Chapter 113

WHO: Health effects of smoking among young people. https://apps.who.int/tobacco/control/populations/youth_health_effects/en/
index.html

4

WHO: Heat-Not-Burn tobacco products information sheet. https://apps.who.int/tobacco/publications/prod_regulation/heat-not-burnproducts-information-sheet/en/index.html

56

WHO: WHO Framework Convention on Tobacco Control. 2003. https://www.who.int/fctc/text_download/en/
Chheng N. New tobacco device banned. The Phnom Penh Post. March 21, 2021. https://www.phnompenhpost.com/national/new-

Mental and physical changes duringadolescence

tobacco-device-banned
7

Ministry of Health, Labour and Welfare: e-healthnet “Health effects of alcohol.” https://www.e-healthnet.mhlw.go.jp/information/
alcohol-summaries/a-01

8

Ministry of Health, Labour and Welfare: e-healthnet “Alcohol and dependence.” https://www.e-healthnet.mhlw.go.jp/information/
alcohol-summaries/a-05

9

Ministry of Health, Labour and Welfare: e-healthnet “Alcohol and social issues.” https://www.e-healthnet.mhlw.go.jp/information/
alcohol-summaries/a-06

10 WHO Western Pacific Region Office. Young People and Alcohol: A Resource Book. 2015. https://apps.who.int/iris/bitstream/
handle/10665/208202/9789290616849_eng.pdf?sequence=1&isAllowed=y
11 Dharmapuri S, Miller K, Klein JD. Marijuana and the Pediatric Population. Pediatrics. 146 (2) e20192629. 2020. https://pediatrics.
aappublications.org/content/146/2/e20192629
12 Global News View: “The Golden Triangle—Rapidly increasing stimulants.” https://globalnewsview.org/archives/9905
13 United States Drug Enforcement Administration. Drug Fact Sheet: Narcotics. https://www.dea.gov/sites/default/files/2020-06/
Narcotics-2020.pdf
14 WHO: Report on the global tobacco epidemic 2019 -Country report Cambodia-. https://www.who.int/tobacco/surveillance/policy/

Learning objectives
You will be able to gain proper understanding and explain:- The mental and physical changes and the issues associated with growth and development duringadolescence and how to handle them.
- Pregnancy and childbearing and sexually transmitted infections in youth.
- The social challenges regarding sexual health in Cambodia and discuss their solutions.
In this chapter, you will learn about the following three topics: characteristics of mental and physicalgrowth and development in adolescence in the context of sexual health; basic information about
pregnancy/childbearing and sexually transmitted infections, and the current landscape and challenges in
Cambodia concerning these issues; and the current state of sexual health and its handling in Cambodia.

country_profile/khm.pdf
15 National Institute of Statistics, Ministry of Planning, Cambodia: National Adult Tobacco survey of Cambodia, 2014. https://
untobaccocontrol.org/impldb/wp-content/uploads/cambodia_2018_annex-1_national_adult_tobacco_survey_report_2014.pdf
16 WHO: Global Youth Tobacco Survey 2016 -Country Report Cambodia-. https://extranet.who.int/ncdsmicrodata/index.php/
catalog/690/related_materials
17 WHO: Global Status Report on Alcohol and Health. 2018. https://www.who.int/substance_abuse/publications/global_alcohol_report/
gsr_2018/en/
18 WHO Cambodia - Global School-Based Student Health Survey 2013. https://extranet.who.int/ncdsmicrodata/index.php/catalog/220/
data_dictionary
19 The Asia Foundation. The Alcohol Industry in Cambodia -A Study of Taxation, Regulation, Distribution, and Consumption of
Alcohol-. 2016. https://think-asia.org/bitstream/handle/11540/7313/The-Alcohol-Industry-in-Cambodia_report.pdf?sequence=1
20 Ministry of Education, Youth and Sports, Cambodia: Most at Risk Young People Survey Cambodia. 2010. https://
healtheducationresources.unesco.org/library/documents/most-risk-young-people-survey-cambodia-2010
21 UNODC: Synthetic Drugs in East and South-East Asia: Latest developments and challenges. 2020. https://www.unodc.org/
documents/scientific/ATS/2020_ESEA_Regonal_Synthetic_Drug_Report_web.pdf
22 AIPA Council on Dangerous Drugs: Country Report of Cambodia-. 2019. https://www.parliament.go.th/ewtadmin/ewt/aipa2019/
download/article/AIPACODD/Annex%20J%20-%20Country%20Report%20of%20Cambodia.pdf
23 Good Neighbors Cambodia: Survey Report -The Child’s Reporting on The Situation of Drug Use in Community-. 2019. http://www.
gncambodia.org/wp-content/uploads/2019/11/GNC_Drug-Survey-Reported-by-Voluntary-Grassroots-Youth-EN.pdf
24 Peltzer K, Pengpid S, Tepirou C. Associations of alcohol use with mental health and alcohol exposure among school-going students
in Cambodia, Nagoya Journal of Medical Science. 78(4): 415–422.2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5159467/
25 Banta JE, Addison A, Job JS, Yel D, Kheam T, et.al. Patterns of Alcohol and Tobacco Use in Cambodia. Asia Pac J Public Health.
25(5 Suppl): 33S–44S. 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5043075/
26 WHO: Global strategy to reduce the harmful use of alcohol. 2010. https://www.who.int/substance_abuse/alcstratenglishfinal.pdf
27 RAD-AR Council, Japan. KUSURI GUIDEBOOK. https://www.rad-are.com/downloads/kusurigb-pdf02.pdf
28 WHO: WHO Global surveillance and monitoring system for substandard and falsified medical products. 2017. https://www.who.int/
medicines/regulation/ssffc/publications/GSMS_Report.pdf
29 Khan MH, Okumura J, Sovannarith T, Nivanna N, Nagai H, et al. Counterfeit Medicines in Cambodia—Possible Causes.
Pharmaceutical Research 28:484-489. 2010. https://www.researchgate.net/publication/47157896_Counterfeit_Medicines_in_
Cambodia-Possible_Causes

188

1. Characteristics of mental and physical growth anddevelopment in adolescence (Table 11.1)
1) Physical changes(1) Signiﬁcance of adolescence as a period of transition from childhood to adulthood

1

Adolescence is a period when a child undergoes dramatic changes biologically, physically, and socially.
During this period, one experiences the appearance of secondary sexual characteristics due tohormonal changes in the body, while mentally, one goes through rapid cognitive and emotional
development. The human brain continues to develop until around the age of 25; during adolescence, one
becomes able to control their impulses and make more rational judgments as they grow older.
The ﬁrst half of adolescence is a period during which, as one grows, one becomes increasingly more
susceptible to the inﬂuence of people of the same age group, while becoming less dependent on theirparents. What you should keep in mind when addressing adolescence is the fact that the duration ofadolescence is growing “longer.” Speciﬁcally, most men and women today are experiencing theappearance of secondary sexual characteristics earlier in life, while entering into a period in life when
they assume social roles expected of adults, such as those connected to marriage, later, compared to what
they used to assume.
2(2) Secondary sexual characteristics

During the second half of adolescence (ages 15–19), one experiences sexual development andmaturation following the growth spurts in the ﬁrst half of adolescence. Physical growth and sexual
Chapter 11

Mental and physical changes during adolescence189

Table 11.1 Physical, cognitive, social, and psychological development in adolescence1■ Physical changes• Start of puberty (typically ages 8–14 in females)• Muscle acquisition and growth spurts• Menstruation and breast growth (females)• Voice change and facial hair growth (males)■ Cognitive, social, and psychological changes• Appearance of self-consciousness and low selfesteem

related to one another. As early as the 19th century, the physical maturation of girls was considered
to be influenced by climate (especially the mean annual temperature), ethnicity, social status, place• Susceptible to peer pressure (influence byfriends and peers)inheritance, and health status.3 The 20th century saw further additions to the list of factors that affect• Tendency to focus on the present rather than the
futureChanges during late adolescence (ages 15–19)• Continued physical growth, especially for males

The age of onset of menstruation is influenced by heredity and environment, which are intricately• Feelings of awkwardness or discomfort related
to physical changes• Improved ability to engage in abstract thinking
and introspection■ Physical changes

Column: Factors contributing to the onset of menstruation and health consequences ofage for menarche

Changes during early adolescence (ages 10–14)■ Cognitive, social, and psychological changes• Increased independence and feelings of
invincibilityof residence (urban or rural), physical activity, level of education, sexual stimulation, housing,the onset of menstruation, including season and month of birth, physique (e.g., BMI), dietary habits,
position in sibship, family income, education and occupation of parents, and family size. A recent
review pointed out that, while the onset of menstruation was now known to be controlled by acomplex neuronal network as well as genes, it was also influenced by factors other than genetics,
including socioeconomic and environmental factors, BMI, exercise, dietary habits, and geographicalfactors, and that more studies were needed.4
In the context of health implications, early menarche is associated with increased risks of• Tendency to seek out novel and varied
experiencescardiovascular diseases and breast cancer mortality, and higher susceptibility to health issues of a

• Increased interest in opposite-sex friendships
and romantic relationships

menarche, meanwhile, has been associated with an increased risk of osteoporosis and bone

• Continued improvements in abstract thinking
and introspection• Improved decision-making, critical thinking,planning skills, and moral development
Source: Skolnik R. Global Health 101 Third Edition. Jones & Bartlett Learning, 2016 (Kihara M and Kihara M, Trans., and Ed.
Gurobaru herusu: Sekai no kenko to taishosenryaku no saishin doko [Global Health: Latest Trends in World’s Health and HealthStrategies]. Medical Science International, 2017).

psychosocial nature, such as anxiety, depression, premature intercourse, and violence. Latefracture.4 Further research is needed in order to find out what consequences early menarche may
have on women’s health later in their lives.

(3) Functions of the male reproductive system
This section gives an overview of the functions and anatomy of the reproductive system and sexual
response in males.5

maturation are considered to be based on different mechanisms from one another. However, when you
consider the onset of menstruation, which is a typical occurrence that represents sexual maturation ina) Anatomy and function

girls, one does not experience the onset of menstruation until after she has reached a certain level ofSperm is a cell that consists of a head of 4–5 μm in diameter and a long, thin tail, with an overall length

physical growth (see Column: Factors contributing to the onset of menstruation and health consequencesof approximately 60 μm. Sperm produced in the testes do not move at all at first; as they leave the testesof age for menarche).

and move through the epididymis, sperm start swimming and gain fertilizing capability. Sperm swim at

The most representative changes during adolescent sexual development are the onset of menstruationa rate of around 1–4mm per minute. Sperm production begins as a male reaches puberty, and it continues

for girls and spermarche for boys. These occurrences of sexual maturation are caused by the actions ofmostly throughout the rest of his life. The two testes of an adult male produce over 120 million sperm

sex hormones; there are also other changes such as the growth of pubic hair, voice changes, andevery day, but the number significantly declines as one reaches old age. Around 100–400 million sperm

enlargement of breasts. These are collectively referred to as secondary sexual characteristics. As theare released in a single ejaculation. Once expelled, sperm can live only for 24–48 hours at human body

appearance of secondary sexual characteristics is one of the most characteristic features of adolescence,

temperature. Yet, they may be preserved for years if frozen at −100°C. Low sperm count, abnormal

it is generally common to refer to ages between 15 and 19 years as “adolescence.” In the second half ofsperm morphology, or low sperm motility can be a cause of male infertility.

adolescence, the development of secondary sexual characteristics is nearly complete, as adolescentscome close to sexual maturity, and the physical build of their bodies is nearly that of an adult.
Such occurrences of the adolescent growth spurt (the dramatic increase in height during adolescence)

See Chapter 2 for the anatomy of the male reproductive system (i.e., a cross-section).

b) Sexual response

and secondary sexual characteristics are not random incidents, but sequentially ordered by the genetic

The male penis becomes erect in response to sexual stimulation. Penile erection is a phenomenon inprogram.

which the firmness and size of the penis increase, and it occurs as the corpora cavernosa fill with blood.

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Mental and physical changes during adolescence191

Upon receiving sexual stimulation, the pelvic parasympathetic nerves send stimulation to the penis,
causing arterioles to dilate. This allows blood to flow into the corpora cavernosa, but as the venous
outflow is restricted, the corpora cavernosa fills with blood and becomes firm, which results in penile
erection. If a man is exposed to further sexual stimulation and becomes highly aroused, the ejaculationof seminal fluid out of the urethra occurs. The seminal fluid consists mainly of fluids secreted from theseminal vesicles, prostate glands, and bulbourethral glands, and contains sperm produced in the testes.

Luteinizing hormone(promotes secretion of estrogen andmaturation of follicles)

Follicle stimulating hormone(Promotes secretion of
estrogen, which promotematuration of follicles)

Folliclestimulating
hormoneFigure 11.1-a

The volume of seminal fluid ejaculate is 2.5–3.5 mL, and the sperm count is 100 million per 1 mL ofseminal fluid.
When either ejaculation occurs or sexual stimulation is interrupted, the sympathetic nervous system
becomes dominant. This removes the restriction of venous outflow, allowing the blood retained in thecorpora cavernosa to flow out, which ends erection.

Remains of follicle (post-ovulatory follicle) turn into
corpus luteum, secreting progesterone and estrogen

Ovarianfollicle

Ovulation

Follicle matures

Degenerates into a
corpus albicans if no
fertilization occurs

Figure 11.1-b(4) Functions of the female reproductive system
Corpus luteum regresses,
ovarian hormones decrease,and menstruation is triggered.

The female reproductive system functions in two different periods: the preconception period with ainvolves two reproductive cycles: the ovarian cycle, which refers to a series of periodic changes that
occur in the ovaries; and the menstrual (uterine) cycle, which occurs due to periodic changes in thevolumes of the hormones secreted by the ovaries.

OvarianHormones
Figure 11.1-c

EstrogenA female has 1–2 million oocytes (immature ova) in her ovaries at birth; the number decreases

Progesterone

down to 300–400 thousand by the time one reaches puberty. Each oocyte is surrounded by a layer offollicular epithelial cells, forming an ovarian follicle. Once a female reaches puberty, one of the follicles
becomes mature, and ovulation (the follicle ruptures at the surface of the ovary and releases ova) occurs
every 28 days. Supposing a female has menarche at age 12, ovulates 13 times in each of the successive
years, and has menopause at age 50, the number of ova ovulated over her lifetime would be around 500.
The remaining oocytes reduce by the hundreds or up to one thousand every time ovulation occurs;

Low temperature phase

Basal bodytemperature

Day ofovulation

reproductive cycle of 28 days on average; and the period of pregnancy. A preconception periodHigh temperature phase

Figure 11.1-d(Temperature becomes on andafter the day of ovulation)

following menopause, there is no oocyte remaining in her ovaries.

a) Ovarian cycle (Figures 11.1-a, b, and c)
The ovarian cycle is divided into the follicular phase and the luteal phase.
During the follicular phase, a number of ovarian follicles begin maturing, but only one of themcontinues to mature while the rest regress. Follicle stimulating hormone (FSH), secreted by theEndometrium

pituitary gland, stimulates the maturation of follicles. Mature follicles within them produce estrogen,Figure 11.1-e

which works on both the follicles and the uterus; it stimulates follicles to mature further while promoting

Ovarian hormone levels become lower,
causing endometrial blood vessels to
shedding of endometrium exept for its
basal layer

Estrogen levels become higher,
triggering restoration of endometrium,with the thickness increasing to 4-10 mmand blood vessels becoming longer

Endomentrium becomes
12-18 mm thick, preparing for
implantation of fertilized ovum

the proliferation of the endometrium. On the 14th day after the start of the follicular phase, the secretionof luteinizing hormone (LH) sees a spike, causing ovulation.
Ovulation is followed by the luteal phase. After the release of the ovum, follicular epithelial cells
luteum releases small amounts of estrogen and progesterone. Progesterone is involved in the maintenanceof the proliferated level of the endometrium and the preparation of the uterus for implantation of a
fertilized ovum.
Female body temperature undergoes periodic changes on a cycle of around 4 weeks. It is lower
192

Proliderative
phase

Menstruation

remain on the surface of the ovary, and these cells form the corpus luteum. Stimulated by LH, the corpus

Day

1

7

Secretory phase

14

21

Menstrutaion

28

The period from the first day of the start of menstruation to the day before the start of
the next menstruation is called the menstrual cycle, and one cycle is about 28 days.

Figure 11.1 Reproductive cycles
Chapter 11

Mental and physical changes during adolescence193

during the follicular phase (i.e., after menstruation) and higher during the luteal phase (i.e., before
menstruation), with a fluctuation of 0.2–0.4°C. In addition, it dips during ovulation, then becomes higher
from the day of ovulation onward (Figure 11.1-d).

6(5) Sexual desire

As a child reaches adolescence, the release of the sex hormones leads to the development of secondary
sexual characteristics, and their body matures into an adult body capable of reproduction. During thisb) Menstrual cycle (Figure 11.1-e)period, it is natural for adolescents to realize their interest in sexuality is heightened and that their desire

The menstrual cycle is divided into the menstrual phase, the proliferative phase, and the secretory

for a closer relationship with someone of the opposite sex is strengthened. It has been said that men havephase. The duration of each of the phases varies among individuals; Figure 11.1 is based on a 28-day

a stronger sex drive than women do. Considering that male sex hormones are responsible for sexual

cycle, which is a typical duration.

desire and that they are found in women’s blood at a level around one-tenth of that found in men, it may

During the menstrual phase, the secretion of female sex hormones, i.e., estrogen and progesterone,

be reasonable to say that men may indeed have stronger libidos and sexual desire. This, however, varies

from the corpus luteum decreases, causing the endometrium to degenerate and eventually be shedconsiderably among individuals, and it does not remain constant but fluctuates greatly depending on

through the vagina along with blood. An unfertilized ovum dies and is shed during menstruation. The

factors such as one’s physical condition or the situation they are in, their values, experience, environment,

menstruation phase lasts from 5 to 7 days, with the first day of menstruation being Day 1.

and personal relationships.6

The proliferative phase sees the maturation of the follicles, which results in increases in the secretionof estrogen and significant proliferation of the endometrium. As a result of the proliferation of the basal
layer and the development of the glands and blood vessels, the thickness of the endometrium increases
from 1 mm at the beginning to around 5–6 mm. The proliferative phase lasts until Day 14.
As the corpus luteum develops after ovulation, progesterone secreted from the corpus luteum puts

2) Mental and social changes7(1) Understanding mental development and problem behaviors during adolescencethe uterus into the secretory phase. The glands and blood vessels develop further, and the glands secrete

Adolescence is a period when one comes to establish an identity as an adult human being while alsoa fluid containing glycogen. A number of folds appear on the surface of the endometrium, whichbeing influenced by others around them. Peer groups have a substantial role to play in this process, andfacilitates the implantation of a fertilized ovum.

peer problems can have consequences on the adolescent’s mental development and any problem

If pregnancy occurs, the corpus luteum will be sustained. As progesterone will also be produced bybehaviors. In addition, in order for you to understand, and take action to address, adolescent problem

the placenta, the endometrium will be kept at its secretory phase. If, on the other hand, no pregnancy
occurs, the secretion of progesterone will decline, and the endometrium will degenerate in around 12days, leading to the start of another menstrual phase.
6

Column: Keep track of your menstrual cycle

Are you female readers keeping proper track of your menstrual cycle? If you know your cycle, you
won’t need to feel worried if you have irregular menstruation, and you can detect irregular menstruation
early should you have it. Irregular menstruation may affect any future pregnancy; if you keep
experiencing irregularities years after your first menstruation, it will be reassuring to determine thecause. If you are not pregnant but experiencing amenorrhea, or the absence of menstruation, andthat lasts for six months or longer, you should see a doctor (or consult an expert) at an early date.
You should also be aware that extreme diets, stress, or irregular/unhealthy lifestyles can also be
the cause of amenorrhea. Your menstrual cycle provides important information to understand yourphysical condition and when you are more likely to get pregnant. For these reasons, and to know
precisely when your due date will be if you do become pregnant, it is important that you always keep
track of your menstrual cycle. If your menstruation lasts only for 1–2 days or for 8 days or longer, it
may potentially be due to amenorrhea or some other factors; in such a case, you are advised to talkto your doctor or an expert first.

Social- Social system- Values- Trends ... etc.

BackgroundPeer (ego)Group- Regional characteristics- Scool culture- Peer groups ... etc.

Family environment- Socioeconomics status- Parents’ child support
capacity- Parents’ personality
tendencies ... etc.

Developmental- Physical characteristics- Cognitive characteristics- Developmental tasks ... etc.

Egodevelopment

Peer (ego)Background

Developmentof identity(physical/sexual)

Source: Kiyota, Akio. Understanding mental
development and problem behaviors duringadolesc ence. e-Health Net.
https://www.e-healthnet.mhlw.go.jp/information/
heart/k-03-002.html
Ministry of Health, Labour and Welfare. (2021)

Figure 11.2 Adolescent mental development and relevant factors7

194

Chapter 11

Mental and physical changes during adolescence195

behaviors, you need to understand what their aims are and the diverse factors behind their behaviors.7

drinking and smoking) in order to conform to peers out of fear of rejection or isolation from their peers,

One of the keys to understanding adolescence is “ambivalence.”or by peer pressure. How peer relationship dynamics work among children of these ages has a significant

Mental development during adolescence involves a number of physical, psychological, and social

impact on their mental development and socially deviant behaviors.

factors. In terms of development, at an individual level, adolescents experience significant physical andBy the time they are in high school and have developed a sense of “I am me, and they are them,” theymental changes, including secondary sexual characteristics, and as they undergo sexual development

become able to accept others who are different from themselves in some ways.7 In this phase, the peer

and maturation, levels of sexual energy become higher. Meanwhile, the values, trends, and institutions

relationships develop into those in which adolescents accept one another’s differences as autonomousof the groups to which one belongs, such as their school, peer groups, and family, as well as society at

individuals, both inside and outside. Through the experience of such relationships, they gain a sense oflarge, have a psychosocial influence on one as a member of these various societies as they explore how

self-contentment and security, which helps their mental development and builds a base for achieving

they want to live their lives and gradually form their own identity as an adult individual. Adolescence isself-identity.

a period in one’s life when they “achieve a self-identity” like this, but some of the influence put on themduring this process may lead to problem behaviors (Figure 11.2).

b) Understanding symptoms and problem behaviors observed in adolescence
Adolescence is also a period for a child who has not successfully accomplished the developmental tasks
for school-age to return to the past developmental tasks and redo or re-experience them. For instance, aColumn: What is ambivalence?

middle-school child who has not fully experienced a sense of unity or intimacy with peers mentioned

Ambivalence is one of the key concepts in addressing adolescence.7 Ambivalence is to have and/or

above may resort to self-harming or truancy out of anxiety or lowered self-affirmation. It is not uncommon

express two contrasting emotions or attitudes towards a certain object simultaneously, such as thefor adolescents to demonstrate different problem behaviors or physical/mental symptoms, but these maykind of affection and aversion that an adolescent girl and her mother may have towards one another.

be interpreted as signs for such children to have another chance to go through developmental challenges

Adolescence is a time when one often feels conflicted over the gap between justice or idealism andthey have yet to accomplish.

reality, or about autonomy from, and dependence on, parents, and this means that they experience

To handle such symptoms or problem behaviors in an appropriate manner, it is important that you

stronger ambivalence and tendencies of extreme behaviors. It is the role of adults who are around a

understand which developmental task(s) the child needs to try again. You also need to explore underlying

child to help the adolescent contain such swings to a state that will not interfere with their social life.

developmental factors to find out why the task(s) have been allowed to remain unaccomplished up toWith proper support from others around them, and through the twists and turns of life, an adolescentnow. Simply looking at the problem behaviors or symptoms that manifest on the surface will not be

will achieve a healthy self-identity and grow into an adult.

7

If, however, ambivalent emotions or attitudes in adolescence manifest in the form of drug abuse,enough to remedy the situation. In order for a teacher to provide support to these children, a teacher
needs to understand child development (see Chapter 3).

eating disorders, violence/delinquency, truancy, or certain physical symptoms, it will become
necessary to consult school staff, experts, or specialist organizations. In Cambodia, human resource
development in school counselors, social workers, and other specialists providing support tochildren, their parents and guardians, and teachers, remains a challenge that needs to be addressed.
And adults who are close to children, including teachers, families, and relations, as well as theirelders, will play a large role in such endeavors.

a) Autonomy and peer relationships

2. How pregnancy and childbirth work and the current
situation around them
51) Pregnancy
Pregnancy brings significant changes to the physiology and shape of the mother’s body. While manysuch changes are designed to prepare the body as an ideal environment for the fetus’s growth, maturation,

In adolescence, while one’s desire to become autonomous from parents becomes stronger, they also feeland delivery, there may also be secondary changes that result from pressure from the enlarging uterus oranxiety and a sense of loss or sadness over being more distant from parents. As if to compensate for thethe changing hormone balance.

unstable emotions, adolescents associate themselves with their peers in an attempt to have a sense of
security and approval of being accepted by their peers and a sense of belonging to peer groups. For a(1) Somatic changes

child in the last years of primary school up to middle school, in particular, what plays a significant role

Physiological weight gain during pregnancy is approximately 8–10 kg. This is partly due to the growing

is groups of peers of one’s own sex, those that are characterized by a sense of unity and closeness based

body of the fetus itself, but other factors also account for the gain, including the enlargement of theon inner similarities. Although this allows adolescents to act autonomously from parents, it may also

uterus and increasing volume of extracellular fluid including blood due to the body’s tendency forlead them to take on socially deviant behaviors (e.g., crime and bullying) or health risk behaviors (e.g.,

fluid retention as a part of physiological changes caused by pregnancy. Other changes include increased

196

Chapter 11

Mental and physical changes during adolescence197

insulin resistance, increases in postprandial hypertension and fasting hypoglycemia, decreased tubular

3) Today’s circumstances surrounding pregnant and nursing mothers11

reabsorption of glucose, which can all often lead to a diabetic state. In addition, increases in serum lipid
levels may also be observed; the levels can be markedly high, especially in late pregnancy.

Cambodia’s maternal and child health situation, despite the large amount of foreign aid it had received,
used to fare poorly on such indicators as maternal mortality and infant mortality until as recently as the(2) Changes to the uterus

beginning of the 2000s. To address this, the Cambodian Ministry of Health positioned maternal health

The most notable pregnancy-related changes are naturally found in the uterus. In a woman who is not

as one of the key issues in its Health Strategic Plan 2003–2007 and set a goal to promote perinatal

pregnant, the uterus is approximately 7-cm long, 5-cm wide, and 3-cm thick. Towards the end ofcheckup by healthcare professionals and skilled birth attendance. As part of this, it established apregnancy, the measurements can increase to 35 cm × 25 cm × 22 cm. This is due to the enlargement of

midwifery training program and had all regional centers employ midwives. Thanks to these efforts,

uterine smooth muscle, as well as the enlargement and growth of connective tissue. Uterine blood flow

maternal mortality in particular saw dramatic declines, with the rate per 100,000 live births down fromalso increases to around 500 mL per minute at the end of pregnancy.

472 in 2005 to 161 in 2015.
Besides medical issues, there are more fundamental issues such as regional differences in infrastructureand disparities in wealth. Data from 2010, for instance, showed stark differences in child mortality (per2) Childbirth (delivery)

100,000 live births), with 13 in the capital Phnom Penh on the one end, compared to 95 in two northeastern
provinces of Preah Vihear and Stung Treng on the other, the worst in the country. The absence of a health

By around the 270th day after implantation, the uterine cervix becomes softer, and the uterine muscle

insurance system is one of the reasons people hesitate to seek medical attention or have surgery; inlayer’s oxytocin sensitivity is increased, making it ready for delivery (childbirth).

addition, there are a number of regions where people lack physical access to a health center, are situatedfar away from a provincial hospital that provides surgery, and/or have no means of transportation in case

The course of parturition (childbirth) is divided into three stages.

of an emergency that requires surgery.

(1) First stage of parturition (dilation stage)

While a mountain of issues still remains, there are signs of change in parts of the rural areas that are

Once regular uterine contractions (labor) have started, and the uterine cervix has extended to the pointclose to urban areas. One such sign is receiving skilled birth attendance at home by calling in a midwife

the external os of the uterus is open to the full dilation (10 cm), the release of oxytocin increases, andaffiliated with a healthcare institution, in place of aging traditional birth attendants. Maintaining thelabor intensifies. Labor intervals gradually become shorter until eventually the amniotic sac breaks, andpractice of home birth helps to preserve its beneficial aspects, such as the traditional healing procedure

the amniotic water is released (water breaking).

known as Ang Pleung (see Column: Traditional culture that supports childbirth (Ang Pleung) andchanges in childbirth), and for an expecting mother to have her family and neighbors around her during(2) Second (expulsion) stage to third (placental) stage of parturitiondelivery. In addition, it also provides secondary benefits through contact with a midwife, such as more

These stages represent a period from the full dilation of the external os until the fetal expulsion. The

people acquiring family planning knowledge, and families getting sound advice, including a switch tofetus is gradually expelled toward the birth canal. The force to expel the fetus (expulsive force) graduallyfacility birth if necessary. This may be an example of coexistence, or harmony, between traditional

becomes stronger, and when it reaches its peak, the fetus is pushed out of the mother’s body, and takes

wisdom and modern medicine.

its first breath. A fetus commonly comes out head-first; if however, its buttocks and/or legs are to comeout first, it can make for a difficult delivery. Following the expulsion of the baby, fetal appendages,
including placentas are expelled, to complete the delivery.
There are no national data available on weight and length at birth for children in Cambodia. However,Column: Traditional culture that supports childbirth (Ang Pleung) and changes inchildbirth

statistics on 4,991 newborn children born in health facilities (in a five-year period between 2010 and

Takahashi11 reported that “there is a traditional healing procedure in Cambodia called Ang Pleung,2014) show that the average birth weight was 3,100 g, with the prevalence of low birth weight being

in which a postpartum mother rests on a delivery bed with charcoal fire underneath her to warm her

8around 7% on average. For reference, data from a Lao hospital showed the average birth weight among
9

body over several days. It is believed to be practiced widely in rural areas. The mother as a rulenewborn children born at the hospital in 2013 to be 3,049 g (in 3,912 children). While average birth

sleeps and eats in an area separated from others throughout the period of the procedure. Ang

weight and length varies among different nationalities, ethnicities, socioeconomic statuses, and sexes,

Pleung is completed on the day the fire is put out, and the newborn and the new mother for the first

typical birthlength and birthweight are approximately 48–50 cm, and 2.9–3.5 kg, respectively.10

time leave the enclosed area and undergo a ritual presided over by Kru Khmer, or a practitioner of
traditional medicine.” However, hospital checkups and delivery are becoming mainstream in many
parts of the country, especially urban areas, where Ang Pleung is no longer practiced; the situationis very different from that of rural areas where access to modern medicine is often difficult.

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Mental and physical changes during adolescence199

According to a recent study12, the percentage of women seeking support from health facilities

5) Youth sexual health and its challenges in today’s Cambodia

during delivery increased from 8% in 2000 to 82% in 2014, showing that more women are deliveringbabies at facilities, both in urban and rural areas. While the increases are more rapid in rural areas,

This section outlines the circumstances that surround youth sexual health in Cambodia and its

the number of facility deliveries is greater among those in urban areas, as it is in more highly educatedchallenges.13, 14

and economically advanced populations, which shows that regional and socioeconomic disparities
remain unresolved. As a health facility delivery has beneficial influence on the child’s future health(1) Child marriage

outcome, improvements in maternal and child health services targeting women and children areChild marriage in Cambodia has been in decline over the years. In 1989, 28% of women aged 20–24

hoped for.

were married before the age of 18, compared to 19% in 2014 (Figure 11.3). The marriage of girls under
the age of 15 declined from 7% in 1989 to 2% in 2014. However, the overall number of child marriages

4) Contraception

was comparable to that of 2009. The median age at first marriage among women in Cambodia hasremained largely unchanged at 20–21 years over the past two decades.
Child marriage is known to be widespread among certain ethnic groups and in certain parts of thePregnancy can threaten or damage a woman’s health. Can you say that your knowledge of contraception

country. The percentage of young women aged 20–24 years who were married before the age of 18

is accurate? Have you been able to talk about contraception with your partner? An unexpected andvaries pretty widely by region, ranging from 36% in Mondulkiri and Rattanakiri to 5% in Phnom Penh.

unwanted pregnancy may lead to abortion, and birth resulting from an unexpected pregnancy is a highrisk factor for child abuse. Contraception is a means for you to determine the interval between pregnancies

Married/in union after age 15
but before age 18

on your own, and it protects the human rights of women and children born as a result of an unexpected
pregnancy. Unwanted pregnancies are avoidable, and we should ensure that pregnancy does not change

Married/in union
before age 15

the course of a woman’s life against her will.6(1) Methods of contraception

28%

30%

30%
25%

Although there are periods of time when a woman is more likely to become pregnant and those when
she is not, there is no true “safe day.” And considering how pregnancy works, the window of fertility is

19%quite wide. Whenever one has sexual intercourse, they should be aware that there is always a possibility

19%

of pregnancy. Men, in particular, should recognize that theirs is the sex that can cause a woman to
become pregnant, and make sure they use a secure form of contraception where necessary.
One of the male-based contraceptive methods, for instance, is condoms. They are inexpensive andreadily available, free of adverse reactions, highly effective when used properly, and effective inpreventing sexually transmitted infections as well. However, cases of contraceptive failures are common
due to improper use. Oral contraceptive pills are a female-based method. They contain female sex
hormones, which inhibit ovulation when taken orally. While proper use of these pills is highly effective

7%
1989

5%

5%

4%

3%

2%

1994

1999

2004

2009

2014

Source: UNICEF Cambodia and Division of Data, Research and Policy, UNICEF New York, A Statistical
Profile of Child Protection in Cambodia, p.11, United Nations Children’s Fund, New York, March 2018.

Figure 11.3 Child marriage today13

for contraception, they can be expensive, and some women cannot use them depending on theirconstitution or pre-existing conditions. Unlike condoms, they have no effect against sexually transmitted
infections.

(2) Youth pregnancy and childbearing

There are multiple methods of contraception, yet none is 100% reliable. Even so, using a combination

In Cambodia, roughly one in eight girls aged 15–19 experiences childbearing. The percentage of girlsof contraceptive methods can boost contraceptive effectiveness. One needs to understand the advantages

aged 10–19 varies across regions, with the provinces of Battambang and Pailin being the lowest (4%)

and disadvantages of each method, and have thorough discussions with one’s partner to choose methods

and Mondulkiri and Rattanakiri, the highest (34%). The percentage of girls aged 10–19 who experiencethat are best suited to them.

childbearing decreases with urbanization, household wealth, and education (Figure 11.4).

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Chapter 11

Mental and physical changes during adolescence201

Table 11.3 Use of condoms by socioeconomic status (%)

12%

Total

2010

2014

Poorest

8.3

10.1

4

Poorer

11.2

8.4

8.7

Middle

16.4

14.5

16.9

Richer

29.1

43.1

17.6

Richest

63.3

52.4

44.9

8%

Age 17 years

4%

Age 16 years

1%
13%

Rural

6%

Urban

20%

No education or primary education

14

Source: Based on Reference

8%

Secondary or higher education

Household wealth

2005

18%

Age 18 years

Age 15 years

Socioeconomic status31%

Age 19 years

18%

Lowest quintile

Table 11.4 Comprehensive knowledge about HIV and AIDS by place of residence (%)

7%

Highest quintile

Source: UNICEF Cambodia and Division of Data, Research and Policy, UNICEF New York, A Statistical
Profile of Child Protection in Cambodia, p.6, United Nations Children’s Fund, New York, March 2018.

Figure 11.4 Youth pregnancy and childbearing today13

Place of residence

2005

2010

2014

FemaleMale

FemaleMale

Female

Male

Urban

62.5

58.6

54.9

67.1

55.3

64.7

Rural

48.1

43.2

42.1

38.1

34.2

43.6

(3) Use of contraception during sexual intercourse

Source: Based on Reference14

The percentage of people who use condoms during sexual intercourse in Cambodia, as shown below,
varies depending on the place of residence, socioeconomic status, and level of education.14
The percentage of males aged 15–24 who use condoms varies by the place of residence, and it has
been consistently higher among those who live in urban areas than in rural areas (Table 11.2).
The use of condoms varies by socioeconomic status, as well. The percentage is higher in wealthier
populations than in poorer ones (Table 11.3). While the percentage declined from 2005 to 2014, it
remained largely unchanged in the middle class.
Whether or not one has a comprehensive knowledge of HIV and AIDS varies by place of residence,and the percentage of those who have a comprehensive knowledge has been consistently higher among
those who live in urban areas than in rural areas (Table 11.4). The percentage is also higher among thosewith higher levels of education (Table 11.5).

Table 11.5 Comprehensive knowledge about HIV and AIDS by the level of education (%)

Level of education

2005

2010

2014

FemaleMale

FemaleMale

FemaleMale

No education

19.7

21.9

16.2

9.7

17.9

20.1

Primary

42.1

30.3

33.4

28.5

25.7

31.0

Secondary

72.0

60.7

54.2

51.0

42.5

53.7

Higher

89.9

87.9

71.5

84.3

74.6

76.2
14

Source: Based on Reference

Table 11.2 Percentage of use of condoms (males aged 15–24) by place of residence (%)

Place of residence

2005

2010

2014

Urban

57.7

50.8

57.2

Rural

23.3

9.5

10.3
14

Source: UNFPA, Sexual and Reproductive Health in Cambodia, 2016

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Mental and physical changes during adolescence203

work together on equal terms. For this reason, it is important for a couple to be able to have serious

Column: Sexual behaviors among university students in today’s Cambodia

conversations about contraception and build a relationship of mutual cooperation before they have a

A 2015 study conducted on sexual behaviors among 1,359 university students in Cambodia (mean9, 15age: 21.3 years; 690 males and 669 females)sexual relationship.

reported the following results. The subjects included

a small number of those married and/or cohabitating (2.1%).
● 144 subjects (10.6%) had sexual intercourse; the figures showed sex differences, with 119 malestudents (17.3%) compared to 25 female students (3.7%).
The results of detailed analyses of those who had experience of sexual intercourse are as follows:

3. Sexually transmitted infections
1) AIDS● Age at first sexual intercourse was 20.7 years for males and 20.2 years for females; no gender

Acquired immunodeficiency syndrome (AIDS) is a condition caused by the human immunodeficiency

difference.
● Condom use during the most recent sex among those who had experience of sexual intercourse

virus (HIV). If not treated properly, severe systemic immunodeficiency can lead to opportunistic
infections or malignancies. With dramatic advancements in the development of medications in recent

was 57.6%; the rate was lower among females at 32.0%, compared to 63.0% in males.
● 9.2% had had sex in exchange for money/gifts, and all were males (11.2% of males).

years, it is now possible for a patient to lead a normal life without weakening their immune system if● 7.1% had had a sexually transmitted infection in the previous 12 months.

they start taking medicine at an early stage. It is therefore critical that a patient takes tests and detects the● The percentage of the subjects who had ever made someone pregnant/been pregnant was

infection early, receives proper treatment, and continues proper medication as instructed for life.
Meanwhile, as of the end of 2019, 38 million people worldwide were living with HIV, 1.7 million

12.7%, with 12.0% for males and 16.0% for females.
These results, which indicate that many of the male students had experience of sexual intercourse

had become newly infected, and 690 thousand people had died a year.17 This shows that HIV remains

and that around 40% had sex without using a condom, point to the importance of sex education

one of the most severe infectious diseases that humankind is faced with today. In Cambodia, however,among male students.

HIV infections among those aged 15–49 have declined, from 2% in 1998 to 0.7% in 2013 and 0.6% in
16

According to Sexual and Reproductive Health of Adolescents and Youth in Cambodia (2016),

Cambodia has a large youth population with the percentage of those aged between 15 and 24 years
among the highest in Southeast Asia. And this young population has issues such as sexuallytransmitted infections, unwanted pregnancies, and unsafe abortions, whose likely causes include

2014. The estimated number of people living with HIV is 74,298, and an estimated ten thousand people
do not know they are infected with HIV.

(1) Causes and routes of transmission

the lack of information on sex, poor educational attainment and high school dropout rates, and rural-The pathogen is the human immunodeficiency virus (HIV-1 and HIV-2). The primary route of

to-urban migration for employment. The study subjects referred to in this column are students of two

transmission is sexual contact, in which the virus contained in seminal or vaginal fluids of a patient isuniversities who had received a certain level of education. Taking these results into consideration,transmitted via mucous membranes (of the urethra, vagina, or anus). Other routes include mother-to-

one may surmise that high-risk sexual behaviors may be even more prevalent among young people

child transmission (transmission during pregnancy, birth, or breastfeeding) and bloodborne

who have received lesser degrees of education or those in rural areas.

transmission, which includes needlestick injuries and needle sharing.

(2) Symptoms and course of the disease6) Reproductive health and rights6

The natural course of HIV infection has three stages: primary HIV infection (acute stage),
asymptomatic HIV infection, and AIDS (Figure 11.5). Throughout the infection, patients sustain

The concept of reproductive health and rights was proposed at the International Conference on

progressive destruction of the immune system, which leads to immunodeficiency in most of those

Population and Development held in Cairo in 1994 and has been widely supported across the world. The

infected.

concept recognizes the basic human right (a right to which a person is inherently entitled as a humanbeing) of people to: have a safe and satisfying sex life; freely decide whether or not to bear a child, whento have one, and how many to have; and have information and the means to do so.

i.

Primary HIV infection (acute stage): 2–3 weeks after infection, the level of HIV in the blood
rapidly reaches its peak. During this period, patients develop influenza- or mononucleosis-like

Although it is a woman who becomes pregnant and gives birth, or undergoes an abortion, it is thesymptoms, such as fever, sore throat, muscle aches, rash, lymphadenopathy, or headache. The

responsibility of a couple, both the man and the woman, to not cause or have an unwanted pregnancy. It

intensity of the symptoms varies widely; some may feel virtually no symptoms, while others

is difficult for a couple to ensure contraception unless they have accurate knowledge, care about their

may suffer from aseptic meningitis. Early-stage symptoms may last for around ten weeks, andsex lives and the lives of one another, and have a relationship in which they respect one another andmay subside on their own.

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Mental and physical changes during adolescence205

abuses, such as people having job offer withdrawn due to HIV infection or facing discriminatory attitudes
or refusal of care by healthcare facilities.
There are only three routes of HIV transmission, namely transmission through sexual contact,

CD4 lymphocyte countbloodborne transmission, and mother-to-child transmission. HIV does not spread through ordinary
everyday contact, such as shaking hands, sharing everyday items, or going into a pool or bath together

HIV RNA level(Table 11.6). It is not transmitted through coughing or sneezing, either. In other words, one does not

Set point

not experience many symptoms even when infected with HIV, there are cases where an infected person

1 Primary HIV infection(acute stage)

HIV RNA levelCD4 lymphocyte count

2 Asymptomatic

HIV infection

contract HIV through everyday activities, but only through sexual contact. However, because one may
passes it on to others through sexual contact, etc., without knowing about their own infection. In this
3 AIDS

Indicator of rate of HIV progression
Indicator of immune status of patient

All Rights Reserved. Copyright © 2021
RESEARCH GROUP FOR THERAPY OF HIV INFECTION. Translated with permission.

Figure 11.5 Course of HIV infection19

regard, HIV infection is not someone else’s problem but is something that can happen to you or someone
close to you. It is, however, preventable by using condoms correctly.
In addition, HIV infection does not equal AIDS, and there may be a long latency period before one
develops AIDS if at all. Today many medicines have been developed, and more are coming; early
detection of HIV infection and early start of treatment makes it possible to suppress the development of
AIDS. This means that even if one is infected with HIV, one can go on with their social life by receiving
proper treatment.
In the United States, the Red Ribbon campaign started in the 1990s when AIDS was becoming asocial issue to commemorate people who lost their lives from AIDS and show understanding and support
for those who are suffering from it. The campaign has since spread across borders and grown into a

ii. Asymptomatic HIV infection: As a result of the immune responses following infection (suchas Cytotoxic T Lymphocytes (CTLs) induction and antibody production), the viral load, after

global movement. The red ribbon conveys that you do not have discriminate against people living with
AIDS. See Chapter 7 to learn more about prejudice/discrimination against infectious diseases.

reaching its peak, decreases to a certain level after 6–8 months and reaches a steady state.
Patients may then be asymptomatic for several years or up to ten or more years; after this period,
they are likely to develop symptoms such as fever, tiredness, and lymphadenopathy, as well as
shingles. During this period, few symptoms characteristic of HIV infection occur.
iii. AIDS: If a patient does not receive anti-HIV treatment following infection, the HIV infection
further progresses, and CD4-positive T cells are rapidly depleted. If a patient’s CD4 lymphocyte
count falls below 200/mm3, they become susceptible to opportunistic infections such as
Pneumocystis carinii pneumonia; if the CD4 lymphocyte count drops further and falls below 50/
mm3, a patient may develop opportunistic infections that are rarely seen in people with a normal
immune status, such as cytomegalovirus infections, atypical mycobacterial infections, andmalignant lymphoma of the central nervous system, as well as malignancies. Symptoms such as
loss of appetite, diarrhea, malnutrition, and debilitation also become marked.
(Source: Yoshimura K. What is AIDS (Acquired Immunodeficiency Syndrome)? -ClinicalSymptoms. National Institute of Infectious Diseases website.18)(3) Issues surrounding sexually transmitted infections (prejudice/discrimination against
people with HIV/AIDS)
Since the world’s first reporting of cases in 1981, HIV/AIDS has spread throughout the world. In its

Table 11.6 Common misconceptions and assumptions about HIV infection and AIDS andcorrect knowledge20

Common misconceptions/assumptions• It spreads by shaking hands or talking• You catch it by going into a bath or pool with aninfected person• It spreads through coughing or sneezing• You catch it by sharing everyday items, such as atoilet seat, dish, or towel• You catch it through the bite of a mosquito or tickthat has consumed infected blood

Correct knowledge• There are only three routes of HIV transmission,
namely transmission through sexual contact,
bloodborne transmission, and mother-to-childtransmission; it does not spread through ordinary
everyday contact• The development of HIV medicines has made it
possible to suppress the development of AIDS
among people infected with HIV through early
detection of infection and early start of treatment• Recently, cases of HIV transmission through sexual
contact are on the rise; even steady partners cannot
be ruled out for risk of transmission. HIV is an
issue that can affect anyone

Source: Japanese Government Public Relations Online, Eliminating Prejudice and Discrimination against HIV and Leprosy.
https://www.gov-online.go.jp/useful/article/201108/3.html

early years, there was no treatment for AIDS, and media reports would emphasize the dangers of thedisease alone. This created misconceptions and prejudices among people, which led to human rights
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Chapter 11

Mental and physical changes during adolescence207

4. Social challenges and solutions surrounding sexual
health2) Other sexually transmitted infections1
Table 11.7 provides a list of sexually transmitted infections that are common around the world. One

should take particular note of the fact that women are more susceptible to sexually transmitted infections.

1) Handling information concerning sex

This is due to biological factors such as that women have more exposed mucosal surfaces and that theyoften show no symptoms of those diseases; as well as social factors such as that women are forced into

Today’s highly advanced information society provides an environment where we have constant accessa disadvantageous position, which makes them less likely to receive treatment for sexually transmitted

to an internet connection, and children are exposed to staggering amounts of information in theirinfections than men.

everyday lives. They also have easy access to information concerning sex. This is leading to instances

If a woman has a sexually transmitted infection other than HIV and does not receive treatment in atimely and appropriate manner, it can have a number of long-lasting effects on her health, such as pelvic
inflammatory disease, chronic pain, ovarian abscesses, ectopic pregnancies, and infertility.

where children who do not possess information literacy are sexually victimized through the Internet
and social media. It can also become their first contact with drugs.
Social media can have an impact on the values about, attitudes to, and norms for sex. We should aim
to ensure that children can acquire basic knowledge about sex and help them develop capabilities ofgathering information they need on their own and making the right decision or choosing the right action(i.e., sexual health literacy).

Table 11.7 Types and overview of sexually transmitted infections 21

Pathogen

Syphilis

Treponema pallidum

Route of transmission

Direct contact with skin or
mucosal lesion via sexual
contact

Latency period

Approx. 3 weeks

Symptoms• Red and hard lumps or sores appear on the original site of infection (e.g., genitals, mouth), accompaniedby swollen lymph nodes in the vicinity (primary stage). Around 3–12 weeks later, systemic symptoms
such as fever and general malaise appear along with various types of rash on the skin (secondary stage). It
affects the heart, blood vessels, or brain over the next 10–30 years (latent and tertiary stages). If left
untreated, the disease gradually progresses from primary to secondary, latent, and tertiary stages. It cancause neuropsychiatric symptoms and can even be fatal.
• A newborn may have congenital syphilis when the mother with syphilis has passed the infection on to thebaby.
• Pain when urinating and pyuria for men, and vaginal discharge and vaginal bleeding between periods;
however, symptoms may often be too mild for patients to notice.

Gonorrhea

Neisseria gonorrhoeae

Direct contact with mucosal
2–7 dayslesion via sexual contact• May cause infections in the rectum and throat, but patients often have no symptoms and may therefore failto notice the infection.
• May result in infertility if left untreated.
• A baby born to a mother infected with gonorrhea may develop gonococcal conjunctivitis.

Chlamydia

Candida infections

Condyloma acuminatum

Chlamydia trachomatis

Direct contact with mucosal
1–3 weekslesion via sexual contact

Candida yeasts

Candida yeasts aretransmissible via sexual
contact, but may notnecessarily lead to disease

VariesDirect contact with skin or
mucosal lesion via sexual
contact

3 weeks
Up to 8 months

Human papillomavirus(often types 6 and 11)• Pain when urinating and itchy urethra for men; women may often have mild or no symptoms.
• May lead to infertility and miscarriage/stillbirth if left untreated.
• It is not common for symptoms to manifest among men with Candida infection; women may experience
itching of the vulva and increased vaginal discharge.
• People can have Candida in their body without it causing any problem.
• It left untreated, the symptoms persist, recur, or relapse; it can not be cured without treatment.
• Warts that look like a chicken’s comb appear around the genitals and anus.
• If left untreated, it resolves spontaneously within 3 months in 20–30% of the cases; some may see amalignant transformation, however.
Source: Japanese Foundation for Sexual Health Medicine. A List of Common Sexually Transmitted Infections. https://www.jfshm.org/
Copyright © 2013 Japanese Foundation for Sexual Health Medicine. All Rights Reserved. Translated with permission.

208

Chapter 11

Mental and physical changes during adolescence2092) Sexual violence

24

Column: Harmful practices performed around the world

According to WHO, sexual violence is defined as “(a)ny sexual act, attempt to obtain a sexual act,

Harmful practices against young girls inflict severe and lifelong trauma on them and deprive them of

unwanted sexual comments or advances, or acts to traffic, or otherwise directed against a person’s

the rights to fulfill their potential. For instance, gender inequalities and negative attitudes towards

sexuality, using coercion, intimidation, or violence, by any person, regardless of their relationship to thewomen and girls are causes of such harmful practices. According to a survey conducted in countries

22

victim, in any setting, including, but not limited to, home and work.”

Globally, sexual violence takes various forms, and they may include, but are not limited to, rape,
sexual harassment, sexual abuse/assault, forced marriage or cohabitation, genital mutilation, forcedthat account for 80% of the world population, 90% of people had certain kinds of prejudice against
women, and over 140 million females were considered “missing” as a result of sex selection at birthor child neglect (i.e., extreme son preference, which privileges sons over daughters).

prostitution, and trafficking of people for the purpose of sexual exploitation. Sexual violence may include

Today, around 200 million girls and women have experienced some form of female genital

intimate partner violence. WHO defines intimate partner violence as “(b)ehaviour by an intimate partner

mutilation (FGM). These harmful practices are being imposed on girls by their family members, andthat causes physical, sexual, or psychological harm, including acts of physical aggression, sexual

supported by discrimination and community norms. The country where FGM is most prevalent incoercion, psychological abuse and controlling behaviours.”

Asia is Indonesia, where 49% of girls aged 11 and under have experienced it. Half of the women andgirls who have experienced FGM believe the practice should be abandoned.

3) Sexual norms in Cambodia23

4) Comprehensive sexuality education

Cambodia has cultural codes of sexual conduct known as the Chbab Pros and the Chbab Srey, theformer applies for men, the latter, women. They have a significant impact on people’s perceptions,Sex education incorporating international policies is actively practiced across the world. This section

behaviors, and health. The male code of conduct says that men are strong and ambitious, serve as theprovides an outline of the International Technical Guidance on Sexuality Education, which is anhead of the household, and should be treated with respect and deference. If a man deviates from the maleinternational standard for such practice.25, 26, 27

code of conduct, it is not common for him to be subjected to sharp criticism or discrimination fromTo meet the need for education on sexual health and rights, UNESCO published the Internationalsociety, and their sexual conduct is likewise tolerated. The female code of conduct, on the other hand, isTechnical Guidance on Sexuality Education in 2009, in partnership with UNAIDS, UNFPA, WHO, andextremely strict; it forbids premarital or extramarital sexual intercourse, and directs women to care for

UNICEF. In light of the accumulation of practice implemented around the world over nine years, as well

the family, perform all household duties, not defy parents, and obey their husband once married. In

as the emergence of new concerns such as the influence of the Internet and social media, the content ofaddition, any deviation from the code committed by a woman will subject her to harsh judgment fromthe guidance was reviewed, and a revised edition was published in 2018.27 In addition to providing thesociety; in rural areas, in particular, their “value as a woman” will be questioned. It has been pointed out

latest scientific evidence, the revised edition presents an updated set of eight key concepts, topics, andthat these cultural codes of sexual conduct help conceal violence against women committed by theirlearning objectives, organized into different age groups (four groups: 5–8 years; 9–12 years; 12–15

spouses or other men. Women who have suffered premarital rape or human trafficking, in particular, andyears and 15–18+ years) (Figure 11.6). The guidance also contains the means of institutionalization for

who should be protected as victims, are often expelled from society on the grounds of the female code

implementing comprehensive sexuality education and specific recommendations on how to deliver23

of sexual conduct and become desperate as a result.

effective programs.

Such instances of gender inequalities are not limited to Cambodia but are a global issue that affects

Comprehensive sexuality education (CSE) is a curriculum-based process of teaching and learning

women’s opportunities in educational, political, social, and economic activities as well as their health.

about the cognitive, emotional, physical, and social aspects of sexuality. It aims to equip children andIn the field of international cooperation, the approach known as “gender and development” has become

young people with knowledge, skills, attitudes, and values that will empower them to: realize theirmainstream since the 1980s. A key to sustainable development in Cambodia is the type of support that

health, well-being and dignity; develop respectful social and sexual relationships; consider how theirempowers women in order to eliminate factors that threaten women’s living environment (such as

choices affect their own well-being and that of others, and; understand and ensure the protection of theirpoverty, violence, and human trafficking) and discriminatory traditions and customs that have a harmful

rights throughout their lives.

impact on women, by understanding specific needs for men and women, and securing understanding andinvolvement from men.

The fundamental components of comprehensive sexuality education are summarized in the ten
elements shown in Table 11.8. As shown here, comprehensive sexuality education regards sex education
as a sexual right. It is based on respect for human rights that is built on perspectives of gender equalityand diversity of gender. Comprehensive sexuality education has been practiced in many countries andterritories, including Thailand, China, Taiwan, South Korea, Australia, New Zealand, Canada, the United

210

Chapter 11

Mental and physical changes during adolescence211

Table 11.8 Basic learning contents of comprehensive sexuality education27

States, and the Republic of South Africa, among others.

Elements

Specific learning content

1. Scientifically accurate

The content of comprehensive sexuality education is based on facts andscientific evidence related to sexual and reproductive health, sexuality,and behaviors

2. Incremental

Comprehensive sexuality education is a continuing educational processthat starts at an early age and where new information builds uponprevious learning, using a spiral-curriculum approach

Key concept 1 :Relationships

Key concept 2 :Values, Rights,
Culture and Sexuality

Key concept 3 :Understanding Gender

Topics:

Topics:

Topics:1.1 Families

2.1 Values and Sexuality

1.2 Friendship, Love andRomantic Relationships

2.2 Human Rights and Sexuality

3.1 The Social Construction of
Gender and Gender Norms

3. Age- and developmentallyappropriate

The content of comprehensive sexuality education is responsive tochanges that accompany the child’s development

3.2 Gender Equality,
Stereotypes and Bias

4. Curriculum based

Comprehensive sexuality education serves as a guide for teachers intheir efforts to support child’s learning

3.3 Gender-based Violence

5. Comprehensive

Comprehensive sexuality education is supported by comprehensive,
deep, and iterative learning

6. Based on a human rights
approach

Comprehensive sexuality education aims to encourage people torecognize their own rights and those of others, and advocate for those
whose rights are violated

7. Based on gender equality

Comprehensive sexuality education addresses how gender norms cancreate inequality and how they can harm people’s overall health andwell-being and have an impact on sexually transmitted infections,
unintended pregnancies, and gender-based violence

8. Culturally relevant andcontext appropriate

Comprehensive sexuality education encourages learners to challenge
and practice how cultural structures and norms affect individuals’
formation of relationships of their choice, and acquire skills to build
responsible relationships

9. Transformative

Comprehensive sexuality education contributes to the formation of amore fair and compassionate society and transformation

10. Able to develop life skills
needed to support healthy
choicesComprehensive sexuality education aims to cultivate the ability to makeinformed decisions, communicate effectively, and demonstrateassertiveness1.3 Tolerance, Inclusion and
Respect

2.3 Culture, Society andSexuality

1.4 Long-term Commitments
and Parenting

Key concept 4 :Violence and Staying Safe

Key concept 5 :Skills for Health andWell-being

Key concept 6 :The Human Body andDevelopment

Topics:

Topics:

Topics:4.1 Violence

5.1 Norms and Peer Influence
on Sexual Behaviour

6.1 Sexual and Reproductive
Anatomy and Physiology

5.2 Decision-making

6.2 Reproduction

5.3 Communication, Refusal
and Negotiation Skills

6.3 Puberty

4.2 Consent, Privacy and Bodily
Integrity
4.3 Safe Use of Information andCommunication
Technologies (ICTs)

5.4 Media Literacy andSexuality

6.4 Body Image

5.5 Finding Help and Support

Source: UNESCO. Revised edition International technical guidance on sexuality education: An evidence-informed approach. 16-17. 2018https://www.unaids.org/sites/default/files/media_asset/ITGSE_en.pdf

Key concept 7 :Sexuality and Sexual Behaviour

Key concept 8 :Sexual and Reproductive Health

Topics:

Topics:7.1 Sex, Sexuality and the Sexual Life Cycle

8.1 Pregnancy and Pregnancy Prevention

7.2 Sexual Behaviour and Sexual Response

8.2 HIV and AIDS Stigma, Care, Treatment andSupport5) Menstrual hygiene management

8.3 Understanding, Recognizing and Reducing the
Risk of STIs, including HIV
Source: UNESCO. Revised edition International technical guidance on sexuality education: An evidence-infomed approach. 36. 2018https://www.unaids.org/sites/default/files/media_asset/ITGSE_en.pdf
27

Figure 11.6 An overview of key concepts, topics, and learning objectives

212

In the field of international development, menstruation has recently come to be discussed in association
with issues such as school attendance and hygiene and is now considered a matter that requires
improvement.28 In Cambodia, issues concerning menstruation that have been identified include thesexual code of conduct mentioned earlier, the cultural norms that regard secrecy and silence about
menstruation as virtuous, and a sense of shame and traditional taboos surrounding menstruation.29
Menstrual hygiene management (MHM) refers to access to the following: accurate knowledge
about health; clean menstrual hygiene materials to absorb or collect menstrual blood; space that provides
privacy for changing materials as often as necessary during a period of menstruation; soap and water for
Chapter 11

Mental and physical changes during adolescence213

washing the body when necessary; and disposal facilities for menstrual materials.29
The International Technical Guidance on Sexuality Education discussed earlier identifies the topic ofand practice, and recognizes the diversity of different national contexts in which sexuality education istaking place.”

menstruation as one of the learning objectives for the age group 9–12 years under Key Concept 6.3

The guidance also notes that “a positive school environment has been shown to facilitate the fullPuberty. The key idea is “Menstruation is a normal and natural part of a girls’ physical development andimplementation of programs, thus supporting their effectiveness.” It identifies “making the school a safe

should not be treated with secrecy or stigma,” and what learners will be able to do are as follows:

environment for the provision of [comprehensive sexuality education], for example by having zero-(a) describe the menstrual cycle and identify the various physical symptoms and feelings that girls
may experience during this time (knowledge);

tolerance policies for sexual harassment and bullying, including stigma and discrimination on the
grounds of sexual orientation and gender identity” as one of the duties of the school.

(b) describe how to access, use and dispose of sanitary pads and other menstrual aids (knowledge);(c) recall how gender inequality can contribute to girls’ feelings of shame and fear during
menstruation (knowledge);2) Gender identity30(d) recognize that it is important for all girls to have access to sanitary pads and other menstrual
aids, clean water, and private toilet facilities during their menstruation (attitudinal); andGender identity refers to the concept of personal sense of one’s own gender. It may be called(e) demonstrate positive and supportive strategies for girls to feel comfortable during their“psychological gender” or “brain gender.” While many people identify with “being a male” or “being amenstruation (skill).”female,” there are a variety of forms of gender identity, such as “not identifying with either male orfemale,” “not sure,” or “don’t want to pick.”

5. Sexual diversity
1) Gender
Gender is a social/cultural distinction, as opposed to sex which is a biological distinction, and it

Many people have a gender identity that matches their biological sex, namely, they are cisgender.
Some people are transgender, meaning they have a gender identity that does not align with their
biological sex.

3) Sexual orientation22,30

refers to differences that are born out of different roles men and women play in society (i.e., genderrole). It is used as a term that expresses social or cultural conceptions of “masculinity” and “femininity,”

Sexual orientation refers to the pattern of sexual attraction to other people. Many people are heterosexual,

such as “men work outside the home” and “women do housework and care for children.”or they are sexually attracted to people of the sex opposite to their own. There are, however, different

In the International Technical Guidance on Sexuality Education mentioned earlier, discussion of

categories of sexual orientation, including homosexuality (sexual attraction to people of the same sex as

issues that concern sexual orientation and gender identity is recommended under Key Concept 3:

their own), bisexuality (sexual attraction toward both males and females), and asexuality (the lack ofUnderstanding Gender.

sexual attraction to others).

Specifically, the guidance suggests goals such as the following:
For learners aged 5–8 years,(a) define gender and biological sex and describe how they are different (knowledge), and(b) reflect on how they feel about their biological sex and gender (skill).

To what degrees are lessons and guidance on sex offered at schools in Cambodia? Some teachers

For learners aged 9–12 years,

may find it difficult to teach the subject as they are hesitant to offer such guidance to children of(c) define gender identity (knowledge),

different sex to their own. Some teachers may not have any experience in giving guidance on sexual(d) explain how someone’s gender identity may not match their biological sex (knowledge),

diversity. If you find yourself in a situation that involves teasing of, or discriminatory comments(e) acknowledge that everyone has a gender identity (attitudinal), andagainst, a child of a sexual minority, how should you handle it as a teacher?

(f) appreciate their own gender identity and demonstrate respect for the gender identity of others(skill).
The aim is for children to acquire basic knowledge, attitudes, and skills by the time they are in thelast years of primary school, and it sets more advanced learning objectives for older learners.
At the same time, the learning objectives presented in the guidance are to be interpreted by curriculum
developers at the local level. “The guidance is voluntary and non-mandatory, based on universal evidence
214

Column: Ingenuities for lessons and guidance on sex at school

One thing you can do is to change the way of giving guidance according to the learning content.
For instance, with the topic of menstruation, it may be a good idea to have boys and girls takelessons separately or to have children take lessons from a teacher of the same sex as that ofthemselves. If the school has only male teachers, one way of going about it is to ask community
health workers or people from relevant NGOs to give lessons.
What about guidance on sexuality for boys? It has been reported that boys may feel flustered by
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Mental and physical changes during adolescence215

the physical and mental changes they experience when they reach spermarche, or feel repulsed orembarrassed during an ejaculation. Acquiring accurate information and correct knowledge helps
them build a good relationship with their partner and conduct appropriate sexual behaviors. Giving
guidance on sexuality for boys is important to ensure that they accept their mental and physicalchanges positively.

8

Chhea C, Ir P, Sopheab H. Low Birth Weight of Institutional Births in Cambodia: Analysis of the 2010 and 2014 Demographic and
Health Surveys. DHS WORKING PAPERS No.131. 2017. https://dhsprogram.com/publications/pdf/WP131/WP131.pdf

9Olsen SJ, Vetsaphong P, Vonglokham P, Mirza S, Khanthamaly V, et al. A retrospective review of birth outcomes at the Mother andChild Health Hospital in Lao People’s Democratic Republic, 2004–2013. BMC Pregnancy and Childbirth. 16: 379, 2016. https://
bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-1168-5

10 Villar J, Ismail LC, Victora CG, Ohuma EO, Bertino E, et al. International standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project. Lancet. 384: 857–68.
2014. https://media.tghn.org/articles/newbornsize.pdf
11 Ueda H, Okada T: Getting to Know about Cambodia in 62 Chapters. Akashi Shoten, Tokyo. 2012.

Exercises for further thought and research[11-1] How do one’s feelings towards and perception of sex change during adolescence? Take a specificexample and look into it.
[11-2] What kinds of environmental improvement or institutions are necessary to support pregnancies
and parenting? What kinds of facilities and services are available in the area where you live?
[11-3] How can one cope with the changes that happen to their feelings towards sex? Use your own
experience as a child as a sample case and discuss.
[11-4] What should one do to communicate their intentions to their partner? Think of a scenario and doa role-play.
[11-5] Pick a case of challenges associated with sex in Cambodia and discuss possible measures for
improvement.
[11-6] What are the challenges one faces when giving children guidance on sex? Give examples anddiscuss.

12 Pierce H. Increasing health facility deliveries in Cambodia and its influence on child health. International Journal for Equity in
Health. 18:67. 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6515616/pdf/12939_2019_Article_964.pdf
13 UNICEF Cambodia and Division of Data, Research and Policy, UNICEF New York, A Statistical Profile of Child Protection in
Cambodia, United Nations Children’s Fund, New York, March 2018.
14 UNFPA: Sexual and Reproductive Health in Cambodia. 2016. https://cambodia.unfpa.org/sites/default/files/pub-pdf/UNFPA_Final_Report_10_October_2016_5pm%28NRT_reformated%29.pdf
15 Sok S, Pal K, Tuot S, Yi R, Chhoun P, et al. Health Behaviors among Male and Female University Students in Cambodia: A
Cross-Sectional Survey. Journal of Environmental and Public Health. 2020. https://www.hindawi.com/journals/jeph/2020/6740236/
16 Kingdom of Cambodia Nimistiry of Planning, Minostry of health. Sexual and Reproductive Health of Adolescents and Youth inCambodia Analysis of 2000 - 2014 Cambodia Demographic and Health Survey Data. 2016.
17 UNAIDS: FACT SHEET – WORLD AIDS DAY 2020. https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf
18 National Institute of Infectious Diseases: What is AIDS (Acquired Immunodeficiency Syndrome)? https://www.niid.go.jp/niid/ja/
kansennohanashi/400-aids-intro.html
19 Research Group for Therapy of HIV Infection, Japanese Society for AIDS Research: Guide to the Treatment for HIV Infection, Rev.
24th ed. http://www.hivjp.org/guidebook/hiv_24.pdf
20 Cabinet Office, Government of Japan: Japanese Government Public Relations Online: Eliminating Prejudice and Discrimination
against HIV and Leprosy. https://www.gov-online.go.jp/useful/article/201108/3.html
21 Japanese Foundation for Sexual Health Medicine: What Are Sexually Transmitted Infections? (Types of Sexually Transmitted
Infections). A List of Common Sexually Transmitted Infections. https://www.jfshm.org/%E6%80%A7%E6%84%9F%E6%9F%93%
E7%97%87%E3%81%A8%E3%81%AF%EF%BC%88%E6%80%A7%E6%84%9F%E6%9F%93%E7%97%87%E3%81%AE%E7%A8%AE%E9%A1%9E%EF%BC%89/%E4%B8%BB%E3%81%AA%E6%80%A7%E6%84%9F%E6%9F%93%E7%97%87%E4%B8%80%E8%A6%A7/
22 WHO. World Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines.
2013. https://apps.who.int/iris/bitstream/handle/10665/85240/9789241548595_eng.pdf;jsessionid=59C1D2D5AC4F030E10B813708F946B49?sequence=1
23 Shimazaki Y: Feminization of Human Trafficking and Poverty: Structural Violence in Cambodia. Akashi Shoten, Tokyo. 2018.
24 UNFPA: Sekai Jinko Hakusho (Trans.) (State of World Population). 2020.
https://tokyo.unfpa.org/sites/default/files/pub-pdf/shi_jie_ren_kou_bai_shu_2020_quan_ye_web.pdf
25 UNESCO (Ed.): Kokusai Sekusharithi Kyoiku Gaidansu: Kagakuteki Konkyo ni Motozuita Apurochi. Akashi Shoten, Tokyo. 2020

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