Abstinence-only education does not work, abstinence-plus probably does

i-a3fea2bb74922daf015fdba7c2f29cfc-nyc_condom_product_shot.jpgThe US government spends millions domestically and billions internationally on abstinence-only education with the intent of lowering the transmission of STIs such as HIV and limiting unwanted pregnancies. Yet abstinence-only education is demonstrably ineffective. The alternative called abstinence-plus education clearly does not make the situation worse -- as some critics have argued -- but it doesn't appear to work that well either. What's a person concerned with public health to do?

Two reviews this year Underhill et al. look at the effectiveness of abstinence-only and abstinence-plus education.

Underhill et al. first published a review of the literature for abstinence-only education in BMJ.

Here is a table of the data for this study (Figure 2 in the paper).


The table depicts the relative risk odds ratio for abstinence-only education the rate of diagnosis for STIs and rate of pregnancy in comparison to controls. The confidence intervals are also indicated. In this chart a movement to the left would indicate a reduction in relative risk for these indicators and would favor abstinence-only education. Note that not one of these studies shows a statistically significant improvement with abstinence-only education; for all of these studies all but one of these studies the confidence intervals cross 1 indicating that there was no overall improvement in outcomes. (Ed. The one study that shows statistical significance showed that abstinence-only education actually increases the rate of STIs and pregnancy. I missed that on the first pass.)

These findings and others cause the authors to rightly conclude that abstinence-only education is ineffective:

In this systematic review the 13 included trials totalling more than 15 900 participants indicate that sexual abstinence only programmes for prevention of HIV infection do not decrease or exacerbate sexual risk among youths in high income countries, as measured by self reported biological and behavioural outcomes. When trials found significant results in either direction these were offset by other evaluations reporting non-significant findings. Evidence from this review suggests that abstinence only programmes that aim to prevent HIV infection are ineffective but that the generalisability of results may be limited to US youths. Although this assessment focused specifically on HIV prevention these results may also be relevant for the prevention of other sexually transmitted infections.

The trial results also suggest that abstinence only programmes do not effectively encourage abstinent behaviour but instead are ineffective for preventing or decreasing sexual activity among most participants....One trial found a protective effect from the programme compared with usual care for incidence of recent sex (n=839), but this was limited to short term follow-up and offset by non-significant findings in six other trials (n=2615). An adverse effect observed for frequency of sex (n=338) compared with usual care was not sustained at long term follow-up and this was also offset by non-significant findings in four other trial comparisons (n=2038). (Emphasis mine. Citations removed.)

With respect to the effectiveness of abstinence-only programs, we are now in the realm of unequivocal. These programs unequivocally don't work, and we should not be paying for them.

What does work then? Unfortunately this is where the matter becomes slightly more complicated.

Publishing this time in PLoS Medicine, Underhill et al. look at similar outcome measures for abstinence-plus education. To clarify what these programs do, "abstinence-plus (comprehensive) interventions promote sexual abstinence as the best means of preventing HIV, but also encourage condom use and other safer-sex practices."

They looked at similar behavioral measures (like how much sex the kids are having) and rates of pregnancy and STIs.

Here is what they found:

The 39 included trials (baseline n ~ 37,724) showed no evidence that abstinence-plus programs increase HIV risk among youth participants in high-income countries, and multiple evaluations found that the programs can decrease HIV risk. In 24 trials (baseline n = 20,982) significantly protective program effects were observed for behavioural or biological outcomes.

This review found no conclusive evidence that abstinence-plus programs can affect STI incidence and found limited evidence suggesting that abstinence-plus programs can reduce pregnancy incidence; however, the direction of findings consistently favoured abstinence-plus programs over any controls. Programs had mixed effects on sexual behaviour: individual trials discovered protective effects on incidence and frequency of unprotected vaginal, anal, and oral sex; incidence and frequency of vaginal and anal sex; incidence of any sexual activity; number of partners; number of unprotected partners; condom use; and sexual initiation. The trials that assessed HIV/AIDS knowledge found significant results favouring the majority of abstinence-plus program participants over various controls. No adverse effects were reported for any outcome. (Emphasis mine. Citations removed.)

Basically, this is saying is that there is no definitive evidence that STI and pregnancy rates are improved by abstinence-plus programs either. However, behavioral indicators such as numbers of partners or amount of unprotected sex did go down in individual studies. The problem is that the particular behavioral indicator that improved varied widely depending on which study you look at.

What is clear, however, is that the concern over abstinence-plus education -- that it encourages promiscuity -- is unfounded. The evidence suggests that abstinence-plus may or may not lower the rates of risky sexual behavior, but it clearly does not make the situation worse.

How do we interpret these findings in terms of policy choices?

As I see it we have three policy choices:

  • (1) We continue to fund abstinence-only programs even though they don't work. Certainly some people will continue to argue this point because we don't have alternatives that clearly work better.
  • (2) We fund abstinence-plus programs instead. They don't make the situation worse, and they are several good reasons to believe that they do improve outcomes. We put our money on the more likely bet even if it isn't the sure bet.
  • (3) We throw up our hands and decide to fund neither. We accept the fact that health education may very well be a lost cause, and that if people are determined to have risky sex no amount of instruction -- however well-intentioned -- is going to change that.

While the libertarian in me thinks that choice (3) has not received a fair hearing in this debate, I am realistic enough to recognize that this is not a politically palatable option. The "people are responsible for themselves and their children" constituency lacks political representation in either major political party. (Why people insist on the government appear to be doing something -- even if that something is useless -- is always a mystery to me, but that is an argument for another day.)

Given the choice between (1) and (2), the answer is undeniable. If you are going to do something, at least fund the policy that probably works as opposed to the one that definitely does not.

Abstinence-only education is a waste of money and time, and it needs to stop. We should throw that money into more aggressive abstinence-plus programs. Furthermore, we should continue to assess whether and what kinds of abstinence-plus programs are effective at generating improved outcomes. It may turn out that abstinence-plus programs are not effective either, and we need to accept that as a possibility. But for the time being, they appear to be the best option, and I think we should run with that.

Hat-tip: Economist

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Logically, there is a fourth option: non-abstinence sex education, i.e., sex education MINUS abstinence promotion. How would that look like, I don't know (comprehensive sex education plus promotion of sex, hoping that kids would rebel against the adults and just not do it?), but I am sure it would be even less palatable in the USA today.

Maybe we should ask the Netherlands how they handle the problem. They have one-seventh our teen birth rate and one-tenth our teen abortion rate.

Maybe they have prayer in the schools or they say the pledge of allegiance every morning or something...

A nitpick: you state that the figure shows the relative risk of various abstinence-only education methods, but the figure itself says that it's showing the odds ratio.

Can you tell us what the control was? Was it "no sex ed at all", or maybe one of the 1980's versions of sex ed that seemed to focus mostly on condom use, or what?


You wrote

While the libertarian in me thinks that choice (3) has not received a fair hearing in this debate, I am realistic enough to recognize that this is not a politically palatable option.

Is there an epidemiologist in the house? Would one make the same argument for choice (3) in the case of other infectious diseases? Or would one press hard for research on effective ways of reducing the incidence of the disease in the population. In general I'm wary of leaving public health issues up to the unaided and uninformed decisions of people who barely know the earth goes 'round the sun.

Given the non-significance of the data, the only scientific based decision would be to eliminate health education. Any policy to keep these programs is pure quackery.

Well, if we as a country could finally admit that the current abstinence-education, whether abstinence-only or -plus, is about the morality of sexual behavior and not about health at all, that would be a nice step in the right direction. Then look to Europe -- much lower incidences of STIs and teen pregnancies. (And purely anecdotally and with a very limited sample size, give me a European any day for generally healthier attitudes about sex and safe sex.)

Part of what keeps the Netherlands rates low is a combination of permissiveness and intolerance that will be hard for most Americans to accept. On the permissive side, by the time a child is 10 they are reasonably well informed about all aspects of sex, and 12 year olds will be fully informed about all sorts of sexual positions, techniques, etc. They will also have ready access to sexual toys in addition to the more expected birth control mechanisms like condoms. The extensive use of toys, birth control, and alternative sexual activity does reduce the risk of pregnancy. But, if a girl should get pregnant, she receives condemnation and intolerance far beyond the usual US level. There is little or no tolerance in terms of accommodations in school requirements, etc. She will likely have to drop out of school. She will not receive much public assistance. After all, she is a stupid idiot for getting pregnant and deserves nothing from society. This combination of education, carrot, and stick is effective.

You have to consider the background information available to the "subjects" of these studies acquired outside the particular programs.

In a typical western country, information about pregnancy, STDs, and HIV transmission is not hard to find. Thus, whatever these programs provide to the subjects, it is on top of widely available, mostly factual, information.

Responsible parents will provide this outside of any formal program, and most schools (except for many "Christian" schools) start feeding this information in science and health classes at the middle school level bit by bit as part of the overall curriculum, not necessarily as part of a formal program. And there will be peer discussions that will further disseminate this information with various degrees of accuracy.

Thus, it is very unlikely that these programs provide the first exposure to risk-reduction information. I doubt that even a small fraction of teens would enter such a program unaware of what a condom is for.

HIV transmission rates were far higher back in the early 1980s before information about the disease were discovered and publicized, and dropped mostly by the general dissemination of that information along with risk-minimization suggestions.

Thus, it may be that these programs are ineffective merely because they don't actually provide anything new. Perhaps people know the risks pretty well, and we've acheived all we can in terms of lowering the risk through education.

From Schmtiz Blitz: schmitzblitz.wordpress.com

It seems now that since the nexus of Christianity is shifting from the global north to the south, were getting more church leaders saying outrageously extreme things. Ive written before about the down right hateful comments made by Bishop Issaac Orama (which are under dispute).

Now theres Archbishop Francisco Chimoio of Mozambique, who is now resorting to scare tactics in order to push the Catholic churchs position on abstinence only for AIDS prevention. He said:

I know of two countries in Europe who are making condoms with (the) virus on purpose, they want to finish with African people as part of their program to colonize the continent People must choose what they want between death and I propose to them that (abstinence) is the best way to fight HIV/AIDS.

Apart from his paranoid delusion of a grand condom conspiracy, Bishop Chimoios words words have potentially deadly consequences. Married women are one of the most at risk groups for contracting HIV in Africa because they already face pressure from their husbands not to use condoms, and now they have a Man of God working against them as well.