The Obfuscation Report

John Santelli MD MPH, Columbia University

Editor's Note: This following letter was sent to Congresswoman Nancy Pelosi and Senator Harry Reid urging Congressional leaders to reconsider continuing federal investments in abstinence-only funding. The letter was sent by John S Santelli MD, MPH at Columbia University and signed by nine other prominent researchers in the field of adolescent sexual and reproductive health last Wednesday, Nov 21. It was sent to RH Reality Check yesterday and we are thrilled to post it below.

Dear Congresswoman Nancy Pelosi and Senator Harry Reid,

As a group of leading scientists who have recently conducted research on adolescents, reproductive health, and abstinence-only education, we are writing to express our strong concern about increasing federal support for abstinence-only education (AOE) programs. This federal support includes monies going to states (Section 510 of the Social Security Act) and those going directly to community and faith-based organizations (the Community-Based Abstinence Education program). Recent reports in professional publications by the authors of this letter have highlighted multiple deficiencies in federal abstinence-only programs. As such, we are surprised and dismayed that the Congress is proposing to extend and even increase funding for these programs. In this letter we identify key problems with abstinence-only education. We also have attached recent scientific reports that are pertinent to the debate over these programs. We note that many of these studies have used nationally-representative data from surveys sponsored by the National Institutes of Health or the Centers for Disease Control and Prevention.

The federal programs promoting AOE have prompted multiple scientific and ethical critiques. These critiques were summarized in a January 2006 paper by Santelli, Ott and others. By design, abstinence programs restrict information about condoms and contraception - information that may be critical to protecting the health of young people and to preventing unplanned pregnancy, HIV infection, and infection with other sexually transmitted organisms. They ignore the health needs of sexually active youth and youth who are gay, lesbian, bisexual, transgendered, and questioning for counseling, health care services, and risk reduction education. Withholding lifesaving information from young people is contrary to the standards of medical ethics and to many international human rights conventions. International treaties and human rights statements support the rights of adolescents to seek and receive information vital to their health. Governments have an obligation to provide accurate information to adolescents and adolescents have a right to expect health education provided in public schools to be scientifically accurate and complete.

Rigorous evaluations of AOE programs find little evidence of efficacy for federally-sponsored abstinence education. Several weeks ago Dr. Douglas Kirby, working with the National Campaign to Prevent Teen and Unplanned Pregnancy, released a comprehensive review of prevention programs for youth (Emerging Answers 2007). This review found that none of the well-designed evaluations of abstinence-only programs presented strong evidence of an impact on abstinence behaviors. (By contrast, Kirby finds clear evidence that many comprehensive sexuality education programs, which include information on both abstinence and contraception, do help young people delay initiation of intercourse.) The large-scale Mathematica evaluation of the Section 510 program, released in April 2007, found no measurable impact on increasing abstinence or delaying sexual initiation among participating youth or on other behaviors such as condom use. This well funded and very well conducted evaluation examined four exemplary local programs, tracking youth over four years. One of the few measurable impacts of the programs was a decrease in adolescent confidence regarding the ability of condoms to prevent HIV and other sexually transmitted diseases. Similar results on program efficacy were found by Underhill, who reviewed abstinence-only programs in a spring 2007 systematic review.

Virginity pledging, one aspect of abstinence programming, appears to have little long-term benefit in preventing outcomes such as sexually transmitted infections, although prevention of these infections is a stated goal of the programs. A spring 2005 longitudinal study by Bruckner and Bearman found that abstinence pledgers, when compared to non-pledgers, experienced similar rates of sexually transmitted infection. Pledgers did delay sexual intercourse for a limited period, but when they did start having sex, they were less likely to use condoms. They were also less likely to seek reproductive health care compared to non-pledgers.

Abstinence until marriage is another stated goal of the federal program; however, evidence from the past several decades indicates that establishing abstinence until marriage as normative behavior would be a highly challenging policy goal. Teitler has shown that over the past 40 years, the median age at first intercourse has dropped (and stabilized) to age 17 in most developed countries.

At the same time, the median age at marriage has risen dramatically. Today, sexual intercourse is almost universally initiated during adolescence worldwide. A January 2007 study by Finer found that almost all Americans initiate sexual intercourse before marriage. In fact by age 44, virtually everyone has experienced sexual intercourse but only 3% have remained abstinent until marriage. Moreover this is not a new trend; Finer's data suggest this pattern has been true for much of the second half of the 20th century.

Importantly, the emphasis on abstinence-only programs and policies appears to be undermining critical public health programs in the U.S. and abroad, including comprehensive sexuality education and HIV prevention programs. During the period of increased state and federal emphasis on abstinence, declines have occurred in the percentage of teachers in U.S. public schools who teach about birth control and the number of students who report receiving such education. In December 2006, Lindberg and colleagues found that the percentage of teenagers who had received formal instruction about condoms and contraception declined from 89% in 1995 to 70% in 2002.

We also note that a December 2004 Congressional report on federal abstinence programs from the U.S. House of Representatives' Committee on Government Reform - Minority Staff found that 11 of the 13 most frequently used curricula contained false, misleading or distorted information about reproductive health - including inaccurate information about contraceptive effectiveness, purported health risks of abortion, and other scientific errors. Recent reviews of these abstinence curricula from Santelli and colleagues at Columbia University have found similar inaccuracies, particularly misinformation about the efficacy of condoms and contraception. This was the basis of an ACLU declaration on this topic from Santelli in the spring of this year.

Abstinence-only requirements also appear to be harming our foreign aid efforts. In April 2006, the U.S. Government Accountability Office issued a report titled "Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Emergency Plan for AIDS Relief" that concluded that the "...requirement that country teams spend at least 33 percent of prevention funding appropriated pursuant to the act on abstinence-until-marriage programs has presented challenges to country teams' ability to adhere to the PEPFAR sexual transmission strategy...[and] challenged their ability to integrate the components of the ABC model and respond to local needs, local epidemiology, and distinctive social and cultural patterns."

We would note that all of the mainstream organizations of health professionals that focus on the health of young people have strongly criticized federal support for current abstinence programs. These include the American Public Health Association, the American Medical Association, the American Academy of Pediatrics, the American Psychological Association, and the Society for Adolescent Medicine. We have also attached the weblinks to the policy statements from each of these groups.

The recent Congressional testimony of former Surgeon General Richard Carmona underscores these critiques from mainstream health organizations. Dr. Carmona's testimony confirms the political motivations behind abstinence funding and the failure to address issues of efficacy and scientific accuracy. He suggested that ideology and theology have taken priority over women's health in the current administration. Dr. Carmona reported that the Bush administration "did not want to hear the science but wanted to, if you will, ‘preach abstinence,' which I felt was scientifically incorrect."

Given these serious scientific and ethical shortcomings, we strongly urge the U.S. Congress to reconsider federal support for abstinence-only education programs and policies. We would be very willing to advise you on shaping alternatives to the current program.

Sincerely,

John S Santelli, MD, MPH

Columbia University

Peter Bearman, PhD

Columbia University

Claire Brindis, DrPH

University of California, San Francisco

Hannah Bruckner, PhD

Yale University

Lawrence B Finer, PhD

Guttmacher Institute

Laura Duberstein Lindberg, PhD

Guttmacher Institute

Mary Ott, MD

Indiana University

Julien Teitler, PhD

Columbia University

Deborah Tolman, EdD

San Francisco State University

Kristen Underhill, DPhil

Yale University

(Organizational affiliations are listed for identification purposes only.)

Cc Senate and House Leadership and Appropriations Committees