The French government's announcement in January of a new policy enabling nurses to offer emergency contraception in the nation's high schools unleashed a flurry of news reports in the United States, with articles appearing in Newsweek, The New York Times and other newspapers across the country. But what may have appeared to be a politically daring and controversial move here was greeted with considerably more equanimity in France itself. Indeed, school-based distribution of emergency contraception is only one component of a widely accepted, ongoing, national campaign to reduce unintended pregnancies among French teens and adult women.
According to French officials and observers, the campaign reflects that society's openness and comfort in dealing with sexuality in general, and teen sexuality in particular. Michel Lavollay, a physician and counselor of health affairs at the French embassy in Washington, puts the matter simply: "The campaign targets young people as a priority because they are the ones we need to touch most." Bridget Dusseau, the Agence France-Presse (AFP) chief editor for the French Service, is even more direct. "It's the right thing to do," she insists. "Young people, we assume, are going to be interested in sexual relationships. You can't forbid sex, but you can ask young people to be responsible. That's what this campaign is about—protecting our young people."
The decision to launch a national campaign to promote contraceptive use was spurred by a government-commissioned report published in February 1999 that looked at various issues related to abortion 25 years after the procedure was legalized. Although the report found that abortion rates were lower than they had been in the first year of legalization, French officials were not satisfied. "It seemed the figures were stabilizing instead of getting better," says the French embassy's Lavollay. "Clearly, something needed to be done." Of particular concern was the country's teenage abortion rate. Even though it is only one-third the U.S. rate, according to statistics compiled by researchers at The Alan Guttmacher Institute (see box), officials were troubled by data indicating that not as many young people were using a contraceptive method at first intercourse as they hoped. "Our policies in France needed to be revitalized," says Lavollay. "We needed to develop more appropriate programs for youth today."
|ADOLESCENT ABORTION AND PREGNANCY RATES IN SELECTED DEVELOPED COUNTRIES*|
|Country||Abortion Rate||Pregnancy Rate|
|England and Wales||18.6||46.9|
|*Rates (per 1,000 women aged 15-19) are for the most recent year available, ranging from 1992 to 1996; countries are ranked by rate of abortion. Abortion data are less than 80% complete.|
In January, France's minister of employment and solidarity, Martine Aubry, launched a national communications initiative called "La contraception, à vous de choisir la vôtre," or "Contraception: It's up to you to choose your own." The major purpose of the monthlong initiative was to provide women with information about the range of contraceptive methods available, to help women choose the one that they are most likely to use consistently. As the centerpiece of the communications initiative, the government sponsored television and radio spots, several of which were targeted specifically at adolescents. (Other spots were aimed at single women in their 30s and at couples who have completed their childbearing.) A one-page guide, which folded to the size of a credit card so that it could be conveniently carried, was also developed to give young people information about contraception, including emergency contraception. Nine million copies of the guide were distributed in schools, youth clubs, family planning clinics and discos. Schools have been strongly encouraged to integrate the initiative message into their ongoing sexuality education efforts; sexuality education is mandatory in French schools, both public and private.
Taking the information-based initiative one step further, France's minister of education, Ségolène Royal, announced a new policy that same month to allow the provision by school nurses of emergency contraception in public and parochial high schools. Consisting of a high dose of regular oral contraceptives, which if taken within 72 hours of unprotected intercourse prevents a pregnancy from occurring, emergency contraception has been available over the counter in France since June 1999.
Royal called the new distribution policy "a gesture of help for those living a painful moment of isolation and fear." And Anne Guinard, a registered school nurse in France, makes clear that dispensing emergency contraception is not a trivial matter. Under the new policy, nurses must counsel students, screen them for health risks and inform them about sexually transmitted diseases (STDs) and prevention. They are also required to encourage parental involvement and to follow up with students with information, counseling and contraceptive services as may be appropriate. "School nurses take their responsibility seriously," Guinard says. "We're part of a team of health professionals in schools ready to provide our teens with the support they need and look out for their health interests. We're not leaving the child alone."
The campaign to promote contraceptive use has enjoyed wide support in France. This includes the decision to distribute emergency contraception in schools. Lavollay stresses that the idea was well tested among community leaders before its launch. Public health and religious officials, parents and school nurses were receptive, he says, because they recognized that many adolescents, especially older ones, are going to be sexually active.
Undeniably, some object to the distribution of emergency contraception in schools on moral grounds and denounce the school policy for intensifying liberal attitudes about sex, contraception and abortion. Yet, even in this largely Catholic country, Guinard says, most adults are not opposed to teens' access to contraceptives, and for that reason, the bulk of the objections are pragmatic. Some fear that the new school policy does not go far enough to encourage young women to talk to their parents. Others fear that teens will use emergency contraception as a regular form of birth control. Still others worry because emergency contraception does not protect against STDs, including HIV. But even in those venues where an effort could have been staged in opposition to the campaign or to the distribution of emergency contraception, no organized fight has emerged. "France has a large system of parochial education—religious schools that are funded by the government in a public-private partnership," explains Lavollay. "These schools offer some emphasis on religious values. Still, there's been no attempt to denigrate the unintended pregnancy prevention campaign."
A Study in Contrasts
The French government's latest campaign to expand access to sexual health information and services to teens fits comfortably within its societal traditions. "French culture is open about sexuality," says Lavollay. "Especially with the advent of AIDS, young people and their parents agree: Adolescents need access to information and services." Indeed, France launched its first national HIV prevention campaign in 1987, promoting free screening and condom use. Since 1994, HIV prevention campaigns have specifically targeted young people. The government has ensured that condom distribution machines are in schools and has developed humorous public messages in an attempt to break down the public's resistance to condoms and to institutionalize condom use.
Observers in the United States cannot help noticing the contrast between France's approach to issues related to teen sexual activity and those that prevail in this country. "Sexually explicit campaigns, like the one in France, arouse little concern among western Europeans," says Barbara Huberman, director of sexuality education at Advocates for Youth, a U.S.-based organization that has conducted tours of France, Germany and the Netherlands to study the countries' different approaches to sexual health issues. In France, she says, the government's response to teenage pregnancy and abortion centers on consistent sexuality education, improved access to contraception and widespread public-education campaigns in support of contraceptive use. In the United States, she argues, policymakers try on the one hand to address high abortion rates by making abortion harder to get and, on the other, to address teen pregnancy by promoting abstinence.
"The gap between our countries' approaches to teen sexual behavior is reflected in a wide gap in our teen pregnancy and abortion rates. It is unfortunate that in the United States, we lag so far behind," says Jacqueline E. Darroch, vice president for research at The Alan Guttmacher Institute, who has studied adolescent pregnancy and STD rates in developed countries. "The United States is in a category with Belarus, Bulgaria, Romania and the Russian Federation, countries having among the highest teen pregnancy rates in the world. We don't even come close to what's been achieved in France."
The author wishes to thank Christine Panchaud, senior research associate with The Alan Guttmacher Institute, for her assistance and insight throughout the preparation of this article.