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DR. DARSHAK SANGHAVI | PEDIATRIC PERSPECTIVE

Teens should abstain from sex, not sex ed

This summer, the American Academy of Pediatrics, a group of 60,000 pediatricians, revised its guidelines on sex education, emphasizing that it is crucial to teach teens to use contraception, and saying that the abstinence-only programs touted by the Bush administration are unproven and risky..

Few people disagree that abstinence is a worthy goal that should be encouraged and taught in school. What bothers the AAP is the parallel move to ban all discussion of contraceptives.

The last time the doctors' group updated its guidelines, back in 1998, the report left open the possibility that abstinence-only education might be a viable way to stop teens from having sex. But in a telephone interview, Dr. Jonathan D. Klein, who wrote the guidelines, said, ''The evidence is fairly clear that abstinence-only education is not an effective way to prevent pregnancy or sexually transmitted diseases."

Abstinence-only education has gained popularity since 1996, when a little-known provision of the federal welfare reform law written largely by Robert Rector of the conservative Heritage Foundation allocated $250 million exclusively for school sex-ed programs that don't mention contraception. According to Wade Horn, a supporter of abstinence-only education and an assistant secretary at the US Department of Health and Human Services, discussing birth control with teens sends a contradictory message that undermines efforts to delay sexual behavior.

But the fact is that many teens are having sex anyway. About half of high-schoolers have had sexual intercourse, one-fourth before their 15th birthday, according to the federal Centers for Disease Control and Prevention.

Half of teen pregnancies occur within six months of losing virginity; however, most teens don't see a doctor for contraception until they've been sexually active for about a year. Almost half of teen couples didn't use a condom during their last intercourse. As a result, 40 percent of American girls get pregnant before leaving their teens.

While some teenaged mothers ultimately do well, they are at higher risk for academic failure, pregnancy complications, premature birth, and having children with behavior problems.

In the face of such overwhelming pregnancy rates, one would hope that all promising therapies including both contraceptive education and abstinence promotion would be directed at the problem. Omitting contraceptive education makes little sense for many reasons.

First, while many abstinence-only supporters think that mentioning contraceptives will drive teens to intercourse, studies from peer-reviewed medical journals rebut this notion. According to the AAP, no study has shown that contraceptive education increases teen sex rates.

Second, there have not been any studies published in nonpartisan peer-reviewed journals -- the gold standard -- showing that education programs that only promote abstinence are better at preventing pregnancies and risky behavior than comprehensive programs that include instruction about contraceptives.

Most studies of abstinence-only education, such as Mathematica Policy Research Institute's review this year of some federally funded programs, simply show that students have better ''attitudes" regarding abstinence than those getting no sex education whatsoever. Though encouraging, none yet has been proven to reduce pregnancy rates.

Furthermore, the only study that directly compared the two types of programs with the same rigor and design of a well-funded drug trial came down squarely on the side of comprehensive education. That study, reported in 1999 in the Journal of the American Medical Association, clearly demonstrated that contraceptive education was superior: Kids exposed to contraceptive education were no more likely to have sex, and were two-thirds less likely to have unprotected sex than those who took abstinence-only classes.

Third and most important, the modest 10 percent reduction in American teen pregnancies over the past decade is due partly to increased contraception (about three-quarters of the reduction), according to an analysis by the Alan Guttmacher Institute, a family and reproductive health research group, which supports contraceptive education. About one-quarter of the reduction is due to decreased sexual activity among teenagers. Though a connection between school-based education and teen pregnancy rates is hard to prove, a combined approach incorporating both abstinence promotion and contraceptive use appears sensible.

The bottom line is that both together can work well.

Still, it's hard for many to admit that teenagers have sex. In a 1998 study from the Archives of Pediatrics and Adolescent Medicine, 98 percent of teens' parents thought their children were virgins.

Abstinence-only education appeals to a parent's instinct to preserve innocence. But it also relies on a faulty premise that our ability to promote abstinence would be jeopardized if we acknowledged that normal teens sometimes have sex. In fact, I think the opposite is true.

That openness may someday prevent another tragedy like one I saw three years ago on a reservation in New Mexico.

A Navajo teenager hid a pregnancy from her parents and teachers at a boarding school where contraceptive education was prohibited. She was too embarrassed. She gave birth alone in her dorm and shut the baby in a suitcase. The baby was found hours later -- too late for our medical team to resuscitate him. Despite that tragedy, the school still lacks comprehensive sex education.

Dr. Darshak Sanghavi, a clinical fellow at Children's Hospital and Harvard Medical School, can be reached at www.darshaksanghavi.com.  

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