Abstract

In the context of social and demographic studies of sexual and reproductive health, this paper discusses the situation of young people in Argentina, emphasizing the problems revolving around Sexually Transmitted Diseases (STDs) and the compliance with sexual rights. This work aims to study the calendars and characteristics of the onset of sexual life in young Argentinean people and to describe the current situation of knowledge, practices, and access related to sexual life. Based on data from the National Survey on Sexual and Reproductive Health ( 2013) we worked with the universe of young people between 15 and 29 years of age (n = 2,084 women, n = 1,872 men, without weighting) and analyzed the differences in the calendars of the onset of sexual life, as well as the knowledge and prevention of STDs by gender sex, age groups, household income and geographical regions.A national scenario was found featuring marked tendencies in the calendars of first sexual intercourse by gender sex, as well as in the knowledge about STDs. However, the analysis by region and household income in each gendersex showed high heterogeneities, which would indicate certain limitations in the access to sexual education and the effective compliance of people’s rights, as well as an increased risk to contracting STDs in specific social groups.

Sexual health; Sexually transmitted diseases; Adolescents; Young adults; Argentina

Introduction

The onset of sexual life is a significant phenomenon in the definition of various aspects of the life cycle. The beginning of sexual activity implies the discovery of new socialization and learning context¹1. Jones D. La primera relación sexual: papeles, escenas y secuencias. Cad Pagu 2010; 35:211-239., the first couple bonds and approach to the marriage market²2. Welti Chanes C. Inicio de la vida sexual y reproductiva. Pap Poblac 2005; 11(45):143-176., and a process of entry into adult life³3. Bozon M, Gayet C, Barrientos J. A Life Course Approach to Patterns and Trends in Modern Latin American Sexual Behavior. J Acquir Immune Defic Syndr 2009; 51(Supl. 1):S4-S12.,⁴4. Juárez F, Gayet C. Transiciones a la vida adulta en países en desarrollo. Annu Rev Sociol 2014; 40:1-18., among other issues.

The first sexual intercourse has been taken as an indicator of various sexual and reproductive health (SRH) realms. On the one hand, one of the predominant approaches of the demographic, sociological and anthropological literature has linked it to the fertility of the population in general and adolescent pregnancies in particular, both in the Argentine literature⁵5. Torrado S. Procreación en la Argentina. Hechos e ideas. Buenos Aires: De la Flor; 1994.

6. Lehner MP. La decisión sobre la descendencia. Buenos Aires 1930-1960. Pap Poblac 2009; 18(71):1-26.

7. Felitti K. La “explosión demográfica” y la planificación familiar a debate. Instituciones, discusiones y propuestas del centro y la periferia. Rev Esc Hist 2008; 7(2):201-231.

8. Govea Basch J. El uso de métodos anticonceptivos en la limitación de los nacimientos en la Argentina contemporánea. Estudio en base a la ENSSyR 2013. Comisión Salud-Investiga. En prensa 2017

9. Ali MM, Cleland J. Sexual and reproductive behavior among single women aged 15-24 in eight Latin American countries: a comparative analysis. Soc Sci Med 2005; 60(6):1175-1185.

10. Binstock G, Pantelides E. Las conductas sexuales y reproductivas de los adolescentes: La iniciación sexual. Resultados de la ENSSyR 2013. En XIII Jornadas Argentinas de Estudios de Población; 2015; Salta.-¹¹11. Pantelides E. Gaudio M. Uso de los servicios de salud reproductiva por varones de dos ciudades argentinas. Salud Colect 2009; 5(2):195-209. and that of other Latin American countries¹²12. Villalobos-Hernández A, Campero L, Suárez-López L, Atienzo E, Estrada F, Vara-Salazar E. Embarazo adolescente y rezago educativo: análisis de una encuesta nacional en México. Salud Publica Mex 2015; 57(2):135-143.. On the other hand, the age of the first sexual intercourse – and the set of variables associated with this event – has also been an epidemiological indicator related to the health of the population and the risk of STDs¹³13. Brown AD, Jejeebhoy SJ, Shah I, Yount KM. Sexual relations among young people in developing countries: evidence from WHO case studies. Geneva: Organización Mundial de la Salud; 2001.,¹⁴14. Kostrzewa K. The sexual and reproductive health of young people in Latin America: Evidence from WHO case studies. Salud Publica Mex 2008; 50(1):10-16., although it has also been pointed out that protection in this first event does not necessarily imply a sexual life with daily use of contraceptive methods¹⁵15. Gayet C. El inicio sexual en México. Retos en la prevención. Coyunt Demogr 2014; 6:43-49..

From both perspectives, the SRH is traversed by the recognition and outreach of people’s rights¹⁶16. United Nations Population Fund (UNFPA). State of World Population 2003. Making 1 Billion Count: Investing in Adolescents, Health and Rights. New York: UNFPA; 2003.. It has been documented worldwide that access to contraceptive methods, comprehensive sexuality education and sexual health programs and policies that transcend mere reproductive issues (and build on a rights-based approach) are central to fostering healthy attitudes and practices¹²12. Villalobos-Hernández A, Campero L, Suárez-López L, Atienzo E, Estrada F, Vara-Salazar E. Embarazo adolescente y rezago educativo: análisis de una encuesta nacional en México. Salud Publica Mex 2015; 57(2):135-143.,¹⁷17. De Maria LM, Galarraga O, Campero L, Walker DM. Educación sobre sexualidad y prevención del VIH: un diagnóstico para América Latina y el Caribe. Rev Panam Salud Publica 2009; 26(6):485-493..

In particular, the young population has been the subject of various studies related to this phenomenon. On the one hand, attention has been drawn to the importance of the study of SRH in this age group, given the demographic relevance of the 15-24 years age group in the region¹⁴14. Kostrzewa K. The sexual and reproductive health of young people in Latin America: Evidence from WHO case studies. Salud Publica Mex 2008; 50(1):10-16.. On the other hand, this age group is more at risk from various STDs¹⁴14. Kostrzewa K. The sexual and reproductive health of young people in Latin America: Evidence from WHO case studies. Salud Publica Mex 2008; 50(1):10-16.,¹⁸18. Shah IH, Leal OF, Bronfman M. Introduction. Sexual and reproductive health of young people. Salud Publica Mex 2008; 50(1):8-9. and, thus, has become the subject of debates around people’s sexual rights and access to the health system. In turn, it has been found that current interventions on the sexual health of the young population have a positive social and economic impact on future generations¹⁹19. Sheehan P, Sweeny K, Rasmussen B, Wils A, Friedman HS, Mahon J, Patton GC5, Sawyer SM, Howard E, Symons J, Stenberg K, Chalasani S, Maharaj N, Reavley N, Shi H, Fridman M, Welsh A, Nsofor E, Laski L. Building the foundations for sustainable development: a case for global investment in the capabilities of adolescents. Lancet 2017; 14(390):1792-1806..

However, some pitfalls linked to the sources of information are found in the SRH study. In Latin America, primary data production is increased in the 1990s²⁰20. Bozón M. At what age do women and men have their first sexual intercourse? World comparisons and recent trends. Population & Societies 2003; 391:1-4.: the sources of information in this thematic area are typically health and demographic surveys, and studies based on convenience samples, making this field of studies a fragmented area in its specific sources and records³3. Bozon M, Gayet C, Barrientos J. A Life Course Approach to Patterns and Trends in Modern Latin American Sexual Behavior. J Acquir Immune Defic Syndr 2009; 51(Supl. 1):S4-S12..

In Argentina, the vital statistics and Population, Housing and Household Censuses⁵5. Torrado S. Procreación en la Argentina. Hechos e ideas. Buenos Aires: De la Flor; 1994.have been the privileged sources of research linked to fertility and birth rates. However, SRH studies linked to the risk of STDs have had more heterogeneous sources, such as the 2005 National Health and Nutrition Survey, the 2003, 2007 and 2012 World School Health Survey (for young people from the first through third year of secondary schools) and surveys developed by international organizations such as the World Health Organization (WHO) and the United Nations Population Fund (UNFPA), among others.

In this regard, the National Survey of Sexual and Reproductive Health (ENSSyR)²¹21. Instituto Nacional de Estadísticas y Censos (INDEC), Programa Nacional de Salud Sexual y Procreación Responsable (PNSSyPR). Encuesta Nacional de Salud Sexual y Reproductiva. Buenos Aires: INDEC-MINSAL; 2013. is an unusual and particularly rich source to describe and analyze the national situation of these phenomena. It is based on a decade of the National Sexual Health and Responsible Procreation Program (PNSSyPR) that was established with the aim of achieving compliance with the provisions of the Law of SRH (Law Nº 25.673). Since its creation, in 2003, the PNSSyPR’s essential purpose has been to promote equality of rights, equity, and social justice and contribute to improving access to comprehensive sexual and reproductive health care of the population.Thus, among other goals, the guarantee of people’s universal and free access to contraceptive methods was established. Since then, SRH programs have been consolidated in all Argentine provinces, and the number of health establishments has increased at all levels of care to provide sexual and reproductive health services.

Also, from a human rights perspective, this survey includes both men and women, extending the achievement of reproductive rights and “... breaking with the traditional and restricted vision, leaving the focus on fertility to replace it with another approach that integrates reproductive health, family planning, education, equality and gender equity”²²22. Morlachetti A. Políticas de salud sexual y reproductiva dirigidas a adolescentes y jóvenes: un enfoque fundado en los derechos humanos. Notas Pobl 2007; 34(85):63-95..

From the ENSSyR, progress in sexual and reproductive rights has been evidenced, considering the advance about consensual and safe sexual debut. There have also been pitfalls in the general population: ignorance of diseases, lack of access to contraceptives, among other aspects⁸8. Govea Basch J. El uso de métodos anticonceptivos en la limitación de los nacimientos en la Argentina contemporánea. Estudio en base a la ENSSyR 2013. Comisión Salud-Investiga. En prensa 2017,²²22. Morlachetti A. Políticas de salud sexual y reproductiva dirigidas a adolescentes y jóvenes: un enfoque fundado en los derechos humanos. Notas Pobl 2007; 34(85):63-95.. However, specific analyses in the young population that consider regional and social sector differences remain to be developed.

Within the framework of these discussions, on the one hand, this paper aims to investigate the calendars of the onset of sexual life and some central characteristics of this initiation (consent, use of contraceptives, etc.) of young Argentines from different generations and regions; on the other hand, it aims to investigate the current situation of knowledge, practices, and accesses linked to the SRH.In particular, the focus is on STD-related issues. When mentioning generations or birth cohorts, we refer to the group of young people who were born in the same calendar year. The primary source of data is the 2013 ENSSyR, which is the first survey on the subject that is conducted in the country at a national level, with representation in various regions of the nation.

Materials and methods

In this paper, we work with data from the 2013 National Survey of Sexual and Reproductive Health (ENSSyR). The universe of the ENSSyR consisted of women aged 14-49 years (n = 5,092) and men aged 14-59 years (n = 4,919) living in private homes in urban centers with 2,000 and more inhabitants in Argentina.

The ENSSyR is a privileged source of information on SRH, given some of its particularities. First, it is a national survey and is alsorepresentative of urban population (for locations with 2,000 and more inhabitants). Second, it was applied for both men and women, which makes it a rich quantitative source for a relational analysis on sexual health that considers both sex. Finally, the survey incorporated a set of variables that are not systematized in the same information collection instrument (socio-economic, housing, first sexual intercourse, knowledge about STDs, and other variables).

Concerning this paper, we worked, in particular, with the universe of young people aged 15-29 years (total of women n = 2,084; men n = 1,872, unweighted) to analyze the differences of the calendars of the onset of the sexual life, as well as knowledge and prevention of STDs by sex, age groups (15-19, 20-24 and 25-29 years), household income (Under ≤ $ 4,500, Medium $ 4,500 > $ 10,000, High ≥ $ 10,000) and regions.

We work with regions grouped by a low “n” (by staying with the sub-universe of young people aged 17-29 years, by region) and the potential sampling errors. The categorized regions are Greater Buenos Aires (CABA and Parts of the Buenos Aires Conurbation); Pampeana (Province of Buenos Aires – excluding the Parts of the Buenos Aires Conurbation – Córdoba, La Pampa, Santa Fe and Entre Ríos); Cuyo/Patagonia (Mendoza, San Juan, San Luis, Chubut, Neuquén, Río Negro, Santa Cruz and T. del Fuego, Antarctica and South Atlantic Islands); NOA/NEA (Catamarca, Jujuy, La Rioja, Salta, S. del Estero and Tucumán; Corrientes, Chaco, Formosa and Misiones).Concerning the processing, data were weighted according to the INDEC recommendations for the use of ENSSyR (leading to a total of cases of young women n = 3,694,948 and young men n = 3,730,708).

Finally, some particularities and limitations of the ENSSyRare highlighted. First, the ENSSyR excludes locations with less than 2,000 inhabitants. Second, there may be some possible record problems due to memory bias. Third, as Cabrera et al.²³23. Rojas Cabrera E, Moyano S, Peláez E. Progresos y desafíos en el ejercicio del derecho a la salud sexual y reproductiva en la Argentina en los últimos 40 años. una aproximación a partir de la información relativa a “la primera vez”. Sex Salud Soc (Rio J) 2017; 25:49-67. point out, there may be possible sampling problems. Added to this last aspect is the fact that the table of sampling errors has not been published together with the Users’ Database.

Firstly, the calendars at the first intercourse of young people, i.e., the age at which sexual debut occurs are described below. To do this, we used the technique of Life Tables with truncated cases, obtaining, thus, the summary measures of calendars: cumulative median and proportion of occurrence of the event at ages 17 and 19 years. Second, the circumstances surrounding the first intercourse, including consent and use of contraception, are examined. We also analyzed the continuous use of contraceptive methods of these young people, and finalized, from a rights approach, with the details of the information they have about STDs and their prevention, as well as free access to contraceptive methods.

Overview of first sexual intercourse and STDs

Regional youth calendars

The calendar of the first sexual intercourse of young people allows us to analyze the conditions and context of sexual socialization, transformations that take place across generations and, from a gender perspective, to account for the persistent asymmetric exchanges between members of the couple¹⁵15. Gayet C. El inicio sexual en México. Retos en la prevención. Coyunt Demogr 2014; 6:43-49.,²⁴24. Bajos N, Bozon M, organizadores. Enquête sur la sexualité en France. Pratiques, genre et santé. Paris: La Découverte; 2008.. At the same time, in contexts of little or no sexual education, early age of sexual intercourse may be associated with less knowledge about STDs and, consequently, an increased risk of STDs. It is also related to a lower frequency of contraceptive use²⁵25. Binstock G, Gogna M. Iniciación sexual entre mujeres de sectores vulnerables en cuatro provincias argentinas. Sex Salud Soc (Rio J) 2015; 20:113-140.,²⁶26. Teixeira AMFB, Knauth DR, Fachel JMG, Leal AF. Adolescentes e uso de preservativos: as escolhas dos jovens de três capitais brasileiras na iniciação e na última relação sexual. Cad Saude Publica 2006; 22(7):1385-1396..

In the case of young Argentines, we have found, firstly, as recorded in several studies³3. Bozon M, Gayet C, Barrientos J. A Life Course Approach to Patterns and Trends in Modern Latin American Sexual Behavior. J Acquir Immune Defic Syndr 2009; 51(Supl. 1):S4-S12., a sexgap: the median at the beginning of the sexual life of young men, in general, is lower than for young women (16.47 and 17.41 respectively) (Table 1). This earlier men’s calendar is also reflected in the fact that, at age 15, some 40% of young men have started their sexual life, compared to almost a quarter of young women. This is probably associated with what some authors point out as a persistent dual sexual-cultural standard: traditional masculinity associated with a need to start as early as possible, and femininity related to postponing the onset³3. Bozon M, Gayet C, Barrientos J. A Life Course Approach to Patterns and Trends in Modern Latin American Sexual Behavior. J Acquir Immune Defic Syndr 2009; 51(Supl. 1):S4-S12..

Also, when analyzing the calendars by age groups (17-19, 20-24, 25-29), we see that, in the younger cohort, there has been anticipation in both men and women, and the median of 17-19 years group is the earliest. This is also consistent with previous studies for Latin America and some Argentine provinces³3. Bozon M, Gayet C, Barrientos J. A Life Course Approach to Patterns and Trends in Modern Latin American Sexual Behavior. J Acquir Immune Defic Syndr 2009; 51(Supl. 1):S4-S12.,²⁵25. Binstock G, Gogna M. Iniciación sexual entre mujeres de sectores vulnerables en cuatro provincias argentinas. Sex Salud Soc (Rio J) 2015; 20:113-140.. Besides, in the case of regional differences, we note that the region of Cuyo/Patagonia – in both young men and women – is the one with the following calendar, with half of the young people already initiated in their sexual life at 17.95 years for women and 16.74 years for men. They are followed by NOA/NEA and GBA regions, with the Pampeana region showing the earliest calendar, with half of the young women initiated at 17.29 years and young men at 16.29 years. Cuyo/Patagonia evidences the most significant gap between sex, with 1.2 years between the medians of young women and men.

Differences are also observed by social groups, while those from households with lower incomes show earlier calendars of the onset of sexual life. This occurs both in young men and women, although the sexgap remains even within each social group. Thus, half of the young men from low-income households have already started their sexual life at 16.23 years vs. the 16.92 years of those from high-income households. In the case of young women, these figures are 17.04 years vs. 17.65 years.

If we observe the differences by social groups within each region, in the first place, only the Pampeana region respects this pattern by social groups for both young men and women. Likewise, in the case of GBA and Cuyo/Patagonia young men, this next calendar pattern is also observed as household income increases, not so for Buenos Aires and Cuyo/Patagonia young women, as those of middle group initiate later their sexuality. The middle groups – of both sex – in the NOA/NEA region are also the ones with the latest calendar, and in the case of young men, those of the highest social group initiate their sexuality earlier.

Finally, the sexgap is maintained in all regions except for young people from high-income households in GBA, while medians in both sexare similar. Likewise, this same region shows the most significant gap, and this occurs in the young people of the lowest social group (almost a 2-point gap between the medians).

First sexual intercourse consent

A first aspect related to the risk to STDs to investigate is the first sexual intercourse consent. Sexual abuse and coercion are not only related to unwanted pregnancies, but also to STDs risk. In turn, the incidence of non-consensual sex is an indicator of gender inequities and patterns of masculinity prevailing in the Latin American context³3. Bozon M, Gayet C, Barrientos J. A Life Course Approach to Patterns and Trends in Modern Latin American Sexual Behavior. J Acquir Immune Defic Syndr 2009; 51(Supl. 1):S4-S12..

At the national level, the intention to engage in sex for the first time the moment it was carried out is different according to sex: the ENSSyR allows to see that whereas 96% of men reported that they started sexually at the time they desired, 89% of women reported this. This sexgap in the intentionality of the first sexual intercourse – always with higher percentages in men – is maintained for all the regions.

Two aspects stand out when analyzing regional differences. On the one hand, in all regions, the proportion of men who report having been forced at the first sexual encounter is low: the region with the highest relative weight is the Pampeana Region, with 0.7%. This ratifies for the Argentine case what several studies indicate³3. Bozon M, Gayet C, Barrientos J. A Life Course Approach to Patterns and Trends in Modern Latin American Sexual Behavior. J Acquir Immune Defic Syndr 2009; 51(Supl. 1):S4-S12.,²³23. Rojas Cabrera E, Moyano S, Peláez E. Progresos y desafíos en el ejercicio del derecho a la salud sexual y reproductiva en la Argentina en los últimos 40 años. una aproximación a partir de la información relativa a “la primera vez”. Sex Salud Soc (Rio J) 2017; 25:49-67.: men sexual initiation is predominantly voluntary. On the other hand, in the case of women, higher percentages are found in the first sexual intercourse, in which they report not having wanted to have sex: 3.7% in the Pampeana Region, 3,2% in the NOA/NEA, 2.6% in the GBA and, lastly, 0.5% in Cuyo/Patagonia.

On the other hand, the analysis by region allows, in turn, to describe differences in the intentions of postponing the first sexual relation. In all regions, the desire to have preferred to postpone the first intercourse is expressed more in women than in men. In the case of women, this preference is expressed more in Cuyo/Patagonia (10.9%), whereas for men this occurs more in the GBA region (7%). One aspect to be highlighted is that most sexual asymmetries between the intentions of postponing sexual initiation are shown in Cuyo/Patagonia: 10.9% of women and 1.2% of men reported having intentions to postpone sexual debut. This gap indicates that, in the same region, the highest percentage of women who preferred to postpone sexual initiation and, simultaneously, the lowest percentage of men for the same variable was expressed.

The fact that there are differences by sexboth in the desire to have had the first relationship later and in having postponed it indicates not only gender asymmetries but also potential risk factors for STDs. As has been pointed out for Latin America²⁷27. Blanc AK. The effect of power in sexual relationships on sexual and reproductive health: an examination of the evidence. Stud Fam Plann 2001; 32(3):189-213., gender violence and sexual abuse in young people are associated with the incidence of STDs.

Contraceptive methods

in the first sexual intercourse

The use of some contraceptive method in the first sexual intercourse is a crucial indicator of the risk of STDs and the progress of sex education programs and policies¹³13. Brown AD, Jejeebhoy SJ, Shah I, Yount KM. Sexual relations among young people in developing countries: evidence from WHO case studies. Geneva: Organización Mundial de la Salud; 2001.,¹⁴14. Kostrzewa K. The sexual and reproductive health of young people in Latin America: Evidence from WHO case studies. Salud Publica Mex 2008; 50(1):10-16.. Table 2 shows that both men and women in the NOA/NEA and the Cuyo/Patagonia regions make less use of contraceptive methods during the first sexual intercourse, 26% and 23% for women, and 23% and 21% for men, respectively. On the contrary, in the GBA region, greater use of contraceptives in the first sexual encounter is noted: of the men surveyed, 10% reported not having used contraceptive methods in their first sexual relationship, against 8% of women for the same intention.

Several studies have revealed the different level of contraceptive use by social class and gender, with young people from popular sectors and women in a more vulnerable situation²⁵25. Binstock G, Gogna M. Iniciación sexual entre mujeres de sectores vulnerables en cuatro provincias argentinas. Sex Salud Soc (Rio J) 2015; 20:113-140.,²⁸28. Kornblit AL, Mendes Diz AM. Modelos sexuales en jóvenes y adultos. Buenos Aires: Centro Editor de América Latina; 1994.,²⁹29. Pantelides E, Cerruti M. Conducta reproductiva y embarazo en la adolescencia. Buenos Aires: Cuaderno del CENEP; 1992.. In the women surveyed, the greater use of some contraceptive method in their first sexual intercourse is associated with a higher level of income. This relationship is found in all regions, except for NOA/NEA, in which the highest percentage of women who used some method are in the middle-income sector: 61% of high-income women used some method, against 81% of middle-income women.

In the case of the men surveyed, the trend is similar: the highest percentages of contraceptive use in the first sexual encounter are found in the population with the highest income. However, the exception is found in the Cuyo/Patagonia region, although there is no significant difference in the use of contraceptives between high- (87%) and medium-income (88%) sectors.

Practices of contraceptive methods

However, because young people have used a contraceptive method in the first sexual intercourse does not necessarily imply that they will continue doing so in their daily practice. That is why we propose to expand the analysis by comparing the use in the first sexual intercourse with the current use of methods (Table 3).

In the first place, we would highlight, at the regional level, that young people of the GBA and Pampeana regions are the ones who maintain the use in both moments, and this is found in both sex, albeit with higher weight in men. On the contrary, young people of the NOA/NEA region – and to a greater extent among women – have a lower proportion of care on both occasions, although a critical weight compensates this in the two sex, which, although they did not use a method in the first sexual intercourse, are doing so now. The latter is also prominent among young men from the Cuyo/Patagonia region, but not so much among their female counterparts. Concerning the opposite situation (that is, having taken care of the first time around but not now), in general, the proportion is low, except for GBA women, and particularly those of the NOA/NEA region (10% and 14% respectively).

Regarding the differences by age, the youngest are the ones who used protection methods on both occasions, in equal measure among the two sex (87% in the 17-19 years age group). On the other hand, in the other two groups – particularly among women – the weight of those who use protective measures in both cases decreases, while the proportion between those who protect themselves the first time but do so now increases.Also, noteworthy is that, among older young women, a small percentage (10%) of women protected themselves the first time, but do not do so now. Finally, about the social group, it is highlighted that as the household income increases, so does the proportion of young people who use contraception on both occasions, and this to a greater extent among men. However, almost 20% – both in men and young women – of the lower social groups indicate that, although they did not protect themselves the first time, do so today.

In short, the GBA and Pampeana regions show a continuing practice of contraceptive use, which at the same time is reflected in particular among “younger” young people (17-19 years) and in higher income groups. On the other hand, among the lower income social groups, continuity shows less weight, particularly in the older generations and in the NOA/NEA region, although it is noteworthy that this is counterbalanced mainly by those who did not protect themselves the first time, but do so today.

This denotes some learning in care/prevention after the onset of sexual life, and the need to perhaps reaffirm prevention policies before its start. Likewise, although most young people point to condoms as the primary method of use (first for men, and the second for women, after pills), the remaining methods do not ensure per se the prevention of STDs.

Simultaneously, worth noting is that the proportion of young people who protected themselves stands at 12% among women and increases to 16% among men: this figure is higher in the case of young men of the NOA/NEA region, at 20.5 %, while among women, the highest proportion (16%) is recorded in the GBA region. Similarly, the youngest are the ones who, to a greater extent, have never used any contraceptive method.

Finally, it is necessary to point out that only in the case of young men (almost 4% of the total country level) are religious reasons mentioned concerning the non-use of contraceptive methods. However, this reason is doubled in the case of the NOA/NEA region, with 8% of young men in that area signaling the lack of use for that reason. Thus, in some cases, beliefs and the level of attachment to family or adolescent religious practices also shape sexual and reproductive practices. Overall, although with essential nuances and degree of emphasis, most religions restrict sexual activity at an early age and particularly that which takes place outside the framework of stable marital relationships. Therefore, it is not surprising that the mere fact of having a religious affiliation is associated with a later sexual debut³⁰30. Cruzeiro ALS, Souza LDM, Silva RA, Horta BL, Muenzer RM, Faria AD, Pinheiro RT. Iniciação Sexual Entre Adolescentes de Pelotas, Rio Grande do Sul. Rev Bras Crescimento Desenvol Hum 2008; 18(2):116-125.. Both the professed religion and the level of religiosity are associated with the age of initiation²⁵25. Binstock G, Gogna M. Iniciación sexual entre mujeres de sectores vulnerables en cuatro provincias argentinas. Sex Salud Soc (Rio J) 2015; 20:113-140.,³¹31. Verona APA. Sexual initiation and religion in Brasil [Tesis doctoral]. Austin: Universidad de Texas; 2010.,³²32. Longmore MA, Eng AL, Giordano PC, Manning WD. Parenting and adolescents´sexual initiation. J Marriage Fam 2009; 71(4):969-982..

The rights approach: access to methods and information

Free methods

Free contraceptive methods (and, in particular, of condoms) are key to understanding the STD prevention policies. However, the fact that contraceptive methods are free – as in the case of Argentina – should be understood as a complementary aspect of the effective access of the population.

In all the regions analyzed, data from the ENSSyR show that most of the respondents reported that they were not able to or cannot obtain free contraceptive methods they use. This trend is found in both men and women, although it is more pronounced in men (for all regions, 79% of men do not get the method free of charge, compared to 67% of women). In both sex, the region in which the lowest free access was found was in the Pampeana region, albeit with different percentages (29% in women, 12% in men). In contrast, the region with the highest free access to contraceptives was, for women, the NOA/NEA region and, for men, the Cuyo/Patagonia region.

In turn, if free access is analyzed in the cohorts of young females studied, we can observe a similar trend: in the three age groups, it is stated that the minority of respondents’ access for free. However, in the youngest cohort (17-19 years), greater free access was reported both for women and men (40% and 23% respectively).

Also, the analysis according to household income does not show a break with the tendency of not getting the method for free. However, in the comparative analysis, it can be seen that the higher the household income, the lower the tendency to acquire the method free of charge, for both men and women.

Knowledge about STDs and their prevention

In Latin America, some 89 million new cases of STDs occur annually in people aged 15 to 49 years, and these diseases affect 1 in 20 adolescents. In addition to the fact that they can cause death directly, STDs contribute to various adverse health outcomes, including infertility, stillbirths, and cancer, and may increase the risk of contracting or transmitting HIV infection. Data’s limitations and the lack of comprehensive national strategies for the prevention, diagnosis, and treatment of STIs are persisting challenges³³33. Langsam M. Preparar la región para los ODS, Capítulo Argentina. Informe Final. Documento preparado para OPS Argentina, no publicado..

Knowledge about STDs and their prevention is a direct product of sexual and reproductive education policies and programs¹⁶16. United Nations Population Fund (UNFPA). State of World Population 2003. Making 1 Billion Count: Investing in Adolescents, Health and Rights. New York: UNFPA; 2003.. The dissemination and learning about STDs not only shapes the people’s practices and attitudes but also modifies the perception of risk, as has been studied around HIV³⁴34. Goldstein B, Castañera M. Conocimiento, percepción y actitudes acerca del VIH. Un estudio longitudinal en adultos jóvenes (1994-2001), Argentina. Pub of Seisida 2002; 13(7):465-473..

Figure 1 shows whether the respondents heard about the main STDs. From the information analyzed, it is worth highlighting the significant proportion of young people who heard about HIV/AIDS. Nationwide, 99% of young men and women heard about it, followed by Hepatitis B (with a small difference in favor of women: 91% and 89% of men) and syphilis / Chancre (74% and 75%, respectively).

Likewise, 65% of women and 62% of young men are knowledgeable about genital herpes, while 62% of women versus 46% of men heard about HPV (human papillomavirus). About half of the young people know about gonorrhea (52% of women and 47% of men). Conversely, other STDs are not as well known, such as leucorrhoea (14% women and 9% men) and trichomoniasis (12% women and 8% men).

Thus, let us have a look at how this pattern is distributed within the regions considered, starting from Figure 1. On the one hand, it is generally the young people of the GBA region who heard the most about STDs, and on the opposite side are those from the NOA/NEA region, which in most cases has lower proportions compared to the rest of the regions. This tendency is found in both sex.

On the other hand, knowledge in all regions about HIV/AIDS is widespread (between 98% and 100% of cases heard about it). This is followed by knowledge about Hepatitis B, albeit with also high values, with greater variability between regions, with young men from the NOA/NEA region who heard about it the least (79%), compared to those from the GBA region (95%). In order of importance of knowledge among these young people is syphilis, whose peculiarity is that – except for the NOA/NEA region – young men have a slightly higher knowledge compared to their local peers.

The HPV deserves special mention. First, because of the significant sexgap in its knowledge, with young women more aware of its existence. Second, because of the substantial gap between young men by region, while 36% of those in the Cuyo/Patagonia region and 38% of those in the NOA/NEA region heard about it versus 52% of those in the GBA region.

Finally, note the low general knowledge of young people about candidiasis, leucorrhoea, and trichomoniasis, particularly among men from Cuyo/Patagonia and NOA/NEA regions, where less than 10% of young men in these regions heard about them.

Concerning knowledge about prevention, at the national level, we found that more than 96% of young people of both sexconsider that condoms can prevent STDs (Figure 2). Conversely, less than 10% of young people (in both sex) consider that having only one partner/being faithful favors the prevention of STDs. To a lesser extent, some believe that prevention is achieved by avoiding sexual intercourse with strangers.

In Figure 2, we observe the regional gaps concerning knowledge about STD prevention. First of all, the high percentage of young people in all regions – of both sex – who declare condoms as the primary factor for STD prevention (in all regions, above 95%) stands out. Secondly, albeit with lower values regarding condoms, in particular, young women of NOA/NEA and Cuyo/Patagonia regions consider that staying with a single partner / being faithful can also prevent STDs (14% and 11%, respectively). The same occurs in the case of young men in the NOA/NEA region, whose proportion reaches 10%. Finally, we highlightthat 13% of young men in the Pampeana region believe that avoiding sexual intercourse with strangers prevents STDs.

Discussion

Data produced by the ENSSyR show, overall, significant trends in the sexual life of young people in Argentina, similar to those of other Latin American latitudes. However, the more detailed analysis allows us to identify a different outlook vis-à-vis the calendars and characteristics of the onset of sexual life and with the knowledge about STDs and their prevention. This heterogeneity is traversed by the regional, generational, sexand social differences of the young people studied.

Regarding the beginning of sexual life, it was possible to identify an overestimated starting median in all regions and, in turn, earlier calendars in people from lower income households, as other authors have also seen²⁵25. Binstock G, Gogna M. Iniciación sexual entre mujeres de sectores vulnerables en cuatro provincias argentinas. Sex Salud Soc (Rio J) 2015; 20:113-140.,²⁸28. Kornblit AL, Mendes Diz AM. Modelos sexuales en jóvenes y adultos. Buenos Aires: Centro Editor de América Latina; 1994.,²⁹29. Pantelides E, Cerruti M. Conducta reproductiva y embarazo en la adolescencia. Buenos Aires: Cuaderno del CENEP; 1992.. At the same time, a gap is maintained in the starting calendars according to sex, ratifying the data found in Argentine and Latin American literature⁵5. Torrado S. Procreación en la Argentina. Hechos e ideas. Buenos Aires: De la Flor; 1994.,¹⁴14. Kostrzewa K. The sexual and reproductive health of young people in Latin America: Evidence from WHO case studies. Salud Publica Mex 2008; 50(1):10-16..

The consent of the first sexual intercourse – as a critical indicator of sexual violence – shows gaps between sex, as has been historically indicated²⁷27. Blanc AK. The effect of power in sexual relationships on sexual and reproductive health: an examination of the evidence. Stud Fam Plann 2001; 32(3):189-213.. Female first intercourseis nuanced and differentiated according to the region. However, particular cases are of concern, such as the Cuyo/Patagonia region, where the highest percentage of women who would have preferred to postpone sexual first intercourse and, simultaneously, the lowest percentage of men for the same variable was expressed. These contrasts cannot only be read as indicators of gender asymmetries, violence and potential risk factors for STDs¹⁷17. De Maria LM, Galarraga O, Campero L, Walker DM. Educación sobre sexualidad y prevención del VIH: un diagnóstico para América Latina y el Caribe. Rev Panam Salud Publica 2009; 26(6):485-493.,³⁵35. Genz N, Meincke SMK, Carret MLV, Corrêa ACL, Alves CN. Sexually transmitted diseases: knowledge and sexual behavior of adolescents. Texto Contexto Enferm 2017; 26(2):e5100015. but also as a result of the lack of sexual education programs that effectively impact the population²²22. Morlachetti A. Políticas de salud sexual y reproductiva dirigidas a adolescentes y jóvenes: un enfoque fundado en los derechos humanos. Notas Pobl 2007; 34(85):63-95..

In turn, the high percentage of respondents who reported not using contraceptive methods in their first sexual intercourse in specific regions transcends mere heterogeneity and becomes an essential contrast against the risk of STDs.

Concerning free access to contraceptive methods and knowledge about STDs, we note some trends that question the advancement and exercise of sexual rights. Despite free contraceptives in Argentina, poor free access was found in different regions, cohorts, sexand social groups. However, in the youngest cohort, greater free access was reported both for women and men (40% and 23% respectively), which could be linked to changes in younger generations as a result of recent policies. At the same time, except for HIV/AIDS and, to a lesser extent, Hepatitis B, there are enormous gaps by region on the knowledge of diseases, although condom knowledge as STD prevention method stands out.

The heterogeneity and contrasts in the situation of young people in Argentina must be read from two perspectives. On the one hand, it responds to the territory-anchored socio-cultural particularities, a product of histories and traditions of each social space. On the other hand, this variety of situations analyzed is also linked to a different advancement of sexual rights and the implementation of sex education programs. How these two dimensions are fed back is still a pending issue in the work and study agenda of the SRH in Argentina.

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