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.)

No.

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.


11.
"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.

We're really not all that far apart

Dan Savage's column last week has a passage that could come straight out of a standard abstinence-plus sex education curriculum, with a few word substitutions.

Look, JON, any faggot who wants to fuck you in the ass without a condom is the LAST PERSON ON EARTH you should be having sex with—anal or otherwise, condoms or no condoms. Guys who pressure you into having sex without condoms are having or have had unsafe sex with other people, which means that they're either infected already or will be shortly. If you don't want to get infected, your best course of action when a guy pressures you into having sex without condoms—or any kind of sex you're not comfortable with—is to pull up your pants and leave.

And since you're not particularly interested in anal sex right now, JON, I'd urge you to tell the guys you do go home with that you're just not up for getting fucked. An aversion to anal sex when you're young and just out and easily manipulated is something you should hold on to, JON, even cultivate. Skipping anal sex during your great-big-slut, just-coming-out, making-your-mistakes phase will greatly reduce your risk of contracting HIV and a host of other STIs. Then one day, with luck, you'll meet a nice, decent guy, also hot, who wants to take things slow—a guy who isn't a manipulative, selfish, barebacking piece of shit. And when you meet that guy, JON, you can explore anal with someone who cares about you enough to take it slow and wear condoms.

Anal sex, despite the impression created by HIV "prevention" materials you may have encountered, should not be a first-date activity. Reserve your asshole for guys you're serious about, JON, and for guys who are serious about you. The hot motherfucker you're seeing right now isn't worthy. Walk away.

What's particularly funny is the last paragraph with scare quotes around "prevention", seeming to insinuate that some materials intended to promote prevention set norms of earlier sex, precisely the motivation for abstinence-only proponents. Maybe some materials don't stress that restraint is the first choice, as is true for comprehensive/abstinence-plus curricula. If they don't, they should.

We are really not all that far apart. Nearly everyone thinks adolescents just coming to dating should take it slowly, protect their hearts and their health, and wait for a committed relationship. People differ on what constitutes a committed relationship, but irrespective of whether that line is at marriage or a committed relationship (whatever that means), it's the same skills.

Oped in today's Baltimore Sun

Here's my oped from today's Baltimore Sun about the need for effective evidence-based sex education.

The editorial staff was really impressive in how much more easily they made the piece flow.

Media coverage of Pediatrics paper

I had my last media interview today, so here's the final list of coverage of the Pediatrics paper.


Professional Journals:
British Medical Journal
American Psychological Association Monitor: Coming

TV:
Today Show
(Columbus ABC TV - consulted)
[WJZ TV Baltimore]

Radio:
WABC New York: Curtis Sliwa Show
KFBK Sacramento.
Family News in Focus Radio
KGO AM San Francisco: ABC News
KPCC Air Talk.: 30 minute call-in show.
Colombia La FM Radio: largest radio station in Colombia
Newstalk Radio, Dublin
Fox News Radio: WINK Fort Meyers, KFAB Omaha, KCMO Kansas City, WGST Atlanta, KOGO San Diego
Doctors' Radio: 1 hour call-in show on xm/sirius satellite radio.
[CBS News Radio]
Indiana Public Radio: Sound Medicine: Coming 2/8/09.

Print:
Washington Post
Reuters
British Medical Journal
New Scientist
Bloomberg
Time Magazine
US News and World Report
Christianity Today
[USA Today]
Baptist Press

OpEds:
Ellen Goodman, Boston Globe
Kathryn Lopez, Washington Times
William McGurn, Wall Street Journal
Cheryl Wetzstein, Washington Times: She also mentions my advisor and collaborators' study.

Web: written or audio
CNN.com: Top 3 emailed article.
Huffington Post
Christian Post
Health.com: this is the original of what CNN used, but the CNN one got broader coverage.
Health Day
Health News
MedPageToday.com: with audio
Time Magazine Q and A
FoxNews.com
World Health News Today (video): coming?


Based on the abstract:
Medical News Today
Web MD

Motivational poster: abstinence programs

via

Non-peer-reviewed research

I'm disappointed that former director of the NIH
Bernadine Healy is citing non-peer-reviewed research. A director of the NIH should know better.

Specifically, she cites of Robert Rector and colleagues at the Heritage Foundation. I read the paper when it came out and found two things notable.

First, research papers are always named with a descriptive title that at best suggest their conclusions to maintain objectivity. The title of their paper was a headline: "Teens who take virginity pledgers have markedly improved life outcomes."

Second, it was extremely thin on both psychological theory and statistics, without which no one can be sure that they didn't just seek out factors that yield the results they want without correction. Given that the paper had a headline rather than a title, the idea that the conclusions preceded the study is not particularly far-fetched.

The advantage of matching on the other hand ensures that you can't search for results: you get a match and once you settle on that being the right match, then you find out what the results are.

Baptist Press article

Today's article in the Baptist Press gives my views a surprising amount of space: the writer just put my email responses to her questions in the middle of her article. I'm glad I checked my spelling!

There's an interesting quote from Rev. Ross, the co-creator of the virginity pledge: "We know of no secular or even religious campaign that is as comprehensive and life-encompassing in its approach to moral purity [as the True Love Waits pledge]."

That seems far-fetched. Both Jewish and Muslim religious law bar men and women from any affectionate physical contact or from being alone together. Certainly those are more comprehensive. If more than 50% of those who keep the laws marry having never had any kind of sex (an upper bound of virginity pledges' effectiveness) --- and I think that's likely --- they are also more effective.

Advice and why it's so rarely taken

This American Life on why people so rarely take advice, which is perhaps truly the crux of this abstinence situation. Conservative evangelicals don't want the advice of researchers on what works. Kids only kind-of want the advice of their parents. Parents don't follow the advice to talk to their kids about sex.

The first 3 minutes involve a guy channeling an Israeli commando. Very worth listening just for that.

Abstinence satire

1. My study inspired this funny satire of abstinence education: "Abstinence Education Not Working; Conservatives Shifting Focus to High School Marriages"

BROOKLYN, New York, 2009-01-05 — Following a recent study showing that vows of celibacy had no effect on pre-marital sex, conservative groups are now shifting to a program they are calling 'Get Married Early and Have Lots of Sex.'

...

In its official response to the proposed changes, the ACLU complained that the program would strengthen the institution of marriage, reduce the number of abortions, and impair Americans' ability to have sex with underage teenagers.

2. Alert reader Jonathan Liu (I've always wanted to use that phrase) sent this ad for Passionex: "self control in a bottle". Slogans: "Because now is not the time"; "Just because it fits doesn't mean it goes there."

"Passionix™ is the innovative new solution to the passions that can override the judgment of our youth and lead them into temptation."

It's part of an intricate web of a ministry spoof called Citizens of Virtue. Which looks half real.

Abortion in Washington Heights

I hadn't known this existed: Dominicans in Washington Heights are taking half of RU486 without prescription in order to induce abortion because they are uninsured or afraid of community disapproval or of immigration consequences, so unable to get a legal abortion. The most surprising thing is that women getting an illegal abortion have been arrested, one in Massachusetts.

[I'm not sure who is reading, so to be up-front about my bias: I'm the standard moderate "Abortion should be legal, but rare.", a 3rd generation Planned Parenthood supporter: my grandfather was a pediatrician very active pre-Roe, and even found an illegal abortion for the teenage daughter of a leader in the state legislature who had six months earlier blocked the bill that would have legalized abortion in Indiana.

I also donate to a fantastic organization, Efrat, that helps poor women in Israel who want more children but are considering abortion for economic reasons. (Israel is also the only country whose national health insurance pays for IVF; they cover I believe two completed pregnancies by IVF, without limit on the number of IVF cycles, and even for women who already have several children.) I know someone whose mother was coerced by his father into ending two pregnancies that she wanted, and they always wondered what these younger siblings would be like. No one regrets being alive and no women who choose to keep their pregnancies regret it. But choice is the key issue.]

All that said, I can't imagine not doing something to ensure that these women in Washington Heights and elsewhere have access to legal and safe abortion. How awful.

Waves of coverage

I don't know why I didn't notice the waves of coverage before, but it helps to be aware to have appropriate talking points for each wave.

1. Factual articles: motivation for paper, what it adds, main findings, conclusion, take-away point. Mostly in print media.

2. Reaction articles and 5-10 minutes radio interviews. Presumably people have already seen the factual articles in whole or part, so findings are presented briefly by someone else. They want to know findings in 1 sentence, take-away point in 1-2 sentences, why for each finding. Then they ask a bunch of questions well beyond the scope of your paper, and if you answered the questions as asked you would be speculating, so you need things to say that you are qualified to say related to their questions.

My favorite question from a radio interview, "Do couples who have sex have better relationships than couples who don't have sex?" I still don't know what I could have said.

Special interest press will pick out a tangential issue and expand on it so it seems like your study was about the background issue.

3. Call-in shows are like radio interviewers with more personal examples. The personal examples may line up exactly with your take-home points, which is extremely gratifying, or they may be interesting but something you only have anecdotal experience with.

4. Reactions to reactions: Party X raises objection Y. Talking point: One 20 word quote if it's a reasonable objection.


The hardest part, I find, is expanding the limits of what one can say. Medical journal papers are so extremely circumscribed, while press coverage asks about all kinds of issues that one could never justifiably publish in a medical journal without a whole separate study that one didn't do, so you just have to quote literature over and over.

Teaching birth control less controversial than thought?

1. The CDC removed information about condoms from its website several years ago, but it just returned the information.

2. I've been corresponding with one of the leaders of the virginity pledge movement, an evangelical minister. In his most recent email, he said that he thinks that virginity pledge leaders are probably all over the map on the question of teaching birth control in schools. That is, they want to encourage abstinence, but that's independent of what they think schools should teach in sex education class. Very refreshing!

I wish I'd known that when I was being ranted at by a Fox News Radio host about how schools "emasculate parents" by teaching birth control. I did tell a Fox News website writer. I'm curious how that will come out.

3. An article about an AME church in Albany that switched from abstinence-only to abstinence-plus approaches.