Doctors should advise adolescents to abstain from sexForAgainst
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7275.1520 (Published 16 December 2000) Cite this as: BMJ 2000;321:1520All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Carys Moseley seems to think that homosexuality is a genetic
disorder, a curable psychological defect, or a conspiracy by paedophiles.
On what sort of evidence does Carys Moseley can base such views?
I would be more particularly curious to know how Carys Moseley, for
example, would explain that all paedophiles would be homosexuals?
Competing interests: No competing interests
With regard to the controversies surrounding homosexuality in
Britain, and male homosexuality in particular, it is deeply regrettable
that there is little public discussion about the problems involved. In
the USA, there exists a body of psychiatrists and psychoanalysts who are
experts on the issue, namely the National Association for Reparation and
Therapy of Homosexuality (NARTH):
http://www.narth.com
It is able to exist in the USA because of the fact that freedom of speech
is enshrined in the US Constitution, and thus it is very hard for the
politically-correct decision-makers and the Gay Rights lobby to deny them
the right to deal in an open and intellectually honest manner with the
considerable problems surrounding homosexuality.
It is worthwhile, if sobering, to read the NARTH documents as they not
only deal with health problems linked to homosexuality, but also to the
sinister way in which homosexual rights activists, allied with militant
radical feminists, have pushed an anti-family agenda into high schools and
into the cultural bloodstream, very similar to this country. Then there is
the deeply sinister problem of the fact that certain sectors of the
homosexual rights lobby in academia have allowed articles calling for the
normalisation of paedophilia and removal of legal, moral and social
sanctions against it. Issues such as these are not going to go away just
because members of the medical profession avoid the hard moral questions.
As someone who is not in the medical profession but takes some interest in
ethics, I feel let down by the way in which many in the profession are so
ready to sneer at those who raise moral and ethical issues surrounding
sexual health and relationships.
Competing interests: No competing interests
An interesting discussion! Unfortunately one that is often clouded by
peoples own interests and belief systems.
The "ideal" situation would be to promote sexual health in teenagers.
Neither total abstinence or open encouragement.
It is important that we are able to give as much information as teenagers
require and request. It takes considerable skill to broach this subject
with teenagers, and even more skills to impart useful and non judgemental
information regarding abstinence, contraception, STD's and the potential
physical and emotional consequences (both positive and negative)of
engaging in sexual activity.
Teenagers will make their individual choices. We cannot police them.
Hopefully we (as medical practitioners) will be able to help them make
informed choices regarding sex. It's OK to say no, it's also OK to say
yes!
Competing interests: No competing interests
As Prof. Michaud's letter is one of very few to offer any evidence-
based reasoning against sexual abstinence as a wise choice during
adolescence, it deserves a considered response.
Prof. Michaud is quite wrong if he believes that abstinence is widely
advocated in the UK.(1) Brook and the FPA have almost total control over
sex education policy here and have no interest in promoting abstinence
education. In fact it is usually their experts who oppose me in media
debates- despite the continuing failure of their own policies. Britain is
without doubt a country which focuses on "safer-sex" promotion and yet its
record on teenage pregnancy rates and STI's is appalling. Conversely,
countries such as Spain and Italy according the very paper cited by
Michaud, (2) have around the same teen pregnancy rates as Holland though
they are hardly noted for their promotion of condoms. It is not a clear-
cut international case of "promote safer sex and teen sexual health with
improve" that Michaud would have us believe.
Michaud's evidence that condom promotion in Switzerland has not
increased the number of adolescents becoming sexually active (3) has also
been challenged elsewhere (4). During the three-year period of initiation
of the programme the percentage of 16 year-olds who had intercourse rose
from 36% to 57%.
If we are focussing on informed choice in condom promotion, teenagers
need to be aware that there is no evidence that condoms give good
protection against HPV, genital herpes and many other STI's (5). I have
been unable to trace any recent papers in English giving rates of genital
warts or herpes in Switzerland. If Prof. Michaud can produce the figures
to show these are decreasing among Swiss teens I would be more impressed
with his argument.
As for his assertion that the expectation of sexual abstinence is
unrealistic and hypocritical, Michaud is again quite mistaken. We live in
a world where violence and normalisation of crime also permeates the
music, television and advertising with which teenagers are saturated. Yet
we still advocate personal abstinence from violence and crime. Indeed it
is only in the realm of sexual intercourse that abstinence is sniped and
carped at. Yet I personally know many teenagers who are happily sexually
abstinent in spite of the lack of encouragement and support from most of
the media.
I am not advocating proscription. The concept of choice is indeed
central. However the choice of abstinence is currently being denied to
many teenagers by those like Michaud who exclusively want to promote the
condom culture.
1. Michaud P Why should we abstain from abstinence? Rapid responses
www.bmj.com
2.Singh S, Darroch JE Adolescent pregnancy and child-bearing: levels
and trends in developed countries Fam Plann Perspect 2000 32 14-23
3.Hausser D, Michaud PA The effects of the Swiss "Stop-Aids Campaign"
on the sex life of Swiss adolescents. Pediatrics 1994 93 580-85
4, Genuis SJ, Genuis SK Adolescent sexual involvement; time for
primary prevention Lancet 1995 345 240-1
5. Cavelieri d'Oro L, Parazzini F, Naldi L et al. Barrier methods of
contraception, spermicides and STDs: A review Genitourin Med 1994 70 410-
7
Competing interests: No competing interests
During recent years rates of teenage pregnancy and
abortions as well as the prevalence of sexually transmitted
diseases increased in Belgium and in several other European
countries.(1,2,3).
Against this background Stammers and Ingham considered
whether advising should be an effective response to
declining teenage sexual health. This debate for and against
was published in the BMJ’s Education and debate section.
Both advocated their opinion with true arguments but we
think there is insufficient evidence to justify one of the
two opinions.
To determine the needs and expectations of adolescent girls
concerning contraceptive use as well as their attitude to
health care providers we did a qualitative research with
focus groups of 17-year old girls (4).
Afterwards a survey among more than 700 adolescents in
Antwerp schools confirmed the results. Knowledge
concerning the daily use and side effects of contraceptives
was insufficient. Most of the girls had a good relationship
with their parents, especially with their mother.
Nearly 50 % of the girls responded that they preferred to
talk to their mother about contraceptives and sexual health.
Also Wellings et al. described an increased proportion of
girls citing parents as the main source of information (5).
Other important information sources are female friends,
sisters and physicians Especially the general practitioner
plays an important role in giving information about the use
of contraceptives.
Sexual experienced girls following their mothers used more
oral contraceptives with their first coitus than home
independent girls (55 vs. 30 %, Chi-square=15.71; p<0,005).
These home independent girls had an unsafe contraceptive
behaviour (17 vs. 9 %) and used more Morning After Pills
(69 vs. 31 %, Chi-square= 4.15; p<0.05). In both groups, 67
% of girls used condoms. Those who followed their mothers
consulted more a gynaecologist (22 vs. 14 %, Chi-square=
10.93; p<0,025). Young Pistella and Bonati also found that
parents have to play an important role in communication
about sexual behaviour (6).
Health care providers should not directly advise adolescents
to abstain from sex. They can rather encourage girls talking
to their parents. Besides the adolescents want an open
approach to sexual conduct In our survey more than 70 % of
the adolescents give a score of 8 or more on a Visual
Analogue Scale for the following attitudes from their
physician: being serene, the doctor is listening to me, is
taking time, having respect. He is answering my questions,
but only those one I want to discuss.
Talking about STD and about their relationships are
subjects they rather discuss with their parents and friends.
Our research rather sustains an open approach and better
communication of health care providers and parents. Ingham
advocated together with encouragement of the parents and
especially of the mother in their role of sources of sexual
information like Stammers.
Lieve Peremans, research assistant
Paul Van Royen, professor and head
Dirk Avonts, professor
Joke Denekens, professor and head
Centre for General Practice, University of Antwerp-UA,
Universiteitsplein1, 2610 Antwerp, Belgium
lieve.peremans@ua.ac.be
1. Nationale Commissie voor de evaluatie van de wet van 3
april 1990 betreffende de
zwangerschapsafbreking. Verslag ten behoeve van het
parlement (National commission for
the evaluation of the law of April the third 1990
concerning abortions. Report for the
parliament.)1januari 1993 - 31 december 1993. 1994
2. Nationale Comissie voor de evaluatie van de wet van 3 april 1990betreffende de
zwangerschapsafbreking. Verslag ten behoeve van het
parlement (National commission for
the evaluation of the law of April the third 1990
concerning abortions. Report for the
parliament.)1januari 1994 - 31 december 1995. 1996
3. The Alan Gutmacher Institute, Sharing responsibility:
Women, Society and Abortion Worldwide, New York, 1999; 56
4. Peremans L HI, Avonts D, Van Royen P, Denekens J.
Contraceptive knowledge and expectations
by adolescents: an exlanation by focus groups. Patient
Education and Counseling
2000;40:133-41.
5. Wellings K, Wadsworth J, Johnson AM, Field J, Whitaker
L, Field B. Provision of sex education and early sexual
experience: the relation examined. Br Med J 1995;311:417-20
6. Young Pistella L, Bonati F. Communication about sexual
behavior among adolescent women,
their family and peers. Families in Society: the Journal o
Competing interests: No competing interests
Watine asks some interesting questions. Though contraception was
Roger Ingham's main theme rather than mine,I would say that homosexuals
should be taught about it because the majority are in practice bisexual.
Over 75% of women who have sex with women, have also had sex with men
within 5 years.(1) For homosexual males, 58.4% reported having had sex
with a woman within the past five years.(1)
What is wrong with male homosexual intercourse is, in part, the same
as what is wrong with smoking. Evidence from Australia, Canada, Denmark,
Norway, Sweden, the UK, and the USA, all indicates that male gay sex
substantially increases mortality.(2,3,4) Indeed the authors of one of
these studies comment "although we have revealed that the life expectancy
of gay and bisexual men has sustained a tremendous deficit relative to all
men, the true effect is likely to be larger because of problems in
underreporting and underdiagnosis of AIDS."(2)
I know of no evidence in peer-reviewed journals to counter this
claim. If Watine can produce any, I will certainly reconsider my answer.
1. Wellings K, Field J, Johnson A, Wadsworth J. Sexual Behaviour in
Britain. Pelican 1994 p211
2. Hogg R, Strathdee S, Craib KJ et al. Modelling the impact of HIV
disease on mortality in gay and bisexual men.
In J of Epidem 1997 26 657-61
3. Thompson S, Manjikan A, Ambrose A et al. HIV positive tests in
coronial services in Victoria 1989-1996: lessons for HIV serveillance. Aus
and NZ J Pub Health 1998 22 532-35
4. Cameron P, Cameron K, Playfair W Does homosexual activity shorten
life? Psychological Reports 1998 83 847-66
Competing interests: No competing interests
Neither in the original article [1], nor in its ensuing e-responses,
did my computer find the word “homosexual”, or even “homo”. What is the
use of speaking of contraception to homosexual teens? Is it fair not to
tell them that there is nothing wrong in their being homosexual?
Incidentally, isn’t homosexuality, together with abstinence, one of the
best solutions to overpopulation?
[1] Doctors should advise adolescents to abstain from sex. For and
against. BMJ 2000;321:1520-1522 (16 December).
Competing interests: No competing interests
In these days of "Choice", what is so wrong with giving our young
people "Abstinence" as a real choice to avoid pregnancy, sexually
transmitted infections and the emotional trauma which goes along with them
(100% effective!).
When young people are informed about the wonderful gift of fertility
and how important it is to respect their bodies and are provided with the
truth about the side effects of contraception, abortion and early sexual
activity,evidence shows that they are eager to form stable relationships
and delay sexual activity.
It is well-documented that abstinence-based programmes help reduce
pregnancies and postpone sexual activity in young people.
The rising number of pregnancies and sexually transmitted infections
is not due to lack of contraception provision but the actual failure of
contraception.
Of course, promoting abstinence would not make any money for the
contraceptive providers - could that be the reason it is not offered as a
choice?
Competing interests: No competing interests
There seems to be some confusion entering this debate and I am going
to bravely try to point this up and offer a way forward!
Peter Morrell and others seem to advocate that youngsters should be
left to make their minds up and (in the case of Morrell) go on to contrast
this with 'pontificating' or 'laying the law down' to teenagers, a policy
said to be deeply damaging. But this ignores the fact that youngsters
will make up their minds themselves whatever adults do in the way of
intervention or non-intervention. The most pontificatory of teachers or
parents cannot engage in the task of making up the mind of a teenager for
them however hard they try.
This sort of debate sets up a false polarity between total abdication
and total control. It is false because no-one on either side of the debate
actually advocates either. The most liberal of the advocates of choice
does not generally refrain from intervention in the form of information
about health risks and the advisability of contraception and the most
ardent advocates of abstinence (see Sue Relf's contribution) makes use of
reasoned debate and broadly based information.
So the real question is what information should be given to the
young? This is not a neutral arena. The information we think should be
given depends entirely on what we think important and what values we wish
to promote. And here we encounter the fact that there is a deep division
in the area of what is believed to be healthy development in the matter of
sex and the teenager. Put another way there are radically different views
as to the aim of sex education and hence what information should be given
and what weight should be attached to such information.
I myself have had to address the matter of sexual relationships with
teenagers in school as part of religious education. I have had to address
the question of what is healthy development for these young people. Is
it healthy development to engage in sexual activity from the onset of
puberty? Is it healthy development to treat sexual activity as a natural
biological behaviour not much different from eating and drinking? Or is
it learning to exert self-control (much more demanding) and to wait until
marriage? And as Dr. Dominian asks us, what of the place of love in sexual
relationships? We cannot abdicate responsibility from making up our minds
(as adults) in this area if we are to teach the young. If we decide that
sex is a natural behaviour and not to be hedged about with restraints such
as abstinence, then we will have to decide whether there are any limits to
this behaviour. Is it healthy to have partners of both sexes? Is it
healthy to indulge every sexual instinct? Even those too dreadful (surely)
to mention? We may decide, perhaps, that the highest and best form of
sexual encounter is within marriage where sacrificial love may, one hopes,
be practised and enjoyed. We may then find ourselves sharing with the
young a vision of sexual relationships that views sex as sacred (the
phrase of one atheist pupil I once taught) and the family as one of the
greatest of God's gifts. On the other hand we may teach differently. The
point is that we have to decide; we cannot avoid this choice.
I found in recent years a strange (for my lessons!) quietness descend
on the class when I talked to them about the place of sex within marriage.
It was as if they wanted to hear what I was saying; as if they knew that
what they read in the magazines and saw on the television relayed to them
by the adult world was not right and that there must be something better.
I attended a wedding recently where the young couple (22 and 23) had not
engaged in sex before marriage and were absolutely determined to wait
until marriage. It is not easy, and falling short of ideals is the lot of
most of us, but they were quite sure that it was the best way. One had
decided this after experiencing at first hand the hassle and bitterness of
promiscuity; the other simply saw abstinence as common sense. The young
will, as I said, make up their own minds.
Competing interests: No competing interests
An adolescent's views on adolescent sex.
I find it surprising that no one seems to have asked teenagers how
they feel about the subject of abstinence.
However, to rectify that slightly, my views.
Teenage sex, premarital sex, or whatever you want to call it is rife
in this country, and especially in Cornwall, where we have one of the
highest rates of teenage pregnancies in Europe. Well, this fact is not
going to change very quickly. At present, having sex is seen as "cool"
and a socially-acceptable thing to do in your spare time when you are a
teenager. Until that changes, and I can't see it doing so in the near
future, teenagers will continue to have sex, and continue to get pregnant.
At Camborne School, in the five years that I have been there, sexual
education has consisted of maybe 2 or 3 lessons a year, in biology,
wherewe learnt about the very basic physical side of sex. In my view this
is not enough. Children need to be taught from the moment they enter
secondary education, that it is OK to say no; what contraceptive devices
are available, where to get them from, and how to use them properly; how
to have safe sex; and the emotional and social issues to do with having
teenage sex.
Telling or advising teenagers not to have sex is NOT going to work
unless it is backed up by society saying that teenage sex is no longer
socially acceptable and, whilst not being wrong, is no longer fully
acceptable in today's Britain.
Competing interests: No competing interests