Adolescent Sexual Health in Europe & the U.S.—Why the Difference?

Advocates for Youth compares sexually transmitted infection (STI) rates of the United States to rates found in France, Germany and the Netherlands.

One significance of the major difference?

None of the countries with much lower STI rates circumcise infant boys.

Unfortunately, almost 50% of baby boys born in the United States continue to have their prepuce organ surgically removed at birth. This is the amputation of an organ that has protection from infections as one of its primary functions. In conjunction with a lack of comprehensive sexuality education (that other nations have), genital cutting is a factor contributing to the CDC estimated 1 in 3 Americans with an STI.

Also available in [PDF] format. Order publication.

by Ammie N. Feijoo

Each summer since in 1998, Advocates for Youth and the University of North Carolina at Charlotte sponsor annual study tours to France, Germany, and the Netherlands to explore why adolescent sexual health outcomes are so much more positive in the three European countries than in the U.S.

Rights. Respect. Responsibility.^® The study tour participants—policy makers, researchers, youth-serving professionals, foundation officers, and youth—have found that this trilogy of values underpins a social philosophy regarding adolescent sexual health in these countries. Each of these nations has an unwritten social contract with young people: "We'll respect your right to act responsibly, giving you the tools you need to avoid unintended pregnancy and sexually transmitted infections, including HIV."

In these nations, societal openness and comfort in dealing with sexuality, including teen sexuality, and pragmatic governmental policies create greater, easier access to sexual health information and services for all people, including teens. Easy access to sexual health information and services leads to better sexual health outcomes for French, German, and Dutch teens when compared to U.S. teens.

Adolescent Pregnancy, Birth, and Abortion Rates in Europe Far Outshine Those in the U.S.*

Pregnancy

In the United States, the teen pregnancy rate is more than nine times higher than that in the Netherlands, nearly four times higher than the rate in France, and nearly five times higher than that in Germany.^1,2,3

Birth

In the United States, the teen birth rate is nearly 11 times higher than that of the Netherlands, nearly five times higher than the rate in France, and nearly four times higher than that in Germany.^2,3,4

Abortion

In the United States, the teen abortion rate is nearly eight times higher than the rate in Germany, nearly seven times higher than that in the Netherlands, and nearly three times higher than the rate in France.^1,2,3

U.S. HIV/STI Rates Also Compare Poorly.

HIV in Young Women and Men

In the United States, the estimated HIV prevalence rate in young men ages 15 to 24 is over five times higher than the rate in Germany, nearly three times higher than the rate in the Netherlands, and about 1 ½ times higher than that in France.⁵

In the United States, the estimated HIV prevalence rate in young women ages 15 to 24 is six times higher than the rate in Germany, nearly three times higher than the rate in the Netherlands, and is the same as that in France.⁵

Syphilis

In the United States, the teen syphilis rate is over six times higher than that of the Netherlands, over five times higher than the rate in former West Germany, and nearly three times higher than that in former East Germany. Data are not available for France.⁶

Gonorrhea

In the United States, the teen gonorrhea rate is over 74 times higher than that in the Netherlands and France, over 66 times higher than the rate in former West Germany, and over 38 times higher than that in former East Germany.⁶

Chlamydia

In the United States, the teen chlamydia rate is over 20 times higher than that in France. Data are not available for Germany or the Netherlands.⁶

American Youth Have Sex at the Same Age or Even Earlier than Youth in Europe. Young People in the U.S. Have More Sexual Partners.

In the United States, young people typically initiate sexual intercourse at the same age or even earlier compared to young people in the Netherlands and France.^3,7 Data are not available for Germany.

Finally, the proportion of sexually active teenage men and women ages 18 to 19 that had two or more sexual partners within the past year is substantially higher in the United States than in France. Data on number of sexual partners are not available for Germany or the Netherlands. Having two or more sexual partners increases youth's potential risk of becoming infected with HIV and other STIs.⁷

	% With Two or More Sexual Partners in Past Year7		Typical Age at First Sexual Intercourse3,7
	Women Ages 18 to 19	Men Ages 18 to 19
United States	48.6%	48.8%	17.4 years
Netherlands	—	—	17.7 years
France	12.8%	28.8%	18.0 years
Germany	—	—	—

Implementing the Model: Potential Impact on Adolescent Sexual Health in the U.S.

If society in the United States became more comfortable with sexuality and if governmental policies created greater, easier access to sexual health information and services, adolescents' sexual health outcomes could improve markedly. Imagine that the United States' adolescent pregnancy, birth, and abortion rates improved to match those in the European nations studied. The reduced rates would mean large reductions in the numbers of pregnancies, births, and abortions to teens in the United States each year—and in the public funds needed to support families begun with a birth to a teen.

If the U.S. Rates Equaled Rates in:	Fewer Pregnancies	Fewer Births	Fewer Abortions	Lower Public Costs8
Netherlands	657,000	441,000	215,000	$921 million
France	550,000	391,000	160,000	$815 million
Germany	588,000	367,000	221,000	$767 million

The Lessons Learned: A Model to Improve Adolescent Sexual Health in the U.S.⁹

So, if Dutch, German, and French teens have better sexual health outcomes, have fewer sexual partners, and initiate sexual activity at the same age or even later than U.S. youth, what's the secret? Is there a 'silver bullet' solution for the United States that will reduce the nearly four million new sexually transmitted infections occurring among U.S. teens each year, or the 20,000 new HIV infections among 13- to 24-year-old youth, or the 900,000 teen pregnancies?^1,10,11

Unfortunately, there is not a single, 'silver bullet' solution. Yet, the United States can use the experience of the Dutch, Germans, and French to guide its efforts to improve adolescents' sexual health. Indeed, the United States can overcome obstacles and achieve social and cultural consensus respecting sexuality as a normal and healthy part of being human and of being a teen by using lessons learned from the European study tours.

• Adults in the Netherlands, France, and Germany view young people as assets, not as problems. Adults value and respect adolescents and expect teens to act responsibly. Governments strongly support education and economic self-sufficiency for youth.
• Research is the basis for public policies to reduce unintended pregnancy, abortion, and sexually transmitted infections, including HIV. Political and religious interest groups have little influence on public health policy.
• A national desire to reduce the number of abortions and to prevent sexually transmitted infections, including HIV, provides the major impetus in each country for unimpeded access to contraception, including condoms, consistent sexuality education, and widespread public education campaigns.
• Governments support massive, consistent, long-term public education campaigns utilizing the Internet, television, films, radio, billboards, discos, pharmacies, and health care providers. Media is a partner, not a problem, in these campaigns. Campaigns are far more direct and humorous than in the U.S. and focus on safety and pleasure.
• Youth have convenient access to free or low-cost contraception through national health insurance.
• Sexuality education is not necessarily a separate curriculum and may be integrated across school subjects and at all grade levels. Educators provide accurate and complete information in response to students' questions.
• Families have open, honest, consistent discussions with teens about sexuality and support the role of educators and health care providers in making sexual health information and services available for teens.
• Adults see intimate sexual relationships as normal and natural for older adolescents, a positive component of emotionally healthy maturation. At the same time, young people believe it is "stupid and irresponsible " to have sex without protection and use the maxim, "safer sex or no sex."
• The morality of sexual behavior is weighed through an individual ethic that includes the values of responsibility, respect, tolerance, and equity.
• France, Germany, and the Netherlands work to address issues around cultural diversity in regard to immigrant populations and their values that differ from those of the majority culture.

Rights. Respect. Responsibility.^®: A National Campaign to Improve Adolescent Sexual Health

In October 2001, Advocates for Youth launched a long-term campaign — Rights. Respect. Responsibility.^® — based on the lessons learned from the European study tours. The Campaign will work to shift the current societal paradigm of adolescent sexuality away from a negative emphasis on fear and ignorance and towards an acceptance of sexuality as healthy and normal and a view of adolescents as a valuable resource.

• Adolescents have the right to balanced, accurate, and realistic sexuality education, confidential and affordable sexual health services, and a secure stake in the future.
• Youth deserve respect. Today, they are perceived only as part of the problem. Valuing young people means they are part of the solution and are included in the development of programs and policies that affect their well-being.
• Society has the responsibility to provide young people with the tools they need to safeguard their sexual health and young people have the responsibility to protect themselves from too early childbearing and sexually transmitted infections, including HIV.

Advocates is developing and disseminating campaign materials for specific audiences, such as entertainment industry and news media professionals, policy makers, youth-serving professionals, parents, and youth activists.

Each summer, Advocates will continue its thought-provoking European study tours. Advocates will also collaborate with key national organizations and state-based stakeholders to promote Rights. Respect. Responsibility.^® through campaign materials, workshops, presentations, and technical assistance. For additional information on the Campaign or to become an organizational partner in this important initiative, contact Advocates for Youth at 202.419.3420 or visit www.advocatesforyouth.org.

References

1. Ventura SJ et al. Trends in pregnancy rates for the United States, 1976-97: an update. National Vital Statistics Reports 2001;49(4):1-10.
2. Singh S, Darroch JE. Adolescent pregnancy and childbearing: levels and trends in developed countries. Family Planning Perspectives 2000;32(1):14-23.
3. Rademakers J. Sex Education in the Netherlands. Paper presented to the European Study Tour. Utrecht, Netherlands: NISSO, 2001.
4. Martin JA et al. Births: preliminary data for 2000. National Vital Statistics Reports 2001;49(5):1-20.
5. UNAIDS. Report on the Global HIV/AIDS Epidemic. Geneva, Switzerland: UNAIDS, 2000.
6. Panchaud C et al. Sexually transmitted diseases among adolescents in developed countries. Family Planning Perspectives 2000;32(1):24-32 & 45.
7. Darroch JE et al. Adolescent Sexual and Reproductive Health: A Developed Country Comparison. New York, NY: The Alan Guttmacher Institute, forthcoming in Family Planning Perspectives.
8. Calculations, using 1997 data, are based on Feijoo AN. Teenage Pregnancy, the Case for Prevention. Washington, DC: Advocates for Youth, 1999.
9. Berne L and Huberman B. European Approaches to Adolescent Sexual Behavior & Responsibility. Washington, DC: Advocates for Youth, 1999.
10. American Social Health Association. Sexually Transmitted Diseases in America: How Many Cases and at What Cost? Research Triangle Park, NC: ASHA, 1998.
11. Office of National AIDS Policy. Youth and HIV/AIDS 2000: A New American Agenda. Washington, DC: ONAP, 2000.

*Throughout this fact sheet, data are the most recent available for each country, ranging from years 1995 to 2000. Pregnancy data do not include fetal losses. U.S. birth data are for 1999 while U.S. pregnancy and abortion data are for 1997.