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10/3/2017 Sex Education Based on Abstinence?

Theres a Real Absence of Evidence - The New York Times


Sex Education Based on Abstinence?

Theres a Real Absence of Evidence
Aaron E. Carroll


Sex education has long occupied an ideological fault line in American life. Religious
conservatives worry that teaching teenagers about birth control will encourage
premarital sex. Liberals argue that failing to teach about it ensures more unwanted
pregnancies and sexually transmitted diseases. So it was a welcome development
when, a few years ago, Congress began to shift funding for sex education to focus on
evidence-based outcomes, letting effectiveness determine which programs would get

But a recent move by the Drumpf administration seems set to undo this

Federal support for abstinence-until-marriage programs had increased sharply

under the administration of George W. Bush, and focus on it continued at a state
and local level after he left office. From 2000 until 2014, the percentage of schools
that required education in human sexuality fell to 48 percent from 67 percent. By
2014, half of middle schools and more than three-quarters of high schools were
focusing on abstinence. Only a quarter of middle schools and three-fifths of high
schools taught about birth control. In 1995, 81 percent of boys and 87 percent of
girls reported learning of birth control in school.

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10/3/2017 Sex Education Based on Abstinence? Theres a Real Absence of Evidence - The New York Times

Sex education focused on an abstinence-only approach fails in a number of


First, its increasingly impractical. Trying to persuade people to remain

abstinent until they are married is only getting harder because of social trends. The
median age of Americans when they first have sex in the United States is now just
under 18 years for women and just over 18 years for men. The median age of first
marriage is much higher, at 26.5 years for women and 29.8 for men. This gap has
increased significantly over time, and with it the prevalence of premarital sex.

Second, the evidence isnt there that abstinence-only education affects

outcomes. In 2007, a number of studies reviewed the efficacy of sexual education.
The first was a systematic review conducted by the National Campaign to Prevent
Teen and Unplanned Pregnancy. It found no good evidence to support the idea that
such programs delayed the age of first sexual intercourse or reduced the number of
partners an adolescent might have.

The second was a Cochrane meta-analysis that looked at studies of 13

abstinence-only programs together and found that they showed no effect on these
factors, or on the use of protection like condoms. A third was published by
Mathematica, a nonpartisan research organization, and it, too, found that
abstinence programs had no effect on sexual abstinence for youth.

In 2010, Congress created the Teen Pregnancy Prevention Program, with a mandate
to fund age-appropriate and evidence-based programs. Communities could apply for
funding to put in only approved evidence-based teen pregnancy prevention
programs, or evaluate promising and innovative new approaches. The government
chose Mathematica to determine independently which programs were evidence-
based, and the list is updated with new and evolving data.

Of the many programs some groups promote as being abstinence-based,

Mathematica has confirmed four as having evidence of being successful. Healthy
Futures and Positive Potential had one study each showing mixed results in
reducing sexual activity. Heritage Keepers and Promoting Health Among Teens
(PHAT) had one study each showing positive results in reducing sexual activity.

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10/3/2017 Sex Education Based on Abstinence? Theres a Real Absence of Evidence - The New York Times

But its important to note that theres no evidence to support that these
abstinence-based programs influence other important metrics: the number of sexual
partners an adolescent might have, the use of contraceptives, the chance of
contracting a sexually transmitted infection or even becoming pregnant. There are
many more comprehensive programs (beyond the abstinence-only approach) on the
Teen Pregnancy Prevention Programs list that have been shown to affect these other
aspects of sexual health.

Since the program began, the teenage birthrate has dropped more than 40
percent. Its at a record low in the United States, and it has declined faster since then
than in any other comparable period. Many believe that increased use of effective
contraception is the primary reason for this decline; contraception, of course, is not
part of abstinence-only education.

There have been further reviews since 2007. In 2012, the Centers for Disease
Control and Prevention conducted two meta-analyses: one on 23 abstinence
programs and the other on 66 comprehensive sexual education programs. The
comprehensive programs reduced sexual activity, the number of sex partners, the
frequency of unprotected sexual activity, and sexually transmitted infections. They
also increased the use of protection (condoms and/or hormonal contraception). The
review of abstinence programs showed a reduction only in sexual activity, but the
findings were inconsistent and that significance disappeared when you looked at the
stronger study designs (randomized controlled trials).
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This year, researchers published a systematic review of systematic reviews
(there have been so many), summarizing 224 randomized controlled trials. They
found that comprehensive sex education improved knowledge, attitudes, behaviors
and outcomes. Abstinence-only programs did not.

Considering all this accumulating evidence, it was an unexpected setback when

the Drumpf administration recently canceled funding for 81 projects that are part of
the Teen Pregnancy Prevention Program, saying grants would end in June 2018, two
years early a decision made without consulting Congress.

Those 81 projects showed promise and could provide us with more data. Its
likely that all the work spent investigating what is effective and what isnt will be

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10/3/2017 Sex Education Based on Abstinence? Theres a Real Absence of Evidence - The New York Times

lost. The money already invested would be wasted as well.

The move is bad news in other ways, too. The program represented a shift in
thinking by the federal government, away from an ideological approach and toward
an evidence-based one but allowing for a variety of methods even abstinence-only
to coexist.

The Society of Adolescent Health and Medicine has just released an updated
evidence report and position paper on this topic. It argues that many universally
accepted documents, as well as international human rights treaties, provide that all
people have the right to seek, receive and impart information and ideas of all kinds,
including information about their health. The society argues that access to sexual
health information is a basic human right and is essential to realizing the human
right to the highest attainable standard of health. It says that abstinence-only-until-
marriage education is unethical.

Instead of debating over the curriculum of sexual education, we should be

looking at the outcomes. Whats important are further decreases in teenage
pregnancy and in sexually transmitted infections. Wed also like to see adolescents
making more responsible decisions about their sexual health and their sexual

Abstinence as a goal is more important than abstinence as a teaching point. By

the metrics listed above, comprehensive sexual health programs are more effective.

Whether for ethical reasons, for evidence-based reasons or for practical ones,
continuing to demand that adolescents be taught solely abstinence-until-marriage
seems like an ideologically driven mission that will fail to accomplish its goals.

Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine

who blogs on health research and policy at The Incidental Economist and makes videos
at Healthcare Triage. Follow him on Twitter at @aaronecarroll. His coming book, The
Bad Food Bible, will be published on Nov. 7.

The Upshot provides news, analysis and graphics about politics, policy and everyday
life. Follow us on Facebook and Twitter. Sign up for our newsletter.

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10/3/2017 Sex Education Based on Abstinence? Theres a Real Absence of Evidence - The New York Times


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