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
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.
Editor's Note: This following letter was sent to Congresswoman Nancy Pelosi and Senator Harry Reid urging Congressional leaders to reconsider continuing federal investments in abstinence-only funding. The letter was sent by John S Santelli MD, MPH at Columbia University and signed by nine other prominent researchers in the field of adolescent sexual and reproductive health last Wednesday, Nov 21. It was sent to RH Reality Check yesterday and we are thrilled to post it below.
Dear Congresswoman Nancy Pelosi and Senator Harry Reid,
As a group of leading scientists who have recently conducted research on adolescents, reproductive health, and abstinence-only education, we are writing to express our strong concern about increasing federal support for abstinence-only education (AOE) programs. This federal support includes monies going to states (Section 510 of the Social Security Act) and those going directly to community and faith-based organizations (the Community-Based Abstinence Education program). Recent reports in professional publications by the authors of this letter have highlighted multiple deficiencies in federal abstinence-only programs. As such, we are surprised and dismayed that the Congress is proposing to extend and even increase funding for these programs. In this letter we identify key problems with abstinence-only education. We also have attached recent scientific reports that are pertinent to the debate over these programs. We note that many of these studies have used nationally-representative data from surveys sponsored by the National Institutes of Health or the Centers for Disease Control and Prevention.
The federal programs promoting AOE have prompted multiple scientific and ethical critiques. These critiques were summarized in a January 2006 paper by Santelli, Ott and others. By design, abstinence programs restrict information about condoms and contraception - information that may be critical to protecting the health of young people and to preventing unplanned pregnancy, HIV infection, and infection with other sexually transmitted organisms. They ignore the health needs of sexually active youth and youth who are gay, lesbian, bisexual, transgendered, and questioning for counseling, health care services, and risk reduction education. Withholding lifesaving information from young people is contrary to the standards of medical ethics and to many international human rights conventions. International treaties and human rights statements support the rights of adolescents to seek and receive information vital to their health. Governments have an obligation to provide accurate information to adolescents and adolescents have a right to expect health education provided in public schools to be scientifically accurate and complete.
Rigorous evaluations of AOE programs find little evidence of efficacy for federally-sponsored abstinence education. Several weeks ago Dr. Douglas Kirby, working with the National Campaign to Prevent Teen and Unplanned Pregnancy, released a comprehensive review of prevention programs for youth (Emerging Answers 2007). This review found that none of the well-designed evaluations of abstinence-only programs presented strong evidence of an impact on abstinence behaviors. (By contrast, Kirby finds clear evidence that many comprehensive sexuality education programs, which include information on both abstinence and contraception, do help young people delay initiation of intercourse.) The large-scale Mathematica evaluation of the Section 510 program, released in April 2007, found no measurable impact on increasing abstinence or delaying sexual initiation among participating youth or on other behaviors such as condom use. This well funded and very well conducted evaluation examined four exemplary local 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. Similar results on program efficacy were found by Underhill, who reviewed abstinence-only programs in a spring 2007 systematic review.
Virginity pledging, one aspect of abstinence programming, appears to have little long-term benefit in preventing outcomes such as sexually transmitted infections, although prevention of these infections is a stated goal of the programs. A spring 2005 longitudinal study by Bruckner and Bearman found that abstinence pledgers, when compared to non-pledgers, experienced similar rates of sexually transmitted infection. 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.
Abstinence until marriage is another stated goal of the federal program; however, evidence from the past several decades indicates that establishing abstinence until marriage as normative behavior would be a highly challenging policy goal. Teitler has shown that over the past 40 years, the median age at first intercourse has dropped (and stabilized) to age 17 in most developed countries.
At the same time, the median age at marriage has risen dramatically. Today, sexual intercourse is almost universally initiated during adolescence worldwide. A January 2007 study by Finer found that almost all Americans initiate sexual intercourse before marriage. In fact by age 44, virtually everyone has experienced sexual intercourse but only 3% have remained abstinent until marriage. Moreover this is not a new trend; Finer's data suggest this pattern has been true for much of the second half of the 20th century.
Importantly, the emphasis on abstinence-only programs and policies appears to be undermining critical public health programs in the U.S. and abroad, including comprehensive sexuality education and HIV prevention programs. During the period of increased state and federal emphasis on abstinence, declines have occurred in the percentage of teachers in U.S. public schools who teach about birth control and the number of students who report receiving such education. In December 2006, Lindberg and colleagues found that the percentage of teenagers who had received formal instruction about condoms and contraception declined from 89% in 1995 to 70% in 2002.
We also note that 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. Recent reviews of these abstinence curricula from Santelli and colleagues at Columbia University have found similar inaccuracies, particularly misinformation about the efficacy of condoms and contraception. This was the basis of an ACLU declaration on this topic from Santelli in the spring of this year.
Abstinence-only requirements also appear to be harming our foreign aid efforts. In April 2006, the U.S. Government Accountability Office issued a report titled "Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Emergency Plan for AIDS Relief" that concluded that the "...requirement that country teams spend at least 33 percent of prevention funding appropriated pursuant to the act on abstinence-until-marriage programs has presented challenges to country teams' ability to adhere to the PEPFAR sexual transmission strategy...[and] challenged their ability to integrate the components of the ABC model and respond to local needs, local epidemiology, and distinctive social and cultural patterns."
We would note that all of the mainstream organizations of health professionals that focus on the health of young people have strongly criticized federal support for current abstinence programs. These include the American Public Health Association, the American Medical Association, the American Academy of Pediatrics, the American Psychological Association, and the Society for Adolescent Medicine. We have also attached the weblinks to the policy statements from each of these groups.
The recent Congressional testimony of former Surgeon General Richard Carmona underscores these critiques from mainstream health organizations. Dr. Carmona's testimony confirms the political motivations behind abstinence funding and the failure to address issues of efficacy and scientific accuracy. He suggested that ideology and theology have taken priority over women's health in the current administration. Dr. Carmona reported that the Bush administration "did not want to hear the science but wanted to, if you will, ‘preach abstinence,' which I felt was scientifically incorrect."
Given these serious scientific and ethical shortcomings, we strongly urge the U.S. Congress to reconsider federal support for abstinence-only education programs and policies. We would be very willing to advise you on shaping alternatives to the current program.
Sincerely,
John S Santelli, MD, MPH
Columbia University
Peter Bearman, PhD
Columbia University
Claire Brindis, DrPH
University of California, San Francisco
Hannah Bruckner, PhD
Yale University
Lawrence B Finer, PhD
Guttmacher Institute
Laura Duberstein Lindberg, PhD
Guttmacher Institute
Mary Ott, MD
Indiana University
Julien Teitler, PhD
Columbia University
Deborah Tolman, EdD
San Francisco State University
Kristen Underhill, DPhil
Yale University
(Organizational affiliations are listed for identification purposes only.)
Cc Senate and House Leadership and Appropriations Committees
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