Eastern Journal of Medicine 16 (2011)113-121

B. Joshi et al / Determinants of youth sexual behaviour

Original Article

Determinants of youth sexual behaviour:

program implications for India
Beena Joshi* , Sanjay Chauhan

Department of Operational Research, National Institute for Research in Reproductive Health, J.M.Street, Parel

Abstract. The objective of this paper is to review the current trend of premarital sexual behaviour among youth in
India and the factors influencing this behaviour. Studies done in India in the last two decades were considered for
the review. However due to paucity of data it could not be a systematic review and data from other developing
countries was considered for comparison. Available data indicates high level of premarital and unsafe sexual
activity among youth in India. Limited evidence reveals that the risk and protective factors, which play a role in
determining the sexual activity of youth in developing countries are different from those in the west and they are
more centered on the youth themselves. Small-scale studies done in India also highlight the factors related to the
environment such as peers and family apart from individual factors. However the review highlights the need to
conduct large-scale representative studies to explore the comprehensive picture of risk and protective factors that
could apply to the youth in India, which has a diverse socio-cultural milieu across regions. Programs must focus on
the interventions, which improve the protective factors and reduce the risk factors and not focus only on risk
awareness alone. Adolescent's access to friendly services and an enabling environment in the community can
improve their health seeking behavior. However multiple players other than health sector such as education, media
and social agencies need to work in unison to promote protective factors that prevent unwanted health outcomes
due to unsafe premarital sex.
Key words: Adolescent Sexual and Reproductive Health (ARSH), premarital sexual activity, risk and protective
factors, safe sex, adolescents and youth

Many are exposed to violence and fear on a daily

basis. Some of the pressures they are under or the
decisions they make can change their lives or
even end them. These outcomes indeed reveal
unacceptable losses that put the health and
prosperity of the society at risk. Adolescents are
especially vulnerable to sexual and reproductive
ill health as they often have unexpected sex and
find access to services difficult or denied. Unsafe
sex is the second most important risk factor for
disability and death in the worlds poorest
communities and the ninth most important in
developed countries (1). Sexual and reproductive
health services are absent or of poor quality and
underused in many developing countries.
In India, on account of rapid urbanization, there
is a growing need for economic independence;
the average age for marriage has risen
considerably. To add to it are the strong familial
and social norms related to sexual activities
making them further vulnerable. The rampant
prevalence of myths and misconceptions,

1. Introduction
Adolescents complete their physical, emotional
and psychological journey to adulthood in a
changing world that contains both: opportunities
as well as dangers. They need a balanced healthy
social, physical and mental environment to enable
them to cope with a list of vulnerable and delicate
issues. The adolescents are tempted more and
more to experiment with sexual activities
resulting in divergent sexual behaviors and casual
sexual relationships. They are exposed to risks of
unwanted
teenage
pregnancy,
sexually
transmitted infections including HIV/AIDS, drug
abuse,
nutritional
disorders
and
sexual
exploitation at workplace, especially child labor.
*

Correspondence: Dr. Beena Joshi

Scientist C Department of Operational Research
National Institute for Research in Reproductive Health,
J.M.Street, Parel
E-mail: nirrhdor@yahoo.co.in

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B. Joshi et al / Determinants of youth sexual behaviour

Sexual awareness seems to be largely

superficial. Social attitudes clearly favour
cultural norms of premarital chastity particularly
for females thereby leaving limited decisionmaking power in their sexual relationship (17).
Double standards exist whereby unmarried
adolescent boys are far more likely to be sexually
active than unmarried adolescent girls. They are
also more likely to approve of premarital sexual
relations
for
themselves.
Further,
their
movements are less likely to be supervised and
they have more opportunities to engage in sexual
relations.
As adolescent health is an important component
of the Reproductive and Child Health (RCH)
program of Government of India, specific
Adolescent Reproductive and Sexual Health
(ARSH) strategy has been laid down. Preventive,
curative and promotive services at primary health
care
level
for
adolescents,
are
being
operationalised in the ongoing program of RCH
phase II in the country. The strategy has
primarily focused its responsibility on the health
sector to co-ordinate the involvement of other
sectors in reaching out to adolescents.

inadequate reproductive health services and

indifferent attitude of service providers further
contributes to the suffering of adolescents.
Compared to many western countries the burden
of premarital sex in India is low (15-20%).
However these figures can't be considered low
looking at the mere population size of adolescents
in India, which contributes to almost 30% of the
total population. The mere size makes a huge
number and given the resource poor settings, it is
difficult to tackle the consequences of premarital
sex such as unwanted pregnancies, unsafe
abortions, prevalence of RTI/STI and HIV in this
population. Hence, interventions for improving
adolescent sexual and reproductive health need to
be more specific in order to make them more
effective.
The current scenario in India based on the
research findings on adolescent reproductive
health clearly shows that adolescents are
indulging in pre-marital sex more frequently and
at an early age. The incidence of teenage
pregnancies in unmarried girls is rising and most
of them face the risk of induced abortions under
unsafe conditions. The incidence of sexually
transmitted infections including HIV infections
has increased rapidly during the last one decade.
Nearly half of all HIV infections occur among
persons aged between 15-25 years age. This has
been substantiated by the data which shows that a
significant proportion of unmarried adolescents
form clients of commercial sex workers.
Adolescents often do not take informed
decisions about whether or not to have sex and, if
they do, whether or not to use condoms and/or
other
contraceptives
often
resulting
in
unprotected premarital sexual activity. Their
young age and/or poor knowledge on matters
related to sexuality, reproductive health coupled
with their inability or unwillingness to use family
planning and health services increases their
vulnerability and exposes them to a significant
risk of experiencing negative consequences (2-4).
Gender discrimination coupled with the stigma
about discussing sex and sexuality issues with
young people further contributes to risk taking
behaviours amongst youth, thus, influencing their
sexual and reproductive health (5-7). Engaging in
sexual activity is often equated as an expression
of masculinity amongst boys in certain societies.
This, most of the times is high-risk in nature (813). Certain factors related to one's family
strongly influence adolescent sexual activity and
also play a major role in a manner in which boys
are stereotyped into gender roles on sexuality and
masculinity issues (12,14-16).

2. Material and methods

The current review was done considering both
published and unpublished quantitative studies
done in India in the last two decades on exploring
premarital sex and factors contributing to its
outcome. But due to the paucity of such studies in
the Indian context, this review could not be a
systematic review. However for comparison,
recent reviews on the situation in the United
States and some developing countries were used.
All the studies were cross sectional study designs
and population based or School/College based.
2. 1. The demographic and health profile of
adolescents in India
In our country 30% of the population is in the
age group 10-24 years. Youth (15-24 years)
contribute to nearly 20% of this population (18).
Despite this, they form a vulnerable and
neglected group. Of the 1.5 million girls married
under the age of 15 years, nearly 20% are already
mothers (19). Mortality in female adolescents
aged between 15-19 years is higher than
adolescents belonging to the age group of 10-14
years and contributes to 20% of the overall
maternal deaths. More than seventy percent girls
and about 25% males in the age group of 10-19
years suffer from severe or moderate anemia (20).
About 40% of girls and boys have low Body
Mass Index. Age specific fertility rate in the age

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B. Joshi et al / Determinants of youth sexual behaviour

Original Article
adolescent and young women have experienced
non-consensual sexual relations (24).
Small-scale community-based studies of 1524year-olds in urban slums and rural settings in
Maharashtra reveal that overall 1618% of young
men and 1-2% of young women reported having
had premarital sex. (25,26) There seems to be
common pattern as regards to the age of coital
debut among boys, which is seventeen years as
reported in a number of studies. Findings from
youth survey across different states confirm that
pre-marital sex is by and large unsafe. Findings
also show that sizeable proportions of sexually
experienced youth had indeed engaged in
multiple partner relations before marriage. While
few young women reported that they had engaged
in sexual relations, very few reported multiple
pre-marital partners. Moreover, consistent
condom use was also limited. Among youth who
reported pre-marital sex, fewer than 10% of
young men and women in most states reported
that they had always used a condom (23).
National AIDS Control Organization has also
reported that sexual activity is frequently risky.
Casual sex and relations with sex workers are
often reported by young males (27). A behaviour
surveillance study conducted by AVERT in seven
districts of Maharashtra among female college
going students revealed 95% female college
students had reported penetrative sex and only
26% among them did not use condoms (28).

group of 15-19 years contributes to 19% of the

total fertility rate. Amongst currently married
women, the unmet need of contraception is the
highest in the age group of 15-19 years ie.27%
and among 20-24 yrs about 21%. Infant mortality
rate among children born to mothers below 20 yrs
of age is 77%. Addictions among young people
are on the rise. Over 35% of all reported HIV
infections in India occur among young people in
the age group of 15-24 years, indicating that
young people are highly vulnerable. Majority are
infected through unprotected sex. About 53% of
children face sexual abuse (21).
2.2. Prevalence of premarital sexual activity and
practice of safe sex in India
In India, the available evidence suggests that
between 20 to 30% of all male adolescents and up
to 10% of all females adolescents are sexually
active before marriage (17). Some large scale
studies with their findings are quoted below:
As per NFHS-3 sexual intercourse by
unmarried youth was reported among 5% males
and 0.4% females in the age group of 15-19 years
and 8.9% males and 0.8% females in the age
group of 20-24 years. Among them, use of
condom was reported only by 31% males and
18% females in the 15-19 years age group and
41% males and 16.8% females in the age group of
20-24 years. High risk sexual activity however
was reported by 63% males and 0.7% females
among 15-19 year olds and 18% males and 0.2%
females among 20-24 year olds and condom use
was reported by 31% - 41% males and 20- 25%
females in the respective age groups. Among
those who were sexually active, about 11%
females and 28% males in 15-24 years age group
complained of one or the other STI (22).
A representative survey of young people was
conducted in both rural and urban settings in
India in the year 2006-2008. Six states were
mainly included namely Andhra Pradesh, Bihar,
Jharkhand, Maharashtra, Rajasthan and Tamil
Nadu. Unmarried females and males and married
females aged 15-24 years were included. This
was in view of the paucity of married males in
these ages and therefore married males aged 1529 years were considered. One-tenth to over onefifth of young men and 5-15% of young women
reported an experience of pre-marital romantic
partnership. Sizeable proportions of young men
(9-17%) and few young women (2-7%) had
engaged in premarital sex (23). A recent review
of non-consensual sexual experience of young
people aged 13-24 years suggests that 2-20% of

2. 3. Risk and protective factors as determinants

of premarital sexual activity - (Refer to Table 1)
While programs try their best to increase
scientific knowledge on various health aspects
that affect youth of today hoping to demote risktaking behaviour, studies increasingly have
demonstrated that this approach is inefficient as
behaviour change is very difficult and takes a
very long time. Other indirect factors that play a
major role in shaping these behaviours need to be
looked at to give comprehensiveness to the
Behaviour Change Communication programs.
This would help in identifying those young
people who are at risk of having sex and more so
unprotected sex. These factors are termed as risk
and protective factors.
"Risk factors are those that encourage one or
more behaviors that might lead to pregnancy or
sexually transmitted disease (e.g., initiating sex at
a young age or having sex frequently and with
many sexual partners) or discourage behaviors
that might prevent pregnancy or sexually
transmitted disease (e.g., using contraception or
condoms in particular). Similarly, protective

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B. Joshi et al / Determinants of youth sexual behaviour

more concentrated around the individual and to a

lesser extent on the environment. This contrasts
to similar research conducted among samples in
United States (39). Early onset of puberty, male
gender, older age, permissive attitudes towards
sex, cigarette smoking, alcohol use, viewing
pornography, having friends who are sexually
active, discussing SRH issues with friends,
polygamous family structure and living in urban
area were significant risk factors related to sexual
debut. However having females in school, stable
family connections and living with both parents
were significant protective factors. Education and
schooling were shown to be key factors for not
only reducing the risk of early sexual initiation,
pregnancy and early childbearing but also for
increasing the likelihood that adolescents will use
condoms and contraception when they have
sexual intercourse. The review demonstrates that
adolescents who perceive their friends or peers to
be sexually active are significantly more likely to
engage in sex themselves as well as have multiple
sexual partners. In fact, the perception that ones
peers are sexually active was one of the strongest
identified risk factors.
Studies conducted in India although very sparse
have revealed certain individual level factors
associated with premarital sexual activity.
Educational attainment was negatively associated
with both types of relationships (romantic and
sexual) for young women, but only with sexual
relationships for young men (25,26,36). Less
exposure to growing up and other sexuality
related education in schools was also strongly
associated with premarital sexual activity (37).
Individual factors-notably access to resources,
attitudes favorable to premarital sex, exposure to
pornographic materials, failure to divert their
mind when aroused with sexual feelings were all
associated with premarital sex. Exposure to
alcohol, drugs or pornographic films was
positively associated with sexual relationships for
both young women and men. Indulgence in
violence related activities and not being able to
control the sexual urge were statistically found
significant among sexually active boys (37).
Multivariate analysis revealed that those who
indulged in violence related activity were 8 times
more likely to be sexually active and 0.16 times if
they lacked self-control.
Closeness to parents was negatively associated
with premarital sexual relationships only for
young women. Young women whose father beat
their mother were more likely than other young
women to form opposite sex partnerships, and
those beaten by their family themselves had an
elevated risk of entering sexual partnerships.

factors are those that do just the opposite i.e.

they discourage one or more behaviors that might
lead to pregnancy or STD or encourage behaviors
that might prevent them. These factors could be
broadly classified at two levels i.e. individual and
environment, based on the values about sexual
behavior, their perceptions of family values and
peer norms about sex, their attitudes about
condoms and other forms of contraception, their
educational and career plans and their connection
to their parents and their schools, all of which are
likely to affect whether or not youth have sex and
whether or not they use protection against
pregnancy and sexually transmitted diseases
(Table 1).
Various studies done in developed countries
have identified a number of key factors relating
to the individual that appear protective against
unsafe sex. These include life skills such as self
esteem, negotiation, problem solving and
decision making (29-32). Supportive family, ideal
school and peer environment also prevent risk
taking. Living with parents, good parent child
communication, absence of violence and good
family connectedness has proved to be protective
against unsafe premarital sex. (29) Behaviour of
peers and their indulgence in premarital and
unsafe sex are important underlying factors that
influence early sexual initiation (30,31,33,34).
Larger peer groups and higher levels of social
interaction lead to greater opportunities for youth
to form romantic partnerships. Substance use and
exposure to pornography were inversely
associated with safe sex. (31, 33)
A Carribean survey of over 15,500 young
people in nine Caribbean countries highlights
four health compromising behaviors studied
namely involvement in violence, sexual
intercourse, tobacco use and alcohol use. Logistic
regression was used to identify the strongest risk
and protective factors, and also to create models
for predicting the outcomes, given the
combinations of the risk and protective factors.
Rage was the strongest risk factor for every
health compromising behavior for both genders,
and across all age groups, and school
connectedness was the strongest protective factor.
For many of the outcomes studied, increased
protective factors were associated with as much
or more reduction of involvement in health
compromising behaviors than a decrease in risk
factors. This research suggests the importance of
strengthening the protective factors in the lives of
vulnerable youth, not just reducing risk (35).
A review of risk and protective factors
affecting adolescent reproductive health in
developing countries has revealed that studies are

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Original Article
Table 1. Risk (-) and protective factors (+) that affect adolescent sexual behaviour, pregnancy, childbearing, HIV AIDS
and STIs
Environmental factors

Individual factors

Family

Sexual beliefs, attitudes, and skills

Family structure

- More permissive attitudes towards premarital sex

+ Father is present

+ Ideal age for sex is older

- Stepfather is present

+ Greater skills to resist unsafe sex

- Higher number of children in household

+ Positive attitudes towards condoms/contraceptives use

Mobility

+ Lower perceived barriers of condoms use

-Residential mobility

+ Believes condoms prevent HIV/AIDS

Positive family dynamics

+ Perceives social support for condom/contraceptive use

-Parent's marriage in conflict

+ Greater self-efficacy to use condoms/contraceptive

Family modeling of sexual attitudes

+ Greater self efficacy to talk to partner about condom/

contraceptive use

+ Mother has traditional sex values

+ Visited by family planning worker

+ Parents approve of condoms/contraception

Educational achievement

Peer

+ In school

Popularity

+ Higher educational aspirations

Higher number of friends

+ Literate

Peer attitudes and behaviors

+ Higher academic performance

-Sexually active peers

- Left school early

- Peers have been pregnant

- Repeated a grade

- Positive norms for HIV/AIDS preventive action

Union status

- Friends drink alcohol

- Engaged

Romantic partner

- Divorced/separated/widowed

Characteristics of partner

Biological factors

+/- Age of current partner

Younger pubertal development

Living arrangements
- Lives out of home , Migrant
Relationship with partner
+ Longer duration of relationship before sex
Problem or risk-taking behaviors
-Substance abuse, attends discos/ clubs
Emotional well-being
- Low future aspiration
Exposure to media
- Views pornographic material
- Watches movies/videos regularly
Previous sexual behaviors
- Anal intercourse
- Victim of sexual abuse/forced sex
- Poor genital hygiene
+ Regular use of condoms
- History of STD
-Genital discharge

(K Mmari and Robert Blum, July 1, 2005, Department of Population and Family Health Sciences, John Hopkins
Bloomberg School of Public Health)

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B. Joshi et al / Determinants of youth sexual behaviour

been below 30% for males and less than10%

among females. Young people reported various
reasons for engaging in sexual activity such as
sexual arousal, want of experience, curiosity, fun,
love, and few said it was forced. However the
findings of the study done by AVERT in six
districts of Maharashtra stand apart from the rest
of the data in the Indian context. There seem to
be a number of commonalities across different
studies reviewed. Males consistently seemed
more likely than females to have reported having
premarital sex. It is well documented that males
tend to exaggerate the sexual encounters and
females tend to underreport them due to the dual
social norms. Drugs, alcohol and watching
pornography, having peers who were sexually
active as also staying away from family were
associated with premarital sex. However factors
like indulgence in violence and inability to divert
mind when sexually aroused emerged as risk
factors for premarital sexual activity in a few
studies, which need to be explored further. This
new dimension needs to be looked at within the
existing awareness programs. It highlights the
need to teach and talk not only about safe sex and
condoms but also encourage adolescents to divert
mind when sexually aroused and refrain from
activities that predispose to violence. Knowledge
on safe sex and increased sexual activity as
reported in some studies needs to be interpreted
carefully as it could be possible that those who
indulge in sexual activities equip themselves with
better knowledge on safe sex compared to others
(28,37,40).

Youth who reported strict parental supervision

were no less likely than others to enter
relationships (25). Findings from a qualitative
study of youth in a Delhi slum setting also
showed that despite of strict parental supervision,
girls found ways of forming romantic friendships
and engaging in sexual relations (38). Staying
away from home, spending less of their leisure
time with parents was positively associated with
premarital sex among males. At the family level,
individuals
who
perceived
their
family
environment to be restrictive or uncomfortable
were more likely than others to report sexual
experience (28). Further, frequent interaction
with peers was positively associated with
romantic and sexual relationships for both young
women and men (25). Unable to negotiate or say
"No" to something that their peers wanted them
to do was also associated with premarital sexual
activity (37).

3. Discussion
The declining age at puberty and the increasing
age at marriage has created a growing period in
which young people may engage in premarital
sexual relations. Likewise, evidence that large
proportions of youth remain in school for
extended periods suggests that opportunities to
spend time together in acceptable places away
from the watchful eyes of parents will increase.
The trends of premarital sexual activity among
adolescents and young people in India in the last
two decades have not shown an increase and have

Table 2. Role of different sectors in improving adolescent reproductive health common programming framework
developed globally by WHO, UNFPA and UNICEF - Action for adolescent health towards a common agenda
recommendations from a joint study group WHO, UNFPA, UNICEF

Health sector

Education
sector

Media

And many others: labour, criminal

justice, social services, parents,
peers, etc.

+++

++

++

Services and
counselling

+++

Safe and
supportive
environment

++

++

+++

Opportunities to
participate

++

Issues
Information and
life skills

+ Denotes the grades in which different sectors can play a major role and influence adolescents

Having a counselor in school, parents

communicating on sexual and reproductive health
issues, adolescents discussing sexuality issues
with parents, are some variables, which were not

reported by any groups in India and seem to be

generally non existent at present in India. Most
parents were staying together which again did not
show any effect unlike in western literature where

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B. Joshi et al / Determinants of youth sexual behaviour

Original Article
high divorce rates are related to early sexual
initiation (41). However, strict parental
supervision did not prove to be a protective
factor. Studies done in African countries also
showed that communication with parents and
family members about avoiding sex and the use
of contraception had only nominal effects among
youth (42). Religious beliefs, education,
occupation and income of parents also did not
influence the sexual behaviors of youth (37).
These studies reveal that having restrictions and
supervisions and strict social norms on youth of
today seem to be less effective. Gatekeepers and
peers must communicate with adolescents and
young people on issues of sex and sexuality, the
risk of experimentation and empower them to
make safe decisions in order to achieve better
reproductive health outcomes.
A review of risk factors associated with
premarital sexual activity in developing countries
showed that they were primarily related to the
adolescents' themselves (39). Very few factors
outside the individual were found to be related to
sexual risk behaviors. Only one study in the
Indian context looking at premarital sex as an
outcome was available for this review. Most of
the studies were from African context. However
the conclusions cannot be generalized to
developing countries as such because the sociocultural milieu is very different in Africa
compared to India even though both are
developing countries. At the individual level with
the exception of exchanging sex for money, the
factors that were found significant for adolescent
reproductive health outcomes in developing
countries were also found significant in the
United States of America. However our review
did not highlight any such factor in the Indian
context. Education status or being academically
good turned out to be significant protective
factor. However, with the growing literacy rates
and young people finding many more
opportunities to interact with the opposite sex
while in school/college, this dimension needs
further exploration in India.

program and a service delivery mechanism to

provide adolescent friendly services. Access to
information regarding the health status of
adolescents in India is critical for effective
planning of interventions. A good step in this
direction
is
the
NRHM's
mission
in
commissioning a secondary data analysis of
relevant data available from National Family
Health Surveys and with the support from WHO a
report was published in July 2009 entitled
"Reproductive and Sexual Health of Young
people in India."
With the available data and the ARSH strategy
in hand, the policy makers and program managers
must critically assess which interventions work
the best. This review highlights that health
services and standalone awareness programs do
not seem to bring in the necessary positive
change in adolescent sexual behaviours. For this,
it is very essential that we understand what risk
and protective factors play a role in the Indian
context that influences such behaviors, and how
they operate. This would help target those youth
who are at greatest risk for negative reproductive
health outcomes. This would further strengthen
the effectiveness of programme interventions of
both Reproductive and Child Health and National
AIDS Control Organization.
Intervention designers and youth service
providers need to consider not only specific type
of risk factors for early sexual initiation but also
accumulation of certain factors in the life of
adolescents, that may not be significant on their
own (43). In this way, an understanding of
individual or cumulative risk factors can provide
insight to design interventions and thus improve
their effectiveness. Adolescent programs need to
target
more
than
one
risk
behavior
simultaneously. Apart from a host of individual
level factors that have shown to influence
adolescent sexual behaviors, the role of peers,
parents and prevailing social norms need to be
explored further. There is a need of a larger
representation of adolescents from urban and
rural areas as well as in school and out of school
adolescents to study factors that could be very
unique to India given the variety of socio-cultural
norms within a country framework.
Also needed are efforts to work on individual
level risk and protective factors that may or may
not be health related but yet influence adolescent
sexual behavior. Among environmental factors,
the only factors that can be influenced by
programs are to do with peers and address
parental inhibitions about discussing sexual
matters with their children and encourage greater

4. Conclusions
Under the RCH-II framework of Government of
India, a National Adolescent Reproductive and
Sexual Health (ARSH) Strategy to implement
adolescent health component in the existing
public health system has been designed. The
strategy highlights the need to create awareness
and a supportive environment for improving
health-seeking behaviour of adolescents. It
focuses on awareness generation communication

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B. Joshi et al / Determinants of youth sexual behaviour

openness and interaction between parents and

children. Reducing gender disparities and
creating equitable socialization patterns and ways
of developing closer interaction with both
daughters and sons could ensure a supportive
environment to the adolescents. Individual level
factors related to sexual beliefs, attitudes and
skills can be influenced by behavior change
communication programs with involvement of
other sectors that deal with adolescents along
with provision of adolescent friendly services.
Sexuality education must be made universal and
should address relationship issues as well as
consent and safety from an early age in schools
and other settings in which young people
congregate.
The
common
programming
framework
developed globally by WHO, UNFPA and
UNICEF for adolescents has included four issues
namely information and life skills, services and
counseling, safe and supportive environment and
opportunities to contribute and participate. There
are multiple players to contribute towards this
framework namely health, education, media and
other social sectors (Table 2).
The challenge is therefore for programs to
ensure that multiple stakeholders work in unison
and facilitate the process whereby young women
and men are fully informed and equipped to make
safe choices and negotiate wanted outcomes.

7.

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