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Science, Abstinence, and Nonsense: Ideological Threats to Public Health
- 1. Science, Abstinence, and Nonsense: IdeologicalThreats to Public Health John S Santelli, MD, MPH Chair, Heilbrunn Dept of Population and Family Health Columbia University Bixby Center, UCLA January 5, 2010
- 2. Stephan Colbert: On Accuracyand The Truth “In order to maintain an untenable position, you have to be actively ignorant, ... One motto on the show is, Keep your facts, I'm going with the truth.”
- 3. Newly Released: CDC STIReport, 2008 John Douglas, Director of Division of STI, CDC: "Chlamydia and gonorrhea are stable at unacceptably high levels and syphilis is resurgent after almost being eliminated. . . . We have among the highest rates of STDs of any developed country in the world." "Better sex education can help. We are not honestly and openly dealing with this issue and it's the larger issue of sexual health. . . We haven't been promoting the full battery of messages. We have been sending people out with one seatbelt in the whole car.”
- 4. Looking Backward, Moving Forward:The End of Abstinence • Critiques of abstinence-only • Lessons learned from the fight against ab-only – Role of research – National advocacy groups – State pubic health establishment • Can we marshal these insights moving forward?
- 5. Federal Abstinence-Only, Until Marriage PrimaryU.S. government strategy for dealing with adolescent sexuality over past 10 years • By 2005, more than 800 programs and $1.5 billion • “Exclusive purpose” is the promotion of abstinence outside of marriage • May not in any way advocate contraceptive use or discuss contraceptive methods except to emphasize their failure rates
- 6. Federal Abstinence-Only, Until MarriageFunding • Increasing rejection of state funding since 2005 • Program slated for termination by Congress in – 2007 – 2008 – 2009 • President Obama proposes to zero out funding (6/09) • Revived in health reform bill from Senate Finance Committee (10/09)!
- 7. Science-Based Critiques of Abstinence-OnlyPolicies • Poorly designed, lack program efficacy, considerable costs • Not medically accurate, promote misinformation • Harm to CSE, public health and foreign aid programs • Inconsistent with sexual realities of young people • Inconsistent with parent preferences
- 8. Rights-Based Critiques of Abstinence-OnlyPolicies • A “moral” agenda, not a public health policy • Promote sexist and racist stereotypes • Insensitive/unresponsive to LGBTQ & other youth • Withhold life-saving information from youth • Counter to international human rights thinking
- 9. Efficacy of ComprehensiveSex Ed: UNESCO (Kirby) 2009 Among the 87 comprehensive sex ed programs (Developed and developing countries) • 31% ↓ frequency of sex (10/32), 3% ↑ frequency • 44% ↓ number of sexual partners (16/36), 0% ↑ • 40% ↑ condom use, 0% ↓ use • 40% ↑ contraceptive use (6/15), 1 ↓ use • 53% ↓ sexual risk ∆ in multiple behaviors (16/30)
- 10. Efficacy of AbstinencePromotion: UNESCO (Kirby) 2009 6 rigorous evaluated studies of abstinence-only • 0/6 showed ↓ initiation of sex, recent sex, # of partners, or condom use 5 weak evaluations • 2/5 showed delay in initiation Recent CDC review • Best evaluated programs (e.g., RCTs) = no impact • Weaker evaluations more likely to find an impact
- 11. Harm to SexualityEducation and Other Public Health Programs • Censorship of textbooks and teachers • Abstinence-only replaced comprehensive sexuality education • Undermining public health goals in Title X & HIV • Harm to foreign aid efforts – PEPFAR prevention
- 12. Key Themes fromthe Language of the Federal Program • Moral language: “chaste,” “virgin,” and “promiscuous” – “a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity” • Frames abstinence as attitude or commitment • Assertions of medical “facts” • Certainty about the efficacy of abstinence • Denigration of condoms and contraception – Fear of the mixed message – Concern that contraception causes sex • “Genesis” story, creation of a post-sex syndrome
- 13. Underlying Assumptions • Sexeducation and access to contraception cause teenagers to have sex • Teaching about abstinence and protection is a mixed message • Describing the limitations of contraceptive methods will stop teenagers from having sex
- 14. Abstinence Only Education: Inconsistentwith Scientific Theory? • Does not build upon scientific findings or create an encompassing paradigm grounded in science • Builds on an ideological belief system which is internally consistent but often not logical • Many separate “facts” are incorrect • Refuses to accept scientific consensus or follow the rules of scientific review (e.g., does not publish) • Creates a veneer of science by using medical professionals and the creating its own communication streams
- 15. Abstinence-Only Policies: Symptom ofa Broader Problem A Broader Problem of • Science and politics • Data and ideology • Denial of global warming • Opposition to – Stem cell research – Emergency contraception – HPV vaccine
- 16. Bad Wine inNew Bottles (An Historical Perspective) • Opposition to sex education in the late 1960s – Christian Crusade: “Is the School House the Proper Place to Teach Raw Sex?” • Historical roots in the Victorian era (Anthony Comstock) – Contraception and information as pornographic • A conservative movement about social mores and political power reached its ascendance in the 1990s-2000s • Opposition to sexuality education, reproductive rights, women’s rights, rights for adolescents, gays and lesbians
- 17. Looking Backward: What Worked? •Multiple science-based and rights-based critiques • Sustained advocacy • Partnership between advocates and scientists • Effective use of wedge issues: – Program efficacy – Medical accuracy • Rejection by the state public health establishment
- 18. Sustained Advocacy • SEICUS,Guttmacher I., Advocates for Youth • Human Rights Watch • Organizations of health professionals – AAP-2008, SAM - 2006, ACOG - 2008, APHA - 2007
- 19. Use of WedgeIssues: Program Efficacy • Multiple evaluations of ab-only and CSE programs • 7 abstinence-only programs (Kirby 2007): – 0% strong evidence of ↓ sexual initiation, 1 program weak evidence – No impact: condom or contraceptive use, sexual risk-taking • 87 comprehensive sex ed programs (UNESCO 2009) – 38% ↓ initiation of sex, 0% ↑ initiation – 40% ↑ condom use – 40% ↑ contraceptive use
- 20. Use of WedgeIssues: Medical Accuracy • By spring 2007, 21 states have required scientific or medical accuracy in sexuality or HIV/AIDS education • Key features of legal definition: – Based on generally-recognized scientific methods – Publication in peer-reviewed journals – Weight of the evidence – Accurate, objective, complete by leading professional organizations: CDC, AMA, ACOG, AAP • Clarify distinctions between science and ideology • Medical accuracy: a useful rhetorical device (hard to oppose!)
- 21. Public Health Rejection: StateRefusal of Federal Funding • 4 states as of December 2006 – CA (1998), ME (2005), PA, NJ • 17 states as of March 2008 • 25 states as of August 2008 (SEICUS) Key concerns: • Accuracy and efficacy (Raymond et al 2008)
- 22. Moving Forward: Reframing thePolicy Debate • Goals: CSE or public health outcomes? • Time for some healthy cohabitation between CSE and contraception • Human rights and medical ethics • Questioning abstinence
- 23. Time for SomeHealthy Cohabitation: Comprehensive Sex Ed and Contraception Not always a steady relationship. . . . Recent history: • Importance of HIV education in improving condom and contraceptive use and decreasing teen fertility • Role of Abstinence-only in undermining condom and contraceptive use and rising teen birth rates
- 24. Reproductive Rights asHuman Rights • Access to accurate health information as a basic human right • Withholding information or supplying misinformation is inherently coercive • Patients have rights to accurate and complete information from health care providers • Governments obligated to provided accurate information to their citizens • Adolescents are people with rights as well
- 25. Is Abstinence aPublic Health Goal? • A goal for government(s)? – Healthy People 2010, 2020 • A healthy choice for individuals? • Abstinent until when? Considerations • Universality of sexual initiation in mid to late teens • Changing age at marriage • Marriage not an option for GLBTQ youth • Non-importance in teen fertility
- 26. Age of FirstIntercourse & First Marriage in Women: 1970, 2002 20.8 19.2 10 15 20 25 30 35 First intercourse First m arriage First intercourse First m arriage AGE 1970 2002 25.3 17.4
- 27. • National YRBStrends – 1991-2007 • Falling and rising pregnancy risk among teens • Changing use of condoms and contraception primarily responsible for – ↓ in teen pregnancy/births 1991-2005 – ↑ in teen births in 2006 and 2007 • HIV education and abstinence only Journal Adolescent Health 2009 Changing Behavioral Risk for Pregnancy Among High School Students in the U.S., 1991-2007 John S Santelli, Mark Orr, Laura D Lindberg, Daniela Diaz
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- 30. 1995 teen fertilityrates. Age at first sex for cohort born in 1970s. Teen Fertility and Sexual Initiation 0 20 40 60 Netherlands Denm ark Belgium France Greece NorwayGreatBritain US Teen fertilty rate Median age 1st sex
- 31. What Can WeLearn from Europe? • European teens not more likely to initiate sex • Europeans more likely to use contraception and to use more effective methods • Dutch parents are more likely to accept teen sex and to expect teens to be responsible/ use contraception • The Netherlands went through a specific period of national dialogue and consensus building in the 1970s
- 32. Looking Backward, MovingForward Implications for the future • Partnerships between advocates and scientists • Partnerships between CSE and health providers • Focus on public health and human rights
- 33. Science, Abstinence, and Nonsense: IdeologicalThreats to Public Health John S. Santelli, MD, MPH Chair, Heilbrunn Dept of Population and Family Health Columbia University UCLA January 5, 2010
- 34. Copyright ©2008 AmericanPublic Health Association Arias, D. C. Am J Public Health 2008;98:396-399 “It was clear the only weapon we had against AIDS was education, education, and more education.” Dr. Koop, 1992
- 35. Reframing and Rethinking •U.S. needs to return to science-based policies • Importance of political leadership • Promoting healthy sexuality
- 37. Looking Backward, MovingForward The basic facts: We were right They were wrong They lost We won! Or did we????
Editor's Notes
- #5 A pic or two?
- #6 While the federal government has supported abstinence or abstinence only programs since 1981 via the Adolescent Family Life Act of 1981 (part of Title XX of the Public Health Service Act), since 1997 there have been major expansions in federal support for abstinence programming and an increasing emphasis on funding programs that are abstinence-only. These expansions include Section 510 of the Social Security Act, which in 1996 was part of welfare reform, and Community-Based Abstinence Education projects, funded through an earmark in the maternal child health block grant for Special Projects of Regional and National Significance (SPRANS) program in 2000. These programs prohibit disseminating information on contraceptive services, sexual identity, and other aspects of human sexuality [Dailard 2002]. The Adolescent Family Life Act stressed premarital abstinence to the exclusion of information about contraception [Thomas 2000]. Section 510 programs must have as their “exclusive purpose” the promotion of abstinence outside of marriage [for people of any age] and may not in any way advocate contraceptive use or discuss contraceptive methods except to emphasize their failure rates [Dailard 2002] .
- #7 While the federal government has supported abstinence or abstinence only programs since 1981 via the Adolescent Family Life Act of 1981 (part of Title XX of the Public Health Service Act), since 1997 there have been major expansions in federal support for abstinence programming and an increasing emphasis on funding programs that are abstinence-only. These expansions include Section 510 of the Social Security Act, which in 1996 was part of welfare reform, and Community-Based Abstinence Education projects, funded through an earmark in the maternal child health block grant for Special Projects of Regional and National Significance (SPRANS) program in 2000. These programs prohibit disseminating information on contraceptive services, sexual identity, and other aspects of human sexuality [Dailard 2002]. The Adolescent Family Life Act stressed premarital abstinence to the exclusion of information about contraception [Thomas 2000]. Section 510 programs must have as their “exclusive purpose” the promotion of abstinence outside of marriage [for people of any age] and may not in any way advocate contraceptive use or discuss contraceptive methods except to emphasize their failure rates [Dailard 2002] .
- #8 Today, I will primarily focus on abstinence as a public health issue put also touch on the human rights aspects at the end. In doing so I will treat abstinence as health professionals treat other behaviors that influence health: examining the epidemiology of the behavior, health consequences, current federal programs to promote abstinence, the efficacy of programs to promote abstinence, secondary effects of AOE, special concerns for sexually active and GLBTQ youth and describing some human rights concerns that have been raised about abstinence.
- #9 Today, I will primarily focus on abstinence as a public health issue put also touch on the human rights aspects at the end. In doing so I will treat abstinence as health professionals treat other behaviors that influence health: examining the epidemiology of the behavior, health consequences, current federal programs to promote abstinence, the efficacy of programs to promote abstinence, secondary effects of AOE, special concerns for sexually active and GLBTQ youth and describing some human rights concerns that have been raised about abstinence.
- #12 While federal funding is provided to support supplemental programs that promote abstinence as the only goal, increasingly abstinence-only education is replacing more comprehensive forms of sexuality education. Evidence from a variety of sources suggests an increasing emphasis on abstinence-only approaches to sexuality education with a corresponding diminution of more comprehensive approaches. For example, in 2003, the Texas Board of Education decided to remove most information about contraception from new health education textbooks. [ http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=2&DR_ID=26615 , accessed 11/10/2004 ] . Recent reports also describe teachers and students being censured for responding to questions or discussing sexuality topics that are not approved by the school administrators [Joint statement from the National Coalition Against Censorhip2002.] The cancellation of Programs that Work from the Division of Adolescent and School Health at the Centers for Disease Control and Prevention, presumably because the only effective programs listed were comprehensive programs with no abstinence-only programs included, provides a final, ominous example. [ www.memoryhole.org ] .
- #16 Today, I will primarily focus on abstinence as a public health issue put also touch on the human rights aspects at the end. In doing so I will treat abstinence as health professionals treat other behaviors that influence health: examining the epidemiology of the behavior, health consequences, current federal programs to promote abstinence, the efficacy of programs to promote abstinence, secondary effects of AOE, special concerns for sexually active and GLBTQ youth and describing some human rights concerns that have been raised about abstinence.
- #19 It would be great if we could get pictures or logos from these various groups. Key individuals were Bill (William) Smith at SEICUS, Cynthia Dailard at Guttmacher, James Wagoner at Advocates.
- #25 Paradoxically, while abstinence appears to be the moral choice for teenagers, the current federal approach to abstinence-only funding raises serious questions about this approach as a violation of human rights. Abstinence-only education has personal and public implications. Access to accurate health information as a human right has been included in a variety of international statements on reproductive rights. Governments have an obligation to provided accurate information to their citizens and eschew the provision of misinformation. Such obligations extend to state-supported health education and clinical counseling.
- #27 While abstinence until marriage is the goal of many abstinence policies and programs, few Americans wait until marriage to initiate sexual intercourse. For women the median age at first intercourse in 2003 was 17.4 years, while the median age at first marriage was 25.3 years, a difference of 8 years. In comparison, in 1970, the median age at first sex was 19.2 years and the median age of marriage was 20.8 years for women, a difference of only 2 years.
- #38 Pics that represent the 5 bullets?