September 2017

Abstinence is making your role as a provider harder. Yes, abstinence can be an effective method to prevent pregnancies and sexually transmitted infections. But as you well know, the pivotal word in that statement is can. What you may be less aware of—though affected by—is that the effort and funding spent on abstinence programs are undermining comprehensive education programs that are proven to promote positive reproductive health behaviors. Washington DC is cutting millions of dollars in funding for programs proven to prevent teen pregnancy and adding millions into abstinence programs proven not to work.

In a 2017 analysis of programs teaching abstinence-only–until-marriage to adolescents, a team led by John Santelli confirmed that comprehensive and factual sex education is diminishing.[1] Between 2000 and 2014, the percentage of middle and high schools requiring programs in human sexuality fell from 67% to 48% and the percentage requiring HIV prevention education fell from 64% to 41%. Only 23% of junior high schools and 61% of high schools instructed students about contraceptives. In contrast, 76% of high school programs and 50% of middle school programs taught abstinence as the best way to avoid pregnancy and STDs.

But isn’t abstinence a good thing? Don’t we want teens to delay having sex? Sure, on both counts. Unfortunately, as the analysis pointed out, “Federal [abstinence-only-until-marriage] programs are inherently coercive, withholding information needed to make informed choices and promoting questionable, inaccurate, and stigmatizing opinions.” Several years ago, an analysis conducted through the Cochrane Database of Systematic Reviews found that those programs did not even achieve their goals.[2] The student participants did not delay sex or decrease their sexual activity and did not have fewer partners. Given that these programs do not promote use of condoms or contraceptives, there was no positive effect on those behaviors either.

In its 2016 review, the Centers for Disease Control and Prevention summarized 224 randomized controlled trials of sex education programs and confirmed that abstinence-only interventions were ineffective.[3] The money funneled into these interventions could have been invested in comprehensive sex education programs, which did have demonstrable effects on reducing the risk factors of unintended pregnancy and sexually transmitted infections: less sex activity, fewer sex partners, and more use of protections in the form of contraceptives and condoms.

Played out on a public health stage, the failure of abstinence education programs have left those States that engage those programs with exceptionally high teen pregnancy rates: “After accounting for other factors, the national data show that the incidence of teenage pregnancies and births remain positively correlated with the degree of abstinence education across states: The more strongly abstinence is emphasized in state laws and policies, the higher the average teenage pregnancy and birth rate.”[4]

Despite the weight of sound evidence, repeatedly reconfirmed, our national effort to prevent teen pregnancy is heading toward a surprising and unsettling direction:

• The Administration cut more than $200 million that had been dedicated to teen prevention programs.[5]
• The current Federal budget proposed by the Administration allocates $277 million to fund abstinence programs.[6]
• The new Chief of Staff to the Assistant Secretary of Health (DHHS) is the national abstinence education advocate Valerie Huber (she says she now prefers to use the phrase ‘sexual risk avoidance’; though as a reproductive health professional, you know that changing the name of the programs won’t change the outcomes).[7]

With the Federal government and too many States failing to step up, it may just take the village. Increasing awareness can be everyone’s responsibility. Abstinence works until it doesn’t, and then the individual needs to know about and how to access contraceptives and protection. Family planning providers do their jobs well, with falling teen pregnancy rates to prove it. But once again, it is time to step out of the office and spread the word.

From the Pages of Contraceptive Technology

And while you’re still in your office? Keep doing the great work you’ve been doing. Plus talk more about abstinence, good as a behavioral goal but not a particularly reliable contraceptive method. People are, after all, human. Including teens. So primary abstinence needs a back-up method.

Abstinence can play a far more effective role in a context different from that promoted by the abstinence-only programs. Spontaneous abstinence is the ever-available back-up method. No other contraceptive on board for protection? Not in the mood? Not the right partner? Either partner drunk or high? These situations call for abstaining. As Santelli notes,

“Although abstinence has become associated with saying “no,” viewed from another perspective, abstinence can mean saying “yes” to a number of other sexual activities and personal priorities. For some people, only penile penetration of the vagina equals intercourse. Not only does this definition fall short in its heteronormity [the restrictive societal norm of heterosexuality], but also most people have a more expansive view of sexual expression…”[8]

[1] Santelli JS, Kantor LM, Grilo SA, et al. Abstinence-only-until-marriage: an updated review of US policies and programs and their impact. J Adol Health 2017;61:283-280.

[2] Underhill K, Operario D, Montgomery P. Abstinence-only programs for HIV infection prevention in high-income countries. Cochrane Database Syst Rev 2007:doi: 10.1002/14651858.CD005421.pub2.

[3] Chin HB, Sipe TA, Elder R, et al. The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections: Am J Prev Med 2012;42:272e94.

[4] Stanger-Hall KF, Hall DW. Abstinence-only education and teen pregnancy rates: why we need comprehensive sex education in the U.S. PLoS ONE 6(10): e24658. https://doi.org/10.1371/journal.pone.0024658

[5] McCammon S. abstinence education is infective and unethical, report argues. NPR August 23, 2017.

[6] Merelli A, Timmons H. Trump’s budget would devote $277 million to the least effective contraceptive known to mankind. Quartz May 23, 2017. Accessed Sept. 1, 2017 at https://qz.com/989317/budget-trump-is-devoting-almost-300-million-to-abstinence-only-sexual-education/

[7]  Hellman J. Abstinence education advocate names to HHS post. The Hill, 06/06/2017. Accessed Sept 1, 2017 at http://thehill.com/policy/healthcare/336620-abstinence-education-advocate-named-to-hhs-post

[8] Santelli J, Kottke M, Grilo SA. Abstinence, noncoital sex, and sexual health:  what every clinician needs to know. In: Hatcher RA, Nelson A, Trussell, J, et al. [Eds.] Contraceptive Technology, 21^st edition. New York: Ardent Media, Inc., in preparation.