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

Journal of Sex Research, Feb, 2002 by Ilsa L. Lottes

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.