By: Merrian Brooks*
The onset of puberty is a pivotal time in many cultures, when children’s bodies evolve into their reproductive potential. This transition time has, in the last 100 years or so, been labeled adolescence, or a time between the end of childhood and the beginning of adulthood that starts with puberty.1
In African societies, this time often informs many rites of passage. It is a time when children are taken away to learn the ways of adults, returning with the skills necessary to fulfill that role in their particular community. The emphasis on the importance of this transition, and the importance of setting aside a time and space to teach young people about what the next stage of life is, indeed, something many African cultures have done ‘right’ for centuries. Young people enter these rites as children and emerge from these ceremonies at adults.
For the most part, in the US, Europe, and other ‘western’ countries, rites of passage don’t formally exist: learning about the changes one’s body may go through and the new implications for a person’s role in society are often randomly and sloppily figured out. Adulthood is described as a state of maturity, and that state is formally estimated to be around the age of 18. Legally, most decisions, except for the right to consume alcohol in the US, can be made independently by an 18 year old–since this is when people are expected to be able to function independently. This leaves a span of many years between when someone has experienced puberty and when they are considered by society to be adults, and this time is seen as a distinct developmental stage with medical problems specific to young people.
Given the distinction between an acknowledged transitory state in Western countries, and the rite of passage model in many African communities, multiple questions arise. What exactly is meant by “adulthood”? What does it mean to be a man or a woman? How does one reach that state? Is the developmental stage of adolescents accepted in cultures which emphasize puberty as the checkpoint to adulthood without a clear transitory stage? In places where tradition continues to dictate young marriage and pregnancy, (as it used to in Europe and the US)2 does that transitory state of adolescence exist and should it?
Adolescence – as a physical stage of bodily changes related to development of the reproductive system–has been researched for years. However, only recently have studies been done on the intellectual development that occurs in the teen years. These studies have shown that there are areas of the brain that continue to develop in adolescence until one enters their twenties. Early on, there is a heightened sense of reward making exciting things even more fulfilling. There is also the development of a more complex understanding of logic that over time evolves to abstract thinking. This translates to smart people that sometimes make poor decisions with a new-found bravery, in pursuit of reward. Studies show that this distinction is associated with the fact that the adult brain–unlike the adolescent brain–has a more developed pre-frontal cortex, an area associated with long-term planning and delayed gratification3. Adolescents are generally healthy, and the things that cause them sickness and death are mostly preventable, having to do with the normal process of learning to navigate decisions involving the pursuit of rewards. What we, as medical professionals often see, then, are accidents, death due to violence, the beginnings of drug addictions, and a high incidence of sexually transmitted infections.
As a healthcare professional with interests in this particular stage of development, I wonder if ‘adolescent medicine’ makes sense in African contexts, particularly those which emphasize rites of passage as an introduction to adulthood. There are numerous studies in the US and Europe showing that adolescents have particular needs within healthcare. Adolescents are treated in pediatric-oriented hospitals and clinics by practitioners trained in the distinct physical, social, emotional and intellectual stage of adolescence. This idea has been supported in South African medical literature, where the importance to adolescent specific care particularly as it relates to chronic disease, is seen as being needed in the South African healthcare setting4.
This particular publication (and many similar to it) are informed by a preconceived notion of what adolescence is, as described by mainstream medicine. The question then becomes: should we use this proposed framework to build a health system for adolescents across Africa? In many medical systems in Africa, teenagers are cared for by adult medicine doctors in adult wards. Should we bring the 13-18 year olds out of the adult medical wards and into the pediatric ones like we do in the US and Europe? Does this fit with the cultural frameworks assumed by a rite of passage being the entry into adulthood?
The question of whether societies should consider adolescence as an extension to childhood, where teens are sheltered from certain adult responsibilities, like marriage and parenting, is not terribly straightforward. On the continent, where an estimated 42 percent of girls marry before age 18, the question of when a community should encourage pregnancy is a complex one, given that a young person is physiologically able to do so at around age 13. There are studies to show that outcomes are much worse when very young teens have pregnancies with high maternal and infant mortality, but giving birth in the later-teen years is not as problematic.
Despite the complexities involved in the societal question of adulthood, I do believe that adolescence should be seen separately from the adult in the medical context. The model of adolescent medicine recognizes that the transition to adulthood involves changes in your body and mind that require special consideration when providing advice, assessing for medical risks, and screening for medical problems more common in these age groups. This is no less true in the African contexts that have been studied. One great study was done by Page et al. in 2009 of almost 25,000 adolescents in 6 countries in Eastern and Southern Africa5. This study found that teens who use alcohol and/or have significant psychosocial stressors are more likely to engage in sexual activity than their non-stressed, alcohol-abstinent peers6. This is one of several similarities we find between young people in African and adolescents in the US and Europe.
The bigger question is whether society also needs to be on board in order for adolescent-specific interventions to be acknowledged and implemented by teens and families. If adolescents in a particular community consider themselves adults, how will they respond to being hospitalized with children, or treated by pediatricians with some training in teen health? If a practitioner saw that an adolescent, based on developmental stage, needed a parent or guardian on board to make a major medical decision, would the family member consider that appropriate for their adult son or daughter? Would the young person reject that necessity? Here sociology meets medicine. I’m not sure what the answer is, but in order to seriously implement a system of ‘adolescent health,’ where it has not existed before, these questions and many more must be addressed. Regardless of how this age group is seen in a culture, there is still a need for medical professionals to be able to address the specific concerns that come up around the teenage body and mind.
*Merrian is a regular Bokamoso Leadership Forum / BLF Contributor. Her short biography and previous articles can be found here.
2 Kuker, Kristin.1997. Dubious Conceptions: The Politics of Teenage Pregnancy
4 Cristina Stefan, Pieter-Luttig van der Merwe Treating adolescents in South Africa: time for adolescent medicine units? SAMJ 2008, 98; 184-187)
5 Countries included Namibia, Botswana, Kenya, Uganda, Zimbabwe, Zambia
6 Page RM, Hall CP, Psychosocial distress and alcohol use as factors in adolescent sexual behavior among sub-Saharan African adolescents. J Sch Health. 2009;79: 369-379.