Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Human love
- Anne M H Williams (22 January 2007)
-
Together on Sexual Health in Adolescents
- Robert J Reynolds (22 January 2007)
-
A helpful editorial.
- Gregory Gardner (23 January 2007)
-
Sexual Health in Adolescents
- Janina M. Harvey (23 January 2007)
-
Sexual Health Editorial - inadequate conflict of interest statement
- Simon W Atkinson (23 January 2007)
-
Too Late!! S&RE is ineffective when given to teenagers
- Caroline F Scherf (26 January 2007)
-
Sexual health in adolescents
- Denise M Pfeiffer (27 January 2007)
-
Re: Sexual Health Editorial - inadequate conflict of interest statement
- Jamie S Robertson (28 January 2007)
-
Sexual health in adolescents: methodology and evidence
- Kristen A Underhill, Don Operario, and Paul Montgomery (30 January 2007)
-
Saved sex and safer sex
- Trevor G Stammers (7 February 2007)
|
|
|||
|
Anne M H Williams, GP Glasgow G52 2AZ
Send response to journal:
|
The evidence for the benefits of abstinence education has been mounting and is now undeniable following this editorial (1). This was studied by us in the SCHB (Scottish Council on Human Bioethics) in 2005(2). We can only hope that policy-makers will now sit up and listen. We already have to answer to a generation of young people who have been given no higher expectation than to respond to their passions. Supplying ever younger school children with condoms and Morning-After- Pills without their parents’ knowledge does not lead them to understand fulfilling human love within the context of self giving. Hopefully, this evidence will lead to less parental exclusion in the education of something so basic. The greater sexual responsibility reflected in ‘Saved sex’ will improve the stability of relationships and will bring many economic and social benefits. (1)Sexual health in adolescents Trevor Stammers BMJ 2007; 334: 103- 104 (2) http://www.schb.org.uk/ Paper: Morning-After Pill Report: Informing Choice - New Approaches and Ethics for Sex and Relationships Education in Scotland Competing interests: Member of the Scottish Council on Human Bioethics |
|||
|
|
|||
|
Robert J Reynolds, Hospital Doctor North Devon District Hospital EX31 4JB
Send response to journal:
|
Thank you for featuring Sexual Health in Adolescence. Henderson et al on the limits of group education, and Trevor Stammers editorial response, will I hope generate debate and initiative. To survive global turmoil we must deal with social fragmentation at home – with special attention to ‘health’ in the transition from childhood to adulthood. If we can agree priority for the more medical of ‘symptoms and signs’ in adolescent departure from ‘complete physical, mental and social health’, we may be able to bring perspectives closer together as to cause and remedy. There need be no division on the place of ‘saving sex’, and of ‘safe sex’, within teaching on sex and relationships. ‘Good advice’ - for survival, physical, social and hence reproductive health - can be separated from what frustration may lead us to describe as ‘ideological baggage’. Though it is not wrong to see, with Stammers’ Family Education Trust, that ‘the government’s teenage strategy is based on ideology...’, what we all seek is of course ever- better ‘ideology’. Our shared task, if we care for each other, is to see the diversity of human situations, to agree the ‘problems’ and coherent solutions, and to keep under review the validity and implications of ‘ideology’ - as it both emerges and guides. Stammers tilts at his own windmills, insults he attributes to others, as he rushes to greet the apparent failure reported by Henderson and colleagues. There is though agreement on value in wider programmes, and the possibility remains that the SHARE programme was merely equal in effect to that of the added personal and social education kindly given as incentive to the ‘control’ schools. Perhaps any ‘programme’ that values participants will bring a Hawthorne effect – given sufficiency of background knowledge. Whatever the causes of the difference Stammers cites, between unstated US declines and more modest UK declines in ‘teenage’ pregnancy rates, they do of course merit study – for the roles of religion, alcohol, drugs, fear of epidemic HIV/ STI, and different types of educational programme. All professionals will welcome understanding and action on factors that can increase acceptance of the ‘saving sex’ message. For those dealing with young couples in sexually- active Gillick-competent relationships, it would also be welcome not to have careless assumptions ascribed to them when the best they may be able to achieve is ‘safe sex’. In its March 2004 press-release, the Family Education Trust might reflect some real and unfortunate experience, but regrettably it certainly misrepresents the nature of ordinary Family Planning practice. Teaching ‘freedom of sexual expression’ to 10-year-olds, in the service of state threat to parenthood, is I hope a portrayal that Stammers would recall with regret. Of far greater now probable seriousness for adolescent sexual health, is the impact of the actual imperatives seen within government, to deal with HIV/ STI, and to deliver grand strategy plus ‘savings’. Against a background of socially-heightened adolescent insecurity, and commercially promoted self-abuse with alcohol, we are seeing the ‘can-do’ use of ‘evidence’ – either decorative or insinuating – to drive a tragic disinvestment in the very workforce most fitted to give the real ‘facts of life’, one-to-one, in our schools. Our national strategy , from 2001, moves from flag-waving (against inequality), to slur (against FP use-access conflated with GUM use/access), to outrage (no longer tolerable), and ‘a programme that begins to put things right’. The premise of the promised ‘improvement and investment’, may all along have been a levelling-down of demand-led specialist provision. Quality provision of Family Planning now stands to be rescued, along with GUM, by the GPs and other Primary Care Providers to whom funding and responsibility are being divested. While relevant experience is no doubt to be found within some, perhaps many, General Practices, it is specialist Family Planning staff (doctors, nurses, counsellors and skilled receptionists) who daily put relevant principles into practice, engaging with young people - their problems, their thinking, and their ever-changing language. If specialist teams and their ethos and their potential are now sacrificed, it will be many years before access is recreated to the best that medicine can offer in this field. We may have to depend for inspiration on anonymized ‘Tales From Family Planning’ – told too late. The special confidentiality of Family Planning has made reporting – and justification of specialist services – somewhat problematic. Now, though specialist roles in GP/nurse training have been envisaged somehow to continue, school educational potential lacks central recognition, and the core of practice, the clinical contribution of specialist Family Planning, has become fair game for managerial disregard. The cancellation of clinics due to a ban on locums is of no concern to at least one senior manager: “…as family planning advice and treatment is also available at all GP practices, and emergency contraception from both (sic) GP practices, MIUs (Minor Injuries Units), A&E and some pharmacies across (the district), the cancellation of some clinics (advertised and hitherto regular) did not present a significant risk to patients”. There is no pretence here that GPs are to be geared-up to take the strain: they have ‘already been paid”. The availability of trained pharmacists is very far from assured for Emergency Hormonal Contraception. Which GP will be turned to, in the window of opportunity for Emergency IUD, when the specialist clinic is found closed? Needless to say, little can be expected of MIUs and A&E. In its 2001 strategy the government lists fine principles, but there is reliance on fantasy: “a culture of positive sexual health…without stigma, fear or embarrassment”. No doubt some will overcome their fears, but do we not know, in ourselves and in most of our patients, well-founded reasons for choice and privacy – not to be labelled as suffering this or fearing that? The public was promised choice, but it turns out to be between one Primary Care Superstore or the next. Where there comes service disruption, we must hope for early restoration of access to care - near enough to centres of education / commerce / industry. May I commend, at all levels, genuine consultation with front-line clinical specialists? With regard to Stammers hopes from compulsory education, to ever- older ages, I fear that unless young people become recognized as contributors, within or alongside their ‘education’, I fear that varieties of social exclusion, intoxication, and self-harm, will continue to divert natural rebellion from its proper targets. 1 Henderson M, Wight D, Raab GM, Abraham C, Parkes A, Scott S, et al. Impact of a theoretically based sex education programme (SHARE) delivered by teachers on NHS registered conceptions and terminations. BMJ 2007; 334:132-6. 2 Stammers T. Sexual health in adolescents. BMJ 2007;334:103-4. 3 Family Education Trust. Government's teenage pregnancy strategy is based on ideology, not research. March 2004. www.famyouth.org.uk 4 DoH. Better prevention, better services, better sexual health – The national strategy for sexual health and HIV. 2001. Competing interests: My wife is a Lead Clinician in Family Planning and a GP. |
|||
|
|
|||
|
Gregory Gardner, Associate General Practitioner Cape Hill Medical Centre, Raglan Rd., Smethwick B66 3NR
Send response to journal:
|
We should be grateful to Trevor Stammers for reminding us that it is end points such as pregnancies, abortions or STI’s that should be looked at when evaluating the success or otherwise of sex education programmes.1 There has long been an assumption that sex education programmes built around secondary prevention strategies (education primarily about the use of contraceptives) will inevitably lead to improvements in these outcomes. This is an assumption based more on ideology than evidence and the report from the SHARE scheme confirms this.2 Differences in family structure play a large part in determining risk taking behaviour of adolescents. By any parameter used, parental marriage is the relationship most closely associated with risk aversion and sexual health of teenagers. It seems perverse for neither the Teenage Pregnancy Strategy nor the National Guidance for its Implementation to have a single positive reference to marriage, when marriage is an aspiration of the vast majority of children in their mid teens. Stammers is rightly calling for a level playing field. For far too long this area of education has been dominated by political correctness, woolly thinking and a knee jerk hostility to any kind of primary prevention programme. Statements such as that delivered by the Chief Medical Officer that, 'evidence does not exist to suggest that abstinence approaches are effective’ (in the teeth of the evidence from Uganda, not to mention other studies dating back to at least 1987), have been particularly unhelpful.3 It is true, as Stammers points out in his editorial that parents should be involved. The job of parenting is made more difficult however when parents are undermined on all sides. The main website sponsored by the DOH/DFES providing information for 11-14 year olds, links to organisations who seem determined to do everything they can to break down a child’s natural inhibitions and who provide misleading information about, for example, the effectiveness of condoms against STI’s.4 Add to that a policy where under 16’s can be given contraceptives without their parents’ knowledge or consent and we clearly have got a long way to go. 1. Stammers T. Sexual health in adolescents. Bmj 2007;334(7585):103- 4. 2. Henderson M, Wight D, Raab GM, Abraham C, Parkes A, Scott S, et al. Impact of a theoretically based sex education programme (SHARE) delivered by teachers on NHS registered conceptions and terminations: final results of cluster randomised trial. Bmj 2007;334(7585):133. 3.http://www.dh.gov.uk/PublicationsAndStatistics/LettersAndCirculars/CMOUpdate/CMOUpdateArticle/fs/en?CONTENT_ID=4003844&chk=2uZJEX 4 http://www.wiredforhealth.gov.uk/cat.php?catid=838 Competing interests: None declared |
|||
|
|
|||
|
Janina M. Harvey, Consultant in Genitourinary Medicine Falkirk Royal Infirmary
Send response to journal:
|
The message is loud and clear - school sex education must change to incorporate `wider sociocultural aspects`in order to encourage delayed sex.Condom use may only help reduce sexually transmitted infections(STIs)and pregnancies when practised consistently.In most cases the message has been ignored hence the rise in infections. With the advent of HIV in the early eighties the message was clear and STIs plummetted.Then with more effective treatment HIV became a more manageable infection.But HIV is also on the increase and like all viral infections it readily mutates and then no longer responds to the same treatment. Parents and teenagers report a lack of involvement as they try and cope with the resulting fallout with the pervading message that`teenagers will have sex anyway`. I agree that further evaluation of `saving sex` programmes should be properly evaluated with adequately funded research. I am Yours Janina Maria Harvey
Competing interests: None declared |
|||
|
|
|||
|
Simon W Atkinson, Consultant General Surgeon Guy's & ST Thomas' Trust, London, SE1 7EH
Send response to journal:
|
Stammers' editorial on sexual health in adolescents draws attention to the
difficulty of finding effective interventions to decrease teenage conception
rates.
I am very concerned, however, that the BMJ has accepted such a poor competing interests disclosure. A cursory search reveals that the organisations of which the author is a trustee are christian lobby groups that not only promote faith-based sexual health propaganda but are also highly ambiguous in their self description on their websites. Challenge Team UK claims to present 'its message from a common sense and health perspective, without any religious references'. The three trustees are all christian activists and one of them (John Chaplin) promotes views on the website of the Africa Inland Mission such as 'not only does Aids present opportunities to share the love and forgiveness of Christ, it also challenges us all to live in obedience to his Word', 'malaria is a major cause of illness and death in Africa but God can even use this to bring life' and the poorly evidence based assertion that 'God's people would see that the way to combat this new enemy, Aids, was through the power of God's Spirit in them'. I was under the impression that the BMJ was keen on evidence based medicine and would not intend to give a platform to overtly religious organisations. Perhaps we can expect an editorial written by a druid or a satanist providing their views on the health issues of the day? http://www.aimeurope.net/index.php?280. Competing interests: None declared |
|||
|
|
|||
|
Caroline F Scherf, Consultant in Sexual & Reproductive Health Cardiff and Vale of Glamorgan
Send response to journal:
|
Trevor Stammers' view on reducing teenage pregnancy rates by promoting abstinence is ineffective and antiquated and in stark contrast with every child's experience (1). Most children will have learned a great many things about Sex & Relationships by the time they reach age 13-14 and in fact about a quarter of them will already have had their sexual debut (2). It is therefore not surprising that no change in effect on teenage pregnancy was noted in either of the studied S&RE programmes in Scotland (3). Children learn everywhere, more so once they have gained access to essential learning tools such as reading and use of the internet, apart from watching the telly or just observing behaviour of people around them. They will analyse and draw conclusion constantly, especially on subjects such as Sex and Reproduction which are of great interest to children. If the education syllabus fails to address any of these in nurseries or primary schools, a vital opportunity is missed to provide children with tools allowing them to critically view all the images they are confronted with. they may thus not be able to make decisions in such a way that they are unlikely to regret later in life. The best time to teach children the 'facts of life' is in pre-school nurseries - in child-adequate ways as already done in many other countries such as the Netherlands with better outcomes on teenage pregnancy rates and regretful first experiences. As long such important decisions are left with individual school governors instead of introducing S&RE alongside the three 'Rs' the teenage pregnancy rate will remain high. References 1)Stammers T. Sexual health in adolescents. BMJ 2007;334:103-4. 2)Ross J., Godeau E. and Dias S. 'Sexual Health' In: HSBC International report, ed Currie C. et al; WHO library 2004 3)Henderson M, Wight D, Raab GM, Abraham C, Parkes A, Scott S, et al. Impact of a theoretically based sex education programme (SHARE) delivered by teachers on NHS registered conceptions and terminations. BMJ 2007; 334:132-6. Competing interests: mother of three |
|||
|
|
|||
|
Denise M Pfeiffer, Freelance writer Leicester, LE2 6FG
Send response to journal:
|
I find it incredible that Simon Atkinson would try to silence those who are commenting on what is obvious to the majority. If those working in medicine are still subject to government brainwashing then what hope do we have?! Even if all the groups that Dr Stammers is a Trustee for were Christian - why does it matter? Do all the groups Simon Atkinson belongs to have an atheist, secular agenda? Does it really matter? Sexual health in this country is a serious issue and there is surely no time to waste trying to silence the opposition. We should be encouraging debate - not stifling it. Maybe one day, when it's much too late for our future generations, people will look back and weep because they did not listen to the warnings given by those medical experts such as Dr Stammers, who have dared to stand out from the crowd and present the truth as it stands. Competing interests: None declared |
|||
|
|
|||
|
Jamie S Robertson, Final year medical student University of Glasgow, G12
Send response to journal:
|
Simon Atkinson seems to be letting his own prejudices get the better of him in his criticism of Trevor Stammers' editorial. On the one hand he argues for a solely evidence-based, pragmatic approach to dealing with sexual health approaches; on the other, he does not even attempt to deal with the practical strategies offered by Dr Stammers, and instead targets his ideology (which he does not once promote or enfore upon others in his editorial). Surely, if EBM is so important, Mr Atkinson will overlook the fact that Dr Stammers has the audacity to approach his life with a faith different to Mr Atkinson's own, and simply deal with how effective the proposed strategies are? Similarly, why does Mr Atkinson seem to assume that John Chaplin's faith makes him incapable of promoting health strategies "without any religious inferences" and on the basis of reason and evidence? Must a doctor be a card-carrying humanist to be considered impartial in matters of medicine? If Mr Atkinson has a moral or ethical bone to pick with Dr Stammers' approach, then he is free to say so. Nevertheless, I would hope that all doctors would be open to examining public health strategies in the light of their efficacy, regardless of the religion, faith or worldview of the advocates of such strategies. Competing interests: None declared |
|||
|
|
|||
|
Kristen A Underhill, Research Officer Centre for Evidence-Based Intervention, University of Oxford, 32 Wellington Square, Oxford, OX1 2ER, Don Operario, and Paul Montgomery
Send response to journal:
|
Stammers’ editorial[1] on sex education raises a number of interesting public health issues. However, in the light of our recent investigation into abstinence-based programmes for HIV prevention in high- income countries, several of his assertions appear flawed on key methodological principles. -Conclusions drawn from Henderson et al.- Stammers’ conclusions do not follow logically from the trial design and results reported by Henderson et al.,[2] because his editorial has not drawn appropriate attention to the actual comparison made. Stammers concludes, “The trial found no significant difference between the intervention and control groups ... The results should stimulate urgently needed change from previous ineffective approaches to school sex education.” This assertion overlooks that Henderson et al. compared the SHARE programme to existing sex education programmes, which already included 7 to 12 lessons of information provision and discussion.[2] In fact, the evaluation did not show that SHARE (or sex education in general) is ineffective; it simply showed that SHARE is no more or less effective than existing sex education programmes. This is an important distinction. The trial results do not necessarily motivate changes to existing methods; instead, they suggest only that SHARE does not improve on the standard sex education already delivered in east Scotland. -The relevance of behavioural and biological outcome measures- We agree with Stammers’ assessment of the clinical relevance of outcomes frequently measured in sexual health programme trials. As we have previously suggested,[3] the field of HIV prevention could benefit from consensus on a set of operationalised and clinically relevant outcome measures, both biological and behavioural, for the evaluation of risk. This recommendation may apply to the fields of pregnancy prevention and sexual health as well. The medical evaluation of HIV, other sexually transmitted infections (STIs), and pregnancy will yield the most clinically relevant assessments of sexual health promotion programmes, especially as there are limits to the reliability of self-reported data[4- 7] and to the predictive validity of sexual behaviour outcomes[8 9] as indicators of actual risk. However, while medical evaluations of biological outcomes indicate risk most directly, self-reported sexual behaviour data remain relevant. Stammers suggests that evaluations showing protective effects for “intermediate outcomes” such as condom use might lead to “false claims of success, whereas more robust outcome measures such as rates of terminations, unplanned conceptions, and sexually transmitted infections show no benefit.” Here, Stammers does not account for the substantial problem of floor effects. Often, rates of terminations, conceptions, and STIs are so low that sample sizes of many hundreds or thousands of adolescents would be necessary to detect a significant programme effect. In the US, for example, the prevalence of HIV among young adults is estimated at approximately 1.0 per 1,000 in the general population.[10] To detect a difference of even one HIV infection per trial arm, a two-arm trial among a general young adult population would require data for at least 2,000 individuals at follow-up. It would not require as many participants to detect a significant difference in pregnancy rates, but the problem of floor effects remains relevant. Most trials lack such expansive sample sizes, but they are often adequately powered to detect significant behavioural differences. As a result, while medically evaluated biological outcomes are crucial, sexual behaviour data such as condom use are a necessary proxy for most trials. The trials that find significant results for behavioural, but not biological outcomes are not necessarily making “false claims” of programme success; few are adequately powered to reliably detect corresponding differences in biological outcomes. Notably, even small trials should collect data on biological outcomes, because the aggregation of many underpowered studies in a meta-analysis can produce adequate power to detect significant effects. -Causes of recent declines in adolescent pregnancy rates- Recent research also contests Stammers’ suggestion that declines in adolescent pregnancy rates (specifically, US adolescent pregnancy rates) are primarily attributable to delayed first sex. A study published this month by Santelli et al.[11] analyses data that correspond to decreases in the US teen birth rate during the years 1995-2002. Analysing data for youth aged 15-19, the study found that “the overall pregnancy risk index declined 38%, with 86% of the decline attributable to improved contraceptive use.” This contrasts with earlier research cited by Stammers.[12] -The evaluation of “Managing the Pressures Before Marriage” by Blake et al.[13]- Referring to a randomised controlled trial by Blake et al., Stammers reports that adding parent-child homework “greatly enhanced” the abstinence-only programme’s effectiveness as measured by “usual intermediate outcomes only, such as self efficacy and intention to have sex.” Although Stammers then calls for more evaluations that assess sexual debut, he does not mention that Blake et al. did assess sexual debut at short-term follow-up: the trial found no significant difference between trial arms in whether students had ever had sexual intercourse. The evaluation also found no significant effects on whether students reported having sexual intercourse in the previous 3 months. Attitudes can be important mediators of sexual activity, but the results of Blake et al. actually indicate that the addition of parent-child homework did not enhance short-term programme effects on sexual behaviour. (This finding was also limited by floor effects, as only 6% of participants in the trial reported ever having had sex.[13]) It is interesting to note the contradiction between Stammers’ suggestion that sex education studies assessing condom use make “false claims of success,” and his acceptance of attitudinal outcomes of an abstinence-only programme trial as indications of “greatly enhanced” effectiveness. -The effectiveness of abstinence-based programmes- Safe sex and “saving sex” need not be mutually exclusive focuses of sexual health interventions, as Stammers has also acknowledged in the past.[14] No one disputes that consistent abstinence from oral, anal, and vaginal sex can be an effective way to avoid pregnancy, STIs, and the sexual acquisition of HIV. However, given limited resources, a major issue is whether it is more effective for programmes to promote only abstinence, or to promote abstinence along with condom use and other safe-sex strategies. The most methodologically rigorous systematic reviews to date have documented no behavioural or biological evidence that abstinence-only programmes can reduce sexual risk with respect to HIV infection[15] or pregnancy,[16] as compared to a range of control groups. One review has even indicated that abstinence-only programmes may cause harm.[16] However, rigorous reviews[17-20] suggest that hierarchical interventions that promote both abstinence and condom use (i.e., “abstinence-plus” programmes) have had long-term protective effects on self-reported sexual behaviour and/or pregnancy. (To date it appears that only three trials of abstinence-plus HIV prevention programmes[21-23] have assessed self- reported STI incidence or treatment, without finding significant effects among approximately 1,734 participants. The control groups for these studies were usual care[22 23] and a time-matched HIV prevention program without skills training.[21] All may have been underpowered to detect significant differences, and more evaluations are necessary to assess this outcome.) Direct comparisons between abstinence-only and abstinence-plus programmes are lacking. In our research, we have found only one randomised controlled trial[24] that explicitly compared an abstinence- only programme against an equal-format programme that prioritised abstinence but also recommended condom use. This evaluation found no significant differences in condom use, incidence or frequency of sex, or number of partners (with analyses representing approximately 194 students aged 18-21 in the two-arm comparison), but it was limited to six-week follow-up and faced serious methodological limitations. Many cite Jemmott et al.[25] as another example, but the abstinence-focused arm in this trial acknowledged the protective effects of condoms and was therefore not an abstinence-only intervention. The lack of abstinence-only vs. abstinence-plus programme trials is problematic, and more evaluations directly comparing the two programme types will provide key evidence in this ongoing investigation. References 1. Stammers T. Sexual health in adolescents: "saved sex" and parental involvement are key to improving outcomes. BMJ 2007;334(103-4). 2. Henderson M, Wright D, Raab M, Abraham C, Parkes A, Scott S, et al. Impact of a theoretically based sex education programme (SHARE) delivered by teachers on NHS registered conceptions and terminations: final results of a cluster randomised trial. BMJ 2007;334:132-6. 3. Underhill K, Montgomery P, Operario D. Reporting deficiencies in trials of abstinence-only programs for HIV prevention. AIDS 2007;21(2):266 -268. 4. Rosenbaum J. Reborn a virgin: adolescents' retracting of virginity pledges and sexual histories. Am J Public Health 2006;96(6):1098-1103. 5. Brener N, Grunbaum J, Kann L, McManus T, Ross J. Assessing health risk behaviors among adolescents: the effect of question wording and appeals for honesty. J Adolesc Health 2004;35:91-100. 6. Lauritsen JL, Swicegood CG. The consistency of self-reported initiation of sexual activity. Fam Plann Perspect 1997;29(5):215-21. 7. Newcomer S, Udry J. Adolescents' honesty in a survey of sexual behavior. J Adolesc Res 1988;3(3-4):419-23. 8. Peterman TA, Lin LS, Newman DR, Kamb ML, Bolan G, Zenilman J, et al. Does measured behavior reflect STD risk? An analysis of data from a randomized controlled behavioral intervention study. Project RESPECT Study Group. Sex Transm Dis 2000;27(8):446-51. 9. O'Leary A, DiClemente RJ, Aral SO. Reflections on the design and reporting of STD/HIV behavioral intervention research. AIDS Educ Prev 1997;9 Suppl 1:1-14. 10. Morris M, Handcock M, Miller W, Ford C, Schmitz J, Hobbs M, et al. Prevalence of HIV infection among young adults in the United States: results from the Add Health study. Am J Public Health 2006;96(6):1091-7. 11. Santelli J, Lindberg LD, Finer LB, Singh S. Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. Am J Public Health 2007;97(1):150-156. 12. Santelli J, Abma J, Ventura S, Lindberg L, Morrow B, Anders J, et al. Can changes in sexual behaviors among high school students explain the decline in teen pregnancy rates in the 1990s? Journal of Adolescent Health 2004;35:80-90. 13. Blake SM, Simkin L, Ledsky R, Perkins C, Calabrese JM. Effects of a parent-child communications intervention on young adolescents' risk for early onset of sexual intercourse. Fam Plann Perspect 2001;33(2):52-61. 14. Stammers T. Abstinence under fire. Postgrad Med J 2003;79:365-6. 15. Kirby D, Laris B, Rolleri L. The impact of sex and HIV education programs in schools and communities on sexual behaviors among young adults. Research Triangle Park, NC: Family Health International, YouthNet Program, 2006. 16. DiCenso A, Guyatt G, Willan A, Griffith L. Interventions to reduce unintended pregnancies among adolescents: Systematic review of randomised controlled trials. BMJ 2002;324:1426-1435. 17. Kirby D. Emerging Answers: Research findings on programs to reduce teen pregnancy. Washington DC: National Campaign to Prevent Teen Pregnancy, 2001. 18. Jemmott JB, III, Jemmott LS. HIV risk reduction behavioral interventions with heterosexual adolescents. AIDS 2000;14 Suppl 2:S40-52. 19. Pedlow C, Carey M. HIV sexual risk-reduction interventions for youth: A review and methodological critique of randomized controlled trials. Behav Modif 2003;27:135-190. 20. Manlove J, Papillo AR, Ikramullah E. Not yet: programs to delay first sex among teens. Washington, DC: National Campaign to Prevent Teen Pregnancy, 2004. 21. St. Lawrence JS, Jefferson KW, Alleyne E, Brasfield TL. Comparison of education versus behavioral skills training interventions in lowering sexual HIV-risk behavior of substance-dependent adolescents. J Consult Clin Psychol 1995;63(1):154-7. 22. Kirby D, Korpi M, Adivi C, Weissman J. An impact evaluation of Project SNAPP: an AIDS and pregnancy prevention middle school program. AIDS Educ Prev 1997;9(SA):44-61. 23. Boekeloo BO, Schamus LA, Simmens SJ, Cheng TL, O'Connor K, D'Angelo LJ. A STD/HIV prevention trial among adolescents in managed care. Pediatrics 1999;103(1):107-115. 24. Hernandez JT, Smith FJ. Abstinence protection and decision- making: experimental trials on prototypic AIDS programs. Health Educ Res 1990;5(3):309-320. 25. Jemmott JB, III, Jemmott LS, Fong GT. Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial. JAMA 1998;279(19):1529-1536. Competing interests: None declared |
|||
|
|
|||
|
Trevor G Stammers, Lecturer in Healthcare Ethics St Mary's University College TW1 4SX
Send response to journal:
|
I am grateful to Underhill et al for some interesting observations on my editorial, even though some misunderstanding and misquotation detract from a number of valid points with which I would completely concur e.g. that saved sex and safer sex are not mutually exclusive. Conclusions from Henderson I did not deny that the comparison was between SHARE and already existing programmes in Lothian and Tayside. However, these two areas were chosen because their teenage pregnancy rates were well above the Scottish average and indeed Lothian’s are among the highest in Scotland (1). The fact that neither SHARE nor the control groups impacted on these high rates surely justifies my call for change "from previous ineffective approaches to school sex education for which Henderson et al themselves admit “evidence of effectiveness is mixed”". By omitting the end of the quote, Underhill makes it appear I alone conclude this, whereas I agree with Henderson. The point is that neither existing Lothian and Tayside education nor SHARE is reducing pregnancy rates and therefore change is surely needed? Behavioural and biological data I accept that floor effects are important but would argue that even small trials should collect data on biological outcomes as these may be useful in later meta-analyses. However with chlamydia rates over 10% in some populations of sexually active teenagers, a much smaller scale study should be able to detect differences in chlamydia rates and some other equally common STIs. I would dispute however Underhill’s unsubstantiated assertion that condom use is a proxy for biological outcomes such as pregnancy rates and STI rates. This is not so, especially for those STIs like HPV, whose transmission is almost unaffected by condom use. There is substantial research linking increased condom use with higher pregnancy rates (2, 3) and increase in STIs (4, 5) so it is certainly not necessarily a good proxy measure for biological indicators of sexual health. Causes of decline in pregnancy rates Mohn (6) is the only peer reviewed study that differentiates between married and unmarried teens. There is a big difference in significance between pregnancy in a married 19 year old and in an unmarried 14 year old. Santelli et al (7), unlike Mohn, lump all such cases together. In the more recent Santelli paper (8) (published after my editorial) it is also assumed that youngsters who abstain would otherwise have used contraception in the same way as those who continue to be sexually active. This assumption has vast potential to skew the result however and may account for the big difference in percentages from their earlier paper based on the same data. If instead one makes the contrary assumption that all the decrease in sexual activity came from those who would otherwise have used no contraception the results are quite different. The Blake Study Some very good points are made by Underhill here but I did not claim, as she asserts, that “studies assessing condom use make false claims of success” but rather that “studies using intermediate outcomes such as pupil satisfaction and condom use” facilitate false claims of success. Such studies include of course those of abstinence programmes as much as those looking at contraceptive interventions. Blake here does fall into this category and I acknowledge this in the editorial. Note though that in Blake, the comparison is between the abstinence programme alone vs. the same programme with extra parental input. Therefore, it is interesting to note the contradiction between Underhill’s grace extended to Henderson et al in the light of their ‘active’ control group and her lack of it given to Blake et al in the light of her theirs. Effectiveness of abstinence programmes I have dealt with this in greater detail elsewhere (9, 10). There is evidence that condom programmes do harm too(3,5) and each programme should be evaluated on its own outcomes (ideally biological) whether focused on saved sex or safer sex or both. References 1.www.opfs.org.uk/factfile/teenpreg.html 2.Williams ES. Contraceptive failure may be a major factor in teenage pregnancy. BMJ 1995; 311:807 3.Richens J, Imrie J, Copas A Condoms and seat belts: the parallels and the lessons Lancet 2000 355 400-3 4.Paton D Random behaviour or rational choice? Family planning, teenage pregnancy and sexually transmitted infections Sex Education 2006 6 281-308 5.Genuis SJ, Genuis SK. Managing the sexually transmitted disease pandemic Am J O and G 2004 191 1103-12 6.Mohn JK, Tingle LR, Finger R An analysis of the causes of the decline in non-marital birth and pregnancy rates for teens from 1991-1995 Adoles and Fam Health 2003 3 39-47 7.Santelli JS, Abma J, Ventura, Lindberg L, Morrow B, Anderson JE, et al. Can changes in sexual behaviors among high school students explain the decline in teen pregnancy rates in the 1990s? Journal of Adolescent Health 2004; 35: 80-90. 8.Santelli J, Lindberg LD, Finer LB, Singh S Explaining recent declines in adolescent pregnancy in the US: the contribution of abstinence and improved contraceptive use Am J Pub Health 2007 97 150-6 9.Stammers T Abstinence under fire Postgrad Med J 2003 79 365-6 10.Stammers T Easy as ABC? Postgrad Med J 2005 273-5 Competing interests: Remained unchanged |
|||