One of the election promises of US President Bush was that his administration, under its plan for welfare reform, would spend at least as much money trying to convince teenagers to abstain from premarital sex as it did on programs for contraception counselling.1 This new funding opportunity (as it has been called) for sex education that breathes nary a word of condoms offers a kind of parity (as it has also been called) for those unwilling to separate mores from public-health objectives. Just what effect this narrow road to harm reduction will have on the welfare of American teenagers — girls in particular — remains to be seen. Former US Surgeon General David Satcher, resisting this approach, saw no evidence that the abstinence message had any effect on the age of sexual initiation, but some evidence that “providing information about contraception [did] not increase sexual activity.”2
The context of sex is wider than biology, and wider than morals. It is also cultural, political and economic. A young woman can practise abstinence or insist on the use of a condom only when she has both the understanding and the power to do so. Both are difficult to achieve for a 13-year-old sex trade worker in Cambodia, or a 14-year-old in Namibia who believes HIV is transmitted by mosquitoes, or a 15-year-old in Nunavut for whom early motherhood is a route to a social identity.3 As Jennifer Kitts and Katherine McDonald discuss in this issue4 (page 1155), access to contraceptive counselling and services is a question not only of context but also of rights. Any attempt by the US and others to impose their conservative political agenda on the outcome document of the UN's Special Session on Children this month is not only unrealistic, but reprehensible.
But how are we faring in promoting the sexual and reproductive health of Canadian teens? Nearly half of Canadian youth aged 15–19 are sexually active and, of these, 51% of girls and 26% of boys reported having sex without a condom.5 Reported rates of chlamydia in adolescent girls are 9 times the national rate.6 Each day 115 Canadian teens aged 15–19 become pregnant; 50% of these pregnancies end in abortion.7 Teenage pregnancy is 5 times more common in the lowest income households than in the highest income households.7
It might be easy to get the impression that this generation of worldly and plugged-in youth know more about sex than is good for them; many parents (perhaps most), feel that awareness of that great frontier is too hard for their children to avoid, not too hard to access. In the face of the pervasive presence of sexuality in popular media, abstinence-only education may become re-entrenched, for cultural, religious or political reasons, in our own public schools.8 All the more reason for physicians to make sure that their adolescent patients have the information they need to make empowered choices affecting their own sexual and reproductive health. — CMAJ