Teenage Pregnancy, STI Infections and Emergency Contraception

It’s been about six weeks since I last slapped Dr Peter Saunders around – metaphorically speaking, of course – but as he’s decided to give me an early Christmas present with a typically misconceived article on teenage pregnancy, STIs and emergency contraception who am I to decline an opportunity to break out the intellectual claws.

The headline claim that Saunders makes is that free emergency contraception increases rates of sexually transmitted infections and by way of support, for once, he actually has a couple of published studies from reputable medical journals, specifically:

Durrance, C. P. (2012), The effects of increased access to emergency contraception on sexually transmitted disease and abortion rates. Economic Inquiry. doi: 10.1111/j.1465-7295.2012.00498.

Girma S, Paton D. (2011) The impact of emergency birth control on teen pregnancy and STIs. Journal of Health Economics. 30(2):373-80. doi: 10.1016/j.jhealeco.2010.12.004

The Durrance study uses data from the United States (Washington State) while Girma & Paton is a British study based on data from Nottinghamshire and both appear to take their data from roughly the same period, starting in 1998.

Both studies report broadly similar findings – no impact on either birth or abortion rates but an increase in STI associated with associated of pharmacy-based emergency contraception (i.e. the ‘morning after pill) which, in the case of the Durrance study, is specific to gonorrhoea while Girma & Paton appear to using combined STI rates for all classes of infection – I say appear as I’ve not yet gained full access to either paper, so I’m working from what I can see for free at the moment.

Saunders also cites a 2007 systematic review which found that increasing access to emergency contraception increases use but still has not appreciable impact on rates of unintended pregnancy.

The favoured hypothesis of both recently published studies – and Saunders – is that these results are best explained in terms of risk compensation, i.e. that some teenagers are more inclined to engage in risky sexual activity, in the knowledge that emergency contraception can be obtained, than might otherwise be the case were it not available, an argument which Saunders then goes on to suggest might also be applicable to condoms, ignoring the fact that only period in the last 45 years that saw a marked decrease in both teenage conception and abortion rates (1990-1995) corresponds to the-then government’s significant investment in its HIV/AIDS public awareness campaign and in schools-based risk reduction education programmes that heavily promoted the use of condoms.

The three year lag between the start of this campaign (1997) and the emergence of significant shift in the trajectory of trends in teenage pregnancy and abortion trends in England and Wales is best explained by a combination of cohort effect in the schools-based programmes and a delay in getting over the message that HIV presented a significant risk to heterosexuals due to its heavily publicised early association with gay men, intravenous drug users and, particularly in the US, with certain migrant populations. To put it rather more bluntly, it took straight white folks, particularly in the United States, quite a while to realise that AIDS didn’t just kill queers, junkies and niggers – and, believe me, those were the terms in large sections of the white American population engaged in the AIDS debate during the 1980′s.

So, there are some things to accounted for here, particularly the the lack of any impact on rates of unintended pregnancy and the apparent increase in STI rates reported by both studies, and the risk compensation hypothesis is certainly plausible, although not the only plausible hypothesis for what is, after, still only a correlation in epidemiological data.

We’ll start with a statement Saunders makes towards the end of his article that clearly betrays his personal biases:

Making the emergency contraceptive pill available over the counter free, without prescription, is sadly an ill-conceived knee-jerk response to Britain’s spiralling epidemic of unplanned pregnancy, abortion and sexually transmitted disease amongst teenagers. It is also not evidence-based.

There is, of course, no ‘spiralling epidemic of unplanned pregnancy’ as can be clearly seen in the following graph, which shows the key trends in teenage pregnancy, abortion and marriage for the forty years following the legalisation of abortion in the UK in 1967.

TP1968-2008

This the actual story of teenage pregnancy in England & Wales* and should be patently obvious things are neither spiralling nor can could one reasonably call this an epidemic. Conception rates amongst women under 20 have fallen, overall, since hitting a post-war peak in 1971 of with a combined live birth and abortion of 45.22 conceptions per 1,000 women under 20, with the most recent figures for 2011 giving a combined rate of 36.5 conceptions per 1,000 women under 20, with the major change over the last three years being an further increase in the proportion of conceptions ending in the termination of a pregnancy to just over 58%. In a time of economic recession this is hardly surprising given the clear evidence, in US studies, that over 70% of women who have abortions cite financial concerns as having been a significant factor in their decision.

* What is rarely, if ever mentioned in media articles about teenage pregnancy is that the big increase in teenage conception and birth rates in England and Wales actually occurred between between 1951-52, when there were only a little over 29,000 live births to mothers under the age of 20, and 1966, when the number of live births peaked at 86,528, with the most rapid increase taking place from 1956 onwards. The conception rate for teenagers, i.e. under 20s, did not alter significantly between the mid 1960s and the early-mid 2000s. The birth rate for under 20s in 1966 was 47.8 births per 1,000 women under 20. In 2004, the combined birth and abortion rates for women under 20 came out at 50.5 per 1,000. Allowing for miscarriages and stillbirths, where the rates for the latter have declined since the 1960s as medicine and medical technology has improved, the conception rates for women under 20 were much the same in 2004 as they were in 1966. What did change significantly over that period was the birth rate, which had more of less halved by 2004 as a result, primarily, of access to legal abortion, and the birth rates for married women under 20 and, in particular, for children born to women under 20 within 8 months of marriage. During the 1960s and early 70s, no one really cared very much about the teenage pregnancy rate, just so long as pregnant teenagers were either married or shoved unceremoniously up to the registry office before the child was born. It was only after the legalisation of abortion effectively killed-off the shotgun wedding that teenage pregnancies, generally, became a matter of political – and often hypocritical – concern.

Okay, so now we’ve got this data up on deck, let’s use it to tell the story of teenage pregnancy, a story that we can usefully divide up into five distinct phases.

1968-1976 – Positive Choices.

Legal abortions became available in the UK from 1968 onwards and, at roughly same time, a change in public policy on oral contraception resulted in ‘the pill’ becoming widely available to unmarried women for the the first time since its introduction in the early 1960s. This led, in the early 1970′s, to a marked decline in conceptions, live births and marriages amongst women aged under 20 as they used a combination of oral contraception and abortion to take control of their own fertility, with a very close match between the trends in conception and marriage rates and a very noticeable fall in the number of children born to women under 20 within eight months of the date on which they married. What we are seeing, here, is the beginning of the end for the ‘shotgun wedding’.

If you look in other data for the period you will easily find corresponding upward trends in the proportion of women entering the labour market and in the average age at which women were having their first child, trends which have pretty much remained on an upwards trajectory since the 1970s.

1976-1987 – Motherhood does not equal marriage.

Between 1976 and 1987, the trends in marriage and conceptions/live births diverge. Marriage rates continued to fall but the corresponding decline in conceptions/births went in the opposite direction, save for on short-lived period at the very beginning of the 1980s.

So what was driving these trends? Punk? The Queen’s Silver Jubilee? Thatcherism, perhaps?

The economy was certainly a major factor during a period which saw a big rise in unemployment and male unemployment, in particular, due to the decline in manufacturing and other industries that had, since the war, provided employment to unskilled and semi-skilled males. But, alongside the economy, what we also so is on both occasions that the trend in conceptions took an upswing, this happened in close proximity to very public health scares which suggested a link between the use of oral contraceptive and a increased risk of female cancers, while the sole significant reversal in that upward trend occurred in conjunction with the emergence of genital herpes as a significant public health concern. This, like the pill scares, attracted a considerable amount of media attention at the time.

So, alongside the broad picture, what we have is evidence of a degree of media sensitivity in the conception and live birth trends and young women responding to what see on the television and read in the press, which is a cause for concern as, in particular, the first significant breaks in the previous downward trend in conceptions followed in the wake of a health scare that was only tangentially related the main oral contraceptive that young women, in particular, were using at the time. The 1975-76 health scare was spawned by research that linked the first generation oral contraceptives, that were introduced in the late 1950s and early 1960s, to an increased risk of breast cancer at a time when most women, at particularly young women, were using much safer second generation oral contraceptives, not that this distinction was made by the media when it reported the claimed pill-breast cancer link.

That said, what is abundantly clear from the data is that this period is marked a profound change in social attitudes towards marriage and motherhood in which the two were no longer seen as being inextricably linked and it became perfectly normal for young women to have children out of wedlock in what was a relatively short period of time.

It was during this period, of course, that single parenthood began to become a significant political issue in the UK albeit in more or less generic terms rather than as specific issue relating to young women. Women of all ages were turning their backs on marriage during this period while still having children and there was also a significant rise in the divorce rate in the mid 1980′s which one can reasonably view as being one of the many unintended consequences of what a period of profound economic and social change and upheaval.

1987-1992 – HIV/AIDS.

I’m not going to walk through the early history of HIV/AIDS  – if you don’t know then it swing by the website of the Terence Higgins Trust and check out its history section (and feel to leave a donation as well, if you can).

What is relevant is that, in 1986, the UK government set up a Cabinet Committee on AIDS out of which, starting in 1987, came a major public health information campaign – ‘AIDS: Don’t Die of Ignorance’ – and major shift in emphasis in schools-based sex education towards risk-reduction and, in particular, promoting the use of condoms to reduce the risk of both pregnancy and sexually transmitted infections.

It took a while for these investments to bear fruit, as can clearly be seen in the data, but when it did it had an impact across the board. For a period of five years, from 1990 to 1995, there was a year-on-year drop in the conception, birth and abortion rates and a fall in STI infection rates.

Unfortunately, following its 1992 election victory, the Conservative government, which was by then led by John Major, began to row back on its previous investment in public health-based in anticipation of the launch of arguably the first modern example of an onmishambles, Back to Basics.

1992-1997 – Back to Basics.

Although ‘Back to Basics’ was formally launched until the 1993 Conservative Party conference, the groundwork for the government’s volte face on taking a public health-led approach to sexual health were laid over the course of the previous year, creating an aesthetically pleasing symmetry in the data. It took public health educators about three years to lay the foundations for a sustained five year fall in teenage pregnancy, birth, abortion and STI rates and more or less the same amount of time for the Major government to squander everything that had been achieved by public health educators on a moral campaign that rapidly became a byword for sleaze and hypocrisy.

The incompetent approach of the Major government did get a significant assist in 1995 courtesy of yet another pill health scare, this time linking third generation oral contraceptives and deep vein thrombosis, a scare that gained additional mileage after what was then the Committee of the Safety of Medicines got involved and issued advice which indicated that a number of third generation pills should not be used as first-line contraceptives. That advice that was withdrawn in 1999 after a review by another advisory body, the Medicines Commission, failed to back up the CSM’s 1995 position. Although the CSM’s advice had been widely criticised, at the time, as both unnecessary and alarmist, it nevertheless had a significant impact on women’s views of oral contraceptives and is considered to have been largely responsible for what was a 9% increase in the number of abortions in England and Wales in 1996, compared to 1995.

1997-2008 (and beyond) – Doing it for the Kids.

From the point at which single parents and unmarried mothers has first appears on the political landscape in the 1980s right up until the mid-1990s, most of the rhetoric had remained fairly generic and lacked any great focus on teenagers, save the occasional bit of conference season knockabout. That changed sometime around 1995-6 and, indeed, the first reference  could find to a UK politician referring specifically to teenage pregnancy as policy issue for government is in a report that ran in the Independent of a speech given by some bloke called Tony Blair, although further investigations also showed that it has previous arrived on the US political map in the early 1990s and that, like most of his pre-1997 rhetoric and polices, Blair was nicking his ideas from an American saxophonist whose stage name was Bill Clinton.

So, in comes New Labour and its specific teenage pregnancy strategy which has met with some modest successes, despite being derailed slightly in 2005 by yet another pill scare, this time triggered by a press release issued by the World Health Organisation announcing that it had added oral contraceptives to its list of known carcinogens, an event which occurred more or less at the start of the annual press silly season when the politicians are off on holiday leaving the way clear for Britain’s cancer obsessed mid-market tabloids to give it a bit of a splash.

Luckily, on this occasion, what we got more of a short-lived up-tick in conceptions rather than a full on upswing.

So. that’s the real story of teenage pregnancies in the UK since the late 1960′s and there is no ‘spiralling epidemic’ in the data – if you really want to see one of those then you need to look at the birth rates for women under 20 from the mid to late 1950s to the early 1960s – contrary to what many social conservatives would like you to believe, teenage sex started well before even the Rolling Stones.

At the time, and indeed right through until the 1980s, no one really cared too much if young women were getting pregnant in their teens, provided that they waited until there reached the age of sixteen. As long as they were safely married off by the time the baby arrived or the child could be put for adoption or passed off as the offspring of another member of the family then there was no need even to give the local backstreet abortionist a call. Only when women stopped getting married but carried on having children did conception rates become a matter of ‘public concern’ and its only in the last fifteen years or so that teenagers became the focal point of those concerns.

Although it’s perfectly true that conception rates amongst British teenagers remain stubbornly high relative to the rest of Western Europe, we are not in a situation in which those rates are spiralling out of control. Rather it’s the case that right now, at the end of 2012, we’re more or less heading towards a point where, if recent trends continue, then in another couple of years or so we might just about have repaired the damage caused by ‘Back to Basics’, at least as far a conception rates are concerned.

Okay, so that the story of teenagers and pregnancy, but what about teenagers and sexually transmitted infections?

Data-wise, we’re a little more limited in what we have to play with both in timespan and age-related statistics, so the best we can do is take a look at the all-age trends since 1995, which look like this:

STIrates

So, with the exception of gonorrhoea, where the trend line follows a very similar trajectory to the trend in teenage conceptions, infection rates for other STIs appear to have risen significantly since 1995 and spectacularly so in the case of chlamydia, although you can, perhaps, get a much better picture of how things have actually changed over time in this next graph, which plots indexed rates for the same period.

STIIndexYou’ll note that I’ve omitted syphilis from this second graph. This is reasons of clarity – although overall rates of infection are low relative to other infections, the actual rise in infections over since 1995 has been dramatic (2,500-3000%) – and because the vast bulk that rise is due to a sharp rise in infection rates in MSMs (men having sex with men).

As far as relating this information back to teenagers goes, the Health Protection Agency’s most recent report on STI infections and young people notes that the 16-24 age group accounts for around 65% of new chlamydia infections, 55% of new diagnoses of genital warts and around 50% of all new cases of gonorrhoea. Overall, infections rates amongst men are higher in the 20-24 age group than in the 16-19 group, but for women the highest rates of infection are found in the 16-19 age group, all of which fits the general cultural pattern of young women tending to date slightly older men.

Again, if we go back to Peter Saunders’ remarks, we are allegedly seeing a ‘spiralling epidemic’ of STIs in teenagers and, for once, it would appear that there is some truth in that proposition, certainly in regards to chlamydia infections and syphilis infections in MSMs. For other infections, the picture is a little more mixed; gonorrhoea has been up and down in a similar fashion to conception rates, the rising trend in genital warts has, it appears, just started to turn the corner thank to the new HPV vaccination programme, which started in 2008 while there has been a bit of an acceleration in the rising trend in new diagnoses of genital herpes since 2006.

However, in the case of chlamydia, things are not quite that straightforward. Chlamydia is a bacterial infection and, until the mid-late 1990s, that mean that testing for chlamydia infections was based on the classic, but rather slow, practice of growing bacterial cultures from specimens provided by patients. However, towards the end of the 1990s, nucleic acid amplification tests for chlamydia were introduced which reduced both the cost of testing and the time it took to obtain results to the point at which proactive screening programmes became a viable option.

The NHS National Chlamydia Screening Programme was launched in 2005 in England and Wales and proved sufficiently successful in it’s initial three-year pilot phase (2005-2007) that it was both extended and significantly expanded in 2008.

chlscreenThere, of course, is the explanation for the big rise in chlamydia diagnoses in 2009, which is almost entirely due a substantial increase in testing through the screening programme and not a substantial increase in infection rates.

So, with the exception of syphilis, claims of a ‘spiralling epidemic’ is sexually transmitted infections would appear to be an exaggeration. Nevertheless, the trends in STI infection rates are a legitimate cause for concern.

Okay, that’s the statistical picture and – just this once, I’m going to throw Saunders a bone because, coming right back to his risk compensation hypothesis, there is actually some pretty supporting evidence and not just from epidemiological studies. In 2009, the journal Human Reproduction published a paper by Baecher et al. which reported the results of a randomised trial in which sexually active young women aged 14-24 years of age were randomly assigned to one of two groups, one of which was given enhanced access to emergency contraception, while the other received only standard access. Demographic, behavioural and psychosocial information for each of the women in the trial was obtained at the outset and was used to assess their baseline risk of pregnancy and their use of emergency contraception was monitored at six and twelve months after enrolment in the study, which produced some striking results:

In our trial, women at low and high baseline risk of pregnancy responded differently to an intervention designed to optimize access to EC. The intervention resulted in increased EC use among both risk groups, but the increase in repeated use was significantly greater in low risk women than in high risk women. Indeed, women at low baseline risk were 10 times more likely to use EC repeatedly if they received increased access than if they were in the standard access group. In contrast, the effect of the intervention on repeated EC use was only half as great among women who had a high baseline pregnancy risk.

This finding is noteworthy because women at low risk for pregnancy are arguably the subgroup least in need of a pregnancy reduction intervention. In our analysis, even the 10-fold increase in repeated EC use produced by the intervention did not result in a significant decrease in the probability of unintended pregnancy among low risk women. This differential effect of the intervention by pregnancy risk—specifically, its relatively poorer success in increasing EC use in the highest risk women—may partially account for its failure to produce a decrease in pregnancy incidence in the full trial population.

There, straight away, is the explanation for why increasing access to emergency contraception has failed to bring down teenage pregnancy rates – it doesn’t really alter the behaviour of those young women who are most at risk of getting pregnant.

But there is more…

Why might the intervention have been more effective in increasing EC use in women at low risk of pregnancy? Our analysis found that low risk participants were substantially more averse to pregnancy at study enrollment, and accordingly, they were more likely to be using highly effective contraceptives and less likely to have recently had unprotected sex. Such women assigned to the increased access group may have continued this predisposition toward protective behaviors by taking advantage of the opportunity to increase their EC use. In contrast, high risk women randomized to the increased access group may have been less primed to make use of EC even when it was readily available.

One other explanation for our findings is that the risk profile of participants may have changed because of the intervention. Recent analyses of these same data suggest that women identified as low risk based on enrollment data, who then received an advanced supply of EC, may have adopted risk behaviors more consistent with a high risk participant, secondary to increased reliance upon EC as a contraceptive method (Raymond and Weaver, 2008;Weaver et al., 2008). Since EC use increased substantially with increased access among both risk groups without a concomitant decrease in pregnancy incidence, it remains feasible that women provided with an advanced supply of EC were using EC as a substitute for other more reliable methods. Under this hypothesis, the intervention may have had two independent and counteracting effects: increasing EC use among high risk women as well as increasing risk behaviors among initially low risk women.

We should be careful about a couple of things here.

First and foremost, then women who were given enhanced access to emergency contraception in this study were given a supply of contraceptives upfront, which is not the same thing as simply making them available over the pharmacy counter without the need for a prescription, so increasing access through pharmacies may not have quite the same effect unless young women are, perhaps, using that access to stock up in advance.

Second, when the study talks about increasing risk behaviours in young women who were initially assessed as low risk, that doesn’t mean that their sexual activity increased after being given an up-front supply of emergency contraceptives. What did alter was they way they used contraception in as much as made more use of what they had to hand, the emergency contraceptives, rather than using condoms – and we can assume that condoms were the preferred alternative as had they used standard oral contraceptives they would would have been excluded from the trial.

Nevertheless, the evidence from this trial is consistent with the studies that Saunders puts forward in support of the argument that widening access to emergency contraception has failed to have impact on conception rates in women under 20 and that, in line with the risk compensation hypothesis, it may even being making an unintended contribution to rising STI infection rates. For once Saunders is correct, widening access to emergency contraception does not, of itself, reduce teenage pregnancies and it may very well increase the risk of STI infection in some young women, specifically those in the low pregnancy risk group who would otherwise use condoms, reducing their risk of infection at the same time as their risk of pregnancy.

What is also clear, however, is that we have two quite different groups of young women here, one that is risk averse in terms of pregnancy but seemingly rather less concerned about the risk of STI infection and another which is equally careless of both risks, and it this last group that explains why teenage pregnancy rates remain stubbornly high in the UK, hence Baecher et al’s final observation:

Further research to elucidate reasons why women at high risk of pregnancy may be relatively unresponsive to efforts to improve their use of EC and test resolutions to this problem is critically needed.

Saunders, however, thinks he already has the answer…

The best way to counter the epidemic of unplanned pregnancy and sexually transmitted disease is to promote real behaviour change. The government would be well advised to enter into dialogue with leaders of communities in Britain where rates of sexually transmitted diseases and unplanned pregnancy are low, especially Christian faith communities, to learn about what actually works.

Church-based programmes such as Love for Life (Northern Ireland), Love2last (Sheffield), Challenge Team, Romance Academy or Lovewise (Newcastle) are getting great results and have much wisdom to pass on. How about financing some serious research into examining them in more depth?

Oh dear, and he was doing so well up to this point, except for the condom argument, but after throwing the guy a bone I now have no alternative but to take it back off him.

All the groups that Saunders suggests we usefully learn from promote abstinence until marriage based on Christian morality, an approach to sex and relationship education that we already know to be an abject failure:

The main objective of Title V, Section 510 abstinence education programs is to teach abstinence from sexual activity outside of marriage. The impact results from the four selected programs show no impacts on rates of sexual abstinence. About half of all study youth had remained abstinent at the time of the final follow-up survey, and program and control group youth had similar rates of sexual abstinence. Moreover, the average age at first sexual intercourse and the number of sexual partners were almost identical for program and control youth.

Some policymakers and health educators have questioned the Title V, Section 510 abstinence education programs, believing that the focus on abstinence may put teens at risk of having unprotected sex. The evaluation findings suggest that this is not the case. Program and control group youth did not differ in their rates of unprotected sex, either at first intercourse or over the last 12 months. Less than 10 percent of all study youth (8 percent of control group youth and 7 percent of program group youth) reported having unprotected sex at first intercourse. Over the last 12 months, 21 percent of both program and control group youth reported having sex and not always using a condom.

Program group youth, however, were less likely than control group youth to perceive condoms as effective at preventing STDs. Compared with control group youth, program group youth were less likely to report that condoms are usually effective at preventing HIV, chlamydia and gonorrhea, and herpes and HPV. Furthermore, program group youth were more likely than control group youth to report that condoms are never effective
at preventing these STDs.

Trenholm et al. (2007) Impacts of Four Title V, Section 510 Abstinence Education Programs. Mathematica Policy Research Inc.

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Because virginity is often culturally linked only to vaginal sex, to preserve virginity, adolescents and young adults may engage in other sexual behaviors that involve exchange of fluid and are thus salient for STD acquisition. Overall, oral sex and anal sex are prevalent behaviors in this population, most commonly in conjunction with vaginal sex. Here we consider those who have oral or anal sex without vaginal sex.

Amongst those who have only oral sex and/or anal sex, pledgers are over-represented. Overall, about 3% of respondents reported oral sex with one or more partners but no vaginal sex. Although just over 2% of nonpledgers fall into this group, 13% of consistent pledgers and 5% of inconsistent pledgers do (p  .000). Similarly, 0.7% of nonpledgers report anal but no vaginal sex, compared with 1.2% for pledgers. Although too few females report anal but no vaginal sex, for males we find a significant difference between pledgers and nonpledgers (p  .021). Specifically, slightly more than 1% of male nonpledgers report anal sex but no vaginal sex, compared with almost 3% for inconsistent pledgers and 4% for consistent pledgers. For oral sex, condom use is almost completely absent—respondents reported condom use for first oral sex for only 4% of the relationships that involved oral sex. For anal sex, condom use is also lower than for vaginal sex. Condoms were used in about 30% of relationships involving anal sex when partners had anal sex for the first time. The combination of low condom use and over-representation of pledgers provides some support for the hypothesis that this behavioral pattern is associated with greater than expected STD acquisition among pledgers, although the numbers are small and provide an insufficient basis from which to make inference.

Bruckner H, Bearman PS. (2005) After the Promise: the STD consequences of adolescent virginity pledges. J Adolesc Health. 36:271– 8.

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Although abstinence from sexual intercourse represents a healthy behavioral choice for adolescents, policies or programs offering “abstinence only” or “abstinence until marriage” as a single option for adolescents are scientifically and ethically flawed. Although abstinence from vaginal and anal intercourse is theoretically fully protective against pregnancy and disease, in actual practice, abstinence-only programs often fail to prevent these outcomes. Although federal support of abstinence only programs has grown rapidly since 1996, existing evaluations of such programs either do not meet standards for scientific evaluation or lack evidence of efficacy in delaying initiation of sexual intercourse.

Although health care is founded on ethical notions of informed consent and free choice, federal abstinence-only programs are inherently coercive, withholding information needed to make informed choices and promoting questionable and inaccurate opinions. Federal funding language promotes a specific moral viewpoint, not a public health approach. Abstinence-only programs are inconsistent with commonly accepted notions of human rights.

In many communities, AOE has been replacing comprehensive sexuality education. Federally funded AOE programs censor lifesaving information about prevention of pregnancy, HIV and other STIs, and provide incomplete or misleading misinformation about contraception. The federal government’s emphasis on abstinence-only approaches may also be harming other public health efforts such as family planning programs and HIV prevention efforts—domestically and globally. Federally funded abstinence-until-marriage programs discriminate against GLBTQ youth, as federal law limits the definition of marriage to heterosexual couples.

Schools and health care providers should encourage abstinence as an important option for adolescents. “Abstinence- only” as a basis for health policy and programs should be abandoned.

Santelli et al. (2007) Abstinence and abstinence-only education: A review of U.S. policies and programs. J Adolesc Health. 38:72– 81.

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Our study is not the only recent work to suggest that abstinence-only education may not reduce sexual risk behaviors among teens. A randomized controlled trial of four federally funded abstinence programs found no significant decrease in number of partners or risk for STD and pregnancy, and no delay in sexual debut [13]. Similarly a systematic review of 13 trials found that abstinence-only programs were not associated with reductions in sexual risk behavior or in diagnosis of STDs [14]. Another review showed that all but one of 11 programs that taught about contraception resulted in no increase in sexual activity [12]. Other studies have shown that sexual activity is not increased with teaching about condoms [15] and HIV/AIDS [16].

Although one study found later sexual debut was associated with abstinence-only virginity pledging, the majority of adolescents who made virginity pledges ultimately broke their “promise” and engaged in sexual intercourse before marriage [17]. In addition the risk for STD was not significantly different between pledgers and nonpledgers, and sexually active pledgers were significantly less likely to use condoms at first sex than were nonpledgers. Similarly our data comparing abstinence-only and comprehensive education revealed no significant difference in initiation of sexual intercourse, while detecting a decreased likelihood of teen pregnancy among those who received comprehensive education. This suggests that preteens and teens who receive abstinence-only education may engage in higher risk behaviors once they initiate sexual activity.

Kohler, P., Manhart, L. & Lafferty, W. (2008). Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy. Journal of Adolescent Health 42 (4): 344-351.

I think that rather proves the point.

We’ve still got one question to try and answer here, the one posed by Baecher at al – why were young women in the high pregnancy risk group in their study unresponsive to efforts to increase their use of emergency contraception or, indeed, any contraception.

A little while ago, I took the local authority area data for conception and abortion rates in young women under 18 in England and used it to plot a number of correlation series against local authority deprivation indices, running three sets of plots, one each for the conception and abortion rates and one for the ratio of abortions to conceptions.

This graph shows the correlation coefficients for each plot across five deprivations domains, the index of multiple of deprivation and individual indices for income, education, employment and health plus additional coefficients for the percentage of Christians and all mainstream religious beliefs in each local authority using recently released census data.

conceptIMD

Right from the off we can see that conception rates are strongly correlated with all five deprivation indices, while abortion rate are most strongly correlated with multiple and income deprivation, a little less so with employment and health inequalities and a bit less still with educational deprivation, although the relationship is still reasonably solid.

Religion, generally, doesn’t seem to make much difference to either conception or abortion rates but there is a weak but noticeable negative correlation between the size of an area’s Christian population and both primary rates, although I wouldn’t get too excited about that because when you plot the size of local religious and Christian populations against deprivation you get this graph, which rather suggest that the negative correlations to conception and abortion rates stem from Christians being more middle class than other religious groups.

religionIMD

Getting back to the first graph, the correlation are noticeably turned on their head when we look at the ratio of abortions to conceptions with moderate negative correlations across all deprivation domains except education, where there is strong correlation – and on that metric the size of religious and Christian populations has no appreciable effect whatsoever.

What this rather clearly suggests is that amongst young women risk aversion, in relation to pregnancy, is strongly influence young women’s economic and educational circumstances and how this impacts on their perception of their own life chances. If we think in terms of rational choice theory then engaging in sexual behaviours in which there is a risk of pregnancy is a rational choice if you live in a social and economic environment which offers very few alternatives to early motherhood, none of which are particularly appealing anyway. The one thing that does seem to make a significant difference, at least in terms of likelihood of a pregnant teenager choosing to have an abortion, is education, which may offer some – but only some – a route out of poverty to something that’s worth delaying motherhood for.

Although comprehensive sex and relationship education is certainly a better approach than the failed abstinence only/until marriage plus Christian morality model favoured by people like Peter Saunders, the data suggests that there are limits to what can be achieved solely by focussing on that type of education. Raising educational standards and aspirations, generally, would help but – and it is very big “but” – is it also likely that any gains one might make by trying to raise young people’s aspirations will be rather limited if we cannot also provide them with things that are worth aspiring to, like a halfway decent job and affordable housing, for starters.