Congress Holds Hearings on Abstinence-Only


Editor's note: John Santelli, MD, MPH, will testify at the April 23, 2008, Hearing on Abstinence-Only Programs before the Committee on Oversight and Government Reform, U.S. House of Representatives. The following is excerpted from his testimony.

Numerous scientific and ethical critiques have been raised about abstinence-only education for young people. These concerns are articulated in reports by the Society for Adolescent Medicine, the American Public Health Association, and others.

Key critiques include

  • Many abstinence-only programs withhold critical information or include misinformation, particularly about important health topics such as contraception and condoms. This puts young people at risk of sexually transmitted disease and unintended pregnancy. Such restrictions on health information are contrary to the medical ethical principle of informed consent and are a violation of human rights principles.

Demographic Trends

Evidence from the past several decades indicates that establishing abstinence until marriage as a normative behavior is a highly challenging policy goal. In 1970, there was a gap of only one and a half years between first sex and marriage; by 2002 this gap was a full eight years. Research has shown that over the past 40 years, the median age at first intercourse has dropped (and stabilized) at around age 17 in most developed countries. At the same time, the median age at marriage has risen dramatically. Thus, expecting people to wait until marriage to engage in sexual intercourse is increasingly unrealistic. Almost all Americans initiate sexual intercourse before marriage. By the time they reach age 44, 99 percent of Americans have had sex, and 95 percent have done so before marriage.

Trends in Adolescent Sexual Activity and Teen Pregnancy

Recent declines in teen sexual activity appear to be unrelated to federal abstinence programs. According to the Centers for Disease Control and Prevention, rates of sexual experience declined from 54 percent in 1991 to 46 percent in 2001 and have been unchanged since 2001. Note that much of the reduction in rates of adolescent sex occurred before the federal government began widespread funding of abstinence-only education in FY1998.

Teen birth and pregnancy rates declined impressively between 1991 and 2005.

Two behaviors contribute directly to teen pregnancy: engaging in sexual intercourse and contraceptive use. From the 1960s through 1990, increasing involvement in sexual activity by teenagers in Western Europe and the United States was accompanied by sharply lower teen birth and pregnancy rates in most countries, due to greatly improved contraceptive use. Today, better use of contraceptives is the major behavioral difference between European and U.S. teenagers. Rates of sexual activity are similar, but European teens have much higher use of oral contraceptives and use of the "double Dutch" method-simultaneous use of condoms and hormonal methods.

Throughout the 1990s, teen sexual activity in the U.S. decreased and contraceptive use improved. Much of the improvement in contraceptive use was related to increasing condom use: between 1991 and 2001 condom use at last intercourse by young women rose from 38 percent to 51 percent. Increases in teen condom use in the 1980s were even more dramatic.

My own research suggests that 86 percent of the decline in teen pregnancy rates among 15-19 year olds between 1995 and 2002 was the result of improved contraceptive use.

Among younger teens (15-17 years old), three-quarters of the decline was the result of improved contraceptive use. My colleagues and I have recently repeated this calculation for 1991 to 2003 using data from the Youth Risk Behavior Survey which is conducted nationwide with high schools students and found similar results. Improvements in contraceptive use between 1991 and 2003 were responsible for 70 percent of the decline in teen pregnancy.

Thus, while an increase in abstinence (i.e., fewer teens having sexual intercourse) explains some of the decline in teen pregnancy rates in the 1990s, more recently there appears to be little impact of abstinence on teen birth or pregnancy rates. Unfortunately these positive trends in contraceptive use reversed in 2005. Both no use of contraception and decreases in condom use occur in the most recent data. These reversals coincide with increases in teen birth rates in 2006 – after steady declines over the previous 14 years.

Evaluations of Comprehensive Sexuality Education and Abstinence-Only Programs

There is now an extensive body of research that demonstrates that comprehensive sexuality education programs that include information about both abstinence and contraception and share several other key characteristics, are effective in helping young people to delay the onset of sexual intercourse and to use contraception and/or condoms when they do have intercourse. Dr. Douglas Kirby conducted an analysis for the National Campaign to Prevent Teen and Unintended Pregnancy that examined well-designed studies and evaluated whether or not programs designed to reduce teen pregnancy and sexually transmitted infections, including HIV, actually worked in changing behavior. That meta-analysis shows compelling evidence that programs that include information on both abstinence and contraception and display a number of other characteristics are effective in helping young people to abstain or protect themselves from pregnancy and STDs.

In contrast, rigorous evaluations of abstinence-only programs find little evidence of efficacy for abstinence-only education. None of the well-designed evaluations of abstinence-only programs has presented strong evidence of an impact on behaviors.

The Mathematica evaluation of the Title V program, released in April 2007, found no measurable impact on increasing abstinence or delaying sexual initiation among participating youth or on other important health behaviors such as condom use. This well funded and well conducted evaluation examined four abstinence-only programs, tracking youth over four years. One of the few measurable impacts of the programs was a decrease in adolescent confidence regarding the ability of condoms to prevent HIV and other sexually transmitted diseases.

In other words, comprehensive sexuality education programs are actually better than abstinence-only programs at helping young people to abstain from sex.

Virginity Pledges

Virginity pledging, which is one approach to encouraging abstinence until marriage among youth, appears to have little long-term benefit in preventing outcomes such as sexually transmitted infections. A longitudinal study by Bruckner and Bearman found that teens who signed abstinence pledges, when compared to non-pledgers, experienced similar rates of sexually transmitted infection (Bruckner and Bearman, 2005). Pledgers did delay sexual intercourse for a limited period, but when they did start having sex, they were less likely to use condoms. They were also less likely to seek reproductive health care compared to non-pledgers leaving them at increased risk for unintended pregnancy and sexually transmitted infections.

Medical Accuracy and Complete Information for Youth

A December 2004 Congressional report on federal abstinence programs from the U.S.

House of Representatives' Committee on Government Reform Minority Staff found that 11 of the 13 most frequently used curricula contained false, misleading or distorted information about reproductive health – including inaccurate information about contraceptive effectiveness, purported health risks of abortion, and other scientific errors. Concerns about the accuracy of information included in abstinence-only programs have also been raised by many different professional organizations. Over the past several years, my colleagues and I at Columbia University have explored this issue. Our recent review of abstinence-only curricula found similar inaccuracies, particularly misinformation about the efficacy of condoms and contraception.

Ethical and Human Rights Concerns

As a physician, I am expected to provide information this is both accurate and complete to my patients. The premise of federal abstinence-only programs is antithetical to this basic principle of medical ethics. Abstinence-only programs require teachers and health educators to conceal information about risk reduction measures such as condoms and contraception-or risk loss of federal funding. Misinformation about condoms is of particular concern given the high rates of sexually transmitted diseases among young people in the United States.

For all of these reasons and more, the leading medical and health organizations in this country have taken the position that abstinence-only education is inappropriate for young people. On this panel you are hearing from two of the key organizations with concerns about abstinence-only approaches, the American Public Health Association and the American Academy of Pediatrics. Abstinence-only education is also opposed by the American Medical Association, the Society for Adolescent Medicine, the Institute of Medicine, and the American Foundation for AIDS Research.

Recommendations

As someone who is deeply committed to the well-being of young people, I urge the committee to encourage policies that will better serve the needs of America's youth.

  • Congress should develop policies to improve adolescent reproductive health based on sound scientific evidence and the realities of adolescents' lives. Policies should support what we know works in helping young people to stay healthy.
  • Congress should require medical accuracy in all federally-supported health education activities.
  • Congress should end federal support for abstinence-only programs that require withholding potentially life-saving information. Teachers should be allowed to teach. Indeed, policy makers have an ethical obligation to ensure that young people have the critical information they need to protect their health.
  • Congress should help ensure that every American adolescent has access to age appropriate, comprehensive sexuality education and comprehensive health care services to help young people to avoid HIV, other STDs and unplanned pregnancy. This approach is consistent with the scientific evidence about what works and echoes the overwhelming support of America's parents and physicians.

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  • invalid-0

    The first two critiques contradict themselves. You cannot have it both ways!

  • http://www.noroomforcontraception.com invalid-0

    >>My own research suggests that 86 percent of the decline in teen pregnancy rates among 15-19 year olds between 1995 and 2002 was the result of improved contraceptive use.

    Dear. Dr. Santelli,

    I’ve read your study multiple times, recreated the formulas (at least the ones included in the study), and have included my critique below.

    Your research, in my opinion, demonstrates that 86 percent of the decline among SEXUALLY EXPERIENCED teens was related to “improved contraceptive use.” (which may have resulted from parental consent laws, abortion restrictions, and dwindling number of abortion providers…)

    It does not, in my opinion, accurately show that improved contraceptive use accounted for 86% of the reductions in teen pregnancy rates among *all* teens.

    Please read my critique below, which largely comes from what I can recall of your study. I would appreciate your thoughts and critique as well…

    Ruben Obregon

    ——————————————————–

    CRITIQUE OF “EXPLAINING RECENT DECLINES IN ADOLESCENT PREGNANCY IN THE UNITED STATES: THE CONTRIBUTION OF ABSTINENCE AND IMPROVED CONTRACEPTIVE USE”

    While contraceptive use among adolescents has improved, there are several problems with this study. To put the study in proper perspective, at its heart, the study *essentially* analyzes only two groups of teens – those who had intercourse within the prior 3 months of their participation in the survey, and sexually experienced teens who did not.

    While the study *does* account for the impact of abstinence in its pregnancy risk index, it does so in a fashion that minimizes – intentional or not – the increased lack of sexual experience on pregnancy rates.

    From there on, the formulas used in the study essentially compare the changes in *recent* sexual activity as compared to changes in the number of those who are *sexually experienced* (ie, had vaginal intercourse) during the periods covered.

    The study DOES NOT contrast changes in a lack of sexual experience and *any* sexual experience (or recent sexual activity).

    Without doing so, it’s simply not possible to say that improved contraceptive use accounted for 86% of the decline in teen pregnancy rates *among* all teens – which the study implies.

    Including abstinence in the pregnancy risk index allowed the authors to claim that those who have never had any sexual experience were accounted for in the study. But what they aren’t saying is that this was accounted for in a manner which de-emphasized the impact of an increased lack of sexual experience among all teens on the pregnancy rate.

    Additionally, in arriving at the 86/14 figures, the authors calculated changes in sexual activity among the sexually experienced – and did not include changes in a lack of sexual experience alltogether.

    Such a methodology biases the results towards improved contraceptive use. My suspicion is that this is intentional, in order to shift the debate away from abstinence and towards contraception.

    At best, the study suggests that among the *sexually experienced*, 86% of the decline was due to improved contraceptive use – but this shouldn’t be confused as meaning that among all teens, including those who are not sexually experienced, improved contraception use accounted for 86% of the reductions.

    PROBLEMS REGARDING DUAL USE

    The study has another problem as well – the study overemphasizes the dual use of the pill and withdrawal in calculating the contraceptive risk index, upon which the aforementioned figures of 14% and 86% are based. It seems that the authors may have assumed that adolescents used multiple methods consistently. [A]

    For example, a teen who relies on the pill and who’s partner *occasionally* uses withdrawal can be said to be using two methods in the same month, but in reality, this may not reflect *consistent use* of dual methods. The authors seemingly assumed that such use of both methods was consistent and therefore reflected typical method use – and as a result, may have derived a much lower failure rate for this combination of methods than is probably applicable. [B]

    ———————————————————-

    FOOTNOTES:

    [A] The failure rate of the Pill and withdrawal, if consistently used together in a manner that reflects typical use of both methods, is 1.8, and is derived by multiplying the typical failure rate of the pill (7.5) and withdrawal (24.5 ) (.075 x .245 = .018) . However, this assumes that withdrawal is practiced with the same consistency that someone who uses it as a primary method would – then the typical failure rate of withdrawal could be used. However, the data does not indicate that withdrawal, when combined with the pill, was used as consistently [typical use] as one who uses it as a primary method. The authors seemingly assume both methods were used in a manner that reflects typical use, and therefore, derived a much lower failure rate than may actually be applicable.

    [B] The NSFG Questionnaire, which was used to collect the data used in the study, does ask women if they used multiple methods in a calendar month and if so, were they were used at the same time. However, the questionnaire does not ask if they were used together consistently during the month (aside from condom and pill usage). Questions regarding consistent condom use were asked for the past 4 weeks and 12 months (p.87)

  • http://www.religiousinstitute.org invalid-0

    Thank you John Santelli for your thorough public health arguments on behalf of sexuality education.

    The Religious Institute submitted a statement for the hearing record on the ethical and moral reasons that Congress must support sexuality education and oppose the current federal abstinence only until marriage program.

    It was endorsed by more than 250 religious leaders, including the heads of 4 denominations and more than 30 national organizations. Read it at http://www.religiousinstitute.org

  • invalid-0

    I have been in the field of teen pregnancy prevention for over 10 years and have talked to thousands of young people. I have studied sex education in 3 European countries and teach human sexuality at a community college. I want to first comment on Ruben’s rebuttal above. The “dual method” or double dutch refers to condoms and the pill, not withdrawal and the pill. We teach young people that if you do decide to have sex, use two compatible methods of birth control. One example of that is the condom and the pill. We teach condom use as, that is what you wear to prevent STDs, and birth control as something different. That way both the man and woman are taking control and both are participating in contraception, and if the condom breaks they will have the pill to back them up. If a woman forgets to take her pill, they have the condom to back them up. Just because we teach contraception does not mean we don’t discuss abstinence. Abstinence is a very important part of any comprehensive sexuality curriculum. We stress that young people should wait for the right person, to have sex when they are ready, not just when their partner is ready. I like to quote Barbara Huberman from her “Raising Healthy Kids” video, “When you can have that experience and feel good about it the next day and know that you protected yourself from STDs and unwanted pregnancy, then it probably will be right for you.” We all know that teenagers don’t like to be “told” what to do. It causes an instant rebellion inside them because they are at an age where they are finding their independence. We need to be careful how we approach this matter and abstinence till marriage is not a universal value for all students. I feel it is socially irresponsible as adults to not give teens all their options. Even if they do wait till they are married, they still need to know about birth control so they can plan their families. The key is to tell them that we would like for them to wait but if they decide they can’t or don’t want to, this is what you should know.

  • http://www.noroomforcontraception.com invalid-0

    >>The “dual method” or double dutch refers to condoms and the pill, not withdrawal and the pill.

    I’m referring to the failure rates used to calculate the contraceptive risk index (CRI) in Santelli’s study, which includes different combinations of methods, including withdrawl and the pill. >>stress that young people should wait for the right person, to have sex when they are ready, not just when their partner is ready And that’s part of the problem – how many abortions are performed on women who had sex when they were ready with the right partner, and who used contraception? PLENTY! The separation of sex from procreation and marriage, at any age, is a significant factor in the high levels of abortion, disease, and teen childbearing here in the US (recent declines notwithstanding). These two factors, among many others, is what keeps abortion anything but rare, and teen/young adult pregnancy and childbearing at high levels her in the US. The attempt to separate sex from procreation has been an utter disaster, as reflected in the tens of millions of abortions since 1973.. Due to time limitations, I’ll have to stop my reply here – we could go round and round for hours on this issue..
  • invalid-0

    There’s a difference between teen pregnancy or sexual intercourse among teens and sex before marriage. Few people marry as teens. I see no contradiction.

  • invalid-0

    Ruben:

    Sex has always been separated from pro-creation. It’s just that up until now, it’s mostly men who got to dictate whom they fucked for fun and whom they fucked for pro-creation. Remember those uptight Victorians, whose upper-class women were discouraged from having sex more than twice a year or so? Their men were having sex much more frequently, with women whom they’d much rather didn’t bear their offspring. (Or if they did, both mother and child would remain unacknowledged and in poverty). Women have been using various herbs from time immemorial to cause abortions. Hell, I’ll be that you yourself, if your sexually active, have breathed a sigh of relief when it turns out that your partner isn’t pregnant this month.

    You can believe that sex should be only to create children all you want, but that’s not how the vast majority of people experience sex. People like to have sex, for a variety of reasons. Also, being smarter than animals rutting in a field, people can control the timing and number of their children, and frequently want to do so, in order to improve their lives.

    (Unless you claim that birth control is unnatural, in which case I wonder what you’re doing on the internet, since animals can’t type, and there are no hard drives in the Bible.)

    People will have sex for fun. People will have sex when they are not ready for children. So what’s better? To give them a long lecture about how wrong they are and how they’re going to hell? Or to give them the information they need to stay safe?

    Actually, don’t answer that. I think we pretty much know what you’ll say, anyway.