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Abstinence Only Sex Ed No Good For HIV Prevention?

August 14, 2007

An article in a recent issue of the British Journal of Medicine has been widely covered recently, often with headlines proclaiming that abstinence-only sex education programs do not reduce HIV risk. On the surface of it, this makes sense – if you don’t tell people how to have safer sex, and they do it anyway, they are probably less informed and less able to reduce their risk. I don’t argue that this isn’t logically possible. However, the “study” that has been so widely touted isn’t some giant, breakthrough, randomized trial – it’s a systematic review, an attempt to consolidate the evidence from several previous studies.

While some folks find systematic reviews to be among the best evidence, the “top” of the evidence pyramid, I tend to disagree. These types of papers are not original research in the “running a trial” sense of medical research, and they can be limited by the quality of the original studies, the reporting of the original studies, the ability of the searchers finding those studies, the raters who decide what gets included in the review, and other factors.

So what did the researchers actually do? They searched the existing medical literature for randomized trials in “high income economies” the encouraged abstinence as the sole means of HIV prevention. They looked for trials that had biological and behavioral outcomes, such as HIV incidence or rates of unprotected vaginal sex. They excluded trials that did not have HIV prevention as a goal, those that focused only on pregnancy prevention. They also excluded trials that did not report biological or behavioral outcomes. This has been criticized by the conservative Family Research Council, which states that:

“Taking a closer look at the scientific studies chosen for the review, trials that did not report biological or behavioral outcomes were excluded. This was a convenient way of ensuring a desired conclusion. Newly introduced prevention programs usually conduct initial evaluations based on intermediate outcomes rather than rapid behavioral change. Such outcomes include increased knowledge, positive attitudes toward the desired behavior, and intentions to practice the behavior.”

The authors of the review seemingly anticipated this criticism, stating in their article that:

“although knowledge, intentions, and attitudes are important mediators of effects, these outcomes may not necessarily correspond to sexual behaviour or actual risk of HIV infection.”

In other words, you can ask teenagers what they know and mean to do all you want, but they’re likely to lie, and not follow through on what they said.

The researchers ultimately identified 13 trials conducted in the United States that met their criteria. The definition of having a control group was pretty loose – in a few of the cases, the subjects of the studies did receive some sex education, but had less “homework” or another modified factor, or had no intervention. None of the included trials actually reported HIV incidence, so the authors relied on “biological outcomes of interest [that] were self reported incidence of sexually transmitted infection and pregnancy.” Keep in mind that many teens, the subjects of such programs, may not be aware of having a sexually transmitted infection, although this would likely reduce the effect the authors find.

The authors looked at risk factors, such as unprotected sex, recent sex, not using condoms, and initiating sexual activity. However, there were only a handful of trials in each group, and only a handful of authors conducting these trials. In general, The researchers report no reduction in these risk factors compared to no intervention or “usual care” – again, though, in some cases “usual care” did include some education about sexual health, and these differences are not well-defined by the authors. The authors also included studies of sex ed programs among various age groups, from elementary school to college. You’d really have to look at the original studies to get a good sense of what was done.

However, the authors ultimately conclude, “that sexual abstinence only programmes for prevention of HIV infection do not decrease or exacerbate sexual risk among youths in high income countries, as measured by self reported biological and behavioural outcomes.”

What’s the bottom line? The review suggests that abstinence-only sex ed that specifically intends to reduce HIV risk may not be any more or less effective than no sex ed, or other forms of sex ed. It has certain limitations. It doesn’t set out to prove that comprehensive sex ed reduces HIV risk, nor is it really a definitive blockbuster study proving that abstinence-only sex ed “doesn’t work,” although you could logically assume that refusing to talk about condoms and overstating their failure rate doesn’t exactly encourage sexually active youth to use them.

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