Sexual health policies in other industrialized countries: are there lessons for the United States?

At least since the early 1980s, health professionals and social scientists in the U.S. have been concerned about high rates of teenage pregnancy, abortion, unplanned pregnancy, and sexually transmitted diseases (STDs). Major questions have been: Why are these rates in the U.S. so much higher than corresponding rates in other western industrialized countries? Why is the U.S. not a leader in the area of sexual health? Why do less affluent and less technologically advanced countries do a better job in dealing with problems that result from sexual behavior? What distinguishes the approaches and policies of other industrialized countries from those in the U.S.?

These questions have concerned researchers and led to projects whose purpose was to compare policies and programs in the U.S. with those in countries with better sexual health indicators. For this discussion, the indicators of most concern involve rates of STDs, teen births, abortion, and unplanned and unwanted pregnancies. In this article I summarize findings of major national and comparative studies that have attempted to understand how the U.S. can better provide for the sexual health of its citizens. I also discuss approaches to sexual health in countries that do substantially better on the aforementioned sexual health indicators than does the U.S.

NATIONAL AND COMPARATIVE STUDIES

In the 1980s the Alan Guttmacher Institute (AGI), a not-for-profit corporation for reproductive health research, policy analysis, and public education conducted a comprehensive comparative study of industrialized countries to identify factors that influenced unwanted pregnancy, abortion, contraceptive use, and teen pregnancy. One part of this study focused directly on outcomes for women under 20 and the other for women 20 and older (Jones et al., 1986; Jones, Forrest, Henshaw, Silverman, & Torres, 1988). The adolescent study included an analysis of 42 possible explanatory factors for 37 countries with an in-depth analysis of six countries. Jones et al. (1986) found that the U.S. had one of the highest teen fertility and abortion rates. Factors characteristic of the U.S. and listed as significant predictors of high adolescent pregnancy rates were restrictive ideas about teenage sexuality, lack of openness and discussion about contraception and sexual responsibility, high levels of poverty and an unequal distribution of wealth and income, high levels of religiosity, low availability of contraceptive education and family planning services, and high cost of such services.

The analysis by the AGI of unintended pregnancy, contraceptive practice, and family planning services for the women 20 and older involved 20 countries, with an in-depth analysis of four of them. The U.S. did not fare well in this study either, for it had one of the highest rates of abortion, unplanned pregnancy, and unwanted pregnancy. Unplanned pregnancy was particularly problematic for American women between 20 and 25. Compared to their counterparts in other countries they had a higher abortion rate, experienced first intercourse at a younger age, used less effective contraceptives, and reported a higher rate of using no contraceptive at all. Jones et al. (1988) concluded that the system of delivering family planning services in the U.S. is less conducive than systems in other western countries for the promotion of the use of effective contraceptive methods. The lack of a "national health plan that includes family planning and provides for everyone, regardless of income" was cited as a major reason for the higher rates of unplanned pregnancy in the U.S. (Jones et al., 1988, p. 58).

In another attempt to examine and suggest ways to reduce the high rate of teenage pregnancies in the U.S., in 1984 the Committee on Child Development Research and Public Policy, within the National Research Council of the National Academy of Sciences, established an expert panel on adolescent pregnancy and childbearing. Its two-volume report (Hayes, 1987; Hofferth & Hayes, 1987) reviewed trends in and determinants of adolescent sexual behavior, decision-making, contraceptive practice, and pregnancy resolution. On the basis of their 2-year review, analysis, and debate, the panel concluded that pregnancy prevention should receive the highest priority. Sexually active teenagers of both sexes should acquire the skills and motivation to avoid unwanted pregnancies. They should also be able to easily receive contraceptive counseling and contraceptives. Thus, the panel recommended public support for contraceptive services to adolescents at low or no cost, sex education about contraceptives in the schools, implementation and evaluation of condom distribution programs, and the use of the media for messages encouraging sexually active teens to use contraceptives. In addition, the panel concluded that there was no scientific basis for restricting the availability of abortion services to teens or for requiring parental consent for abortion or contraceptives. However, the panel also emphasized that adolescents should be encouraged to discuss sexual decisions with their parents.

Another more recent project investigating unintended pregnancy took place in the first half of the 1990s. For this project (also approved by the governing board of the National Research Council, whose members come from the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine), members were selected for an expert committee on unintended pregnancy (Brown & Eisenberg, 1995). The conclusions of this committee stated that nearly 60% of all pregnancies are either mistimed or unwanted altogether, a percentage higher than in many other western democracies. In addition, the authors stressed that "unintended pregnancy is not just a problem of teenagers or unmarried women or of poor women or minorities; it affects all segments of society" (Brown & Eisenberg, 1995, p. 1). Changes recommended included (a) improving knowledge about contraceptives, (b) increasing access to contraceptive services, and (c) providing greater support for research evaluating programs to reduce unwanted pregnancies.

Yet another project, also approved by the National Research Council, gathered together experts to form a committee to examine the epidemic of STDs--other than HIV/AID--min the U.S. This committee found that rates of curable STDs are the highest in the developed world and even higher than in some developing countries. Many of the factors found to be associated with unplanned pregnancy were also found to correlate with high risk of having an STD. Factors influencing STDs were poverty, inequity of wealth and resources, lack of sex education and media coverage of information about STDs, conservative attitudes fostering secrecy, shame and punishment, inadequate access to health care, alcohol and drug use, and inadequate attention to special population groups such as substance abusers, sex workers, teenagers, the homeless, immigrants, and those in detention facilitates (Eng & Butler, 1997).

Currently, although rates of teen births in the U.S. are at their lowest level in the 6 decades for which data exist (49.6 per 1000 in 1999 vs. 96 per 1000 in 1957), this rate is still higher than in most other industrialized countries (Singh & Darroch, 2000). In Singh and Darroch's analysis, the U.S. had the second highest birth rate of 25 countries for both 15 to 17 and 18 to 19 adolescent age categories. Sixteen countries had birth rates less than a third of the U.S. rate for the younger age group. Similarly, the U.S. had the second highest abortion rate for the two age groups in comparisons with 18 developed countries for which data were available.

In a recent comparative study of the U.S., Canada, Sweden, France, and Great Britain, the U.S. was also found to fare poorly (Darroch, Singh, Frost, & Study Team, 2001). It had the highest rates of adolescent childbearing and abortion as well as higher rates of STDs among adolescents. In addition, a higher proportion of American teenagers reported no contraceptive use at both first and most recent intercourse. The higher rate of STDs was at least partially attributed to the greater number of sex partners reported by American youth compared to their counterparts in the other countries. In another article by the same research group (Singh, Darroch, Frost, & Study Team, 2001), the explanation for the higher rate of adolescent pregnancy was thought to be primarily a result of the substantially greater proportion of poor and disadvantaged teenagers in the U.S. compared to the other western democracies. Thus, the primary recommendation was that because in all countries, economic disadvantage was associated with higher teen pregnancy rates, a major strategy to reduce such rates is to improve the economic and disadvantaged circumstances characteristic of so many American teenagers.

APPROACHES TO SEXUAL HEALTH IN EUROPE

The Advocates of Youth--whose goal is to help young people make safe and responsible decisions about sex--and the University of North Carolina at Charlotte sponsored a study tour to learn about European approaches to adolescent sexual behavior (Berne & Huberman, 1999). Experts from the U.S. in adolescent health, teen journalists, and graduate students participated in the study tour and worked together to write a report of their findings. The three countries visited--The Netherlands, Germany, and France--all have significantly lower rates of STDs and teen pregnancy than does the U.S. In these countries teens are older, on average, than teens in the U.S. when they have their first sexual intercourse.

Adolescent sexual health in these countries is based on values of rights, responsibility, and respect. Government and the general society consider it not only a duty to provide accurate information and confidential contraceptive services to the young, but also that provision of such services and information to adolescents is part of their rights. There is no attempt to motivate behavior of teenagers through a collective effort to demand abstinence. Thus, the goal is not to prevent adolescents from having sex but to educate and thereby empower them to make responsible decisions. By respecting the independence and privacy of adolescents the expectation is that, in return, the majority will act responsibly to try to avoid pregnancy and STDs. The more tolerant attitude toward sexual expression of teenagers also makes it easier for them to get the services they need. Teenagers do not have to feel guilty or ashamed of using contraceptives. In fact, they will more likely feel they have been irresponsible if they fail to use it.

A similar approach has also been adopted in the Nordic countries, and it also has not led to promiscuity. In the Nordic countries as well as the previously mentioned study tour countries, public health policy is based on public health research and input from well-trained sex educators, not on political or religious definitions of moral behavior. In addition, these countries provide national health insurance that covers most of the costs of contraceptives and related services. The low cost and easy accessibility of services help adolescents take advantage of preventive health measures.

The Netherlands deserves attention, for it is the western country that has had the lowest rates of unplanned pregnancy, abortion, and teen pregnancy for quite some time (Jones et al., 1988; Ketting, 1994; Ketting & Visser, 1994; Singh & Darroch, 2000). In 1995 the teenage abortion and pregnancy rates in the U.S. were about seven times that of The Netherlands (29.2 vs. 4.0 and 83.6 vs. 12.2, respectively; Singh & Darroch, 2000). Dutch policy makers use research, pragmatism, and an ethics approach that tries to teach responsibility in sexual decision making as the basis for their sexual health programs. The goal is to allow an open discussion about sexual issues and encourage adolescents to talk about sex and topics that interest them. The attitude of the government is that both the public and families have a responsibility to help young people avoid unwanted pregnancies and STDs. The goal is to instill a sense of responsibility in the young and to give them the knowledge to act accordingly. It is also important that the general public is tolerant and accepting of teenage sexual experiences. The view is that it is impossible and quite ridiculous to try to prevent teenagers from having sex. Thus, the sensible action is to prepare them to act responsibly. Contrary to the view held by many in the U.S., this liberal attitude seems to be consistent with the findings that Dutch teenagers have fewer partners than their American counterparts and have their first sexual intercourse at an older age--15.8 for USA and 17.7 for The Netherlands (Berne & Huberman, 1999). Condom use does not vary greatly in the two countries but what distinguishes The Netherlands is that sexually active young adults use more effective contraception such as the pill at a much higher rate: 67% of sexually active female adolescents used the pill at their most recent intercourse in contrast to 20.5% in the U.S.(Berne & Huberman, 1999).

A major component in the Dutch approach to sexual health is their mass media campaigns. According to Berne and Huberman (1999, pp. 13-14), these campaigns help to "keep sexual health on the public agenda, reduce stigma by emphasizing community responsibility for health problems, serve in educating youth by providing catalysts for discussion and reinforcing messages, reach higher risk groups not generally accessible through traditional channels, encourage intermediaries (teachers, youth workers, pharmacists) to draw attention to safer sex, and stimulate organizations to provide training and education to intermediaries." One of the media campaigns in The Netherlands popularized the use of the slogan "double dutch"--meaning to use the double protection of a condom (to lower STD risk) and the pill (for protection against pregnancy) when having sex. Media campaigns are well coordinated with the education and health sectors to ensure consistency and accuracy of messages to the young.

Additional strategies used by clinics that provide sexual health services to Dutch youth include (a) accept teen sexuality and sexual behavior, (b) guarantee anonymity or confidentiality, (c) waive PAP smear and pelvic exams as prerequisites for initial contraceptives, (d) provide nonjudgmental service, and (e) require minimal paperwork and no parental consent (Berne & Huberman, 1999).

Because The Netherlands has many port cities, STDs have been a major public health concern. To keep health risks minimal, accessible and government-funded STD clinics provide testing, treatment, education, pre- and posttest counseling, and contact tracing. National Public Health Insurance (which covers over 99% of the Dutch population) funds all reproductive health services except condoms. These include contraceptive pills and devices, emergency contraception, abortion, testing for pregnancy and HIV/STD, prenatal care, delivery, and all drug therapy associated with diagnosis and treatment of STD, HIV, and AIDS (Berne & Huberman, 1999). These authors also stress that the AIDS case rate per 100,000 is several times higher in the U.S. than in The Netherlands.

Research (Rademakers, 1994; Vanwesenbeeck, Van Zessen, Ingham, Jaramazovic, & Stevens, 1999) in The Netherlands in the 1980s and 1990s supports the view that adolescents with good interactional competence skills are better at avoiding high-risk sexual behavior. In the Rademachers study, girls who had experienced an unwanted pregnancy had given the boy control over taking initiatives in decisions regarding both the use of contraceptives and choice of sexual activity. More recent research by Vanwesenbeeck et al. (1999) and Papp, Kontula, and Kosonen (2000) supports the importance of good interactional skills for avoiding and reducing risk behavior. Thus, a major topic to include in sex educational curricula is the teaching of interactional competence skills to both girls and boys.

A comparative study of family planning services in the U.S., Great Britain, The Netherlands, and Sweden provides insight into the difference in effectiveness of such services. Cromer and McCarthy (1999) conducted interviews with 75 key informants (clinicians, politicians, public health administrators, social and behavioral scientists, and antiabortion activists) in these four countries. Interviewees were asked to describe the optimal family planning services for adolescents. These included comprehensive and multidisciplinary care provided in confidence by nonjudgmental staff with good counseling and communication skills. Interviewees in The Netherlands and Sweden described good coordination between family planning services and local schools, whereas informants in the U.S. reported parental resistance to such coordination. Government support and funding were considered to be adequate in The Netherlands and Sweden but in the U.S. informants felt they received very little governmental, medical, or familial support for their work. Family planning staff in The Netherlands and Sweden had high job-related prestige and had a positive view of their work situation. This feeling was lacking in the U.S.

Finland provides an excellent example of a country whose changes in sexual health policy resulted in better indicators of sexual health for its population. In the 1960s health and social work professionals identified several health problems linked to sexuality. Women were having more babies than they could handle, morbidity and mortality rates due to illegal abortions were considered too high, and STDs also posed health risks. As a result, new policies and comprehensive education campaigns were enacted. First, in the early 1970s a new abortion law made abortion legal and education on how to provide such a service was provided at hospitals. When the abortion law was passed, the goal was to make abortion an uncommon event, and so every effort was made to provide comprehensive contraceptive information and services. The government mandated that family planning and maternity/infant/child health services be provided free or at low cost in all local health centers. Every local municipality was charged with these tasks and given precise and detailed instructions and education from national experts on how to provide family planning and abortion services. Nurses in the schools were instructed to provide contraceptive education to classes and in individual counseling. As a result of these new policies, teen pregnancy rates dropped from 49 out of 1000 for girls aged 15 to 19 in 1975 to 19 out of 1000 in 1994; during this period, the teen abortion rate also declined--from 21 out of 1000 to 9 out of 1000 (Kosunen & Rimpela, 1996).

Finland also has a low rate of STDs compared to other countries. From the 1970s to the mid 1990s, cases of syphilis decreased and nearly disappeared, and thus a whole generation of doctors had almost never seen a syphilis patient (Hiltunen-Back & Ranki, 2000). The lower rates of STDs can be attributed to the high quality of diagnostic and treatment methods, the free or low cost of these services, the guarantee of confidentiality provided at STD clinics, and a high rate of condom use. Because there is less of a stigma of having an STD in Finland and treatment is free or low cost, barriers to treatment and greater spread of STDs are also reduced.

The general level of HIV/AIDS in Finland is also low by international comparison. When it was discovered in 1998 that new cases of HIV had occurred because of intravenous drug use, the response was quick. First, clean needles and syringes were supplied at safe places in the major cities. Second, drug treatment programs were expanded to try to meet the needs of all those who sought treatment. Third, outreach programs were developed to meet the needs of special population groups such as prisoners, sex workers, and immigrants.

Rimpela (1998), one of Finland's sexual health experts, attributes the good sexual health outcomes to five factors: (a) the use of preventive approaches in public health; (b) a change of focus from abortion to the prevention of its main cause, unintended pregnancy; (c) excellent cooperation and coordination between the health and education sectors; (d) strong and skilled guidance from the national health authorities; and (e) professional attitudes and skills of nurses and doctors in sex education and family planning. The general delivery system of sexual health services in Finland facilitates easy access and low cost of these services. In addition, Finns do not take a moralistic approach to sexuality and the sexual activity of the young. The emphasis is on helping teenagers make responsible sexual decisions by providing them with adequate knowledge and skills. The national government has provided funding for many sexual health initiatives including evaluation of programs and surveying representative samples of providers and clients of sexual health services.

This review would not be complete without reemphasizing the high quality sex education and sexual health services of all the Nordic countries (David, 1994; David, Morgall, Osler, Rasmussen, & Jensen, 1990; David & Rademakers, 1996; Friedman, 1992; Lindahl & Laack, 1996; Lindahl, Vikorsson & Rasmussen, 1995; Lottes & Kontula, 2000; Skeldestad, 1994; Sundstrom-Feigenberg, 1988; Vilar, 1994). For example, Sweden has been known for its long tradition of sex education in the schools, compulsory since 1955 (Lennerhed, 1995). Lewin (1987) emphasizes that Swedish adolescents have an emotional perception of sexuality, and very few view sexuality in purely hedonistic terms. Surveys support the view that adolescents believe that the purpose of sexuality is primarily to allow people to feel closeness and express tenderness. In this regard, it is interesting that Schmidt et al. (1994) found that in Germany also, the trend has been for adolescent boys to link sexuality with love or with a steady relationship; boys feel less at the mercy of their sexual urges. There is little evidence of a similar trend in the U.S.

Swedish sex education has been based on the principles of democracy, tolerance, and human equality. Ethical principles of Swedish sex education include: (a) "Nobody is entitled to regard and treat another human being simply as a means of selfish gratification," (b) "Mental pressure and physical force are always a violation of individual liberty," and (c) "Sexuality forming part of a personal relationship has more to offer than casual sex and is therefore worth aspiring to. This, it will be observed, does not imply any moral castigation of persons dependent on casual sexual relations during periods of their lives. Nearly all young persons take the view that sexual fidelity towards a person with whom one has a personal relationship with is a duty. Schools should support this conviction" (Swedish National Board of Education, 1986, p. 5). Survey findings are also consistent with the view that recreational sex is much more common among adolescents and university students in the U.S. than in Sweden (Lewin, 1987; Weinberg, Lottes & Shaver, 1995).

CONCLUSION

In western countries with the best indicators of sexual health, citizens generally regard sexual expression as a normal part of growing up. Sexual development is viewed as a healthy biological, social, emotional, and cultural process. Sexual health is promoted by nonjudgmental attitudes of adults and by mass media campaigns that are well coordinated with school sex education and providers of contraceptives and contraceptive counseling. National health insurance covering most of the cost of sexual health services encourages young and old alike to take preventive measures for their sexual well-being.

The recommendations and policies outlined by the experts in the U.S. in the studies cited in the first part of this article are consistent with the approaches to sexual health of the western and northern European countries described in the later part. These policies have uniformly resulted in reductions in rates of unplanned pregnancy, teen births, abortion, and STDs. The Surgeon General's recent efforts to promote sexual health and responsible sexual behavior presents an opportunity for American politicians, policy makers, and health and education professionals to adopt new policies that have been shown to work. Although many will argue that what works in other countries will not work in the U.S., there is surely much that can be adapted and applied from an understanding of how policies in other countries have done a better job of promoting the sexual health of their citizens.

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Ilsa L. Lottes
University of Maryland Baltimore County

Address correspondence to Ilsa L. Lottes, University of Maryland Baltimore County, Dept. of Sociology and Anthropology, 1000 Hilltop Circle, Baltimore, MD 21250; e-mail: [e-mail].