Condom Use Decline Fueled by Sex Ed Resistance in Europe

A report on adolescent sexual health has highlighted what its authors call an “alarming decline” in adolescent condom use across Europe, which they said could increase the risk for sexually transmitted infections (STIs), unintended pregnancies, and unsafe abortions in the region.

The report, by the World Health Organization (WHO) Regional Office for Europe, was published last week as a part of the Health Behaviour in School-aged Children study, which surveyed more than 242,000 15-year-olds across 42 countries and regions in Europe, Central Asia, and Canada between 2014 and 2022. Its findings showed that 20% of 15-year-old boys and 15% of 15-year-old girls reported having had sexual intercourse in 2022, a relatively stable proportion since 2014.

Among those who had intercourse, 61% of boys and 57% of girls reported using a condom at last sexual intercourse. However, in addition to the third or so of adolescents (30% of boys and 36% of girls) who did not use a condom, another 9% of boys and 7% of girls did not know if they or their partner had used a condom.

Condom use has significantly declined between 2014 and 2022, from 70% to 61% among boys and from 63% to 57% among girls. According to the report, the decrease is “pervasive,” spanning multiple countries and regions, though some experienced more dramatic reductions than others. The use of contraceptive pills has remained stable at around 26%.

The WHO said the high prevalence of unprotected sex indicates “significant gaps in age-appropriate comprehensive sexuality education, including sexual health education, and access to contraceptive methods.” It underscored “the urgent need for targeted interventions to address these concerning trends and promote safer sexual practices among young people,” the WHO said. In a press release, Hans Henri P. Kluge, WHO regional director for Europe, said the report’s findings were “dismaying” but “not surprising.”

“Age-appropriate comprehensive sexuality education remains neglected in many countries, and where it is available, it has increasingly come under attack in recent years on the false premise that it encourages sexual behavior, when the truth is that equipping young persons with the right knowledge at the right time leads to optimal health outcomes linked to responsible behavior and choices,” he said.

Medscape Medical News asked report co-author, Margreet de Looze, assistant professor of interdisciplinary social science at the Utrecht University in Utrecht, the Netherlands, for her assessment of the findings.

The report stresses the need for appropriate and nonjudgmental sex education. Has provision changed over the period of comparison since 2014?

Good sex education programs have been developed and implemented in Europe in the past few years. But at the same time, resistance against comprehensive sex education has become more organized. One of the most common misconceptions is that providing sex education to young people makes them have sex earlier. In fact, the opposite is true. An abundance of scientific evidence demonstrates that adolescents who received comprehensive sex education initiate sexual behaviors later in life, and once they are sexually active, they are more likely to use contraceptives.

Why the resistance to sex education?

While misconceptions about sex education are not new, in recent years, influential people, such as politicians and online influencers, have increasingly echoed these erroneous and misleading claims. This is harmful because their words may affect the beliefs of many people; eg, parents may decide to keep their children at home on days sex education is provided at school. As a result, their children will miss out on essential information and the development of essential skills, values, and attitudes that contribute to healthy, safe, and pleasurable relationships.

The distrusting discourse about sex education also has an impact on schools, which may become more hesitant to discuss certain topics because they fear the reactions from parents.

Are adolescents themselves happy with the sex education they receive?

It is a misconception that sex education is well arranged in most European countries. For example, while the Netherlands has an international reputation for high-quality sex education, Dutch adolescents are not satisfied at all with the sex education they receive at school. Recent research showed that not even half of them feel they received sufficient information on topics such as romantic relationships, contraception, pregnancy, and STIs.

Moreover, societies are rapidly changing, and sex education should be provided in such a way that it addresses the needs of today’s adolescents. Adolescents indicated they desire a much more elaborate discussion on topics such as consent, sexual media literacy, and sexual pleasure. The discussion of these topics contributes to healthy sexual development and is also directly related to young people’s contraceptive use.

Given the decline in condom use, it is now more important than ever to invest in the implementation of comprehensive sex education programs across Europe.

What other factors might be involved in declining condom use?

Potentially, the internet and social media may play a role. Online spaces can offer incredible opportunities to reach young people and provide them with valuable information. However, it can also expose them to misinformation and risks. Comprehensive sex education can contribute to building adolescents’ media literacy and the ability to distinguish fact from fiction online.

Might exposure to pornography play a role? 

Research on the effects of pornography on young people is ongoing and complex, with some studies suggesting potential negative impacts on attitudes, behaviors, and relationships. Pornography may normalize condomless sex. This is another topic that can be addressed well in sex education; it is crucial to have open and honest conversations with young people about pornography, media literacy, consent, and healthy sexuality.

The report noted that adolescents who initiate sexual intercourse early, before the age of 15 years, may be less able to negotiate consent and contraceptive use and consequently are more likely to engage in risky sexual behaviors. Yet evidence suggested that young people nowadays initiate sexual behaviors at a later age than previous generations. How does age at the initiation of sexual activity influence condom use? 

Our findings suggest that, while the group of early starters has indeed become smaller, those adolescents who do belong to this group nowadays run a higher risk in terms of contraceptive use than early starters a decade ago. Early starters in more recent years may have become even less well-informed about safe sex or have experienced worse access to contraceptives compared to a decade ago.

The report showed that a striking proportion of both sexes did not know if they or their partner had used a condom or the contraceptive pill at the time of their most recent intercourse. What might explain this?

If boys do not know whether their partner used the contraceptive pill or if girls are not aware whether a condom was used during sex, then this may indicate that they were so drunk they cannot remember. However, alcohol and drug use have not increased to the extent that they can explain the decline in condom use. In fact, alcohol use decreased among 15-year-old boys over the period.

It is very likely that they did not dare to raise the topic. If we want young people to use contraceptives and have safe and pleasurable sexual relationships, we have to normalize sexual communication. This may be especially challenging for girls due to stereotypes claiming that girls are sluts if they communicate about sex or carry condoms with them.

Sex education can provide young people with the tools to negotiate contraceptive use and realize respectful and consensual relationships. It also contributes to reducing gender inequality in society.

How primary care physicians might raise these issues with their teenage patients?

My message to primary care physicians would be to take young people seriously, treat them in a confidential and nonjudgmental way, and be respectful of their autonomy. If they have made the decision to come and see you, then this is often a big step for them. So make them feel that you appreciate and admire that they took this step. While responding to their needs, it is important that you challenge the social norms and stigma surrounding adolescent sexuality and promote a positive, respectful approach to sexual health that emphasizes informed decisions, consent, safe sex, and sexual pleasure.

What other tips would you offer?

• Proactively raise the topic of sexual health during routine checkups.
• Provide clear, accurate information about contraception options, including proper condom use.
• Offer STI testing and discuss the importance of regular screening.
• Be aware of local youth-friendly sexual health services for referrals.
• To ensure accessibility, services should be located in convenient locations, have flexible hours, and offer care that is free or available at a nominal fee.

Finally, it is important to involve young people in the design and evaluation of these services to ensure that they meet their needs and preferences.