Conclusions: Implications for Practice and Policy in the United States
The Netherlands has long boasted some of the lowest teen pregnancy, abortion, and fertility rates in the world. Dutch public policy and health practice have, for much of the past 3 decades promoted acceptance of adolescent sexuality and easy access to contraceptives, rather than promoting abstinence or instilling fear of the potential dangers. This article has explored the cultural concepts and practices that guide middle-class parents in the Netherlands as they deal with the sexual maturation of their children, shedding light on the culture that makes the Dutch public policies viable and successful. What we have seen is that Dutch parents normalize adolescent sexuality -- assuming that teenagers can self-regulate their sexual development, that relationships and emotional intimacy form the basis for their sex, and that adolescent sexuality should be discussed openly, rather than cause secrecy, between family members. In this normalization, parents have been supported by healthcare providers, educators, and policy makers.
What can be learned from the Dutch case by healthcare providers who work in a country that tops the industrialized world in teen pregnancy, abortion, and birth rates? The answer to this question is not that providers should encourage American parents to permit their teenage children to spend the night with their boyfriends or girlfriends. This would be like transporting the tip of an iceberg and expecting to find a mountain of ice. Cultures are complex entities. One cannot introduce one particular practice without all the concurrent assumptions and expectations, legal frameworks and resources structures, and have it produce the same results as it does in the environment in which it originated. The cultural assumptions and practices that underpin the dramatization of adolescent sexuality in American middle-class families are deeply held and consequential. One cannot simply change such a dense cultural fabric, and the ways in which this fabric is intertwined with longstanding educational, legal, and religious traditions and institutions.
That said, there are, as I have pointed out, a number of precepts that underlie the normalization of adolescent sexuality in the Netherlands, and these could, and I believe should, be adapted to fit American healthcare practices regarding adolescent sexuality. The first pertains to the self-regulation, and more fundamentally, self-determination of sexuality. To instill adolescent self-determination requires treating adolescents as the owners of their own bodies and the agents of their own sexual behavior and to commit to providing them access to the information and resources they need to exercise this rightful ownership over their bodies and agency over their sexual behaviors. Concretely, this means giving teenagers the right to full knowledge about their anatomy and about the contraceptives that exist to protect them against unwanted and dangerous consequences of sexual intercourse. A vast majority of American parents want their children to receive this information in their public school sex education classes (see footnote 12). But bowing to political pressures, schools and governmental agencies are increasingly shying away from teaching consistent and effective contraceptive use, emphasizing instead the dangers of sex, the failure rate of contraceptives, and no-sex-until-marriage as the way to be safe (see footnote 13).[23,24,25] Ironically, abstinence-only-until-marriage, touted as the only full-proof safe sex, leaves young people unprepared to take precautions when they do have sex before marriage (see footnote 14).
Beyond technical knowledge, American teenagers must be given a language through which to understand their own sexual feelings and desires in positive terms. Providers must speak to young people about sexuality in terms of the whole range of behaviors and experiences that constitute sex, rather than suggesting that vaginal intercourse is the only or best way to "do it." Adolescents should be encouraged to respect their own internal boundaries, and those of others, as they explore their sexuality. A positive, realistic language of sexuality, which advocates the gradual, self-chosen and individual nature of first sexual experiences, would form a welcome alternative to the 2 equally unrealistic propositions that currently govern public discourse in the United States. The no-sex-until-marriage doctrine is widely preached, yet rarely practiced (see footnote 15).[27,28] But equally troubling are the images of invulnerability and conquest propagated by popular media and culture, which suggest that one can "be a sexual hero in one day."
The second implication of the Dutch case for American healthcare practice is that adolescent sexuality is not only, or even primarily, a biological phenomenon. It is necessary to recognize adolescents' emotions, desires for intimacy, and real relationships. The notion of raging hormones is deeply ingrained in American folk and healthcare lore. They are blamed for an entire host of behaviors that are thought to be age-appropriate, if dangerous. Yet, the talk of hormones can obscure desires that are deeply social in nature. Regardless of whether or not one believes that sexual intercourse is a healthy form of closeness for a teenage couple, those who provide care to adolescents and their parents would do well to view adolescent sexuality not just as a problem but also as the expression of an age-blind desire for meaningful intimacy and connection with others.
The third implication of the Dutch case is that American families must find their version of talking "normally" about sexuality and that the healthcare profession can help. The Dutch normalization of adolescent sexuality was not a given; it was a particular response to changes in sexual behavior during and after the sexual revolution, a response, moreover, in which members of the medical establishment played a decisive role. In the United States, real-life patterns of sexual behavior have also changed drastically since the mid-1950s. Most people become sexually active before marriage and many continue after marriage. Some people form marriage-like bonds with those of their own sex. In other words, sex and marriage are not related in the way that they once were. Not having a way to talk honestly, and without shame and guilt, about these new patterns of sex and relationships is not good for the health of individuals or for the health of families.
In truth, the most important thing that healthcare providers can do to normalize adolescent sexuality in the United States will not come from their practice as individuals. Instead, it requires the use of their voice and power as a professional group to demand an adherence to the standards of science and the provision of true healthcare to adolescents. There is no denying that we are currently witnessing the onslaught against empirical knowledge and honest dialogue, and with it, the denial of fact and the fanning of fear. Sex education curricula across the country are providing young people incomplete and distorted facts about sex in an effort to "scare them chaste." (See footnote 16). Political organizations make unscientific claims to empirical proof, which are nevertheless used in policy debate. The sexuality of teenagers, which quite understandably is a source of anxiety for parents, is at the forefront of this critical political struggle about what constitutes truth and care. With its commitment to the health and well-being of young people and their families, and its access to empirical knowledge about public health in other countries, the American healthcare profession must exert its power as a social institution to ensure that US policy be guided by scientific evidence and by the belief that adolescents deserve to receive the resources and respect they need to grow into informed and empowered human beings.
Footnote 12: A recent survey, conducted by NPR, The Henry J. Kaiser Foundation, and the Harvard Kennedy School of Government, found that more than two thirds of Americans agree that federal money for sex education should be used to "fund more comprehensive programs that include information on how to obtain and use condoms and other contraceptives." Less than a third of those surveyed agree that such money should be used to "fund education programs that have "abstaining from sexual activity" as their only purpose."
Footnote 13: American public schools, encouraged, in part, by federal funds that are contingent upon the teaching of "abstinence-only until marriage" are increasingly de-emphasizing teaching about contraceptives in their sex education curricula, or even removing any mention of the available technology for preventing pregnancy and protecting against disease.[23,24] Even the US government's own Centers for Disease Control and Prevention obscures the health benefits of using contraceptives effectively in favor of emphasizing not having any sex at all outside of marriage as the best way to protect one's health.
Footnote 14: Assessing the impact of "abstinence-only" sex education based on evaluations from 10 different states, Debra Hauser concludes that such programs do not succeed in delaying sexual initiation for very long, if at all. They do, however, have "some negative impacts on youths' willingness to use contraception, including condoms, to prevent negative sexual health outcomes related to sexual intercourse."
Footnote 15: By the time they turn 20, more than three quarters of American teenagers have experienced their first sexual intercourse. Meanwhile, only 3% of American teenagers marry -- down from 17% in 1950.
Footnote 16: For a review of the fear-based, abstinence-only-until-marriage programs, see Kempner, 2001.
Amy Schalet, PhD, Center for Reproductive Health Research & Policy, University of California at San Francisco, 2356 Sutter Street, Suite 200, San Francisco, CA 94143. Email:firstname.lastname@example.org
© 2004 Medscape
Cite this: Must We Fear Adolescent Sexuality? - Medscape - Dec 29, 2004.