Recent trends in adolescent sexual health in the United Kingdom are cause for concern. In England alone, almost 90,000 teenagers became pregnant in 1997. Slightly fewer than 7,700 of these girls were less than 16 years old, and about half had abortions.[1] In 1995-7, the rate of increase in gonorrhoea among 16-19 year olds was 45% - the highest increase seen in any age group. During the same period and in the same age group, the incidence of chlamydia rose by 53% and that of genital warts by 25%.[1] Early intercourse often leads to subsequent regret: only two fifths of respondents in a recent study indicated that first intercourse occurred ‘at about the right time’; 45% of girls and 32% of boys indicated that it had happened too early or should never have happened at all.[2] Sexually active teenagers are more likely to be emotionally hurt (figure) and have an increased risk of depression and suicide.[3]
Contraception is not enough
These indices reflect the outcome of years of unprecedented availability of contraception among young people and increasing sex education in schools. Contraception as the cornerstone of sexual health promotion for adolescents has manifestly failed. In almost 15 years of general practice I have never seen a single case of unplanned pregnancy resulting from ignorance about or unavailability of contraception. Up to 80% of unplanned pregnancies result from failed contraception.[4] Data from 1975-91 show a positive correlation between increasing rates of use of condoms at first intercourse and higher rates of teenage conceptions.[4] Oral contraceptives, while providing the greatest protection from unplanned pregnancy, offer no protection against sexually transmitted diseases and may actually increase the risk of cervicitis.
The younger the age of first intercourse, the greater the risks involved. Early teenage sex is associated with poor use of contraception as well as multiple sexual partners and increased rates of depression and suicide, and it is often part of a wider spectrum of harmful behaviour that includes substance abuse, smoking, and excessive alcohol consumption.[3] Young people who start having intercourse before they are 16 are three times more likely to become teenage parents than those who wait.[1]
‘You didn’t get pregnant. You didn’t get AIDS. So why do you feel so bad?’ says the first page of this leaflet produced by US Department of Health and Human Services:
Getting pregnant and catching diseases aren’t the only ways that sex can hurt you. Contraceptives fail more often than you probably imagine. In fact, there’s no such thing as completely ‘safe sex’. But even if you’re ‘lucky’ premarital sex can leave emotional scars that you’ll feel for the rest of your life.
You may have thought it was love but it was really just sex. When you’re having sex with someone, it’s hard to tell what you love - the person or the sex. So it’s easy to wind up in a relationship, or even a marriage, with someone who’s wrong for you. Waiting to have sex lets you find out if it’s really someone you can love. Having sex is no guarantee you’ll stay together. Lots of teenagers give in and have sex to ‘keep’ someone. And then that person leaves anyway. If you have to have sex to keep someone you love - is that person really worth keeping?
After you’ve had sex with someone, breaking up hurts twice as bad. When you trust someone completely and then that person walks away, you’ll feel used in a way you never have before. After all, you can have sex the rest of your life, but you can only give away your virginity once. If you give it to the wrong person, it won’t take a baby or a disease to make you feel terrible. So think about waiting. You may be surprised at how good it can feel.
Abstinence makes sense
I am not the first doctor to say in this journal that ‘sexual activity is far from appropriate’ for young teenagers.[3] It is widely recognised that delaying the onset of intercourse is an important objective in assessing the effectiveness of sexual health promotion and sex education programmes. Medical journals in the United States (where teenage pregnancy rates are now falling) regularly publish articles encouraging healthcare professionals to recommend abstinence and giving detailed advice on how to do so most effectively.[5] One recent article states, ‘Abstinence is the greatest sexual health promotion behaviour available to Americans, especially to adolescents’.[6]
Abstinence is effective
The evidence is becoming clearer too that a thoughtful, reasoned advocacy of abstinence does work. A recent overview cites several studies of abstinence programmes showing ‘a sharp reduction in the number of pregnancies’ and that ‘women who were not participants in the course were as much as [15] times more likely to have begun sex than were the participants.’[7] The first randomised controlled trial of an abstinence intervention in the United States showed that participants were less likely to report having sexual intercourse at three, six, and twelve months (though this was statistically significant only at three months). This abstinence programme provided accurate information, portrayed sex in a positive light, and was not ‘moralistic’. Although its undoubted effectiveness diminished with longer term follow up, the authors concluded that ‘future research must seek to increase the longevity of these promising effects’.[8]
Any total abstinence programme will be at a disadvantage when compared with ‘safer sex’ education because abstinence, unlike condom use, runs against the tide of peer pressure. Much, if not most, adolescent sexual activity is about the expression of non-sexual needs. First intercourse is rarely about love; it is often about peer pressure and the need to conform to it. The strongest predictor of frequency of sexual intercourse among teenagers is the influence of peers.[9] Effective promotion of abstinence involves equipping teenagers to resist such pressure.
Encouraging parents
This is where parents make such a vital difference. A recent study of over 400 adolescents clearly showed that where parents, especially mothers, were the major source of sexual information, their adolescents’ sexual behaviour was less risky.[10] Those adolescents who reported discussing a greater number of sex-based topics with their mothers were more likely to express conservative attitudes about sex and were less likely to have engaged in it. Doctors promoting abstinence for teenagers should encourage parents to talk with their children about sex and be able to recommend resources to help them to do so.[11], [12] Parents in the Netherlands communicate much more with their children about sex,[1] and this may contribute as much to teenage sexual health there as the more usually cited school sex education.
Realistic promotion of abstinence is not the mere mouthing of platitudes such as ‘just say "No!"’ Teenagers often view abstinence as a threat to the development of intimate relationships and will require convincing reasons to regard abstinence as a positive choice for sexual health. They need to understand why there is ultimately no such thing as casual sex - except in the same sense as casual theft. It may be casual in intent but never in its consequences. Sex education should have its prime focus not on contraceptives but rather on sex as a means of communication. Teenagers should be encouraged to think about what they are communicating by their sexual activity and what kinds of relationships are appropriate for varying degrees of sexual intimacy.
Easier availability of contraception and more explicit sex education at an earlier age are tired and inadequate responses to declining teenage sexual health. Great sex involves abandonment and restraint, the excitement of anticipation as well as the thrill of release. The discipline of abstinence in teenage years is good preparation for fulfilling sex in later life. Doctors should encourage adolescents to avoid early sexual intercourse so that they can enjoy better long term sexual health.
