Teens & Sex

In Western Europe: Not About Risk

Tuesday, May 16, 2006; Page HE01


Pierre-Andre Michaud, chief of the Multidisciplinary Unit for Adolescent Health at the University of Lausanne Hospital in Switzerland and a leading researcher in European teen sexuality, dismisses the idea--widely held in the United States--that sex constitutes risky behavior for teens. In an editorial in May's Journal of Adolescent Health, he wrote:

"In many European countries -- Switzerland in particular -- sexual intercourse, at least from the age of 15 or 16 years, is considered acceptable and even part of normative adolescent behavior." Switzerland, he noted, has one of the world's lowest rates of abortion and teen pregnancy. Teens there, like those in Sweden and the Netherlands, have easy access to contraceptives, confidential health care and comprehensive sex education.

A 2001 Guttmacher Institute report, drawing on data from 30 countries in Western and Eastern Europe, concluded: "Societal acceptance of sexual activity among young people, combined with comprehensive and balanced information about sexuality and clear expectations about commitment and prevention childbearing and STDs [sexually transmitted diseases] within teenage relationships, are hallmarks of countries with low levels of adolescent pregnancy, childbearing and STDs." The study cited Sweden as the "clearest of the case-study countries in viewing sexuality among young people as natural and good."

Cecilia Ekéus, a nurse midwife with a PhD in public international health who works with the Institute of Women and Child Health at Karolinska Institute in Stockholm, says Swedish society teaches that sex should occur in a committed relationship "and also that teenagers should use contraceptives, be informed and take responsibility. But in general we are open and positive and think that it's okay."

In Sweden, compulsory sex education starts when children are 10 to 12. Without parental consent, teens can get free medical care, free condoms, prescriptions for inexpensive oral contraceptives and general advice at youth clinics. Emergency contraceptives (the so-called morning-after pill) are available without a prescription.

Religion tends to insert itself less in government policy on sex education, contraception and abortion in Western Europe than in the United States, says Michaud. The Catholic Church exerted minimal influence in Switzerland's AIDS prevention campaign, he said. "All in all, the church has been very tolerant and does not really get involved in sexual matters," Michaud wrote in an e-mail.

Straightforward messages on how to prevent STDs and teen pregnancy help offset the impact on teens of sexually explicit ads, movies and other mass media -- as ubiquitous in Western Europe as in the United States, said Robert Blum, chair of the Department of Population and Family Health at the Johns Hopkins Bloomberg School of Public Health.

Western Europe also attaches more social stigma to teen pregnancy and teen motherhood than do some American sub-cultures, says Bill Albert, spokesman for the National Campaign to Prevent Teen Pregnancy, a U.S. group: "The focus [in Western Europe] is much more on preventing pregnancy and less on sex itself," Albert said.

Although some experts argue that economic, educational and racial diversity in the U.S. distort national figures and invalidate comparisons with more homogenous Western European countries, Michaud said he has studied Swiss teens who have dropped out of high school, used drugs or lived in disadvantaged areas of the country. They tend to use contraception regardless of economic status, he said.

"My feeling is that it is impossible to have a double message toward young people," Michaud said, in a phone interview from his Lausanne office. "You can't say at the same time, 'Be abstinent, it's the only fair, good way, to escape from having HIV . . . and at the same time say, 'Look, if you ever happen to have sex, then please do that and that and that.' You probably have to choose the message."

Abstinence, he said, is not something the Swiss press on teens. "We think it's unfair. It's useless. It's inefficient. We have been advocating the use of the condom . . . and I think that we tend to be successful."

Joan-Carles Surís, head of the research group on adolescent medicine at the University of Lausanne, puts it another way:

"The main difference is that in the States sexual activity is considered a risk. Here we consider it a pleasure."

Elizabeth Agnvall is a frequent contributor to the Health section. Comments: health@washpost.com. Join Robert Blum, of the Johns Hopkins School of Public Health, in a Live Online chat today at 11 a.m. on handling teen sexuality.

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In the United States: Conflicted Messages

Tuesday, May 16, 2006; HE01


Of course there is no official U.S. position on teen sex, but a portion of the federal Healthy People 2010 report summarizes a set of carefully balanced goals: reduce unwanted pregnancies; cut the proportion of unmarried teens who have had sex; increase the use of birth control and disease prevention techniques among teens who are sexually active; and make contraception, including emergency contraception, more widely available.

But in practice, teens in our culturally heterogenous American society receive many conflicting messages. Many churches in the United States urge abstinence until marriage. Under government and local citizen pressure, many school sex education programs express disapproval of premarital sex and limit information about contraception. A 1999 Kaiser Family Foundation study found that about a third of U.S. public high schools have sex education programs that advocate strict abstinence until marriage. Experts at the Sexuality Information and Education Council of the United States say the number has since grown, with some states not only accepting federal funds for abstinence education, but also including federal government language in their sex education guidelines.

Mary Stetson is a Fairfax County health and physical education teacher who has taught sex education for 11 years. (State guidelines suggest sex ed should run from kindergarten through 12th grade, but individual school districts can decide whether or not to teach it, and parents can have their kids opt out.) Her course focuses on decision-making and values clarification, with an emphasis on encouraging kids not to have sex until marriage. Students learn the consequences of impulsive and risk-taking behavior. Some of her religiously oriented students take abstinence pledges.

Students' outside-class knowledge of sex tends to vary based on their parents' education and socioeconomic status. "The more education the parent has, the more likely the parents are going to talk to kids about sex," she said.

Poverty alone (the United States is home to a greater proportion of poor teens than Western Europe) doesn't account for the disparity in teen sex behavior here and abroad. According to a 2001 Guttmacher study, the poorest U.S. teens are nearly 80 percent more likely to have a child by 18 than similar teens in Britain.

Outside the classroom, U.S. teens face a barrage of provocation. A study last month in the journal Pediatrics found that the higher the exposure to sexual content in movies, TV, music and magazines, the more likely teens were to have intercourse. The study found "frequent and compelling portraits of sex as fun and risk-free."

This message falls on too many teens who are ill-informed or unprotected, says Robert Blum, chairman of the department of population and family health at the Johns Hopkins Bloomberg School of Public Health.

"We have a very hyper-sexualized media and, concurrent with that, a total aversion to giving clear and consistent messages about how you reduce risk," he says. In a 1995 survey, he asked both teens and their parents if the teens had had sex. Half the parents who said their kids were not sexually experienced were wrong, he said. (According to a 2003 survey by the Centers for Disease Control, nearly half of all U.S. students in grades 9-12 have had sex.)

But many American educators and parents say more permissiveness is not the way to go.

Angela Griffiths, executive director of an abstinence-based sex education program in California called Await & Find, said she sees an attitude among some California educators that teen sex is inevitable. Her program focuses on how condoms and birth control sometimes fail to prevent pregnancy and disease, and on the benefits of postponing sex. She said many educators are unwilling to combat what she called the prevailing media attitude that sex is fine for teens.

Too many teachers "are accepting that this is part of youth," she said.

Jonathan Klein, chairman of the American Academy of Pediatrics Committee on Adolescents, says there is a risk that children's best interests are getting lost in the debate over teen sexuality.

"We have some groups in our country who would like to prevent unintended pregnancy and sexually transmitted diseases, and some groups that would like to prevent people from having sex," Klein said. Both are willing to twist research to support their position, he said.

Regardless of a parent's opinions about teen sex, he said, more open communication is healthier: "Healthy sexual behavior is part of development. From a medical perspective it's important that parents and children and teenagers are well-educated about the implications of normal, psychosocial and sexual development."

But what of the emotional consequences? While a series of decades-old studies tied teen sex to other risky behaviors -- like drug and alcohol use -- many researchers say those findings are not nationally representative. Newer research has linked teen alcohol and drug use to failure to use a condom and more sexual partners, but there's no proof a cause-and-effect relationship exists, or, if it does, which behavior might trigger the other.

"Although advocates of abstinence-only government policy have suggested that psychological harm is a consequence of sexual behavior during adolescence, there are no scientific data suggesting that consensual sex between adolescents is harmful," wrote Columbia University's John Santelli in the January issue of the Journal of Adolescent Health. That's despite several studies that have looked at the psychological impact of sex on teens.

Where mental health problems are associated with early sexual activity, he says, research suggests that the sexual activity is a consequence of the psychological problems, not vice versa.

In research recently published in the Journal of Adolescent Health, Lydia Shrier, an assistant professor of pediatrics at Harvard Medical School and director of clinic-based research for the division of adolescent/young adult medicine at Children's Hospital Boston, showed that sexually active people aged 15 to 21 reported more positive feelings on the days they had sex than on the days they didn't. Shrier said sex education messages should take that into account.

"We have to tailor the messages to reflect our understanding that for many people, sex is not a bad thing or a thing that is ridden with guilt, but as a more positive and less negative experience, for some of these young people, than other things in their lives," Shrier said.

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Virginity Pledges Can't Be Taken on Faith: Virginity Pledge-Takers Tell All

By Sandra G. Boodman
Washington Post Staff Writer
Tuesday, May 16, 2006; HE04


Many abstinence programs have embraced the concept of virginity pledges, encouraging children as young as 9 to promise to wait until marriage to have sex.

So how reliable are reports of sexual activity by teenagers who took such a pledge?

Not very, according to a study by Harvard doctoral candidate Janet Rosenbaum published in the June issue of the American Journal of Public Health. Rosenbaum found that 53 percent of adolescents in a large, federally funded study who said they made a virginity pledge denied doing so a year later, often after they had become sexually active.

At the same time, 10 percent of teenagers who said they had had intercourse and then made a pledge or became born-again Christians subsequently said they were virgins.

Rosenbaum's study is based on an analysis of 1995 and 1996 data from the National Longitudinal Study of Adolescent Health, which involved more than 13,000 teenagers in grades 7 to 12. At the time virginity pledge programs, many of them sponsored by evangelical Christian groups, were proliferating as a way to combat teenage sex, sexually transmitted diseases (STDs) and perceived moral decay.

Rosenbaum said her study shows that efforts to evaluate such programs' effectiveness is complicated by teenagers' reports of behavior that may be influenced by religious or social factors. "Whatever environment you're in, you're more likely to conform," Rosenbaum said.

Sarah Brown, director of the National Campaign to Prevent Teen Pregnancy, a nonprofit organization headquartered in Washington, agreed. "This study confirms that when people are asked about sensitive behavior, you have to take their answers with a grain of salt."

"What's interesting is that it showed changes over time and tried to tease out what might lead to those changes," she added.

Previous studies have found that teenagers who make pledges contract STDs at nearly the same rate as those who don't, but that they have fewer sexual partners, are less likely to use condoms and more likely to engage in anal or oral sex.

Leslee Uhruh, president of the nonprofit National Abstinence Clearinghouse in Sioux Falls, S.D., called Rosenbaum's study "junk science."

"These programs work," said Unruh, calling the study a "politically motivated attack" on pledge programs. "We see it all the time. I don't trust this data," she said, noting that the information that Rosenbaum used was collected 10 years ago. "Things have changed."

Denny Pattyn, founder of Silver Ring Thing, an evangelical Christian program that has received federal funding, said that about 60,000 youths have made virginity pledges after attending a three-hour sound and light show sponsored by his Pittsburgh-based group. Participants spend $15 for a silver ring inscribed with a Biblical verse -- a virginity symbol to be removed on the wearer's wedding day and given to his or her spouse.

"We teach abstinence because it's the truth," said Pattyn. "We don't analyze ourselves based on reducing the risk."

Pattyn said that his program assesses its effectiveness in part by sending e-mails to participants for four months after they take a pledge to ask if they are abstinent.

The group is about to launch a study of its long-term effectiveness, according to researcher Paul Kennedy. Kennedy said an online survey he conducted in March involving 2,500 youths who attended Silver Ring Thing found that 97 percent of attendees reported having an improved understanding of the benefits of abstinence and an awareness that oral sex does not eliminate the risk of contracting an STD.

Like other pledge programs, Silver Ring Thing leaders endorse the concept of "secondary virginity," which means that a teenager who is not a virgin can start fresh by taking an abstinence pledge. That notion, Rosenbaum suggested, might cause some teens to discount previous intercourse as experimentation not worth reporting to researchers, thereby complicating accurate evaluation of pledge programs.

To Columbia University sociology professor Peter S. Bearman, who has published several studies on the effectiveness of virginity pledges, Rosenbaum's findings are not surprising.

"Study after study that's peer-reviewed has showed that these programs make no appreciable impact on public health, and increase dangerous behavior" because pledge-takers are more likely to engage in unprotected sex, Bearman said. "Pledging leads to a form of promise-breaking that's riskier."

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Run the Numbers

Tuesday, May 16, 2006; HE04

U.S. and Western European teens start sexual activity at about the same age--the median age for first intercourse is 16 in Sweden, 17 in Switzerland, Germany and the United States, and 18 in France.

Chief of the Multidisciplinary Unit for Adolescent Health at the University of Lausanne Hospital in Switzerland, Pierre-Andre Michaud says Swiss teens differ from their U.S. counterparts principally in that they are more likely to use contraceptives.

Almost half (47 percent) of all U.S. high school students report having had sexual intercourse, according to a 2003 survey conducted for the Centers for Disease Control and Prevention; for high school seniors, the figure is 62 percent. In Sweden approximately 80 percent of teens have had sex by age 20, according to Tanja Tydén, professor in the Department of Public Health and Caring Services at Uppsala University in Sweden.

U.S. teens are more likely to have sexual intercourse before age 15 and to become pregnant than teens in England and Wales, France and Sweden, according to a 2000 report from the Guttmacher Institute, a nonprofit group that studies sexual health. The study also found that Western European teens are likelier to be in a committed relationship when they have sex.

U.S. teens also have a higher rate of infection and STDs -- due to lower condom use, according to the report.

The U.S. teen pregnancy rate (84 out of every 1,000 girls age 15 to 19 become pregnant each year) is higher than that that of Denmark (23), Finland (21), Germany (16) and Sweden (25), found a 2000 report in Family Planning Perspectives. (Differences in birth rates are also striking: Roughly six out of every 1,000 teen girls have babies every year in Switzerland, eight per 1,000 in Sweden, 10 per 1,000 in France, and 28 per 1,000 in England and Wales, according to the report, compared to about 54 per 1,000 in the United States. The U.S. abortion rate (then 29 per 1,000) was higher than that in Sweden (17), France (10), Finland (10) and the Netherlands (4), found the report.

According to the Guttmacher Institute, a third of all U.S. girls become pregnant before they turn 20; 80 percent of them are unmarried.

In the U.S., rates of teen sex, pregnancy, abortion and birth have all declined since 1991, as a result, most experts agree, of a combination of teens' postponing sex and increased contraception. But the rates are still higher than those in virtually all Western European countries.

--Elizabeth Agnvall

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What Can Parents Do?

Tuesday, May 16, 2006; HE04


While parents can't control when their children will have sex or whether they will use contraception, their values and parenting style can make a difference, show studies by Robert Blum at the Johns Hopkins Bloomberg School of Public Health and others.

To help parents talk with their kids about love, sex and relationships, Blum recommends this advice from the National Campaign to Prevent Teen Pregnancy:

· Be clear about your own sexual values and attitudes.

· Talk early and often with your children about sex.

· Help teenagers find options for their future that are more attractive than early pregnancy and parenthood.

· Let your teens know that you value education.

· Know what your kids are watching, reading and listening to.

· Supervise and monitor your children.

· Know your children's friends and their families.

· Discourage early, frequent and steady dating.

· Build close, caring relationships with your children early in childhood.

-- Elizabeth Agnvall

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Birth, Abortion and Pregnancy Rates for Developed Countries, Ages 15-19
Teenage pregnancy is more common in the United States than in most other industrialized countries, according to the The Alan Guttmacher Institute report on Teenage Sexuality and Reproductive Behavior in Developed Countries.

Country Births Abortions Pregnancies*
Russian Federation 45.6 56.1 101.7
United States 54.4 29.2 83.6
Bulgaria 49.6 33.7 83.3
Romania 42.0 32.0 74.0
Belarus 39.0 34.3 73.3
Georgia 53.0 13.4 66.4
Estonia 33.4 32.8 66.2
Rep. of Moldova 53.2 11.6 64.8
Hungary 29.5 29.6 59.1
Latvia 25.5 29.0 54.5
New Zealand 34.0 20.0 54.0
England and Wales 28.4 18.6 47.0
Canada 24.2 21.2 45.4
Australia 19.8 23.8 43.6
Slovak Republic 32.3 11.1 43.4
Iceland 22.1 21.2 43.3
Scotland 27.1 14.5 41.6
Czech Republic 20.1 12.3 32.4
Norway 13.5 18.7 32.2
Northern Ireland 23.7 4.8 28.5
Israel 18.0 9.8 27.8
Sweden 7.7 17.2 24.9
Denmark 8.3 14.4 22.7
Finland 9.8 10.7 20.5
France 10.0 10.2 20.2
Slovenia 9.3 10.6 19.9
Ireland 15.0 4.2 19.2
Germany 12.5 3.6 16.1
Belgium 9.1 5.0 14.1
Spain 7.8 4.5 12.3
Netherlands 8.2 4.0 12.2
Italy 6.9 5.1 12.0
Japan 3.9 6.3 10.2

*Note: pregnancies exclude miscarriages; data from mid-1990's

SOURCE: The Alan Guttmacher Institute report on Teenage Sexuality and Reproductive Behavior in Developed Countries

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Table 1: Birth, Abortion and Pregnancy Rates; and Abortion Ratio, By Country, Ages 15-19, Mid-1990s

Country Births per 1,000 Abortions per 1,000 Pregnancies per 1,000 Abortion ratio
Sweden (1996) 7.8 17.2 25.0 68.8
France (1995)* 10.0 10.2 20.2 50.5
Canada (1995) 24.5 21.2 45.7 46.4
Great Britain (1995)** 28.3 18.4 46.7 39.4
United States (1996) 54.4 29.2 83.6 34.9

*Rates are adjusted to the young woman's age in completed years when the event occured, to be comparable with other countries. Rates are not inflated for the underreporting of abortions.
**Rates for Great Britain (which comprises England, Wales, and Scotland) are calculated by combining data for these administrative areas.
Note: Pregnancy rates include births and induced births but do not include spontaneous abortions or miscarriages. The abortion ratio is the number of abortions per 100 pregnancies, excluding miscarriages.

SOURCE: The Alan Guttmacher Institute report on Teenage Sexuality and Reproductive Behavior in Developed Countries

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Table 2: Births per 1,000 women Ages 15-19

Teenage birthrates declined less steeply in the United States than developed countries between 1970 and 2000.
Year Sweden France Canada England and Wales United States
1970 33.9 37.4 42.8 49.7 68.3
1975 28.8 33.1 35.3 36.5 55.6
1980 15.8 25.4 27.2 29.6 53.0
1985 11.0 16.9 23.2 29.5 51.0
1990 14.1 13.3 25.6 33.2 59.9
1995 8.6 10.0 24.2 28.4 56.8
2000 6.8 9.4 20.2 30.8 48.7

SOURCE: The Alan Guttmacher Institute report on Teenage Sexuality and Reproductive Behavior in Developed Countries

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Table 3: Percentage of Sexually Active Teenagers, Ages 18 to 19, With Two or More Partners in the Past Year

Country Women Men
Sweden (1996)* 42.8 31.3
France (1992, 1994) 12.8 28.8
Canada (1996) 23.5 38.1
Great Britain (1990-1991) unavailable unavailable
United States (1995) 48.6 48.8

SOURCE: The Alan Guttmacher Institute report on Teenage Sexuality and Reproductive Behavior in Developed Countries

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Table 4: Annual Syphilis, Gonorrhea and Chlamydia Rates, Rate per 100,000

Country Adolescents 15–19 General Population
Female Male Total
Syphilis
Sweden 1995 1.2 0.0 0.6 0.8
Canada 1996 0.9 0.3 0.6 0.3
England and Wales 1996 0.2 0.2 0.2 0.3
United States 1996 8.6 4.3 6.4 4.3
Gonorrhea
Sweden 1995 2.0 1.5 1.8 2.8
France 1996* 8.4 7.0 7.7 8.4
Canada 1996 86.4 33.3 59.4 16.8
England and Wales 1996 83.4 51.5 67.0 22.4
United States 1996** 758.2 394.8 571.8 125.1
Chlamydia
Sweden 1995 921.0 235.2 569.6 156.0
France 1996** 110.9 1.6 55.1 60.2
Canada 1996 998.6 148.5 563.3 114.8
England and Wales 1996** 339.0 74.2 202.9 75.9
United States 1996** 2,067.0 245.8 1,131.6 192.6

*General population rates for France are calculated using the number of infection cases per 100,000 population at ages 15–59.
** This country has medium or low reporting rates; that is, fewer than 70% of diagnosed cases are estimated to be reported.

SOURCE: The Alan Guttmacher Institute report on Teenage Sexuality and Reproductive Behavior in Developed Countries

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Examples of Interventions
Programs From Five Developed Countries Aim at Affecting Adolescents' Sexual Attitudes and Behaviors Through School-Based Sexuality Education


Sweden

Sexuality and Interpersonal Relationships

The National Agency for Education provides sexuality education reference materials to schools. These guidelines focus on feelings and sexuality and emphasize dialogue rather then lecturing students. Teaching goals cover basic facts, norms and values, social and psychological contexts and personal decision-making. The Main Thread The Stockholm County Council unit for promoting sexual health and preventing HIV/STDs, LAFA, funded with federal money, develops sexuality education teaching methods and produced a methodological handbook of 40 different teaching methods for use in Sexuality and Interpersonal Relationships.

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France

Training in sexuality education

The Ministry of Education organizes a national training program to train physicians, school nurses, social workers, management or supervisory personnel, teachers and guidance counselors to facilitate their involvement in sexuality education. Training is conducted by local school districts using funds specfically earmarked by the Community Health Office. Mandated sexuality education The Ministry of Education mandates that students in middle schools (ages 11–15) receive two hours per year of sexuality education covering issues self-image, legal, social and ethical dimensions of human sexuality, relationships, preventive behaviors and sources of care; in addition to covering physiology, STDs, contraception, abortion and assisted reproduction in the life and earth sciences curriculum. Sexuality education is also included in the 40 mandated hours of citizenship and health education provided during the first four years of secondary education.

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Canada

Canadian Guidelines for Sexual Health Education

Health Canada, the national ministry of health, developed, with nongovernmental participation, and distributed 30,000 copies of a 33-page booklet of (voluntary) guidelines targeted to anyone developing and delivering sexuality education programs. The guidelines are based on principles of democratic society, achievement of positive outcomes and avoidance of negative outcomes. Skills for Health Relationships A joint venture of national and provincial ministries of health and education developed and distributes a curriculum on sexuality, AIDS and other STDs for grade 9 (aged 13–14) to any school, school board or ministry of education that assumes costs of duplicating the materials for their own use. In-service teacher training is also available. The curriculum is thoretically based, and supports abstinence, use of protective measures by sexually active youth and compassion and tolerance.

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Great Britain

Action Plan to Reduce Teenage Pregnancy

The Government's Social Exclusion Unit's action plan to reduce teenage pregnancies will include a new guidance for schools on sexuality and relationships education which helps young people deal with pressures to have sex too young and encourages contraceptive use if they do have sex, along with new school inspection and better teacher training.

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United States

The Guidelines for Comprehensive Sexuality Education, Kindergarten–12th Grade

A private, not-for-profit organization, SIECUS, with foundation funding convened a volunteer task force to develop a framework to promote and facilitate the development of comprehensive sexuality education programs from kindergarten through 12th grade. SIECUS sells the publication and makes it available free on its website. Abstinence-only education The federal and state governments fund programs of abstinence-only education programs focused on youth aged 12–18. Local programs range from media campaigns to after-school activities with educational classes related to abstinence. Some programs substitute for contraceptive education; some complement contraceptive education; some replace contraceptive education with emphasis on contraceptive failure and risks.


SOURCE: The Alan Guttmacher Institute report on Teenage Sexuality and Reproductive Behavior in Developed Countries

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Adolescent Sexuality

Robert Wm. Blum, MD, MPH, PhD
William H. Gates, Sr. Professor and Chair of the Department of Population and Family Health Sciences, Johns Hopkins Bloomberg School of Public Health
Tuesday, May 16, 2006; 11:00 AM

Dr. Robert Wm. Blum was online Tuesday, May 16, at 11 a.m. ET to field questions and comments about risk and protective factors associated with sexually active teenagers. He also took medical questions relating to adolescent sexuality.

Blum is the William H. Gates, Sr. Professor and Chair of the Department of Population and Family Health Sciences, Johns Hopkins Bloomberg School of Public Health. He has edited two books, and has written more than 220 journal articles, book chapters and special reports.

Blum is a Past-President of the Society for Adolescent Medicine; has served on the American Board of Pediatrics; was a charter member of the Sub-Board of Adolescent Medicine, is a past chair of the Alan Guttmacher Institute Board of Directors and served as chair of the National Academy of Sciences Committee on Adolescent Health and Development. He is a consultant to The World Bank and UNICEF as well as the World Health Organization where he has served on the Technical Advisory Group of the Child and Adolescent Health Department as well as the Scientific and Technical Advisory Group of the Human Reproductive Program.

The transcript follows.

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Dr. Robert Wm. Blum: Welcome to this chat on adolescent sexuality. I will respond to questions as they come in. am a professor at Johns Hopkins University School of Public Health ands have worked in adolescent health for the past 25 years as a physician and researcher.

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Cambridge, Mass.: Why is it generally assumed that it is bad for adolescents to have sex? Of course, there is the risk of STDs; but this risk can be managed, and doesn't seem to be what really bothers people about adolescent sexuality. There is also the argument that adolescents are something like too "emotionally immature" for sexual relations; but this is a mushy argument that doesn't explain why emotional maturity is needed, what it is, and whether or not adolescents generally, or can ever, have it. So if we leave aside the specter of STDs and avoid mushy generalities: should adolescents ever be sexually active, and, if so, under what conditions?

Dr. Robert Wm. Blum: The question is complicated since "adolescence" spans an 8 to 10 year period depending on how you define it and there is a lot of development that occurs during that time. The issues: when there is a wide difference in age between 2 adolescents (often defined as more than 3 years) it may very well be an unequal power relationship; 2. developmentally, some young adolescents may not really understand what they are consenting to when they have consensual sex. There is little data, however, that shows that young people who willingly engage in mutually consenting, non-abusive sexual relations are harmed by it.

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Washington, D.C.: My daughter is 15 and claims that she is bi-sexual. She claims that she had not had sex yet but finds both boys and girls attractive. How can this be? Is this normal or is this is just her way of rebelling? I am not sure what to say or do.

Dr. Robert Wm. Blum: It depends on how you define "normal". Most young people define themselves as predominantly attracted to the opposite sex. Perhaps one in about 20 young women are like your daughter attracted to both. It is adolescent rebellion? NO. It is probably an honest reflection of how she feels and that she can discuss it with you is very good. She needs help to feel comfortable with who she is and her sexual orientation. When young people are confused by their sexuality they are at greater risk for "proving" that they are heterosexual by getting pregnant. What is critical is that your daughter feel comfortable with both attractions. Having an attraction does not mean that you have to act on it; you have to learn to live with it.

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Guangzhou City, China: Dear Dr. Robert Wm. Blum,

After reading the articles, I find that in the American society, almost all the parents and teaching institutions give a double message towards young people at the same time, just as some experts like Michaud mentioned---On one hand, parents and teachers teach the adolescents to be abstinent until marriage. While, on the other hand, they give guidance on having sex to the children at the same time. This way of guiding is strongly opposed by Western Europeans who support premarital sexual activities with appropriate contraceptives. Well, since the rates of premarital pregnancy, STDs and abortions in US are evidently much higher than those in European Countries such as Sweden. I am wondering that what you think of the popular teaching of abstinent in US nowadays. Is it suitable for American teenagers? Do you agree that sex is a normal part of adolescent development? Will American society achieve successful result in preventing premarital pregnancy, STDs and abortion of adolescents by using the European way of guiding? Thank you very much!

Dr. Robert Wm. Blum: Your question has many questions in it. In the United States we are very ambivalent about sexuality--witness what we teach in school and what young people witness on music videos. There is no evidence that abstinence education devoid of contraceptive information makes much of an impact. Can kids understand complex messages? Yes. The message is not so complex: Not now but if you have sex contracept.

I would suggest that that is essentially the message that many European parents give their kids.

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Boston, Mass.: Isn't it unrealistic to expect adolescents to wait until marriage? Unless we advocate very early marriage, which I don't want to see. As I understand it, 200 years ago girls went through puberty (defined as the first period) mostly between 17 and 19, and got married around the same age. Nowadays, girls go through puberty between 12 and 14, and don't get married until 25 or later. I'm not sure about male puberty, but it's probably similar.

Dr. Robert Wm. Blum: Between 1860 and 1960 female puberty declined by about 3 months per decade to about 12.5 years for females and about 14 years (plus or minus) for males. Marriage is delayed and so you are correct that the period between onset of reproductive capability and marriage is longer now than ever b4. Is it reasonable for young people to wait until marriage? You decide but it appears that approximately 85% of young people believe that it is not.

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Arlington, Va.: Usually, none of the articles or studies cited on this topic include the impact of religious teachings on teens decisions to engage/not engage in premarital sex. Why is that?

Dr. Robert Wm. Blum: Sadly, as much as we would like to believe, religious teachings have little or no impact on adolescent sexual behavior. My colleagues and I did an analysis (recently published in Social Science and Medicine) where we looked at the impact of religion and while it has an impact on smoking and drinking it has no impact on sexual behavior. In 1984 we looked at you people who got abortion in Wisconsin and Minnesota and we analyzed it by religion. What we found was that the distribution of those who were getting abortions was exactly the same as the distribution by religion of the population in those 2 mid-western states. I know that we would like to believe that a religion's prohibitions have an impact; the data do not support it.

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Fort Washington, Md.: Now that the prom weekends are among us, what are the statistics that many of the young adolescent females loose their virginity during this time of their lives? What kind of parental advice is suggested?

Dr. Robert Wm. Blum: I don't know the data between proms and pregnancy. My advise to my daughters was: 1. if you have sex with someone make sure it is you who want it as much as him-- if not tell him to buzz off;

2. if you do have sex, contracept.

Having sex is not an accident-- don't make it one.

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Washington , D.C.: It seems to me that abstinence-only education is incredibly short-sighted. Most people don't get married at 19 these days! Do we really expect these kids to be virgins on their wedding nights when they're 25 or 35?

Isn't it disingenuous to tell kids to abstain until marriage when really we only expect them to do so until they hit 20 or so? And then what? They don't know anything about birth control or STDs or anything else because all you taught them was to say no!

Dr. Robert Wm. Blum: I think that I have addressed this in a prior comment.

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Washington, D.C.: I am noticing that a lot more young people, especially teen girls seem to be claiming to be bisexual or gay. Is there a growth in teen homosexuality or is it just more acceptable to come out today than in the past?

Dr. Robert Wm. Blum: I do not know the data historically. Today about 3% of girls (and about double that for boys) say that they are homosexual; and about 5% of girls identify as bisexual. Is it a fad? Probably not; rather, it probably reflects actual sexual orientation. My hunch (without data) is that it probably hasn't changed much over the years.

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Rockville, Md.: I'm not sure why this seems so hard for so many people. My folks were pretty basic about sex: You should probably wait, but if you don't use a condom so you don't get her pregnant or catch a disease. I'm 25, but my wife is pregnant now, and these seem to be simple rules I'll use for my own kids one day.

Dr. Robert Wm. Blum: I agree... not so complicated.

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Arlington, Va.: To what extent is sexuality in adolescence biological and to what extent cultural? I had always assumed it was a biological "fact of life" that at a certain age boys and girls start experiencing sexual feelings, but after talking to friends and partners who grew up in societies with fewer sexual images and opportunities, I'm amazed at the different responses I've received to questions about first recalled sexual attraction, experience, crush, all of these things.

Dr. Robert Wm. Blum: Complicated question. When you look around the world there is wide variance culturally in sexual behaviors. In Vietnam and Japan, for example, less than 5% of girls and probably no more than about 10% of boys have sex as adolescents. Prevalence rates of sexual onset in adolescence varies widely in sub-Saharan Africa. That having been said, there is a strong biologic basis for a sex drive that has a lot to do with testosterone.

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New York, N.Y.: What roles do you feel educators and parents should play in terms of sex education for adolescents? It seems in the US, there is a tendency for educators to want that responsibility to belong to parents, often parents often want their personal ethics to be reflected in the general literature. Are there any studies that evaluate the effectiveness of sex education from each source?

Dr. Robert Wm. Blum: There is a lot of data on effective sex education in schools--I'd refer you to the work of Doug Kirby available on the web-site of the National Campaign to Prevent Teen Pregnancy. We do know quite a bit about what works (why we don't use it is a different story). Parents are not keen on being their kids sex educator. That having been said, parents are key. We are our kids sex educator in how we role model talking to our spouses. We role model sex education if we are in dating relationships with others and how we behave. we are our kids sex educator when we turn off the TV and avoid discussing some sexual message that we and they saw and pretend that we didn't see it. We are our kids sex educators in everything that we do even if we never discuss sex with them directly.

Which do I think is more important? The indirect sex education that our kids get from birth by watching their parents.

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Arlington, Va.: I guess the problem I have with all this is that it seems to communicate the message that it is not normal to want to wait to have sex. For teens who do choose not to have sex, whether out of fear of pregnancy or religious upbringing, are they getting a message that they are abnormal and out of the mainstream? That's certainly what I hear in the attacks on the abstinence programs.

Dr. Robert Wm. Blum: The fact that there is no data to support abstinence programs in no way is meant to suggest that delaying sex is abnormal. To the contrary. For me the best abstinence program is to give kids a meaningful future. Kids who do better in school delay first sex. Kids who have an adult in their lives who is "crazy about them" delay first sex. As Marion Wright Edelman said a generation ago: "The best contraception is a meaningful future."

That's what the data support.

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Washington, D.C.: How do teen pregnancy rates in Western Europe compare to those in the United States and across what types of demographics do you see adolescent pregnancies in Western Europe? Additionally, how do abortion rates compare? Finally, do you see any connection between the lower rates of marriage in Western Europe to the more liberal attitudes toward teen sex and unwed parents?

Dr. Robert Wm. Blum: Pregnancy rates in ALL of Europe is much lower than in the United States. Even when you control for demographic variability, the US is still way ahead of every country in Europe. US has higher abortion rates than every country in Europe (with perhaps the exception of Russia. You ask if delayed marriage reflects more liberal attitudes; I think not. Most people delay marriage because they have competing options such as employment and school. Without those options early pregnancy might look pretty good.

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Washington, D.C.: Can you speak about the influence government has on adolescent health with regards to this topic? It seems that we are devolving into a position in which science is being replaced by unsupported belief. Is my belief accurate?

Dr. Robert Wm. Blum: Your belief is quite accurate. For example in the name of "balance" a recent scientific meeting of the international STD association was forced to add to a panel of those who represent an unsubstantiated pseudo-scientific perspective while a peer-reviewed presentation was bumped to accommodate that change. That was done by the CDC. The FDA web-site touts the association between abortion and breast cancer where the association is spurious at best. The CDC web-site speaks about the limitations of condoms. The federal government prohibits the use of federal funds to teach the efficacy of contraception. Enough?

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Washington, D.C.: You've mentioned statistical variance of sexual activity in different countries. Do you have data on the sexual activity rates between the ethnicities in the US? I ask this in general but specifically because I know that the rate of STD infection including HIV is significantly higher for African-Americans, at least in DC. I was wondering if you can comment on why that may be.

Dr. Robert Wm. Blum: There is substantial variation by race and gender. For example while the rate of teen pregnancy has declined in the US since 1991 the decline has been steepest for African Americans and least steep for Latinos (and steepest decline has been among African American males. There are variations in STD and HIV rates as well. But when you look at adolescents (as we did in a paper published 4 years ago in the American Journal of Public Health) race is a very poor predictor of outcomes. Rather, school, parent supports and "connectedness", peer relationships, meaningful activities, academic performance, whether your parents know your friends and their parents, connectedness with a teacher or other adult in the school are much more powerful predictors than race of outcomes. Their parents

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Arlington, Va.: I don't understand how parents can be so outraged by the current perceived lack of morals of today's teens when they themselves want to push the responsibility of sex education to the school system. Do you really want to trust something as sensitive as your child's sexuality to a one size fits all agenda created by the schools? Why are parents so afraid to talk to their children about sex? Is it just a case of having their heads in the sand? Trying to avoid embarrassment? They would rather deal with the embarrassment of a pregnant teenaged daughter instead?

Dr. Robert Wm. Blum: As I mentioned earlier, whether we choose to be explicit or not, we are our kids sex educators. They are watching us all the time.

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Seattle, Wash.: We talk a lot about the roles of parents in sexuality in terms of things like sex education and talking to kids about sex, but isn't it true that by just being highly involved parents can make a big difference in their kids' lives. One study in TX showed daughters with highly involved dads abstaining from early sex.

Dr. Robert Wm. Blum: Yes, Yes, Yes.

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Tampa, Fla.: Are there key differences in adolescent sexuality between young men and women. Theoretically, a male sex drive is highest at 18, whereas a female's is highest at 35.

Dr. Robert Wm. Blum: There are vast gender differences from the age of puberty to hormonal influences to socialization... but variations within gender are equally great.

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Fairfax, Va.: In regards to the religious aspect, is the data broken down in that regard? I have heard that some religions hold hard and fast with no pre-marital sex. Is there any data that by taking "vows" to not have pre-marital sex that it works? Does heavy religious pressure help? Thanks.

Dr. Robert Wm. Blum: We have looked at 43 religions and see no difference as to age of first sex. Regarding chastity vows, there is a cohort effect short term (see, for example the work of Peter Bearman) but the evidence that is emerging is that it does not have long term staying power.

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Chicago, Ill.: What role does the media play in shaping attitudes/beliefs in teens regarding sexuality? Does the heavily sex-soaked film/TV show environment make it more tempting for young people to enter sexual relationships?

Dr. Robert Wm. Blum: The data are not in like it is with media violence but it does suggest that sexually provocative media may have an impact on behavior especially where sexual intercourse is uncoupled from the risks of pregnancy and STDs/HIV and the need to contracept.

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Falls Church, Va.: Based on the supporting articles and information from Western European countries, it appears that the strategy used in the US pertaining to teen sexuality is not effective. Do you think the US government and various religious groups play too much of a role in teaching children about sexuality and that parents are possibly involved too little? And do you have any recommendations on books parents can read to better prepare for discussions with children?

Dr. Robert Wm. Blum: I don't think that the government is playing too much of a role; rather, it is compelling unproven interventions while avoiding interventions where there is an evidence-base.

As for book, I have been out of this for a while but when my kids were little I always had Peter Masyle's books lying around so that they could pick them up. look at them and when they were older start to read them (but I may be dating myself with this suggestion).

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Gaithersburg, Md.: Hello Dr. Blum -

Would you please address HPV and it's relationship to cervical cancer. How is it diagnosed and can one contract the virus by other means than sexual transmission? Thank you for your time.

Dr. Robert Wm. Blum: HPV is a sexually transmitted disease and early cervical cancer is diagnosed by Pap smear and culposcopy. The evidence is mounting that the 2 primary strains of HPV that cause cervical cancer can be prevented with the new vaccines.

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Dr. Robert Wm. Blum: Thank you for joining me for this discussion. It is noon EDT and we need to conclude.