs thereby enabling referral for appropriate treatment giving the opportunity for better health outcomes. Treatment of EDs should be individually tailored and requires a holistic approach including counselors, patients and their families.
Anorexia Nervosa (AN)
AN may present with low weight, self-induced starvation and an intense fear of gaining weight. The underlying cause is weight or shape concerns and a distorted view of body image. Its prevalence peaks between 13 and 14 years of age. Diagnosis can be difficult as the patient may feel their behavior is not abnormal. AN affects all organs and systems and results in severe medical complications due to malnutrition and purging behaviors. Amenorrhoea is a pivotal feature of AN due to hypothalamic dysfunction. In adolescents presenting with hypothalamic amenorrhoea, early onset AN should be considered and is suggested by other symptoms such as obvious weight loss, cold intolerance, bloating, constipation or diarrhoea, fatigue, fainting, easy bruising, hair loss and dry skin. There is no longer a BMI cut off required to make a diagnosis of AN. This ED is associated with multiple psychiatric comorbidities. AN has the highest mortality rate of all psychiatric disorders at 5-6%, with one in five of these deaths due to suicide. When the condition is suspected a multi-disciplinary approach including a mental health provider with expertise in EDs should be adopted. Inpatient care is advised when severe bradycardia, hypotension, orthostasis, and/or electrolyte imbalance occur.
Menstrual function recovery is usually delayed after adolescents reach a healthy weight. Bone density may however be severely affected by AN. In the setting of significantly low bone density, replacement with the short-term use of combined hormonal therapy may protect bone health. The addition of calcium and vitamin D might further optimize bone health.
Restricted eating may also occur in athletes and contribute to Relative Energy Deficiency in Sports (RED-S). Recognised by the International Olympic Committee, and other international sports associations, the condition can be triggered by weight requirements for certain sports (for example wrestling) or expected body habitus of certain athletes, such as figure skaters. Often presenting with amenorrhea, RED-S can affect athletic performance and increase risk of stress fractures. In addition to medical providers, coaches and parents should be aware of RED-S in young athletes.
Bulimia Nervosa (BN) and Binge Eating Disorder (BED)
BN and BED are characterized by recurrent episodes of over eating. BN is defined by extreme compensatory behaviors designed to control weight such as induced vomiting. BED is associated with recurrent episodes of binge eating but with fewer compensatory behaviors than in BN. Obesity is prevalent in all cases as are other metabolic disorders, however both can be diagnosed at any weight.
Self induced vomiting has been associated with three times the rate of irregular menses. BN can also lead to menstrual irregularity even when controlling for factors of PCOS and obesity. Laxative abuse may lead to melanosis and secondary hyperaldosteronism. BN and BED may be associated with high risk sexual behaviours, decreased self-respect and psychiatric comorbidities. The primary aim of laboratory workup is to exclude medical conditions that may have contributed to the presenting symptoms of malnutrition. PAGs should be able to recognise red flags for BN or BED in history and examination. It is important the adolescent is evaluated alone and shaming of behaviors avoided. Psychiatrists and a dietician should be involved in these cases.
There have been concerns for decades about the media’s impact on adolescents’ body image and resulting EDs. This has only been further amplified with the advent of social media and online influencers. Social media is used to share information and it has become a significant tool for influencing others. It places huge value on the perfect body and appearance which may impact EDs in a number of ways. The solution for this is to use social media in a positive aspirational way to promote self confidence and respect, and a body positive attitude.
Call for action
- Providers should be trained to evaluate for eating disorders in adolescents presenting for gynecology care.
- National medical societies should encourage social media to promote a variety of body images, encourage exercise and support healthy eating habits.
- Providers, schools and social media should promote education strategies about normal body changes during puberty.
- Medical providers, coaches and parents should be trained to recognize RED-S in young athletes and refer them for treatment to avoid long-term health consequences.
Emily Gelson, United Kingdom Anastasia Vatopoulou, Greece
Menstrual Health Globally
Across the globe, the onset of menstruation (menarche) marks the entry of adolescent girls into the reproductive years of her life. Menstruation is a natural, inevitable biological process that is nevertheless highly stigmatized, to the point of making a serious impact on menstrual health, education, freedom, intimacy, autonomy, and personal development. Adolescent girls with menstrual disorders, such as severe pain or heavy menstrual bleeding, can experience significant impairment in quality of life. With the simple and cost-effective provision of education, hygiene supplies, and treatment of menstrual disorders, adolescent girls can stay in school, avoid shame, and live more productive lives. This document is a call to action for policy makers and providers of care for adolescent girls globally to address the menstrual health needs of adolescent girls.
Care providers should use the menstrual cycle as a vital sign for adolescent health, and treat menstrual disorders to improve the quality of life in adolescents.
Menstruation is a vital sign—just like heart rate, respiratory rate, or temperature. A person’s menstrual history offers valuable information regarding their overall health, yet it is often made invisible like no other physiological function. The menstrualhistory should be a routine part of the medical history taken of adolescent girls. Menarche usually occurs around 12 years of age, but can vary regionally by about12 months. Girls beginning menses before age 10 or without onset of menses by age 15 years should be evaluated for precocious or delayed puberty. It should be noted that, among adolescents, 90% of post-menarche menstrual cycles span 21 to 45 days. Girls with shorter cycles than 21 days are at risk of anemia from blood loss and should be evaluated, as should girls with persistently longer menstrual cycles than every 3 months, especially after the first year after menarche.
Heavy menstrual bleeding leading to anemia is a most common emergency gynecological issue in adolescents. HMB causes great concern for adolescents and their families, with school accidents triggering discomfort, shame, and low self esteem, and contributing to a lower quality of life. In adolescents, the most common causes of heavy menstrual bleeding are anovulatory cycles and underlying bleeding disorders, unlike in adults, where heavy menstrual bleeding can be structural due to myomas or malignancies.
The most common cause of abnormal uterine bleeding in adolescents (95%) is anovulation due to an immature hypothalamic pituitary gonadal (HPG) axis. Bleeding is characteristically heavy, protracted and irregular. Sleep disturbances and increased major stressors may trigger anovulatory bleeding. Underlying conditions such as hypothyroidism should be ruled out, but are less common in adolescents than adults. When patients with heavy menstrual bleeding present with severe anemia or profuse bleeding,or have a family history of heavy menses, 20% or more are found to have underlying bleeding disorders, most commonly Von Willebrand Disease.
Heavy menstrual bleeding can be safely controlled using combined oral contraceptives, even in young adolescent patients. These are widely available and inexpensive. The medication reduces menstrual blood loss by stabilizing the endometrium and reducing endometrial thickness. It is also safe to use oral progesterone, levonorgestrel intrauterine devices, DepoMedroxyprogesterone, and the contraceptive implant in adolescents who have never been sexually active to control blood loss. These medications do not impair future fertility, do not encourage sexual activity, and do not increase cancer risk. Where hormonal medications are not available or accepted by families, tranexamic acid can be used to decrease menstrual blood loss.
Significant pain with menses, dysmenorrhea, can significantly affect quality of life. 15-20% of adolescents miss school every month due to menstrual pain. Simple heating pads have been shown to reduce menstrual pain. Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen and naproxen as well as antispasmodics are effective in reducing the pain triggered by prostaglandins causing uterine contractions. Oral contraceptives also significantly reduce menstrual pain as well as blood loss. Adolescents with persistent pain not responding to these medications should be referred for specialty evaluation for uterine anomalies or endometriosis. Endometriosis has been found in up to 75% of adolescents with menstrual pain refractory to medical management.
Menstruation is a physiologic process, not a reflection of maturity or self-worth. Providers within cultures should advocate that girls should be protected from abuse or shame related to menses.
Menarche is a physiologic process that does not reflect readiness to engage in relationships or sexual activity, yet In some cultures, menarche is still perceived as a signal a girl is ready for arranged marriage and the onset of reproductive potential. This leaves girls exposed to forced child marriage and sexual abuse, especially in times of humanitarian crises. Menstruation is one indication of biological fertility but does not mean girls have reached physical, mental, psychological and emotional maturity.
When menstruation is not handled with dignity, related shame or teasing, as well as exclusion is common. Menstruation in some cultures is perceived as shameful or dirty. Not only does this view negatively affect individual self-esteem, it can also lead to restriction of access to religious spaces, school or extracurricular activities, and social gatherings, making women less able to participate in
public life due to common misconceptions. Conversely, adolescents who have delayed onset of menses can be disparaged as not real women and not be permitted to participate fully in society.
Providers and healthcare educators within cultures can help reduce the stigma and outsized societal role associated with menses.
Access to menstrual hygiene should be promoted to ensure the continued education of girls and to thereby reduce poverty.
In many areas of the world, menarche unfortunately marks the beginning of interrupted education due to lack of menstrual education, hygiene supplies, and facilities to cope with menstruation.
According to a study carried out by the World Bank and the United Nations Children’s Fund (UNICEF), out of the 1.8 billion menstruating people around the world, 500 million have no access to adequate facilities where they can fulfill their menstrual hygiene needs. It is estimated that, at the global level, 2 out of every 5 menstruating children miss 5 school days per month, on average, because of the lack of adequate infrastructure for menstrual hygiene.
In low- and middle- income countries, even adolescents with normal menses may struggle due to lack of access to menstrual management products,lack of adequate facilities for their private, acceptable handling, as well as the lack of safe water. In Latin America, 106 million people still lack an adequate restroom at home. This is compounded by the lack of education and guidance for menstruating children before their menarche, particularly in the more isolated, rural areas, as well as by cultural and religious factors that can create taboos that exacerbate the issue.
The high cost of menstrual management products leads to gender inequity. Girls with low socioeconomic status often rely on homemade, lower-quality dressings, owing to a scarcity of resources. When food or clothing drives are organized, or aid bags are given by the State, menstrual hygiene products should be included. Access to menstrual hygiene supplies such as sanitary towels or tampons should be provided in public restrooms.
Taxation of menstrual hygiene supplies creates a uniquely gendered barrier for poor families. In South America, Colombia passed in 2019 the VAT exemption of sanitary towels and tampons. In Argentina, several local and nationwide bills have been introduced to consider the provision of menstrual management products forfree at public establishments such as schools, hospitals, prisons, universities, and
shelters, among others, as well as the elimination of taxes on these kinds of items.In Peru, a bill was introduced in July proposing that menstrual management
products are recognized as basic necessities.
More and more countries are now beginning to address this issue, with the backdrop of feminist organizations’ campaigns such as “Free Period” in the United Kingdom, “Menstruación libre de impuestos” in Colombia and “MenstruAcción” in Argentina. Scotland has become the first country to legislate that free sanitary products are available to anyone who needs them.
Call to action:
1. Integrate scientific, gender-sensitive health education in school curriculum.
2. Encourage appropriate management of disabling menstrual symptoms such has heavy bleeding and severe pain so that girls can stay in school and have improved quality of life.
3. Support legislation and initiatives to provide funding for basic necessities
suchas clean water and private sanitary facilities to improve menstrual hygiene among adolescents
4. Advocate for a revisiting of cultural norms to end discriminatory and stigmatizing beliefs and practices surrounding menstruation that limit female adolescents from realizing their full potential in society.
FIGIJ, 10 January 2021
This advocacy statement has been endorsed by:
FIGO (International Federation of Gynecology and Obstetrics),
RCOG (Royal College of Obstetricians and Gynaecologists), and
EBPCGO (European Board and College of Gynaecology and Obstetrics).
Mental health in children and adolescents from a PAG perspective
As health care professionals delivering care to girls and adolescents, we must first be aware of the serious and important role played by mental health within this group of patients, with the goal of early detection of those who are vulnerable and at risk.
The hormonal and biological changes associated with puberty make the adolescent period a time of profound psychological and social transformation. The social world and peer interactions become increasingly important. The adolescent spends more time with peers than with their family and form more complex peer relationships. The importance of obtaining peer social approval increases and peer influence is heightened.
Gynecologists may be the only health care professional having a consultation with the adolescent and this provides a tremendous opportunity to address not only gynecologic problems and disease, but also the psychosocial determinants of health.
During consultation, all healthcare providers need to create opportunities to develop life skills and provide health services with safe and supportive environments. Gynecologists should develop skills to create a safe, nonjudgmental and supportive environment during consultation. The use of widely available screening tools allows for early detection of those who are at risk, permitting referral for supportive care, early interventions and management of mental health concerns. Mental health care professionals could also be trained primary care providers. The high frequency of mental health disorders and their associated negative consequences on reproductive health, render them a major health priority compared to other childhood chronic health conditions, such as obesity and asthma. Therefore, this document is a call for action for scientific societies, policy makers, professional associations, and providers of care for girls and adolescents globally to address mental health needs of girls and adolescents.
Global perspective of Mental Health Disorders
Globally, 10-20% of children and adolescents are affected by mental health disorders. This is equal in low, middle, and high-income countries. The prevalence of diagnosed mental health disorders across the world has increased, with three quarters of mental health disorders now identified before the age of 25. The worldwide prevalence of anxiety disorders in children and adolescents has been reported to be 6.5%, any depressive disorder 2.5%, attention-deficit hyperactivity disorder 3.4%, and any disruptive disorder 5.7%. The association between mental health disorders and suicide is well established. Some key problems that directly relate to teenage depression and anxiety are suicidal thinking (or behavior), and substance abuse. Teenagers who hide their depression and anxiety from parents and friends are at greater risk, and healthcare providers should be alert of these disorders, and their signs. Health providers should screen teenagers for signs of depression and suicidality privately to obtain as much accurate information, just as for sexual health and substance abuse.
Suicide is a global public health problem. Close to 800 000 people die by suicide every year. This equates to one person every 40 seconds. Suicide occurs in all regions of the world. Indeed, 79% of global suicides happen in low- and middle- income countries. More important worldwide, it is the second leading cause of death amongst 15-29 year-olds. The association between suicide and mental disorders is well established.
Many suicides happen impulsively in moments of crisis. A previous suicide attempt is the strongest risk factor for suicide. Other risk factors include experience of loss, loneliness, discrimination, a relationship break-up, financial problems, chronic pain and illness, (gender-based) violence, (domestic) abuse, and conflict or other humanitarian emergencies.
In the scientific literature, the evidence indicates that transgender adolescents have elevated rates of suicidal ideation and attempt compared with cisgender adolescents. Future research examining adolescent suicidality should also include transgender adolescents, so that the mechanisms of suicidality among transgender adolescents will be explained, helping to inform future intervention and prevention strategies designed to reduce suicidality within this vulnerable population.
How are mental health issues in adolescents affecting gynecological health?
The menstrual cycle can be used as a vital sign, not only for hormonal and medical conditions but also as a window into the psychosocial and mental health of adolescents. It is both affected by psychosocial stressors and at times directly affects the mental health of adolescents. Anovulation, which is common in normal adolescence and visible as menstrual cycle irregularity, can all be triggered by eating disorders or malnutrition, sleeping disorders or a stressful environment. In addition, heavy menstrual bleeding and painful cycles can interfere with school and social activities that can affect mental health. Depression and anxiety increase the perception of pain. In adolescents this may be manifest as severe dysmenorrhea or chronic pelvic pain, especially in girls who have a history of physical or sexual abuse.
Normal adolescence may be a time of risk taking, however adolescents with major
psychosocial stressors and/or mental health issues may engage in acting-out
behavior or substance use, which increases their risk of unsafe sexual behavior. This increases the risk of unplanned pregnancy or a sexually transmitted infection. These risks are augmented in teens thar are neglected or abused.
While most gynecologists are not comfortable treating psychosocial and mental
health issues in adolescents, providing a point of detection and referral, as well as a supportive environment and management of gynecologic sequelae is within the
scope of practice. Asking about trauma and abuse and referring to appropriate
authorities and counselors should be routine part of practice. Recommending the
use of long acting reversible contraceptives (LARCs), frequent sexually transmitted
infection (STI) screening, and encouraging condom use in girls with high risk sexual behavior can provide a safety net until better decision-making skills are developed. Finally, for girls with significant psychiatric illness, the gynecologist should be aware of the side effects of some psychiatric medications such as antipsychotics like oligomenorrhea and hypoestrogenemia induced by elevated prolactin.
What did COVID-19 bring to this issue?
The Covid-19 pandemic has aggravated and accentuated the issue of mental health in adolescents as it has affected them socially, academically, and emotionally, and for many, generating a large negative impact that cannot be fully appreciated at this point of time.
In this global pandemic, an adolescent’s individual, familial, and social vulnerability, as well as individual and familial coping abilities, impact upon resilience and risks for long-term mental health.
Consequences of the Covid-19 pandemic have included extended home confinement, virtual education and deprivation of social interaction, intrafamilial violence and overuse of the internet and social media. All these factors can influence the mental health of the adolescents.
Besides previously recognized risk factors for poor mental health such as abuse and trauma, increased reliance on virtual education resulting in social isolation, as well as pressure from and social media may be leading to increased depression and anxiety.
Young people’s use of social media results in less face to face communication, overdependence on being “liked” for social validation, shaming by peers over appearance or behavior, and even pressure to keep up with discussion for 24 hours leading to impaired sleep. Girls are more vulnerable to the negative effects of social media than boys.
All providers of reproductive health services caring for adolescents should take into consideration the role of the psychosocial determinants of health, and should utilize tools and skills to screen for mental health issues, and timely refer adolescents detected at risk.
Call to action
1. Screen adolescents for major psycho social stressors and mental health issues that affect reproductive health, and be able to refer adolescents in a timely manner for help.
2. Promote the development of enhanced mental health services. Despite global recognition of the importance of mental health promotion and prevention in children and adolescents, a gap remains between need and available resources.
3. Include education and training in gynecology society meetings on identification and management of psychosocial determinants of health, especially as they affect gynecologic health.
4. Recognize the long-term impact of Covid-19 on the mental and reproductive health of adolescents.
14 March 2021
This advocacy statement has been endorsed by:
FIGO (International Federation of Gynecology and Obstetrics),
RCOG (Royal College of Obstetricians and Gynaecologists), and
EBPCGO (European Board and College of Gynaecology and Obstetrics).
Single Dose HPV Vaccination
The International Federation of Pediatric Adolescent Gynecology (FIGIJ) supports the initiation of single-dose human papilloma virus (HPV) vaccination programs, especially in low- and middle- income countries (LMICs) where they can have the greatest impact. A recent review by Gallant et al in the Journal of Pediatric Adolescent Gynecology provides ample evidence for support of this strategy, highlights of which are emphasized in this advocacy statement.
Cervical cancer is the world’s fourth cancer type among women after breast, colorectal and lung cancer. It affects more than half a million women annually, and it caused 311,000 deaths in 2018. 84% of invasive cervical cancer cases occurs in LMICs, and low-income nations bear 88% of this type of cancer’s mortality rate.
90% cervical cancer is caused by high risk HPV, and that 80% of women are infected with HPV at some point in their lifetime. Persistence of HPV infection and development of cervical dysplasia are the greatest risk factors for cervical cancer.HPV vaccination and cervical dysplasia screening programs are the major public health strategies to prevent cervical cancer in the general population. HPV vaccination is safe and effective, and would have the greatest impact in prevention of cervical cancer in resource-poor countries where screening is unaffordable or unavailable, treatment options are limited, and morbidity and mortality remain high.
Current Global HPV vaccination coverage
While 80%of high income countries have implemented HPV vaccine programs, only 41% of LMIC have vaccination programs, resulting in 15% global HPV vaccination coverage.
Reflecting the implementation of HPV vaccination programs in HIC, by 2014, 32% of females aged 10-20 had received the full course of the HPV vaccine, while 41% had received at least one dose. In contrast, in Latin America, 19% of females aged 10-20 had received the full course of the vaccine, and 22% had received at least one dose. A large majority of the female population worldwide, but concentrated in Africa and Asia, have still not been vaccinated. This means that the most vulnerable populations, which would benefit most from vaccination, remain unprotected.
Evidence for Single-Dose HPV Vaccination Efficacy
Current WHO guidelines recommend a 2-dose vaccination for girls between age 9-14 years, ideally prior to onset of sexual activity and exposure to HPV. HPV vaccines are known to be highly immunogenic, and the earlier they are given the higher immune response is achieved. In fact, several studies are now assessing the level of protection against cervical cancer from a single dose. Observational studies carried out in the last decade have shown that a single dose of the HPV vaccine can achieve a good level of protective antibodies for at least 7-10 years. The Costa Rica Vaccine Trial (CVT), the Papilloma Trial against Cancer in Young Adults (PATRICIA) and a large Indian research project conducted by Sankaranarayanan et. al. suggest that a single dose of the vaccine provides long-lasting protection against infections with HPV 16 and 18. In their review, Gallant et al cited 8 large multinational, multiethnic long-term studies, including those mentioned, which demonstrate observational data that single doses of HPV vaccination provides at least 7-10 years of prevention against persistent HPV and cervical dysplasia.
Equity in HPV vaccination
The COVID pandemic and COVID vaccine implementation has highlighted global disparitiesinvaccination. Throughcost-effectivestrategies,thesignificantburdenof HPV-related disease can be reduced in LMICs. School-based single dose HPV vaccination, done when girls are aged 9-14 years would provide optimal coverage especially in poorer countries, where continuation through secondary education is lower for girls. Sexual assault and abuse of girls is unfortunately a global issue, and HPV vaccination may help prevent cervical cancer as a sequela in this very vulnerable group. Single-dose vaccination will increase the vaccine dose availability, supply of which has been noted to be low at the moment. Finally, single dose vaccination will facilitate vaccine access and affordability for LMIC.
Call for action
1. Increased availability of HPV vaccination globally, including LMICs.
2. Where possible, WHO guidelines recommending 2-dose vaccination for age 9-14 year olds should be followed.
3. Consideration of global endorsement of single-dose HPV vaccination, especially for LMICs where access is currently limited.
Copyright FIGIJ 2021
Judith Simms-Cendan, MD, United States Clara Di Nunzio, MD, Argentina Anastasia Vatapoulou, MD, Greece
Nutrition and Reproductive Health in Childhood and Adolescence
Introduction / Purpose
While nutrition is important during the whole life span, for children and adolescents adequate nutrition is of utmost importance for growth and development. During adolescence, the nutritional needs are the greatest. These nutritional needs relate to the fact that adolescents gain up to 50% of their adult weight, more than 20% of their adult height, and 50% of their adult skeletal mass during this period.
In low and middle income countries (LMIC) each year nearly 6 million deaths among children under-five years of age are associated with malnutrition. The world’s adolescent population, about 19% of the total population, faces serious nutritional challenges not only affecting their growth and development but also their health and livelihood as adults.
The World Health Organization (WHO) identified the main nutritional problems affecting adolescent populations worldwide, they include:
- undernutrition in terms of stunting and severe underweight, with subsequent catch-up growth leading to obesity,
- perpetuation of intergenerational undernutrition through intrauterine growth retardation of the fetus in undernourished pregnant adolescent girls;
- iron deficiency and anemia, exacerbated by the onset menstruation
- deficiencies in vitamin and mineral intake necessary for physical and mental health, especially of vitamin A, iodine, calcium, folate, zinc and other micronutrients;
- obesity, especially due to intake of high calorie, low nutrient foods and sedentary behavior.
Worldwide, the prevalence of being overweight has increased, however the prevalence of being underweight has remained the same in recent decades. As a result, the global distribution of BMI has widened. However, it remains important to realize that the global burden of being moderately or severely underweight is still
higher than that of being overweight. This Statement focuses on the gynecological consequences of over- and undernutrition. For undernutrition due to eating disorders, see FIGIJ Statement Eating disorders.
The global prevalence of being underweight among children and adolescents is 8.4% for girls. It is important to understand that undernutrition goes along with poverty, but also with family structure. Gender bias in child care, which often puts females at a greater disadvantage in terms of nutrition, means that female children may be served last in disadvantaged families.
The prevalence of being moderately and severely underweight is highest in South Asia. While the lowest mean BMIs for children (aged 5–9 years) are found in East Africa and the lowest mean BMIs in adolescence in South Asia.
The consequences of chronic malnutrition, in early infancy and childhood mainly and to a lesser extent inadequate nutrition in adolescence, can potentially retard growth and sexual maturation. When using maximum growth spurt or menarche as an indicator, the onset of puberty can be delayed in malnourished girls by an average of two years. In addition, the delayed growth and maturation in girls attributed by malnutrition further increases the risks associated with adolescent pregnancy, as biological age lags behind chronological age, for example leading to increased maternal morbidity. Adolescent pregnancy exposes both the stunted or undernourished mother and her child to adverse health and socioeconomic consequences. Decreased bone mineralization occurs when puberty is delayed and there is inadequate energy availability for bone development. Low iron intakes alone do not fully account for the high prevalence of anemia. A 12% menorrhagia rate was found among menstruating girls aged less than 20. Heavy menstrual bleeding was suspected to be an important contributor to the high rate of anemia (40%, see also FIGIJ Statement Menstrual Health).
A massive global epidemic of obesity is emerging in children and adolescents. Globally, the prevalence of obesity has risen from <1% in 1975 to more than 5% in girls. Obesity has increased in all regions of the world, with the largest proportional increase in southern Africa. At the moment, 10% of school children have obesity in (high income countries) HIC.
The increase in sedentary lifestyle, largely due to the increase in the time spent in front of screens added to bad eating habits, with excessive consumption of fast foods, quickly leads to overweight and obesity. Mandatory COVID isolation and school closures further contributed to decreased activity.The lack of correct labeling of food products, providing information on food content, added to the poor food education of adolescents, are two serious issues that aggravates this problem and should be addressed.
Obesity, and poor metabolic profile in adolescence are associated with non-communicable diseases, e.g. hypertension and diabetes mellitus, and mortality later in life. Obesity is increasing globally in LMIC undergoing a nutrition transition from food insecurity and undernutrition problems, to overnutrition with high caloric low-nutritional value food..
Obesity may be brought about by poor nutritional choices of adolescents (poverty, access to healthy food, education (school/families)). In high-income countries overnutrition can focus more on life-style interventions, whereas for LMIC access to healthy food and education are more important.
We, as healthcare providers, should be concerned about adolescent overnutrition because we are already observing the impact and it’s gynecologic consequences amongst our patients. Childhood obesity leads to earlier pubertal onset which can put the child at risk of sexual abuse.
Overnutrition leads to cycle disturbances like, oligomenorrhea and amenorrhea. As a consequence of obesity, there is an increased risk of developing PCOS, fertility disorders, and increasing the risk of endometrial cancer later on in life.
- Adolescence is a vulnerable period and provides a window of opportunity for nutrition education and prevention of non-communicable disease
- When a patient with early puberty, delayed puberty, or cycle disturbance comes to the office, nutrition status should be assessed.
- Adolescents are usually open to new ideas and many habits acquired during adolescence will last a lifetime. With increasing age, adolescents’ personal choices and preferences gain priority over eating habits acquired in the family, and have progressively more control over what they eat, when and where. For these reasons, adolescents are an ideal target for nutrition education.
Call for action
- All healthcare providers should screen nutritional health status in the adolescent population in order to prevent negative reproductive health consequences of nutritional problems.
- Legislation for adolescent nutrition programs (IEC, screening, program intervention) and support for healthy school-based meals.
- Stakeholders (national gynecologic societies, (social) media, schools,families) should advocate for healthy evidence-based nutritional policies in schools, cafeterias and clinics.
- FIGIJ supports and endorses the WHO and UNICEF statements for proper adolescent nutrition.
©2022, second version
Angela Aguilar, Philippines
Mariela Orti, Argentina
Evelien Roos, the Netherlands
Pediatric and adolescent gynecology through a global lens
Girls and adolescents, aged 0–19 years make up almost 30% of the world’s female population yet their specific healthcare needs often slip between the gaps of pediatrics and adult women’s health. Pediatric and adolescent gynecology is the clinical field that endeavors to address the reproductive health needs of this age group. The environment and psychosocial well-being, social determinants of health, have direct bearing on reproductive health, affecting menstrual cycles, menstrual hygiene, and risks for unintended pregnancy and sexually transmitted infections. This narrative review will highlight common gynecologic conditions of adolescents, especially where diagnosis and management are distinct from adult women. It will also present preventive health strategies to improve reproductive health through vaccination, improved access to hygiene supplies and contraception.
This article will highlight common gynecologic conditions of adolescents, and will also present social determinants to improve reproductive health.
Eveline J. Roos, Judy Simms-Cendan, Charleen Cheung, Deborah Laufer, Sonia R. Grover, on behalf of FIGIJ board in collaboration with FIGO
Published in the International Journal of Gynecology & Obstetrics
© 2020 International Federation of Infantile and Juvenile Gynecology. All Rights Reserved.