Saving sex for sexual health

Anisa Nasir argues for doctors to suggest abstinence as a solution to unwanted pregnancies and sexually transmitted infections

Sexual health is the topic of our times. It is a subject of amusement, fear, embarrassment, and complexity. From diagnosing the common sexually transmitted infections that blight fertility to the global epidemic of AIDS; from the young age of first sexual encounter to the near total disappearance of lifelong monogamy; and from the increasingly accepted practice of safe abortion to the high rate of teenage pregnancy: not a month goes by when sexual health is not widespread in the popular and medical media.

The West is a sexualised society—our literature thrives on sex, as does our comedy, art, music, film, and fashion—covering audiences from children to grandparents. Sadly, it is not sexual health in the spotlight, but sexual ill health. This article explores some problems in sexual health and presents a rarely considered potential solution—abstinence.

Imperfect prevention

At first glance, contraception and barrier protection seem perfect counters to all the problems of sexual ill health. But their difficulties are manifold. Firstly, it is necessary to have access to them, which is difficult in less poorer countries, where cost is a big factor. Where does the money come from to pay for and distribute the product and to educate the user? Secondly, it is necessary to ensure its successful use.

Success depends on two outcomes: the prevention of unwanted pregnancy and the prevention of sexually transmitted diseases. The combined oral contraceptive pill has high success rates in preventing pregnancy—just 8 per 10,000 sexually active women will become pregnant in a year.^w1 But this is only if it is taken at the right time for 21 days each month in the absence of certain other drugs, and diarrhoea and vomiting can influence effectiveness. Of course the oral contraceptive pill affords no protection against sexually transmitted diseases. For this we need to think about barrier protection, which, again, if used correctly allows 88 out of 100 to be sexually active for a year without becoming pregnant,^w1 while also obviously providing some protection against infection.

Condoms also place reliance on one partner to have one to hand, and it can be awkward if nobody has one. How many couples in the middle of an intimate moment will stop to think “we’d better not,” particularly if it is a first encounter. And first encounters might be the most risky from the point of view of knowing comparatively little about each other’s sexual history. As the National Health Service’s awareness campaign pointed out, there is no “gonorrhoea” embroidered at the top of her underwear or “chlamydia” tattooed around his navel. Not all sexual encounters begin with a haphazard culmination of a night out, though. But even if the first sexual experience of two consenting adults comes after months, you still have a whole sexual history to trawl through.

Emotional vulnerability

Contraception and barrier protection can be considered positive because they prevent unwanted pregnancies, and therefore abortions and transmission of disease. But what about the emotional aspects of sexual health? A sexual relationship involves a high level of intimacy between people. It is a defining line between “something else” and family relationships or friendships. Allowing another person into your sexual space involves vulnerability. Social, physical, and emotional shields are lowered, and by the nature of arousal and orgasm at least some self control is lost in front of the other person.

The cynic may raise an eyebrow at this description of what has become a casual activity. However, no matter how society has reduced sex to merely “just another thing we do” it retains its power to seduce, intrigue, confuse, and overwhelm. When a sexual relationship is over, it is almost universal that the people involved feel that they have given something to each other—be it purely on a physical or emotional level. This is perfectly normal because a sexual union is bonding and can cement relationships because you’ve shared an intimate experience with another person.

Looking at sexual health from this angle you can begin to appreciate the potential negative nature of flippant sexual relationships. Imagine the gravity of emotion that would be felt if temporarily close relationships were to begin and end repeatedly with parents, siblings, or close friends—the sense of loss would be substantial.

To improve sexual health

In the United Kingdom what almost never, in the author’s experience in five years of medical training and exposure to medical media, seems to be suggested is the concept of abstinence. Abstinence from sexual intimacy has become a laughable concept among most of the UK population. It is discussed in an off-hand manner, considered nothing more than a joke and something embraced by only people who are either old fashioned or strictly religious. It is deemed unfashionable, unrealistic, undesirable, and, by many, just plain weird. Perhaps it is time that this age old method of preserving sexual health was reconsidered.

The physical side of any benefit is immediately obvious. For example, abstaining from sexual intercourse until in an emotional relationship of a level where both partners are happy about any potential pregnancy may lower the number of unwanted pregnancies and abortions. The same concept of waiting for “emotional readiness” applied to all aspects of a sexual relationship may result in a reduction in the number of lifetime sexual partners, and hence a similar reduction in the spread of sexually transmitted infections. Sex may lose some of its gloomy entourage—and this could mean great things for emotional sexual health.

Sharing intimacy may become something to celebrate rather than to fear. Apprehension over how one person is perceived by the other person; what will happen in the morning; whether one person is just using the other as a means of fulfilment; who will find out about it; who is being compared with whom; and so on may become the exception rather than the rule.

Abstaining from sex may also allow a greater understanding of the people we feel attracted towards. If we limit our physical intimacy with others it may give more time to explore their emotional intricacies. With sex on the shelf, our minds may remain less clouded and come more quickly to the conclusion as to whether we really have an emotional link strong enough to warrant further exploration, leading to relationships with more solid foundations.

It is incredible how sexual intimacy, with its bonding properties, can hold a relatively dead relationship together for a long time because it confuses physical and emotional desires towards another person. Such long standing relationships coming to an inevitable but drawn-out ending is commonly the cause of much unhappiness.

A feasible proposal?

Many readers may by now have their eyebrows deep in their hairline because of the optimism I attach to what is seen as an outdated concept. But can we so easily brush this idea aside? The global evidence for abstinence programmes is not always encouraging; much of the literature indicates that they have no effect on sexual health.^w2 Some evidence points to success, however.^{w3 w4 w5} “Abstinence plus” programmes, which also encourage monogamy and condom use, have also shown some effectiveness.^w6

So should we consider abstinence when there are so few examples of success? Perhaps our society is too well embedded in its current way of thinking to even consider this idea—particularly in view of so much evidence of no effect. But it does not necessarily follow that evidence from one part of the world will fit another, as proved by the existence of contrary evidence that shows effectiveness.

There may be scope for using the media to introduce the idea in the UK as a public health promotion in the same way that we have encouraged eating healthily, taking exercise, not smoking, and so on, rather than as a prescriptive programme. This can be combined with appropriate education in schools. Young people have varied concepts of abstinence,^w7 so it may be possible to help them understand the full physical, social, and emotional implications of a sexual relationship on health—in the same way that drugs and smoking have been presented.

General practitioners’ simple suggestion to smokers to stop smoking has been effective in prompting them to make attempts to quit.^w8 Hence there may be scope for counselling, particularly of adolescents, who are often under sexual pressure.^w9 Various situations may be appropriate access points—for example, a young girl requesting contraception. Approaching such a situation and subject would require detailed training to maintain sensitivity and avoid alienation. However, with high numbers of females stating that they wished they had started having sex later,^w10 it seems neglectful as a profession not to explore this avenue further. The physical and emotional benefits of abstinence from sex are apparent, and as healthcare professionals we have a duty of care to our patients. Can we still justify leaving this solution as it is currently—untouched and ignored?

Competing interests: None declared.

References w1-w10 are on student.bmj.com

Provenance and peer review: Not commissioned; externally peer reviewed

See also the Head to Head “Are condoms the answer to rising rates of non-HIV sexually transmitted infections?” http://student.bmj.com/issues/08/03/life/096.php and Life http://student.bmj.com/issues/08/03/life/100.php.

What do you think? Send us your views as a rapid response at student.bmj.com.

Anisa Jabeen Nasir fifth year medical student Manchester University Medical School
Email: ajnasir@doctors.org.uk
Student BMJ 2008;16:98-99 | 17

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