Does the Pill encourage teenage sex? No.

Apologies, this is likely to be a long one

Executive Summary

You're a busy person, Gentle Reader, so here's the scoop: after a discussion over at Illinipundit, I went looking in the peer-reviewed literature to find out whether or not access to oral contraception increased sexual activity in teenagers. Basically, I was trying to find out whether making oral contraception available encourages teenagers to have more sex. I couldn't find much of anything specifically limited to the Pill, but found quite a lot on contraception in general.

The undeniable conclusion is that access to contraception does not increase sexual activity in teenagers. Similarly and not surprisingly, access to sexual education about contraception also does not increase sexual activity in teenagers. If anything, comprehensive sexual education delays the onset of sexual activity and increases the use of contraception and condoms.

Background

Over at Illinipundit, there was a discussion about a public middle school in Maine with a health clinic that decided to proscribe birth control pills to its sexually active students. Some quick factoids from the NY Times article: there are about 500 students in the school, 135 have the parental permission required to use the clinic, 5 of those were sexually active, and they were all either 14 or 15 years old.

The scope of the teen pregnancy problem is stunning: over 40% of teenage girls are pregnant at least once by the time they're 20. (Kirby) Furthermore, a quarter of sexually active teenagers contract an STD each year. (Kirby)

In the discussion at IP D. Boon asked this:

I would really like to see some of these studies that show the prevalence of The Pill has not led to increased sexual activity at a young age. I have no qualms about saying abstinence only education is probably a not effective, but I've head the opposite about the pill.

Now, I'm pretty sure the research shows that access to contraception does not increase sexual activity in teenagers, but most of what I could remember was about condoms, not the Pill. So I went to look for the actual information.

D. Boon and redstatewannabe both also said that contraception being made available would constitute an "endorsement" of the situation. It was never really explained what that meant, specifically, but I take it to mean that it would have the effect of encouraging teenagers to have sex at a young age.

Methodology

Google Scholar. Really, that's about it. I searched for various combinations of "oral contraception", "the pill", "birth control", "contraception", "sexual activity", "teenager", "adolescent", and similar terms. I found several of what looked like good papers, read them, and followed their references to papers they cited.

I want to make it clear this wasn't an exhaustive or comprehensive search. Google Scholar isn't the best database out there, and finds lots of extraneous stuff. I'm a scientist and engineer; the databases I usually use don't index this sort of social science material. I know there are other databases like Pubmed and Medline, but I don't know how to use them. I also want to make it clear that I'm not a social scientist, so I'm generally relying on the analysis of the authors (I really don't understand how p-values and statistical significance work). Nor did I want to spend more than an hour or two (or five, by now) on this, so I limited myself to less than a dozen papers.

My search was limited to published, peer-reviewed information and their citations. I specifically did not want to rely on any press reports because they almost inevitably over-simplify the science or get it plain wrong.

Findings

In short, neither access to contraception nor sex ed that discussion contraception hasten the initiation of sexual activity. (Committee, Kirby) Everything I found supported that conclusion. It was unanimous. Kirby even describes the amount of evidence supporting this conclusion as "overwhelming."

I was not able to find data specifically limited to the Pill, but part of that may be due to the fact that there are currently at least thirteen different contraceptive methods available, including three different formulations of the Pill. Most studies looked at contraception generally, one I found looked specifically at the effect of condoms on behavior, in the context of HIV prevention.

One thing that became clear is that access to contraception isn't enough. Access to information and education is also very important. Zabin found that access to a health clinic that sounds very similar to the one in Maine (access to sexual education, counseling, and access to contraception and medical services) actually resulted in a significant delay in the onset of sexual behavior. Quoting the study:

While the changes in the age at first intercourse are not large, they are substantial enough -- in the direction of delay -- to refute charges that access to such services as those provided by the program encourages early sexual activity... The project appears to demonstrate that if students in junior high schools are given access to nearby services and if they are offered information and continuity of care, they will use such services, and at levels comparable to those shown by older teenagers.

It usually takes about a year for an adolescent female to seek contraceptive services after the onset of sexual activity. (Committee) The Zabin study found that with one year's access to the program, a female student was about twice as likely to have sought out such services before becoming sexually active, and the percentage at six months was 70%. In other words, it is important that sexual education and contraceptive access start before the onset of sexual activity. The median age for this onset in the Zabin study was about 15. (Admittedly, this was a study in an urban high school, were it is likely to be younger than elsewhere.)

Guttmacher et al. did a study on the effect of the condom distribution program started in 1991 in all New York City schools. This was done in the context of HIV prevention, but their results should be relevant in this discussion of sexual activity as well. They found:

Clearly, making condoms available at school does not lead to increases in sexual activity.

Furthermore,

higher-risk students reported getting a condom from school in significantly higher proportions than lower-risk students.

There was also some concern raised in the IP discussion about the confidentiality of these medical services. Several commenters felt that not informing parents that their children were sexually active was a violation of their "parental rights." According to the Committee report:

The primary reason adolescent's [sic] hesitate or delay obtaining family planning or contraceptive services is concern about confidentiality.

In other words, the best way to make sure teenagers do not use birth control or condoms is to tell their parents. I understand the concern here, but a parent's rights over an adolescent are not absolute. It is the moral and ethical duty of any health care worker to care for his patient's medical needs first; the abrogated rights of a third party are a secondary concern. This isn't to say they're unimportant, as in the case of mandatory reporting of rape or abuse, but a teenager above the age of consent has some medical privacy rights.

Conservatives have been pushing for abstinence-only sex education for some years now. There's even a new TV ad pushing parents to tell their children to not have sex. Personally, I think this is stupid. Not only does it completely ignore the existence of gays and lesbians, not only is it a practice that isn't used by 90% of the American population, and not only is it the only instance I know of where mandated ignorance is a form of education, but there's this to consider:

About 26% of adolescent couple trying to abstain from intercourse will become pregnant within 1 year. [Committee]

Conservatives usually inflate and distort condom failure rates when they try to claim they're ineffective, but they never cite the failure rate for their abstinence programs. Over one quarter of abstinent teenage couples get pregnant within a year, and that's not counting the couples that fail at abstinence and don't get pregnant!

Lastly, I just want to point this out to parents that still look down on sex education and contraception. This has got to be one of the most frightening statistics I've seen:

First intercourse was nonvoluntary for 9 percent of teen females. This percent was higher among those who were younger at first intercourse. (Abma)

If that doesn't make you think "Holy crap!", what does? I'm not quite sure if the use of the word "nonvoluntary" means some of these girls were just pressured into having sex as opposed to out-and-out rape, or if that's just scientific jargon for rape, but it's a stunning percentage. One in ten.

Mind you, that's just for first intercourse. One in four women will be raped in their lifetime. I can't find statistics that break it down any further, but women between 16 and 25 years old are at more than three times the risk of women in any other age group, and about 20% of women are raped by the time they're college-aged. It's sort of out of the scope of this blog post, but remember that women are not the only ones at risk. Six percent of rape victims are men, and in about 10 percent of both rape attempts and sexual assaults, men are the victims.

Conclusions

The literature conclusively states that access to contraception does not hasten the onset of sexual activity. Access to a comprehensive sex ed program as well as contraception actually seems to delay sexual activity in teenagers, if they get it early enough.

References

• Abma, J. C., G. M. Martinez, W. D. Mosher, and B. S. Dawson. "Teenagers in the United States: Sexual Activity, Contraceptive Use, and Childbearing." Advance Data from Vital Health and Statistics. Series 23. Number 24 (2004).
• American Academy of Pediatrics Committee on Adolescence. "Contraception and Adolescents." Pediatrics 104. 1161 (1999).
• Guttmacher S., L. Lieberman, D. Ward, N. Freudenberg, A. Radosh, and D. Des Jarlais. "Condom Availability In New York City Public High Schools: Relationships to Condom Use and Sexual Behavior." American Journal of Public Health. 87. 1427. doi:10.1542/peds.104.5.1161 (1997).
• Kirby, D. "Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy (Summary)." Washington, DC: National Campaign to Prevent Teen Pregnancy (2001).
• Mosher, W. D., G. M. Martinez, A. Chandra, J. C. Abma, and S. J. Willson. "Use of Contraception and Use of Family Planning Services in the United States: 1982–2002." Advance Data from Vital Health and Statistics. No. 350 (2004).
• Zabin, L. S., M. B. Hirsch, E. A. Smith, R. Streett, and J. B. Hardy. "Evaluation of a Pregnancy Prevention Program for Urban Teenagers." Family Planning Perspectives 18. 119 (1986).

Abstinence education is unsafe

A good engineering design is fault tolerant. A designer must realize that components are not always reliable and design accordingly. A suspension bridge shouldn't fail because a single cable breaks.

A good software design fails gracefully. In other words, when faced with unexpected or intelligible input, the program reacts in a predictable manner. The case of the USS Yorktown going dead in the water when a sailor left an unexpected zero in a database field is a great example of software that was not well-designed.

When it might be possible for a piece of equipment to be put in a state where injury or death could occur to the user, an engineer must take this into account. As a simple example, my coffee grinder can't be run with the lid off. There's an interlock that prevents it from turning on when it is possible for my hands to be near the blades.

Lastly, a good designer must take into the possibility of human error. Any potentially lethal piece of equipment, even any policy which could lead to damaging consequences, that does not take this into account is a poor one. This is why we mandate that truck drivers work at most eight hour shifts -- we acknowledge that a tired human being at the wheel is unreliable.

I guess this is why abstinence-only sex education pisses me off: it fails all these criteria. It is not fault tolerant, nor does it fail gracefully. If a kid screws up and has sex before being really ready for it, then it's more likely that he or she will wind up with an STD or a bun in the oven while still in high school (or earlier).

Abstinence education also doesn't acknowledge the possibility of human error. In my last blog post, I quoted the rather repugnant Jill Stanek where she said in a recent column decrying the HPV vaccine that she can't understand why a "virtuous young woman" would want to marry a man who wasn't a virgin. Really? She honestly can't fathom why? One can't help but wonder what Stanek's reasons for getting married actually are.

Abstinence educators are always quick to quote condom failure rates (they almost always use misleading and inaccurate information, when it's not outright falsehoods, but that's a blog post for a different day). What you never hear them cite is the failure rate for a vow of celibacy. Abstinence-only programs do not protect kids from STDs.

Not only do the religious conservatives that push abstinence-only education completely ignore the existence of gay kids, but they're pushing an unsafe agenda. There is no other activity in our society where we consider deliberate ignorance a safety strategy.

All of this is because these religiously-based programs aren't intended to stop STDs and unwanted pregnancy. They're intended to prevent sex. They're intended to prevent sin.

I her book Kingdom Coming: The Rise of Christian Nationalism, Michelle Goldberg tells of a speech given by celibacy advocate Pam Stenzel. Stenzel was appointed by President Bush to an abstinence task force at the Department of Health and Human Services. This is how Goldberg describes Stenzel's speech at the 2003 Reclaiming America for Christ conference:

Stenzel told her audience about a conversation she’d had with a skeptical businessman on an airplane. The man had asked about abstinence education’s success rate—a question she regarded as risible. "What he’s asking," she said, "is does it work. You know what? Doesn’t matter. Cause guess what. My job is not to keep teenagers from having sex. The public schools’ job should not be to keep teens from having sex." Then her voice rose and turned angry as she shouted, "Our job should be to tell kids the truth!"

"People of God," she cried, "can I beg you, to commit yourself to truth, not what works! To truth! I don’t care if it works, because at the end of the day I’m not answering to you, I'm answering to God!"

Later in the same talk, she explained further why what "works" isn’t what’s important—and gave some insight into what she means by "truth." "Let me tell you something, people of God, that is radical, and I can only say it here," she said. "AIDS is not the enemy. HPV and a hysterectomy at twenty is not the enemy. An unplanned pregnancy is not the enemy. My child believing that they can shake their fist in the face of a holy God and sin without consequence, and my child spending eternity separated from God, is the enemy. I will not teach my child that they can sin safely."

These are the sorts of people Republicans want to turn our country over to. People who aren't interested in the actual effects of their policies, so long as they are consistent with their supernatural beliefs.

Do Christians really want women to die?

ArchPundit reads WorldNetDaily so I don't have to. Today, he linked to a column written by nutjob Jill Stanek, who in turn wrote about how horrible the HPV vaccine is. I'm almost starting to think that conservative Christians want there to be horrible consequences for sex, because it makes it dangerous. Stanek says:

Aside from the fact Winokur has no business telling other people's children about "precautions" to avoid pitfalls of promiscuous sex, her advice stinks. Let's not address the real cause. Let's try to avoid the ramifications of the cause.

Winokur or People magazine are fueling the exploitation and health demise of women by refusing to acknowledge the only full-proof [sic] way to avoid HPV or cervical cancer: abstinence.

Let's ignore the fact that she calls any sex before marriage "promiscuous." No, Jill, actually, that's not the only full-proof way to avoid HPV. Twenty percent of women are forced to have sex before they reach their twenties. So I guess you have to add "not getting raped" to that list of "full-proof" (dumbass) ways to avoid HPV.

Fig has pointed out that HPV can live on surfaces for a short while. It's possible to infect yourself by touching an HPV-laden surface, and then touching yourself. So we also have to add "not touching things" to the list of foolproof ways to avoid HPV.

Then Stanek gets into full-self-righteous mode and gets all judgmental on the slutties:

There is only one good reason a virtuous young woman should consider getting the HPV vaccination. That is if the man she plans to marry has had sex with other women, meaning he could be infected with HPV or an array of other STDs. I don't know why a virtuous young woman would want to marry such a man, but there you go.

Seriously, Stanek has absolutely no idea why a woman would want to marry a man who has had sex? "I love you and want to spend the rest of my life with you. What, you're not a virgin? Get lost, tramp!" Is this really what goes through the mind of conservative Christians? Fewer than 10% of Americans are virgins when they get married. So when a woman meets a guy, she has a roughly 90% chance of picking one that has had sex at some point in his life. Those really aren't such great odds when we're talking about a disease that's (a) incredibly common, (b) easy to catch, (c) easy to prevent, and (d) can kill you.

UPDATE: Stanek shows up in the comments and largely apologizes for her attitude towards non-virgins at the end. What she doesn't mention is that many thousands of women are exposed to this virus, even though they do everything "right." This is a simple way to protect a woman from a virus that she is very likely to be exposed to during her life, possibly even against her will. Remember, even, that the adultery rate in American marriage is roughly 40%.