Advancing Sexual and Reproductive Health and Rights
Perspectives on Sexual and Reproductive Health
Volume 36, Number 5, September/October 2004

Are Alabama, Michigan and Washington, D.C., to the illegitimacy bonus what some people think Paul Hamm is to the Olympic gymnastics gold medal? Maybe, according to an analysis of birth and census data for these top three winners of the annual bonuses, which are meant to reward the states that see the greatest reductions in out-of-wedlock fertility without any increase in their abortion rate.1 These jurisdictions won at least four times apiece and garnered nearly 60% of the cash in the first five years the bonus, a provision of the 1996 welfare reform legislation, was granted. Yet economists have found that rather than reflecting the kind of social change the legislation is after—less childbearing by single women or more marriage—their reductions in nonmarital fertility generally reflect changes in the makeup of their populations. For example, in Washington, D.C., the main factor in the decline in out-of-wedlock births was a drop in the number of black women younger than 35, a group at high risk of nonmarital childbearing; shifts in the racial distribution of newborns accounted for all of the change in Alabama. "In sum," the analysts write, "despite a desire to reward states where a woman's risk of nonmarital birth declined, the illegitimacy bonus appears to have rewarded a variety of demographic changes."

1. Korenman S et al., What did the "illegitimacy bonus" reward? NBER Working Paper, Cambridge, MA: National Bureau of Economic Research, 2004, No. 10699.


Despite the effectiveness of highly active antiretroviral therapy (HAART), the mental health of New York City women with HIV is no better now than it was in pre-HAART years, according to a study comparing two matched samples of infected women, one interviewed in 1994–1996, before the therapy became available, and another in 2000–2002, after its use had become widespread.1 Mean scores on standard scales measuring depression, self-esteem and mental health were statistically indistinguishable between samples. Likewise, the groups averaged comparable scores on six of seven measures of psycho- social adjustment to chronic illness; the exception was that women in the later sample scored higher than those interviewed in the mid-1990s on a measure related to family life, indicating greater distress. Why the lack of improvement? According to the researchers, women with HIV may experience "multiple chronic stressors" that outweigh any psychological benefit of effective treatments, or they may become demoralized if HAART's effects do not meet their expectations. The researchers urge continued attention to interventions to improve HIV-infected women's mental health and quality of life.

1. Siegel K, Karus D and Dean L, Psychosocial characteristics of New York City HIV-infected women before and after the advent of HAART, American Journal of Public Health, 2004, 94(7): 1127–1132.


Clubgoers and barhoppers in North Carolina, beware: The dude who just asked you to dance or bought you a drink may be an undercover health educator, sent to your favorite social venue by the state health department to teach you a thing or two about HIV and other sexually transmitted diseases.1 In an initiative focusing on black men who have sex with men, the state is recruiting "popular opinion leaders" at clubs and bars, training them in prevention education and turning them loose on the social scene to encourage people to reduce risky behaviors. The educators may work messages about condom use and the importance of HIV testing into bathroom chats, casual conversations while waiting to get into a club or exchanges in Internet chat rooms. A similar initiative is planned for at least one college or university campus, using popular students as health educators.

1. Ross J, HIV effort gets tweak, News & Observer, Aug. 10, 2004, <http:// 1514773p-7683042c.html>, accessed Aug. 13, 2004.


Women who have taken aspirin at least weekly for six months or longer have 20% lower odds of developing breast cancer than nonusers, according to results of a case-control study conducted in 1996–1997 in two New York counties.1 The odds of cancer are reduced among women who take seven or more tablets a week and among those who take aspirin at least four times weekly, but they are not affected by the duration or timing of use. While these results largely confirm those of earlier research, this study further showed that only tumors that are stimulated by hormones may be prevented by use of the drug, a finding that could lead to greater understanding of the connection between aspirin and estrogen. The investigators comment that "there are many attractive features" to using aspirin to prevent breast cancer, including its ease of use. Nonetheless, they acknowledge that the potential benefits of long-term aspirin use have to be weighed against its possible harmful effects and that their findings need to be replicated in diverse populations.

1. Terry MB et al., Association of frequency and duration of aspirin use and hormone receptor status with breast cancer risk, Journal of the American Medical Association, 2004, 291(20):2433–2440.


Continuing a roughly decade-long decline, the rate of congenital syphilis fell 21%, from 14.2 to 11.2 cases per 100,000 live births, between 2000 and 2002.1 An analysis of national surveillance data shows that the rate was stable (at 1.5 cases per 100,000 live births) among non-Hispanic white infants, but that all racial and ethnic minority groups (who have rates ranging from 4.4 to 43.7 per 100,000) registered marked declines: American Indians and Alaska Natives, 51%; Asians and Pacific Islanders, 22%; and non- Hispanic blacks, 20%. The rate was up 1% in the Northeast but fell 13–30% in the South, West and Midwest. Three-quarters of cases in 2002 involved mothers who had received no or inadequate treatment for syphilis before or during pregnancy, or for whom no information on treatment was reported. Nearly one-third involved women who had not received prenatal care, and most mothers who had gotten prenatal care had started it after the first trimester. Noting that "the majority of [congenital syphilis] cases reported in 2002 were preventable," the Centers for Disease Control and Prevention calls for broad-based efforts "to promote access to and use of comprehensive prenatal care for women who are uninsured or who are covered by public insurance programs."

1. Edozien AO et al., Congenital syphilis—United States, 2002, Morbidity and Mortality Weekly Report, 2004, 53(31):716–719.


When you think of groups of people who are at high risk of contracting sexually transmitted diseases (STDs), chances are that backpackers don't spring to mind, but a group of Australian family planning and research organizations are concerned enough to have launched a prevention campaign aimed at the sleeping-bag set.1 The impetus for Safe in the Sack was preliminary research indicating that 40% of young travelers have casual sex while in Australia and that 25% of backpackers never used a condom with a new partner on a backpacking trip. Posters developed for the campaign, as well as condoms, are being distributed to backpacker accommodation services and other venues that backpackers frequent in one region of the country. The campaign materials, which include the phone number of a sexual health information and referral service, are intended to get out the messages that "there is a real risk of catching an [STD] while traveling and...every traveler can reduce their health risks by adopting safer sex practices."

1. FPA Health, Safe in the sack? a wake up call for backpackers, news release, Ashfield, NSW, Australia: FPA Health, Aug. 25, 2004, <http://www.fpahealth. 20040825_sack.html>, accessed Sept. 3, 2004.


Women who have had pelvic inflammatory disease (PID) can reduce their risk of its recurrence if they use condoms consistently.1 In a multisite U.S. study of 684 sexually active women who had an episode of PID in 1996-1999, those subsequently reporting consistent condom use (defined as use in six of the 10 sexual encounters preceding a follow-up interview) had a 50% lower risk of recurrent PID than those reporting no use of condoms. Their risk of infertility, a possible effect of PID, also was reduced (relative risk, 0.4). The investigators point out that because prospective data have not demonstrated that condoms are effective in preventing bacterial sexually transmitted diseases that cause PID, the use of condoms in primary prevention is surrounded by controversy. However, they conclude that their findings—which are based on a large, diverse sample and prospective data adjusted for potentially confounding factors—"support the use of condoms for the prevention of PID sequelae."

1. Ness RB et al., Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease, American Journal of Public Health, 2004, 94(8):1327-1329.


A national cervical cancer screening program put in place by the British government in 1988 reversed the trend of rapidly increasing incidence of the disease that began in the late 1960s, but even that achievement only hints at the program's success.1 Projections resulting from a birth cohort analysis suggest that without screening, the annual number of diagnoses of invasive cervical cancer would have reached 11,000 in England and Wales by 2030; the annual number of deaths from the disease, 5,500. Furthermore, 3% of women now younger than 50 would have developed cervical cancer, and 2% would have died of it before reaching age 85. The annual cost of the program comes to an estimated £36,000 per life saved and £18,000 per cancer prevented. Although the national screening program has suffered what the analysts call "unjustified criticism and occasional widely publicised failures," they contend that it is "remarkably successful and...still improving."

1. Peto J et al., The cervical cancer epidemic that screening has prevented in the UK, Lancet, 2004, 364(9430): 249-256.


"The thunder of teen dating practices and sexual activity may signal the lightning of substance abuse": This is one key message stemming from results of an annual survey of 12-17-year-olds conducted by the National Center on Addiction and Substance Use.1 For the first time in its nine years, the survey explored the relationship between teenagers' dating practices and their risk of substance use. Among the findings: Higher proportions of teenagers who spend at least 25 hours a week with their boyfriend or girlfriend than of those who spend 10 or fewer hours drink (70% vs. 28%), get drunk (35% vs. 7%) and smoke cigarettes (45% vs. 17%). Two-thirds of youths who say that half or more of their friends are sexually active, compared with one in 10 other teenagers, drink; 31% and 1%, respectively, get drunk; 45% and 8% smoke. Female adolescents whose boyfriend is two or more years their senior are more likely to use substances than are their peers with no boyfriend or a boyfriend closer to their age. The lesson for parents, in the researchers' words, is "Make sure you are aware of the dating practices of your child and get to know your child's friends."

1. National Center on Addiction and Substance Abuse at Columbia University (CASA), National Survey of American Attitudes on Substance Abuse IX: Teen Dating Practices and Sexual Activity, New York: CASA, 2004.