British Medical Journal recently published a review of studies of the efficacy of abstinence-only sex-education programmes, which concluded that such programmes are ineffective. Based on that analysis, an accompanying BMJ editorial flatly stated that funding to abstinence-only programmes should be cut and re-directed to condom-promotion programmes.
Jokin de Irala, Professor of Epidemiology at the University of Navarre, Spain, believes those conclusions unwarranted and unsupported by the evidence.
Underhill and colleagues have reviewed 13 trials of abstinence only programmes and have done a great job putting together and summarising very heterogeneous studies. Indeed, the methodological pitfalls they have encountered within all studies are a sign of how difficult it is to achieve well designed studies for evaluating the effect of educational programmes on human behaviour, and/or to implement such studies. Most of the methodological problems cited by Underhill and colleagues are crucial:
- lack of intention to treat analysis (intention to treat analysis tends to underestimate any effect),
- heterogeneity in programme and trial designs making it impossible to perform a meta-analysis (and this means it is impossible to obtain a valid quantitative summary of programme performance),
- wide range of programme lengths (from one to 720 sessions and a median duration of 8 sessions),
- control groups were mostly “usual care groups” but such groups were rarely defined and reviewers affirm “they could have included any programme type”,
- missing information, making the assessment of methodological quality difficult,
- only four trials reported procedures for generating the sequence of assignment to intervention or control group and no trial reported procedures for concealing the randomisation process,
- attrition rates ranged from 5% to 45% (median 20%).
What puzzles me most, however, is the conclusion drawn by the authors after such a meticulous job reviewing the trials. They bluntly state that programmes that exclusively encourage abstinence are ineffective for preventing HIV and, by implication, generally ineffective.
The BMJ researchers and editorialists fail to mention other studies challenging the effectiveness of condom-promotion programmes.
For example, a trial in Uganda found an increase in HIV risky behaviours in the intervention group where condom use and supply was promoted. And a meta-analysis by Dicenso and colleagues showed various programs, including ones in family planning clinics, were actually not very effective at improving contraceptive use, delaying sexual debut or avoiding unwanted pregnancies. No-one then requested the elimination of funding to family planning clinics. [footnotes omitted]
African countries that implemented programmes oriented solely to promoting condom usage have failed to reduce HIV incidence, whereas Uganda succeeded in slashing its HIV prevalence from 16% to 6% by encouraging abstinence and faithfulness before condom usage.
In North America, sex-education programmes introduced in schools during the 1970s and 1980s failed to stop rising rates of teen pregnancy and sexually transmitted diseases. Yet, the reaction of the experts was not to recommend scrapping the programmes. To the contrary, they called for more detailed and more explicit instruction. In the face of demonstrable failure, the programmes expanded.
If the medical and educational authorities had judged those programmes with the same hasty and single-minded harshness accorded abstinence programmes, sex education would have been removed from schools twenty years ago.
So, why have many public-health experts been so quick to urge cessation of abstinence-oriented sex-education programmes?
Jokin de Irala, MD, is Deputy Director of the Department of Preventive Medicine and Public Health in the Faculty of Medicine at the University of Navarre, Spain. He holds a Master of Public Health (University of Dundee, Scotland), a Ph.D. in Medicine (University of Navarre, Spain), and a Ph.D. in Biostatistics and Epidemiology (University of Massachusetts).
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