To the Editor:

I currently live in an area of the Texas Panhandle better termed as the “Bible Belt.” The rule here is to only discuss abstinence. After 11 years in the health department and 10 years as a nurse practitioner in clinics, I disagree with this approach. It has not been effective in this region, and we have a very high rate of teen and preteen pregnancy. It has been an advantage to be in the health department and clinics, where the staff can discuss sexuality with the young patients who really want to know more about how to take care of themselves and how to make wise choices. Providing that knowledge of risks – both physical and emotional – assists them in making wiser choices when confronting early sexual experiences. It is interesting that it seems those who are the loudest in their protest of sexual education are the ones who whisk their daughters off for a quiet abortion. This provides a confusing atmosphere for our young teens and preteens. Thank you, Dr. Schalet, for doing this study.[1] I hope it receives a lot of notice by our members of Congress so they begin to recognize the need for funding of sex education.

To the Editor:

I just wanted to say that Dr. Schalet's article[1] made me think. I can't say that I agree with a lot of what is said, but I think there is a medium road between the United States' and The Netherlands' approaches to sex.

I don't think that just because one could attempt to normalize teenage sex that it is right. There are many things that our society calls “normal” that I believe are not. I also disagree with the thinking that normalized sex will not have a harmful emotional impact on a teenager. I think sex should be normalized. I really like the idea of helping teenagers set their own boundaries and communicate feelings and boundaries to someone with whom they are in a relationship, but I also think sexual intercourse inside the commitment of marriage is the best sex and that people should wait for marriage.

I feel the article was remiss in labeling pregnancy and sexually transmitted disease/infection the worst consequence of teenagers having sex. I think the emotional damage is just as bad; and, as I stated above, I feel that even normalized sex has the potential for negative effect on the emotions of people if conducted outside of marriage.

I was a virgin when I married at 26 and have no regrets. I do not wish I would have had sex before I was married, and I do not feel my life would have been enhanced by having sex as a teenager. I do feel, however, that as a teenager I could have benefited from learning how to discuss sex and boundaries. On the other hand, I have many friends who did have sex – even within loving relationships – before they were married, and they do regret their sexual past and wish they had waited.

One has to admit that abstinence really is the “safest sex.” I have married friends who got pregnant while using condoms or while being on the pill and taking it as prescribed; so I feel that sex education needs to at least address that contraception is a good idea and works most of the time, but not all of the time. I don't think scare tactics need to be used, but if one is presenting all of the “scientific” sexual facts, then risk of failure of contraception needs to be addressed.

I know that I will never convince Dr. Schalet of my views, and she will not convince me of hers, but thanks for the article and for taking the time to read my mail. The article has made me think about how I will respond to my children and their sexuality. They are very young now, but it is never too early to think about this.

To the Editor:

After reading “Must We Fear Adolescent Sexuality?”[1] the conclusion that should be reached is that the issue is not whether to permit an adolescent to have sex, but rather the importance of having a good relationship with the child and valuing the importance of relationships vs the importance of sex. Our media constantly bombards our teens with the casual sex concept. Demanding that media take responsibility and reinforcing the importance of having good relationships would be the best way for medical professionals to care for their teen patients. Abstinence-based curricula have been shown to be effective, and abstinence is the only true way to avoid sexually transmitted infections. It was effective for the vast majority in past generations and will continue to be effective again, given the proper support.

To the Editor:

I think if we approached adolescents with more respectful education, we could be more effective in preventing pregnancies, sexually transmitted infections, abortions, and ruined lives. Why would adolescents approach healthcare institutions for help if they are going to be treated like criminals for having normal sex lives? Look at the way they have to hide what they're doing! Thanks to Dr. Schalet for all her work.

To the Editor:

You invite comments regarding the article “Must We Fear Adolescent Sexuality?”[1] and I feel compelled to comply.

Dr. Schalet does a very thorough analysis of data that were gathered with high quality. I think there's another dimension missing from her analysis, though, and that is the cultural difference regarding the concept of personal responsibility. To illustrate, consider the following scenarios:

• A speeding drunk driver causes a fatality.
• A hiker ventures into the woods alone and gets lost.
• A craftsman uses a tool improperly and severs a finger.
• A driver spills hot coffee in her lap.

Although I do not have personal knowledge of The Netherlands, I have traveled Europe quite a bit and will extrapolate European culture to The Netherlands. If I may make that assumption, then I wish to point out that all of the above scenarios would be viewed quite differently in Europe than in the United States. Americans have largely abandoned the concept of personal responsibility, seeking to shift the blame and responsibility from the individual to anyone else, to big bad corporations (as if the adjectives were redundant) or to society as a whole. I suspect that this issue is part of the larger fabric of each society, of which one manifestation is the expectation of how adolescents are expected to handle their sexuality.

Dr. Schalet brings this point to light in Frank Mast's comments regarding the irresponsibility of (American) boys, ie, they can walk away; whereas the girl gets stuck with the “mistake.” Iris DiMaggio also touched upon this concept, in that taking on adult responsibilities results in gaining adult privileges. Dr. Schalet concludes that “…permitting a sleepover under their roof would violate a deeply held belief that children must first prove themselves independent and fully separate from their parents, before parents sanction their sexual relationships.” Perhaps this is a parental attempt at ensuring that there is some level of responsibility accepted and handled before becoming sexually active?

Dr. Schalet does shed some light on the Dutch/European expectation for responsibility, such as, “Dutch policy is aimed at assisting young people to behave responsibly in this respect” and “One theme that recurs throughout the Dutch interviews is that of self-regulation. In contrast to their American counterparts, Dutch middle-class parents assume that teenagers can be self-regulating sexual agents.”

Unfortunately, Dr. Schalet describes this cultural difference as “Dramatizing vs Normalizing Adolescent Sexuality.” I disagree with the interpretation of American responses as “dramatizing” since the parental concerns may be driven by a culture that instills a lack of responsibility in our youth. We should all be very concerned about giving responsibilities to those who are not yet ready, but European culture seems to do a better job of teaching responsibility and the consequences of irresponsibility than does American culture.

In concluding, Dr. Schalet asks, “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 first part of her answer is “self-regulation,” but I fear that this is impossible in the greater context of American irresponsibility.

I should conclude by saying that I have no issue with Dr. Schalet's second and third conclusions, ie, it is necessary to recognize adolescents' emotions, desires for intimacy, and real relationships; and that American families must find their version of talking “normally” about sexuality.

I look forward to reading Dr. Schalet's subsequent articles on this subject, and I hope that she will explore the cultural differences regarding personal responsibility further. To attempt to change how we handle sexuality without first changing how we handle responsibility would be putting the proverbial cart before the horse.

To the Editor:

As a medical doctor with an interest in birth, I find it very interesting that Dr. Schalet has chosen The Netherlands as comparison,[1] which, as well as having the lowest rate of teen pregnancy also has some of the lowest rates of obstetric intervention and the highest rates of home birth in the world. The United States also has some of the highest rates of birth intervention in the world.

The finding that attitudes toward teen sexuality are overdramatized in the United States and normalized in The Netherlands is very similar to findings about attitudes towards birth. In The Netherlands, birth is seen as a normal part of family life, often takes place in the home, and is often witnessed by family members. In the United States, birth is often seen as dangerous, dramatic, and unpredictable and generally takes place in a hospital – isolated from the community and family.

My belief is that attitude toward birth (and being born) is a strong indicator and predictor of attitudes to sexuality, especially female sexuality. When birth is seen as normal, not a drama, and the process is smooth and uncomplicated, the whole family gains confidence and trust in the natural processes. Such attitudes and experiences can extend to teen sexuality.

I also wonder about the parenting styles and rates of breastfeeding in the United States and The Netherlands. My guess is that many more Dutch babies are breastfed and that Dutch babies receive more physical contact and touch in the first year of life. I wonder if the motivation of some US teens is to get the touch that they lacked as a baby through a sexual relationship, and, for the mothers, having a baby may represent the fantasy of getting love from the baby, or “having someone to love.”

Thank you, Dr. Schalet, for your research and thoughtful interpretations.

Best wishes,

To the Editor:

Thank goodness! Thank you for running this series!

At last, a rational psycho-sociocultural discourse about human sexuality[1] at least obliquely associated with my medical education! This is good, cause I ain't gettin' it in med school.

Picture this: a self-selected group – relatively young, high (read over) -achieving, and consequently less socially experienced and less sexually experienced (perhaps even sexually repressed) – who, when done with their training, are culturally perceived as expert in darned-near anything and everything and who are, in fact, trained in some disparate bits and pieces of medicalized human sexuality. This group is then turned loose on its society to advise and treat, among other things, sexuality concerns. A profile, in my mind, of the group of average med students/interns/residents/physicians.

It may fall to me to actually do the research to accept or reject my implied hypotheses of this recipe for medico-ethico-psycho-sociocultural disaster.

I am witnessing my own medical education and have done some preliminary research (not much out there). Hopefully we can improve the training of physicians in human sexuality in order to better serve our patients.

I, for one, think that it is ironic to remember that the puritan pilgrims of Plymouth Colony fame, after abandoning England, eventually left Leiden, The Netherlands, to come to New England in North America.

I await the next installments in the series with great interest.

To the Editor:

I teach fertility awareness methods in Canada (Vancouver Island) and correspond with many other sex educators and Planned Parenthood administrators (I forwarded your paper to some of them). Mostly we agree that sex education is very important to reduce risky behavior, and we see teen sexuality as a normal part of life that should be managed to preserve health and respect and to help the individual grow into a caring adult capable of intimate bonding.

I'm concerned (like other Canadians) that the repressive climate in the United States will result in distorted, unhealthy outcomes. We would prefer more enlightened neighbors who make the effort to talk to their kids and who promote healthy sexuality and bonding experiences so that their children would grow up to be less of a threat to us and our kids.

How can we trust that a kid who has grown up with the message that sex is “bad” will turn into a caring partner the day he or she gets married – like flipping a light switch? It just doesn't make sense, does it? I worry that the culture of repression will backlash, putting us into a situation where young people have unhealthy notions of sex and sexuality. This will damage more than the individual, since these people will go out into the world with notions that will affect the lives of others, including people outside of the United States.

With respect and appreciation for all Dr. Schalet's hard work on this issue,

To the Editor:

It was with some interest that I read Dr. Schalet's article[1] regarding adolescent sexuality. One very important aspect she seemed to ignore is the fact that sex outside marriage is morally wrong. The foundations of our country are based on a reliance on God. He was quite clear in the Bible in clarifying what is right and wrong. The fact that we, as humans, fail to exhibit self-control in this area (as we also often do in other areas such as lying, drinking, drug use, obesity, etc) does not mean we should give in to this behavior. I am a strong supporter of sex education. I am not afraid to tell people about contraceptives, condoms, etc. However, I do strongly feel abstinence-based education is the most appropriate and moral approach.

This approach is not “fear-based,” as Dr. Schalet stated, but based on truth and the values upon which this country was founded. We as adults are often unwilling to discipline ourselves in whatever area of weakness we have in our lives. This leads to many being unwilling to discipline or teach discipline to their children. Have you ever met an alcoholic or an obese person (or someone with any other addiction) who just gives up trying to fight the problem? It is sad to see the results of just giving up. The same would be true for sex. Sex outside marriage is immoral and we should never surrender, but always fight against that immoral behavior in our own lives as well as teach it to our children. Failure to do so will result in a moral decay and ultimate destruction of this country.

I have worked as an emergency physician for 20 years. I see the results psychologically, as well as physically, from our lack of discipline in our lives as people. I did not have sex before marriage and have 7 children, 4 of those between 17 and 23 years old. They are also firm believers in saving sex for marriage. It does not mean they are not aware of sex. It does mean that they know the difference between right and wrong.