Issues & Implications vention is obviously much smaller than the group of people who are not Understanding ‘Abstinence’: having sex. The size of the popula- tion of abstinence users, however, Implications for Individuals, has never been measured, as it has for other methods of contraception. Programs and Policies When does abstinence fail? The def- By Cynthia Dailard inition of an abstinence user also has implications for determining the The word “sex” is commonly at the individual and programmatic effectiveness of abstinence as a acknowledged to mean different levels, and clarifying all of this for method of contraception. The presi- things to different people. The same policymakers, remains a key chal- dent, in his July 2002 remarks to can be said for “abstinence.” The lenge. Meeting that challenge should South Carolina high school students, varied and potentially conflicting be regarded as a prerequisite for the said “Let me just be perfectly plain. meanings of “abstinence” have signif- development of sound and effective If you’re worried about teenage preg- icant public health implications now programs designed to protect nancy, or if you’re worried about that its promotion has emerged as Americans from unintended preg- sexually transmitted disease, absti- the Bush administration’s primary nancy and STDs, including HIV. nence works every single time.” In answer to pregnancy and sexually doing so, he suggested that absti- transmitted disease (STD) prevention nence is 100% effective. But scientif- Abstinence and Individuals for all people who are not married. ically, is this in fact correct? What does it mean to use absti- For those willing to probe beneath nence? When used conversationally, Researchers have two different ways the surface, critical questions most people probably understand of measuring the effectiveness of abound. What is abstinence in the abstinence to mean refraining from contraceptive methods. “Perfect first place, and what does it mean to sexual activity—or, more specifi- use” measures the effectiveness use abstinence as a method of preg- cally, vaginal intercourse—for moral when a contraceptive is used exactly nancy or disease prevention? What or religious reasons. But when it is according to clinical guidelines. In constitutes abstinence “failure,” and promoted as a public health strategy contrast, “typical use” measures how can abstinence failure rates be mea- to avoid unintended pregnancy or effective a method is for the average sured comparably to failure rates for STDs, it takes on a different conno- person who does not always use the other contraceptive methods? What tation. Indeed, President Bush has method correctly or consistently. specific behaviors are to be described abstinence as “the surest For example, women who use oral abstained from? And what is known way, and the only completely effec- contraceptives perfectly will experi- about the effectiveness and potential tive way, to prevent unwanted preg- ence almost complete protection “side effects” of programs that pro- nancies and sexually transmitted against pregnancy. However, in the mote abstinence? Answering ques- disease.” So from a scientific per- real world, many women find it diffi- tions about what abstinence means spective, what does it mean to cult to take a pill every single day, abstain from sex, and how should and pregnancies can and do occur to the “use” of abstinence as a method women who miss one or more pills of pregnancy or disease prevention during a cycle. Thus, while oral con- CONTRACEPTIVE EFFECTIVENESS RATES FOR be measured? PREGNANCY PREVENTION* traceptives have a perfect-use effec- tiveness rate of over 99%, their typi- CONTRACEPTIVE PERFECT TYPICAL Population and public health cal-use effectiveness is closer to 92% METHOD USE USE researchers commonly classify peo- (see chart). As a result, eight in 100 ABSTINENCE 100 ??? ple as contraceptive users if they or women who use oral contraceptives FEMALE STERILIZATION 99.5 99.5 their partner are consciously using will become pregnant in the first ORAL CONTRACEPTIVES 99.5–99.9** 92.5 at least one method to avoid unin- year of use. MALE CONDOM 97 86.3 tended pregnancy or STDs. From a WITHDRAWAL 96 75.5 scientific standpoint, a person would Thus, when the president suggests *Percentage of women who successfully avoid an unintended pregnan- be an “abstinence user” if he or she that abstinence is 100% effective, he cy during their first year of use. **Depending on formulation. Sources: intentionally refrained from sexual is implicitly citing its perfect-use Perfect use—Hatcher, RA, et al., Contraceptive Technology, 17th ed., 1998, activity. Thus, the subgroup of peo- page 216. Typical use—AGI, Fulfilling the Promise: Public Policy and U.S. rate—and indeed, abstinence is Family Planning Clinics, 2000, page 44. ple consciously using abstinence as a 100% effective if “used” with perfect method of pregnancy or disease pre-

The Guttmacher Report on Public Policy December 2003 4 consistency. But common sense sug- doms fail as much as 14% of the that exclusively promote “absti- gests that in the real world, absti- time, they should be given a compa- nence from sexual activity outside of nence as a contraceptive method rable typical-use failure rate for marriage” (“Abstinence Promotion can and does fail. People who intend abstinence. and Teen Family Planning: The to remain abstinent may “slip” and Misguided Drive for Equal Funding,” have sex unexpectedly. Research is What behaviors should be abstained TGR, February 2002, page 1). The beginning to suggest how difficult from? A recent nationally representa- law, however, does not define “sex- abstinence can be to use consis- tive survey conducted by the Kaiser ual activity.” As a result, it may have tently over time. For example, a Family Foundation and seventeen the unintended effect of promoting recent study presented at the 2003 magazine found that half of all 15–17- noncoital behaviors that leave young annual meeting of the American year-olds believed that a person who people at risk. Currently, very little Psychological Society (APS) found has oral sex is still a virgin. Even is known about the relationship that over 60% of college students more striking, the APS study found between abstinence-promotion activ- who had pledged virginity during that the majority (55%) of college stu- ities and the prevalence of noncoital their middle or high school years dents pledging virginity who said they activities. This hampers the ability had broken their vow to remain had kept their vow reported having of health professionals and policy- abstinent until marriage. What is not had oral sex. While the pledgers gen- makers to shape effective public known is how many of these broken erally were somewhat less likely to health interventions designed to vows represent people consciously have had vaginal sex than non- reduce people’s risk. choosing to abandon abstinence and initiate sexual activity, and how Abstinence is 100% effec- There is no question, however, that many are simply typical-use absti- increased abstinence—meaning nence failures. tive if ‘used’ with perfect delayed vaginal intercourse among consistency. But common young people—has played a role in To promote abstinence, its propo- sense suggests that in the reducing both teen pregnancy rates in nents frequently cite the allegedly real world, it can and the United States and HIV rates in at high failure rates of other contracep- least one developing country. tive methods, particularly condoms. does fail. Research by The Alan Guttmacher By contrasting the perfect use of Institute (AGI) indicates that 25% of abstinence with the typical use of pledgers, they were equally likely to the decrease in the U.S. teen preg- other contraceptive methods, how- have had oral or anal sex. Because nancy rate between 1988 and 1995 ever, they are comparing apples to oral sex does not eliminate people’s was due to a decline in the proportion oranges. From a public health per- risk of HIV and other STDs, and of teenagers who had ever had sex spective, it is important both to sub- because anal sex can heighten that (while 75% was due to improved con- ject abstinence to the same scien- risk, being technically abstinent may traceptive use among sexually active tific standards that apply to other therefore still leave people vulnerable teens). A new AGI report also shows contraceptive methods and to make to disease. While the press is increas- that declines in HIV-infection rates in consistent comparisons across meth- ingly reporting that noncoital behav- Uganda were due to a combination of ods. However, researchers have iors are on the rise among young peo- fewer Ugandans initiating sex at never measured the typical-use ple, no research data exists to young ages, people having fewer sex- effectiveness of abstinence. confirm this. ual partners and increased condom Therefore, it is not known how fre- use (see related story, page 1). quently abstinence fails in the real Abstinence Education Programs world or how effective it is compared But abstinence proponents fre- with other contraceptive methods. Defining and communicating what is quently cite both U.S. teen preg- This represents a serious knowledge meant by abstinence are not just nancy declines and the Uganda gap. People deserve to have consis- academic exercises, but are crucial example as “proof” that abstinence- tent and accurate information about to public health efforts to reduce only education programs, which the effectiveness of all contraceptive people’s risk of pregnancy and STDs. exclude accurate and complete methods. For example, if they are For example, existing federal and information about contraception, are told that abstinence is 100% effec- state abstinence-promotion policies effective; they argue that these pro- tive, they should also be told that, if typically neglect to define those grams should be expanded at home used correctly and consistently, con- behaviors to be abstained from. The and exported overseas. Yet neither doms are 97% effective in preventing federal government will provide experience, in and of itself, says any- pregnancy. If they are told that con- approximately $140 million in FY thing about the effectiveness of pro- 2004 to fund education programs

The Guttmacher Report on Public Policy December 2003 5 grammatic interventions. In fact, sig- most public health experts stress the Finally, there is the question of nificant declines in U.S. teen preg- importance of achieving desired whether delays in sexual activity nancy rates occurred prior to the behavioral outcomes such as delayed might come at an unacceptable implementation of government- sexual activity. price. This is raised by research funded programs supporting this indicating that while some teens particularly restrictive brand of To date, however, no education pro- promising to abstain from sex until abstinence-only education. Similarly, gram in this country focusing exclu- marriage delayed sexual activity by informed observers of the Ugandan sively on abstinence has shown suc- an average of 18 months, they were experience indicate that abstinence- cess in delaying sexual activity. more likely to have unprotected sex only education was not a significant Perhaps some will in the future. In when they broke their pledge than the meantime, considerable scien- those who never pledged virginity in To date, no education tific evidence already demonstrates the first place. Thus, might strate- program focusing exclu- that certain types of programs that gies to promote abstinence inadver- sively on abstinence has include information about both tently heighten the risks for people abstinence and contraception help when they eventually become sexu- shown success in delay- teens delay sexual activity, have ally active? ing sexual activity. fewer sexual partners and increase contraceptive use when they begin Difficult as it may be, answering program intervention during the having sex. It is not clear what it is these key questions regarding absti- years when Uganda’s HIV prevalence about these programs that leads nence eventually will be necessary rate was dropping. Thus, any teens to delay—a question that for the development of sound and assumptions about program effec- researchers need to explore. What is effective programs and policies. At a tiveness, and the effectiveness of clear, however, is that no program of minimum, the existing lack of com- abstinence-only education programs any kind has ever shown success in mon understanding hampers the in particular, are misleading and convincing young people to post- ability of the public and policymak- potentially dangerous, but they are pone sex from age 17, when they ers to fully assess whether absti- nonetheless shaping U.S. policy both typically first have intercourse, until nence and abstinence education are here and abroad (see related story, marriage, which typically occurs at viable and realistic public health and page 13). age 25 for women and 27 for men. public policy approaches to reducing Nor is there any evidence that the unintended pregnancies and Accordingly, key questions arise “wait until marriage” message has HIV/STDs. about how to measure the success of any impact on young people’s deci- abstinence-promotion programs. For sions regarding sexual activity. This This is the fourth in a series of articles examining emerging issues in sex education example, the administration is defin- suggests that scarce public dollars and related efforts to prevent unintended ing program success for its absti- could be better spent on programs pregnancy and sexually transmitted nence-only education grants to com- that already have been proven to diseases. The series is supported in part by a grant from the Program on Reproductive munity and faith-based organizations achieve delays in sexual activity of Health and Rights of the Open Society in terms of shaping young people’s any duration, rather than on pro- Institute. The conclusions and opinions intentions and attitudes with regard grams that stress abstinence until expressed in these articles, however, are those of the author and The Alan Guttmacher to future sexual activity. In contrast, marriage. Institute.

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