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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