Do Abstinence-Plus Interventions Reduce Sexual Risk Behavior among Youth?

Perspectives A bstinence until marriage has emerged as a primary policy goal in efforts to promote adolescent sexual and reproductive health—in the United States and increasingly worldwide. While few would argue with abstinence as a personal choice (no one should be forced to have sex), there are serious questions about whether government promotion of abstinence should be a public health goal. Marriage is not free of HIV risk. Early marriage— particularly of young women to older, sexually experienced men—carries a substantial risk of HIV infection. Around the globe, a young woman's primary risk of HIV infection is often through sex with her husband [1]. Sexual intercourse is almost universally initiated during adolescence worldwide. By age 20, 77% of young people in the US have initiated sex, and 76% have had premarital sex [2]. By age 25, over 90% people have had sex, with only about 3% waiting for marriage. Over the past 40 years, the median age at fi rst intercourse has dropped (and stabilized) to age 17 in most developed countries [3]. Even more dramatic, however, has been the increasing age at marriage. In the United States, between 1970 and 2002 the median age at fi rst sex for young women fell from 19 to 17 years, while the median age at marriage rose from 20 to 25 [4]. These enormous demographic changes stand in sharp contrast to the modest impact of health education in promoting abstinence or the small decline during the 1990s in sexual activity. The most vociferous criticism of abstinence as a public health goal has been directed toward abstinence-only education (i.e., education that presents abstinence as the best and only solution and restricts information about other prevention strategies such as condom use). Scientifi c and ethical objections to such education have come from the major professional organizations in the US focused on adolescent health, including the American Academy of Pediatrics, the Society for Adolescent Medicine, the American Medical Association, and the American Public Health Association [5–8]. Two recent systematic reviews of abstinence-only curricula suggest that the best implemented and evaluated programs fail to delay initiation of sexual intercourse or to produce other demonstrable reductions in HIV risk behaviors [9,10]. A six-year longitudinal study of virginity pledgers found short-term delays in sexual intercourse but no impact on laboratory-verifi ed sexually transmitted infection [11]. A 2004 US Congressional review found that 11 of the 13 most frequently …