Safe sex vs. abstinence: Which is most effective?
States implement abstinence-only programs
Both abstinence and safe-sex philosophical interventions can reduce HIV risk behaviors, but safe-sex education appears to be more effective and longer-lasting with adolescents who have already had sex, according to a new study.1 Nonetheless, states will spend $50 million in federal funding on abstinence education this year, as legislators rely on ideology rather than science for making policy, says a leading behavioral scientist.
The first randomized controlled trial comparing an abstinence intervention with a safer-sex intervention recruited 659 African-American adolescents at three middle schools in low-income communities in Philadelphia. The results, published in the Journal of the American Medical Association, found that both approaches to reducing HIV exposure were effective, but that safer-sex interventions curbed unprotected sexual intercourse, while abstinence did not. Additionally, safer-sex education influenced behavior longer than abstinence education, and yet it did not lead to increased sexual intercourse - a concern commonly cited by those who oppose sex education in schools.
A rigorous study with 12 months of follow-up, the trial provides the first hard comparative data for the two approaches, says Ralph DiClementi, PhD, chairman of the behavior sciences department at the Rollins School of Public Health for Emory University in Atlanta.
"Empirical data substantiating the efficacy of abstinence programs are sorely lacking," he says in an editorial accompanying the JAMA article. "Initial studies suggested that abstinence programs could delay adolescent sexual debut. However, [the study's] findings fail to identify a long-term advantage for the abstinence intervention relative to the control or safer-sex intervention."
The adolescents had a median age of 11.8 years and were recruited from sixth and seventh grades. In pre-intervention questionnaires, one-quarter of the participants reported having had sexual intercourse, with 15% reporting intercourse in the previous month. Stratified by age and gender, the students were randomly assigned to one of three interventions: a safer-sex HIV intervention, an abstinence HIV intervention, or a health promotion intervention that served as the control. The interventions comprised eight one-hour sessions divided equally over two consecutive Saturdays. The highly structured modules included group discussions, videos, games, exercises, and skills-building exercises.
Primary outcome measures were sexual behaviors, condom use, and unprotected sexual intercourse. Secondary outcome measures included behavioral beliefs about condoms.
As the researchers anticipated, students in the abstinence group were significantly less likely to report having sexual intercourse in the three months following the intervention compared to those in the control group and marginally less likely than those in the safer-sex group. However, the abstinence intervention was more effective only at three-month follow-up. At six-month and 12-month follow-ups, abstinence intervention had no advantage over the control or safer-sex intervention, the authors report.
Moreover, the abstinence intervention showed no advantage for students who were sexually active prior to the intervention, compared to those in the safer-sex intervention. And the safer-sex intervention continued to have significant impact on lowering unprotected sexual intercourse at six- and 12-month follow-up for those who were previously sexually active.
Why the short-term impact of the abstinence intervention message? "It's a message that is competing with a variety of other messages from multiple channels," DiClementi tells AIDS Alert. "You have all those countervailing influences working against a very short intervention."
A safer-sex intervention message, on the other hand, resonates more with adolescents because it is more relevant to their lives, he argues, noting that one-quarter of these students had sex before entering eighth grade. "Many adolescents are having sex earlier and having more partners," he says. "The reasons for that are hard to tell, but clearly it is a trend."
Impact of just saying no questioned
The findings of this study and several others suggest to DiClementi that data are lacking on whether abstinence programs are effective. Yet policy-makers have chosen to put their eggs in the abstinence basket, committing $50 million a year in matching money through the Welfare Reform Act that states receive for implementing such programs.
"Interestingly, we have made this important departure from standard operating procedures in that we have allocated a ton of money for programs that have very little in way of evidence to support their efficacy," he says. "On the other hand, we did not do something comparable for safer-sex education programs, which have some data to support efficacy."
All 50 states have implemented abstinence education programs, according to the Sexuality Information and Education Council of the United States (SIECUS) in New York. As part of the Welfare Reform Act, Congress allocated $50 million through the Maternal and Child Health Branch annually through 2002. The program defines abstinence education as teaching youngsters to delay sexual activity outside marriage, and that sexual activity outside marriage can be harmful physically and psychologically, according to a recent SIECUS report.
Although Congress also allocated funds to evaluate the programs, states appear to have considerable leeway in setting up their programs. Initiatives range from extensive public service announcements to handing out brochures. Most states targeted children below age 14, but four states included those up to 16 years, seven up to 19 years, and two up to 24 years of age.
"There isn't a whole lot of guidance here," DiClementi says. "You can provide the education in any place and in different age groups. Some are targeting adolescents as old as 20 to 24 years of age."
With such strong political support for abstinence programs, public health officials don't expect this study or others to sway public policy. Nonetheless, having the study's findings confirmed by a larger study using a different intervention model and a different adolescent population would add to weight to its significance, DiClementi adds.
Reference
1. Jemmott J, Jemmott L, Fong G. Abstinence and safer sex HIV risk-reduction interventions for African American adolescents. JAMA 1998; 279:1,529-1,536.
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