In his State of the Union address earlier this year, President Bush expounded on the dangers that young people face from exposure to sexually transmitted infections (STIs). "Each year, [millions of] teenagers contract sexually-transmitted diseases that can harm them, or kill them, or prevent them from ever becoming parents," he said. His prescription was simple: "We will double federal funding for abstinence programs, so schools can teach this fact of life: Abstinence for young people is the only certain way to avoid sexually-transmitted diseases."
Meanwhile in Congress, Rep. Mark Souder (R-IN) is reviving efforts to amend current condom labeling to include a cigarette-type warning that condoms do not protect against human papillomavirus (HPV). As chairman of the House Government Reform Subcommittee on Criminal Justice, Drug Policy and Human Resources, Souder has charged the Centers for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA) with failing to educate Americans about the dangers of HPV and demanded that they "inform consumers that condom[s] do not provide effective protection against infection with the virus that can cause cervical cancer."
As teenage pregnancy rates have continued to fall, STIs have largely replaced pregnancy in the drive for funding for abstinence-only education programs. Social conservatives dismiss sexual risk reduction strategies as ineffective. Instead, they advocate a risk elimination approach: a clear and simple message that the best means of preventing STIs is to avoid risk altogether.
STIs in Perspective
New estimates published in the January/February 2004 issue of Perspectives in Sexual and Reproductive Health show that nearly 19 million new STIs occurred in the United States in 2000. Although they make up only a quarter of the sexually active population, young people aged 15-24 account for nearly half of new infections. This is not surprising, as most young people are not yet in a long-standing, stable relationship. According to the U.S. Census Bureau, 78% of 20-24-year-olds in 2000 had never been married.
With the exception of HIV, STIs are not new; the diseases or their manifestations have been recognized for decades, even centuries. The impact of STIs on people's lives varies widely. At one end of the spectrum is HIV, which still must be considered inevitably fatal, although new drug regimens are helping many people with HIV/AIDS live longer. Many of the most common STIs, however, are either harmless or can be treated and cured.
|Estimated Incidence of Selected STIs Among 15–24-Year-Olds, 2000|
|STI||New Cases||% of All New Cases|
|Source: Weinstock H, Berman S and Cates W, Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health, 2004, 36(1):6–10.|
HPV accounted for half of all new STIs among young people in 2000 (see table). HPV is so common, in fact, that it is considered a virtual marker for having had sex. Most HPV infections cause no clinical problems and resolve on their own without treatment. (As many as 70% of new infections clear within one year and 91% within two years.) Sometimes, infection can lead to genital warts, which are usually harmless and can also be treated. Rarely, certain strains of HPV can progress to cervical cancer if left untreated, usually over decades.
Despite the high prevalence of HPV, cervical cancer in the United States is relatively rare. The reason for this is the widespread availability of Pap tests, which can detect not only early-stage cervical cancer but also precancerous cervical abnormalities that are easily treatable ("HPV in the United States and Developing Nations: A Problem of Public Health or Politics?" TGR, August 2003, page 4). Since the introduction of the Pap test in the 1950s, rates of cervical cancer have fallen dramatically‚—by approximately 75% according to CDC‚—to the point that they now represent a small fraction of cancers in women. The American Cancer Society estimates 3,900 women will die from cervical cancer in 2004. Among the 10,520 women who will develop cervical cancer this year, about half will never have had a Pap test.
Trichomoniasis and chlamydia are the next most common STIs among youth and can be cured with antibiotics. Whereas untreated trichomoniasis can be an irritant, causing vaginal discharge, discomfort during intercourse and painful urination, chlamydia has sequelae that reverberate through life if left untreated. Untreated chlamydia infections in women may lead to pelvic inflammatory disease, a serious infection that often leads to ectopic pregnancy, infertility and chronic pain.
Together, HPV, trichomoniasis and chlamydia represent nearly nine in 10 new STIs among 15-24-year-olds. Of the remaining 12% of new cases among American youth, gonorrhea and syphilis have serious consequences if left untreated, but can be cured with antibiotics when detected in a timely way. The remaining three STIs‚—genital herpes, HIV and hepatitis B‚—are viral, and although incurable and undeniably serious, they have become increasingly manageable in the United States.
Social conservatives' solution to the problem of STIs is simple: Young people should simply abstain from all sexual activity until they are married to a disease-free spouse. Organizations such as Focus on the Family and the Medical Institute for Sexual Health say we must stop promoting condoms, which are known to have high failure rates in actual use. Instead, they say we should be promoting abstinence, which is 100% effective, 100% of the time.
If the president's proposal to double funding for abstinence-only education is adopted, the federal government will spend almost a quarter of a billion dollars in the fiscal year beginning October 1 to promote abstinence for all unmarried people. In accordance with the requirement that these programs have abstinence promotion as their "exclusive purpose," they may include instruction about the failure rates of condoms and other forms of contraception, but they may not provide any information about contraceptive methods that could be construed as promoting contraceptive use. The Bush proposal is sparking hope among abstinence-only proponents who are a key component of the president's political base of support. "This is a president who's finally putting his money where his mouth is," said LeAnna Benn, a pioneer in the abstinence-only movement, to the Washington Times. Benn went on to say that what is needed now is for abstinence-friendly government officials to structure grant programs so that an abstinence network can be built to match the powerful family planning network.
Meanwhile, Rep. Souder and other social conservatives hope that a warning label on condoms will dissuade people from having sex, but public health experts are skeptical. Because in the real world, abstinence can and does fail ("Understanding 'Abstinence': Implications for Individuals, Programs and Policies," TGR, December 2003, page 4), a more comprehensive and nuanced approach is needed, they say. "There is no magic bullet," says Ralph DiClemente, a researcher at Emory University who has been studying HIV prevention among adolescents. "That's why young people need a 'menu' of interventions, including information about condoms. There is no moral justification for withholding information or, worse yet, discouraging individuals from adopting behaviors that could save their life." Theresa Raphael, executive director of the National Coalition of STD Directors, agrees. "While abstinence is a public health message that we can all support, it cannot be the only message," she says in a February 5, 2004, press release. "Public health officials are obligated to dwell in the real world and support an approach...that reflects how Americans actually live."
Public opinion data have consistently shown that while American adults want abstinence to be promoted to young people, they also want those young people to have information about contraception and condom use. According to a 2003 poll conducted by NPR, the Kaiser Family Foundation and Harvard's Kennedy School of Government, 93% of adults support instruction in school-based sex education programs about waiting to have sexual intercourse until marriage. At the same time, overwhelming proportions also support giving teens information on how to use and where to obtain contraceptives (86%), how to put on a condom (83%) and how to get tested for HIV and other STIs (94%).
Even conservatives cannot avoid the inescapable conclusion that most Americans do not support abstinence-only sex education. According to a Heritage Foundation analysis of a survey conducted earlier this year by Zogby International for Focus on the Family, "Some 75 percent of parents want teens to be taught about both abstinence and contraception."
Although social conservatives vastly and dangerously underestimate condom efficacy in preventing STIs, it is true that even perfect condom use cannot guarantee 100% success. Certainly with respect to HPV, which is transmitted through skin-to-skin contact, protection is limited because condoms can only be effective to the extent that the infection is at an area that the condom covers. Sexual risk reduction, therefore, ought not be the sole preventive approach. Helping young people to delay sexual activity is an important component of STI prevention, as is encouraging people to reduce their number of sexual partners.
Moreover, as critical as primary prevention is to stemming the spread of STIs and their consequences, it is not the entire answer either. Young people also must have ready access to a health care system that provides them with STI screening on a regular basis and treatment services if necessary. This is especially important because the most common STIs either are treatable and curable, or their sequelae‚—notably cervical cancer‚—are largely preventable; other STIs, if not curable, are at least manageable. Access to regular STI screening and treatment services, plus balanced prevention efforts, would begin to constitute the kind of truly comprehensive national strategy for addressing STIs that the problem requires.