Sexual behaviour and the spread of disease

Consider the following facts regarding the Maltese Islands: last year, 19.8% of all live births occurred outside marriage, up from 10.6% in 2000, 4.3% in 1995 and 1.7% in 1990.

The crude marriage rate (number of marriages per 1,000 mid-year population) has fallen from 16.2 in 1945 to 5.9 in 2005.

In 2005, approximately 8% of marriages were remarriages.

Almost half (46%) of the 1,832 new patients attending the Genito-Urinary (GU) clinic at Boffa Hospital admitted to casual sex and two-thirds (65.5%) to never using condoms.

The mean age at first intercourse among GU attendees was 16; of these 75% did not use a condom on that occasion.

There were 23 cases of gonorrhoea diagnosed; 20 in males and three in females. Although the actual total is small there has been an increase of 28% over 2004.

Cases of syphilis rose by 80% (from 10 cases in 2004 to 18 cases in 2005). Four of the cases in 2005 were non-Maltese, but they were all permanent residents. Although these numbers appear small, only a handful of cases were reported in the 25 years before 2000. The rise is therefore significant and consistent with what is happening in the rest of Europe.

There were seven cases of HIV diagnosed in 2005, up from three in 2004. The ages ranged from 17 to 49 years.

Consistent condom use remains low at 11.5% (compared to 14% in 2004) with 65.5% of the young never using one (compared with 63% in 2004); 28% (175 of 621) admitted to anal sex. The rate of anal sex among teenagers was 30%.

Seventy per cent of the married group and 74% of the separated group never used condoms; 31% of the separated group admitted to anal sex, with 14% of the married group doing so.

In 2005, 43 cases of chlamydia trachomatis were diagnosed; 15 cases in females and 28 in males.These are an important cause of pelvic inflammatory disease, ectopic pregnancy, tubal infertility and chronic abdominal pain in women. In men infection can cause prostatitis and epididymitis. Vertical transmission from mother to infant can lead to conjunctivitis and pneumonia. Chlamydial infection increases HIV infectiousness and susceptibility.

From a statistical point of view, one should emphasise that facts 1-3 are based on national figures (NSO, 2006), whereas the remainder are derived solely from patients seen in the GU Clinic at Boffa Hospital in 2005. These latter are not representative of the Maltese Islands, or indeed of other practitioners' practises, and should not be interpreted as such. Nonetheless, they are the only figures we have that relate to the sexual health of our population.

It should be pointed out that only 0.1% of the new patients seen in the GU clinic in 2005 were non-residents. What we see here is a local problem, one that needs a local solution.

Parents' attitude

What are the possible solutions? Fr Anton Gouder (The Sunday Times, May 14) and others before him, propose abstinence-only, a message that the Catholic Church has been espousing for years on moral grounds. I have no quarrel with that view, and as I have stated before, it is exactly the position that I have taken as a parent.

However, I am a realist, and I note that 90 per cent of the sexually active women in my practice are unmarried, and intend to stay so for a few more years. (Please note that my medical practice is primarily focused on women of reproductive age, hence the inherent bias in these data.)

I suspect that the powerful effects of the media coupled with the passive role taken by many parents of youngsters who are experimenting with risk-taking behaviour are responsible for the eye-catching statistics quoted earlier. Why are these parents so passive? Is it because they are blind to what is happening around their children? Or perhaps it's because they are made to feel guilty by the establishment if they openly talk about sexual matters with their children. Perhaps they are concerned that if they bring up the subject, their kids will feel that they are somehow endorsing their risk-taking behaviours (not just sexual, but also related to smoking, binge drinking and reckless driving)?

In scientific matters, it is rarely possible to obtain "definite and airtight proof" as indeed suggested by Fr Gouder. This is why I chose to focus on credible studies of the effectiveness of abstinence-only programmes in the US: those that are methodologically sound and have taken into account as many of the biases as possible.

Fr Gouder has quoted from a few studies that purport to show that the abstinence-only message is effective. Unfortunately, I am not as optimistic as he seems to be regarding the credibility of the studies he quotes. Specifically, I am concerned that these studies measured knowledge, attitudes and beliefs, rather than changes in behaviour. It is so much easier for a teen to tell you s/he has changed their attitudes, than it is for researchers to measure that their behaviour has actually changed.

Perhaps this is why none of the abstinence-only programmes evaluated by the Mathematica study (Devaney et al, 2002) was able to demonstrate a positive impact on sexual behaviour over time. Moreover, pregnancy rates, and rates of contracting STIs remained steady or increased following completion of the abstinence-only programme in each state-sponsored study evaluated by the Mathematica researchers. It is important to note that a great deal of research contradicts the belief that changes in knowledge and attitudes alone will necessarily result in behaviour change.

This is why I am not convinced that the abstinence-only message will be effective in halting the inexorable spread of STIs in our young.

Another limitation of the studies quoted by Fr Gouder is that they did not have a comparison group, i.e., a group of teens whose knowledge, attitudes and behaviour were being monitored without experiencing the intervention. Ideally this would be tested in a randomised manner, with some participants randomly assigned to treatment (abstinence-only messages) and the others to either nothing (controls) or some other relevant intervention.

Although not tested through a randomised design, there have been two studies comparing the impact of comprehensive sex education with that of abstinence-only-until-marriage programmes (Hauser et al, 2004). In Iowa, abstinence-only students were slightly more likely than comprehensive sex education participants to feel strongly about wanting to postpone sex, but less likely to feel that their goals should not include teen pregnancy. There was little to no difference between the abstinence-only students and those in the comprehensive sex education programme in understanding of why they should wait to have sex. Evaluation did not include comparison of data on the sexual behaviour of participants in the two types of programmes.

In Pennsylvania there were few to no differences between the abstinence-only and comprehensive approaches in attitudes towards sexual behaviour. Evaluators found that, regardless of which programme was implemented in 12-13-year-olds, sexual attitudes, intentions, and behaviours were similar in 15-16-year-olds.

Sex education

This brings me to the area where, if I have understood Fr Gouder correctly, we seem to agree: comprehensive sex education is the way forward. I think that what Fr Gouder is saying is that what makes comprehensive sexual education effective is implicitly included in the abstinence-only message. While I cannot comment regarding this issue in Malta, abstinence-only programmes in the US stress abstinence as the only way to prevent unintended pregnancies and STIs, and do not provide information about birth control methods, except to stress their failure rates. In other words, abstinence-only programmes in the US provide youth with no information, other than abstinence, regarding how to protect themselves from pregnancy, HIV, and other STIs. By no stretch of the imagination can this be termed comprehensive sexual education.

I agree with Fr Gouder that abstinence education should "teach teenagers the importance of setting goals, sound decision-making skills, character and self-esteem building, withstanding peer pressures, responsibility, teamwork, aspiring to healthy marriages, sexually transmitted diseases and the realities of parenthood."

I would like to invite the Diocesan Youth Commission (KDZ), the Cana Movement and Dar Guzeppa Debono who jointly have embarked on the campaign "Towards a more beautiful sexual life" to come forth and explain the extent to which their campaign that promotes abstinence also includes information about contraception, parenting, sexual abuse, and family diversity, all of which are important aspects of comprehensive sexual education.

Dr Philip Carabot, director of the GU Clinic at Boffa Hospital (from whose 2005 reported I have quoted so liberally), has strongly urged that safer sex health promotion campaigns be greatly intensified and that sex education in schools (and its uniform delivery) be thoroughly reviewed. As a medical practitioner in a related field, I fully endorse these steps, and call upon the Ministry of Health, the Elderly and Community Care to launch a campaign in collaboration with Church representatives and other NGOs to address this matter comprehensively.

This option is not as far-fetched as it might seem. Some senior Church prelates have mooted lifting the absolute ban on condom use (by married couples) to halt the inexorable spread of HIV/AIDS. This will help counter the dangerous effect of President Bush's Emergency Plan for AIDS Relief, which has granted funding to 15 countries that have been affected by HIV/AIDS, and requires grantees to allocate at least one-third of their prevention spending to abstinence-only-until-marriage programmes. The spill-over effect of such a brave decision would also be monumentally important to our local situation.