Sex education distorts information on condoms 

Key to prevention, condoms, often are ignored

With a safe HIV microbicide still years away and safe HIV vaccines maybe decades in the future, the world’s health community would do well to focus on making the best use of one of the cheapest and most effective HIV interventions currently available: the latex condom, experts say.

Condoms bought in bulk can cost less than a nickel a piece, and yet how many HIV and sexually transmitted disease (STD) clinics hand out a year’s supply of condoms at a cost of maybe $10 per person to each patient? asks Robert A. Hatcher, MD, MPH, senior author of Contraceptive Technology, and professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta.

All health care professionals would have to do is ask the HIV-infected or at-risk patient, "Would you like a year’s supply of condoms?" he says. "And they’d absolutely love it."

"Condoms work 95% of the time, and I agree that they are underutilized and would prevent HIV and STDs if used," says Deborah A. Cohen, MD, MPH, a senior natural scientist for the RAND Corp. in Santa Monica, CA.

"It’s a big mistake to throw away something that works," she says. "In STD clinics where the patients are people who are having unprotected sex, there should be a standard of having condoms provided to every patient, just like we distribute penicillin for syphilis."

Also, every patient should be taught how to use condoms appropriately, Cohen adds. "Unfortunately, that’s not the case."

Research shows that no matter how condoms are provided, if they’re free, people will use them, she notes. "Giving people condoms makes a difference: You have a significantly lower return rate to the STD clinic. Condoms should be around everywhere to remind people that sex is not safe."

Cohen and Thomas A. Farley, also of RAND, wrote a comment in the July 3, 2004, issue of The Lancet in which they state that the greatest obstacle to prevention of HIV transmission across the world is a lack of condom availability.1

They describe a program started in Louisiana in 1993 that by 2004 distributed 13 million free condoms a year through retail outlets and publicly funded clinics. Within three years of this program’s initiation, investigators found that condom use increased from 40% to 54% by men and from 28% to 36% by women.1

When funding was cut in the mid-1990s, the program switched to selling the condoms for 25 cents each, and immediately the condom distribution dropped by 98%, and the reported condom use among people with multiple sex partners dropped, as well.

Subsequently, the program returned to free condom distribution, and condom use once again rose.

But it’s not just the lack of funding or initiative to distribute millions of free condoms that has created obstacles to this particularly effective method of HIV prevention. Experts also cite the anti-condom campaign waged by religious conservatives and funded by the federal government as a major factor and growing problem.

For example, in December 2004, U.S. Rep. Henry A. Waxman released a report that analyzed the content of federally funded abstinence-only education programs for scientific accuracy and found that 11 out of 13 curricula contained major errors and misleading information.

The misinformation is taught to increasing numbers of middle school and high school students since the Bush administration has doubled abstinence-only grant funding between 2001 and 2005 to about $170 million this year.2

Widely discredited research was heralded as fact, and factual statistics were distorted and used incorrectly to support false claims, including one parent guide, Choosing the Best, The Big Talk Book (Parent Book), which states, "When used by real people in real-life situations, research confirms that 14% of the women who use condoms scrupulously for birth control become pregnant within a year."2

The commonly known statistic of the condom failure rate was intentionally misrepresented, since research typically has shown that condoms fail primarily because people don’t use them scrupulously or because they use them incorrectly; when used correctly, condoms have a failure rate of less than 5%.2

Several curricula also cite Susan Weller’s 1993 study, which was discredited by the Department of Health and Human Services nearly a decade ago, that condoms reduce HIV transmission by 69%.2

Waxman’s report demonstrates how most of the abstinence-only curricula go out of the way to attack the effectiveness of condoms at preventing STDs, HIV, and pregnancy. These curricula also are the source for the recent late-night television jokes about how certain members of the federal government believe HIV transmission can be spread through tears and sweat.2

Even without the factual inaccuracies found in most of the curricula, HIV and public health scientists say the emphasis on abstinence-only education is problematic.

"Among the challenges we’re encountering is we have a sort of cultural war, and young people get caught in the middle," says Claire Brindis, DrPH, director of the Center for Reproductive Health Research and Policy at the University of California, San Francisco.

California is the only state that has not accepted the federal government’s money for abstinence-only education, which requires states to contribute $3 in state funding for every $4 in federal funding, she adds.

No scientific proof

However, these resources are being spent on a prevention strategy that has not been adequately tested through science and for which there is no reason to suspect it will achieve its goal of preventing youth from having sex until marriage, Brindis says. "I don’t think we’re going to see kids stopping from having sex."

Instead, the likely result will be more kids having unprotected sex, which will increase the rate of STDs and teen pregnancies, both of which have been on a decline since the 1990s, she says.

Current research suggests this already is happening. Advocates for Youth of Washington, DC, produced a report titled, Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact, which found that the majority of abstinence-only programs showed no long-term positive impact on participants’ attitudes about sex or their intention to abstain from initiating sex.3

However, the report also found that students who participated in abstinence-only programs often were sexually active by the second year of the program and were ambivalent about using condoms or other forms of birth control.

In one county, only about half of the participants who reported experiencing their first sexual intercourse during ninth grade had used any form of contraception.3

The first of two important studies of abstinence-only education is expected to produce some initial results this year, and that at least will provide some scientific basis for the claims made by people both for and against abstinence-only education, says Douglas Kirby, PhD, senior research scientist with ETR Associates in Scotts Valley, CA. One of the two accurate curricula used by recipients of abstinence-only grants is "Sex Can Wait," which was created by ETR Associates, according to Waxman’s report.

Kirby points out that there is little scientific evidence to confirm the effectiveness of abstinence-only sex education programs. "There have really been only three or four, and those studies indicate that [teenagers] did not delay the initiation of sex."

Still, since the research is so slim in this area, the jury still is out whether a type of abstinence-only education could work, he notes.

However, there’s ample scientific evidence that comprehensive sexual education programs, most of which today contain a message that also emphasizes abstinence, are effective, he says.

"These do not increase any measure of sexual behavior; they do not hasten the initiation of sex; they do not increase frequency of sex, and nor do they increase sexual partners," Kirby adds. "Some of them do the reverse, causing [youth] to delay sex, reduce partners, and reduce frequency; and some, but not all of them, increase condom and contraceptive use."

Even better news is that the most long-term of studies looking at comprehensive sex education has shown that these positive effects can last for at least as long as 31 months, he explains.

For example, teen birthrates have declined dramatically in Baltimore, which once was the nation’s capitol for teen mothers, because of a citywide school health clinic and education program that emphasizes comprehensive sex education, health, and condom distribution.

In the 1980s, Baltimore had the nation’s highest rate of teens giving birth, and now the city is not even in the top 10, and the teen birthrate has dropped 40% since 1991, says Peter Beilenson, MD, MPH, Baltimore health commissioner.

Also, despite the fact that many more youth are being tested for gonorrhea than a decade ago, the number of gonorrhea cases has dropped from 11,000 in the mid-1990s to 4,000 cases in 2004, he says.

One of the major strategies leading to the city’s success with youth has been putting the schools’ health clinics under the jurisdiction of the city’s health department, which has made certain that condoms are available, often piled in baskets for anyone to grab, in each middle school and high school, Beilenson says.

"First of all, the bottom line is we do things based on science, not on politics. We look at data, and we hold ourselves very accountable so whatever programs we’re offering we want to make sure there is no one suffering the consequences," he adds.

References

1. Cohen DA, Farley TA. Social marketing of condoms is great, but we need more free condoms. Lancet 2004; 364:13.

2. U.S. House of Representatives Committee on Government Reform — Minority Staff Special Investigation Division. The Content of Federally Funded Abstinence-Only Education Programs. Washington, DC; 2004.

3. Hauser D. Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact. Washington, DC: Advocates for Youth; 2004.