Teenagers special: Going all the way

[impulse]

Teenagers special: Going all the way
05 March 2005
NewScientist.com news service
Alison George

Teenage mothersLYNSEY TULLIN was 15 when she became pregnant. The only contraception she and her boyfriend had used was wishful thinking: "I didn't think it would happen to me," she says. Tullin, who lives in Oldham in northern England, decided to keep the baby, now aged 3, although as a consequence her father has disowned her.

Tullin is not alone. In the UK nearly 3 per cent of females aged 15 to 19 became mothers in 2002, many of them unintentionally. And unplanned pregnancies are not the only consequence of teenage sex - rates of sexually transmitted diseases (STDs) are also rocketing in British adolescents, both male and female.

The numerous and complex societal trends behind these statistics have been endlessly debated without any easy solutions emerging. Policy makers tend to focus on the direct approach, targeting young adolescents in the classroom. In many western schools teenagers get sex education classes giving explicit information about sex and contraception. But recently there has been a resurgence of some old-fashioned advice: just say no. The so-called abstinence movement urges teens to take virginity pledges and cites condoms only to stress their failure rate. It is sweeping the US, and is now being exported to countries such as the UK and Australia.

Confusingly, both sides claim their strategy is the one that leads to fewest pregnancies and STD cases. But a close look at the research evidence should give both sides pause for thought. It is a morally charged debate in which each camp holds entrenched views, and opinions seem to be based less on facts than on ideology. "It's a field fraught with subjective views," says Douglas Kirby, a sex education researcher for the public-health consultancy ETR Associates in Scotts Valley, California.

For most of history, pregnancy in adolescence has been regarded not as a problem but as something that is normal, so long as it happens within marriage. Today some may still feel there is nothing unnatural about older adolescents in particular becoming parents. But in industrialised countries where extended education and careers for women are becoming the norm, parenthood can be a distinct disadvantage. Teenage mums are more likely to drop out of education, to be unemployed and to have depression. Their children run a bigger risk of being neglected or abused, growing up without a father, failing at school and abusing drugs.

The US has by far the highest number of teenage pregnancies and births in the west; 4.3 per cent of females aged between 15 and 19 gave birth there in 2002. This is significantly higher than the rate in the UK (2.8 per cent), which itself has the highest rate in western Europe (see Chart).

Another alarming statistic is the number of teenagers catching STDs. In the UK the incidences of chlamydia, syphilis and gonorrhoea in under-20s have all more than doubled since 1995. The biggest rise has been in chlamydia infections in females under 20; cases have more than tripled, up to 18,674 in 2003. Chlamydia often causes no symptoms for many years but it can lead to infertility in women and painful inflammation of the testicles in men.

No surprise, then, that teenage sex and pregnancy has become a political issue. The UK government has set a target to halve the country's teen pregnancy rate by 2010, and the US government has set similar goals. But achieving these targets will not be easy. In an age when adolescence has never been so sexualised, in most western countries people often begin to have sex in their mid to late teens; by the age of 17, between 50 and 60 per cent are no longer virgins.

Since the 1960s, UK schools have increasingly accepted that many teenagers will end up having sex and have focused efforts on trying to minimise any ensuing harm. Sex education typically involves describing the mechanics of sex and explaining how various contraceptives work, with particular emphasis on condoms because of the protection they provide from many STDs.

The sex education strategy gained further support in the early 1990s when policy makers looked to the Netherlands. There, teenage birth rates have plummeted since the 1970s and are now among the lowest in Europe, with about 0.8 per cent of females aged between 15 and 19 giving birth in 2002. No one knows why for sure, as Dutch culture differs from that of the UK and America in several ways. But it is generally attributed to frank sex education in schools and open attitudes to sex. Dutch teenagers, says Roger Ingham, director of the Centre for Sexual Health Research at the University of Southampton,"have less casual sex and are older when they first have sex compared with the UK".

“Why do virginity pledgers catch STDs? It's difficult to imagine intending not to have sex while also being contraceptively prepared”But a new sexual revolution is under way. Spearheaded by the religious right, the so-called abstinence movement is based on the premise that sex outside marriage is morally wrong. "We're trying to say there's another approach to your sexuality," says Jimmy Hester, co-founder of one of the oldest pro-abstinence campaigns, True Love Waits, based in Nashville, Tennessee.

Abstinence-based education got US government backing in 1981, when Congress passed a law to fund sex education that promoted self-restraint. More money was allocated through welfare laws passed in 1996, which provided $50 million a year.

A key plank of the abstinence approach is to avoid giving advice on contraception. The logic is that such information would give the message that it's OK to have sex. "The moment we do that, we water down the commitment," says Hester.

If contraception is mentioned at all, it is to highlight its failings - often using inaccurate or distorted data. A report for the US House of Representatives published last December found that 11 out of the 13 federally funded abstinence programmes studied contained false or misleading information. Examples of inaccurate statements included: "Pregnancy occurs one out of every seven times that couples use condoms," and: "Condoms fail to prevent HIV 31 per cent of the time." They also use some questionable logic regarding the success rate of abstinence (see "Heads I win, tails you lose").

While some states advocate "abstinence-plus" programmes, providing a level of advice on contraception alongside heavy promotion of chastity, the hard-line "abstinence only" approach is in the ascendant in the US. Around a third of US secondary schools have abstinence-only programmes, and nearly 3 million young people have publicly pledged to remain virgins until they marry.

And it is spreading. Last June an American group came to the UK to promote the Silver Ring Thing, a Christian movement that encourages teens to publicly pledge to remain virgins until marriage and to keep their promise with the aid of a $12 ring. And True Love Waits has held virginity rallies in Australia.

This trend comes amid claims that the UK's more liberal approach not only does not work, but has the opposite effect. "Free pills and condoms boost promiscuity" screamed the headline on the front page of UK newspaper The Times last year (5 April 2004). It was prompted by research by David Paton, an economist at the University of Nottingham, UK, which found that in some areas that had increased access to family planning services, teen pregnancy rates had remained the same and STD rates had actually risen.

“Despite many people's assumption that sex education is the best way to reduce pregnancies, there is little evidence backing this view”There are now increasing calls from conservative and religious groups for schools in the UK to consider the abstinence option. A programme called Love for Life is now operating in 60 per cent of schools in Northern Ireland. It could be described as abstinence-plus that is heavy on the abstinence. Its founder, Richard Barr, a GP from Craigavon, County Armagh, says that focusing on contraception ignores the bigger picture of human sexuality. "There's a massive need for a more holistic approach, not just a damage-limitation approach."

And the UK mainland is home to a small but growing number of groups, most of them with Christian roots, promoting abstinence-centred education. The word abstinence is less in vogue than across the Atlantic, however, and such groups are more likely to talk in terms of delaying sex until young people are in a committed relationship.

But does the abstinence approach work? Do teenagers - a group not renowned for their propensity to do what they are told - take any notice when adults tell them not to have sex?

Proponents of abstinence claim research supports their strategy. But the vast majority of studies that have been done in this area have been small, short-term evaluations without control groups. "There have only been three well-designed trials where an 'intervention' group is compared with a control group and participants are tracked over time," says Kirby.

One of these, published in 1997, looked at a five-session abstinence-only initiative in California. The trial tracked 10,600 teenagers for 17 months (Family Planning Perspectives, vol 29, p 100). The researchers found it had no impact on the sexual behaviour or pregnancy rates of teenagers. The other two studies had similar results. "None of them show that any abstinence-only programmes had any impact on behaviour," says Kirby.

Although not a controlled trial, one of the largest studies of the effect of abstinence pledges tracked the sex lives of 12,000 US teenagers aged between 12 and 18 (American Journal of Sociology, vol 106, p 859). A group led by Peter Bearman, a sociologist at Columbia University in New York, investigated whether taking a virginity pledge affected the age when people first had sex. It did, with an average delay of 18 months. The pledgers also got married earlier and had fewer partners overall.

But when Bearman went back six years later and looked at the STD rates in the same people, now aged between 18 and 24, he was in for a surprise. In research presented at the National STD conference in Philadelphia last year, he found that though pledgers had had fewer sexual partners than non-pledgers, they were just as likely to have had an STD. And the reason? "Pledgers use condoms less," says Bearman. "It's difficult to simultaneously imagine not intending to have sex and being contraceptively prepared."

Here lies the problem that many have with the idea of abstinence-only education. While it may work for those kids who live up to the ideal, those who don't are left without the knowledge to protect themselves when they do have sex. "It's not rocket science," says Bearman.

But here's where proponents of the liberal approach can stop feeling smug. Because despite many people's unquestioning assumption that comprehensive sex education is the best way to reduce teenage pregnancy, there is actually little good-quality evidence backing this view.

One of the problems in carrying out randomised controlled trials in this area is the question of who should be used as the control group. Most schools now have some form of sex education in place, however rudimentary, and it would be unethical to take this away from some children to create the control group. Instead researchers have tended to compare standard sex education with new initiatives specially designed to reduce pregnancy rates. But the results have been unimpressive. A systematic review in 2002 of 26 such studies showed that not one of them improved the use of birth control or reduced the teenage pregnancy rate (British Medical Journal, vol 324, p 1426).

But in the past few years, a handful of randomised controlled trials have been published showing that some carefully designed sex education programmes do appear to work. One of the most effective is the Carrera Adolescent Pregnancy Prevention Program, aimed at 13 to 15-year-olds in a poor area of New York (Perspectives on Sexual and Reproductive Health, vol 34, p 244). Abstinence is mentioned during the programme, but most of the emphasis is on contraception. A three-year study showed that the pregnancy rate of teenage girls who took the programme was less than half the rate of those who didn't. Analysis showed this was due to both greater condom use and delayed onset of sex.

Why should these programmes be any different? As well as lasting longer, they were, says Kirby, "interactive and personalised, not just abstract facts". The Carrera programme, for example, not only covered sexual behaviour, it tackled the social disadvantages that lead to teenage pregnancy. Along with information on and free access to contraceptives, it involved intensive youth work such as sports, job clubs and homework help.

Most UK sex education programmes seem half-hearted in comparison, providing the bare biological facts, perhaps alongside a demonstration of how to put a condom on a cucumber. "It's something I feel quite angry about," says Michael Adler, a former STD physician at University College London Hospital. In his job he saw many casualties of unsafe sex. "We're failing young people right at the beginning," he says.

Unfortunately policy makers have recently lost a good source of information about what works and what doesn't. The US Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, commissioned a panel of external experts to carry out a rigorous review of various sex education programmes. The panel identified five strategies that were successful in reducing the rate of teenage pregnancy, all based on comprehensive sex education, and the details were posted on the organisation's website. But in 2002 that information disappeared and the CDC will no longer release it.

According to the CDC press office, the review programme is being "re-evaluated". But sceptics fear it has been dumped because its conclusions don't fit with the Bush's administration's views. "They were inconsistent with the ideology to which this administration adheres," says Bill Smith of the Sexuality Information and Education Council of the United States, a liberal sex education advocacy group based in New York.

“Sceptics fear the information on successful sex education programmes has been dumped because it doesn't fit with the Bush administration's views”What of the study that made the newspaper headlines in the UK last year, showing that contraception provision is linked with higher STD rates? Perhaps it should not really be taken as a damning indictment of the liberal approach. The study looked at National Health Service family planning clinics, not school-based comprehensive sex education. Simply doling out condoms without tackling the wider issues is unlikely to have much impact. Anyway, should the correlation between sex clinics and STD levels really be so surprising? "Has it occurred to [David Paton] that they put more services in areas with high rates?" asks Roger Ingham.

In fact, amid all the scare stories, the average age when a person first has sex now appears to be levelling out at around 17 in the US and 16 in the UK. And although rates of STDs are on the increase in the UK, teenage pregnancy and birth rates are on a downward trend, as they have been in most developed countries for several years. A report from the Alan Guttmacher Institute, a reproductive health research group in New York, concludes this is due to factors such as the rise of careers for women, and the increasing importance of education and training (Family Planning Perspectives, vol 32, p 14). Perhaps it is unsurprising, then, that it is among society's lowest income groups that teen pregnancy rates are highest.

In the face of such complex societal forces, those who try to influence teenagers' behaviour on a day-to-day basis undoubtedly have a tough job on their hands. There may be no single solution. More research is needed to produce detailed information on which kind of sex education programmes work best, and in which contexts.

One approach is to involve older teenagers, on the premise that 14-year-olds may be more likely to listen to 18-year-olds than people of their parents' generation. Since having her son, Lynsey Tullin has started working for Brook, a young people's sexual health charity, to ensure that today's teenagers are more savvy about sex. "We talk the same language," she says.

A tactic that she finds hits home is to describe new parenthood in all its gory details - the nappies, the lack of sleep, a social life in tatters. "We run workshops about being parents, telling them what we went through," she says. "It's a shock."

From issue 2489 of New Scientist magazine, 05 March 2005, page 44
Different approaches to teenage sexuality
Comprehensive sex education

Provides explicit information about contraception, sexuality and sexual health

Abstinence-only approach

Teaches that the only place for sex is within marriage, and the only certain way to avoid pregnancy and STDs is abstinence. Does not teach about contraception

Abstinence-plus

Promotes abstinence as the best choice, but provides varying degrees of information on contraception in case teens do become sexually active

Heads I win, tails you lose
LOOK at any abstinence-only literature, and you'll read that this is the only certain way to prevent pregnancy and avoid catching a sexually transmitted disease (STD). "Abstinence. Failure rate 0 per cent," is the claim on one pro-abstinence website.

But does this make sense? The most important measure of any method of preventing pregnancy and STDs is not its ideal effectiveness, but its "use effectiveness" - how successful it is in the real, sometimes messy, world of sex. Condoms, for instance, have a 97 per cent success rate at preventing pregnancy if used correctly, but have an estimated use-effectiveness of 86 per cent, due to problems such as tearing or slipping. If people who intend to use condoms but never get as far as opening the pack are included, some studies suggest the use-effectiveness of condoms could be as low as 30 per cent - the sort of figure abstinence fans shout from the rooftops.

What about applying the same real-world rules to abstinence? Unfortunately there are no studies detailing the use-effectiveness of abstinence in preventing pregnancy, but it is highly unlikely to be 100 per cent, as commonly claimed by its proponents. Their reasoning goes like this: individuals who set out to remain abstinent but succumb to temptation and have sex are no longer seen as abstinence "users". And those who become pregnant may even be marked up as a failure for the contraception strategy if, say, they attempted to use a condom but bungled it.

Abstinence campaigners are very vocal about the failings of contraception. But is it perhaps time to own up about the failure rate of abstinence?

[shokin]

Yes, it is a great problem, a great trend : the "déresponsabilisation" (how do you say it in english ? the unresponsibility, making us unresponsible)

another trend is to "make the things younger". To do many things younger. For example, making love, smoking, drinking, etc. And the market-goal (do you say so ?) is more and more the young boys and girls, young and younger.

And one other trend, that I don't like, is the "here and now" ideal. "Do it now. Maybe you won't be able to do it later." which makes us do things at once, as if it was an emergency. The global view is dying, the individualism is becoming powerfull, badly...

Shokin