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Sex Education Vol. 5, No. 2, May 2005, pp.

171188

School-based sex education policies and indicators of sexual health among young people: a comparison of the Netherlands, France, Australia and the United States
Heather Weavera, Gary Smithb and Susan Kippax*b
a

Pediatric Department, Shands Hospital, Florida, USA; bNational Centre in HIV Social Research, University of New South Wales, Australia

This paper investigates the relationship between school-based sex education policies and sexual health-related statistics of young1 people in four developed countries: the Netherlands, France, Australia, and the United States of America. Drawing upon literature searches in relevant CDROM databases, Internet websites, government reports and libraries, school-based sex education policies and a range of sexual health indicators for young people are described for each country. While the average age of first intercourse is approximately the same for each country, the analysis indicates that those countries with pragmatic and sex positive government policies (France, Australia and especially the Netherlands) have better sexual health-related statistics than the one country with a primarily sexual abstinence-based policy (the United States). The findings suggest that abstinence-based policies do not necessarily result in improved sexual health outcomes for young people. Furthermore, liberal policies do not necessarily promote sexual activity and may serve to better equip young people with skills that enable sexual health sustaining behaviours. Although a causal relationship between school-based sex education policies and sexual health outcomes cannot be proved, the analysis does suggest that young peoples reproductive and sexual health is best served when sex between young people is acknowledged, accepted and regulated rather than proscribed in all contexts outside marriage.

Introduction The regulation of sex, especially sex between young people, is a central concern of all societies (Bozon & Kontula, 1998; Warner, 1999). This concern is heightened in the context of sexually driven epidemics such as HIV. Most developed countries have
*Corresponding author: National Centre in HIV Social Research, University of New South Wales, Sydney, NSW 2052, Australia. Email: s.kippax@unsw.edu.au ISSN 1468-1811 (print)/ISSN 1472-0825 (online)/05/020171-18 # 2005 Taylor & Francis Group Ltd DOI: 10.1080/14681810500038889

172 H. Weaver et al. maintained low HIV prevalence rates, though prevalence is high among specific groups (Coulter, 1998; Piot et al., 2001). There is growing concern that HIV incidence in some developed countries is again on the increase, for example, among gay men (McFarland et al., 2000; Calzavara et al., 2002), and there has been renewed attention on sexual activity of young adults. It is important to recognise that ongoing containment depends upon maintaining low HIV risk behaviours. In the context of young people and sex, the most effective way of achieving HIV risk reduction is through the provision of sex education in schools that speaks to the real world in which young people live rather than to an ideal world in which some people would like to see them live (Piot et al., 2001). In the real world of most industrialised Western countries, young people engage in sexual intercourse. While there is agreement that it is imperative to eliminate or at least reduce the risk of HIV transmission among young people, there is disagreement about how sexual health and harm reduction should be promoted (Mendelsohn, 1983; Noland et al., 2002). A deeply entrenched and ongoing tension exists between those who accept or tolerate sex between young people and those who do not. This tension may be framed as a question: what constitutes responsible sex between young people? For some, the answer is clear. Any sex between young unmarried people is unacceptable. From this perspective, the problem of sex between youth is how to prevent it from occurring. Others accept that sex between young people is inevitable and that sexual responsibility is about ensuring that the sexual activity is free from the transmission of HIV and other sexually transmissible infections (STIs), unwanted pregnancies and other negative consequences. Those who advocate sexual abstinence prior to marriage ignore a number of factors affecting sexual practice in the developed world. For example, as a consequence of increased nutrition, throughout the twentieth century the age at which puberty is achieved has decreased (Stevens-Simon & Kaplan, 1998; Berne & Huberman, 1999). During the second half of the twentieth century men and women have been engaging in first intercourse at increasingly earlier ages (Laumann et al., 1994, pp. 324326; Bozon & Kontula, 1998, p. 40) and people are marrying at older ages (Berne & Huberman, 1999). The gap between age of marriage and physical sexual maturity has also widened during the second half of the twentieth centuryy (Santelli & Beilenson, 1992; Kirby, 1997). Sex before marriage in much of the developed world has become the behavioural norm (Berne & Huberman, 1999). For women to be virgins at marriage in contemporary Anglo-European societies is statistically less normal than to be nonvirgins. For example, of American women born between 1933 and 1942, 54.4% were virgins prior to marriage whereas for women born between 1963 and 1974, the same figure had dropped to 20.1% (Laumann et al., 1994, p. 503). Men and women are marrying later and cohabiting prior to marriage (Wadhera & Strachan, 1992; Wu & Balakrishnan, 1995). Kinseys research in the 1940s in the United States showed that the trend toward premarital sex began in the decade following the First World War, especially for women (Kinsey et al., 1953, pp. 298303). More recent data from the United Kingdom, as well as in the United States also indicates that the

School-based sex education policies and indicators of sexual health 173 trend toward earlier age at first sex is more pronounced for women than for men (Rubin, 1989; Johnson et al., 1994, pp. 6976; Laumann et al., 1994, pp. 324326). Given this evidence for increasing sexual activity among young people and the current concern about HIV transmission, how should sexual health be promoted among the young? Schools are settings that prioritise learning and reach almost all young people. As such, schools are a vital resource for providing children, adolescents and young adults with the knowledge and skills they need to make and act upon decisions that promote sexual health (McKay, 2000). After the family, school-based sex education programs are the main method by which adolescents receive information about sex related issues (Sexuality Information and Education of the United States [SIECUS], 1999). Most developed countries have some form of sex education in schools, ranging from reproductive biology classes to comprehensive sex education programs that encompass reproductive health and development, STIs, sexual identity, sexual behaviour, gender issues, and interpersonal relationships. The programs can be pragmatic and focus upon preventing STIs, HIV and unwanted pregnancy, as in the Netherlands and France, or morally-based, as the United States, where most young people are encouraged to abstain from sex until married (StevensSimon & Kaplan, 1998; Lindberg et al., 2000; Anonymous, 2002; Clymer, 2002). Sex education policies are generally considered public policy (Lewis, 1998) where public policy acts as a reflection of broader social and political climates. Thus, an examination of school-based sex education policies affords insight into how different countries (or their governing bodies) perceive young peoples sexuality and the kinds of efforts being made to ensure sexual and reproductive health. International studies of adolescent sexuality provide researchers, educators and policy-makers with valuable information on a range of programs and policies about which they may not be aware, potentially improving the sexual health of youth in their own countries in the long run. In this paper we aim to describe the relationship between sexual health education and reproductive health statistics of young people aged 15 to 19 years in the United States, Australia, France and the Netherlands. In particular, we examine how different models of school-based sexual education policy are reflected in sexual health outcomes for young people, including age at first intercourse, rates of pregnancy and abortion, proportion of young people using contraceptive methods other than abortion, and the incidence and prevalence of STIs and HIV.

Method The data for this paper are based upon a literature search from a number of sources, including CD-Rom databases (MEDLINE, APAIS-Health, Expanded Academic ASAP, EMBASE, Popline and Web of Science), Internet searches (Alan Guttmacher Institute, Planned Parenthood International, UNAIDS, WHO and SIECUS), library databases and governments departments. Primary resources were a priority for both government policy statements and sourcing relevant health statistics.

174 H. Weaver et al. Sex education policies are described with reference to a number of factors. We consider whether the personal and social aspects of sex and sexuality are included in school curricula as well as the biological; content areas that are covered; and the general framing of sex and sexuality (e.g. whether religious or pragmatic acknowledgment of young peoples sexuality). Sexual health outcomes included in this study are: pregnancy, birth and abortion rates; age of first intercourse, contraceptive use (including the contraceptive pill and condoms); and STI and HIV incidence rates. The collected data have been organised in two separate sections: policies regarding school-based sex education and sexual health statistics. The policy and statistical data are summarised at the end of each Results section. Similarities and differences between the countries are discussed in the Discussion. Collecting and integrating sexual health and policy information across countries is difficult. Policy information is often couched in general rather than specific terms and may vary from region to region within countries. Reports on the sexual health behaviours of young people are often imprecise, underreported and subject to differences: the logistics of collection varies from country to country, for example, data are collected from young people at different ages; legal and moral issues create barriers to data collection; and there is variation in the manner in which health indicators are defined. In this paper, preference has been given to indicators that were available in all or most countries and where it has been possible to recalculate sexual health outcome measures to make them comparable. Results Sex education policies: the Netherlands Since 1993 sex education in the Netherlands has been mandatory under the national health promotion program Living Together. Although there is still no topic called sex education or any mandatory national curriculum or textbook about sex education (Berne & Huberman, 1999), 97% of secondary schools and 50% of primary schools include sexuality information in their curriculum (Health Education Board for Scotland [HEBS], 2001). Dutch schools are free to determine the materials, methods, approach and time spent on each objective (Greene et al., 2001, p. 48) and typically schools have incorporated sex education within existing and related subject areas (e.g. Biology) rather than impose a curriculum on or create a subject area devoted to sex education. Nevertheless, schools in the Netherlands are obliged to cover the topics of pregnancy, STIs, sexual orientation and homophobia, value clarification, respect for differences in attitudes, and skills for healthy sexuality (Greene et al., 2001, p. 48). Teachers are trained through the provision sex education tuition in pre-service teacher training. Additionally, teacher training on sex and sexuality has been provided by the Netherlands Institute for Health Promotion and Disease Prevention (HEBS, 2001). Schools are directed to provide students with skills that prepare them for a capacity to be self-regulating in their sexual health, activities and choices (Valk, 2001). The goal of all sex education programs is to non-judgementally equip

School-based sex education policies and indicators of sexual health 175 students with a capacity to behave responsibly if they decide to have sex and to be able to identify safe and unsafe sexual practices. Students are encouraged and expected to be active in their own education, an empowerment concept mainstreamed in the 1970s and 1980s (Greene et al., 2001). An example of this is the use of youth advocates to inform the content of local sexual health policies through student councils and youth organizations, such as the Dutch Youth Group (Greene et al., 2001). The school-based sex education programs are also supported through encouraging the teaching of contraception indirectly by subsidizing mobile educational teams that operate under the auspices of the private family planning association (Jones et al., 1985). In addition, sex-related materials are provided for parents, clinics, family doctors and the media. Sex education policies: France Sexual health policies that target youth in France are also relatively recent. Adolescent sexuality was formally acknowledged by the government in 1973 when the legal age for consensual sex was lowered from the age of 21 to 18 (Dyrand & Bajos, 2001). In the same year the High Council on Sexual Information, Birth Control and Family Education was formed, and the Ministry of Education included sexual education and information within the curriculum (Dyrand & Bajos, 2001). Sex education at the time was primarily focused upon biological reproduction and was taught within natural science classes to students aged 13 years and over (HEBS, 2001). In 1981, the age limit for the commencement of sex education in classes was lowered to 12 years, and the specific topic of contraception was introduced at the age of 14 years. By 1985, sex education was included in life education classes taught at the primary school level (Dyrand & Bajos, 2001; HEBS, 2001). By the mid to late 1980s the Ministries of Education and Health began to encourage schools to include HIV/AIDS information in their sex education curriculum as a means of preventing infections. School-based sex education policies remained unchanged until 1996, following which they were revised to include a focus upon HIV risk practice among youth. The Ministry of Education implemented two hours of mandatory sex education for students aged 1214 years. Sex education classes in secondary schools remained optional, but secondary students are required to attend 20 to 40 hours of health education workshops over a four-year period (Dyrand & Bajos, 2001). Attendance at these workshops is mandatory and parents may not prevent their children attending, thus upholding a young persons right to receive sex education. In Elementary school, parents may prevent their children receiving such education (Berne & Huberman, 1999). Although sex education in France became more comprehensive with the onset of the AIDS epidemic, the primary focus continued to be upon biological sexual maturation, sexual reproduction, HIV and STD prevention and methods of contraception (HEBS, 2001).

176 H. Weaver et al. Sex education policies: Australia In 1957, the Director of the NSW Marriage Guidance Council stated: A conspicuous example of the failure of our society to train the young for marriage is the escapist and hypocritical attitude to sex education. Neither at home from qualified parents, nor at school from competent teachers, do our children even yet receive as a matter of course the rudiments of factual knowledge or the glimmering of a healthy attitude (Lewis, 1998, p. 230). Concern over the increase in STIs and sexual permissiveness, thought to be a result of the sexual revolution, sparked calls for effective sex education programs in schools. In 1967, sex education in New South Wales was formalized in schools when the NSW Department of Education incorporated sex education into the health syllabus for early secondary school students. The focus of that education was family life and included social, emotional and sexual development (Lewis, 1998). Over the next decade, all the states adopted formal policies on the provision of school-based sex education. The changing social and political environment of the 1970s laid the foundation for modern sex education in Australian schools. The emergence of the AIDS crisis in the mid to late 1980s further reinforced the need to provide open and candid discussion on sexual relations and encouraged major reforms in how sex education was approached. While the initial school-level response to AIDS was to focus upon disease transmission, more recently there has been an increased focus upon comprehensive sex education (Mitchell et al., 2000, p. 23). In 1998, the Commonwealth Department of Health and Family Services commissioned a research project to develop a framework to promote sexual health among young people. An outcome of that research was the development of national policy guidelines for teaching secondary school students about STIs, HIV/AIDS and Blood Borne Viruses (Australian Research Centre in Sex, Health and Society [ARCSHS], 1999). The five key components that informed the policy are: taking a whole school approach; accepting young people as sexual beings and providing the skills to enable them to control and enjoy sexual activity; catering for the sexual diversity of all students; and providing appropriate and comprehensive curriculum content in areas such as personal decisions and behaviours, sexual health, diversity and social justice (Curriculum Corporation [CC], 1994a, b; Australian Health Promoting Schools Association [AHPSA], 1997; ARCSHS, 1999; Mitchell et al., 2000). Sex education policies: United States There are no federal laws in the United States that require sexual health education in schools. Indeed, four statutes prevent the federal government from dictating state and local curriculum standards (SIECUS, 1999). This leaves sex education provision up to the individual states: nineteen states and the D.C. mandate sex education in schools and 35 states (and D.C.) require schools to provide HIV/AIDS or STI education (SIECUS, 1999). Of the state and federal policies that do exist, abstinence-based programs, which proscribe sex outside of marriage, are currently the predominant form of sex

School-based sex education policies and indicators of sexual health 177 education. The foundation of these policies was laid in 1981, when the United States Congress passed the Adolescent Family Life Act (AFLA). The purpose of the program was to prevent premarital adolescent pregnancy by promoting the values of chastity and self discipline, as well as to promote adoption as the preferred option for pregnant adolescents and to provide support for pregnant and parenting adolescents (Sonfield & Gold, 2001). The AFLA became a central organizing tool for subsidizing the developing abstinence-only based curricula in schools (Landry et al., 1999). In 1996 a new abstinence education incentive was developed at the federal level of government, known as Title V, Section 510 of the Social Security Act (Title V). An aspect of that act was to promote abstinence-based sex education in schools, especially among groups considered to be at risk of having children outside of marriage (Sonfield & Gold, 2001). To guide the states the government provided details of what counted as abstinence education: part of what was to be included was the claim that sexual abstinence was the only way to avoid STIs, pregnancy and psychological harm. Also claimed was that sex and childbirth outside of marriage was against social standards and harmful to individuals, children, parents and society (Sonfield & Gold, 2001). Recent initiatives within the United States Department of Health and Human Services have further supported Title V and its sexual abstinence school-based programs (Department of Health and Human Services [DHHS], 1999; Thomas, 2000). Broadly, there are two kinds of abstinence-based programs that operate in the United States: abstinence-plus and abstinence only. Abstinence-plus policies promote abstinence as the preferred option for adolescents; this policy allows contraception to be discussed as effective in protecting against unintended pregnancy and STD or HIV (Landry et al., 1999). Abstinence-only policies require that abstinence be taught as the only option outside of marriage; discussion of contraception is either prohibited or its ineffectiveness in preventing pregnancy and STIs or HIV is highlighted (Landry et al., 1999, p. 283). A late 1990s survey of school district sex education policies found that 69% of school districts had a policy to provide sex education, and the other 31% left sex education policies to individual schools within the district or to individual teachers (Landry et al., 1999). Of those districts with policies in place, 14% were comprehensive, 51% were abstinence-plus, and 35% were abstinence-only. Although broad public support exists for encouraging abstinence among teenagers, the great majority also believe that sexually active youth should have access to contraception (Landry et al., 1999). Research has also found support among teachers to teach students about contraception (Wilson, 2000). A number of reviews, including one conducted by the United States Surgeon General, have recommended that more comprehensive sex education approaches be adopted in schools (Anonymous, 2002), although such recommendations are in opposition to current government emphasis upon abstinence-only sex education in schools. Critics of the governments current sexual conservatism suggest some government-funded agencies are drawing back from the promotion of condoms and other more sexually liberal positions (Clymer, 2002).

178 H. Weaver et al. There was a marked decline between 1988 and 1999 in the provision of and teacher support for comprehensive sexual health curricula in United States schools. In 1988 2% of teachers taught abstinence-only sex education, which in 1999 rose to 25%. Also, in 1988 25% of teachers cited abstinence as the most important message. This figure rose to 40% in 1999 (Darroch et al., 2000). The introduction of Title V, in large part a continuation of an existing abstinence-based sex education trend, was a consequence of federal priorities and approaches around HIV/AIDS and teenage pregnancy (Wilson, 2000), the growing political and economic strength of right wing Christian organisations, and increased conservative parental involvement in the school environment (Mendelsohn, 1983). One in every ten dollars of Title V money was expended by faith-based organisations (Sonfield & Gold, 2001). This suggests a significant overlap between the church and the state. Comparison of national sex education policies The timing of the development of school-based sexual health policies was similar for the Netherlands, France, the United States and Australia. Prior to the 1960s and 1970s each country had some form of sex education, grounded in population control. With the emergence of the womens movement and the sexual revolution, broader sexual health needs of young people came to be addressed. Another shared milestone was the response to the HIV epidemic in the early 1980s, when each country began to develop sex education policies that went beyond basic reproductive biologyparticularly in terms of information on AIDS, HIV and safe sex practices. The HIV epidemic was a major turning point in the evolution of sex education policies. Although none of the four countries adopted a formal national curriculum, the commonalities between the four countries stopped there. The school-based sex education policy gap between the United States and the other three countries grew wider in the 1990s. The Netherlands increased its support for research-based sex education policies. The government took a hands-off approach to sex education programs, while at the same time requiring that certain topics such as sexual orientation and homophobia be taught in a comprehensive manner. Australias and Frances policies were similar in as much as young peoples sexuality was recognised and the focus was on building skills to promote sexual health. In the United States, teacher-delivered comprehensive sex education began to decline and abstinence and abstinence-plus programs began to increase. This decline coincided with increasingly conservative federal sex education policies. To date, each of the countries except the United States begins sex education in primary school. Each country except the United States has programs in place to further teacher training in the area of sexual health and each requires that the teachers, who teach sex education, are qualified to do so. In addition, teachers in France, Australia and the Netherlands are encouraged to go beyond the obligatory sexual health topics and address any questions students might have about sexuality and sexual health. In the United States, on the other hand, only 69% of school

School-based sex education policies and indicators of sexual health 179 districts have a policy to teach sex education (Landry et al., 1999), sex education is usually introduced at the secondary school level, and it is typically taught by teachers without training in sexual health. In addition, sex education is limited in many cases to biological aspects of sex and to sexual abstinence (United States Department of Health and Human Resources [USDHHR], 1997). Sexual health statistics The following tables provide details of a range of adolescent sexual health indicators, including: rates of pregnancy, birth, and abortion (Table 1); age of first sexual intercourse, contraceptive, including condom, use (Table 2); and prevalence of STIs and HIV (Table 3) for each of the four countries: the Netherlands, France, Australia and the United States. The United States has the highest rates of youth pregnancy, birth and abortion among young women in the developed world (Jones et al., 1985; Singh & Darroch, 2000; Feijoo, 2001; UNICEF, 2001). In the United States the number of births per 1000 adolescents between the ages of 15 and 17 years is 8.5 times greater than in the Netherlands, 5.5 times greater than in France, and almost 3 times greater than in Australia. Similar proportional differences hold for pregnancies within the 1719 year old age brackets (UNICEF, 2001). Again, the United States has the highest rates of abortion among the 1519 year olds, almost 8 times greater than the Netherlands, more than 5 times greater than France, and 1.2 times greater than Australia (see Table 1). Within the countries being investigated, most young women and men initiate first sexual intercourse in their teenage years (Table 2) (see also UNICEF, 2001). There is conflicting evidence, however, regarding the specific ages at which most young people initiate intercourse. Different studies from the late 1990s suggests that the average age of first intercourse is lower in the United States (15.8 years) than in the other countries (16 to 17.7 years). Other research however, from representative national samples, suggests that the age of first intercourse in the four countries is approximately the same18 years of age for those born between 1961 and 1970 (see also Darroch et al., 2001; Feijoo, 2001). Post World War II trends in Western Europe, Australia and the United States are in the same direction: men and women are engaging in first intercourse at increasingly earlier ages, though these trends have

Table 1. Birth, pregnancy and abortion rates (data are for 1998) Netherlands Births per 1000 women aged 1517 (1998)a Births per 1000 women aged 1819 (1998)a 20 year-olds who had a child in their teens (%) (1998)a Abortions per 1000 females aged 1519 (1996)a a: UNICEF, 2001. 2.2 12.0 3 3.9 France 3.4 18.6 4 13.2 Australia U.S. 9.5 31.0 9 23.9 30.4 82.0 22 30.2

180 H. Weaver et al. recently flattened (Laumann et al., 1994; Bozon & Kontula, 1998; Rissel et al., 2003). Within countries, however, there are important differences in age of first intercourse in relation to a range of variables. For example, Australian research indicates that technical college students initiate first intercourse considerably earlier than those attending university (Grunseit, 2001, p. 11), and United States data show that African Americans initiate sexual intercourse earlier than Anglo Americans (Mosher, 1988; Laumann et al., 1994). The highest rate of contraceptive use at first intercourse was among Dutch (85%) and Australian (90% for males and 95% for females) youth, followed by the French (74% and 77%) and the United States (75%, 65% and 69% according to different data sets). Among Australian youth, the very high rates of contraceptive use at first intercourse may in part reflect the recency of the data, which refers to those who initiated first intercourse since the year 2000. In Western countries, rates of contraceptive use (especially condom use) has steadily increased since the 1950s (Rissel et al., 2003). Different contraceptive methods figured more prominently in some countries than others. At last intercourse, condoms were used by the majority of young people in France (73% of males and 51% of females), in Australia (72% of males and 53% of Females) and in the United States (75%). Among Dutch youth though, only 29% used condoms at most recent intercourse. However, a different study (not included in Table 2) indicated that approximately 42% of Dutch youth use condoms consistently for intercourse; the older the person was the less likely they were to use condoms, which probably tracks a movement into long term
Table 2. Age at first intercourse, contraception use and condom use among 1519 year olds2 Netherlands Average age of first sexual intercourse years and monthsa 1519 year olds who have engaged in intercourse (%) Approximate age of first intercourse for those born between 1961 and 1970 Reported use of any contraception at first intercourse (%)a Those who reported using pill at last intercourse (%) Those who reported using condoms at last intercourse (%) 17.7 17.7b France 16.8 17.4d# 18b 44.3d# 50.7/46.1e* 17.5/18.2e* 74k 78.9/74.4d# 22/18.6d*# 72.5/51.1d*# Australia 16c U.S. 15.8

18/18e* 85

17.4b 40f 51.3g 17.6/18.1h* 17.5i*** 90/95h* 65 69l 76f 16.7l

67a 63m@ 29a

66.3n**

71.6/53.4n* 75.2l

a: Berne & Huberman, 1999; b: Feijoo, 2001; c: Grunseit & Richters, 2000; d: Lagrange et al., 2000; e: Bozon & Kontula, 1998; f: Kaufmann et al., 1998; g: Darroch et al., 2001; h: Rissel et al., 2003; i: Laumann et al., 1994; k: Phillips, 2001; l: Manning et al., 2000; m: Vogels et al., 1998; n: Kippax & Crawford, 1997. * Male/Female reports; ** Refers to self reports of women age 1819; *** refers to white men and women only; # 1518 year olds; @ 1218 year olds.

School-based sex education policies and indicators of sexual health 181


Table 3. STD/HIV infections among 1519 year olds Netherlands Chlamydia rate of males and females age 1519 (per 100,000)b Gonorrhea rate of for ages 1519 (per 100,000)b Of all reported Gonorrhea infections, % that occurred in that age group Syphilis rate of males and females age 1519 (per 100,000)a HIV prevalence rate (%) in young females (age 1524), end 1999a HIV prevalence rate (%) in young males (age 1524), end 1999a France 55.1 (96) Australia 292 (98)*c U.S. 1,131.6 (96)

7.7 (95) 5

7.7 (96) 10

65 (98)*c

571.8 (96) 31

1.0 (95)

11 (97)*c

6.4 (96)

.07.11

.14.21

.01.02

.18.27

.16.24

.21.31

.09.14

.38.57

a: UNICEF, UNAIDS & WHO, 2002; b: Panchaud et al., 2000; c: Moon et al., 1999; * includes ages 1224.

monogamous relationships (Vogels et al., 1998, p. 238). Approximately two thirds of Dutch and Australian youth used the contraceptive pill at last intercourse, a rate that was three times that of young people in the United States and France. The most complete STI data (Table 3) are for gonorrhoea. Among men and women aged 1519 years the highest rates of gonorrhoea occurred in the United States with 1,132 per 100,000. This rate is 74 times greater than that in France and the Netherlands. Despite Australian data including youth between the ages of 12 and 24 years, gonorrhoea rates in United States were 9 times higher than those in Australia. As a proportion of all cases of gonorrhoea in national population samples, a sizable minority of United States cases were among 1519 year olds (31%). In France and the Netherlands the proportions were 10% and less (no data are available for Australia). Statistical data for other STIs among 1519 year olds are somewhat patchy. However, available statistics indicate that chlamydia is more prevalent in the United States than it is in the other countries. The United States had a 20-fold greater rate than does France and a four-fold higher rate than Australia (remembering that the Australian data refer to 1224 year olds). Australia has a rate of syphilis among young people that is almost double that of the United States, although the United States has a six-fold greater rate of syphilis than does the Netherlands. In the United States and Australia, comparatively recently colonised countries, indigenous populations have very poor healthincluding sexual health. These and other inequities between young people may partly account for the overall higher rates of STIs within these countries.

182 H. Weaver et al. HIV prevalence rates in the adult population are low in all the countries considered here: below 1% among 1549 year olds. Rates are very low in Australia (0.1%), the Netherlands (0.2%), and France (0.3%), and slightly higher in the United States (0.6%) (UNAIDS, 1992). HIV prevalence among 1519 year olds is very low in all countries though the highest rates are recorded in the United States, followed by France. It should be noted that some infections among older age groups would have been contracted in the teenage years and diagnosed at a later time (HEBS, 2001). In general, compared with the other three countries, 1519 year olds in the United States fared the worst on most indicators of sexual health used in this study. In terms of STIs and HIV, syphilis infection among young people was the only health outcome indicator in which the United States did not fare the worst: Australia did. Contraceptive use at first intercourse was high across all the countries, and was especially high in the Netherlands and France. Oral contraceptives rather than condoms are the preferred contraceptive among Dutch youth and, therefore, the low rates of HIV and STIs among them cannot be explained in terms of condom use. Australian youth, despite reported high rates of contraceptive pill and condom use at last intercourse, have generally worse sexual health outcomes when compared with youth from France or the Netherlands. The low rates of pregnancy, births and abortions among Dutch youth are no doubt an effect of the generally higher rates of contraceptive use by them, especially the use of oral contraceptives. In contrast, the relatively high rates of condom use among United States youth have not prevented high rates of STIs, pregnancies and abortions. Discussion There is a common but unfounded belief that providing sex education will encourage sex among young people. Research suggests that skills-based sexuality education does not lead to early initiation of vaginal intercourse nor increased numbers of sexual partners (Grunseit et al., 1997; DiCenso et al., 2002). In some cases sex education may delay age at first sex, reduce the frequency of intercourse and number of sexual partners, and increase the use of condoms and contraception (SIECUS, 1999; Piot et al., 2001). Young people in the Netherlandsa country with one of the most comprehensive and liberal school-based sex education programshave one of the lowest fertility rates, one of the highest rates of contraceptive use, and an age of first intercourse that is no higher than in other countries. In a representative sample of Dutch students, students were asked under what minimal conditions premarital sex was acceptable (Vogels et al., 1998, p. 230). Whereas 23% of boys and 10% of girls believed that sex without real affection was acceptable, the majority of students saw strong feeling toward ones partner or being in a steady relationship as a precondition for engaging in sexual intercourse. Approximately 8% of students believed that premarital intercourse was unacceptable. There is a clear correlation in the countries examined in this paper between comprehensive sex education and positive sexual health outcomes. Among 1519

School-based sex education policies and indicators of sexual health 183 year old women in the United States, pregnancy, abortion and birth rates fell in the 1990s (Stevens-Simon & Kaplan, 1998). Despite these falls, the United States continues to fare worse than comparable countries across a range of sexual health indicators. Although young people in the United States use contraception and STI prophylactics at rates that are comparable to other developed countries, their use is not reflected in the sexual health outcomes of pregnancy, abortion and STI rates. A number of reasons have been put forward to explain the discrepancy. Firstly, it has been suggested that high rates of STIs among United States youth relative to their European counterparts may be a result of comparatively higher numbers of sexual partners (Darroch et al., 2001). If condom use is inconsistent, as Kaufmann et al. (1998) reported, increased risk from STIs may indeed be the consequence. Secondly, socio-economic disadvantage is more widespread in the United States than in comparable countries (Singh et al., 2001). Singh et al. note that such socioeconomic disadvantage is linked to lower personal competence, skills and motivation. This disadvantage relates to a fundamental underpinning of comprehensive sex educationa capacity to become highly self-regulating. Another element of disadvantage was said to be limited access to health care and social services. In the context of sexual health among young people, the provision of comprehensive sexual health services (such as access to contraception, abortion and STI screening and treatment) should lead to improved sexual health outcomes. Although the provision of sexual health services has not been the focus of this paper, it is difficult to separate sex education from sexual health services. In societies where sexual activity is not limited to one monogamous partner (as none of the countries discussed here do), no matter how comprehensive sex education is STIs and pregnancy are potential problems. As such, comprehensive and accessible sexual health services are an important structural support to the sexual self-regulation that young people are expected to achieve. Relative to the other countries considered in this paper, it can be said that youth in the United States are generally disadvantaged by the United States limited provision of comprehensive sex education and sexual health services. The widespread socio-economic disadvantage within the United States, identified by Singh et al. may be of considerable significance here. United States youth are doubly disadvantaged because they are less likely to become sexually self-regulating and are less able to access relevant sexual health services. Several authors, most of them United States-based, have noted an important difference between the United States and European approaches to sexual health. While many European countries accept sexual activity between young unmarried people, the United States does not (Berne & Huberman, 1999; Furstenberg, 1998; Widmer et al., 1998; Brick, 1999; Huberman & Berne, 1999; Carpenter, 2001; Feijoo, 2001; Noland et al., 2002). This difference has sexual health consequences for young people. Although the dominant sex education model in the United States is abstinence-based, young people initiate sexual activity at approximately the same age as countries where the dominant sex education model is one of encouraging informed and safe sexual activity. Dutch sex education policy (and to a lesser extent French and Australian policy) acknowledges that young people are sexually active.

184 H. Weaver et al. Thus a learning environment is created in which sexual shame can be reduced and sexual responsibility enhanced, remembering that sexual responsibility is not equivalent to sexual abstinence. Emphasising sexual abstinence among young people has the danger of directly or indirectly promoting the idea that sexual health problems are reducible to sexual activity itself, rather than a problem of ill-informed and unprotected sexual activity. In addition, channelling resources into abstinencebased programs contradicts programs that educate young people about how to become sexually responsible and safe (Peak & McKinney, 1996; Stevens-Simon & Kaplan, 1998; Landry et al., 1999; Sonfield & Gold, 2001). Sexual abstinence programs also restrict the creation of society-wide complementary and integrated sexual health programs for young people (Jones et al., 1985; Anonymous, 2002). Sex education in schools should be a component of broader and interrelated sexual health programs. The four countries discussed here, except the United States, provide sexual health services that complement their school-based sex education policies, such as the general provision of contraception, emergency contraception, abortion, counselling, ready access to condoms, STI screenings and treatment, education, and referral (Dyrand & Bajos, 2001; Greene et al., 2001). In the United States, the absence of a comprehensive national health insurance scheme means that contraception is not provided for all youth. Furthermore, the contradictions inherent in a society in which television portrays sex in all its forms but does not regularly advertise contraception or safe sex loom large. The dominant United States sexual abstinence programs in the United States have not generated a culture of sexual abstinence among most young people. More problematically, such programs prevent the development of a safe sexual culture among youth (e.g. developing sexual negotiation skills, access to sexual health clinics, access to STI and pregnancy prophylaxis and encouraging informed and responsible sexual activity). In countries where comprehensive sex education encourages young people to regard sex as positive, healthy and pleasurable, there is the opportunity to promote sexual responsibility. For the Dutch, the French and to a lesser degree the Australians, sexual responsibility is not measured by sexual abstinencean impractical expectation given the early age of puberty relative to the age at which most people now marry or cohabitate. The research discussed in this paper points toward a complex picture with respect to the sexual health of young people. The relationship between policies framing school-based sex education and sexual health indicators among young adults does not mean that the policies directly produce the desired sexual health outcomes. However, the data are difficult to resist. Although no single factor is entirely responsible for sexual health outcomes such as unwanted pregnancy rates and STI statistics, comprehensive sex education appears to be one of the more effective means of empowering youth against the negative consequences of sexual activity. The key is to provide a sex positive environment for young people to learn how to protect themselves from the potential harms that may flow from sexual activity and take responsibility to prevent those harms. Secondly, sexual responsibility among young people needs to be supported by ready access to sexual health services.

School-based sex education policies and indicators of sexual health 185 Notes
1. The phrase young people and the term youth are used interchangeably. They typically refer to males and females between the ages of 15 and 19. Where possible our data refer to this age bracket. 2. Two sets of symbols are used within the table. Letter symbols refer to the source of the publication. Other symbols refer to variations between data sets in terms of gender, ethnicity and age of the young people surveyed.

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