UNIT 3: ADOLESCENT VULNERABILITIES, RISK-TAKING BEHAVIORS, AND CONSEQUENCES INTRODUCTION: Adolescence is more than a time of individual social, emotional and physical change. Their interactions with adults and their peers change as well. Understanding the social and cultural forces that shape adolescents and young peopleÕs choices and behaviors, and create risks and vulnerabilities enables providers and counselors to better serve youth. Understanding and managing risk is a vital part of the transition from adolescence to adulthood, and one that cannot be managed without support, especially since some risks have long-reaching consequences. Providers need to discuss with young people the potential outcomes of risk-taking, help them to learn from their experiences, and counsel on protective factors. UNIT TRAINING OBJECTIVE: To help providers identify adolescent vulnerabilities, understand adolescent risk-taking behavior and its consequences, and promote protective behaviors that better address the sexual and reproductive health needs of all adolescent clients. SPECIFIC LEARNING OBJECTIVES: By the end of the unit participants will be able to: 1. Identify vulnerabilities, social and cultural pressures, rights and concerns of adolescents. 2. Identify the WHO standards of care for adolescents. 3. Discuss specific vulnerabilities and adolescent risk-taking behavior and its benefits and consequences. 4. Build skills and advance protective factors that empower adolescents with regards to risk-taking, vulnerability, and health. TOTAL TIME: 3 HOURS UNIT OVERVIEW: Session Methods Materials Time 3.1 Powerwalk exercise TrainerÕs Tool 3a 45 minutes 3.2 Group discussion Trainer presentation Participant Handout 3a (from previous Unit) Slides 3.1-3.10 10 minutes 45 minutes 3.3 Fishbowl debate Group discussion Chairs 1 hour Unit Summary Reflection 20 minutes WORK FOR TRAINERS TO DO IN ADVANCE: * Review Slides 3.1-3.10 * SO 3.1: Prepare participant role cards (TrainerÕs Tool 3a) for powerwalk exercise. Review for local contextual relevance and print onto cards or slips of paper for participants. MAJOR REFERENCES AND TRAINING MATERIALS: United Nations Definitions of Human Rights, found at http://www.un.org/en/sections/issues-depth/human-rights/ UNFPA Definition of sexual and reproductive health, found at http://www.unfpa.org/sexual-reproductive-health World Health Organization Definition of sexual health found at: http://www.who.int/topics/sexual_health/en/ SPECIFIC OBJECTIVE 3.1: IDENTIFY VULNERABILITIES, SOCIAL AND CULTURAL PRESSURES, AND RIGHTS CONCERNS OF ADOLESCENTS. TIME 45 minutes METHODS * Powerwalk Exercise * Group discussion MATERIALS NEEDED * TrainerÕs Tool 3a: Powerwalk role cards STEPS Time: 45 minutes 1. Explain that people experience different levels of vulnerability and understand their rights differently depending on their age, sex, disability and other factors. Tell participants that this activity is to explore the experience of being young or marginalized in their society. 2. Ask participants to line up on one side of the room. Make sure thereÕs enough space for participants to move in front of them. This may require moving chairs or pushing tables out of the way. 3. Hand out Powerwalk Role Cards (see TrainerÕs Tool 3a: Powerwalk Role Cards below) to participants. You can adapt these cards to fit your context as needed. Give each participant one card. 4. Explain to participants that for this activity you want them to assume the ÔroleÕ on their card. Invite participants to visualize their character. Where would they live? Do they have one or multiple disabilities? If yes, which type(s)? What would their family be like? What would they do during a typical day? What kinds of problems would they have to face? 5. Tell participants that you will read out a series of statements. For each statement, consider whether it would be ÒtrueÓ for their character or Òfalse.Ó If the statement would be ÒtrueÓ for their role, participants should take one step forward. If it doesnÕt, they should stay where they are. 6. Read Content: Powerwalk Statements (below) one statement at a time, giving participants time to consider each statement and take a step as appropriate. Content: Powerwalk Statements (Adapted from Amnesty International: Respect my rights, respect my dignity) * I can read and write. * I know where my next meal will come from. * I can move about easily and freely. * I have had or will have opportunities to complete my education. * My family would support me if I got pregnant now. * I have time to read and keep up with news every day. * I know and understand what changes are happening in my body. * I have people in my life that I can talk to about my body and my relationships. * I know where I can find money when I need it. * I can decide when to see a doctor and what doctor to see. * I can refuse sex for money or other resources, such as school fees or a place to live. * I can leave my partner if s/he threatens my safety. * If my sister or my friend gets pregnant, I know where to take her. * I can ask my partner to use a condom or some other form of contraception. * I can easily obtain contraception. * I have emotional support when IÕm unhappy. * I can choose who I marry and when I marry. * I can decide how many children I have and when. * I know how to protect myself from unwanted pregnancy. * I know how to protect myself against HIV and other sexually transmitted infections. * I can take steps to protect myself from HIV and other sexually transmitted infections. * I am in control of my sexuality. * I am in control of my future. * If a crime is committed against me, the police would listen and help. * I can be out at night and not worry about being assaulted. * I can easily find work. * I am respected by most members of my community. 7. After reading all the statements, have participants stay in place. Start with the participant closest to the front of the room, who has taken the most steps forward, and ask them to reveal to the group who their character was. Compare their character with a participant at the back of the room, who has taken fewer steps. 8. Ask the group why they think they ended up distributed this way. Have participants reflect individually on how they feel about where they have ended up. 9. In plenary or in small groups of 2-3, have participants consider the following questions: a. How did your characterÕs age affect your answers to these questions? How did their sex affect your answers? How did their disability status affect your answers? b. What vulnerabilities did your character have? How did these vulnerabilities affect your answers with respect to their health? c. Did the Ònon-healthÓ questions raise any areas of concern for you when it comes to young peopleÕs abilities to obtain health services? How so? d. What general risks and vulnerabilities do you think adolescents experience? e. What are some things that might protect young people from these risks and vulnerabilities? Refer to TrainerÕs Resource 3b as needed. f. What things could you as a health care provider do to make it easier or safer for young people to seek services? How can you promote these protective factors? TRAINERÕS TOOL 3A: POWERWALK ROLE CARDS 14-year-old boy, with a visual disability, attending a special school Unmarried, mother of 1 or more children with physical disabilities. 17-year-old gay male with depression Married mother of 3, with a psychosocial disability Commercial sex worker, 21, female, with a hearing disability 16-year-old, with a hearing disability, domestic worker Refugee, 17, out of school Girl, 12, living in a rural community Bank teller, female University student, male 14-year-old girl, in school 15-year-old girl, married, out of school Male business executive 12-year-old girl living in slum area WomenÕs rights activist, female 17-year-old gay male Male from a minority ethnic group Teenage girl living in a very religious/traditional family Teenage boy living in a very religious/traditional family 25-year-old questioning their sexual orientation Commercial sex worker, 21, female Political leader, 35, male Grandmother, 65, living in poverty 10-year-old male, living on the street 16-year-old domestic worker Married mother of 3, working in a market Unemployed openly gay male activist, 32 Female doctor, 42 Male taxi driver, 33 SPECIFIC OBJECTIVE 3.2: DISCUSS SPECIFIC VULNERABILITIES AND ADOLESCENT RISK-TAKING BEHAVIOR AND ITS BENEFITS AND CONSEQUENCES TIME 55 minutes METHODS * Trainer presentation * Group discussion MATERIALS NEEDED * Slides 3.1-3.10 STEPS Time: 10 minutes 1. Ask participants to revisit their handout from the previous unit, Participant Handout 3a: Developmental Characteristics of Adolescence and Young Adulthood. Draw their attention to the language under ÒSocial and Emotional DevelopmentÓ that discusses how adolescents push boundaries, take risks, and demonstrate increased independence. 2. Tell participants that the discussion will focus on how adolescence is a time when young people are comfortable with and attracted to taking risks. We will discuss how Òrisk takingÓ affects the adolescent both positively and negatively. 3. Ask participants to call out some examples of adolescent risk-taking behavior. 4. Challenge participants to brainstorm some positive reasons for and results from adolescent risk taking. Use this brainstorm to transition into presenting Content: Adolescent Risk-Taking (Slides 3.1-3.10) below. Time: 45 minutes Content: Adolescent Risk-Taking (Slides 3.1-3.2) Slide 3.1-3.2: Reasons for Risk-Taking We know that major physical, cognitive, emotional, sexual and social changes occur during adolescence that affect young peopleÕs behavior. These include: * New social relationships. Peers become very influential and family influence decreases. Adolescents may engage in risky behaviors that identify them with their peer group or demonstrate how they Òfit inÓ. * Curiosity combined with sexual maturity. Adolescence is naturally a time of experimentation. Experimentation is a normal aspect of development because it helps adolescents learn more about their body, feelings, and values * Questioning authority and established ÒrulesÓ. An important ÒtaskÓ of adolescence is to create an independent identity and personality. However, this questioning of authority can also lead to impulsive decision-making and a lack of awareness of future consequences. * Adolescents test their limits. Young people often underestimate risk, although the level of risk and vulnerability varies with culture, individual personality traits, social influences, needs, pressures, and opportunities. * Brain development. There is a period of significant brain development during adolescence; however, areas of the brain grow and mature at different rates. The limbic system grows rapidly in early adolescence, while the prefrontal cortex completes its growth in late adolescence/young adulthood. The limbic system gives us a rewarding feeling when we take a risk, which likely contributes to young peopleÕs propensity to engage in Òrisk behaviors.Ó Since the pre-frontal cortex completes its growth later as young people mature they also develop better reasoning skills, more control over impulses and better judgment. Pause and ask participants to reflect on adolescents they know, whether personal or as clients. What types of risks do they take? What kinds of vulnerabilities do they face that might contribute to risk taking? Are there benefits to risk-taking? 5. Return to presentation with Slide 3.3: Common Vulnerabilities below. Encourage participants to add additional vulnerabilities Slide 3.3-3.8: Common Vulnerabilities * Age-based discrimination o Adolescents are frequently denied information and services based on their age or marital status. o Adolescents are denied the choice and autonomy/independence to make their own decisions. * Gender inequality o Adolescent women are discriminated against for being sexual. o Adolescent women are not encouraged to act independently and make their own choices, especially with regards to sexuality. o Adolescent women are expected to be responsible for their own and their partnersÕ health. o Adolescent women are more likely to experience discrimination in housing, education, employment, or other areas. o Harmful traditional practices, like female genital mutilation and early and forced marriage, seriously affect the sexual and reproductive health of adolescents. o Adolescent boys are expected to conform to rigid norms of masculinity, including expectations around sexual prowess. * Sexual and gender-based violence o Adolescents experience violence in their families, intimate partnerships, and societies. o Adolescents who experience sexual violence are frequently stigmatized or shamed for their experience when they report it. o Adolescent women and men may face violence to correct their behaviors when they fail to conform to social norms about gender and sexuality. * Economic hardship o Adolescents have less access to money, employment opportunities, and disposable income than other age cohorts. o Adolescents who work, frequently do so to support their families. * Disability-based discrimination o Adolescents with disabilities are rarely regarded as subjects of sexual rights. o Adolescents with disabilities are often assumed as asexual, not sexually active, or hypersexual. o Adolescents with disabilities are often assumed as not able to decide by themselves about their sexual life. o Adolescents with disabilities face significant attitudinal, physical, communication and financial barriers in reporting violence and abuse and when accessing SRH information and services. o Adolescents girls with disabilities are often denied their reproductive autonomy. o Adolescent boys with disabilities may be considered less able to meet the expectations around sexual prowess. o Adolescents with disabilities are three to four times more likely, to face violence than their peers without disabilities. o Behaviours such as undressing or masturbating in public, hugging, kissing or touching other peopleÕs breasts and genitalia without permission have been reported as frequent among young persons with intellectual and developmental disabilities who are entering adolescence. They are usually unaware of such behaviours being perceived as inappropriate. Parents and teachers often recur to punishment trying to control and prevent them. o Mental health conditions such as depression or schizophrenia often set in during adolescence and result in psychosocial disabilities. Parents and teachers often mistakenly attribute them to adolescentsÕ attitudes and tend to criticize or punish them instead of providing adequate support. Slide 3.9: Types of Risk-Taking Behavior * Impulsive decision-making * Failure to consider consequences * Lack of information about risk * Social, sexual, or other experimentation * Provoking or testing limits through argument Slide 3.10: Outcomes of Adolescent Risk-Taking * Development of sense of independence, resiliency * Potential for unintended pregnancy, infection with HIV/STIs * Growth in or failure of social and family relationships * Early child-bearing, complications in childbirth and/or unsafe or forced abortion, and forced sterilization * Risk of sexual or interpersonal violence * Loss of educational or economic opportunities * Poor nutrition or other health outcomes 6. Ask participants to reflect on the relationship between vulnerability and risk. Ask for examples of how they can help adolescents navigate risk. What are some factors that can protect adolescents from or lessen the effect of risk? SPECIFIC OBJECTIVE 3.3: BUILD SKILLS TO EMPOWER ADOLESCENTS WITH INFORMATION ABOUT RISK-TAKING, VULNERABILITY, AND HEALTH TIME 1 hour METHODS * Fishbowl debate * Group discussion MATERIALS NEEDED * None STEPS Time: 1 hour 1. Set up the room with all the chairs in a circle and two chairs in the center. Ask for two volunteers to sit in the center chairs to start the conversation. Identify one of the chairs as the Òpro-adolescentÓ position, and the other as the Òhealth providerÓ position. 2. Explain to participants that they will be taking part in a fishbowl debate/discussion, using the following rules: a. The participant in the Òpro-adolescentÓ position will be asked to respond to the prompts (below) posed by the facilitator from the perspective of an adolescent who wants to be able to Òtake risksÓ and have fun while staying healthy. b. The participant in the other, Òhealth providerÓ chair will be asked to respond to the prompt as a provider who discourages risk taking. c. At any time, participants in the outside circle of chairs can jump in to the discussion by tapping one of the participants on the shoulder and taking their seat. d. When a new participant joins the discussion, they take on the position of the seat they are in. e. When a participant in one of the fishbowl seats is tapped on the shoulder, they should finish their immediate thought or sentence and then allow the new participant to come in. They can tap back in later if they would like to rejoin. 3. Give participants the following prompt and allow 5-10 minutes for discussion. If the discussion slows, or starts to falter, move on to the next prompt. Prompt 1: Having information about sexuality and sexual and reproductive health, could encourage young people to begin sexual activity at a younger age. 4. Use the following prompts to continue discussion. You may use as many or as few of the prompts as needed to keep discussion going. Prompt 2: Adolescents should explore their sexuality through masturbation or watching porn before entering a sexual relationship with another person. Prompt 3: All adolescents need the same information about the risks of sexual activity and be counseled to avoid sexual activity, regardless of their sex as well as economic, relationship, disability, educational, or other status. Prompt 4: Since adolescent girls are most likely to experience negative consequences associated with sexual activity such as pregnancy or HIV, they have the most responsibility to avoid risk. Prompt 5: Since adolescent girls with disabilities are more likely to be affected by sexual violence than their peers without disabilities, they should refrain from dating or engaging in intimate relations. 5. When participants are finished discussing the prompts, have them remain in the circle for a quick wrap-up discussion. Ask participants to reflect on how they found playing the Òpro-adolescentÓ and Òhealth providerÓ role. Ask the participants if they felt constrained by either role, and how they found common ground between the two roles. UNIT 3 SUMMARY TIME 20 minutes METHODS Reflection MATERIALS NEEDED None STEPS 1. Ask participants to come together to reflect on the sessions. Use the following questions to guide discussion: * What new information did participants learn in these sessions about adolescent vulnerability and risk-taking? * How does adolescent vulnerability affect risk-taking behavior? * How can we reduce adolescent vulnerabilities? * What are some protective factors that we can encourage? * What, if anything in these sessions surprised you? Why or why not? NOTES PAGE What was the least useful part of this training? What suggestions do you have to improve the module?