The hidden cost of free condoms

Young people will soon be able to get free condoms at their doctors’ surgeries – but only after undergoing tuition in New Labour-style sexual morality.

In that lifelong quest for personal and professional development which it is my duty to pursue as a doctor in the new NHS, I recently attended a course – at the taxpayer’s expense – entitled ‘Hackney GP Condom Scheme Training’. According to UK prime minister Tony Blair, ‘Britain has the worst record on teenage pregnancy in Europe’, so the government has established a special unit and has invested £60million over three years to achieve the target of cutting the pregnancy rate by half (1). In Hackney, which has one of the highest rates in Britain, doctors and nurses have been chosen to take the crusade forward. The strategic device in the campaign to curtail youthful sexual activity is the humble condom.

Before I arrived at the course – widely advertised as mandatory for both GPs and practice nurses in surgeries that want to secure supplies of free condoms to give out to patients – the invitation had already raised a few questions.

Why is teenage pregnancy suddenly regarded as such a problem? A closer look at the figures reveals a high degree of government ‘spin’. It may be true that Britain has a higher rate than other European countries, but it is still lower than Canada’s or New Zealand’s; in the USA the rate is more than twice that in Britain. In many respects Britain has more in common with these countries than those of continental Europe, in which low levels of fertility have been a recurring focus of social and political concern over the past century.

Contrary to the impression of a recent upsurge in births to teenagers, the rate of teenage pregnancy has been fairly steady, with minor fluctuations over the past two decades after a fall in the 1970s (2). There was some increase in the early 1980s and a further decline in the early 1990s. The 1995 pill scare produced a temporary rise, but this was seen in all age groups.

Furthermore, the total number of babies born to teenagers is fairly small. Though the government trumpets the headline figure of 90,000 teenage pregnancies, the vast majority of these are among 18- and 19-year olds – and around a third end in abortions. The government’s 1999 report noted 7700 conceptions among girls under 16, of which more than half had terminations. The facts that nearly 3700 girls of school age are having babies and a similar number undergoing abortions is undoubtedly a serious issue for them and their families – but in a nation of 55million people it would appear to be a relatively minor social problem.

Nor is pregnancy necessarily a problem for teenagers. A few weeks ago, an 18-year-old couple, Polish-speaking gypsies recently arrived in London, came in to my surgery complaining of three years of infertility. In a community in which early marriage and childbearing are traditional, failure to achieve teenage pregnancy may be regarded a serious problem.

The government’s report noted three ethnic minorities which are ‘at substantially greater risk of teenage pregnancy’: Bangladeshi, African Caribbean and Pakistani. All these communities are strongly represented in east London, no doubt partly explaining the high teenage pregnancy rate. Though the report acknowledges that ‘the reasons for these variations are very complex’, it seems not to recognise that government initiatives that are insensitive to cultural particularities are likely to fail.

All the official reports emphasise associations between teenage pregnancy and wider social problems of poverty, poor housing, poor education, poor prospects and low expectations. No doubt some young people choose to have a baby because this provides them with a source of identity and purpose that is otherwise lacking in their lives. A campaign that focuses narrowly on trying to deter teenage pregnancy and ignores the wider social factors seems unlikely to have much impact.

The origins of the campaign against teenage pregnancy in the government’s unit dealing with problems of ‘social exclusion’ indicate that it has wider social objectives than merely deterring conceptions. Campaigners are keen to point out that their programmes also aim to provide more support to teenage parents. Numerous schemes offer parenting classes and other forms of counselling to young mothers – and are particularly enthusiastic about engaging young fathers.

The Social Exclusion Unit is preoccupied by the concern that many young people, especially young men, especially young black men, are becoming increasingly alienated from society. They are more likely to be excluded from school, to drop out of further education, to be unemployed, to become involved in drugs and crime, and to end up in prison. The government hopes that initiatives around issues of sex can provide some point of contact between disaffected youth and professionals working for the state.

Why choose GPs to front the condom campaign? The familiar avuncular figure in a tweed jacket with leather elbow patches does not seem the obvious choice to distribute condoms to truculent teenagers. Young people – especially boys – have traditionally been infrequent attenders at GPs’ surgeries.

How things have changed! The old-style aloof GP has largely been replaced by a younger generation of doctors who are much more likely to be female, with earnestly cultivated communication skills. Young people are now flocking into surgeries just like their elders, seeking immunisations, screening tests and reassurance about the latest health scare. Whereas young people often scorn teachers and social workers, doctors appear at least in a more neutral if not more benign light. While the government is keen to deliver more and more of its social policies through GPs’ surgeries, the condom campaigners are anxiously encouraging doctors to make their waiting rooms and their reception staff more welcoming towards self-conscious teenagers – and their boisterous mates.

Why condoms? This most unreliable and unsatisfactory method of contraception appears an unlikely choice for a campaign aiming to reduce teenage pregnancy. Though the intensive promotion of condoms in the era of AIDS has gone some way towards overcoming historical associations with soldiers and brothels, condoms are still widely regarded as inimical to passion, dampening to finer sensations and rather tacky.

They also have a high failure rate. Studies suggest that the overall failure rate in the first year of use is between two and fifteen pregnancies (per 100 woman-years). While results are better for couples over the age of 35 (the failure rate: 2.9), for those between 25 and 34 they are twice as high (6.0); failure rates for teenagers are likely to be even higher (3). By comparison, the failure rate of the combined oral contraceptive pill is between 0.2 and 3. Perhaps suitable for middle-aged couples with routine sex-lives and low fertility, condoms are particularly inappropriate for the typical teenage combination of hectic sexual activity and high fertility.

In the section on contraception for ‘the very young’ in his authoritative handbook, Professor John Guillebaud, Britain’s leading authority on family planning, does not even mention condoms. He emphasises that ‘for many young women, the most suitable initial method currently remains a modern, low-oestrogen, combined oral contraceptive’ (4). In an earlier book he commented that condoms required ‘a very high degree of motivation and extremely meticulous use’, noting that ‘these characteristics are regrettably possessed by relatively few men’ (and, we might add, even fewer teenagers) (5). Though condoms have been made much more widely available – and fairly cheaply – over the past decade, this has not apparently reduced teenage pregnancies. It is difficult to believe that giving them away free will make much difference.

Though condoms might help to curtail sexually transmitted infections, the goal of preventing pregnancy would be better achieved by making the pill – in both the routine and the ‘morning-after’ forms – more easily available, or even by popularising contraceptive implants (an option for teenagers favoured by some authorities). From the perspective of the government, the defect of all these methods is that they focus on young women. The advantage of pushing condoms to the fore is that this technique relies on the active participation of the male. It thus becomes clear that, for the government, it is more important to get young men into doctors’ surgeries than it is to reduce the rate of teenage pregnancies. The Hackney condom training course revealed why.

The course was run by two rather stern and prim young ladies. In the first half we were instructed how to use condoms; in the second we were taught the importance of confidentiality. The principle seemed to be that before we could be considered qualified to patronise the youth of Hackney we had to have the experience of being patronised ourselves.

The highlight of the day was the demonstration, using a dildo, of how to use a condom. Under the scheme, each GP surgery is to be issued with a dildo so that doctors and nurses can pass on their newly acquired skills to their teenage patients. At some length the trainer explained the intricacies of checking the seal and the expiry date, removing the condom from the packet (not with the teeth and careful with those sharp nails!), getting it the right way around, applying it to the penis and then removing it and disposing of it. We were warned of the importance of storing condoms at the right temperature and avoiding sunlight.

It was striking that, though the trainer had obviously done this performance on many occasions, she enjoyed the frisson of embarrassment when she produced the dildo and the slightly anxious giggles provoked by her requests for audience participation. My first reaction was one of some amusement at the silliness of this spectacle together with some irritation at the notion that both ourselves and our teenage patients needed such intensive instruction in skills that generations of men seem to have acquired spontaneously, even in the dark. But I quickly realised that the dildo performance had a more profound significance.

By presenting the banal act of applying a condom as a task of great technical complexity, the trainer established the need for expert tuition as a condition for providing condoms. ‘Me highly trained expert – you unbelievably incompetent’: these were the terms of the relationship between the trainer and those undergoing training on the course, with the implication that they were shortly to be reproduced between doctor and teenage patient in the surgery.

The performance also rendered the obscene commonplace: though the depiction of the erect penis remains taboo – indeed illegal – in Britain, here was a group of health professionals calmly observing, even better handling, a highly naturalistic representation of this most profane and menacing of human organs in its state of maximal arousal. By giving a customarily private and personal experience a public and impersonal character, the condom demonstration aims to break down embarrassment about the discussion of intimate matters of sex and relationships. Once doctors and nurses have overcome their personal inhibitions in these areas, then they will – equipped with their own dildo and stock of condoms – be able to break down the reserve of their teenage patients.

The condom thus provides a means, not merely of getting teenagers into the surgery, but of gaining professional access to their inner lives.

In the second half of the course – focusing on confidentiality – the wider ambitions of the campaign against teenage pregnancy emerged more clearly. According to the book – ‘a toolkit’ – distributed to course attendees, ‘improving young people’s trust in the confidentiality of their practice should help remove one of the main obstacles that deter some teenagers from seeking early sexual health advice’. (Confidentiality and Young People: improving teenagers’ uptake of sexual and other health advice is endorsed by the Royal College of General Practitioners, the British Medical Association, the Royal College of Nursing and others, and is funded by the Department of Health and the Teenage Pregnancy Unit).

This document – and the course – reiterate the familiar principles of confidentiality, which is always useful but may be of limited value in dealing with the complexities of problems that arise in day-to-day practice. My objection that these issues, the ‘bread and butter’ of general practice, are well understood by GPs was met by the rejoinder that some young people have reported breaches of confidentiality. On the basis of such anecdotes, it is considered necessary that all GPs receive elementary tuition in these matters – from people who have neither knowledge nor experience of general practice. Suitably humbled by the course, doctors will be better equipped to humble their patients.

Establishing trust is crucial to turning the request for condoms into a wider discussion. ‘What issues will be raised when the condoms are distributed?’ asks the Hackney Condom Protocol:

‘You may want to discuss issues such as: ensuring that the young person is sure they want to engage in a sexual relationship, whether they want to talk to their parents about relationships and sex…’

It is in these discussions, beginning from suggestions that subtly discourage sexual activity, that the crucial moralising mission of the condom crusade is accomplished.

The moralistic character of the condom programme is disguised by its superficially permissive character – and by the way that its advocates deny having any moral agenda and proclaim their ‘non-judgemental’ credentials. The scheme flaunts a wide range of condoms: ‘nature condoms, noppy condoms, flavoured condoms, also ultra-strong condoms and lube available for young gay men or those exploring their sexuality.’ Indeed, it insists that condom posters and publicity material are displayed prominently in the surgery. Yet underlying this – rather childish – contempt for the sensitivities of an older and more reticent generation, lurks a deeply anti-sex and misanthropic message.

The assumptions about teenage sexuality underlying the teenage pregnancy campaign have an overwhelmingly negative character. As the Social Exculsion Unit report puts it, ‘Sex among teenagers is often opportunistic, unplanned, affected by alcohol and takes place outside of any long-term commitment’. (Of course, sex among adults is never like this!) The campaigners assume that if teenagers become pregnant, it is because they are ignorant about sex and about contraception, not because they have chosen to have a baby. If young people are having sex, campaigners believe that this implies that they have low self-esteem, not that they are expanding their range of experience.

Young people are believed to be succumbing to the pressure of their peers and the mass media, not engaging in a collective project of experimentation and self-discovery. Sex is associated with abusive and coercive relationships, not with love, passion or friendship. All teenage relationships, whether with partners, peers or parents, are depicted as potentially damaging, requiring careful negotiation, ‘supported’ and regulated by professionals, counsellors and mentors.

Instead of behaving spontaneously and impulsively in sexual matters, young people must now learn how to negotiate and pursue their affairs in a calculating and instrumental manner. Quoting surveys showing that many young people regret their first sexual experience and wish they had delayed it longer, sexual health workers emphasise that sex should be undertaken as a deliberate choice, with fully informed consent. But in the real world occupied by teenagers, learning about sex and relationships is an inevitably fraught process, in which people do things that on mature reflection they wish they hadn’t, experience triumphs and disasters, and usually emerge as mature adults, all the wiser for their mistakes.

If teenagers are obliged to conduct their relationships under the glare of adult professional supervision, this process is likely to be jeopardised rather than enhanced.

Doctors’ particular contribution to the disparagement of teenage sexuality is to emphasise the danger of sexually transmitted infections. The first bullet point on the ‘toolkit’ list of reasons why young people need confidentiality is the claim that ’16-19 year old women have the highest rate of chlamydia of any age group’. Thus promoters of ‘sexual health’ invoke the spectre of ‘sexual disease’ to discourage youthful sexual experimentation. Just as the menace of HIV displaced the herpes scare of the 1980s, now chlamydia – and the risk of infertility – has become the new favourite in the world of health promotion. Fortunately, chlamydia can be easily detected and rapidly treated (6).

Having enticed teenagers into the surgery with brazen free condom posters, GPs and nurses can then discuss sex freely in the context of infectious disease and toxic relationships. Thus the condom provides the framework for the promotion of a new form of moral regulation of youthful sexual behaviour.

Nor are the anti-sex campaigners content to restrict their activities to trying to put young people off sex. The confidentiality toolkit emphasises that young people should be encouraged ‘to seek advice on other personal issues too, such as drugs, bullying and depression’. Whether or not GPs are competent to advise teenagers on such matters – and whether or not these areas should be considered legitimate concerns of medical practice – the dynamic behind the teenage pregnancy campaign towards wider and deeper intrusion in the intimate personal lives of young people is clear.

The Hackney condom course exposes something of the psychology underlying the campaign against teenage pregnancy, one of New Labour’s flagship initiatives. This government has developed something of an obsession with the problems of youth: its measures against antisocial behaviour, football hooliganism and ‘yob culture’ reveal a pervasive fear, amounting almost to hatred, of young people.

The teenage pregnancy campaign projects the social anxieties of the ruling elite in the form of a bleak vision of the sexual depravity of young people. The priapic phallus so crassly paraded at the condom course symbolises the forces of chaos and disorder that are so threatening to Tony Blair and his colleagues. The moral crusade disguised in the teenage pregnancy campaign offers a mechanism for containing adolescent sexuality and for controlling the behaviour of disaffected youth.

It is no secret that laddish bravado generally conceals insecurity, and this insecurity is often greatest in the sphere of sexuality. Through the agency of compliant GPs and nurses, the teenage pregnancy campaign aims to reach parts that politicians alone could never reach, seeking to exploit vulnerabilities, physical and emotional, that are a familiar feature of adolescence.

To any teenager attracted by the offer of free condoms from their GP, I would say: be careful. The hidden cost of a packet of condoms is the surrender of your personal life to professional intrusion. Though your GP or practice nurse may simply regard the scheme as a means of distributing free condoms, beware that this programme is driven by an outlook that lacks respect for young people, for their parents, for doctors and nurses, indeed – and this is the rotten root of the official ideology – for humanity itself.

Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

Read on:

(1) Teenage Pregnancy, Social Exclusion Unit, June 1999

(2) Young people and pregnancy: a review of research, Cabinet Office, 2000

(3) John Gillebaud, Contraception Today (Third Edition) Martin Dunitz, 1997

(4) Guillebaud, 1997, p3

(5) John Guillebaud, Contraception: your questions answered, Churchill Livingstone, 1986

Read on:

Catching chlamydia, by Ann Furedi