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
- Abstinence-only-until-marriage as a program goal is out of touch with broad demographic trends toward both an earlier age at first sex and a later age at marriage. Indeed, 95 percent of Americans have intercourse prior to marriage.
- Recent declines in adolescent sexual activity precede widespread federal funding of abstinence-only education in the U.S.; as such, federal abstinence-only programs are not responsible for reductions in adolescent sexual experience and teen pregnancy in the U.S. Rather, most of the decline in teen pregnancy rates in the U.S. can be attributed to better contraceptive use among adolescents.
- Evaluations of comprehensive sexuality education programs show that many programs help young people to delay intercourse. In addition these programs help young people use contraception and condoms when they do have intercourse. In contrast, abstinence-only programs that have been carefully evaluated have failed to demonstrate behavioral results.
- 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.
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 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.
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.