Nine years ago, I contributed a commentary on the medical aspects in tackling fertility decline among Japanese [1]. It is so unfortunate that the official policies currently adopted by the Japanese government on the issue of fertility decline in the past quarter of a century, is akin to crossing a violent river in a leaky boat with bare hands of the boat passengers as an aid to prevent the leaks in the boat. Two important phases of this vital problem have to be taken into account. These are,

• Pre-birth phase: Unmarried singles leading to pair formation and mating that results in viable conception of a baby.
• Post-birth phase; welfare of the babies and parents to achieve and lead stable family lives.

In 1949, at the peak of the 1^st baby boom in post-war Japan, 2,696,638 babies were born. Fifty years ago, in 1973, at the peak of the 2^nd baby boom in Japan, 2,091,983 babies were born. Based on these statistics, an unnamed official in the Ministry of Health in Japan was quoted in 2001, those who were born during the 2^nd baby boom, ‘are currently in their late 20s, and maybe after they turn 30, we can see a rise in the birthrate’ [2], What a false prediction this turned out to be! The number of babies born in the year 2020 were only 840, 832 [3]. Why this has to be so?

In the past two decades of the 21^st century, politicians, policy planners and administrators have turned a blind eye to the multiple problems occurring during the pre-birth phase, other than financial assistance for infertility treatment of couples, who are mostly in their mid or late thirties. By choice, politicians focus mainly on the post-birth phase such as reducing the economic burden of young parents (proposals for daycare for toddlers, increasing child allowance, tax reduction for children), paternity leave, financial assistance for higher education of children etc. The intention of the politicians by proposing such measures is short sighted and ill-founded, towards targeting for party victory in the next election [4-6], Typical is a 2018 news item in the Japan Times noting, ‘Prime Minister Shinzo Abe has pledged to stem the population decline by expanding support for child care and education [7]. It’s akin to counting the chicken before eggs are hatched.

Eight factors ruining fertility in contemporary Japan, during the pre-birth phase are as follows:

1. Excessive alcohol consumption by youth in the reproductive phase [8-14]
2. Intimate Partner Violence (IPV) [15-19]
3. Menstruation related disabilities [20-26]
4. Selective abortion as a birth control method [27-32]
5. Rising incidence of sexually transmitted diseases (STDs) [33-37]
6. Parturition -related
7. Tocophobia [38-42]
8. post-traumatic parturition syndrome [43]
9. Sex-related disorders [44-47]
10. Sexuality education deficit for teenagers [48-54]

These eight factors have been notably omitted in the policy pronouncements of the current and previous prime ministers. Among these, four factors (namely, intimate partner violence, menstruation-related disabilities, selective abortion as a birth control method and tocophobia) are female gender specific. The issue of intimate partner violence problem needs serious attention and prevention from law enforcement personnel. Other three have to be attended and clinically evaluated by medical care providers.

Sexuality education deficit is a serious problem in secondary and tertiary levels of educational system in Japan. Proliferation of pornography in the digital SNS and Victorian-era prudish thinking of decision-making bureaucrats not-withstanding, the sexuality education curriculum adopted in Japanese schools and universities leaves much to be desired. The internal conflicts between two organizations namely Japanese Association for Sex Education (JASE – Nihon Seikyouiku Kyoukai) and The Council for Education and Study on Human Sexuality (Ningen to Sei Kyouiku Kenkyu Kyougikai – Seikyokyo) from purity education policy ‘junketsu kyoiku’ to sexology-oriented policy has been highlighted by Hiroko Hirose [51], in an obscure local journal in 2016. These two organizations were led by two individualistic teachers Yuuki Tanomura (1923-2009) representing JASE and Naohide Yamamoto (1932-2000) representing Seikyokyo. Despite these organizational conflicts, the proverbial ‘elephant in the room’ was that, according to Iwamuro’s study in 2007, ‘ten percent of junior-high school pupils and 40% of high school pupils have initial sexual intercourse in Japan. However, only half of them use condom. Therefore, the prevalence of sexually transmitted diseases and the risk of unexpected pregnancy are high in Japanese teenagers [36].

An embarrassing brief commentary on the sex education deficit in Japan appeared in the Economist in 2016. First few sentences of this commentary are reproduced below:

“FIVE 17-year-old students take turns to give a three-minute presentation at Koishikawa high school in Tokyo. The first speaks about government services for pregnant women; next come the risks of childbearing for women older than 35, then the history of contraception, the morning-after pill and infertility. The teacher gives a brief outline of abortion law in Japan before turning to sexually transmitted diseases (STDs), and the 45-minute sex-education lesson is over.

Japan has a complex relationship with the birds and the bees. Sex is everywhere, in gleefully commercialised form, from explicit manga comics to love hotels where rooms are rented by the hour. Some of these businesses involve young people: ‘JK’ services, for example, involve men paying schoolgirls to lie next to them or go for a walk. Yet in many respects Japan is very conservative: sex remains a subject that parents and teachers are embarrassed to discuss. When they do, it is usually in the context of having a family…” [55].

On this issue, I gained first-hand experience. In the past 12 years, my teaching of da Vinci’s reputed human coitus sketch and a clinically-relevant polymastia photo of a young Japanese woman of Meiji period in two universities, at class room setting were tagged as ‘sexual harassment’ by the prudish minders of morals at these institutions [56,57].

Aren’t there any study sections or associated group(s) in the Ministry of Health, which look into solving the above-mentioned eight factors seriously? If such group exists, how often they report to the Prime Minister and the Cabinet for urgently needed policy action?

Conflict of Interest and Funding: None.

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