Monica is seventeen years old. When I met her in January, she was seven months pregnant with her second child. Her fifteen-month-old girl, Anevaeh, wandered through the room with a purple pacifier in her mouth. Monica should have been preparing to graduate from high school. Instead, she was finishing tenth grade. She and her nineteen-year-old boyfriend, Thomas, swore that they usually used condoms, which they acquired free from their local Planned Parenthood clinic. But twice, when they were caught in the heat of the moment without a supply, they took their chances. Both times Monica got pregnant.
Monica had no illusions about how it had happened. “I got sex ed in school,” she said, sitting on a queen-size bed in the couple’s cramped apartment, located on the second story of her parents’ house, in Austin. “Maybe in fifth or sixth grade.” She received additional instruction in middle school as part of her probation for possession of marijuana. But certain details were still unclear; for instance, she had the mistaken notion that condoms would not help protect her from HIV.
“I learned what gonorrhea and chlamydia look like,” she told me. “The teachers didn’t say if there were cures. I think there were some STDs they wouldn’t talk about.” She didn’t recall any official discussions about pregnancy in her school. Most of what she knew she learned from her teenage girlfriends, the majority of whom were already mothers.
Monica’s situation is more common in Texas than in any other state. Texas ranks number one in teenage births, which, all told, cost taxpayers at least $1 billion a year. (Twenty-four percent of those births are not the girl’s first delivery.) While the number of teenage births in Texas is actually going down of late, it is decreasing at a slower rate than the nation’s at large. And 52.5 percent of Texas teens are having sex, compared with the national average of 47 percent. Rates of HIV/AIDS infection among teens are currently on the rise. Texas ranks fifth in teenage pregnancy (a number even more disconcerting in light of the fact that the U.S. ranks near the top in this category among developed nations).
To confront these challenges, Texas has become a leader in abstinence education. Thanks in part to the efforts of powerful advocates, from George W. Bush to the Medical Institute for Sexual Health (MISH), based in Austin, the state has endorsed abstinence education as its primary agent to combat teenage sexual activity. Texas now gets more money through Title V, a stream of federal funding for abstinence programs, than any other state, more than $4.5 million a year. The Texas Education Code, written by the Legislature, lists directives with regard to sex education. One states that in the classroom, abstinence must be given more attention than any other approach; another requires that it be presented as the only method that is 100 percent effective at preventing pregnancy, STDs, HIV/AIDS, and the “emotional trauma associated with adolescent sexual activity.” These two directives haven’t been terribly controversial. Whether “emotional trauma” results from adolescent sexual activity is debated (studies suggest that activity is a consequence—not a cause—of mental health problems), but critics rarely belabor this point. Health care workers agree that it would be good if teenagers remained virgins.
More problematic is what isn’t taught. No law mandates that methods of contraception be included in sex ed classes, and nowhere in the code is condom instruction encouraged. Teachers in Texas who do promote condom use must cite “actual use” rates of condom effectiveness, not theoretical rates (more on that later). Only one of the four state-approved high school student health textbooks uses the word “condom,” and that book reaches only a small percentage of the Texas market. Because the language of the code does not insist on condom instruction, schools are free to leave it out. Garnet Coleman, a Democratic state representative from Houston who has been on the House Committee on Public Health since 1993, explained to me, “Abstinence-only wasn’t the intent of the legislation, but it de facto became that.”
“What I say we do is absent education,” said David C. Wiley, the president of the American School Health Association and a professor of health education at Texas State University. “I have never met anyone in all my fifty years that has ever had a comprehensive sex ed program in their schools—ever. We are raising generation after generation of sexually illiterate adults.”
And the situation is getting worse. Over the past thirty years, the age of the average female at the time of her first menstruation has decreased (about one month per decade), while the age of a person at the time of his or her first marriage has increased (by at least three years). At the same time, children are becoming sexualized earlier than ever before. Recently, Abercrombie & Fitch marketed thong underwear emblazoned with the phrases “wink, wink” and “eye candy” for “tweens”—consumer marketing—ese for seven- to twelve-year-olds. Kids trying to navigate this terrain want to hear from their parents about sex, but only about half of them do. More often, they pick up their information (and misinformation) from magazines, television, the Internet, and their peers. Without a sex ed curriculum in the classroom that works, these kids, and the taxpayers who end up footing the bill for their mistakes, are extremely vulnerable.
In the next decade, teenage mothers like Monica will become even more typical. Projecting a change in racial and ethnic composition and an increase in the teenage population, the Texas Department of State Health Services anticipates “serious implications for the patterns and trends in adolescent pregnancy.” As the crisis worsens, local school boards will become desperate for solutions to prevent teen pregnancy and disease. Proponents of abstinence programs claim that they have the answer; those who support comprehensive sex ed fundamentally disagree. The question is, What works?
The Texas State Board of Education adopts new health textbooks every eight to ten years. Since the content of these books pretty well dictates what happens in the classroom, the process of textbook adoption has historically been contentious. To better understand why, in 2008, the vast majority of Texas teens will not see the word “condom” in their textbooks, we need to go back to the 1994 health textbook debates. Back then the state board still had a great deal of power in the process and could edit textbooks at will (in 1995 the Legislature took this power away). Items some of the members deemed objectionable for the eyes of children included an image of a woman with a briefcase in her hand and a toddler looking up at her. Line drawings illustrating breast and testicular self-exams were considered too explicit. The board asked at least one publisher to erase the clitoris from a drawing of the female anatomy and reduce the size of the penis in a drawing of the male anatomy, prompting Lorena Bobbitt jokes.
Those who did not vote with the small but vocal ultraconservative faction faced swift and extreme retaliation. Patsy Johnson, a Democratic board member from 1992 to 1994, remembers that a few days before meetings, her husband’s office, where she worked, would be paralyzed by a flood of angry letters. “We’d have boxloads of mail and faxes saying, ‘Mrs. Johnson is for condoms, vaginal, anal, oral’—awful stuff,” she said. “I’m a traditional Methodist lady!”
Board members are unpaid. But electoral contests grew so heated in the mid-nineties that you would have thought a seat was something prestigious. The fifteen board members are elected officials with four-year terms who represent areas larger than congressional districts. Incumbents are traditionally difficult to unseat, but in the mid-nineties, members such as Johnson, who campaigned on shoestring budgets, found themselves attacked from the right by candidates with funding from wealthy San Antonio doctor James Leininger, whose deep pockets offered considerable resources for persuasion mail and TV ads. In the same wave of conservatism that ushered in Newt Gingrich’s Republican Revolution, Johnson and other incumbents less friendly to the conservatives were overcome. One mailer used to defeat her and at least one other board member depicted two men kissing. The accompanying text read, “This is just an example of the materials the current majority of the State Board of Education wants your children to read.” The mailer went on to explain that the image on the mailer was from a handout available at a clinic listed as a resource in four of the health textbooks that Johnson and others had approved, but the damage had been done.
Though the board was not scheduled to adopt new health textbooks for another decade, in the intervening years, increasing numbers of more-conservative members were voted onto the board, and Republicans were quietly encouraged by the most conservative members to vote in a bloc. Cynthia A. Thornton, a Republican and a teacher with 31 years of experience in high school classrooms, prided herself as an independent thinker. (“This is how naive I was: I thought most of the board would be educators. I sat between two dentists,” she told me. “I have a master’s degree in curriculum instruction. Some of these folks didn’t even have a college degree.”) Despite her qualifications, the far-right members reprimanded her for resisting their pressure. Gradually, the coercion became more overt. In one instance, a member of the board grabbed her and threatened her. (She would not give his name but said he was a fellow Republican.) Afterward, at Thornton’s request, an armed Capitol guard was in the room for all board meetings, and Thornton regularly received an escort to her car.
While this drama has subsided since 1994, unease with the growing number of radical board members has intensified. Some Republican members, like Patricia Hardy, found it necessary in our conversations to distinguish themselves from the pack. “I’m as far-right as you can be and still be normal,” Hardy said. Geraldine “Tincy” Miller, a Republican who has been a board member since 1984, took some time to choose her words before telling me that she was “concerned about the board’s direction.”
Now, soap opera aside, none of this may seem like that big of a deal. The school board doesn’t write legislation; it just carries it out. It isn’t allowed to edit the textbooks anymore. All the board can do now is issue the Texas Essential Knowledge and Skills (TEKS) guidelines and adopt books that match them. But at this most basic level, the board is responsible for just about everything students are taught.
By 2004, publishers mindful of the millions of dollars at stake had learned to steer clear of controversy. The TEKS guidelines state unequivocally that textbooks must “analyze the effectiveness and ineffectiveness of barrier protection and other contraceptive methods including the prevention of Sexually Transmitted Diseases (STDs), keeping in mind the effectiveness of remaining abstinent until marriage.” But publishers detected a loophole that would keep their books agreeable to those who believed in abstinence-only education: The TEKS guidelines had not distinguished between teacher and student editions. Erring on the side of caution, most publishers restricted all information about condoms and contraceptives to the teacher’s manual and supplementary materials. Two of the four student editions up for adoption used the mysterious phrase “barrier protection,” with no elaboration. Instead of receiving information about what barrier protection was and how it might work to prevent pregnancy and STDs, students were given generic advice that had little to do with sexual activity. One book recommended that students “get plenty of rest” in order to make good decisions.
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.”
The majority of the board members viewed the placement of the word “condom” in the teacher’s edition, and not the student edition, as a good idea and not in violation of the TEKS mandate to “analyze the effectiveness and ineffectiveness of â€Šbarrier protection and other contraceptive methods.” Abstinence proponents applauded their judgment. Kyleen Wright, the president of the Texans for Life Coalition, an antiabortion advocacy group based in Irving, testified, “The placement of sensitive information in the teacher’s edition is a brilliant win-win move on the part of publishers. . . . The comprehensive-education crowd has run this show since I was in high school. And on their watch, we have seen skyrocketing teen pregnancy rates and sexually transmitted disease. Nowhere can they point to any success with their programs. You are on the right track and I thank you.”
Before the four textbooks were approved, Democratic member Mavis B. Knight asked the board, “Does anyone have any data to correlate dropout or the reduction in the teen pregnancy rate with this abstinence approach?” No one in the room had that data. A consensus would have been difficult to find.
None of the hullabaloo in the world of sex ed is new, of course. University of Kansas history professor Jeffrey P. Moran notes in Teaching Sex: The Shaping of Adolescence in the 20th Century that the inspiration for sex instruction began in the 1800’s, when a strange creature emerged in the family unit, a new category of person too young to be an adult but too mature to be a child. “Due perhaps to nutritional changes,” Moran writes, “the average age at puberty declined over the course of the century, so young people were becoming sexually mature earlier in life.” At the same time, men and women were delaying marriage until they found themselves on more-secure financial footing. This category of citizenry was such an anomaly, historically, that in 1904 a psychologist had to invent a word to describe it: “adolescence.”
But this new group did not immediately draw the attention of social reformers. The first sex ed program, initiated in 1913 by a group of progressives who’d formed the chastely named American Social Hygiene Association, targeted adults. Swarms of men were visiting bordellos and spreading infections around the country, and initially, the social hygienists attempted to frighten audiences with slide-show presentations exhibiting the most visually upsetting effects of syphilis. On occasion, spectators did faint (a marker of success).
But eventually adults were deemed corrupted goods, impervious to instruction. Scanning the landscape for an unspoiled population, the social hygienist crusade focused its efforts on the adolescents. Youngsters, furthermore, could be reached with ease since more of them were attending schools than in preceding decades. Nevertheless, the proposition that sex be taught to children in a public setting was a tough sell. In 1913 high schoolers in Chicago were the first to receive sex ed (younger students received “personal purity” talks). The experiment was short-lived. After just one year of lectures on “personal sexual hygiene” and “problems of sex instincts,” as well as “a few of the hygienic and social facts regarding venereal disease,” conservative members of the Chicago school board saw to it that the controversial curriculum was rarely taught again.
But the movement would not die. According to Alfred Kinsey’s 1953 report “Sexual Behavior and the Human Female,” each generation of women born after 1900 became sexually active earlier than the last. In the twenties, veterans who had returned from World War I with disease were contaminating reputable young ladies. Recognizing that fear of cupid’s itch was not a sufficient motivator for chastity, educators began to stress the immorality of sex outside marriage and the reckless behavior’s potential damage to marital bliss.
Morality, it turned out, was the key to making sex ed palatable, and as the focus shifted from sex itself to related subjects like marriage and parenthood, the programs became so diffuse that for the next few decades they could hardly be called sex ed at all.
Then came the pill. The Food and Drug Administration’s approval of oral contraceptives in 1960 transformed the way women thought about sex. The percentage of sexually active eighteen-year-old women rose from about 25 percent in the late fifties to 35 percent in the late sixties to more than 50 percent by the end of the seventies. Meanwhile, the median age of first marriage steadily climbed. With more people having sex outside marriage, sex ed became increasingly important.
Except that according to critics, sex ed simply exacerbated the problem. Politicians charged that American society was suffering from an epidemic of teenage pregnancy. In reality, the rate of teenage pregnancy from 1960 to 1975 remained constant and the birthrate declined; the sense of there being an “epidemic” was a result of more unwed teen mothers, not more pregnancies. But to abstinence supporters, teenage sexual activity itself rang the alarm bells. In 1981 President Ronald Reagan signed the Adolescent Family Life Act (AFLA), which mandated that the programs funded with its $4 million be based in the teaching of abstinence. University of California at Berkeley sociology professor Kristin Luker writes in her book When Sex Goes to School that, as near as she could tell, “AFLA is where the idea of ‘abstinence education’ made its debut on the national scene.”
The perils of teenage motherhood were soon overshadowed by a much more ominous threat. AIDS didn’t seem to be a prevalent problem among teens in the early eighties, but the specter of the disease caused many sex ed traditionalists to abandon their misgivings about unambiguous instruction. In 1987, 70 percent of girls and 80 percent of boys had had sex before reaching age twenty, yet only 15 percent of the girls surveyed said they had recently used a condom. Reagan’s surgeon general C. Everett Koop strongly advocated educating kids about condoms. “When we talk about condoms,” he said, “the education that goes with that has to be extraordinarily explicit.”
As AIDS education became the focus of sex ed and condom instruction became more widespread, educators were teaching that abstinence was the best way to prevent pregnancy and STDs. Still, critics of these programs said the emphasis on “safe sex” sent a mixed message that encouraged kids to indulge in their basest desires. Worse, for some detractors, the curricula didn’t address the immorality of sex outside marriage. In 1987 William J. Bennett, Secretary of Education under Reagan, wrote of mainstream sex education: “While speaking to an important aspect of human life, it displays a conscious aversion to making moral distinctions.”
Abstinence-only education took a while to gain momentum, but once it did, it revolutionized the discourse. In 1996 a provision under Title V of the Social Security Act was attached to welfare legislation that would finance abstinence programs with $50 million a year, to be distributed among participating states that agreed to match every four federal dollars with three state dollars. This gave abstinence ed the boost it needed. In 1988 only 2 percent of programs taught that abstinence was the only way to eliminate the risk of contracting STDs or becoming pregnant; by 1999, that number had increased to 23 percent.
In 2000 President Bill Clinton signed legislation funding a program called Community-Based Abstinence Education (CBAE) that empowered the movement with a new pot of money, which grew from $20 million in 2001 to $113 million in 2007. CBAE money goes straight from the federal government to community programs. Funding streams such as these had never been offered for any type of sex ed before. (Family planning money is sometimes seen as a funding stream for comprehensive sex ed, but these dollars go to clinics, not classrooms.) The sources of money for abstinence education—AFLA, Title V, and CBAE—now total more than $150 million a year.
The availability of this money tended to influence the decision-making process for school boards debating what type of sex ed they would provide for their students. Thanks to generous federal support, abstinence organizations could come into classrooms without costing the districts much financial hardship. Gradually, the type of education that kids received changed. From 1995 to 2002, comprehensive instruction decreased while abstinence education increased. And yet the question posed by Mavis Knight—“Does anyone have any data to correlate dropout or the reduction in the teen pregnancy rate with this abstinence approach?”—was still largely unanswered.
At the time of the 2004 textbook debate, despite the enormous amount of effort and money being poured into Texas’s abstinence programs, no study had yet been published monitoring the effects of these curricula. But one was close. Since 2000, with funding from the Texas Department of Health, two Texas A&M researchers, B. E. “Buzz” Pruitt and Patricia Goodson, had been sifting through about sixty abstinence-only-until-marriage curricula, teacher’s guides, and videos with titles like “Baby, Think It Over” and “Not Me, Not Now.”
They tried their best to create an airtight study. Ideal research design has two components: a control group, which does not receive the intervention, and an experimental group, which receives the intervention randomly. In addition, the sample size must be adequate, something usually achieved through a mathematical formula. Behavior should be measured for at least a year and a half.
But this clinical gold standard is enormously expensive and challenging, and reality defied design from the beginning of the A&M study. “We didn’t have the luxury of randomization,” Pruitt explained. “We were given programs that were in progress, and we didn’t have the ability to ask them to stop or change what they were doing.” The A&M team couldn’t access a control group. “We couldn’t find a substantial group of kids in Texas who had not heard the message of ‘abstinence only until marriage,’â€Š” Pruitt said. The team gathered a good sample size and followed more than 1,500 middle and high schoolers through four separate programs. But Pruitt and Goodson could monitor the students for a maximum of one school year. Goodson compensated, as much as she could, with statistical controls in an effort to isolate the effect of the programs. But at best, she said, the results would be “good clues” as to what was happening.
Over five years of examination, the researchers learned a great deal about the type of instruction kids were receiving. “What we found is that abstinence education is a culture, a movement,” said Goodson. “Interestingly enough, we concluded it has very little to do with sexuality education. It is very aligned with character education.” Within the movement, the word “abstinence” was defined differently. “A lot of the programs—not all, but a lot of them—would talk about abstinence not only from sex but drinking, drugs, pornography,” Goodson said. “I did a focus group with kids and I threw out the question ‘When you think of abstinence, what do you think about?’ and a little girl said, ‘Not eating.’â€Š”
Another discovery was that Title V recipients, though hardworking, dedicated, and well-meaning, frequently operated in an information bubble. Typically, these were small operations, independent of their local school districts, with more zeal than training. For example, one common focus of the curricula was self-esteem. “There was no evidence in the literature, and we found no evidence in our work, that the child with higher self-esteem initiates sex any later than the child with lower self-esteem,” Pruitt said. “Yet one of the most common goals of the programs that are funded in Texas is to boost self-esteem.” This might have been more of a surprise if the groups that received the Title V grants were experienced health instructors. But, generally, they were not. “In the entire state we found two people that were involved in these programs that had degrees in health education,” Pruitt said. “Two of the curricula didn’t contain a single fact.”
In 2005 the researchers presented the results of their study to the Texas Department of State Health Services. The good news: The abstinence message was being heard and understood. After participating in an abstinence program, kids said their attitudes about abstinence improved. The bad news: These attitudes didn’t seem to affect behavior. Those who received abstinence programs didn’t initiate sex any later than their peers.
Pruitt and Goodson’s study was big news. By the end of the week following its release, the results had scrolled across the bottom of CNN’s broadcasts and made front-page headlines in New Zealand and London. But the researchers didn’t receive a single phone call from legislators or program directors asking for more information on their study. Critics in the abstinence-only camp dismissed the findings through press releases and opinion letters in newspapers. (One abstinence group, to the puzzlement of Pruitt and Goodson, issued a press release titled “Texas A&M Study Shows Abstinence Education Works.”)
But critics were tested again in April 2007, when the independent, Princeton, New Jersey-based Mathematica Policy Research released its study of abstinence programs to the U.S. Department of Health and Human Services. More than two thousand youths in four Title V programs had been studied for four to six years. In this case, researchers had achieved the gold standard of design, with students who were randomly assigned to the intervention and control groups. It was the most reliable study of abstinence programs to date.
The results were flabbergasting (as well as validating to the A&M researchers). Typically, health education programs have some impact, however insignificant, but the abstinence-only programs studied in the Mathematica report showed none: no delay in sexual initiation, no impact on the number of partners, no impact on the frequency of sex. Students who heard the abstinence message were just as likely to have sex and use contraception in the future as those who did not hear the message. Students in abstinence programs didn’t delay losing their virginity even one month later than students in comprehensive sex ed classes or kids who had had no instruction at all.
You might think that the conclusions of both the A&M study and the Mathematica study provide answers to the question of whether abstinence programs work. But, as with all questions pertaining to sex, it is not so simple. According to the Austin-based Medical Institute for Sexual Health, the A&M and Mathematica studies’ findings are entirely disputable. After the release of the Mathematica report, MISH issued a statement challenging its “small and unrepresentative study sample” and raising questions about whether “methodological issues may have affected the findings.”
MISH is one of the most important resources for abstinence educators in the country. It was founded in 1992 by Joe McIlhaney, an Austin gynecologist who had become concerned about his patients’ sexually transmitted infections. McIlhaney began presenting slide shows to high schools showing the dangers of the diseases. The presentations evolved into a treasury of DVDs, pamphlets, and medical information that suited the abstinence industry’s growing needs. Government support has helped MISH’s cause. Sixty percent of the nonprofit’s $2.4 million budget comes from donations, sales of products, and foundation grants; the remaining 40 percent is government grants.
The group’s headquarters is located in a small street-level office space nuzzled into a cluster of buildings. I met the current president and chief executive officer, Gary L. Rose, in January. His white mustache was trimmed straight across, and he wore a blue suit with a red tie. He is a former pulmonologist with a sweet temperament and a musical voice. While we talked, he sat in a leather chair situated in front of a framed red-and-white print that read “Let’s Roll.”
Right away, Rose wanted to be clear that he didn’t consider MISH an abstinence outfit. He separated MISH from the group to which they are often compared, the Abstinence Clearinghouse, which frowns on condom instruction. “They would say that we are baddening the mission,” Rose said. “I think we’re just trying to give the facts. We’re going to talk about condoms because you need to know about condoms.” (One look at MISH’s national advisory board, though, reveals major players in the abstinence field, most remarkably W. David Hager, an obstetrician and gynecologist who served on the FDA’s Advisory Committee for Reproductive Health Drugs until critics publicly derided his recommendation of Scripture readings as treatment for premenstrual syndrome and his opposition to making the emergency contraceptive Plan B available over the counter. MISH’s Web site doesn’t mention Hager’s book As Jesus Cared for Women, only that he is “a writer and has had numerous peer reviewed articles published.”)
Rose feels that MISH has been portrayed unfairly. “If you were to ask, many people think we’re a right-wing religious organization,” he said. He conceded that there was some religious language early on, as well as a moral tone. The group’s “National Guidelines for Sexuality and Character Education,” published in 1996, stated that “some people who have a homosexual orientation decide for health, moral, or religious reasons not to practice homosexual sex” and “the charge of ‘homophobia’ has been used inappropriately to shut off debate.” Rose contends that the organization has changed, and not just in attitudes toward homosexuality. “We’ve tried to neutralize that [language] as best we can,” he said. “We’re not an abstinence organization. We’re a medical and scientific organization.”
Rose’s insistence that MISH be considered a kind of apolitical research institute is not uncommon in the world of abstinence. Many groups take a similar approach, casting themselves as impartial providers of clinically tested information. Yet on numerous occasions MISH has been found to present highly questionable data in support of abstinence. In 1995 the Texas Department of Health confronted MISH with a report stating that the slide show that McIlhaney was taking around to the high schools contained assertions that were “misleading” and “ridiculous.” More recently, MISH’s tactics were criticized in a 2004 report prepared for California congressman Henry A. Waxman. Called “The Content of Federally Funded Abstinence-Only Education Programs,” the report evaluated thirteen of the most popular federally funded curricula, including one published by MISH titled “Sexual Health Today.” Waxman’s report noted a number of inaccuracies: “The curriculum erroneously states that touching another person’s genitals ‘can result in pregnancy,’â€Š” and “one curriculum makes a spurious claim about chlamydia’s health effects . . . in fact, the research cited in the curriculum found an association between heart disease and a type of chlamydia (called Chlamydia pneumoniae) that is not sexually transmitted . . . it is an entirely different bacteria from Chlamydia trachomatis, which is sexually transmitted.”
MISH claimed that Waxman’s criticisms had distorted its material and paired with the U.S. Department of Health and Human Services to investigate nine comprehensive curricula in an attempt to show that mistakes were just as common, if not more so, on the other side. But the findings were innocuous compared with the blunders in Waxman’s review. Errors listed in the report included trivial inaccuracies relating to condom failure rates for users with less than one year of condom experience (one curriculum quoted 12 percent, “when the correct statistic is 15 percent”) or the use of the term “dental dam” instead of the FDA-approved term “rubber dam.”
There are other problems with Rose’s claim to a purely objective, research-based position. When I asked him for scientific proof that abstinence education really works, he cited four studies and encouraged me to look them up. Not one of them, it turned out, had achieved as strong a standard of design as the Mathematica study. The author of one study, Murray Vincent, who published his findings in 1987 in the Journal of the American Medical Association, told me he had written four or five letters to MISH over the years, telling MISH that his intervention model, the one they praised in so many newsletters, was not even abstinence-based. It was comprehensive. “I often wonder if the MISH staff have ever read my JAMA article,” he told me.
But it is no surprise that Rose would cite these studies. Methodologically sound research that has focused explicitly on abstinence has generally reported fewer positive findings. “There have been six programs that have been evaluated with really strong design,” said Douglas Kirby, a senior research scientist at ETR Associates, a California nonprofit that studies health promotion. Kirby, who has authored or co-authored more than one hundred volumes, articles, and chapters on adolescent sexual behavior and sex and STD/HIV education programs for major health organizations over the past thirty years, is generally considered a respected, unbiased figure. “All six of them found that the abstinence programs had no positive impact on behavior. Absolutely flat. That’s discouraging. On the other hand, there are a handful of abstinence programs which have studies that are much weaker but do show encouraging results.” Kirby supposes that there are some abstinence programs that are effective. “I would assume there probably are,” he said. “But at this point in time we don’t have any strong evidence that any abstinence program delays the initiation of sex.”
In November of last year, Kirby finished a study called “Emerging Answers 2007.” Released through the National Campaign to Prevent Teen and Unplanned Pregnancy, Kirby’s report summarized 48 studies of curriculum-based comprehensive sex ed that supported use of contraception as well as abstinence and identified seventeen characteristics common among the most effective programs. The evidence overwhelmingly shows that the majority of comprehensive sex ed programs can have a positive impact on behavior. They do not increase the number of sexual partners or hasten the initiation of sex or increase the frequency. In perhaps the greatest irony, many of the students who received comprehensive sex ed were more likely to remain abstinent longer.
To a certain extent, the whole debate over what to tell kids about sex boils down to condoms. Proponents of comprehensive sex ed say they are a crucial tool, pointing to a 2007 American Journal of Public Health report that found that 86 percent of the decline in teenage pregnancy among fifteen-to nineteen-year- olds from 1995 to 2002 was attributable to improved contraceptive use. This position is supported by the American Medical Association, the Texas Medical Association, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Adolescent Medicine.
But Gary Rose charges that comprehensive programs that do not hammer away at the failings of the condom give kids false assurances. For too long, he says, these dangers have been hidden in the comprehensive teaching, which only gives lip service to abstinence before launching into condom instruction. Kids are told that condoms are “very effective,” though when it comes to some STDs, they are not nearly as effective as the user might wish.
MISH presents what are called the “actual use” statistics on condom performance. These percentages reflect the number of times the average user is unable to escape unwanted outcomes. For example, in a chart showing the effectiveness of contraceptives against pregnancy in the highly respected, doctor-authored report Contraceptive Technology, now in its nineteenth edition, the male condom, when used perfectly and consistently, fails (that is, slips off or breaks) only 2 percent of the time. But 15 percent of the time, people who consider themselves “condom users” throw caution to the wind and either neglect to use a condom at all or deploy it only in the final throes.
This means that as far as pregnancy goes, condoms have an “actual use” failure rate of 15 percent. Thus, in some “abstinence-plus” classes—which promote abstinence but discuss condoms—the students hear that condoms are effective in preventing pregnancy only 85 percent of the time. I asked Rose: As an adult, wouldn’t you be concerned upon hearing, without explanation, that sex with condoms results in pregnancy 15 percent of the time? And if you heard that “user failure” was to blame for most of the unintended pregnancies, wouldn’t you want more details instructing you how to prevent such failure?
“Information alone doesn’t change behavior, and so much of the time kids aren’t using condoms consistently,” he said. This, in essence, is the root of the debate. Like many other abstinence advocates, Rose believes that telling teens not to have sex and then giving them detailed instructions on condom use is a mixed message. “It’d be like saying, ‘I urge you not to smoke, but you’re going to smoke anyway, so let me show you how to smoke a filtered cigarette; I want you to smoke it right,” he said.
In the next adoption of health textbooks, tentatively slated for 2014 school year, student editions will have to address the effectiveness of “barrier protection and other contraceptive methods.” The Legislature has insisted on it. Still, the current chairman of the State Board of Education, Don McLeroy, told me he thinks there should be two sets of books.
“I don’t mind [condoms] in a comprehensive plan, but I think there ought to be another one,” he said. “You don’t want to undermine what parents are teaching their children either way. Golly, if you have a kid who can’t keep his hands off a girl, sign him up for the comprehensive one.” After some consideration, McLeroy shifted his position. “You can use the words, but in the context of marriage . . . If you explain it to them neutral and say, ‘Oh, we know you’re going to have sex,’ that’s like a green light.”
Furthermore, a shift away from abstinence-only curricula could be a hard sell to the local school boards, no matter how many studies are published. It will certainly be a hard sell with the State Board of Education. “What’s really realistic?” McLeroy asked me. “Is comprehensive realistic or is abstinence realistic? I went up and looked at the kids I knew at Bryan High School, and I could look at that high school and find lots of kids who were abstinent. That was realistic, in other words. But I was thinking, how many children are being promiscuous and doing what they’re supposed to do—refraining from having sex with only one partner at a time, not multiple at the same time? How many are going to refrain if they don’t have contraception there?” He decided that, given this observation, the comprehensive approach was unrealistic. (During the course of fact-checking this article, McLeroy denied many of the quotes that are attributed to him; the quotes as printed, however, accurately reflect a recording of our interview.)
Monica and Thomas, of course, were among those teens who did not refrain from having sex when they had no condoms. Would a truly comprehensive sex education have taught them to wait until they did? Or would they have been better served by an abstinence program that had instructed them not to have sex at all?
For Monica, those questions are academic. She had her second baby in March, and not surprisingly, she is now more concerned about her future than her past. “I don’t know how it’s going to be with two,” she told me. “I know my first baby will help me take care of the new one.” Thomas was laid off from his job at a roofing company, and Monica won’t be able to work for a while. But she hopes to get her degree, no matter how long it takes. “It’ll all work out,” she said.