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Regularly since 1998, Advocates for Youth has sponsored study tours to France, Germany, and the Netherlands to explore why adolescent sexual health outcomes are more positive in these European countries than in the United States.

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 France, Germany, and the Netherlands. Each of the three nations has an unwritten social contract with youth: “We’ll respect your right to act responsibly and give you the tools you need to avoid unintended pregnancy and sexually transmitted infections, including HIV.”

In France, Germany, and the Netherlands, two things create greater, easier access to sexual health information and services for all people, including teens. They are: 1) societal openness and comfort in dealing with sexuality, including teen sexuality; and 2) pragmatic governmental policies. The result – better sexual health outcomes for French, German, and Dutch teens when compared to U.S. teens.

Adolescent Pregnancy, Birth, and Abortion Rates in Europe Are Lower Than Those in the United States*

Pregnancy

The United States’ teen pregnancy rate is over six times that of the Netherlands, almost four times that of Germany, and almost three times that of France.^1,2,3  

Pregnancy rates for the United States and the Netherlands are for young women ages 15-19. Pregnancy rates for France and Germany are for young women under age 20. Dutch pregnancy data do not include fetal losses.

Birth

The United States’ teen birth rate is nine times higher the Netherlands’, nearly six  times higher than France’s, and over four times higher than Germany’s.^4,5

Abortion

In the United States, the teen abortion rate is more than twice that of Germany and of the Netherlands.^1,2,3

US HIV/STI Rates Also Compare Poorly

HIV

Syphilis

Gonorrhea

Chlamydia

Contraceptive Use at Most Recent Sexual Intercourse  

U.S. teens report using contraception (usually either birth control pills or condoms or both) far more often that their peers of previous decades.  However, condom and contraceptive use leveled off between 2003 and 2007.  U.S. teens still use contraception or condoms much less consistently than their peers in Europe. When measuring use of highly effective hormonal contraception, condoms, or both, researchers found that German, French, and Dutch youth were significantly more likely to be well protected at most recent sex than were their U.S. peers. The greatest disparities were in contraceptive pill use among females. French young women were more than twice as likely to have been using contraceptive pills at last intercourse as young women in the United States, German youth five times as likely, and Dutch youth almost six times as likely. ^10,11,12,13

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

If society in the United States were to become more comfortable with sexuality and if governmental policies were to create greater and easier access to sexual health information and services, then U.S. teens’ sexual health outcomes would improve markedly. Imagine that the United States’ teen pregnancy, birth, and abortion rates would improve to match those of the Netherlands, Germany, and France. Improved rates would mean large reductions in the numbers of pregnancies, births, and abortions to U.S. teens each year.

It has been estimated that the public costs associated with teen birth in the United States were at least $9.1 billion in 2004, an annual average cost of $1,430 per child born to a teen mother.¹⁴

Therefore, if the U.S. could reduce its teen birth rate to equal that of France, Germany or the Netherlands, it would save significantly on public funds expended each year to support families begun by a teen birth.

The Lessons Learned: A Model to Improve Adolescent Sexual Health in the United States

So, if Dutch, German, and French teens have better sexual health outcomes than U.S. teens, what’s the secret? Is there a ‘silver bullet’ solution for the United States that will reduce the following statistics?

• Nine million new cases of sexually transmitted infections among 15- to 24-year-old youth;¹⁵
• More than five thousand new HIV infections among 13- to 24-year-old youth;¹⁶
• An estimated 750,000 pregnancies among U.S. teens;¹⁵
• Approximately 200,000 abortions among U.S. teens;¹ and  
• 445,000 births among 15- to 19-year-old women.⁴

Unfortunately, there is no single, ‘silver bullet’ solution! Yet, the United States can use the experience of people in the Netherlands, Germany, and France to guide its efforts to improve adolescents’ sexual health. The United States can achieve social and cultural consensus that sexuality is a normal and healthy part of being human and of being a teen. It can do this by using the lessons learned from the European study tours.

• Adults in France, Germany, and the Netherlands 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 health policies to reduce unintended pregnancies, abortions, 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 ensuring easy access to contraception and condoms, consistent sex education, and widespread public education campaigns.
• Governments support massive, consistent, long-term public education campaigns, through the Internet, television, films, radio, billboards, discos, pharmacies, and health care providers. Media is a respected partner in these campaigns. Campaigns are direct and humorous and focus on both safety and pleasure.
• Youth have convenient access to free or low-cost contraception through national health insurance.
• Sex education is not necessarily a separate curriculum and is usually 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 to 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. Youth rely on the maxim, ‘safer sex or no sex’.
• Society weighs the morality of sexual behavior through an individual ethic that includes the values of responsibility, respect, tolerance, and equity.
• France, Germany, and the Netherlands struggle to address issues around cultural diversity, especially in regard to immigrant populations whose values related to gender and sexuality 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 works to shift the current U.S. societal paradigm of adolescent sexuality away from a negative emphasis on fear and ignorance and towards an acceptance as sexuality as healthy and normal and a view of adolescents as valuable and important.

• Adolescents have the right to balanced, accurate, and realistic sex education, confidential and affordable health services, and a secure stake in the future.
• Youth deserve respect. Today they are often perceived as part of ‘the problem’. Valuing young people means they are part of the solution to societal issues and participate in developing 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 develops and disseminates campaign materials for specific audiences, such as the entertainment industry and news media professionals, policy makers, youth-serving professionals, parents, and youth activists. Advocates will continue its thought-provoking European study tours. Advocates will also collaborate with key national and statewide organizations to promote Rights. Respect. Responsibility.^® through Campaign materials, workshops, presentations, and technical assistance. For additional information on the Campaign or to become a partner in this important initiative, contact Advocates for Youth at 202.419.3420 or visit www.advocatesforyouth.org.

References:

* Throughout this fact sheet, data are the most recent available for France, Germany, and the Netherlands.. N/A means not available.
+  Please note: French and German pregnancy, birth, and abortion data are calculated by age as defined by years of birth, not complete years of age. French and German data are for women under age 20.
$  Pregnancy rates for the United States and for the Netherlands are for young women ages 15-19.  Pregnancy rates for France and Germany are for young women under age 20.  Dutch pregnancy data do not include fetal losses.

1. Ventura SJ, Abma JC, Mosher WD et al. Estimated pregnancy rates by outcome for the United States, 1990-2004. National Vital Statistics Reports 2008; 56(15):1-24; http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_15.pdf; accessed 7/7/2008.
2. Henshaw S.  Personal Communication. Guttmacher Institute, October 31, 2007.
3. Wijsen C, van Lee L. National Abortion Registration, 2007. Utrecht: Rutgers Nisso Groep, 2008. Accessed from http://www.rng.nl/productenendiensten/onderzoekspublicaties/
   downloadbare-publicaties-in-pdf/rapport_LAR_2007.PDF on 4/22/09
4. Hamilton BE et al.  Births: Preliminary Data for 2007. National Vital Statistics Reports 2009; 57(12):1-23; http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf
5. World Bank. GenderStats: Database of Gender Statistics; http://devdata.worldbank.org; accessed 6/30/2008.
6. Kaiser Family Foundation. Globalhealthfacts.org: Global Data on HIV, TB, Malaria and More. http://www.globalhealthfacts.org; accessed 6/30/2008.
7. CDC. STD Surveillance, 2006 Atlanta, GA: Author, 2007; http://www.cdc.gov/std/stats06/toc2006.htm; accessed 4/27//2009.
8. van Veen MG et all.  Sexually Transmitted Infections in the Netherlands in 2006. Epidemiology and Surveillance, Centre for Infectious Disease Control. National Institute for Public Health and the Environment, 2007:  The Netherlands.  Rates calculated using Netherlands population data:  CIA World Factbook, accessed from https://www.cia.gov/library/publications/the-world-factbook/print/nl.html on 6/30/2008.
9. Statline. “Population:  age, sex, and nationality, 1 January.” Netherlands, 2006: Central Bureau voor de Statistiek.
10. Eaton DK et al. Youth risk behavior surveillance, United States, 2005. Morbidity & Mortality Weekly Report 2006;55(SS-5):1–108.
11. Eaton DK, Kann L, Kinchen S et al. Youth risk behavior surveillance, United States 2007. Morbidity & Mortality Weekly Report, Surveillance Summaries 2008; 57(SS-4):1-105.
12. Santelli, JS and Orr, MG.  Personal communication. Columbia University, November 6, 2008.
13. Currie C, Gabhainn SN, Godeau E et al. Inequalities in Young People’s Health: HBSC International Report: From the 2005/2006 Survey. Geneva, Switzerland: World Health Organization, 2007.
14. Hoffman SC. By the Numbers, The Public Costs of Teen Childbearing.  Washington DC: The National Campaign to Prevent Teen and Unintended Pregnancy, 2006.
15. Guttmacher Institute. Facts on American Teens’ Sexual and Reproductive Health [In Brief] New York: Author, 2006; http://www.guttmacher.org/pubs/fb_ATSRH.pdf; accessed 7/7/2008.
16. CDC. HIV/AIDS among Youth. [CDC HIV/AIDS Fact Sheet] Atlanta, GA: Author, 2006; http://www.cdc.gov/hiv/resources/factsheets/PDF/youth.pdf; accessed 7/87/2008.

Updated by Sue Alford, MLS and Deb Hauser, MPH
3rd edition, September 2009 © Advocates for Youth

This document is an updated edition of Adolescent Sexual Health in Europe and the U.S. – Why the Difference?, written by Ammie Feijoo, MLS, and published by Advocates for Youth in  2000 and 2001.