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Only abstinence as the answer

THE BALTIMORE SUN

Marquis Page has been tempted, plenty of times.

"I could have a baby, the situations I've been in," he says.

But so far, the witty, outgoing 19-year-old has stayed chaste. He traces his discipline to the weekly abstinence classes he attends at New Creation Christian Church in Northeast Baltimore. Led by the program's charismatic director, Anthony Allen, a group of 20 to 35 teen-agers meets every Wednesday night in the church basement.

Sitting in a large circle, they talk openly about the physical and emotional risks of premarital sex, the pull of peer pressure and the reality of hormone-fueled adolescent urges. Last year, Allen led a prom-like celebration at a downtown hotel, at which about 20 teen-agers, including Page, made a formal pledge to avoid sex until marriage.

Page, who studies business at the Community College of Baltimore County's Essex campus, is a model of "abstinence-only" education. This approach encourages young people to avoid sex until marriage, while offering little information about contraception.

Since 1998, abstinence-only instruction has proliferated, fueled by a huge increase in federal funding. Over that time, federal and state governments have given out almost $1 billion to programs such as the one at New Creation.

The Bush administration hopes to spend even more. In his State of the Union speech last month, President Bush promised to double annual funding for abstinence-only education to $270 million. "Abstinence for young people is the only certain way to avoid sexually transmitted diseases," Bush said.

But many public health researchers say the programs remain, at best, unproven. While the method works well for some, they say, it has no effect on many others, who become sexually active with little knowledge of safe sex. At the same time, some "comprehensive" approaches - which include information about condoms and contraception - have been proven, these scientists say.

"We have programs that have been demonstrated to work. There's no reason not to use them," said Douglas Kirby, a sociologist for ETR Associates, a private firm that studies and carries out public health programs. Kirby, who has studied teen-age sexual behavior for 25 years, says five comprehensive programs have been rigorously evaluated and shown to work.

Abstinence-only proponents say that providing contraceptive information undermines the no-sex message and encourages teen-agers to think that protected sex is without risk.

"It's like if I put my seat belt on and then drive 120 miles per hour," said Alma L. Golden, deputy assistant secretary for population affairs at the Department of Health and Human Services. A longtime proponent of the abstinence-only approach, she is deeply involved in the administration's efforts.

Until the late 1990s, the main approach to sex education was the comprehensive method, which encourages abstinence while also offering information on condoms and other contraception. This approach assumes that many teen-agers will have sex regardless of what adults tell them and should know how to minimize their risk.

From this perspective, abstinence-only seems illogical. "It's an ideological position, not a public health strategy," said sociologist Judy Auerbach, public policy director of the American Foundation for AIDS Research, which opposes increasing federal funds for abstinence-only programs. She says that it is unrealistic to expect people to stay abstinent until they are 26 - the average age of marriage in the United States.

Everyone agrees that teen-age sexual behavior must be changed. Although teen-age pregnancy rates in the United States have been falling for a decade, they remain much higher than in most other Western countries: Six in 10 teen-agers are sexually active by the time they finish high school; every year, almost 3 million teen-agers contract a sexually transmitted disease; and each year more than 20,000 Americans between 13 and 24 are infected with HIV.

Because it is so new, abstinence-only has received relatively little analysis. In an attempt to settle the question conclusively, the federal government has funded a major four-year, $5 million national study of 2,500 youths who are taking abstinence courses. Preliminary findings will be out this spring, but results won't arrive until next year. Unlike many sex-education studies, which only examine attitudes toward sex, this one will focus on behavior, which is more difficult to measure.

The study's leader, University of Pennsylvania social scientist Rebecca A. Maynard, underscores her objectivity: "I don't have a personal view on this. My job is to find out how well these programs work, and for whom."

The few serious studies of abstinence-only programs have generally found them ineffective. A recent evaluation of Minnesota's $5 million program reported that it made no difference among middle school students.

Before the training, 82 percent said they had decided against sex. A year later, after receiving the instruction, that number dropped to 67 percent. Before the class, 6 percent of the students had had sex; a year later that group was more than twice as large. Had the program kept these levels stable, it would have succeeded, researchers said.

"We said, 'This doesn't look like it's working,'" said researcher Connie Schmitz, who oversaw the study, which recommended that the state use a comprehensive program.

There have been no studies comparing the two approaches.

A few researchers say abstinence-only has been proven. "Programs that are well-designed, well-implemented, and have committed teachers, these programs have an effect," said Stan Weed, director of the Institute for Research and Development, a private nonprofit analysis firm in Salt Lake City. He has evaluated more than 40 abstinence-only courses across the country.

Weed thinks that adolescent brains are not intellectually developed enough to handle serious choices about sexual behavior. Sex education programs don't succeed by offering information and options, but by instilling a belief system, he says.

Anecdotal success stories abound. Allen, the class leader at New Creation, says he has seen his program work repeatedly. Over the past five years, more than 100 teen-agers have taken part in the program. One key, he says, is positive peer pressure. "It's encouraging to hear from other kids who are doing the right thing," said one group member, 18-year-old Ricky Alston. Like his friend Page, he has promised to stay abstinent until marriage.

But researchers say more rigorous evidence is lacking. In 2001, the National Campaign to Prevent Teen Pregnancy - generally seen as a moderate group - commissioned a review of 10 studies that backed abstinence-only. The study, which was written by Kirby, found that nine had serious design flaws, while the tenth offered only weak proof.

Like many researchers, Kirby emphasizes that he favors teen-age abstinence, and says successful comprehensive courses portray chastity as the best option. "Everybody agrees that abstinence is the best approach for young people," he said.

Some worry that the abstinence-only strategy may be counterproductive. By law, federally funded abstinence instruction can only mention contraception and condoms to emphasize their flaws.

By lowering contraceptive use, critics say, abstinence-only could increase pregnancy and sexually transmitted diseases. Condom use among teen-agers rose for most of the past 20 years, but now seems to be waning. The spread of abstinence-only programs may partly explain this, says David J. Landry of the Alan Guttmacher Institute, a nonpartisan sexual-policy think tank.

Teen-age pregnancy rates decreased in the United States between 1991 and 2002, the most recent year for which statistics are available. Both sides claim these numbers show that their approach works. Rates for sexually transmitted diseases are more variable, and don't provide clear evidence for either view.

"To propose that the only way for adolescents to make healthy decisions is to have no information, that's clearly not responsible," said Columbia University sociologist Peter Bearman.

In 2001, Bearman published a study of several thousand "virginity pledgers" - teen-agers who promise to abstain until marriage. He found that those who pledged delayed sexual intercourse by an average of 18 months. But when they did have sex, they were less likely to use contraception than their non-pledging peers. In the end, both groups ended up with the same risk for sexually transmitted diseases and pregnancy.

Bearman calls pledging a "useful tool," but not the only one: "Pledging does not replace education, because most adolescents will eventually have sex."

In an odd twist, abstinence-only backers are using a developing African country as an example of how the United States should teach sex education. In the early 1990s, to combat a raging AIDS epidemic, Uganda began a campaign known as the "ABC model," because it focused on abstinence, being faithful and condom use. The effort worked, reducing HIV rates among Ugandans from almost 20 percent to 6 percent.

Some researchers, led by Harvard sociologist Edward Green, argue that the ABC model succeeded largely by increasing abstinence and faithfulness. Those in favor of abstinence-only in the United States have latched onto this idea, and say the same strategy can be applied here. "Not until Uganda did we really have an abstinence model," said Melissa G. Pardue, a public policy analyst for the Heritage Foundation, a conservative think tank.

But some say condoms were crucial to Uganda's success. "There are three letters in the ABC strategy," said University of Minnesota sociologist Michael Resnick, who directs the school's National Teen Pregnancy Prevention Center.

Others, including Green, wonder whether Uganda's policy can work in the United States. The ABC model worked, they say, because Uganda was in the throes of an epidemic. Abstinence and faithfulness were depicted, accurately, as lifesaving measures. But while HIV is a threat to young Americans, disease rates are much lower. Here, that reality may undercut the abstinence message.

"In Africa, virginity is a life or death decision," Green said. "In America, it's not."

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