Abstinence study: it works!

I've been reading about the Jemmotts' work with inner city kids for a while. There's an article in this month's Archives of Pediatrics and Adolescent Medicine - one of the American Medical Association journals - about a randomized trial of abstinence-only vs. "safer sex" with encouragement to use a condom. The results were a significant difference in first intercourse and intercourse in the previous 3 months, during the 24 months of follow up. There was no difference in condom use between the two groups, when the kids did have sex. A repeat intervention decreased the likelihood of multiple sexual partners.


Here's the abstract:

Objective To evaluate the efficacy of an abstinence-only intervention in preventing sexual involvement in young adolescents.

Design Randomized controlled trial.

Setting Urban public schools.

Participants A total of 662 African American students in grades 6 and 7.

Interventions An 8-hour abstinence-only intervention targeted reduced sexual intercourse; an 8-hour safer sex–only intervention targeted increased condom use; 8-hour and 12-hour comprehensive interventions targeted sexual intercourse and condom use; and an 8-hour health-promotion control intervention targeted health issues unrelated to sexual behavior. Participants also were randomized to receive or not receive an intervention maintenance program to extend intervention efficacy.

Outcome Measures The primary outcome was self-report of ever having sexual intercourse by the 24-month follow-up. Secondary outcomes were other sexual behaviors.

Results The participants' mean age was 12.2 years; 53.5% were girls; and 84.4% were still enrolled at 24 months. Abstinence-only intervention reduced sexual initiation (risk ratio [RR], 0.67; 95% confidence interval [CI], 0.48-0.96). The model-estimated probability of ever having sexual intercourse by the 24-month follow-up was 33.5% in the abstinence-only intervention and 48.5% in the control group. Fewer abstinence-only intervention participants (20.6%) than control participants (29.0%) reported having coitus in the previous 3 months during the follow-up period (RR, 0.94; 95% CI, 0.90-0.99). Abstinence-only intervention did not affect condom use. The 8-hour (RR, 0.96; 95% CI, 0.92-1.00) and 12-hour comprehensive (RR, 0.95; 95% CI, 0.91-0.99) interventions reduced reports of having multiple partners compared with the control group. No other differences between interventions and controls were significant.

Conclusion Theory-based abstinence-only interventions may have an important role in preventing adolescent sexual involvement.

Trial Registration clinicaltrials.gov Identifier: NCT00640653

Texas teens form pro-life club

And, it seems that the kids in Coppell, Texas (near Dallas) are only "anti-abortion" because of the undue influence of their families and churches. From the Dallas Morning News:

Abortion rights advocates say it's even harder for them to organize high school students because of the focus on abstinence.

"We're up against a movement that has federal dollars going into public schools," said Kierra Johnson, director of Choice USA. "You compound that with what they could be learning in church, and it sets us back in terms of outreach to young people under 18."

Of course, the Dallas Morning News calls the club "anti-abortion," not "pro-life." In spite of the fact that the kids call themselves "The Pro-Life Club." The author calls for tolerance on the part of the "anti-abortion crowd but can't even bring herself to use the term the teens would prefer.

I guess the DMN doesn't keep up with the latest research. Otherwise, they'd know that the study on abstinence that was in the news earlier this month informed us that teens - whether they sign a pledge or not - who come from religious, conservative backgrounds are more likely to delay their first intercourse for about 3 years longer than their peers. I nominate the author of the article,Katherine Leal Unruth, her editor, and Ms. Johnson for Twits of the Year and definitely award them my own Yellow Brick Road award. ("Do Not Look Behind the Curtain, Ignore That Little Man." Or small woman.)

Bravo Coppell teens, their parents, and their churches!

Virginity pledges: the rest of the story

The "kids" aren't "kids" and they aren't "teens." And they wait 3 years longer than their peers and no one knows if they even had a sex ed course in school.

Fox News reports on their interview with the author of a report on teens who take virginity pledges. She told them that religious teens wait 3 years longer than non-religious teens and (as reported here, last week), the background of those who take virginity pledges is more important than the pledge itself.

Click here to read the study in Pediatrics.

Note that there is no way to know whether any of the students took any type of abstinence-based sexuality education course, that the ages of the "pledgers" and "non-pledgers" evaluated and matched in the study were at least 15 in the first "wave," 22 or so at the end, and the average age of first intercourse for the group is 21 years old, three years older than the national average.

Rosenbaum, the author of the "new" study also removed all of the married participants in the study:

Her study also only looked at teens who were unmarried five years after taking virginity pledges, now ages 20 to 23. "The married are out of the picture, so they're not as interesting," she said.

Edited 1/3/09 at 6 AM.

New study on virginity pledges and behavior

The article in question can be downloaded from Pediatrics, here.


The final "wave 3" data came from the group that the author calls "adolescents" -- who were 22 years old. Data from those who had married was treated as "missing."

We don't know anything about the actual sex ed courses that the students took, who paid for the course, or whether they actually took a course or just made a pledge.

From the article: “Virginity pledges are also now used to measure AOSE program effectiveness, which the US government considers successful if they produce many virginity pledgers, irrespective of participants’ sexual behavior.”

(Is it true that the pledge is considered a marker for the success of abstinence-only sex ed? I know that I’ve read several articles showing short term increase in the intention to remain abstinent, so that would not surprise me. However, I haven’t seen this “marker.”)

As far as I can tell, it appears that the author took data from a series of national questionnaires , matched kids for background and family, and found that they have similar outcomes after 5 years.

Oddly, a huge number - 80% - of the pledgers denied having pledged in follow up. The other number that seems to stick out is that the non-pledgers did pay for sex and/or get paid for sex more often.

Nevertheless, the only study that I’ve seen that measured pregnancy rates after a course that included teaching proper condom use did not show prevention of pregnancy, either. I posted a review of the pay-for-view article in the British Medical Journal.

Abstinence vs "plus"

The Texas Legislature is about to reconvene and the sex ed debate in our State is already in the news. (Free subscription required.)

Unfortunately, the news article blurs the line between sex ed for all children in our schools and the problem that some of our girls have multiple pregnancies as teenagers. What little evidence we have about "abstinence-plus" vs "abstinence-only" sex ed (some of which is reviewed here and here) is never mentioned, while the fact that our State teen pregnancy rate has dropped is seen as a failure or completely ignored.

Along with many of our local physicians, I teach the doctor's portion of "Worth the Wait." The program is taught in all our county's schools. The classes begin in the 6th grader (the students are 11 and 12 years old) and continue into High School health classes (through grade 12, or 17 to 18 years old). The course consists of 16 or 17 classes, including one on STD's that is taught by local doctors and one on the legal consequences, taught by local lawyers.

The main contrast between "Worth the Wait" and "Big Decisions," the program mentioned in the article ( available for download, free, here), is that in each of the 10 to 12 lessons, the latter emphasizes condom use for those who do choose to have sex. There's even a supplemental lesson that teaches how to correctly use a male condom.

Many point out that since some teens will have sex before marriage, and that many will do so much earlier than expected, the earlier these lessons are taught, the better. However, in my experience, the kids who are having sex before 17 or 18 are the ones who are also engaged in other risky behavior, including drinking alcohol and smoking, or who are being abused. (See the story about the 18 year old young man, here.)

I'm uncomfortable with early discussions about "taking action" to buy condoms and how to use them because it seems to actually endorse the idea that there is a healthy way to have sex outside of a committed, monogamous relationship - one that 14, 15 and most 16 and 17 year-olds are not able to establish.

I believe that the best decision is the one that parents, teachers and our schools should teach. We do not talk about the safest way to drive a car before they are 16 and have passed several tests or that seat belts will protect them if they drive recklessly, we don't teach them which alcohol to drink when they are under the legal age limit, and we never tell them that if they are going to smoke, here's the way to do it.

In my "How to live a healthy life" talk that I give adolescents and teens (and sometimes adults) I talk about the physiological and medical reasons we encourage helmets for skaters, seat belts in cars, and why we discourage certain other behavior. I mention the job of the liver, the differences in the body as it matures, the risk of addiction, injury, and infections. Then, I talk about the psychological and social risks and consequences.

For instance, can you really trust someone selling an illegal drug to be honest about what he's selling you? If someone pressures you to have sex without a condom, knowing the risk of even deadly infections (yes, I talk about condoms in my office) does he even love himself, much less you?

It astonishes me how varied the apparent ages of these children are - even through the High School classes (up to age 18). Some still appear to be prepubescent and some look to be fully developed physical adults. While discussing sexual abuse, I remind the 11, 12, and 13 year-olds that in the State of Texas, that it is absolutely illegal to have sex under the age of 14.

And in every class of 6th graders, there's at least one girl who raises her hand and asks if she could go to jail.

UK Teens, Abortion Rights?

The Family Planning Association in the United Kingdom is pushing a video called "Why Abortion" for use in schools teens, according to the Telegraph.co.uk website.

The laws in the United Kingdom differ in different regions. Abortion is still illegal in Northern Ireland, for instance. England and Wales, where abortion is legal and, like contraception and the morning after pill, paid for by the National Health System, has the second highest abortion rate is the second highest in Europe.

Nevertheless,

the Government announced that sex and relationships education will become compulsory in primary schools as part of a drive to cut teenage pregnancy rates. The National Children's Bureau also wants all secondary schools to have on-site sexual health clinics, while girls as young as 13 will be urged to have contraceptive injections and implants.

The FPA is offering schools the chance to buy a copy of the DVD for £25 together with a booklet that claims to explode the "myths" that having a surgical abortion can harm a woman's ability to conceive in the future, and that terminating a baby is always upsetting.

No mention that parents might not wish their daughters and sons to have sex at 13 -- and that the great majority do not. Or the risk that the 13 year old might be a victim of sexual abuse.

I'm quoted in Texas Monthly

Over the weekend, at the annual convention of the Texas Medical Association, a friend said that she'd read my quote in "Texas Monthly." I assumed she meant an old article in Texas Medicine, the journal of the Texas Medical Association. I was wrong. (And, maybe now I know why I can't get appointed to any of the TMA Councils or Committees!)

In an article titled, "Faith, Hope and Chastity," in the very liberal Texas Monthly the author (without contacting me at all, by the way) used a statement that I made at a 2004 Texas School Board hearing on the content of high school textbooks on sex education.

The board met to consider these textbooks in July and September of 2004. More than one hundred people testified or submitted written testimony. Those who testified in person were given three minutes each to make their case. According to Gordon Crofoot, a specialist in HIV and STD treatment and research, many of the board members appeared totally uninterested in his testimony. Crofoot cares for about one thousand patients in his practice in Houston and is currently seeing more young patients with HIV than he has in his 31 years of practice.

“These textbooks do not meet the criteria and are factually and scientifically incorrect in what they say,” he told the board, “but their major fault is in what they don’t say and the resulting consequences. . . . If we do nothing [about STDs], the direct cost over the next ten years would be $10.6 billion. Comprehensive sex education programs might reduce this cost by fifty percent. Can Texas afford this cost?”

Crofoot was cut off when his three minutes were up. He offered to answer any questions. The board had none. Later in the day, he watched as Beverly Nuckols, a family doctor in New Braunfels opposed to comprehensive sex ed, was asked about the implications of human papillomavirus for men. She answered that HPV affected women differently than men before stating her position that condom instruction, in her experience as a family doctor, would do little good. “Yesterday I saw a boy who had had three partners in the last month,” she said. “He’s had twenty-two partners. He’s eighteen. He uses condoms every time. Unfortunately, a lot of the times he’s drunk and so they break or they don’t work. I mean, condoms are not a solution for teenagers outside of monogamous relationships. They don’t use them right even if we teach them.”

I'm not quite sure why I was chosen as the representative of those who "opposed comprehensive sex ed." I can't quite remember telling the story, but I probably did -- however, I don't think I would say, "I mean . . ." In order to read it in the journal, you'd have to turn to the "continued on page 200-something." However, I believe that the story was to refute testimony that high school boys and girls should be taught that condoms are the answer to all risk from the consequences of sex. My more common story is to note that condoms are more likely to be used correctly by couples in a monogamous relationship, that couples get better as time goes on, and that if a hundred couples use condoms to prevent pregnancy, 11 of them will get pregnant within a year.

The part that I remember addressing was a comment from a nurse practitioner who stated that there was no risk of contracting the Human Papilloma Virus for a girl, if the male wore a condom. The concern, according to her, is the infection of the girl's cervix. This was about the time that the public was becoming aware that cervical cancer is caused by HPV 99% of the time. According to the nurse, the tip of the penis when covered by the condom wouldn't actually touch the cervix. I felt compelled to delicately explain that the most common human sexual activity involves ins and outs, and that there is much more contact and potential for spread of the virus to all of the male and female genitalia -- except for the parts actually covered by the condom.

Let me correct one thing: I'm not against comprehensive sex education. I disagree with some people about the definition of "comprehensive," and believe that anything beyond the basics of very boring biology - the medical and legal responsibilities of human sexual activity - ought to be vetted by the parents in the local school districts. The school is not the place to teach methods and techniques and condoms are not the panacea they're far too often made out to be.

I do believe that the State (schools) should encourage sex within monogamous marriage, since that is the healthiest for individuals, families and their children, and for the taxpayer. While some people do very well in different arrangements, it takes a lot more work and the risks are far greater.

Oklahoma abortion Bill survives Governor's veto

The Oklahoma State Legislature has overturned Governor Henry's veto of an "omnibus" bill containing abortion regulations. (The veto is explained at the United Kingdom site of Medical News Today. Besides gives the best definition of human embryo that I've seen in legislation:

“Human embryo” means a human organism that is derived by fertilization, parthenogenesis, cloning, or any other means from one or more human gametes or human diploid cells.

Pro-abortion groups are concerned that the bill requires the facility doctor to perform an ultrasound before every abortion, that the girl or woman be allowed to see it, and that the results be explained to her. Not only is there a requirement to post a notice in the facility informing the women and girls that it is "against the law for anyone, regardless of his or her relationship to you, to force you to have an abortion" and the abortionist evidently must actually speak the words out loud before each abortion!

Called the "Freedom of Conscience Act," (The text is here, in a Word document) the bill offers protection to any medical professional who refuses to act in a way that goes against his or her conscience.


The best news article that I've found is here, at the "Daily Women's Health Policy Report" of the National Partnership for Women and Families, a group I'd never heard of before. It appears that the main focus has been legislation to protect women in the workplace.
Robert Cole, an Oklahoma native, writing for Associated Content, has explained the bill in this article. Here's an article from The Feminist Majority, with good links.

Ironically, Democratic Presidential Candidate, Barack Obama, used the objection to abortion by the Senator from Oklahoma, Senator and Obstetrician Tom Coburn, to justify his relationship with the Weatherman bomb-building conspirator and now-college professor, William Ayers. (Ayers is the man who was quoted in the New York Times on September 11, 2001 as regretting that he did not do enough bombing and fighting the US government in the early '70's.)

"Modest" Increase in Sexually Transmitted Diseases

After a decline in STD's in the late '80's and '90's that is believed to have been driven by "safer sex" strategies brought on by the spread of HIV, numbers of infections have increased for the second year in a row.

The increase may actually be the result of increased efforts at screening and more sensitive tests, according to the CDC.

The report notes that the greatest risk is found in men having sex with men and girls 15-19. These numbers may simply reflect the fact that these populations are more likely to be screened for diseases and that there's been a push to increase screening, particularly in the former demographic.

There's a physiological explanation about why younger girls are more likely to catch diseases like chlamydia and HPV, the virus that causes abnormal pap smears and can lead to cervical cancer. There's also a behavioral explanation: younger girls are more likely to engage in riskier behavior, have higher-risk partners and have more partners.

The cells of the cervix of the young girl are more susceptible to injury and to invection. As the girl matures, the columnar epithelium is replaced by squamous cell epithelium. (At the risk of grossing people out being indelicate - think of it as the difference between the tissues of the inside of your cheeks and the tissue on the outside of the lips.)

(Similar risk factors probably apply to the men having sex with men category, too, although I didn't see any specific discussion about these risks for girls or men in the mainstream press articles here, here, and here. This this article in a gay publication does review the girl's tissue changes and the difficulty of notifying the partner of an infected patient who is more likely to have anonymous sex partners. )


It is alarming, however, that the two vulnerable groups are also the people who are most likely to have life-long consequences of STD's. The girls risk early pregnancy and infertility and the men having sex with men risk truly deadly diseases like drug resistant strains of HIV/AIDS, syphilis, and gonorrhea.

I'm afraid that this report will fuel criticism of abstinence education. But let's face it, teaching condom use and oral contraceptives are not the answer for either of these populations.

We know a little about what works and a lot about what doesn't.

Edit, 11/27/07, grammar typos.

Two sex ed reviews, still no conclusions

We're finding that nothing changes the rates of pregnancies and STD's in teens except parental and peer pressure and concerns ("costs") of pregnancy.

I'm afraid that two published reviews of the literature on studies on sex education for adolescents and teens done by Kristen Underhill, Don Operario, and Paul Montgomery at the Centre for Evidence-Based Intervention at the University of Oxford ( here)and (here ) don't tell us much more than we knew before.

Although the authors report that there are few if any reports that give biological data or actual pregnancy and STD (including HIV) infection rates, the first study found no significance in behavior in "abstinence only" sex education compared with "usual care" in the community. (We're not sure what the "usual care" at those schools is, however.)

In the second study, authors did a review focusing on reports on sex education in "high income" societies, comparing "abstinence only" (which are defined as not promoting condom use) and "abstinence plus" (those which emphasize abstinence but promote condom use if you're going to have sex). report that there is a significant difference in decrease of "HIV risk behavior," but no evidence that teens have sex later, actually contract STD's less often, or have fewer pregnancies.

Neither of these studies tell us that abstinence based sex education does not work. I'm afraid that the only thing they do tell us is that there are factors we are not measuring and that our young people are engaging in risky behavior.

Hat Tip to "Pure Pedantry."

UK: Teaching children how to use condoms no help

This month, the British Medical Journal (sorry, subscription only) has published a report on a randomized controlled study on enhanced sex ed that failed to reduce the numbers of pregnancies or abortions in teen girls. Essentially, the "programme" involves education for boys and girls 13 to 15 years old, including teaching them to obtain and "handle" condoms (how to put them on), role playing and games about sexual situations. This is in contrast to "Conventional Education" in the UK, which is described this way in the report:

In the 12 control schools sex education for third and fourth years varied from seven to 12 lessons in total, primarily devoted to provision of information and discussion. Only two control schools routinely demonstrated how to handle condoms, and none systematically developed negotiation skills for sexual encounters. The cost of conventional education varied, with individual packages starting from about £20. Few teachers had more than one day’s training, which would have cost about £180 a day, and some had received none or only a few hours’ training.

Luckily, there are some good reviews online:
"Sex Education Fails to Cut Teenage Pregnancies" from the Guardian.

"Role playing sex classes fail to cut abortions," from the Telegraph.

An enhanced sex education programme for teenagers has proved no better than conventional teaching in cutting unwanted pregnancies or abortions, a detailed research study said yesterday.

The programme was based on an intensive £900 training course for teachers that was then delivered to 15-year-olds over three years.

Five years later, conception rates were measured in 20-year-olds who had been on the programme and compared with those in young people who had not.
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The teaching system, called Share — sexual health and relationships: safe, happy and responsible — included group work, role play and games. The teenagers were shown how to use condoms and access sexual health services and were given leaflets on sexual health.

The programme and research was devised and supported by the Medical Research Council (MRC) and the Education Board for Scotland, now Health Scotland.

Teachers in the schools used for comparison had less instruction or none at all.

"Sex education "only does so much'" from BBC News notes that schools are required to teach sex ed from ages 11-14 in England and Wales, but there has been no such requirement in Scotland.

And from the November 23 "Learning and Teaching Scotland" web site, we learn that the program was introduced throughout that region last week.

The UK press reports that the teen pregnancy rates under 18 are going down, from 44.3 births per 1000 girls ages 15 to 17 to 42.9 since 1998, and declared this a "success."

Edited 12/29/08 for labels.