This is one reason that I am unashamedly pro sex-education. In 1995 I went from full-time to part-time practice as a GP, and am now helping to develop a variety of parent-friendly materials including books, training courses, videos - and most recently a CD-ROM, on various aspects of family life, with a strong emphasis on sex education.

It is essential that medical students today see the importance of a career in sexual medicine. So much physical morbidity - and indeed mortality, is related to unwise sexual choices. Yet even this is overshadowed by the flood-tide of psychological damage with sexual origins that constitutes such a large part of our national clinical workload. Hardly a day goes by in my own practice without my seeing at least one sexually-related disorder. A recent BMJ editorial on teenage sex concluded 'The scale of morbidity associated with under-age sex is sobering....' [2]

Appropriate sex education plays such a vital role in preventing such problems that no Christian should turn their back on the subject. If we do not seize the day of opportunity, others will, and their agenda may well be very different from ours, particularly if commercial interests are involved. Alex Mellanby in a characteristically even-handed review of teenage magazines suggests that girls reading some of them 'may continue to consider that sex is "the price of going out with a boy"'.[3]

Why the battle?

If the case for sex education is as clear-cut as I have indicated, why is there still so much controversy surrounding the subject? In August last year I found myself on both the BBC and ITN national news, at loggerheads with some of the leading lights of our profession. What was it all about?

In essence the debate covers three main areas: 'evidence for effectiveness', 'methods and morality' and 'whose responsibility?'.

Evidence for effectiveness

The content of sex education is crucial - 'being instructed only about biological topics and about birth control are significantly associated with earlier first intercourse'.[4]

Organisations such as the Family Planning Association (FPA) have long maintained that sex education (irrespective of the content) deters rather than encourages earlier teenage sexual intercourse. Good evidence for this claim, however, has been difficult to find.

Up until 1995, a WHO study[5] was almost the only reference in articles promoting the FPA view.[6] This 'study' has proved remarkably elusive to obtain, hardly surprising given that it originated as a poster presentation at a WHO conference. The poster was based on a review of 35 other studies and although I eventually obtained the review from the authors, it has still to date never been published either by the WHO or in any peer-reviewed journal. Yet this was 'the evidence' being cited everywhere as proof that sex education was effective! The convoluted tale of its dubious evolution is well detailed elsewhere.[7]

The exposure of the WHO poster was soon overshadowed in August 1995 when the BMJ published two important papers on sex education. Given the skullduggery behind the WHO evidence however, these studies merit close examination. As one of the more astute journalists observed, 'Few media analysts looked closely at what the BMJ studies were actually saying or (just as important) what they were omitting to say'.[8]

The first paper by Mellanby et al[9] is a fascinating report that explodes once and for all the myth that 'teenagers will have sex anyway and whatever you say won't alter it'. The study points out that those who have sex before 16 take greater risks, have more sexual partners each year during their lifetime, start sex earlier in new relationships and express more regret over their actions. The authors conclude that 'postponement of first intercourse would be likely to have medical and social benefit',[9] and then go on to demonstrate that their programme of sex education which included behavioural values, raised the age of first intercourse.

The paper by Wellings et al[l0] used data from the comprehensive British national survey of sexual attitudes and lifestyles. Hailed as a triumph for the effectiveness of school-based sex education, the study actually showed that by age 16, girls whose school was their main source of sex education were equally likely to have had sex as girls whose main source of sex education was their peer-group. In other words, school sex education was no more effective than schoolgirl chatter in influencing the age of a girl's sexual debut.

The study did however show that boys were less likely to have had intercourse by the age of 16 when their sex education had come mainly from school. But again the comparison was with peer education, and no comparison was made against parental sex education (only the vague category of 'relatives' was tabulated).

A 'positive association between receiving most information from school and use of contraception at first intercourse'[10] was also emphasised in the Wellings paper. However the abortion and unplanned pregnancy rates of the different groups were not published, even though these were known. This is a particularly significant omission since a few weeks later the BMJ published data showing that 80% of 187 teenagers with an unplanned pregnancy said they were using contraception at the time.[11]

In summary the Mellanby and Wellings papers show that:

1. Some excellent local school sex education schemes do indeed raise the age of first intercourse when compared with other schools programmes.
2. Nationally, school sex education has no effect on the age of girls' first intercourse.

These two conclusions taken together must surely raise the ghastly spectre that some school sex education programmes are associated with lowering the age of first intercourse (at least for girls). There are some recent reviews which give no cause for complacency about sex education in this regard.[4,12]

Given however that the best school sex education programmes in schools are not counterproductive, I now turn to the next area of potential conflict.

Methods and morality

'Get over your giggles by using condoms... and getting used to them. Blow them up at parties - see who can burst theirs first... Girls can practice opening a packet and putting them on their partners (using a banana as a model) and boys can practise putting them on and wanking... try it on your own and you'll soon become an expert.'[8]

Such advice from the Brook Advisory Centres still circulates under the banner of sex education today and is a major reason why we have to remain vigilant and involved in this field. Much material (including some that in other respects is truly excellent[13]) is based on the assumption that having sex is such fun that it must simply be accepted as a normal part of teenage life. Sex is indeed fun and sex education shouldn't be stuffy, but it should present the excitement within the context of other important features such as commitment and respect. Does the leaflet quoted above indicate any awareness of such qualities?

Minimum requirements for a comprehensive sex education include the perspective that sexuality is not seen in isolation from the total meaning and purpose of human life. The distinction between love and desire, sacrifice and self-centredness, commitment and manipulation are all involved here and clearly necessitate a moral base.

It is here that the greatest conflicts arise. Modern morality is based on expediency and short-term consequences. At a sex education meeting at the RCOG last summer,[14] Mary Porter of the Sex Education Forum suggested the following as a moral foundation for sex education. I have added a few pertinent questions to each point!

1. Sexual morality is determined by your own conscience, not rules
   Even if you happen to be Jack the Ripper?
2. We should adopt a live and let live approach to others' sexual choices
   Why then did Isobel Allen say to loud acclaim at the conference that people with my kind of non-libertarian sexual views 'should not be allowed a voice'?
3. We should accept teenage sexual activity
   Accept that it exists, or that it's intrinsically a good thing? What of Mellanby's evidence that it isn't?
4. Sexual commitment and marriage are separate concepts
   Who says so and would it make people happier if they were?
5. Sex is good
   Yes, but even necrophilia, bestiality, rape, paedophilia etc?
6. Sex is for pleasure not for duty
   Always? Who has priority when my pleasure becomes my partner's duty and vice versa?
7. Divorce is better than dead relationships?
   Better for whom? The children?
8. Quality is more important than form
   I wonder what this means when de-coded?

The patent inadequacies of such a moral framework are obvious, and it concerns me deeply that some of the leading proponents of sex education in Britain today have such a fragile utilitarian ethical basis. The glaring contradictions that stem from such a patchwork morality were well illustrated at another conference I attended at the RCOG. Several family planning experts had been brought over from Holland to lecture to us on how to do sex education the Dutch way. Confidentiality was one of the sacred principles drummed into us all morning. If twelve year old Clara wants you to put her on the pill, you must maintain confidentiality. An afternoon speaker however openly advocated telling 'little white lies' to her parents. If they complain about your prescribing to Clara, you simply make up a story such as 'only the day before Mrs Van Dooren, I saw a little girl like yours, 10 weeks pregnant and she had to have an abortion, so when your daughter came, I thought of that other girl....' None of the speakers seemed remotely aware of the irony in lying to the adults, yet expecting the teenagers to believe your promises of confidentiality. Obviously there is no problem when truth is all relative. For the Christian, truth is not relative but revealed in the Scriptures. The whole Bible has much to say about human sexuality, but two NT passages are of particular importance. 1 Corinthians 6:15-20 indicates that there is no such thing as casual sex (I have written about this at greater length elsewhere[l5]), and in Matthew 19:4-6 Jesus restates the biblical norm that sexual intercourse should be in the context of heterosexual marriage.

There is not space to further unpack these passages here. For those interested I recommend Smedes classic Sex for Christians,[16] which more than twenty years after its first publication, remains the most helpful popular paperback I know on biblical sexual morality.

Whose responsibility?

At least on the surface, the old debate over parents vs schools in sex education is over. The two sides would now admit that both have a part to play. However old suspicions die hard, and I have already shared some of my current concerns about some sex education experts' attitudes to parents. A recent pack for training GPs in adolescent sexual health promotion has advice on dealing with difficult situations such as 'getting a parent out of the room'.[17] Collaboration with parents does however characterise the best of current practice and I have been very impressed when this has been demonstrated - even at RCOG conferences on occasion. The same conference which presented the 'new morality' discussed previously, also showed sex education at its finest. One sex educator told of how she was in a friend's kitchen when the friend's little girl came in naked and proudly announced 'Mummy I've found another mouth down here'! After a moment's thought the mother replied. 'That's right, it does look a bit like a mouth but its proper name is a vagina. You might find it easier to call it gina though.' Later the friend asked why the sex educator had not stepped in since she was after all the professional. She showed she was a true professional by replying, 'I couldn't have done it better than you did as her mother'.

School sex education that both supports and is supported by parents is the best way forward. As doctors we are well placed to facilitate that better way, and as Christians let us have the will, the wisdom and the courage to do so.