Teen sexual risk behavior news is both good and bad 

Experts promote comprehensive education

HIV prevention and sexual education in schools have produced both a good picture and a bad picture, experts say.

"The good news is there are many more adolescents who do use condoms today than probably at any other time in history," says Claire Brindis, DrPH, director of the Center for Reproductive Health Research and Policy at the University of California, San Francisco.

"And we have national data based on school samples of young people that clearly demonstrate the adoption of condoms by young men and women has increased dramatically," she explains. "The bad news is young people seem to be using condoms initially in new relationships, but over time, they tend not to use condoms in those relationships."

Young people need a lot of positive reinforcement for their ongoing use of condoms, and that’s a public health and community problem that has not been solved adequately, Brindis says.

"In the area of condom distribution programs, I think we’re going backward. We have a network of 2,000 school-based health centers across the country, but a very small proportion of them are actually at liberty to give out contraceptives, including condoms, on site," she continues.

Likewise, it appears the trend is shifting away from comprehensive sexual and HIV-prevention education in schools because of the increased federal funding for abstinence-only education, Brindis notes.

After 1985, public schools began to teach AIDS education, and this may be one reason why the United States has had a decrease in pregnancy rates among teens, an increase in the percentage of teens using condoms when they have sex, and an increase in teens abstaining from or delaying sex, says Douglas Kirby, PhD, senior research scientist with ETR Associates in Scotts Valley, CA.

Sex education programs teaching abstinence as the safest approach also have increased since the 1980s, he says. The improvements in teen sexual health is partly because of AIDS and partly because the education programs have gotten better, Kirby explains.

Research in the late 1990s has demonstrated that programs may succeed in reducing teen pregnancy rates when they’re developed in one of three categories:1

  • Programs that focus on sexual antecedents: These include HIV and sex education programs that increase the use of condoms, delay onset of sex, etc.1
  • Programs that focus on nonsexual antecedents: These include certain service learning programs, which do not focus on sexual issues, but have reduced teen pregnancy rates.1
  • Programs that focus on both sexual and non-sexual antecedents: At least one comprehensive and intensive intervention, Children’s Aid Society — Carrera Program, includes both youth development and sexual health components and has demonstrated a reduction in teen pregnancy and birth rates over a long period of time.1

"Earlier programs were much less likely to be effective because they focused more on knowledge," Kirby explains. "Recent programs include other factors such as the perception of peer norms, what are the teens’ beliefs about sex and using condoms, personal values about sex and condom contraception, and the self-efficacy to say No’ to having sex."

However, the comprehensive HIV and sex education programs that were started in the 1980s and early 1990s as an offshoot of the public health concern about AIDS now are followed by new programs that are more limited in their educational and prevention approach, Brindis says.

Based on data from school-based clinics, investigators have found that if a clinic is more than 10 years old, an average of 41% of those clinics provide birth control and/or condoms on the school campus, she notes. If the clinic is less than 10 years old, then about half of that percentage provide birth control to students, Brindis adds. "The older ones were more experienced and worked hard at getting community support, so they’d reflect community values."

Free is the best price

Research conducted in the 1990s when more school districts began to distribute condoms to students has shown that many students will pick up and use condoms when they’re handed out for free.2

Comprehensive health education and condom distribution can make an enormous difference, as evidenced by the success the city of Baltimore has had with reducing teen pregnancy and sexually transmitted disease (STD) rates.

Baltimore health officials achieved these improvements because of four major reasons, says Peter Beilenson, MD, MPH, Baltimore health commissioner. They are as follows:

  • Contraceptive availability: Condoms and pharmaceutical contraceptives are available to middle-school and high-school students at each of the city’s 21 school-based health centers, all located within schools, he says.

"We see thousands of girls and boys, but mostly girls, for family planning in the schools, so there’s a significant increase to access," adds Beilenson. "In addition to the school-based clinic, we have a large adolescent clinic in midtown that serves a couple thousand more kids, so there’s really more access to family planning services, particularly school-based ones, than in most major cities."

  • Condom use on the rise: Nationally, there has been a significant increase in condom use among teenagers, predominantly due to fear of AIDS, he says.
  • Abstinence support groups: "Although these are not hugely common, we do have abstinence support groups run by peers in many of our school-based health centers," Beilenson says.

"These are run by teenagers who generally have been sexually active and have become secondarily abstinent; and through discussion groups with younger peers, they talk about why it is important to not become sexually active very young," he explains. However, the vast majority of Baltimore teens, like teens nationwide, have become sexually active by the time they graduate from high school, Beilenson notes.

  • After-school activities: "There’s been a real push by a kids support network called Safe and Sound, as well as by the mayor here, to promote after-school activities," he points out. "The reason that’s important is because a lot of teen sexual activity occurs between 3 p.m. and 7 p.m. when teens come home from school and don’t have after-school activities, and their parents are out of the house working."

The activities are an offshoot of after-school enrichment programs, focusing on the three A’s of athletic, artistic, and academic, and they’re available to ages 5 through 18, Beilenson says.

While Baltimore’s sexual health program for youth could be seen as a model for other cities, it wasn’t an easy program to implement, he recalls.

When Beilenson first put the birth contraceptive Norplant in schools nearly 13 years ago, it was well received by students and parents, he says.

"But there was a male-run populace campaign to stop that, and there was a huge amount of attention," Beilenson says. "I was threatened with death, and we had a huge amount of international and national press coverage."

Nonetheless, Beilenson persevered, and the schools’ contraceptive program grew with less public attention as the years went by.

"The health department runs the school health program, and what the school board has done is to get out of the controversy of dealing with parents by saying, It’s the health department in the school, and we have no control over it,’" he says. "And it’s not a controversy now at all."

In Canada, comprehensive sexual education and HIV prevention are the norm. Programs in that country have the solid backing of the Canadian government, and the social norms are quite different from the United States.

A recent study of youth and sexual health in Canada also reports some positive findings of long-term decreases in teen pregnancy, an increase in the percentage of sexually active teens who have reported having had only one sexual partner, and a decline in the percentage of teens who report six or more lifetime sexual partners.3

In Canada, the federal government has issued guidelines for a broadly based approach to sexual health education, and the government does not endorse the teaching of abstinence in schools, says Alexander McKay, PhD, research coordinator for the Sex Information and Education Council of Canada (SIECCAN) in Toronto.

Also, Canada has universal health care and a different cultural/social norm regarding teenagers and sex with only a weak minority of lobbying groups speaking out in favor of abstinence-only programs, he says.

The report also found that Canadian youth continue to have increasing rates of some STDs, such as chlamydia, although the teen pregnancy and STD rates in the United States are higher.3

"In terms of percentages of youths who are sexually active, we’re pretty much equal to the U.S.," McKay adds.

"I wouldn’t say the state of HIV or sexual health education in Canada is anything to brag about, but it’s fair to say issues around HIV and reproductive health are taught in middle schools, and obviously in high schools," he explains. "And we don’t take the whole abstinence-only approach."

Beilenson is a firm believer in the comprehensive approach to sex education.

"Most teenagers will be sexually active; and therefore, you have to take that into account and have a comprehensive array of prevention strategies available to kids to get to them where they are," he adds.

References

1. Kirby D. Emerging Answers, Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: The National Campaign to Prevent Teen Pregnancy; 2001.

2. Schuster MA, Bell RM, Berry SH, et al. Students’ acquisition and use of school condoms in a high school condom availability program. Pediatrics 1997; 100:689-694.

3. McKay A. Adolescent sexual and reproductive health in Canada: A report card in 2004. Can J Hum Sex 2004; 13: 67-81.