The American Academy of Pediatrics (AAP), through its Committee on Adolescence led by Dr. Jonathan D. Klein, published a report, “Adolescent Pregnancy: Current Trends and Issues,” in the July 2005 issue of AAP journal, Pediatrics.
The report is a great disappointment, an ideological treatise rehashing old, failed arguments that condoms and contraceptives are the primary solution for the teen pregnancy problem. (Fifty-seven of the 74 references are more than 5 years old and most new credible references on important issues have been ignored.) Almost as egregious as this poor scientific scholarship, however, is what was omitted. Dr. Klein and his committee never discuss the following issues:
The psychosocial effect of adolescent sexual activity. For example, sexually active adolescents, both boys and girls, are far likelier to be depressed and attempt suicide than those still virgins. Condoms and contraceptives do not solve this problem.
The majority of adolescents who become sexually active frequently change sexual partners and will have more sexual partners in their lifetime, one of the greatest risks for acquiring a sexually transmitted infection (STI).
There is an epidemic of STIs among adolescents. About 50 percent of sexually active adolescents are infected with Human Papilloma Virus. HPV causes 99 percent of cervical cancer and 99 percent of truly abnormal pap smears. This cancer causes about as many deaths among women as AIDS.
About 10 percent of sexually active adolescents are infected with chlamydia, a major cause of infertility. STI is the major cause of infertility in America today. About 20 percent are infected with herpes, a lifelong and disabling problem.
Oral and injectable contraceptives, which the paper advocate, offer no protection against any STI.
The National Institutes of Health and other sources now note condoms have limited value in reducing STI risks. The most up-to-date data acknowledge condoms, if used 100 percent of the time, reduce the risk of HIV by 85 percent. For the infections most common to adolescents (such as chlamydia, gonorrhea, herpes) condoms, even when used 100 percent of the time, only reduce the infection risk about 50 percent. For HPV, the most common STI for adolescents, condoms do not reduce the infection risk. There may be some risk reduction for some HPV-caused problems, such as reduced risk of cervical cancer and reduced risk of genital warts.
How can condoms or contraceptives be a solution when 60 percent of adolescents under age 15 have involuntary sex; up to 67 percent of adolescent pregnancies are fathered by adult men; about 20 percent want to be pregnant; and 25 percent were under the influence of drugs or alcohol when they last had sexual relations.
Though the AAP paper mentions parental involvement, it does not view it as the primary factor in getting adolescents to avoid risky behaviors. All studies of adolescent risk behavior and decisionmaking note those least inclined to risky behavior have the best parental connections.
A full review of comprehensive sexuality education programs shows only one program has reduced pregnancy rates among adolescents. The Carrera Program started in New York and has lowered pregnancy rates primarily by giving young women regular hormone injections. Though the teen pregnancy rates have been low, they have never published the STD rates.
The AAP paper also ignores literature about the dramatic effect of abstinence education programs. In 1991, the Public Health Department of Monroe County, N.Y., which includes the city of Rochester, had an effective abstinence program shown by scientific studies to produce a significant and practical drop in teen pregnancy rates, compared with surrounding counties.
The most recent study reported in the peer-reviewed literature was on the Best Friends program that originated in Washington, D.C. The Best Friends girls were found one-sixth as likely to have premarital sex and one-eighth as likely to use drugs as girls outside the program. The Diamond Girls, who stayed with the program throughout high school, were 120 times less likely, or less than 1 percent as likely, to have premarital sex than girls outside the program.
Published in Adolescent Family Health, the Best Friends study is the most sophisticated and thorough examination of the cause of curtailed U.S. teen pregnancy rates. It clearly shows increased abstinence accounted for 67 percent of the drop in pregnancy rates for girls 15-19 and a 51 percent drop in the birthrate for single teenage girls ages 15-19.
The American Academy of Pediatrics should emphasize the importance of parents in guiding young people away from risky behavior, and should not be fatalistic about young people. The National Campaign to Prevent Teen Pregnancy’s annual surveys consistently show 90 percent of teens feel they need a strong sexual abstinence message all the way through high school. In these same surveys, two-thirds of teens consistently say it is wrong for teens, throughout their high school years, to have sexual intercourse whether they use protection or not. And two-thirds of those who have had sexual intercourse wish they had waited.
We need to encourage American culture to support teens in making the very best decisions. We should help them decide not to be sexually active before marriage and to return to sexual abstinence if sexually active at present.
JOE S. MCILHANEY, M.D.
Medical Institute for Sexual Health