Abstinence an option for adolescents: counseling of adolescents should include both abstinence and the use of contraceptive methods.

Evidence that sexual abstinence may have played an important role in reducing HIV infection in Uganda (1) has renewed interest in promoting this method of protection against unplanned pregnancy, HIV, and other sexually transmitted infections (STIs).

Abstinence offers adolescents, in particular, a number of advantages. Young people are vulnerable to unplanned pregnancy, but they often find it difficult to obtain contraceptives. Sexual abstinence requires no supplies or clinic visits. And complete abstinence is the most effective means of protecting against both pregnancy and STIs.

In practice, however, abstaining from sex tends to be less effective than many contraceptive methods because complete abstinence requires strong motivation, self-control, and commitment. (See chart, page 8.) Also, many questions about sexual abstinence remain unanswered. How can it be encouraged? How should it even be defined? Controversy surrounds programs that promote abstinence as the only means of protection against unplanned pregnancy and STIs, and the effectiveness of such programs is still unknown.

Meanwhile, evidence from many countries suggests that comprehensive sexual health programs that encourage abstinence while providing medically accurate information about contraception and condom use can reduce sexual activity among young people. Such programs can also increase condom and other contraceptive use among sexually active youth. (2)

"Counseling of adolescents should include information about both abstinence and the use of contraceptive methods," says Dr. Roberto Rivera, director of FHI's Office of International Research Ethics and principal author of a World Health Organization (WHO) special communication on adolescent contraception. (3) "The World Health Organization states that age alone is not a medical reason to deny any available contraceptive method to an adolescent. Many adolescents--married and unmarried--are sexually active and have the right to information that will enable them to protect themselves from unplanned pregnancy and STIs. Providers should be aware of adolescents' special needs to help them make well-informed choices about contraception."

ENCOURAGING ABSTINENCE AND FIDELITY IN UGANDA

Uganda's dramatic decline in HIV prevalence during the past decade has coincided with marked increases in sexual abstinence and greater fidelity in relationships, according to an analysis of data from the 1995 and 2000 Demographic and Health Surveys (DHS) and from Ugandan Ministry of Health (MOH) behavioral surveys conducted in 1997, 2000, and 2001. (4)

In 1996, Uganda became the first African country to report a substantial decline in national HIV rates. (5) During the 1990s, the proportion of women testing positive for HIV in antenatal clinics (a population considered fairly representative of the adult population) dropped from 21 percent to 6 percent. (6)

Meanwhile, in the DHS and MOH surveys, a higher proportion of respondents reported being faithful to their partners, having fewer sex partners, abstaining from sex, or delaying sexual debut than reported using or beginning to use condoms. About one out of every five Ugandan men and women said they had ever used a condom, while only 5 percent to 9 percent reported having "non-regular" partners--a measure of fidelity to a regular partner or partners. Twenty-five percent to 35 percent said they abstained from sex. (7)

This high rate of sexual abstinence is mainly a result of the increasing number of young Ugandans postponing their first sexual activity. Nationally, the proportion of 15- to 19-year-olds reporting that they had "never had sex" rose from 31 percent to 56 percent among young men and from 26 percent to 46 percent among young women from 1989 to 1995. (8) A study in the major urban districts of Kampala and Jinja, Uganda, found a two-year delay in sexual debut among 15- to 24-year-olds between 1989 and 1995. (9) The increasingly high rate of sexual abstinence was even more striking among younger adolescents surveyed in Soroti District, Uganda. The proportion of 14- and 15-year-old students there reporting that they had "never had sex" rose from 39 percent to 95 percent among boys and from 66 percent to 98 percent among girls from 1994 to 2001. (10) (See graph below.)

Uganda's unprecedented success in controlling HIV has been attributed to strong government leadership and its "ABC" approach to HIV prevention. Since the late 1980s, governmental and non-governmental HIV prevention programs have urged Ugandans to: abstain from sex, be faithful to one partner, or--if they cannot do "A" or "B"--use condoms.

To gain a better understanding of the impact of each of these prevention strategies in Uganda, Zambia, and other countries, the U.S. Agency for International Development (USAID) is funding a two-phase "ABC Study." Conducted by the Harvard School of Public Health, MEASURE Evaluation, Population Services International, and the U.S. Bureau of the Census, the study will begin with a thorough review of data to assess "ABC" behavior change and its effect on HIV prevalence in countries where infection rates have declined and in countries where they have not.

The study will also analyze the effect of "ABC" behavior change on fertility. In Uganda, where the average number of children per family is seven, (11) reduced sexual risk behavior does not appear to have affected fertility.

THE ABSTINENCE-ONLY DEBATE

Many experts endorse a comprehensive strategy, such as Uganda's "ABC" approach, as the most effective way to prevent HIV and other STIs or unplanned pregnancy among youth. Others support promoting abstinence only, saying that teaching young people about both abstinence and condom or other contraceptive use sends a mixed message and encourages them to become sexually active.

Abstinence promotion has become the main approach of the federal government to preventing adolescent pregnancy and HIV infection in the United States, where the government provides $100 million a year for abstinence-only education. Schools, youth programs, and media campaigns that receive this funding are required to teach that sexual activity outside of marriage is likely to have "harmful psychological and physical effects." They are also prohibited from providing information about contraception, except method failure rates. (12) In a recent review of U.S. programs to reduce teen pregnancy, Dr. Douglas Kirby of California-based ETR Associates identified three studies with experimental or quasi-experimental designs evaluating the impact of abstinence-only programs. None of these studies found any effect on sexual behavior, but Dr. Kirby warns that the programs evaluated do not reflect the diversity of such programs. (13)

A conclusive answer to whether the abstinence-only approach is effective will require larger, more rigorous studies than have been conducted to date. (14) One such study, which is being conducted for the U.S. Department of Health and Human Services, is a five-year evaluation of 11 abstinence-only programs. Findings on the short-term effects of the programs are due in 2003. (15)

Meanwhile, two major reviews have looked at the behavioral impact of comprehensive sexual health and HIV education. One analyzed 67 experimental and quasi-experimental studies conducted in the United States. The other reviewed 47 published studies from more than eight countries, including 11 controlled intervention studies. Both reviews found that comprehensive sex education did not lead to increased sexual activity among adolescents. In fact, some studies found that it had raised the age of sexual initiation, reduced the frequency of sex, and convinced young people to have fewer sexual partners. (16)

WHAT IS ABSTINENCE?

The U.S. law that created abstinence only education programs defines these programs but does not define abstinence itself. (17) Some abstinence-only programs have developed their own definitions of the kinds of sexual activity that should be avoided until marriage. Others do not define the term, believing that identifying the behaviors to abstain from would violate children's innocence and provide them with a "how-to" manual of sexual activity. (18)

But studies from a number of countries suggest that without such information, young people may conclude that vaginal intercourse is the only sexual behavior that is risky. They may then engage in other sexual activities that can put them at some--if not heightened--risk of contracting HIV and other STIs.

Young women interviewed for a study in Mauritius described a practice known as dans bords (light sex), which involves rubbing the penis against the vagina and some penetration, but is not considered sexual intercourse because it does not cause bleeding or pain. In focus group discussions and interviews conducted in Brazil and Guatemala, young people reported that some of their peers practice anal sex to protect a girl's virginity and prevent conception. (19) A number of surveys have found high rates of heterosexual anal sex among young people, from 9 percent to 38 percent among female adolescents in low-income, urban areas in the United States, to 12 percent among female college students in Togo, to 44 percent among sexually active, male college students in Puerto Rico. Studies of heterosexual HIV transmission have identified anal sex as the most predictive risk factor for becoming infected with HIV. (20)

Unlike anal or vaginal sex, oral sex presents very little risk for HIV transmission. (21) However, other STIs, including human papillomavirus, herpes simplex B, gonorrhea, syphilis, and chlamydial infection, can be transmitted orally. (22) Data on oral sex among youth are scarce. The only nationally representative study to look at this question found no increase in reported experience with oral sex among U.S. adolescent males ages 15 to 19 years from 1988 to 1995. (23) But largely anecdotal reports suggest that U.S. adolescents are engaging in oral sex at earlier ages. (24)

FROM CONTROVERSY TO CONSENSUS

Talking to young people about non-vaginal sexual intercourse can be controversial worldwide. In Jamaica, for example, opposition to the definition of sexual intercourse used in the facilitator's manual for a curriculum developed by the Ashe Caribbean Performing Foundation and FHI threatened a promising family life education program in the schools. Some religious and community leaders feared that including anal intercourse in this definition of sexual intercourse promoted homosexuality.

In response, the Ministry of Education brought together political and religious leaders, educators, child development specialists, and representatives of nongovernmental organizations to review and revise the facilitator's manual. After many discussions, the group agreed on a definition that still included anal sex but was also sensitive to local concerns, emphasizing that many people define sex as vaginal intercourse.

This consensus-building process had positive consequences for youth reproductive health programs in Jamaica, says FHI's Hally Mahler, who edited the manual and participated in the review meetings. Mahler is the youth involvement and behavior change communication coordinator for YouthNet, a program supported by USAID and coordinated by FHI to improve reproductive health and prevent HIV/AIDS among youth.

"In hindsight, it was the best thing that ever happened to the program," she says. "A multisectoral coalition of influential people confronted the risks facing young people in Jamaica and came to consensus that with H1V in the world, and with young people defining sex in many different ways, you cannot ignore anal sex."

OFFERING OPTIONS

The word "abstinence" sometimes has negative connotations, in part because many of those who advocate abstinence before marriage also oppose any discussion of contraception, condom use, or alternatives to intercourse, such as masturbation. However, abstinence can be an important, empowering concept when framed in the context of several options for protecting reproductive health in an intimate relationship.

The Jamaican manual helps facilitators guide discussions about ways of showing affection in a relationship, from holding hands and kissing to sexual intercourse. Urging young people to wait until they are physically and emotionally prepared to be sexually active, it describes three options: abstinence, protected sexual activity, and "reclaiming" one's virginity. (25)

"Some people think that once they start having sex, they cannot stop," explains Ashe Director Joseph Robinson, who wrote the facilitator's manual. "We tell them, `Yes, you can stop.'"

Dr. Cynthia Waszak, a researcher with the YouthNet Project, says that "abstinence is a very important message, particularly for girls. Girls need to understand that abstinence is their choice if they do not feel comfortable having sex. And that message should be just as applicable to boys and to all young people who are already sexually active."

On the other hand, programs need to recognize that abstinence is not always an option for youth. "Many girls are caught in situations where they are physically coerced to have sex or have no choice but to do so because of economic pressures," Dr. Waszak notes.

REFERENCES

(1.) Green E. What are the lessons from Uganda for AIDS prevention? What Happened in Uganda? [panel discussion]. U.S. Agency for International Development, Washington, February 5, 2002.

(2.) Grunseit A, Kippax S, Aggleton P, et al. Sexuality education and young people's sexual behavior: a review of studies. J Adol Res 1997;12(4):421-53; Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington: National Campaign to Prevent Teen Pregnancy, 2001.

(3.) Rivera R, Cabral de Mello M, Johnson SL, et al. Contraception for adolescents: social, clinical and service-delivery considerations. Int J Gynaecol Obstet 2001;75(2):149-63.

(4.) Green.

(5.) Okware S, Opio A, Musinguzi J, et al. Fighting HIV/AIDS: is success possible? Bull WHO 2001;79(12):1113-20.

(6.) Green.

(7.) Green.

(8.) World Bank. Uganda: The Sexually Transmitted Infections Project. Findings. Washington: World Bank, 1999.

(9.) Asiimwe-Okiror G, Opio AA, Musinguzi J, et al. Change in sexual behaviour and decline in HIV infection among young pregnant women in urban Uganda. AIDS 1997;11(14):1757-63.

(10.) Green.

(11.) Uganda Bureau of Statistics, ORC Macro. Uganda Demographic and Health Survey 2000-2001: Final Report. Calverton, MD: Uganda Bureau of Statistics and ORC Macro, 2001.

(12.) Dailard C. Abstinence promotion and teen family planning: the misguided drive for equal funding. Guttmacher Rep 2002;5(1):1-3.

(13.) Kirby.

(14.) Devaney B, Johnson A, Maynard R, et al. The Evaluation of Abstinence Education Programs Funded under Title V Section 510: Interim Report. Princeton: Mathematica Policy Research, Inc., 2001; Kirby; Satcher D. The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behaviour. Rockville, MD: Office of the Surgeon General, 1991.

(15.) Devaney.

(16.) Grunseit; Kirby.

(17.) Sonfield A, Gold RB. States' implementaton of the Section 510 abstinence education program, FY 1999. Fam Plann Perspect 2001;33(4):166-71.

(18.) Remez L. Oral sex among adolescents: is it sex or is it abstinence? Fam Plann Perspect 2000;32(6):298-304.

(19.) Weiss E, Whelan D, Rao Gupta G. Gender, sexuality and HIV: making a difference in the lives of young women in developing countries. Sex Rel Ther 2000;15(3):233-45.

(20.) Halperin DT. Heterosexual anal intercourse: prevalence, cultural factors, and HIV infection and other health risks, part I. AIDS Patient Care STDs 1999;13(13):717-30.

(21.) Dailard.

(22.) Edward S, Carne C. Oral sex and the transmission of non-viral STIs. Sex Trans Inf 1998;74(1):6-10; Edwards S, Carne C. Oral sex and the transmission of non-viral STIs. Sex Trans Inf 1998;74(2):95-100.

(23.) Gates GJ, Sonenstein FL. Heterosexual genital sexual activity among adolescent males: 1988 and 1995. Fam Plann Perspect 2000;32(6):295-97, 304.

(24.) Remez.

(25.) Robinson J. Preparing for the VIBES in the World of Sexuality (revised). Kingston, Jamaica: Ashe Caribbean Performing Foundation, 2001.