A key plank of the abstinence approach is to avoid giving advice on contraception. The logic is that such information would give the message that it's OK to have sex. "The moment we do that, we water down the commitment," says Hester.
If contraception is mentioned at all, it is to highlight its failings – often using inaccurate or distorted data. A report for the US House of Representatives published last December found that 11 out of the 13 federally funded abstinence programs studied contained false or misleading information. Examples of inaccurate statements included: "Pregnancy occurs one out of every seven times that couples use condoms," and: "Condoms fail to prevent HIV 31 per cent of the time." They also use some questionable logic regarding the success rate of abstinence (see "Heads I win, tails you lose").
While some states advocate "abstinence-plus" programs, providing a level of advice on contraception alongside heavy promotion of chastity, the hard-line "abstinence only" approach is in the ascendant in the US. Around a third of US secondary schools have abstinence-only programs, and nearly 3 million young people have publicly pledged to remain virgins until they marry.
And it is spreading. Last June an American group came to the UK to promote the Silver Ring Thing, a Christian movement that encourages teens to publicly pledge to remain virgins until marriage and to keep their promise with the aid of a $12 ring. And True Love Waits has held virginity rallies in Australia.
This trend comes amid claims that the UK's more liberal approach not only does not work, but has the opposite effect. "Free pills and condoms boost promiscuity" screamed the headline on the front page of UK newspaper The Times last year (5 April 2004). It was prompted by research by David Paton, an economist at the University of Nottingham, UK, which found that in some areas that had increased access to family planning services, teen pregnancy rates had remained the same and STD rates had actually risen.
"Despite many people's assumption that sex education is the best way to reduce pregnancies, there is little evidence backing this view"
There are now increasing calls from conservative and religious groups for schools in the UK to consider the abstinence option. A program called Love for Life is now operating in 60 per cent of schools in Northern Ireland. It could be described as abstinence-plus that is heavy on the abstinence. Its founder, Richard Barr, a GP from Craigavon, County Armagh, says that focusing on contraception ignores the bigger picture of human sexuality. "There's a massive need for a more holistic approach, not just a damage-limitation approach."
And the UK mainland is home to a small but growing number of groups, most of them with Christian roots, promoting abstinence-centered education. The word abstinence is less in vogue than across the Atlantic, however, and such groups are more likely to talk in terms of delaying sex until young people are in a committed relationship.
But does the abstinence approach work? Do teenagers – a group not renowned for their propensity to do what they are told – take any notice when adults tell them not to have sex?
Proponents of abstinence claim research supports their strategy. But the vast majority of studies that have been done in this area have been small, short-term evaluations without control groups. "There have only been three well-designed trials where an 'intervention' group is compared with a control group and participants are tracked over time," says Kirby.
One of these, published in 1997, looked at a five-session abstinence-only initiative in California. The trial tracked 10,600 teenagers for 17 months (Family Planning Perspectives, vol. 29, p 100). The researchers found it had no impact on the sexual behavior or pregnancy rates of teenagers. The other two studies had similar results. "None of them show that any abstinence-only programs had any impact on behavior," says Kirby.
Although not a controlled trial, one of the largest studies of the effect of abstinence pledges tracked the sex lives of 12,000 US teenagers aged between 12 and 18 (American Journal of Sociology, vol. 106, p 859). A group led by Peter Bearman, a sociologist at Columbia University in New York, investigated whether taking a virginity pledge affected the age when people first had sex. It did, with an average delay of 18 months. The pledgers also got married earlier and had fewer partners overall.
But when Bearman went back six years later and looked at the STD rates in the same people, now aged between 18 and 24, he was in for a surprise. In research presented at the National STD conference in Philadelphia last year, he found that though pledgers had had fewer sexual partners than non-pledgers, they were just as likely to have had an STD. And the reason? "Pledgers use condoms less," says Bearman. "It's difficult to simultaneously imagine not intending to have sex and being contraceptively prepared."
Here lies the problem that many have with the idea of abstinence-only education. While it may work for those kids who live up to the ideal, those who don't are left without the knowledge to protect themselves when they do have sex. "It's not rocket science," says Bearman.
But here's where proponents of the liberal approach can stop feeling smug. Because despite many people's unquestioning assumption that comprehensive sex education is the best way to reduce teenage pregnancy, there is actually little good-quality evidence backing this view.
One of the problems in carrying out randomized controlled trials in this area is the question of who should be used as the control group. Most schools now have some form of sex education in place, however rudimentary, and it would be unethical to take this away from some children to create the control group. Instead researchers have tended to compare standard sex education with new initiatives specially designed to reduce pregnancy rates. But the results have been unimpressive. A systematic review in 2002 of 26 such studies showed that not one of them improved the use of birth control or reduced the teenage pregnancy rate (British Medical Journal, vol. 324, p 1426).
But in the past few years, a handful of randomized controlled trials have been published showing that some carefully designed sex education programs do appear to work. One of the most effective is the Carrera Adolescent Pregnancy Prevention Program, aimed at 13 to 15-year-olds in a poor area of New York (Perspectives on Sexual and Reproductive Health, vol. 34, p 244). Abstinence is mentioned during the program, but most of the emphasis is on contraception. A three-year study showed that the pregnancy rate of teenage girls who took the program was less than half the rate of those who didn't. Analysis showed this was due to both greater condom use and delayed onset of sex.
Why should these programs be any different? As well as lasting longer, they were, says Kirby, "interactive and personalized, not just abstract facts". The Carrera program, for example, not only covered sexual behavior; it tackled the social disadvantages that lead to teenage pregnancy. Along with information on and free access to contraceptives, it involved intensive youth work such as sports, job clubs and homework help.
Most UK sex education programs seem half-hearted in comparison, providing the bare biological facts, perhaps alongside a demonstration of how to put a condom on a cucumber. "It's something I feel quite angry about," says Michael Adler, a former STD physician at University College London Hospital. In his job he saw many casualties of unsafe sex. "We're failing young people right at the beginning," he says.
Unfortunately policy makers have recently lost a good source of information about what works and what doesn't. The US Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, commissioned a panel of external experts to carry out a rigorous review of various sex education programs. The panel identified five strategies that were successful in reducing the rate of teenage pregnancy, all based on comprehensive sex education, and the details were posted on the organization"s website. But in 2002 that information disappeared and the CDC will no longer release it.
According to the CDC press office, the review program is being "re-evaluated". But skeptics fear it has been dumped because its conclusions don't fit with the Bush's administration's views. "They were inconsistent with the ideology to which this administration adheres," says Bill Smith of the Sexuality Information and Education Council of the United States, a liberal sex education advocacy group based in New York.
"Skeptics fear the information on successful sex education programs has been dumped because it doesn't fit with the Bush administration's views"
What of the study that made the newspaper headlines in the UK last year, showing that contraception provision is linked with higher STD rates? Perhaps it should not really be taken as a damning indictment of the liberal approach. The study looked at National Health Service family planning clinics, not school-based comprehensive sex education. Simply doling out condoms without tackling the wider issues is unlikely to have much impact. Anyway, should the correlation between sex clinics and STD levels really be so surprising? "Has it occurred to [David Paton] that they put more services in areas with high rates?" asks Roger Ingham.
In fact, amid all the scare stories, the average age when a person first has sex now appears to be leveling out at around 17 in the US and 16 in the UK. And although rates of STDs are on the increase in the UK, teenage pregnancy and birth rates are on a downward trend, as they have been in most developed countries for several years. A report from the Alan Guttmacher Institute, a reproductive health research group in New York, concludes this is due to factors such as the rise of careers for women, and the increasing importance of education and training (Family Planning Perspectives, vol. 32, p 14). Perhaps it is unsurprising, then, that it is among society's lowest income groups that teen pregnancy rates are highest.
In the face of such complex societal forces, those who try to influence teenagers' behavior on a day-to-day basis undoubtedly have a tough job on their hands. There may be no single solution. More research is needed to produce detailed information on which kind of sex education programs work best, and in which contexts.
One approach is to involve older teenagers, on the premise that 14-year-olds may be more likely to listen to 18-year-olds than people of their parents' generation. Since having her son, Lynsey Tullin has started working for Brook, a young people's sexual health charity, to ensure that today's teenagers are savvier about sex. "We talk the same language," she says.
A tactic that she finds hits home is to describe new parenthood in all its gory details – the nappies, the lack of sleep, a social life in tatters. "We run workshops about being parents, telling them what we went through," she says. "It's a shock."
Different approaches to teenage sexuality
Comprehensive sex education
Provides explicit information about contraception, sexuality and sexual health
Abstinence-only approach
Teaches that the only place for sex is within marriage, and the only certain way to avoid pregnancy and STDs is abstinence. Does not teach about contraception
Abstinence-plus
Promotes abstinence as the best choice, but provides varying degrees of information on contraception in case teens do become sexually active
Heads I win, tails you lose
LOOK at any abstinence-only literature, and you'll read that this is the only certain way to prevent pregnancy and avoid catching a sexually transmitted disease (STD). "Abstinence. Failure rate 0 per cent," is the claim on one pro-abstinence website.
But does this make sense? The most important measure of any method of preventing pregnancy and STDs is not its ideal effectiveness, but its "use effectiveness" – how successful it is in the real, sometimes messy, world of sex. Condoms, for instance, have a 97 per cent success rate at preventing pregnancy if used correctly, but have an estimated use-effectiveness of 86 per cent, due to problems such as tearing or slipping. If people who intend to use condoms but never get as far as opening the pack are included, some studies suggest the use-effectiveness of condoms could be as low as 30 per cent – the sort of figure abstinence fans shout from the rooftops.
What about applying the same real-world rules to abstinence? Unfortunately there are no studies detailing the use-effectiveness of abstinence in preventing pregnancy, but it is highly unlikely to be 100 per cent, as commonly claimed by its proponents. Their reasoning goes like this: individuals who set out to remain abstinent but succumb to temptation and have sex are no longer seen as abstinence "users". And those who become pregnant may even be marked up as a failure for the contraception strategy if, say, they attempted to use a condom but bungled it.
Abstinence campaigners are very vocal about the failings of contraception. But is it perhaps time to own up about the failure rate of abstinence?
The final verdict is, that no one can tell with certainty what works, but we concur with the notion that to educate our teenagers to abstain is to impart to them the virtues of self-control.
(Published in the University of Liverpool Gazette, where Dr. Slade teaches psychiatry)
Furnished on request
Autor:
Dr. Félix E. F. Larocca
Peter D. Slade MD
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