Birth control became the subject of debate when the National Health Security Office (NHSO) started offering free contraceptive pills earlier this month, which will be followed by condoms in April at its service points -- including clinics, pharmacies and private hospitals -- to people aged 15 and above to prevent unintended pregnancies and sexually transmitted diseases.
However, Thailand is experiencing an unprecedented demographic crisis. With the prospect of becoming a super-aged society by 2031, the country has seen a decade of declining births, which has dropped below 600,000 for two consecutive years. This is a sharp contrast to the baby boom years from 1963 to 1983 when new births were over 1 million per annum.
According to the Department of Health, the number of births by teen mothers (15-19) has also dropped from over 120,000 in early 2010 to around 56,000 in 2020. An abortion surveillance survey found that 16.5%, or 89 teens out of 540, had an abortion due to financial and social constraints.
In light of this, some critics have said these campaigns of free birth control pills and condoms were just quick fixes. Life spoke to sexual health experts who pointed out that two major obstacles -- a non-open attitude towards sex and unequal power relations -- can discourage safe sex in teenagers and cause unintended pregnancies.
Uncomfortable with sex
"Birth control has been offered for a long time, but it was not accessible to teenagers because they were kept in clinics and hospitals only. It was not until recent years that schools and communities started offering them," said Pornnuch Sathapholsawat, a project manager for the Path2health Foundation, an NGO specialising in adolescent health development.
"Besides the inconvenience, some adults disapprove and request personal details in exchange for handouts, making students feel uncomfortable."
Pornnuch cited a trial in which after three years of sex education, a group of ninth-graders failed to put theory into practice. When they entered local drug stores, they glanced around searching for contraceptive pills and condoms, but they came back empty-handed.
"They worried that pharmacists would tip their parents off and this could spread like wildfire in close-knit communities," she said.
In those days, sex was a taboo subject. Children were expected not to have premarital sex and express sexual desire. However, these values have gradually begun to change. For example, a legal amendment on abortion took effect early last year, allowing abortion up to 12 weeks and later terminations in certain conditions.
Pornnuch said teenagers also decide not to use free birth control pills and condoms due to privacy concerns. From her experience, they cannot afford them when allowances run out at the end of the month. In her view, the government should make them free, accessible and secure, for example, by post.
"The NHSO is now giving them to people aged 15 and above. What about those aged under 15? Don't they have sex? Are we restricting their right to access free contraception? If it is the case, they must support themselves or not at all. Whoever has sex should get free contraceptive methods," she said.
Worachote Lamudthong, a project manager for the Planned Parenthood Association of Thailand, echoed a similar view. After a lecture on sex education, he handed out condoms to students unconditionally, making them feel comfortable. But when they seek professional services, they are reluctant to reveal identities for fear of privacy breach and stigmatisation. In some services like abortion, they worry about being tracked.
"I agree with the NHSO's campaign, but it comes at the price of privacy," he said. "We will work harder to ensure that their personal data will be safe."
Dr Nittaya Phanuphak, executive director of the Institute of HIV Research and Innovation, said sexual health is treated as an embarrassing issue in Thai society, and this leads to reduced access to these services. A sexual health package should be inclusive. Besides free condoms and birth control pills, screening for sexually transmitted diseases should be expanded.
"Teenagers who use condoms, but engage in oral sex, are also at risk of infection. Their condition will remain unknown if they don't get screened, which is the start point of treatment and recovery. If it isn't detected, we won't be able to get rid of sexually transmitted diseases," she said.
Unequal power relations
Pornnuch said many female students are not equipped with negotiation skills and therefore do not know how to speak up when asked for unprotected sex. She said the law requires schools to teach sex education, but it does not guarantee their willingness.
"It needs training and an open mind. Basically, schools are not willing to teach the subject. In light of Covid-19, sex education has been left out because teachers are falling behind schedule," she said.
Worachote said unequal power relations influence different views of love. While some women expect men to be loyal, their partners just want to have sex for fun. It boils down to a lack of self-esteem and body integrity. He talked to many female students who have condomless sex to please their lovers in the hope of expecting loyalty in return.
"I am pushing for comprehensive sexual education, which covers negotiation skills, self-esteem and sexual consent," he said. "Because students are not taught properly, unintended pregnancies will continue. Many use condoms only before orgasm or pull out, which can increase the chance of pregnancy."
Dr Nittaya said hierarchical relations, particularly between men and women, involves safe sex and sexual consent, making some people feel that sex with little consent is not wrong and punishable. If one must depend on the other, the person with more power can choose how to have sex without considering sexual consent.
"Sex education can come in handy to promote sexual consent. Having sex today does not imply a willingness to have sex tomorrow," she said.
Dr Nittaya said there is no specific law on the violation of sexual consent. In her view, a change in mindset is more sustainable. Sex education is not necessarily confined to the classroom because nowadays students can learn outside the curriculum such as on constructive online platforms.
"It is like a cup of tea. A person may enjoy drinking it [now], but if he or she no longer wants it, stop boiling tea. It can be applied to every stage of sexual intercourse," she said.
