Teenage pregnancies on the increase

The British teenage pregnancy level is now the highest in Europe. Currently 9.4 per 1000 13-15 year-olds and 63 per 1000 16-19 year-olds get pregnant each year:[1],[2] twice the rate in Germany, four times that in France and seven times that in Holland. 87% of teenage mothers in Britain are unmarried and 29% of children are brought up by a single parent.[3] The incidence of STDs is also rising and of about 180,000 abortions each year, about 40,0 00 occur in teenagers.[4],[5]

Everyone is concerned about this state of affairs - and the almost universal response is a call for contraception to be more easily available. Prof John Guillebaud, Professor of Family Planning at University College London, has proposed that girls of twelve should be fitted with a contraceptive implant that works for three years, with parents' consent, at the same time as their rubella injections[6] and the Royal College of Nursing has called for school nurses to be given the power to prescribe emergency contraception for girls as young as eleven.[7] More than 80% of hospital doctors and 95% of GPs believe that the contraceptive pill should be available to girls below the legal age of consent.[8]

National Lottery money is to be used to provide free condoms and sex education in the hope of reducing teenage pregnancies and œ300 million will be spent on new centres which will offer advice on contraception, abortion, relationships and avoiding STDs.[9] In April, the Government announced a new policy to deal with the growing problem; aimed to combat the perceived widespread ignorance on sexual and reproductive health.[10]

Is more contraception really the answer? With teenage pregnancy rates in Britain at their highest level in history - despite teenage sex and contraception being more readily discussed than ever before - surely it is time to question the prevailing wisdom. In aiming to prevent the social and public cost of the rise in teenage pregnancy, STDs and abortion, we shouldn't revert to knee-jerk solutions. Public Health policy should be evidence-based and cost-effective.

How did we get here?

At the start of this century, the illegitimacy rate was 3% and childhood pregnancies in those under 16 were rare. From 1945 to 1956 conceptions in girls under 16 remained constant at 200 per year (0.8 per 1,000).[11] By the end of the 1960s this figure had risen to 6.8 per 1,000.[12] In 1991 the figures had risen to their present levels of 9.3 conceptions per 1,000.[13] Teenage prescriptions for 'post-coital contraceptives' doubled from 14,395 per year to 24,800 between 1989 and 1992 alone.[14] Since 1969 the rate of teenage abortions has quadrupled.[15]

What accounts for this rising trend? The 'swinging sixties' heralded liberal attitudes to extramarital sex, fuelled in 1961 by the introduction of the oral contraceptive pill. The oral contraceptive met the 'need' of society to control its fertility and illegitimacy - sex could be separated from reproduction. But by 1969 teenage pregnancy rates had risen dramatically and the Government was pressured into 'acting'.

The reaction of the Government, encouraged by pharmaceutical companies and pro-contraceptive groups, was to make contraceptives more readily available. There was strong media support for 'sexual freedom' and none of the denominations of the church protested vociferously.

In 1964 the Family Planning Association turned from its central policy of helping married couples space children, to supporting contraception for the young and unmarried. They assisted and funded Lady Helen Brook in setting up her Brook Advisory Clinics (BACs, now numbering 27 throughout Britain) alongside similar clinics run by local health authorities. All this was largely tax-payer funded.

By 1974, the Government had authorised the provision of contraceptive advice to young girls under the legal age of consent - 16 years of age - without parental consent.

BACs operate on the premise that teenage sex is both normal and desirable - on the sole provision that it is undertaken 'safely'. Typifying this attitude is Caroline Woodruffe (long-time secretary of the BACs) who has said, 'We try to get them (the parents) to see that they should be pleased not shocked when children engage in sexual intercourse'.[16] 'We must be prepared to challenge our established attitudes that sexual activity in young people is dangerous. There are still too many workers in birth control clinics who believe consciously or subconsciously that sex before sixteen is sinful.'[17] In other words, teenage sex is 'fun and freedom', waiting is repressive and Victorian, and abstinence is impractical and indeed impossible.

The 1956 Sexual Offences Act makes having sex with a girl under 16 illegal, unless the man can plead in his defence that he believed either that he was married to the girl, or that she was over 16. But no man has ever been prosecuted under this law and (ironically) it is perfectly legal for contraceptives to be given to children under 16 by specialist clinics.

Why have teenage pregnancies increased?

Advocates of teenage sexual freedom will of course argue that teenage pregnancy rates would be much higher if contraceptives were not as readily available - but there is good circumstantial evidence to suggest that free contraception has exacerbated the situation - primarily by enabling the development of a culture where promiscuity is seen as acceptable.

Three factors have not been considered in the government's equation: the teenage psyche, the effectiveness of contraceptives themselves and the questionable value of sex education.

The teenage psyche

Whoever persuaded successive ministers to provide free secret contraception to teenagers knew very little about the behaviour of teenagers. They also underestimated the power of the TV and media in encouraging promiscuity. Today, one need only pick up any of 20 teenage magazines and see that they are full of sex and innuendo. However, aside from mentioning the 'side-effect' of becoming pregnant, they rarely deliberate on all the other possible detrimental sequelae. How often does casual sex on TV lead to pregnancy, STD or emotional hurt - and yet how often are condoms or contraceptives used? Peer pressure is also powerfully endemic.

Mentally and emotionally, unmarried teenage partners lack the commitment and trust that is necessary for lasting relationships. They also suffer more when partnerships break up. Girls in particular, are badly affected because they tend to seek long-term commitment and security from their sexual partner more than boys do. Correlations between age of first episode of intercourse, abortion and suicide are well recognised.[18] Orr[19] found that sexually active 12-16 year-old girls were six times more likely to report having attempted suicide. Most women regret having intercourse before age 16 and being forced into first intercourse is commonly reported.[20] Some have described sex before marriage as the equivalent to opening the present before Christmas day - all the surprise, expectation and fun has been taken away.

Sexually active teenagers are also more likely to be involved in risk-taking behaviour than those who remain virgins. Minor delinquency, school difficulty, drug, alcohol and substance abuse in association with early sexual activity are on the increase. The younger the age of commencing sexual activity, the greater the risks taken and the worse the outcome.[21] Teenagers typically put off long-term goals for short-term gains and are notorious for their 'it will never happen to me' behaviour. Denial and disregard of consequences characterise adolescent thinking. One study found that over 70% of teenage girls thought they could not become pregnant.[22]

The effectiveness of contraception

The teenage years are characterised by emotional lability which strikes discord and conflict into relationships. This is readily exemplified by the animosity between parents and their teenagers as the latter establish their identity, challenge the status quo and develop their own directives on life. Such turmoil is also inherent within the relationships teenagers have with their peers. The result is inconsistent use of contraception leading to higher failure rates. A recent BMJ letter asserted that, 'Contraception in teenagers does not prevent unplanned pregnancies - used long enough it virtually assures them'. [23] Society has lacked the foresight to recognise that contraception is made up of 'contraceptive plus user'- the two are both sides of the one coin.

Even Pauline Crabbe, one-time Vice chairman of BACs admitted, 'These mini pills for adolescents have to be taken at the same time each day. They probably live lives where they never do anything at the same time each day'.[24]

Contraceptive failure is a major factor in teenage pregnancy;[25] 80% of teenagers with unplanned pregnancy in one study claimed to have been using contraception at the time of conception.[26]

The problem is that failure rates of 3% for the pill and 1.8% for the diaphragm,[27] (in mature adults) have been extrapolated by the Department of Health and applied to young, inexperienced children, some of whom are below average social and educational levels. More correct statistics for under 16s are: 11% for the pill and 32% for the diaphragm.[28] The Government seems equally misguided on the effectiveness of condoms. The advent of HIV saw campaigns encouraging their use yet even mature couples have been reported to have failure rates as high as 52%.[29] Nervous teenagers are hardly likely to do better. Misapplied failure rates have been used to justify a misapplied policy.

Many cite Holland's success in preventing unplanned pregnancies as evidence of the effectiveness of making contraceptives widely available. However, Holland has also promoted early 'abortion' through the vigorous advocacy of the 'morning after pill' and 'menstrual extractions'. Statistics for this latter procedure of 'early termination' are not formally recorded because conveniently they can be performed in unlicensed clinics. This means that true figures for conceptions and abortions in Holland are very difficult to find.[30]

The questionable value of sex education

Even before the British Government implemented its contraceptive policy evidence from elsewhere should have prompted caution. The increased availability of the pill and sex education in the USA had actually run parallel with increases in child pregnancies amongst the US school population.[31] Research suggests that although in the USA contraceptive education resulted in gains in sexual knowledge, it also led to appreciable shifts towards promiscuity.[32] This makes some sense. If lack of contraceptive knowledge alone accounted for rising illegitimacy rates, then we would expect teenage pregnancy rates to have been higher 50 years ago when most women and all children were totally unaware of any way to prevent pregnancy.

The reality is that so many more teenagers are having sex today than 50 years ago, that any protective effect from contraception is far outweighed by the dramatic increase in 'copulation rate'.

While there is some evidence that good sex education delays the age of first intercourse,[33] the majority of programmes in the UK are no more effective than peer group influence, at least for girls.[34]

Is contraception a lesser evil?

Many justify the use of contraception on the grounds that it is better than an unwanted pregnancy followed by an abortion. However, withholding contraception does not guarantee these sequelae. Abstinence was perfectly effective as a contraceptive measure in past years. When the real health consequences of promiscuity become evident and accepted we may well see a swing of the pendulum of public opinion - as we have against tobacco use. The Government may have rather 'shot itself in the foot' by promoting contraception because its failures may have paved the way for the passing of the Abortion Act in 1967. With abortion providing another means of 'birth control' the impression that sexual activity was without consequences was intensified.

Further evidence of 'cause-and-effect' comes from the fact that attendance at birth control clinics by those aged 13-15 mirrors the number of unplanned conceptions and abortions. Only in 1985 (when Victoria Gillick campaigned against underage prescribing) did pregnancies and abortions not rise (despite contraceptive clinic attendance figures falling in that year from 49 to 33 per 1,000). On the contrary, when the Appeal Courts reversed their decision to allow free contraception to under 16s, attendance increased to 44 per 1,000 and the pregnancy rate to 9.3%.[35]

The risks of teenage sex

It is not just contraceptive side effects that we need to consider. The 'bio-psycho-social-spiritual' effects of underage sex can leave life-time scars influencing future relationships and hindering the young person's sense of esteem, identity and attitude to life. Sexual activity in girls under 16 is medically and emotionally undesirable.

The physical risks of teenage sex, through sexually transmitted disease, have been well documented. A sexually active 15 year old runs ten times the risk of a 23 year old in catching STD. One fifth of genital herpes and one third of gonorrhoea and genital warts occur in women under 20. In the USA in 1992, 19.5% of AIDS sufferers were aged 20-29, and given the long incubation period, it is likely that a substantial proportion of these developed the disease during adolescence.

The risks of abortion including haemorrhage, infertility, infection and post-abortion syndrome are also worse in those of a younger age-group.[36]

Socially, there is the harm done to children and the catastrophic effect on society of the breakdown of family life as unstable teenage relationships fall apart.

Ironically, even those who pressed for increased contraceptive availability and education have recognised the costs to children. Dr Mary Calderone, (Executive Director in 1964 of the Sex Information and Education Council of the United States) has admitted, 'No-one knows what effect sex precociously experienced will have...Sex experience before confidentiality, empathy and trust have been established can hinder and may destroy the possibility of a solid permanent relationship.' [37]

Sexual sin always hurts someone. It hurts God because it shows that we prefer following our own desires instead of the leading of the Holy Spirit. It hurts others because it violates the commitment so necessary to a relationship. It can often bring disease to our bodies; and it deeply affects our personalities, which respond in anguish when we harm ourselves physically and spiritually.

Where do we go from here?

The Government set out to treat a problem but it had the wrong diagnosis. The problem is not lack of contraception. Our society has lost its way and needs a whole new approach to relationships and sexuality. As Dr Margaret White says, 'It is time to recognise that a generation of boys and girls has suffered a serious injustice at a vulnerable stage of their lives, and to offer a better tomorrow based on a recognition of the need for change'.[38]

What can we do as Christian medics?

Know the Medical Facts.

The facts in this article speak for themselves and constitute a powerful argument against current social policy. We need to have the diligence to learn them and the courage to make them known to colleagues, teachers, patients and lawmakers. Sex outside marriage is dangerous for the physical, mental and spiritual health of our patients. Teenagers need to be informed, protected, disciplined, supported and encouraged that saying 'no' is the best option.

Promote Christian Values.

Christians are called to be salt and light both in affirming sex as the good gift of a loving creator (1 Tim 4:4) and in affirming lifelong heterosexual marriage as its only proper context (Mt 19:4-6). God created sex and loves it, and gives us guidelines for the proper use of sex for our pleasure, protection and welfare. Virginity is a virtue to treasure and needs to be promoted. CARE's 'Make Love Last' video, now in 45% of UK secondary schools, is an excellent example of how the positive Christian message can be put across in a tasteful and convincing way. Its overall message, and that of other successful Christian sex education packages[39] is that 'true love waits'

Repent from wrong attitudes and actions.

God's will is that we ourselves should be sanctified, avoiding sexual immorality and learning to control our bodies in a way that is holy and honourable (1 Thes 4:3-4). This involves not just our actions, but our thoughts as well (Mt 5:27-28).

We are all subject to temptation and it may be that we first need to know God's love and forgiveness ourselves so that we can be an example to others.

Promote Just Legislation.

 Legal reform is needed to discourage teenage sex and free contraception. The law is a very powerful educator of public opinion - and, as has been seen in the case of smoking, a dramatic change in public opinion is possible once society starts to wake up to the implications of lifestyle choices. Just laws may not change people's hearts but they do restrain the heartless and protect the innocent. In a democracy we are all (in a sense) rulers - and so we have a responsibility before God to do what we can to ensure that just laws are on the statute books - through lobbying, educating decision-makers about the medical facts and electing people who hold to biblical values. (Is 10:1) Some of also need to be in decision-making positions ourselves; in education, local and national government and on BMA and Specialist committees.

Serve the suffering.

We must avoid the temptation of being mere moralisers. As Jesus dealt with the woman caught in adultery, likewise we must never lose sight of the individual person. We are called to minister in love (1 Cor 13) with the message of the cross of forgiveness (Ne 9:17; Is 57:18), healing (Ps 103:3) and freedom (Jn 8:32; Gal 5:1). When people are suffering as a result of unwise lifestyle choices we need to be on the front line being ready to love and serve them. Christians should be at the forefront of initiatives to support girls with unplanned pregnancies, provide alternatives to abortion,[40] treat sexually transmitted disease, give wise sex education[41] and show by example a better way of living.

Preach the Gospel.

Ultimately, true freedom comes only in knowing that we can be forgiven and restored to a right relationship with God through faith in Christ's death on the cross. Living according to Christian values is possible only with the power of God's indwelling spirit. What our society most needs is not morals, good medicine nor just laws but to return individually and corporately to knowing God.