Saturday, January 31, 2009

FAQ: Pediatrics paper

1. What's the connection between virginity pledges and abstinence education? All you know is that these people took pledges; they may not have been in abstinence education at all.

I looked at abstinence pledges taken in 1995 to about April 1996, at the beginning of the pledge movement. The first abstinence pledges were in 1993, True Love Waits (TLW) pledges from the Southern Baptists: a 6 hour curriculum over 6 weeks, and about half of program participants signed the pledge, according to Rev. Hester, and these numbers have not changed over the program's lifetime. School abstinence programs, the Silver Ring Thing (SRT), and other pledge programs did not exist at the time. I'm not aware of any casual virginity pledge programs from the time, but if there were, it seems unlikely that many participants would sign pledges or continue to identify with the pledges long enough to identify themselves as virginity pledgers on a survey. (Over half of the pledgers from the first two years of TLW retracted their pledge within a year after reporting it.)

2. Who's included in the study outcomes?

The same proportion of pledgers and similar non-pledgers got married five years after pledging, but because married couples are at low risk of STDs, I looked at only singles when looking at condom and birth control use. Whether or not married people use condoms and birth control has virtually no impact on public health. Married people were, however, included in every other outcome: oral and anal sex, STD test results, etc.

3. Even the non-pledgers didn't use condoms at perfect rates. Why not?

About 54% of non-pledgers used condoms "most of the time" or "always", versus 42% of non-pledgers. But there are 46% of non-pledgers who are not using condoms "most of the time." When you are dealing with entire populations, one can't expect perfection or even close to it, and yet when you move an indicator for an entire population by even a few percentage points --- increasing the proportion of people who use condoms, take statins, eat enough vegetables --- it can have an enormous impact. Looking at a range of behaviors, the proportion of people who don't make the "most beneficial" choices is really staggering, and the health and economic system just has to learn to work around these choices to encourage the best behavior. Unfortunately there just doesn't seem to be a condom equivalent of automatic enrollment in retirement plans.

4. Delaying sex is good for teens. Doesn't that mean we should have more abstinence education?

See my oped in the Baltimore Sun.

5. I have idea X for a sex education plan. Will it work?

The National Campaign to prevent teen and unplanned pregnancy has a great publication called Emerging Answers that describes sex education programs that work and lists characteristics of successful programs. It's available here.

6. The public health world says that any sex is okay as long as it involves condoms, and seems to assume that teens are "sexually incontinent" and that "chastity's relevance to contemporary culture ranks with that of buggy whips and slide rules.". Isn't teaching teens about birth control like telling them that we expect them to have sex? Shouldn't we teach higher standards?

First, I think the language is terrific: "sexually incontinent" is a punchy phrase and buggy whips and slide rules is vivid and sharp.

On the substance: Delay is clearly best. The public health world finds unequivocally that people with younger sexual initiation are at higher risk for STDs (higher risk for chlamydia and gonorrhea persists to about 17 or 18, high risk for HPV I understand persists into early 20's), less likely to use birth control, more likely to have a large age difference with their partner (sketchy and unsafe), and that two thirds of teens who have had sex say they wish they had waited. Correct and consistent use of condoms protect completely against fluid-transmitted STDs such as chlamydia, gonorrhea, and HIV, but condoms protect against contact-transmitted STDs such as HPV and herpes only to the extent that they cover.

On the other, see my oped in the Baltimore Sun.

7. The study is "liberal ideology disguised as science" (quote of head of Illinois Right to Life): it looks at 16 and 17 year old abstinence pledgers, instead of younger ones who are at the crucial ages to take pledges.

It's ironic that an abstinence proponent is irked at the subject group restrictions because many abstinence proponents are actually the ones responsible for limiting the study's ability to look at younger adolescents. My data comes from a multi-million dollar project funded by Congress, and when this study was being debated in Congress, many social conservatives objected to asking questions about their attitudes towards and knowledge about sex and birth control to adolescents ages 12-14 (e.g., "Would you feel guilty if you had sex?" and about 50 other questions). These questions are crucial factors in understanding why someone pledges, so I had to omit the 12-14 year olds since they were not asked these questions.

I also took out anyone who had had sex, so these kids at an average age of 16 had not yet had sex and few had much sexual experience at all, so the generalization that it's important to get them while they're young doesn't apply to the same extent.

8. Aren't you a liberal youth homosexuality promotion group? (The first comment.)


9. Should this be the death knell for abstinence-only? Should the item be cut from the budget because
it is clearly wasteful

Cutting the $200 million may be unnecessarily risky: redefining the program as abstinence-plus would preserve the funding. If the program were entirely cut out, it might not be replaced with effective sex ed.

10. Where does it say that programs may measure virginity pledges and don't have to be medically accurate?

From the GAO study on abstinence education.

Less than 5% of the total federal abstinence budget goes to programs required to be accurate: these come from a different funding mechanism than the program that grew so rapidly since its creation in 1996. Also, some states require the curricula to be accurate; if these states are among the 25 states still getting abstinence funding (originally all 50 were applying for this funding), they review the curricula independently.

"Abstinence-only" is an unfair term
: it implies that the curricula are simplistic just say no, but our program does more than that.

That's not a question. Addressing the point, though, the 8 part definition of abstinence-only education in the law requires one-sided education: by definition, abstinence programs have the exclusive purpose of showing the benefits of abstaining from sex. Abstinence programs can teach people to plan their lives and negotiate and all kinds of great personal development lessons, and that's great, but they cannot teach people the benefits of using condoms: they can only say where condoms fail. That is, they can say condoms do not protect fully against HPV and herpes (which is true). Because virtually no abstinence programs are required to be medically accurate, they can also say untrue things such as that condoms do not protect against HIV. They cannot say that correctly used condoms protect completely against chlamydia and other fluid-transmitted STDs, or teach how to use condoms correctly.

1 comment:

Hal said...

On point 11, I'd just like to mention that, in your op-ed, you didn't just say that abstinence-only programs can say misleading things about birth control, but that they must.

That seems a bit too strongly worded to me.