Sexual health in adolescents
Authors: Trevor Stammers
Journal: BMJ (2007)

Despite increasing provision of school sex education, teenage sexual health in the United Kingdom is in overall decline, with increasing rates of terminations and sexually transmitted infections in under 18s outweighing recent modest reductions in conception rates in this age group.1 2 w1

Counterintuitively, rather than improving sexual health, sex behaviour interventions can make it worse.w2 Most studies on sex education programmes in schools examine intermediate outcomes only, such as pupil satisfaction or reported condom use. This often facilitates premature false claims of success, whereas more robust outcome measures such as rates of terminations, unplanned conceptions, and sexually transmitted infections show no benefit. 

In this week's BMJ Henderson and colleagues report the effect of a theoretically based teacher delivered sex education programme (SHARE) on registered conceptions and terminations.3 The trial found no significant difference between the intervention and control groups in National Health Service registered conceptions (per 1000 pupils: 300 SHARE v 274 control; difference 26, 95% confidence interval −33 to 86) or terminations (127 SHARE v 112 control; difference 15, −13 to 42) between ages 16 and 20. 

The results should stimulate urgently needed change from previous ineffective approaches to school sex education for which, as the authors admit, “evidence of effectiveness is mixed.” Evidence shows that increased knowledge is a necessary but insufficient cause of change in sexual behaviour.w3 It is also clear that strategies such as promoting availability and correct use of condoms and increasing use of the emergency pill do not necessarily lead to a reduction in sexually transmitted disease rates,1 pregnancies,w4 or terminations.4

So what needs to happen next? Henderson and colleagues stress the need for more comprehensive approaches that incorporate the influence of parents on sexual experience in teenagers, and to improve the future life opportunities for vulnerable young people. The false assumption that “young teens will have sex anyway” is an insult to many young people who have the capacity to rise to a far more effective challenge than just “use a condom every time.” 

Delaying first intercourse is recognised as an important outcome measure of sex education programmes, and teenagers are more likely to save sex (a more positive and helpful term than “abstinence”) when their parents communicate the importance of doing so.5 Of course, to be involved in this way, parents have to be with their children.w5 Much evidence points to the effectiveness of maternal involvement in sex education.6 However, the presence of a father is also an important factor in teenagers saving sex until adulthood.w6 In the Netherlands, many more mothers and fathers talk with their children about sex than in the UK.7 The lower rate of single parenthood in the Netherlands is an important factor in the lower rate of teenage pregnancy seen in that country.7

Giving students homework to complete with their parents greatly enhanced the effectiveness of one school based abstinence only programme.8 This study, however, measured the usual intermediate outcomes only, such as self efficacy and intention to have sex, and more randomised controlled trials of abstinence programmes are needed to look at effects on sexual debut, unplanned conceptions, and sexually transmitted infections. 

Much teenage sex has little to do with sex itself but is connected with searching for meaning, identity, and belonging.w7 These wider sociocultural aspects influencing sexual behaviour need greater attention.9 Their importance is highlighted by a Seattle community based programme for children up to age 12, designed to help avoid health risk behaviours in later adolescence. Though good social decision making (including abstaining) in areas such as conflict resolution or drug use was encouraged, this programme contained no specific sex education. Nevertheless, at nine year follow-up, people in the programme were significantly older at first sexual experience and were significantly less likely to become pregnant by age 21 (38% v 56%; P <0.05, 95% confidence interval 0.27 to 0.93).10 A key factor in the Ugandan success in reducing HIV rates so dramatically during the 1990s was a community wide, mass media communication of messages to achieve the desired outcomes of abstinence and being faithful, in addition to condom use.w8 w9

Blanket assertions that abstinence programmes “don't work” abound.w10 Ironically, however, the only randomised trial of school sex education identified by the SHARE team to use clinical data on pregnancies was of an abstinence only programme that resulted in a significant reduction of pregnancies.11

With the introduction of its recent “Leave it till later” campaign, the UK government is belatedly recognising that saved sex is a vital component of truly safer sex. In the United States, teenage pregnancies are at their lowest level in more than 30 years, and the teenage abortion rate has been halved since its peak in 1988. The only peer reviewed studies of reasons for these trends published up to 2006 attribute two thirds of the teen pregnancy reduction in unmarried teenage girlsw11 and just over half of the total reduction to delayed first sex.12 With a recent study showing that education to save sex does not lead to decreased condom use at first sex,w12 it is time the evaluation of saved sex programmes had a share of UK funding for sex education research. However, if saving sex is seen as a way for young people to avoid unplanned pregnancy more than just an educational structure, then last week's government announcement of plans to raise the school leaving age to 18 should do more to reduce teenage pregnancy rates than anything they have done so far.w13