Virginity pledges: the rest of the story

The "kids" aren't "kids" and they aren't "teens." And they wait 3 years longer than their peers and no one knows if they even had a sex ed course in school.

Fox News reports on their interview with the author of a report on teens who take virginity pledges. She told them that religious teens wait 3 years longer than non-religious teens and (as reported here, last week), the background of those who take virginity pledges is more important than the pledge itself.

Click here to read the study in Pediatrics.

Note that there is no way to know whether any of the students took any type of abstinence-based sexuality education course, that the ages of the "pledgers" and "non-pledgers" evaluated and matched in the study were at least 15 in the first "wave," 22 or so at the end, and the average age of first intercourse for the group is 21 years old, three years older than the national average.

Rosenbaum, the author of the "new" study also removed all of the married participants in the study:

Her study also only looked at teens who were unmarried five years after taking virginity pledges, now ages 20 to 23. "The married are out of the picture, so they're not as interesting," she said.

Edited 1/3/09 at 6 AM.

New study on virginity pledges and behavior

The article in question can be downloaded from Pediatrics, here.


The final "wave 3" data came from the group that the author calls "adolescents" -- who were 22 years old. Data from those who had married was treated as "missing."

We don't know anything about the actual sex ed courses that the students took, who paid for the course, or whether they actually took a course or just made a pledge.

From the article: “Virginity pledges are also now used to measure AOSE program effectiveness, which the US government considers successful if they produce many virginity pledgers, irrespective of participants’ sexual behavior.”

(Is it true that the pledge is considered a marker for the success of abstinence-only sex ed? I know that I’ve read several articles showing short term increase in the intention to remain abstinent, so that would not surprise me. However, I haven’t seen this “marker.”)

As far as I can tell, it appears that the author took data from a series of national questionnaires , matched kids for background and family, and found that they have similar outcomes after 5 years.

Oddly, a huge number - 80% - of the pledgers denied having pledged in follow up. The other number that seems to stick out is that the non-pledgers did pay for sex and/or get paid for sex more often.

Nevertheless, the only study that I’ve seen that measured pregnancy rates after a course that included teaching proper condom use did not show prevention of pregnancy, either. I posted a review of the pay-for-view article in the British Medical Journal.

Abstinence vs "plus"

The Texas Legislature is about to reconvene and the sex ed debate in our State is already in the news. (Free subscription required.)

Unfortunately, the news article blurs the line between sex ed for all children in our schools and the problem that some of our girls have multiple pregnancies as teenagers. What little evidence we have about "abstinence-plus" vs "abstinence-only" sex ed (some of which is reviewed here and here) is never mentioned, while the fact that our State teen pregnancy rate has dropped is seen as a failure or completely ignored.

Along with many of our local physicians, I teach the doctor's portion of "Worth the Wait." The program is taught in all our county's schools. The classes begin in the 6th grader (the students are 11 and 12 years old) and continue into High School health classes (through grade 12, or 17 to 18 years old). The course consists of 16 or 17 classes, including one on STD's that is taught by local doctors and one on the legal consequences, taught by local lawyers.

The main contrast between "Worth the Wait" and "Big Decisions," the program mentioned in the article ( available for download, free, here), is that in each of the 10 to 12 lessons, the latter emphasizes condom use for those who do choose to have sex. There's even a supplemental lesson that teaches how to correctly use a male condom.

Many point out that since some teens will have sex before marriage, and that many will do so much earlier than expected, the earlier these lessons are taught, the better. However, in my experience, the kids who are having sex before 17 or 18 are the ones who are also engaged in other risky behavior, including drinking alcohol and smoking, or who are being abused. (See the story about the 18 year old young man, here.)

I'm uncomfortable with early discussions about "taking action" to buy condoms and how to use them because it seems to actually endorse the idea that there is a healthy way to have sex outside of a committed, monogamous relationship - one that 14, 15 and most 16 and 17 year-olds are not able to establish.

I believe that the best decision is the one that parents, teachers and our schools should teach. We do not talk about the safest way to drive a car before they are 16 and have passed several tests or that seat belts will protect them if they drive recklessly, we don't teach them which alcohol to drink when they are under the legal age limit, and we never tell them that if they are going to smoke, here's the way to do it.

In my "How to live a healthy life" talk that I give adolescents and teens (and sometimes adults) I talk about the physiological and medical reasons we encourage helmets for skaters, seat belts in cars, and why we discourage certain other behavior. I mention the job of the liver, the differences in the body as it matures, the risk of addiction, injury, and infections. Then, I talk about the psychological and social risks and consequences.

For instance, can you really trust someone selling an illegal drug to be honest about what he's selling you? If someone pressures you to have sex without a condom, knowing the risk of even deadly infections (yes, I talk about condoms in my office) does he even love himself, much less you?

It astonishes me how varied the apparent ages of these children are - even through the High School classes (up to age 18). Some still appear to be prepubescent and some look to be fully developed physical adults. While discussing sexual abuse, I remind the 11, 12, and 13 year-olds that in the State of Texas, that it is absolutely illegal to have sex under the age of 14.

And in every class of 6th graders, there's at least one girl who raises her hand and asks if she could go to jail.

I'm quoted in Texas Monthly

Over the weekend, at the annual convention of the Texas Medical Association, a friend said that she'd read my quote in "Texas Monthly." I assumed she meant an old article in Texas Medicine, the journal of the Texas Medical Association. I was wrong. (And, maybe now I know why I can't get appointed to any of the TMA Councils or Committees!)

In an article titled, "Faith, Hope and Chastity," in the very liberal Texas Monthly the author (without contacting me at all, by the way) used a statement that I made at a 2004 Texas School Board hearing on the content of high school textbooks on sex education.

The board met to consider these textbooks in July and September of 2004. More than one hundred people testified or submitted written testimony. Those who testified in person were given three minutes each to make their case. According to Gordon Crofoot, a specialist in HIV and STD treatment and research, many of the board members appeared totally uninterested in his testimony. Crofoot cares for about one thousand patients in his practice in Houston and is currently seeing more young patients with HIV than he has in his 31 years of practice.

“These textbooks do not meet the criteria and are factually and scientifically incorrect in what they say,” he told the board, “but their major fault is in what they don’t say and the resulting consequences. . . . If we do nothing [about STDs], the direct cost over the next ten years would be $10.6 billion. Comprehensive sex education programs might reduce this cost by fifty percent. Can Texas afford this cost?”

Crofoot was cut off when his three minutes were up. He offered to answer any questions. The board had none. Later in the day, he watched as Beverly Nuckols, a family doctor in New Braunfels opposed to comprehensive sex ed, was asked about the implications of human papillomavirus for men. She answered that HPV affected women differently than men before stating her position that condom instruction, in her experience as a family doctor, would do little good. “Yesterday I saw a boy who had had three partners in the last month,” she said. “He’s had twenty-two partners. He’s eighteen. He uses condoms every time. Unfortunately, a lot of the times he’s drunk and so they break or they don’t work. I mean, condoms are not a solution for teenagers outside of monogamous relationships. They don’t use them right even if we teach them.”

I'm not quite sure why I was chosen as the representative of those who "opposed comprehensive sex ed." I can't quite remember telling the story, but I probably did -- however, I don't think I would say, "I mean . . ." In order to read it in the journal, you'd have to turn to the "continued on page 200-something." However, I believe that the story was to refute testimony that high school boys and girls should be taught that condoms are the answer to all risk from the consequences of sex. My more common story is to note that condoms are more likely to be used correctly by couples in a monogamous relationship, that couples get better as time goes on, and that if a hundred couples use condoms to prevent pregnancy, 11 of them will get pregnant within a year.

The part that I remember addressing was a comment from a nurse practitioner who stated that there was no risk of contracting the Human Papilloma Virus for a girl, if the male wore a condom. The concern, according to her, is the infection of the girl's cervix. This was about the time that the public was becoming aware that cervical cancer is caused by HPV 99% of the time. According to the nurse, the tip of the penis when covered by the condom wouldn't actually touch the cervix. I felt compelled to delicately explain that the most common human sexual activity involves ins and outs, and that there is much more contact and potential for spread of the virus to all of the male and female genitalia -- except for the parts actually covered by the condom.

Let me correct one thing: I'm not against comprehensive sex education. I disagree with some people about the definition of "comprehensive," and believe that anything beyond the basics of very boring biology - the medical and legal responsibilities of human sexual activity - ought to be vetted by the parents in the local school districts. The school is not the place to teach methods and techniques and condoms are not the panacea they're far too often made out to be.

I do believe that the State (schools) should encourage sex within monogamous marriage, since that is the healthiest for individuals, families and their children, and for the taxpayer. While some people do very well in different arrangements, it takes a lot more work and the risks are far greater.

Give me liberty or give me condoms!

Where are the condom squads who go around making sure that every grocery store, drug store, and 24 hour convenience store stocks latex condoms and the appropriate lubricants, "at all times"? Condoms are a much more basic public health issue than Plan B, which only works (when it works) for about 5 days in the woman's cycle.

Siricou Raven is keeping the conversation alive as to whether or not pharmacists should be forced to stock and dispense all legal medicines. She asks,

What is the difference between a pharmacist refusing to distribute contraception because it offends his own morality, and one refusing to dispense HIV medication because it offends his own morality?

Treating disease has never been controversial. Have you ever heard of a doctor or pharmacist who refuses to treat syphilis, gonorrhea or chlamydia? Have you noticed any that have ceased doing Pap smears since we learned that abnormal Paps are due to a Sexually Transmitted Disease, Human Papilloma Viruses that are only transmitted by sexual contact?

(I do know a pulmonologist - a lung specialist - who will not take on patients who smoke. I could draw all sorts of parallels between sex and smoking, but I'll leave that to you.)

At issue is the very basic question is that of the "unalienable" individual right to liberty, expressed as following the conscience.

As Judge Lawrence wrote in the Injunction, the Washinton State law is very clear on the right to conscience and freedom to practice religion.

There is no reason to carve out contraception and "reproductive health" (a Newspeak term, if I ever heard one) as a special, protected class of medicines, devices and procedures.

For that matter, why on earth would any woman who doesn't want to become pregnant have sex without two or more contraceptives in hand/body before the act itself and/or know her fertile periods? If men didn't have the back up insurance of abortion, I'd bet they would be more careful, too. (Rape is an Emergency Room issue - the ER doc and SANE nurse can dispense and counsel on fertility risk, right along with prophylaxis for STD's).

While I'm ranting:

Ethics lesson 1: Life trumps liberty, since pretty much everything else depends on being alive.

Ethics lesson 2: The only reason the State should force action from a citizen is in cases of life and death. Each law that is enforced puts the citizen's life and liberty at risk, since the enforcement will involve the real and virtual guns of the State. There is a long history of recognizing the relationship between the right to own property and the right to liberty. If the State may take the property or restrict the livelihood of a person, the person is at risk of prison or hunger and is not free.

Ethics lesson 3: People who will do acts that they believe morally wrong for any reason other than to save lives (to stay out of jail, keep their jobs or avoid controversy) are either unethical people or insane. And I'm not too sure about the people who would force them, either.

Two sex ed reviews, still no conclusions

We're finding that nothing changes the rates of pregnancies and STD's in teens except parental and peer pressure and concerns ("costs") of pregnancy.

I'm afraid that two published reviews of the literature on studies on sex education for adolescents and teens done by Kristen Underhill, Don Operario, and Paul Montgomery at the Centre for Evidence-Based Intervention at the University of Oxford ( here)and (here ) don't tell us much more than we knew before.

Although the authors report that there are few if any reports that give biological data or actual pregnancy and STD (including HIV) infection rates, the first study found no significance in behavior in "abstinence only" sex education compared with "usual care" in the community. (We're not sure what the "usual care" at those schools is, however.)

In the second study, authors did a review focusing on reports on sex education in "high income" societies, comparing "abstinence only" (which are defined as not promoting condom use) and "abstinence plus" (those which emphasize abstinence but promote condom use if you're going to have sex). report that there is a significant difference in decrease of "HIV risk behavior," but no evidence that teens have sex later, actually contract STD's less often, or have fewer pregnancies.

Neither of these studies tell us that abstinence based sex education does not work. I'm afraid that the only thing they do tell us is that there are factors we are not measuring and that our young people are engaging in risky behavior.

Hat Tip to "Pure Pedantry."

Who needs these ads?

Blog.bioethics.net, the blog of the "American" Journal of Bioethics editors and pseudoeditors, are protesting the fact that some TV networks won't sell advertising time to a condom manufacturer. As I commented on their site, the ed's and pseudo-eds have forgotten that most Americans don't live on a college campus. ((Where one in four the residents contract Sexually Transmitted Diseases each year and where nearly that many - one in five - girls are sexually assaulted during their stay.)

How many of us have had to explain "Gentleman's Club" billboards to a 4 year old? How about finding ourselves needing to teach our 7 or 8 year old who just saw a commercial what a condom is?

Since we're talking "should:" I'd go so far as to say that most people believe that sex is properly private and that children shouldn't be exposed to sexual behavior of adults around them.

There, I've said it.

I guess parents could turn condom and K-Y jelly commercials into a sort of lesson that kids used to get on the farm when they saw sex between animals at a young age. Of course, those kids were exposed to birth and death in the home and in the barnyard, as well as watching their own food be killed and dismembered, too.

And, since I'm saying things that need to be said: (in my opinion) the constant public (in media such as TV and the Internet) the "selling" of sex of all kinds at at all hours of the day and night has resulted in an unintended social experiment.

That experiment has failed: the age of first sex has declined, and the variety and incidence of STD's has increased, even in those who report that they use condoms - and far too many don't, and don't believe that they're at risk. I don't believe it's healthy, physically or mentally.

Follow-up: HPV Testing, Men, and Prevalence

I did a little research on testing for HPV, especially in men.

The CDC site on HPV is here and it's up to date. http://www.cdc.gov/std/HPV/STDFact-HPV.htm

Digene, http://www.digene.com/labs/labs_hpv_01.html is a swab test for women. Negatives are true negatives for current risk of cancerous changes at the cervix. If negative, then 99.5% accurate - no HPV present at that time. (Can not rule out past infection, but only 1 in 1000 chance of cancerous changes without active infection.)

There is no approved test for males. A few urologists will test with the Digene test - but it's not very sensitive and can miss a lot of disease.

There is a blood test for some of the strains of HPV. However, one article (free online) states that less than 60% of the women who had HPV never become "seropositive."

The new article in the Journal of the American Medical Association from March on the numbers of infection in women is free at http://jama.ama-assn.org/cgi/content/full/297/8/813
Table 1 is very good - and look at the married women: infection rate is 17%. However, for those who said they'd never had sex, the infection rate is 5% and for those with only one partner, 11%.

More on HPV, mandates, and tax money

All State Medicaid programs must offer the vaccines recommended by the (Federal) Advisory Committee on Immunization Practices, under the Vaccines for Children program. The States don't have to mandate the vaccine, however.

Some of the docs I've talked to are convinced that Medicaid and uninsured patients will have an easier time accessing and affording Gardasil than insured patients - unless the insurance companies are forced to cover it somehow.

I predict that within just 2 or 3 years, the private insurers will see that the girls who receive the vaccine don't have to have nearly as many repeat paps, fewer colposcopies and biopsies. Eventually, in 5 or 6 years, there will be fewer freezing and laser therapy treatments. Somewhere in there, they will begin to cover and strongly encourage the vaccine, without being forced.

It turns out that the transition from infection with the more virulent strains to a precancerous or even carcinoma intraepithelial neoplasm (cancerous cells in the surface layer - the kind that leads to repeat pap smears, colposcopy and biopsies and then freezing or laser ablation or removal of the surface layer of the cervix. The pathology-reported names given to these spots on the cervix include "Low Grade Squamous Intraepithelial Lesions, High Grade SIL, Carcinoma in Situ ) can occur within 2 to 3 years, although most take 10 years or so.

From an article available here, free on line,

The traditional view has been that this process takes years, if not decades, to occur after initial HPV infection. Recent studies suggest that these changes may develop more quickly than previously thought. Winer et al followed women after initial HPV infection for the development of CIN 2/3.

As shown in Figure 3, approximately 27% of women with an initial HPV 16 or 18 infection progressed to CIN 2/3 within 36 months [20]. A second study of a large health maintenance cohort found that approximately 20% of women 30 years of age or older who were initially infected with HPV 16 developed CIN 3 or cervical cancer within 120 months.

Women who had an initial HPV 18 infection had approximately a 15% risk of developing CIN 3 or cervical cancer at 120 months [21].

The strong correlation between infection with high-risk types of HPV and LSIL, HSIL, and cervical cancer suggests that HPV DNA testing would be a useful tool for the management of women with abnormal Pap test results, especially in the case of those with equivocal test results. In the case of an equivocal Pap test result, HPV DNA testing can help determine whether the individual should be referred for colposcopic assessment [22].

(Ault, Kevin. "Epidemiology and Natural History of Human Papillomavirus Infections in the Female Genital Tract." Infect Dis Obstet Gynecol. 2006; 2006: 40470. Published online 2006 January 30. doi: 10.1155/IDOG/2006/40470. Copyright © 2006 Kevin A. Ault.)


The biggest financial gain to the Medicaid program and then the insureres - as well as the biggest gain in decreased worry and actual pain and suffering of women - will not be from a decrease in diagnoses of the cancer, itself. It will be from the decrease in the visible warts, as well as precancerous changes from the occult infections that can't be seen with the naked eye and the repeat testing and biopsies, along with the cervical damage from excisions, lasers and freezing which can lead to infertility and premature births.

More information at this summary of another research paper. And this paper reports on 2 year risk of developing CIN.

UK: Teaching children how to use condoms no help

This month, the British Medical Journal (sorry, subscription only) has published a report on a randomized controlled study on enhanced sex ed that failed to reduce the numbers of pregnancies or abortions in teen girls. Essentially, the "programme" involves education for boys and girls 13 to 15 years old, including teaching them to obtain and "handle" condoms (how to put them on), role playing and games about sexual situations. This is in contrast to "Conventional Education" in the UK, which is described this way in the report:

In the 12 control schools sex education for third and fourth years varied from seven to 12 lessons in total, primarily devoted to provision of information and discussion. Only two control schools routinely demonstrated how to handle condoms, and none systematically developed negotiation skills for sexual encounters. The cost of conventional education varied, with individual packages starting from about £20. Few teachers had more than one day’s training, which would have cost about £180 a day, and some had received none or only a few hours’ training.

Luckily, there are some good reviews online:
"Sex Education Fails to Cut Teenage Pregnancies" from the Guardian.

"Role playing sex classes fail to cut abortions," from the Telegraph.

An enhanced sex education programme for teenagers has proved no better than conventional teaching in cutting unwanted pregnancies or abortions, a detailed research study said yesterday.

The programme was based on an intensive £900 training course for teachers that was then delivered to 15-year-olds over three years.

Five years later, conception rates were measured in 20-year-olds who had been on the programme and compared with those in young people who had not.
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The teaching system, called Share — sexual health and relationships: safe, happy and responsible — included group work, role play and games. The teenagers were shown how to use condoms and access sexual health services and were given leaflets on sexual health.

The programme and research was devised and supported by the Medical Research Council (MRC) and the Education Board for Scotland, now Health Scotland.

Teachers in the schools used for comparison had less instruction or none at all.

"Sex education "only does so much'" from BBC News notes that schools are required to teach sex ed from ages 11-14 in England and Wales, but there has been no such requirement in Scotland.

And from the November 23 "Learning and Teaching Scotland" web site, we learn that the program was introduced throughout that region last week.

The UK press reports that the teen pregnancy rates under 18 are going down, from 44.3 births per 1000 girls ages 15 to 17 to 42.9 since 1998, and declared this a "success."

Edited 12/29/08 for labels.