In the news today is coverage of research suggesting abstinence-based sex education leads to children delaying sex and is better than other approaches to sex ed. But is this what the study actually found? Here’s the low down on the paper and what the findings really mean for sex education.

Study: abstinence programs most effective at delaying sex among youths – CNN

Teaching abstinence makes children delay first sexual intercourse: research – Telegraph

Study: abstinence only program shows promise – Baltimore Sun

Study finds benefit in abstinence programme – New York Times

These stories, and countless others like them in the global media today suggested abstinence only sex education is more effective than other forms of sex education. The press coverage was based on a study by Jemmott et al entitled ‘Efficacy of a Theory-Based Abstinence-Only Intervention Over 24 Months’ in the journal Archives of Pediatrics and Adolescent Medicine (unfortunately not open access). But did the research actually find abstinence sex education is superior to other approaches?

Before we can answer that question, let’s look at the study itself.

What did the research involve?
The research was based on 662 male and female low income African American students aged between 11-15 (grades 6-7) mean age 12 at the time the study started in 2001. Students were recruited through announcements in school assemblies, adverts in schools and youth clubs, and letters to parents as part of a pre-existing health promotion project. Those who volunteered were randomly assigned to one of four interventions that lasted an hour and ran over an eight week period in schools on Saturdays. 16 male and 51 female African American facilitators (mean age 43) were trained to deliver the interventions all of which included group work, games, watching videos, and skill building activities. The interventions were:

Abstinence information only
Focused on abstinence (not having sex) to “eliminate the risk of pregnancy and STIs including HIV. It was designed to (1) increase HIV/STI knowledge, (2) strengthen behavioural beliefs supporting abstinence including the belief that abstinence can prevent pregnancy, STIs and HIV, and that abstinence can foster attainment of future goals and (3) increase skills to negotiate abstinence and reduce pressure to have sex. It was not designed to meet federal criteria for abstinence-only programs. For instance, the target behaviour was abstaining from vaginal, anal or oral intercourse until a time later in life when the adolescent is more prepared to handle the consequences of sex. The intervention did not contain inaccurate information, portray sex in a negative light, or use a moralistic tone. The training and curriculum manual explicitly instructed the facilitators not to disparage the efficacy of condoms or allow the view that condoms are ineffective to go uncorrected” (p.153)

Safer sex information only
Promoted condom use as a means of preventing HIV and other STIs and pregnancy, it did not mention abstaining from/delaying sex.

Comprehensive intervention
Combined both abstinence/delay and safer sex messaging (some of these sessions were 8 hour sessions in total, some were 12 hours in total).

Health promotion intervention
This activity served as a control and covered health-related education on topics such as preventing heart disease, stroke, or diabetes, and encouraging exercise plus avoiding cigarettes.

Participants in all of the interventions were asked to complete questionnaires before the study began, straight after the last intervention session and during follow up at 3,6,12, 18 and 24 months afterwards. The self-reported questionnaires assessed whether students had engaged in sexual activity, number of sexual partners, unprotected sex, and condom use.

What was the aim of the study?
The researchers sought to identify which approach to delivering sex education resulted in teenagers delaying sexual activity, and the researchers hypothesised the abstinence based approach would be most successful at delivering this.

Why focus on these participants?
In the US the rates of HIV and other STIs and unplanned pregnancy are higher among low income African American youth than other groups of teenagers. The study aimed to identify effective means of enabling this group of young people to reduce their risks of pregnancy and infection.

What did the study find?
The results indicated those who received the abstinence only intervention were significantly more likely than students in the health promotion (control) group to have delayed having sex at 24 months post-intervention. From the paper “the abstinence-only intervention reduced sexual initiation (P=.03). The model-estimated probability of ever having sexual intercourse by the 24-month follow-up was 33.5% in the abstinence-only intervention and 48.5% in the health-promotion control group. The safer sex and comprehensive interventions did not differ from the control group in sexual initiation” (p.156). This suggests the abstinence based approach was not significantly more effective than condom promotion only or combining delay plus condom use messaging. [Update 03/02/10: I was emailed about my review of the research by Joe Paxton from Harvard who pointed out I'd previously not been clear about the differences between the conditions and to question the outcomes presented in the paper - specifically that the claims that abstinence only education was 'better'. It appears better than control in delaying sexual activity, but not signficantly different to the other conditions (safer sex or combined interventions). This has led some critics to question the study further in terms of its outcomes and claim of the effectiveness of abstinence based education].

What were the limitations of the research?
As with any study there will be limitations on research, and educational interventions are notoriously difficult to manage and directly demonstrate effects. The researchers are very clear about potential limitations on this current study which include reliance on self report data (which can be biased by recall problems and pressure to provide socially desirable answers). They also note that across all groups most of the young people had not had sex by 24 months follow up (probably due to the wide age range of participants and the fact most teens don’t have sex aged under 16). So although a difference in groups was noted, overall participants hadn’t had sex regardless of whatever intervention they received. And that would make it impossible to assess issues like safer sex, number of partners or condom usage reliably.

The students were perhaps also unrepresentative because they volunteered to be in the research and were willing to attend 8-12 hourly educational sessions in school at weekends. Not only were they motivated but they presumably had family support too. The researchers explain this makes it difficult to assess whether similar interventions on different kinds of pupils in the US or elsewhere would be as effective. This is particularly important given a growing awareness that while young people would like access to social clubs or sexual health clinics many find those offered at the weekend to be particularly inaccessible (particularly those with strict parents, or for girls who may be more likely to have their movements more closely monitored).

In addition to the concerns noted by the researchers, I’d raise some further questions that aren’t addressed in the paper. A large number of facilitators were involved in delivering the interventions. All of them were trained but with so many people included in a study there is potential for messages to differ. An account of how this was controlled for would have been very helpful within this paper.

There’s also the issue of the timing of this research. As a follow up study it naturally required time to run, however the study began in 2001 with data collected until 2004, yet it was only submitted for publication in 2009. While there is nothing suspicious about this, it does raise questions about the cohort being studied as over the past decade (during which time this research was completed, analysed and published) there have been many changes in Western culture in relation to a shifting consumerist and sexualised culture. So it may well be the outcomes obtained might be different were the research to be replicated. This is not a reason to dismiss the study but it would have been useful to see this issue addressed within the paper.

The biggest problem with the paper however is the use of the term ‘abstinence only’. To many this may well imply a faith based approach and yet if you read the description of the abstinence only intervention quoted above it is very clear this was not remotely faith based and in fact differed quite markedly from such approaches – particularly around the accurate mentions of condoms. The focus appeared to be about confidence, delay and anticipating sex as a positive event.

When I read about the paper in the press coverage I anticipated a study that compared a faith-based abstinence programme with other approaches. In fact this study is really about a delay-based programme that anticipates sex positively. And that is not what many people would understand as abstinence.

This is unfortunate as it may well be many working within sex education and healthcare will dismiss or perhaps not consult this paper believing it is promoting a faith based, sex negative approach. And faith groups who advocate abstinence will claim this paper supports their educational approaches which often spread misinformation about condoms and do not adequately cover issues about STIs or pregnancy. Indeed such approaches tend to use scare tactics and a lack of information to encourage young people not to have sex until they are married. This was not a feature of this current study. If I had reviewed this paper I would have recommended the term ‘abstinence’ be replaced by ‘delay messaging’ which would be more accurate and helpful to those searching for educational interventions that might inform their sex education practice.

Unfortunately the media for the most part didn’t make this clear. Admittedly a few journalists (and media blogs) did pick up on some of the issues I’ve touched on above (particularly relating to the idea of faith based abstinence approaches). However most did not explain the research – most likely because they did not read the paper (or failed to understand it). This is problematic because the coverage does not faithfully explain the study. It has suggested that faith based, sex negative abstinence approaches are better than other forms of sex education. And this study (and countless others) clearly show that’s not true.

So what’s the take home message?
This is a useful paper and a fair piece of research. It has limitations which means it can’t reliably be used to inform sex educational policy, but it would certainly benefit from adaption and replication and a longer follow up. Unfortunately the problem is less about the study (which is clearly discussed by the researchers) and more about how the media has misreported it and how politicians and faith based groups are misrepresenting the findings to suit sex-negative abstinence programmes.

Rather than falling into that trap we should take this research as further evidence that sex education is effective when it is tailored to the individual needs of different children; builds confidence; resists peer pressure; addresses feelings and emotions as well as infections and contraception; promotes delay until a young person is ready for intimacy (see also here and here); and prepares them for positive relationships when they are older.

Brief background – female sexual dysfunction

Over the past 10 years the race has been on with pharmaceutical companies to find the ‘female Viagra’ – a drug to treat female sexual dysfunction (FSD).

At the same time, concern has been growing within healthcare, therapy and education about the medicalisation of sexual functioning. FSD in particular is a diagnosis with a controversial heritage, with concerns expressed that common (but often upsetting) female problems around lack of desire and difficulty experiencing orgasm have been repackaged within a illness-based model.

[You might also find this discussion held a couple of years ago on Woman's Hour that addressed FSD useful (includes links to support organisations relating to sexual difficulties). Plus this special issue of the journal Sexualities tackles the problem of medicalising sex for women and men, and Liz Canner's amazing documentary Orgasm Inc provides a thorough backdrop to the topic]

Over the years several drugs have been developed, although many did not get past early trial stages. Of those that did, testosterone patch Intrinsa was heralded as being the answer to lack of sexual desire in women, although was later found not to be clinically effective (and was never approved for use in the US). Another drug – PT141 – aimed at boosting desire (and aimed at men and women) also failed to meet safety standards and wasn’t developed further (although that wasn’t before the media promoted it as the sex wonder-drug of the future). Alongside these promised medications there’s been a whole slew of herbal products and ‘super foods’ (usually fruits, seeds and berries) promoted in the media and all guaranteed to boost desire or enhance orgasms.

Latest trials – Flibanserin
Flibanserin is a centrally acting anti-depressant type drug made by Boehringer-Ingelheim who have been developing it over the past few years. It is aimed at a condition referred to as Hypoactive Sexual Desire Disorder (HSDD) – or a lack of/no desire for sex in lay terms. Reports suggest the latest trials of the drug are about to be announced, and it’s likely the product will be promoted for public use within the six to eighteen months (pending FDA and EMEA approval). Early trials claim the drug boosts sexual desire, but (as with other SSRIs) this drug must be taken every day for 3-6 weeks before any effects will be noticed and continuously thereafter.

What’s interesting about this drug is it indicates a shift around how we conceptualise and ‘cure’ female sexual problems. Previously the message from drug companies was FSD was a hormonal problem and could be managed with additional testosterone. Flibanserin reframes FSD as a ‘desire is in your head’ model, working on neurotransmitters to increase libido. Moreover, previous drugs tended to focus on women who were approaching or had gone through the menopause (naturally or surgically). Flibanserin is being targeted at all women (so a far larger market share than products just for post menopausal women).

Aside from the wider worries about medicalising female sexual problems (which are caused by numerous factors), critics of Flibanserin question how an antidepressant can boost desire given a common side effect of such drugs are to reduce desire. There are also worries from healthcare workers and therapists around the long term safety of using such drugs and potential problems with withdrawal.

Those defending Flibanserin (and drugs like it) argue that therapists are only criticising the products as they want to promote talking cures over medical ones (and thus have a conflict of interest). They also have reappropriated feminist discourse to talk about women being left out or needing the same access to sex drugs as men (although the products available for men are actually limited and mostly only for erectile dysfunction).

The difficulty with discussing this area is that women do experience sexual problems for a variety of reasons. Many of these can be helped with education, better contraception, improving (or leaving) a difficult relationship, therapy, addressing psychological or physical health problems, or better sexual communication between a woman and her partner. These issues should be tackled as a first port of call, rather than recommending a pill or patch. However, given the embarrassment women experience over sex problems, plus additional pressures from the media and partners to be good in bed (and a desire for pleasure and intimacy), it’s easy to see why someone would prefer a magic bullet than having to work through what’s causing their problems.

Sadly drug companies (and practitioners allied to them) exploit this by making out anyone who questions the FSD diagnosis is anti-women or out to stop women enjoying sex.

What you can expect from media coverage
At each stage of development Flibanserin has already been promoted via the media as a forthcoming drug that will transform women’s sex lives. No doubt coverage over latest research on the drug will follow this format. It’s a dream for health writers and particularly glossy men and women’s magazines as you can discuss sex (and the stereotypical ‘women don’t like it’ angle) with a mix of science and the promise women who’re not sexy enough can be fixed.

You can expect plenty of headlines promoting a wonder drug to boost sex – and reinforcing the idea that women’s sex problems are ‘all in her head’.

What you won’t see is questioning about the drug, safety and long term effects. Nor will you see any critical reflection on the construction of FSD as a medical condition, nor any practical advice on the many reasons women may not experience the sex life they expect – and what they might do about this.

What journalists probably don’t know – behind the scenes of marketing Flibanserin
While Flibanserin has been developed, there has also been a systematic approach from Boehringer-Ingelheim to promote the product before it has been developed. In 2008/9 I’ve had two invitations to attend two two-day long ‘training days’ at top London hotels (with an honorarium of £1000 per session). This invitation has been extended to other practitioners within sexual health.

My understanding of the aim of these events were to highlight FSD (or more specifically Hypoactive Sexual Desire Disorder) as a problem and inform practitioners about treatment approaches. From that, key advisors who’d attended training days could speak further and influence colleagues to also promote FSD as a problem and recommend future treatments as they came on board. Here’s a copy of the agenda for one of the events to give you an idea about what was covered.

I did not attend these events. However, this did not prevent Boehringer-Ingelheim from trying to engage me in other ways. On 1 April this year I was sent an unsolicited invitation to write a paper for their journal British Journal of Sexual Medicine. You’ll see from both the letter and instructions for writing the paper that they had clear instructions about what they wanted me to say and how this would set the scene that HSDD was a prevalent and distressing problem doctors ought to be aware of – presumably so they could be alerted to a problem and be more willing to prescribe a pill when said medication became available.

This may not seem like a major issue, but it’s worth noting that such activity is frowned upon by reputable academics as really all you are doing is marketing a product, not engaging in true peer reviewed science. So obviously I didn’t accept this offer either.

[Since writing this Boehringer Ingelheim's Medical and Scientific Affairs Manager contacted me and requested a right to reply. You can read their response here].

I’m raising this here as journalists and the public need to know this may be considered a case where the market for the product is being worked upon at the same time the product is being developed.

Nobody is denying women have problems, but there are many ways to approach these without slapping a clinical diagnosis on women who don’t feel sexy.

Questions you should be asking about FSD and sex drugs
If you’re a journalist, healthcare provider or member of the public you should think about what may cause women’s problems with sex and solutions to those. Question whether a clinical intervention is the best option, and research how the category of FSD (and related diagnoses like HSDD) have been created (and who by). In particular you should ask the question whether taking SSRIs on a long term basis is the best answer to women who aren’t feeling desire.

Update 16/11/09
The press release for Flibanserin is now available. If you’re a journalist covering this story you may want to ask questions about efficacy, safety and medicalisation (as outlined above). You may also want the drug company to clarify exactly how many ‘satisfying sexual events’ (their term) were classed as significant as compared with placebo. The press release states a significance, but in lay terms how much more satisfying sex per month can a woman expect if she’s taking her daily dose of Flibanserin?

Update 17/11/09
Cory Silverberg has a clear and thoughtful analysis of the Flibanserin studies, reflecting particularly on how sexual experiences were measured. This blog highlights how Flibanserin is still an experimental drug (not quite how the media are reporting it). Also, it’s worth noting from Cory’s appraisal of the research how not all women in the study did experience significantly better ‘satisfying sexual events’ compared with placebo. Well worth a read for an appraisal of both the research and marketing approaches from Boehringer-Ingelheim.

Also, Neuroskeptic has a fantastic blog that tackles in depth the trials for Flibanserin and the interpretation of the findings.