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ss triple helix - spring 2003,  Abstinence education

Abstinence education

The Chief Medical Officer's claim, that there is no evidence sexual abstinence programmes work, is simply untrue. The best data for their effectiveness come from the USA, where abstinence education has been well funded and rigorously evaluated, and Uganda where sexual abstinence is a major factor in plummeting HIV rates. However it is very difficult to get this message across in our hedonistic and postmodern culture where sex education is more ideologydriven than evidencebased. The difficulties have been accentuated by the church's general approach to sexuality which emphasises control rather than celebration and saying 'no' to sex rather than saying 'yes' to God's pattern for it.
'Why are we not being told the truth?' asks Trevor Stammers
If a lie is repeated loudly enough and often enough, it is not surprising that many people who ought to know better will believe it. I was surprised though, that the Chief Medical Officer did not check the evidence base for his recent claim in an Update sent to all GPs: 'Evidence does not exist to suggest that abstinence approaches are effective'.[1] This is simply untrue. The Department of Health may be unaware of the evidence or perhaps reluctant to engage in debate about it. Still, the evidence does exist and its strength is growing year on year.

The largest amount of data comes from the USA, where abstinence education has been both wellfunded and certainly as rigorously evaluated as any safer-sex programs. In 1998, a randomised controlled trial compared both abstinence and 'safer-sex' interventions (including, even in the latter group, the information that abstinence was the 'best choice') with a control group (who received neither intervention).[2] At three month follow-up, subjects in the group receiving the abstinence intervention were significantly less likely to report sexual intercourse compared with the control group. This effect was not sustained at six months, but even a three-month delay in initiating intercourse is a worthwhile outcome in the high-risk group of mainly low-income, urban African-Americans studied.

A comprehensive and balanced review, 'Teen pregnancy: do any programs work?' (my emphasis), reviewed eleven primary pregnancy-prevention programs and showed published evidence of effectiveness as far back as 1987.[3] At least four of these are abstinence-focused approaches.[4,5,6,7,8,9 ] In the community-based abstinence programme there was a significant drop in the pregnancy rate during the full implementation period of the program.[10] Even some of the more contraceptive-focused programs include a strong abstinence message.[11] Another community-based program to help adolescents avoid health risk behaviours was presented to children up to the age of eleven in Seattle.[12] At nine year follow-up when they reached the age of 21, participants in the programme were less likely to have started having sex by age 21, were significantly older at first sexual experience, had fewer sexual partners, were less likely to have become pregnant and were more likely to have used a condom at first intercourse. The striking features of this program are that it had no specific sex education component at all, though good decision-making (including abstinence) in many fields was encouraged more generally. The effects of this programme lasted for many years after completion.

The authors of a comprehensive database analysis concluded that making a virginity pledge (one of the aims of some USA abstinence programs) delayed the onset of sexual intercourse by up to three years. Even though this strong effect was conditioned by both age and social context, it still constitutes powerful evidence for some elements of abstinence education.[13,14]

Another recent paper describes the highly significant effect of an abstinence program in Monroe County, New York.[15] By the third year after implementation of the program, the percentage of students reporting intercourse by the age of 15 had fallen from 47% to 32%. The slope of the regression line for the fall in pregnancy rates of 15-17 yrs olds in Monroe County was two to three times that for surrounding areas of New York that did not run the program.

The wealth of data from the USA is given added weight by results just emerging from abstinence education projects in Uganda.[16,17] ABC programs (Abstain, Be faithful or wear a Condom - very much in order of emphasis) are the norm in Uganda, following the strong leadership of President Museveni and his wife. HIV rates are plummeting in Uganda and sexual abstinence is a major factor. In one district between 1994 and 2001, the percentage of 13-16 year olds who had sex fell from over 60% to 5% for boys and from 25% to 3% for girls.[18] At the UN child summit last year, First Lady Museveni was quite blunt: 'The young person who is trained to be disciplined will, in the final analysis survive better than the one who has been instructed to wear a piece of rubber and continue with business as usual'.[19] The CMO and indeed the Government's current Sexual Health Inquiry would do well to act on her comments, rather than making indefensible statements opposing abstinence education. This is even more important at a time when the effectiveness of condom and contraception promotion alone is being increasingly questioned and the myth of Holland's teenage sexual utopia is gradually being exposed.[20,21,22,23] Often there is a way, like condom promotion, that superficially looks right but it ends in death.[24] Far from being unrealistic, abstinence is the only pathway for teenagers to find sexual heath and fulfilment in later life, whether in subsequent marriage, temporary singleness or in lifelong celibacy. However, it is extremely difficult to get this message across in our hedonistic, post-modern culture. For many people, the only ethical question to be asked about sex is 'Is it consensual?'. If the answer is 'Yes', then anything goes. The task is not made any easier by two frequent imbalances in the church's general approach to sexuality.

Firstly, we have given the impression that sex is a detrimental legacy of the Fall, rather than an integral component of Creation.[25,26] In emphasising control, we have forgotten celebration. Yet many teenagers, as well as older Christians, can and do celebrate their sexuality in celibacy. Newsweek recently ran several major articles on abstinence in the USA. The comments of young people interviewed were typified by one who said, 'It's a pretty special thing…Abstinence has to do with 'Hey, are you going to respect this person?''[27]

Secondly, we have failed to set a positive agenda by proudly proclaiming the positive dynamic of scriptural teaching on sex. This has meant Christian pronouncements about sex have largely been negative responses to specific issues such as abortion or homosexuality. For example, we have emphasised 1 Corinthians 7 rather than The Song of Songs. In promoting sexual chastity, we need to remember that it is not so much saying 'No' to sex but saying 'Yes' to sexuality expressed as God intended for our good.

The monstrosity of sexual intercourse outside marriage is that those who indulge in it are trying to isolate one kind of union (the sexual) from all the other kinds of union which were intended to go along with it and make up the total union. The Christian attitude does not mean that there is anything wrong about sexual pleasure, any more than about the pleasure of eating. It means that you must not isolate that pleasure and try to get it by itself, any more than you ought to try to get the pleasures of taste without swallowing and digesting, by chewing things and spitting them out again.

CS Lewis, Mere Christianity
  1. CMO's Update 35 DoH Jan 2003
  2. Jemmott JB et al. Abstinence and safer-sex HIV reduction interventions for African American adolescents. JAMA 1998; 279:1529-36
  3. Card J. Teen pregnancy: do any programs work? Annual Review Public Health 1999; 20:257-85
  4. Donaghue MJ. Technical Report of the National Demonstration Project Field Test of Human Sexuality: Values and Choices. Minneapolis: Search Institute, 1987
  5. Howard M et al. Helping teenagers postpone sexual involvement. Fam Plann Perpsect 1990; 22:21-26
  6. Howard M et al. Preventing teenage pregnancy: some questions to be answered and some answers to be questioned. Pediatr Ann 1993; 22:109-18
  7. Jorgenson SR et al. Project taking charge; six-month follow-up of a pregnancy prevention program for early adolescents. Fam Relat 1993; 42:401-6
  8. Vincent ML et al. School/community Sexual Risk Reduction Program for Teens Columbia, Columbia: Univ. SC Sch. Public Health, 1987
  9. Vincent ML et al. Reducing adolescent pregnancy through school and community-based education. JAMA 1987; 257:3382-6
  10. Ibid
  11. Kirby D et al. Reducing the Risk; impact of a new curriculum on sexual-risk-taking. Fam Plann Perspec 1994; 109:339-60
  12. Lonczak H et al. Effects of the Seattle Social Development Project on sexual behaviour, pregnancy, birth and sexually transmitted disease outcomes by age 21yrs. Arch Pediatr Adolesc Med 2002; 156:438- 447
  13. Resneck MD et al. Protecting adolescents from harm: findings from the national longitudinal study on adolescent health. JAMA 1997; 278:823-32
  14. Bearman PS et al. Promising the future; virginity pledges and first intercourse. Am J Sociology 2001; 106:859-912
  15. Doniger AS et al. Impact evaluation of the 'Not Me, Not Now'' abstinence-oriented, adolescent pregnancy prevention communications program, Monroe County, New York. J Health Communication 2001; 6:45-60
  17. Hogle J et al. Whatever Happened in Uganda? Declining HIV prevalence, behaviour change and the national response. Washington DC: USAIDWashington and The Synergy Project TvT Associates, 2002
  20. Kirby D. Making condoms available in schools - the evidence is not conclusive. West J Med 2000; 172:149-51
  21. Paton D. The economics of family planning and underage conceptions. J Health Econ 2002; 21:207- 225
  22. Stammers TG. Sexual Spin. Postgrad Med J 1999; 75:641-2
  23. Van Loon J. Deconstructing the Dutch Utopia - sex education and teenage pregnancy in the Netherlands. London: Family Education Trust, 2003
  24. Proverbs 14:12
  25. Genesis 2:23-25
  26. Matthew 19:4-6
  27. Choosing Virginity. Newsweek 2002; 9 December:66
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