Thank you, Chairman Bilirakis and distinguished members of the Subcommittee.
I am a gynecologist who practiced medicine for twenty-eight years. I had a rewarding practice of in vitro fertilization and surgery, but I left my practice to commit the remainder of my medical career to helping prevent two of the most profound medical problems of our day, out-of-wedlock pregnancy and sexually transmitted disease. I have been doing this through an organization called The Medical Institute for Sexual Health, which I founded in 1992. The mission of the Medical Institute for Sexual Health is to identify, evaluate and communicate credible scientific data in practical, understandable and dynamic formats to promote healthy sexual decisions and behavior in order to dramatically improve the welfare of individuals and society.
The good news
In 1996, I testified before the House Ways and Means Subcommittee on Human Resources on the proposed Welfare Reform Act. My message then was that sexually transmitted disease and non-marital pregnancy are hurting far more people in society than most members of Congress and other Americans realize. To its credit, in an effort to constructively and meaningfully deal with these pregnancy and disease problems, Congress funded abstinence education with $50 million a year for five years through the Title V provision of the Welfare Reform Act. This funding has helped more than 700 abstinence education programs around the country to devote serious and much needed attention to these problems.
I come today with good news and bad news. The good news is that there is credible evidence showing that abstinence education is having an impact. More young people are living an abstinent lifestyle, and fewer teens are becoming pregnant. Today, more than half of all high school students are virgins.1 Also, beginning in 1990, the number of teens becoming pregnant began declining. Today we have the lowest teen birth rate that we have had since the 1950s, and teen pregnancy rates are lower than they have been any time since 1976.2,3
A ray of light and hope is emerging. Trend data showing declining sexual activity among adolescents and declining teen pregnancy rates reveal a societal shift in a positive direction -- it is reasonable to conclude that one contributing factor is the concomitant rise in abstinence education programs, though how large of a contributing factor we do not know. Some specific programs, such as the one in Monroe County, New York, and the Best Friends program that began in inner city Washington, DC, show a very marked decline in pregnancy rates.4,5
The bad news
But the bad news is that we still have an enormous problem. Sexually transmitted infection is highly prevalent among adolescents. Three to four million STDs are contracted yearly by 15 to 19 year-olds, and another five to six million STDs are contracted annually by 20 to 24 year-olds.6 Approximately six percent of adolescent females tested at family planning clinics and nine percent of female U.S. Army recruits (12.2% of 17 year-olds) are infected with Chlamydia trachomatis.7,8 5.6% of 12 to 19 year-olds and 17% of 20 to 29 year-olds are infected with herpes simplex virus type 2 (the virus that causes genital herpes).9 And whereas in the 1960s, only two STDs were of real concern, we are now aware of more than 25 (Appendix A). It is clear that, if and when young people begin sexual activity prior to marriage, they are at very high risk of acquiring an STD.
One reason STDs have become so prevalent among young people is that, in spite of the recent trend toward later sexual initiation, we had for years been experiencing a trend toward earlier sexual initiation, and the trend toward later marriage continues.10,11 The combination of these two factors means that people are likely to be single and sexually active for a significant period of time -- 5 to 10 years or longer -- during which they will normally accumulate a number of sexual partners. In fact, age of sexual onset is a very strong predictor of lifetime number of sexual partners.12 And an individual's risk of ever having contracted a sexually transmitted disease is strongly linked to his or her lifetime number of sexual partners.13,14,15
In addition, a major shift has occurred over the past three decades. The diseases primarily infecting young people are no longer syphilis and gonorrhea, which are frequently symptomatic and treatable with penicillin, but viral diseases such as human papillomavirus (HPV), herpes, and the unusual bacterium, chlamydia. The viral diseases cannot be cured -- only managed. And chlamydia, a major cause of infertility in young women, is asymptomatic in up to 85% of infected women16 but can still cause significant problems even without the presence of noticeable symptoms.
The sexually transmitted disease that has become the most common is a virus called human papillomavirus (HPV). The most recent major study about young women and HPV shows that 50% of sexually active women between the ages of 18 and 22 are infected with HPV.17,18 The National Institutes of Health Workshop On The Scientific Evidence On Condom Effectiveness For STD Prevention reported that there is no evidence that condoms reduce the sexual transmission of this infection.19 The NIH report also found no evidence for risk reduction for the transmission of herpes. A recent study has shown that condom use can produce a significant reduction (but not elimination) in the risk of herpes acquisition by women; however, the study did not find any impact for men.20 In addition, researchers at Johns Hopkins University, upon completing a study of STD prevalence at an adolescent clinic, found re-infection rates of chlamydia in adolescent girls to be so high that they recommended testing every sexually active adolescent girl in the United States every six months for chlamydia infection (regardless of reported condom use).21
Even though the pregnancy rate among teens has declined, today, 78% of teen births are out-of-wedlock, compared to 15% in 1960.22 These out-of-wedlock births contribute to poverty, crime, and negative outcomes for children including physical and emotional health problems, and educational failure. For example:
1. Poverty -- In 1995, 66% of families with children headed by a never-married single parent were living in poverty.23
2. Child health --White infants born to unmarried mothers are 70% more likely to die in infancy. Black infants born to unmarried mothers are 40% more likely to die.24
3. Education -- Living in a single-parent family approximately doubles the likelihood that a child will become a high-school dropout.25
4. Crime -- Boys raised in single-parent homes are twice as likely to commit a crime that leads to incarceration by their early thirties.26
"Abstinence Plus" education Is not the answer
Many have suggested that so-called "abstinence plus" -- dual message programs discussing abstinence while also teaching all about contraception -- is the appropriate answer to the twin epidemics of sexually transmitted diseases and out-of-wedlock pregnancies. Yet, for many years, it is just such programs that have been the predominant approach of sexuality education. And what did we see during these years? A genuine epidemic of sexually transmitted diseases is devastating our young people.
There have been many studies of dual message educational programs. Only a handful of these studies have found any significant impact on ANY behavioral or health outcome.27 And most of these have only made "statistically significant" impacts on behavioral outcomes (many times of questionable practical significance -- such as "condom use at last intercourse" and "frequency of unprotected sex" in the past few months). Only two of the CDC's "Programs That Work" have reported statistically significant delays in the initiation of sexual activity, and only one of these has reported a truly substantial impact on this outcome.28,29 Recently and to the acclaim of the media, a study reported a reduction in pregnancy rates among participants in a teen pregnancy prevention program. The intervention made no impact on rates of sexual activity and did not even measure STD rates. And the impact on teen pregnancy was almost entirely attributable to injectable contraception use, which provides NO risk reduction for HIV or any other STD.30 Additionally, this intervention was so expensive, per student, that it cannot be considered a reasonable option in most settings. Finally, not a single one of the CDC's so-called "Programs That Work" has even investigated its impact on STD or pregnancy rates!31
Despite what you may sometimes hear, there is no abundance of evidence that "dual message" or "comprehensive" programs are effective at preventing teen pregnancies and STDs. In fact, there is precious little evidence that these programs are really successful at all. Proponents of dual message programs face the same problems today as they have for many years -- an inability to document tangible success in protecting adolescent health. And to whatever extent these programs give young people the impression that "sex is really not a big concern, as long as you 'protect yourself'," such programs may even contribute to the problem.
Additionally, "safer sex" programs do not even address the problem of out-of-wedlock pregnancy. At best, these programs may encourage young people to wait before having sex; but there is rarely if ever any mention of the importance of actually being abstinent UNTIL MARRIAGE. As I have already stated, in spite of the recent decline in teen pregnancy rates, there has been a steady increase in the proportion of teen births occurring to unmarried teens. Similarly, the proportion of all births occurring out of wedlock has risen dramatically in the past few decades, so that in 1999, 33% of all American births occurred to unmarried women (compared to just 18% in 1980)32. Could this increase be related to the lack of an emphasis on marriage in our classrooms over that period? It has only been in the past few years that this trend has begun leveling off, but certainly there must be a much greater emphasis placed on abstinence until marriage, not just until some unspecified later date -- an emphasis that is clearly required by the Section 510 definition of abstinence education.
Much has been made of the fact that many parents and sexuality education teachers believe it is necessary, as an element of public sexuality education, to teach kids very directly how to use condoms and contraceptives. Clearly, parents care about their adolescent children and desperately want to protect them from harm. Unfortunately, far too many parents are inadequately informed about the problems of contraceptive and condom use. How many parents know, for example, that condoms do not appear to reduce the risk of infection with human papillomavirus, which is the cause of almost all cervical cancer and most abnormal Pap smears? Do most parents understand that even with 100% consistent condom use, their sexually active adolescents are at risk of contracting one of the other prevalent STDs (gonorrhea, chlamydia, trichomoniasis, etc...)? Do parents understand that, for many sexually transmitted diseases, if condoms are not used 100% of the time it is little or no better than not using a condom at all, ever?33 If America's parents knew the facts -- and these are scientifically supported facts, not conjecture nor ideology -- we know they would agree with us: Their children need to hear that the only reliable way to protect themselves from a sexually transmitted disease that can have lifelong, physically and emotionally painful ramifications, is to abstain from sexual activity.
Marriage is a health issue
Title V clearly articulates an abstinence-until-marriage message. Marriage involves both personal and public health issues. An individual's number of sexual partners is directly linked to his or her risk of contracting a sexually transmitted disease. The one environment where people are most likely to have one sexual partner for a long period of time is marriage. The largest study ever done examining sex in America was conducted by researchers at the University of Chicago and published in the aptly named book, Sex in America.34 These researchers reported that, in contrast to what most Americans believe, when a marriage is intact, married couples almost never have sex outside of that marital relationship. Young people should be encouraged to maximize their own personal health by reserving sexual activity for marriage.
With STD prevalence among young people continuing at high levels, condoms clearly not eliminating the risk of any STD, and a continued increase in the proportion of births occurring to unmarried mothers, there is abundant evidence that the "safer sex" paradigm, despite more than 20 years and a variety of education programs designed to promote condom use, has not solved the problem. Since new research is beginning to suggest that abstinence education can effectively address these problems, it is important that we continue the effort begun in 1996 and allow these programs sufficient time to continue to prove their effectiveness. Title V, including the definitions A through H, must be maintained as is. Doing so will ensure that research and evaluation can continue so that we can learn how this option is best delivered, and how abstinence education can best protect young people.
We recognize that we do not yet have sufficient data to positively determine the degree of effectiveness of abstinence education. But results are promising. The national evaluation of abstinence programs by Mathematica will be completed in 2005. If we do not continue with the current level of funding, or if we change the focus of the programs funded under Title V, we will lose an invaluable opportunity to learn how we can effectively help young people avoid sexual activity -- a risk behavior at least as detrimental to their health as the use of alcohol, drugs, and tobacco. And there will be no going back. If we damage the integrity of Title V the opportunity to fully explore this public health option will be lost. This is not about politics or ideology. This is about medicine, science, and data. All of which tell us the old approaches aren't working, not when millions of adolescents are contracting sexually transmitted diseases. We owe it to our young people to fully explore and evaluate the abstinence education approach, and that means continuing the Title V program as it is currently designed and being implemented.
Appendix A: List of Sexually Transmitted Diseases
Lymphogranuloma venereum (caused by certain strains of Chlamydia trachomatis)
Donovanosis (Granuloma inguinale)
Human Immunodeficiency Virus (HIV) Types I and II
Herpes Simplex Virus Types I and II
Human Papillomavirus (approximately 30 sexually transmitted strains)
Body or pubic lice
Human Herpes Virus type VIII
* Sexual transmission occurs but is not the primary mode of transmission.
Joe S McIlhaney Jr., M.D.
The Medical Institute for Sexual Health
P.O. Box 162306
Austin, TX, 78716-2306