Admitting the possibility

Ye gods! The same day I confront the anti-vaccination know-nothings, I am forced to address a scientific challenge to my own belief systems. The irony, people. The irony.

From the Times:

The ongoing debate over sex education has been rekindled by a provocative new study suggesting that teaching abstinence can delay the start of sexual activity among inner-city youngsters — if it is freed from the moralistic overtones and ideological restrictions that were the hallmark of abstinence-only programs under the Bush administration.


The study, published in the Archives of Pediatrics and Adolescent Medicine, a journal of the American Medical Association, was led by a husband-wife team at the University of Pennsylvania. They randomly assigned 662 African-American students in grades six and seven to one of four different programs — an eight-hour abstinence-only program stressing the benefits of delaying intercourse; an eight-hour safer-sex program stressing condom use; a comprehensive intervention that covered both abstinence and condoms; and a control group that offered health information unrelated to sexual behavior.

The only program that successfully delayed the start of sexual activity was the abstinence-only instruction. By the end of two years, only a third of the abstinence-only group had engaged in sexual intercourse compared with almost half of the control group.

I, like many others who specialize in the care of adolescents, have taken a dim view of so-called "abstinence-only" sex education programs. In fact, I co-authored a position paper (PDF) for the Society of Adolescent Medicine in which we argued against funding for such programs. During the previous adminstration, the programs in question tended to be fraught with ideological language, and to encourage an unrealistic goal of abstinence until marriage. We also argued that such programs were ineffective, and left adolescents unprepared for informed decision-making about contraception and disease prevention when they made the very common decision to engage in intercourse.

The abstract for the study indicates that the program praised by the Times was free of value-judgement language, and advocated for a delay in "sexual debut" (an adolescent medicine term of art I find equal parts amusing and disturbing) until a point of greater maturity, but not necessarily marriage. Apparently, participants in both the abstinence-only and the condom-use focused groups used condoms to an equal degree when they did eventually have sex, which is an encouraging sign, though it does raise the question about where the participants in the former group got their information about contraception.

One thing I think I should make clear is that I always, without exception, include abstinence in my discussions with adolescent patients that have not yet become sexually active. I consider it the standard of care to do so, and I think most conscientious providers do the same. The beef is not with advocating for abstinence per se, but in denying adolescents information about contraception that they will eventually need to stay healthy.

Without access to the full-text of the article (which, thanks to the particular online subscriptions of my hospital, I cannot get) I can't fully evaluate the study. Certainly, the abstinence-only program seems to have been effective at reaching its goal of delaying sexual activity. In addition, the kids enrolled who did become sexually active apparently used condoms to the same degree that kids in the condom-use education program did. I'm not sure how to account for that, which confounds my interpretation of the study.

If appropriately-developed abstinence programs can delay the onset of sexual activity, then of course I think we need to incorporate them into our approach to sex education in general. However, it's also important to keep in mind that some participants in all programs ended up having sex (as is reliably the case, despite the protestations of the famously non-abstinent) and in those circumstances it's important to be sure that teenagers know how to keep themselves free of unintended pregnancy or STIs. I remain skeptical that abstinence-only programs really meet the needs of all adolescents, but am willing to see what further study shows.


  1. whoa Dr. Dan, this study refers to young teenagers, of the 13 year old variety. For a host of reasons they are more naturally able to follow an abstinence regimen, because even without it there are not many kids that age who have sex, telling them not having sex is good is bound to make them feel more comfortable with themselves not having sex, which is something most of them won't be having anyway. Of course you should teach 13 year olds this. But 17 year olds? I went to Catholic school and yet virtually everyone of my peers (and this was in the 70's) had sex around the age of 16.
    Now in Asia, they have sex later, but young people are not free. It isn't abstinence that keeps them pure (they aren't even taught about sex at all) it is overwhelming parental oversight.


  2. Dan, I, too, was shocked when I read the summary of the study last week. Despite the small sample and the reality that these were very young adolescents (10-13 years oldd) from a high risk population were not enough to keep me from rethinking my position on abstinence-only education. I guess if children are young enough, they need the world to be in black and white. As they hit high school they seem (from other studies) to do much better with comprehensive education; so that should be part of the dialogue.
    What I find quite upsetting is that even after the program, kids were participating in sexual activity in dangerously high numbers. The quote above notes success in that 30% of 8th graders, rather than 50% of 8th graders are sexually active after an eight-hour abstinence only program. Dramatic. But 30% seems really freaking high for middle school.
    Let's get someone to study self-esteem training and see if that helps kids in all aspects of their lives as well as keeping them physically and emotionally safe.

  3. Charo, having worked in a dedicated adolescent health center in upper Manhattan for three years, I can assure you that adolescents as young as those described in the study often are sexually active. Like Naptimewriter, I was (and still am) dismayed by this reality, but reality it remains.

  4. But I think Charo may be on to something about beginning first at a very young age (say, 10? They're not THAT young, are they??) with an abstinence-only program (of-the-wait-until-you're-a-bit-older variety, not a wait-until-marriage variety). Then gradually phase in the condoms.

  5. 30% seems freaking high for middle school

    NTW, Mama Nature doesn't care. She wired brains up to like sex and to seek it out. If the body has matured to the point that it is producing sufficient sex hormoes, well, it takes conscious effort to override hundreds of thousands of years of evolutionary conditioning. Humans need civilizing.

  6. Dr. Dan, I guess it depends on what you consider "sexually active" is petting or a little show and tell "sexually active?" I had my first kiss when I was 12 (proceeding to necking) and played strip poker when I was 13, but didn't go any further until I was 16. This was back in the 70's and I went to Catholic school. Intercourse is the at risk behavior, not kissing, so I would like a clear definition of what "sexually active" means.

    jeez gj, hundreds of thousands of years, how about billions. Are you a creationist? You can't civilize the sex drive, but you can control it. As to pre-teens, it is curiousity, not sex drive that leads to experimentation (like playing Doctor) lets distinguish the two, shall we.


  7. By "sexually active," I mean "having vaginal intercourse." Your experience is very different from a large number of my patients back at Mt. Sinai.