sex education

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a 3-4 page summary of the assigned article and description of the interviews they conducted, what they learned from the research, and feedback on the article.
Each assignment must be typed 3-4 pages in length (12 pt font, 1.5 line spaced, 1 inch margins).
2 additional articles from peer-reviewed scientific journals should be used to help you expand on the information discussed in the assigned article.Original article
Abstinence-Only and Comprehensive Sex Education and the Initiation
of Sexual Activity and Teen Pregnancy
Pamela K. Kohler, R.N., M.P.H.a,c, Lisa E. Manhart, Ph.D.b,c, and William E. Lafferty, M.D.a,* a
Departments of Health Services and b
Epidemiology, and the c
Center for AIDS and STD, University of Washington, Seattle Washington
Manuscript received April 17, 2007; manuscript accepted August 29, 2007
See Editorial p. 324
Abstract Purpose: The role that sex education plays in the initiation of sexual activity and risk of teen
pregnancy and sexually transmitted disease (STD) is controversial in the United States. Despite
several systematic reviews, few epidemiologic evaluations of the effectiveness of these programs on
a population level have been conducted.
Methods: Among never-married heterosexual adolescents, aged 15–19 years, who participated in
Cycle 6 (2002) of the National Survey of Family Growth and reported on formal sex education received
before their first sexual intercourse (n  1719), we compared the sexual health risks of adolescents who
received abstinence-only and comprehensive sex education to those of adolescents who received no
formal sex education. Weighted multivariate logistic regression generated population-based estimates.
Results: Adolescents who received comprehensive sex education were significantly less likely to
report teen pregnancy (ORadj  .4, 95% CI  .22– .69, p  .001) than those who received no formal
sex education, whereas there was no significant effect of abstinence-only education (ORadj  .7,
95% CI  .38–1.45, p  .38). Abstinence-only education did not reduce the likelihood of engaging
in vaginal intercourse (ORadj  .8, 95% CI  .51–1.31, p  .40), but comprehensive sex education
was marginally associated with a lower likelihood of reporting having engaged in vaginal intercourse
(ORadj  .7, 95% CI  .49–1.02, p  .06). Neither abstinence-only nor comprehensive sex
education significantly reduced the likelihood of reported STD diagnoses (ORadj  1.7, 95% CI 
.57–34.76, p  .36 and ORadj  1.8, 95% CI  .67–5.00, p  .24 respectively).
Conclusions: Teaching about contraception was not associated with increased risk of adolescent
sexual activity or STD. Adolescents who received comprehensive sex education had a lower risk of
pregnancy than adolescents who received abstinence-only or no sex education. © 2008 Society for
Adolescent Medicine. All rights reserved.
Keywords: Sexually transmitted disease; Teen pregnancy; Sex education; Abstinence
Rates of sexually transmitted disease (STD), teen pregnancy,
and teen births are higher in the United States than in
most other industrialized countries [1,2]. In a 2000 study of
STD incidence among 16 developed countries, the rates of
syphilis, gonorrhea and chlamydia in the United States (U.S.)
were exceeded only by those in Romania and the Russian
Federation [2]. Although there are minimal differences in levels
of sexual activity across developed countries (Sweden,
France, Canada, Great Britain, and the U.S.) [3], teen pregnancy,
birth rates and abortion rates are higher in the U.S. than
in other developed countries [1]. In 1995 adolescent pregnancy
rates were 83.6 per 1000 in the U.S. compared with 47.0 in
England and Wales, 45.4 in Canada, 20.2 in France, and 24.9
in Sweden.
In the U.S., although 15–24-year-olds represent only
*Address correspondence to: William E. Lafferty, M.D., Associate Professor/Director,
Department of Health Services, Health & Policy Research
Track, Health Sciences Center, Box 357660, Seattle, WA 98195-7660.
E-mail address: billlaf@u.washington.edu
Journal of Adolescent Health 42 (2008) 344–351
1054-139X/08/$ – see front matter © 2008 Society for Adolescent Medicine. All rights reserved.
doi:10.1016/j.jadohealth.2007.08.026
25% of the sexually active population, they account for
nearly one-half of all new sexually transmitted infections
[4], and rates are highest among young women and minorities
[5]. Compared with male adolescents of the same age,
rates of gonorrhea among 15–19-year-old women are more
than twice as high (624.7 vs. 261.2 per 100,000), and rates
of chlamydia are more than five times higher (2796.6 vs.
505.2 per 100,000). Among African-American adolescents
aged 15–19 years, the 2005 rate of gonorrhea was 14 times
greater than the rate among white female adolescents of
similar age (2814 vs. 204.7 per 100,000).
Formal school-based or church-based sex education programs
aimed at reducing risks of teenage pregnancy and
STD acquisition generally promote one of two types of
messages regarding sexual activity: (1) abstinence-only
messages, or (2) comprehensive sex education messages.
Abstinence-only messages teach that sex should be delayed
until marriage, and discussion of birth control methods is
typically limited to statements about ineffectiveness [6].
Comprehensive programs include abstinence messages, but
also provide information on birth control methods to prevent
pregnancy and condoms to prevent STDs.
Although several avenues of federal funding for formal
sex education programs are available, all require adherence
to abstinence-only messages. In 1996 Congress introduced
Section 510(b) of Title V of the Social Security Act, allocating
federal dollars for state initiatives promoting abstinence-only
programming and establishing criteria for defining
abstinence education. To receive federal Title V
funding, a sex education program must have as its exclusive
purpose “teaching the social, psychological, and health
gains to be realized by abstaining from sexual activity” [7].
These programs must teach that abstinence from sexual
activity outside marriage is the expected standard for all
school-age children and the only certain way to avoid outof-wedlock
pregnancy and STDs.
Over the past 5 years, U.S. fiscal policy has allocated
increasing amounts of funding to abstinence-only prevention
programs. In 2001 abstinence-only education programs received
$80 million in federal funding [6], and by 2005 federal
funding had more than doubled to $167 million [8]. The 2008
fiscal year budget proposes $204 million for abstinence education
[9]. Consistent with this increase in funding, analyses of
Cycle 5 (1995) and Cycle 6 (2002) of the National Survey of
Family Growth (NSFG) revealed that whereas only 9.3% of
adolescents aged 15–19 received abstinence-only education in
1995, nearly a quarter (23.8%) did so in 2002 [10].
Systematic reviews suggest that the effects of abstinence-only
programs on sexual risk behavior have been
minimal, and that initiation of sexual activity is not hastened
by receiving instruction about measures for safer sex [11–
15]. However the majority of reviewed trials have been
conducted in specific subgroups of the population, and there
have been no population-level evaluations of the effectiveness
of these programs. In addition the question of whether
comprehensive or abstinence-only sex education is most
effective at reducing risk for teen pregnancy and STD has
stimulated a heated and politicized debate. To address this
gap in the evidence, we used data from Cycle 6 of the NSFG
to determine whether STD and pregnancy risk is signifi-
cantly different based on the type of formal sex education
adolescents receive and whether teaching about contraception
increases risk for sexual activity before marriage.
Methods
The NSFG is a nationwide survey conducted by the National
Center for Health Statistics. Data were collected in
collaboration with the University of Michigan’s Institute for
Social Research by trained personnel, from January 2002 to
March 2003, through an in-home interview process that included
Audio Computer-Assisted Self-Interviewing (ACASI).
Overall information collected included basic demographics;
knowledge, attitudes, and beliefs regarding family planning
issues; and self-reported sexual behavior and previous diagnoses
of STDs.
Sample
The NSFG is based on an area probability sample designed
to represent the national noninstitutionalized population 15–44
years of age. It includes responses from 12,571 male and
female individuals from across the United States. The adolescent
subset of this cohort (aged 15–19 years) was asked additional
questions related to sex education, sexual behavior, pregnancy
and STDs. A total of 1150 adolescent girls and 1121
adolescent boys responded to the NSFG general questionnaire
and special adolescent interview.
To assess the effect of formal sex education programs on
pregnancy and STD risk, the sample was restricted to nevermarried
heterosexual teens aged 15–19 years who reported no
formal sex education, formal sex education on “how to say no
to sex” only (abstinence-only), or formal sex education covering
both “saying no to sex” and teaching about birth control
(comprehensive).
We excluded respondents who were married (n  36), in
whom formal sex education programs would not be expected
to delay sexual debut or reduce risk for pregnancy. Individuals
reporting sexual orientation other than heterosexual were also
excluded (n  318), as programs do not address same-sex
behaviors. We further excluded respondents who reported exposure
to sex education that taught only birth control without
mentioning abstinence, as such programs were not consistent
with our definitions of either abstinence-only or comprehensive
programs (n  111), as well as respondents who did not
answer sex education questions (n  1) or who reported an age
of first intercourse 10 years (n  8). To ensure temporal
sequence in our assessment of whether formal sex education
delayed sexual initiation or reduced teen pregnancy, we excluded
those who reported first vaginal intercourse before
formal sex education. We computed this by adding 5 years to
P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351 345
the grade at sex education and subtracting age at first sex
education from age at first sex (n  60). Another 18 adolescents
who reported teen pregnancy or using birth control at last
sex but reported no vaginal sex were also excluded (n  18).
Type of formal sex education
Exposure to specific types of sex education was measured
based on two separate questions. The first asked whether respondents,
before the age of 18 years, ever received “any
formal instruction at school, church, a community center, or
some other place about how to say no to sex.” A follow-up
question asked the same about receiving instruction about
methods of birth control. Individuals who reported birth control
education in addition to education emphasizing saying no
to sex were classified as having participated in comprehensive
sex education. Respondents who reported only receiving sex
education about how to say no to sex were classified as participants
in abstinence-only programs.
Measures of adolescent sexual risk
We examined three dichotomous measures of adolescent
sexual risk: ever having engaged in vaginal intercourse; pregnancy;
and STD. Self-report of ever having had vaginal sex
was coded as ever/never, and teen pregnancy was assessed by
computing the total number of pregnancies reported by males
and females by ACASI. Prior STD diagnosis was assessed by
self-report of chlamydia, gonorrhea in the last year, or ever
having been diagnosed with herpes, genital warts, or syphilis.
Characteristics previously associated with adolescent
sexual risk behaviors were assessed as potential confounding
factors and included: respondent age (integer years
15–19), household income quartiles ($20,000; $20,000–
39,999; $40,000–74,999; $75,000), race/ethnicity (black,
white, other), residence (rural, suburban, central city) and
intactness of the family unit (residing with the same two
biological/adoptive parents since birth).
Analysis
We conducted a stratified weighted analysis to account for
the complex survey design of the NSFG using STATA 9 (Stata
Corp., College Station, TX). A design based Pearson’s 2 test
was used to compare proportions, and weighted multivariate
logistic regression was used to determine the association of
type of formal sex education with measures of sexual risk
(engaging in vaginal sex, pregnancy and STD). Covariates
were retained in the model if they were significantly associated
with the outcome and/or if their inclusion substantially
changed the estimates for type of sex education by 10%.
Although we performed analyses stratified by gender, there
were no substantive differences in results; thus we present
combined analyses.
Results
Population, sample, and sex education
Of the 1719 never-married heterosexual adolescents included
in these analyses, 47.4% were female (Table 1). The
Table 1
Characteristics of heterosexual adolescents aged 15–19 years reporting on sex education (none, abstinence only or comprehensive) in the 2002 Cycle 6
of the National Survey of Family Growth (NSFG) (population and sample, n  1719)
Characteristic Total No sex education: Abstinence-only education: Comprehensive sex education:
Weighted % (95%CI)
n  168
Weighted % (95% CI)
n  390
Weighted % (95% CI)
n  1161
Overall 9.4 23.8 66.8
Agea Mean  17.0 (.04) Mean  17.2 (.12) Mean  16.8 (.10) Mean  17.1 (.05)
Gender
Female 47.4 42.0 (34.5–50.0) 45.4 (39.1–51.9) 48.8 (44.7–52.9)
Male 52.6 58.0 (50.0–65.5) 54.6 (48.1–60.9) 51.2 (47.1–55.3)
Race/ethnicity
White 76.7 69.4 (60.2–77.2) 75.1 (69.3–80.2) 78.2 (74.4–81.6)
Black 14.0 19.2 (12.8–27.8) 16.4 (12.0–21.9) 12.5 (10.2–15.2)
Other 9.3 11.4 (6.8–18.6) 8.5 (5.5–13.0) 9.3 (7.1–12.0)
Household income quartile (per year)a
$20,000 23.7 36.9 (28.4–46.3) 24.9 (20.5–29.9) 21.4 (18.6–24.6)
$20,000–39,999 27.0 23.0 (17.1–32.5) 32.6 (27.0–38.8) 25.6 (22.4–29.1)
$40,000–74,999 27.3 18.2 (12.4–25.9) 24.3 (20.0–29.2) 29.7 (26.7–32.8)
$75,000 21.9 21.9 (13.7–33.1) 18.2 (13.8–23.6) 23.3 (19.8–27.1)
Residencea
Metropolitan, central city 53.3 39.0 (27.4–52.1) 53.4 (44.9–61.6) 55.3 (48.7–61.7)
Metropolitan, not central city 27.0 26.8 (17.6–38.5) 24.7 (19.2–31.2) 27.9 (22.9–33.5)
Not metropolitan 19.7 34.2 (21.2–50.1) 22.0 (14.6–31.7) 16.8 (11.2–24.5)
Nonintact family unitab 41.3 53.8 (43.5–63.8) 36.9 (31.1–43.1) 41.2 (37.7–44.8)
a Design-based Pearson 2 test for difference between categories significant at p .05. b Intact family unit defined as adolescent residing with the same two biological or adoptive parents from birth until age 18 years or living on own.
346 P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351
median age was 17 years; 76.7% were of white ethnicity and
14.0% black. Household incomes less than $40,000 per year
were reported by half (50.7%) of the participants. The majority
of respondents resided in a central city (53.3%), and 41.3% of
respondents reported a nonintact family unit.
Overall 9.4% of participants reported that they had not
received any sex education, whereas 23.8% reported abstinence-only
education and 66.8% comprehensive sex
education. Univariate analysis of sociodemographic characteristics
revealed significant differences between type
of education received with respect to age, income, residence,
and family unit intactness. Generally individuals
receiving no sex education tended to be from low-income
nonintact families, black, and from rural areas. Participants
reporting abstinence-only education were typically
younger and from low-to-moderate–income intact families,
whereas adolescents reporting comprehensive sex
education were somewhat older, white, and from higherincome
families and more urban areas.
Initiation of sexual activity
Almost half of respondents (46.3% of males and 45.7%
of females) reported having engaged in vaginal intercourse
by the time of the survey. In univariate analyses (Table 2),
respondents who were older, black, from a lower-income
household, resided in a noncentral city metropolitan area,
and came from a nonintact family unit were significantly
more likely to report ever having engaged in vaginal intercourse,
whereas those who had received any type of formal
sex education were less likely to report this (p .05 for all).
After adjustment for other significant predictors of engaging
in vaginal intercourse (age, race, gender, and family intactness),
abstinence-only education was not significantly associated
with an adolescent ever engaging vaginal intercourse
(ORadj  .8, 95% CI  .51–1.31, p  .40), whereas comprehensive
sex education was marginally associated with
reduced reports of engaging in vaginal intercourse (ORadj 
.7, 95% CI  .49–1.02, p  .06).
Table 2
Characteristics associated with report of ever engaging in vaginal intercourse among heterosexual adolescents aged 15–19 years reporting on sex
education (none, abstinence-only, or comprehensive) in the 2002 Cycle 6 of the National Survey of Family Growth (NSFG)
Characteristic Ever had vaginal intercourse: Never had vaginal intercourse: p** Univariate Multivariate††
Weighted % (95%CI) Weighted % (95%CI) OR (95% CI) OR (95% CI)
Sex education
No sex education 11.5 (8.9–14.7) 7.6 (5.5–10.4) .06 (Ref) (Ref)
Abstinence-only sex education 22.6 (19.1–26.5) 25.0 (21.6–28.7) .60 (.39–.92)* .82 (.51–1.31)
Comprehensive sex education 66.0 (61.6–70.2) 67.4 (62.9–71.5) .65 (.45–.95)* .70 (.49–1.02)
Age (mean  SE) 17.6 (.06) 16.6 (.06) .001§§ 1.79 (1.58–2.02)‡§ 1.91 (1.67–2.18)‡
Gender .83
Female 47.1 (42.4–51.8) 47.7 (43.9–51.6) (Ref) (Ref)
Male 52.9 (48.2–57.6) 52.3 (48.4–56.1) 1.02 (.81–1.29) 1.07 (.81–1.40)
Race/ethnicity .001
White 73.2 (68.6–77.4) 79.6 (75.5–83.2) (Ref) (Ref)
Black 18.5 (14.6–23.0) 10.3 (8.2–12.8) 1.95 (1.46–2.61)‡ 1.86 (1.35–2.58)‡
Other 8.3 (6.1–11.4) 10.1 (7.5–13.5) .90 (.59–1.37) .85 (.53–1.37)
Household income quartile (per
year)
.02
$20,000 27.6 (24.2–31.2) 20.5 (17.6–23.7) (Ref)
$20,000–39,999 25.2 (21.6–29.1) 28.4 (24.8–32.3) .89 (.81–.98)*¶
$40,000–74,999 26.7 (23.2–30.6) 27.9 (24.7–31.4)
$75,000 20.6 (17.1–24.5) 23.2 (19.7–27.1)
Residence .002
Metropolitan: Central City 48.1 (41.7–54.6) 57.6 (50.4–64.5) (Ref)
Metropolitan: Not Central City 31.8 (26.5–37.7) 23.0 (18.2–28.5) 1.66 (1.28–2.16)‡
Not metropolitan 20.0 (13.5–28.7) 19.4 (13.1–27.8) 1.24 (.89–1.72)
Nonintact family unit‡‡ 49.3 (44.9–53.6) 34.5 (30.4–38.8) .001 1.85 (1.42–2.40)‡ 2.29 (1.67–3.13)‡
CI  confidence interval; OR  odds ratio.
OR is significant at
* p .05, †
p .01, ‡ p .001. § OR represents increase in risk for each additional year.
¶ OR represents increase in risk for each additional income quartile.
** Design-based Pearson’s 2 test for difference between categories unless otherwise specified. †† ORs adjusted for all variables in the column. Further adjustment for income and residence did not appreciably change the estimates for type of sexual
education and thus were not included. ‡‡ Intact family unit was defined as residing with the same two biological or adoptive parents from birth until age 18 years or living on own. §§ p Value obtained by design-based t test
P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351 347
Pregnancy
Among all respondents, 7.3% reported a pregnancy, although
this was more common among females (10.2%) than
males (4.7%) (p .001). In univariate analyses, increased
odds for teen pregnancy were significantly associated with
older age, black race, lower household income, noncentral
city metropolitan residence, and nonintact family unit status
(p .05) (Table 3).
In multivariate analyses adjusting for age, gender, race,
income, residence, and family intactness, abstinence-only
sex education was not significantly associated with reported
teen pregnancy when compared with no sex education (ORadj
 .7, 95% CI  .38–1.45, p  .38). However adolescents
who reported having received comprehensive sex education
were significantly less likely to report a teen
pregnancy compared with those who received no sex education
at all (ORad j  .4, 95% CI  .22–.69, p  .001). The
causal pathway intermediary of birth control use at last
sexual intercourse was also associated with a decreased
likelihood for reported pregnancy (ORadj  .3, 95% CI 
.13–.48, p .001), adjusted for the same characteristics as
teen pregnancy. Finally, when comparing adolescents who
reported receiving a comprehensive sex education with
those who received an abstinence-only education, comprehensive
sex education was associated with a 50% lower risk
of teen pregnancy (ORadj  .5, 95% CI  .28– .96, p 
.04).
Previous STD diagnosis
Few adolescents (3.4%) reported any prior STD diagnoses,
and previous STD diagnoses were twice as common
among females (4.8%) as among males (2.1%). In univariate
analyses, increased likelihood of STD diagnosis was
also significantly associated with older age, black race, and
coming from a nonintact family unit (Table 4). However in
multivariate analyses adjusted for age, gender, race, and
family intactness, neither abstinence-only nor comprehensive
sex education were significantly associated with risk
for STD when compared with no sex education (ORadj  1.7,
95% CI  .57–4.76, p  .36; and ORadj  1.8, 95% CI 
Table 3
Characteristics associated with report of teen pregnancy among heterosexual adolescents ages 15–19 years reporting on sex education (none, abstinenceonly,
or comprehensive) in the 2002 Cycle 6 of the National Survey of Family Growth (NSFG)
Characteristic Ever had teen pregnancy: No teen pregnancy: p** Univariate Multivariate††
Weighted % (95% CI) Weighted % (95% CI) OR (95% CI) OR (95% CI)
Sex education .003
No sex education 19.4 (13.2–27.4) 8.6 (6.6–11.0) (Ref) (Ref)
Abstinence-only sex education 27.1 (17.7–39.1) 23.6 (21.1–26.4) .51 (.27–.98)* .74 (.38–1.45)
Comprehensive sex education 53.5 (42.3–64.5) 67.8 (64.3–71.1) .35 (.21–.60)‡ .39 (.22–.69)‡
Age (mean  SE) 17.9 (.11) 17.0 (.04) .001§§ 1.72 (1.46–2.02)‡§ 1.87 (1.57–2.24)‡§
Gender .001
Female 66.5 (54.6–76.5) 45.9 (42.7–49.1) (Ref) (Ref)
Male 33.5 (23.5–45.4) 54.1 (50.9–57.3) .43 (.26–.70)‡ .44 (.26–.74)†
Race/ethnicity .002
White 66.7 (56.7–75.4) 77.4 (73.9–80.6) (Ref) (Ref)
Black 26.4 (18.6–36.0) 13.1 (10.7–16.0) 2.34 (1.49–3.67)‡ 1.28 (.81–2.03)
Other 6.9 (3.0–15.3) 9.5 (7.4–12.0) .85 (.35–2.07) .72 (.28–1.85)
Household income quartile (per year) .001
$20,000 46.6 (37.6–55.9) 21.9 (19.4–24.7) (Ref) (Ref)
$20,000–39,999 25.7 (19.1–33.7) 27.2 (24.2–30.3) .59 (.46–.74)‡¶ .69 (.53–.89)†¶
$40,000–74,999 15.4 (9.4–24.1) 28.3 (25.9–30.8)
$75,000 12.3 (6.9–20.9) 22.6 (19.7–25.9)
Residence .001
Metropolitan, central city 38.5 (28.7–49.4) 54.4 (48.0–60.7) (Ref) (Ref)
Metropolitan, not central city 43.6 (33.8–53.9) 25.7 (21.3–30.8) 2.39 (1.51–3.79)‡ 1.83 (1.15–2.91)*
Not metropolitan 17.9 (10.3–29.4) 19.8 (13.7–27.9) 1.27 (.71–2.28) .88 (.47–1.67)
Nonintact family unit‡‡ 64.5 (53.9–73.8) 39.5 (36.4–42.8) .001 2.78 (1.75–4.41)‡ 2.51 (1.54–4.08)‡
Birth control method at last intercourse 71.3 (61.2–79.6) 92.5 (88.8–95.0) .001 .20 (.11–.36)‡ .25 (.14–.48)‡¶¶
OR is significant at
* p .05, † p .01, ‡ p .001. § OR represents increase in risk for each additional year.
¶ OR represents increase in risk for each additional income quartile.
** Design-based Pearson’s 2 test for difference between categories unless otherwise specified. †† ORs adjusted for all variables in the column except birth control at last intercourse. ‡‡ Intact family unit was defined as residing with the same two biological or adoptive parents from birth until age 18 years or living on own. §§ p Value obtained by design-based t test. ¶¶ Adjusted for age, gender, race, income, residence, and family intactness.
348 P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351
.67–5.00, p  .24, respectively). The strongest predictor for
STD was nonintact family unit status; such adolescents
were four times more likely to report a previous diagnosis of
STD (ORadj  3.9, 95% CI  2.00–7.74, p .001).
Although condom use at last vaginal sex was significantly
associated with a 50% decrease in odds of reported STD
diagnoses in univariate analyses (p  .03), after adjusting
for age, gender, race, and family intactness, this was no
longer statistically significant, despite a similar odds ratio
(ORadj  .55, 95% CI  .24–1.20, p  .13).
Discussion
This assessment of the impact of formal sex education
programs on teen sexual health using nationally representative
data found that abstinence-only programs had no
significant effect in delaying the initiation of sexual activity
or in reducing the risk for teen pregnancy and STD. In
contrast comprehensive sex education programs were significantly
associated with reduced risk of teen pregnancy,
whether compared with no sex education or with abstinence-only
sex education, and were marginally associated
with decreased likelihood of a teen becoming sexually active
compared with no sex education.
As has been previously reported [10], receipt of formal
sex education was associated with important sociodemographic
characteristics including age, income, and residence.
In addition, we also found a strong relationship
between family intactness and receiving sex education.
Teens from intact families were more likely to receive
formal sex education than teens from nonintact families.
Furthermore approximately 10% of teens ages 15–19 years
participating in the NSFG had received no formal sex education
at the time of the survey; these adolescents were most
often nonwhite and from low-income families. Like many
other health indicators, the opportunity for formal sex education
appears to vary by social strata, with disadvantaged
youth being the least likely to benefit from formal programs.
Table 4
Characteristics associated with report of previous STD diagnoses among heterosexual adolescents aged 15–19 years reporting on sex education (none,
abstinence only or comprehensive) in the 2002 Cycle 6 of the National Survey of Family Growth (NSFG)
Characteristic Reported STD diagnosis: No reported STD diagnosis: p** Univariate Multivariate††
Weighted % (95% CI) Weighted % (95% CI) OR (95% CI) OR (95% CI)
Sex education .55
No sex education 6.9 (3.0–15.4) 9.5 (7.4–11.9) (Ref) (Ref)
Abstinence-only sex education 19.7 (11.1–32.6) 24.0 (21.4–26.8) 1.12 (.39–3.22) 1.65 (.57–4.76)
Comprehensive sex education 73.4 (59.5–83.8) 66.6 (63.0–69.9) 1.50 (.56–4.00) 1.82 (.67–5.00)
Age (mean  SE) 17.6 (.15) 17.0 (.04) .001§§ 1.37 (1.14–1.65)‡§ 1.45 (1.21–1.75)‡§
Gender .03
Female 66.9 (48.7–81.1) 46.7 (43.4–49.9) (Ref) (Ref)
Male 33.1 (18.9–51.3) 53.3 (50.1–56.6) .43 (.20–.93)* .47 (.21–1.06)
Race/ethnicity .05
White 64.1 (49.5–76.5) 77.1 (73.6–80.3) (Ref) (Ref)
Black 25.0 (15.4–38.1) 13.7 (11.1–16.7) 2.20 (1.14–4.25)* 1.67 (.85–3.27)
Other 10.9 (4.9–22.5) 9.2 (7.2–11.8) 1.42 (.56–3.55) 1.49 (.58–3.85)
Household income quartile (per year) .33
$20,000 31.6 (20.0–46.0) 23.4 (20.9–26.2) (Ref)
$20,000–39,999 25.4 (15.8–38.1) 27.1 (24.2–30.2) .80 (.61–1.06)¶
$40,000–74,999 31.3 (17.1–50.1) 27.2 (24.8–29.7)
$75,000 11.8 (5.0–25.1) 22.3 (19.4–25.5)
Residence .50
Metropolitan, central city 46.7 (31.3–62.7) 53.5 (47.3–59.7) (Ref)
Metropolitan, not central city 34.1 (21.6–49.2) 26.8 (22.3–31.8) 1.46 (.74–2.90)
Not metropolitan 19.2 (10.0–33.6) 19.7 (13.6–27.8) 1.12 (.52–2.42)
Nonintact family unit‡‡ 72.2 (58.0–83.0) 40.2 (37.1–43.4) .001 3.85 (2.00–7.42)‡ 3.93 (2.00–7.74)‡
Condom use at last vaginal intercourse 47.3 (31.8–63.3) 65.1 (61.0–68.9) .03 .48 (.25–.94)* .55 (.25–1.21)¶¶
CI  confidence interval; OR  odds ratio.
OR significant at
* p .05, †
p .01, ‡ p .001. § OR represents increase in risk for each additional year.
¶ OR represents increase in risk for each additional income quartile.
** Design-based Pearson’s 2 test for difference between categories unless otherwise specified. Further adjustment for income and residence did
not appreciably change the estimates for type of sexual education and were not included. Condom use at last intercourse was not considered in the
model. ‡‡ Intact family unit was defined as residing with the same two biological or adoptive parents from birth until age 18 years or living on own. §§ p Value obtained by design-based t-test. ¶¶ Adjusted for age, gender, race, and family intactness.
P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351 349
However a recent review suggests that abstinence-only programs,
whether conducted in low- or middle-income settings,
had similarly modest effects on risk behavior [14].
Our study is not the only recent work to suggest that
abstinence-only education may not reduce sexual risk behaviors
among teens. A randomized controlled trial of four
federally funded abstinence programs found no significant
decrease in number of partners or risk for STD and pregnancy,
and no delay in sexual debut [13]. Similarly a systematic
review of 13 trials found that abstinence-only programs
were not associated with reductions in sexual risk
behavior or in diagnosis of STDs [14]. Another review
showed that all but one of 11 programs that taught about
contraception resulted in no increase in sexual activity [12].
Other studies have shown that sexual activity is not increased
with teaching about condoms [15] and HIV/AIDS
[16].
Although one study found later sexual debut was associated
with abstinence-only virginity pledging, the majority
of adolescents who made virginity pledges ultimately broke
their “promise” and engaged in sexual intercourse before
marriage [17]. In addition the risk for STD was not significantly
different between pledgers and nonpledgers, and
sexually active pledgers were significantly less likely to use
condoms at first sex than were nonpledgers. Similarly our
data comparing abstinence-only and comprehensive education
revealed no significant difference in initiation of sexual
intercourse, while detecting a decreased likelihood of teen
pregnancy among those who received comprehensive education.
This suggests that preteens and teens who receive
abstinence-only education may engage in higher risk behaviors
once they initiate sexual activity.
The decreased risk of teen pregnancy we observed
among adolescents receiving comprehensive sex education
was likely mediated by use of birth control and condoms.
Considerable evidence suggests that barrier contraceptives
are effective in preventing teen pregnancy and infection
with sexually transmitted pathogens. Vital statistics reports
from the Department of Health and Human Services show a
consistent decrease in teen pregnancies as use of condoms
and contraceptive methods increases [18].
Although we observed a nonsignificant reduction in STD
risk associated with condom use at last vaginal intercourse,
the NSFG was not designed to evaluate the effectiveness of
condoms in preventing STDs, making it difficult to draw
firm conclusions about condom efficacy. Furthermore adolescents
who have previously received an STD diagnosis
may be more likely to use condoms, but we were unable to
determine whether STD diagnosis or teen pregnancy preceded
use of condoms or (other) contraception. Stronger
epidemiologic evidence summarized in a review of prospective
studies indicates that condom use is significantly protective
against several bacterial STDs including chlamydia,
gonorrhea, and syphilis [19]. More recent data indicate that
condoms are more efficacious than previously thought
against viral STDs such as herpes simplex virus [20] and
human papillomavirus [21].
Despite the protective effects of birth control and condom
use, results of numerous studies assessing the association
of sexual debut, frequency of intercourse, numbers of
partners, or contraceptive use associated with any type of
sex education have been inconsistent [11,12]. Furthermore a
population-based analysis using Wave I data from the National
Longitudinal Study of Adolescent Health (Add
Health) concluded that offering sex education to teens had
no measurable health benefits; but there were no data on
whether the teens subsequently received the education [22].
In contrast we demonstrated a significantly reduced risk for
teen pregnancy and a marginally reduced risk of initiating
sexual activity, but also showed no impact on likelihood for
STD associated with either abstinence-only or comprehensive
sex education.
This modest effect on STD outcomes may have several
explanations. First, as suggested by the strong effect of
family intactness on all three outcomes examined, sexual
risk behavior is likely driven strongly by parental influence
[23] in addition to, or possibly more than, curriculum content.
Other potential unevaluated factors include risk perception,
community resources, peer influence, and media
messages. A second possibility is the limitation inherent in
using reported STD diagnosis as a measured outcome. Reported
STD diagnoses reflect access to care and symptomatic
infection, and most STDs among U.S. teens are asymptomatic
[24]. The absence of a measure of laboratory
diagnosed STD in the NSFG suggests our estimates of the
effect of formal sex education on STD are conservative and
may even be biased, although it is impossible to determine
in which direction. Third, even in a large, nationally representative
sample, small numbers of reported STD cases can
result in low statistical power to detect associations.
Other limitations make the overall interpretation of these
data challenging. Although use of a nationally representative
survey such as the NSFG allowed us to evaluate the
effects of formal sex education in the U.S. population, and
although we restricted our study population to adolescents
who received formal sex education before engaging in sexual
activity, the cross-sectional nature of this survey precludes
any firm conclusions regarding cause and effect.
Also the small number of individuals who received no sex
education may have limited our power to detect smaller
reductions in odds associated with abstinence-only education.
Furthermore the NSFG was not initially designed to
evaluate abstinence-only programs. The survey merely
asked whether an individual ever participated in a formal
program—a question that provides no information as to the
quality, content, context, or duration of the program. The
measures we created to indicate the type of sex education
received can only be considered proxy measures. In addition
recall or selection bias among adolescents who become
350 P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351
pregnant may have resulted in inaccurate reporting of type
of sex education received.
Evaluations of abstinence-only programs may also be
limited by social desirability bias, as participants in these
programs may be less likely to report sexual activity before
marriage. A recent study found that virginity pledgers were
four times more likely than nonpledgers to initially admit to
sexual activity and then later to deny it [25]. Given this
social desirability bias, the true difference between these
programs may be greater than what we observed. Similarly
recipients of abstinence-only education may be less likely to
seek testing for STDs, and thus be less likely to report
diagnoses than recipients of a comprehensive education.
The lack of geographical measures in these data is also a
limitation. A national survey of teachers providing sex education
in grades 7–12 found significant differences in the content
or approach of the education by geographic region [26].
Landry et al reported that teachers in the South, Midwest, and
West were more likely than those in the Northeast to emphasize
the ineffectiveness of birth control measures or not to
cover them at all. Teachers in the South and Midwest were
more likely than those in the Northeast to teach abstinenceonly
education. Regrettably the public-use version of the
NSFG does not provide data on region of the U.S..
Although future prospective studies expressly designed to
evaluate the effects of formal sex education programs are
required, these data suggest that formal comprehensive sex
education programs reduce the risk for teen pregnancy without
increasing the likelihood that adolescents will engage in sexual
activity, and confirm results from randomized controlled trials
that abstinence-only programs have a minimal effect on sexual
risk behavior. To ensure better data to evaluate the effect of sex
education programs in the future, national surveys should more
specifically assess types of formal sex education in an effort to
more clearly understand its role and effectiveness, and, to the
extent possible, seek biologic specimens to ascertain current
infection with sexually transmitted pathogens.
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P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351 351
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a 3-4 page summary of the assigned article and description of the interviews they conducted, what they learned from the research, and feedback on the article.
Each assignment must be typed 3-4 pages in length (12 pt font, 1.5 line spaced, 1 inch margins).
2 additional articles from peer-reviewed scientific journals should be used to help you expand on the information discussed in the assigned article.Original article Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy Pamela K. Kohler, R.N., M.P.H.a,c, Lisa E. Manhart, Ph.D.b,c, and William E. Lafferty, M.D.a,* a Departments of Health Services and b Epidemiology, and the c Center for AIDS and STD, University of Washington, Seattle Washington Manuscript received April 17, 2007; manuscript accepted August 29, 2007 See Editorial p. 324 Abstract Purpose: The role that sex education plays in the initiation of sexual activity and risk of teen pregnancy and sexually transmitted disease (STD) is controversial in the United States. Despite several systematic reviews, few epidemiologic evaluations of the effectiveness of these programs on a population level have been conducted. Methods: Among never-married heterosexual adolescents, aged 15–19 years, who participated in Cycle 6 (2002) of the National Survey of Family Growth and reported on formal sex education received before their first sexual intercourse (n  1719), we compared the sexual health risks of adolescents who received abstinence-only and comprehensive sex education to those of adolescents who received no formal sex education. Weighted multivariate logistic regression generated population-based estimates. Results: Adolescents who received comprehensive sex education were significantly less likely to report teen pregnancy (ORadj  .4, 95% CI  .22– .69, p  .001) than those who received no formal sex education, whereas there was no significant effect of abstinence-only education (ORadj  .7, 95% CI  .38–1.45, p  .38). Abstinence-only education did not reduce the likelihood of engaging in vaginal intercourse (ORadj  .8, 95% CI  .51–1.31, p  .40), but comprehensive sex education was marginally associated with a lower likelihood of reporting having engaged in vaginal intercourse (ORadj  .7, 95% CI  .49–1.02, p  .06). Neither abstinence-only nor comprehensive sex education significantly reduced the likelihood of reported STD diagnoses (ORadj  1.7, 95% CI  .57–34.76, p  .36 and ORadj  1.8, 95% CI  .67–5.00, p  .24 respectively). Conclusions: Teaching about contraception was not associated with increased risk of adolescent sexual activity or STD. Adolescents who received comprehensive sex education had a lower risk of pregnancy than adolescents who received abstinence-only or no sex education. © 2008 Society for Adolescent Medicine. All rights reserved. Keywords: Sexually transmitted disease; Teen pregnancy; Sex education; Abstinence Rates of sexually transmitted disease (STD), teen pregnancy, and teen births are higher in the United States than in most other industrialized countries [1,2]. In a 2000 study of STD incidence among 16 developed countries, the rates of syphilis, gonorrhea and chlamydia in the United States (U.S.) were exceeded only by those in Romania and the Russian Federation [2]. Although there are minimal differences in levels of sexual activity across developed countries (Sweden, France, Canada, Great Britain, and the U.S.) [3], teen pregnancy, birth rates and abortion rates are higher in the U.S. than in other developed countries [1]. In 1995 adolescent pregnancy rates were 83.6 per 1000 in the U.S. compared with 47.0 in England and Wales, 45.4 in Canada, 20.2 in France, and 24.9 in Sweden. In the U.S., although 15–24-year-olds represent only *Address correspondence to: William E. Lafferty, M.D., Associate Professor/Director, Department of Health Services, Health & Policy Research Track, Health Sciences Center, Box 357660, Seattle, WA 98195-7660. E-mail address: billlaf@u.washington.edu Journal of Adolescent Health 42 (2008) 344–351 1054-139X/08/$ – see front matter © 2008 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2007.08.026 25% of the sexually active population, they account for nearly one-half of all new sexually transmitted infections [4], and rates are highest among young women and minorities [5]. Compared with male adolescents of the same age, rates of gonorrhea among 15–19-year-old women are more than twice as high (624.7 vs. 261.2 per 100,000), and rates of chlamydia are more than five times higher (2796.6 vs. 505.2 per 100,000). Among African-American adolescents aged 15–19 years, the 2005 rate of gonorrhea was 14 times greater than the rate among white female adolescents of similar age (2814 vs. 204.7 per 100,000). Formal school-based or church-based sex education programs aimed at reducing risks of teenage pregnancy and STD acquisition generally promote one of two types of messages regarding sexual activity: (1) abstinence-only messages, or (2) comprehensive sex education messages. Abstinence-only messages teach that sex should be delayed until marriage, and discussion of birth control methods is typically limited to statements about ineffectiveness [6]. Comprehensive programs include abstinence messages, but also provide information on birth control methods to prevent pregnancy and condoms to prevent STDs. Although several avenues of federal funding for formal sex education programs are available, all require adherence to abstinence-only messages. In 1996 Congress introduced Section 510(b) of Title V of the Social Security Act, allocating federal dollars for state initiatives promoting abstinence-only programming and establishing criteria for defining abstinence education. To receive federal Title V funding, a sex education program must have as its exclusive purpose “teaching the social, psychological, and health gains to be realized by abstaining from sexual activity” [7]. These programs must teach that abstinence from sexual activity outside marriage is the expected standard for all school-age children and the only certain way to avoid outof-wedlock pregnancy and STDs. Over the past 5 years, U.S. fiscal policy has allocated increasing amounts of funding to abstinence-only prevention programs. In 2001 abstinence-only education programs received $80 million in federal funding [6], and by 2005 federal funding had more than doubled to $167 million [8]. The 2008 fiscal year budget proposes $204 million for abstinence education [9]. Consistent with this increase in funding, analyses of Cycle 5 (1995) and Cycle 6 (2002) of the National Survey of Family Growth (NSFG) revealed that whereas only 9.3% of adolescents aged 15–19 received abstinence-only education in 1995, nearly a quarter (23.8%) did so in 2002 [10]. Systematic reviews suggest that the effects of abstinence-only programs on sexual risk behavior have been minimal, and that initiation of sexual activity is not hastened by receiving instruction about measures for safer sex [11– 15]. However the majority of reviewed trials have been conducted in specific subgroups of the population, and there have been no population-level evaluations of the effectiveness of these programs. In addition the question of whether comprehensive or abstinence-only sex education is most effective at reducing risk for teen pregnancy and STD has stimulated a heated and politicized debate. To address this gap in the evidence, we used data from Cycle 6 of the NSFG to determine whether STD and pregnancy risk is signifi- cantly different based on the type of formal sex education adolescents receive and whether teaching about contraception increases risk for sexual activity before marriage. Methods The NSFG is a nationwide survey conducted by the National Center for Health Statistics. Data were collected in collaboration with the University of Michigan’s Institute for Social Research by trained personnel, from January 2002 to March 2003, through an in-home interview process that included Audio Computer-Assisted Self-Interviewing (ACASI). Overall information collected included basic demographics; knowledge, attitudes, and beliefs regarding family planning issues; and self-reported sexual behavior and previous diagnoses of STDs. Sample The NSFG is based on an area probability sample designed to represe
nt the national noninstitutionalized population 15–44 years of age. It includes responses from 12,571 male and female individuals from across the United States. The adolescent subset of this cohort (aged 15–19 years) was asked additional questions related to sex education, sexual behavior, pregnancy and STDs. A total of 1150 adolescent girls and 1121 adolescent boys responded to the NSFG general questionnaire and special adolescent interview. To assess the effect of formal sex education programs on pregnancy and STD risk, the sample was restricted to nevermarried heterosexual teens aged 15–19 years who reported no formal sex education, formal sex education on “how to say no to sex” only (abstinence-only), or formal sex education covering both “saying no to sex” and teaching about birth control (comprehensive). We excluded respondents who were married (n  36), in whom formal sex education programs would not be expected to delay sexual debut or reduce risk for pregnancy. Individuals reporting sexual orientation other than heterosexual were also excluded (n  318), as programs do not address same-sex behaviors. We further excluded respondents who reported exposure to sex education that taught only birth control without mentioning abstinence, as such programs were not consistent with our definitions of either abstinence-only or comprehensive programs (n  111), as well as respondents who did not answer sex education questions (n  1) or who reported an age of first intercourse 10 years (n  8). To ensure temporal sequence in our assessment of whether formal sex education delayed sexual initiation or reduced teen pregnancy, we excluded those who reported first vaginal intercourse before formal sex education. We computed this by adding 5 years to P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351 345 the grade at sex education and subtracting age at first sex education from age at first sex (n  60). Another 18 adolescents who reported teen pregnancy or using birth control at last sex but reported no vaginal sex were also excluded (n  18). Type of formal sex education Exposure to specific types of sex education was measured based on two separate questions. The first asked whether respondents, before the age of 18 years, ever received “any formal instruction at school, church, a community center, or some other place about how to say no to sex.” A follow-up question asked the same about receiving instruction about methods of birth control. Individuals who reported birth control education in addition to education emphasizing saying no to sex were classified as having participated in comprehensive sex education. Respondents who reported only receiving sex education about how to say no to sex were classified as participants in abstinence-only programs. Measures of adolescent sexual risk We examined three dichotomous measures of adolescent sexual risk: ever having engaged in vaginal intercourse; pregnancy; and STD. Self-report of ever having had vaginal sex was coded as ever/never, and teen pregnancy was assessed by computing the total number of pregnancies reported by males and females by ACASI. Prior STD diagnosis was assessed by self-report of chlamydia, gonorrhea in the last year, or ever having been diagnosed with herpes, genital warts, or syphilis. Characteristics previously associated with adolescent sexual risk behaviors were assessed as potential confounding factors and included: respondent age (integer years 15–19), household income quartiles ($20,000; $20,000– 39,999; $40,000–74,999; $75,000), race/ethnicity (black, white, other), residence (rural, suburban, central city) and intactness of the family unit (residing with the same two biological/adoptive parents since birth). Analysis We conducted a stratified weighted analysis to account for the complex survey design of the NSFG using STATA 9 (Stata Corp., College Station, TX). A design based Pearson’s 2 test was used to compare proportions, and weighted multivariate logistic regression was used to determine the association of type of formal sex education with measures of sexual risk (engaging in vaginal sex, pregnancy and STD). Covariates were retained in the model if they were significantly associated with the outcome and/or if their inclusion substantially changed the estimates for type of sex education by 10%. Although we performed analyses stratified by gender, there were no substantive differences in results; thus we present combined analyses. Results Population, sample, and sex education Of the 1719 never-married heterosexual adolescents included in these analyses, 47.4% were female (Table 1). The Table 1 Characteristics of heterosexual adolescents aged 15–19 years reporting on sex education (none, abstinence only or comprehensive) in the 2002 Cycle 6 of the National Survey of Family Growth (NSFG) (population and sample, n  1719) Characteristic Total No sex education: Abstinence-only education: Comprehensive sex education: Weighted % (95%CI) n  168 Weighted % (95% CI) n  390 Weighted % (95% CI) n  1161 Overall 9.4 23.8 66.8 Agea Mean  17.0 (.04) Mean  17.2 (.12) Mean  16.8 (.10) Mean  17.1 (.05) Gender Female 47.4 42.0 (34.5–50.0) 45.4 (39.1–51.9) 48.8 (44.7–52.9) Male 52.6 58.0 (50.0–65.5) 54.6 (48.1–60.9) 51.2 (47.1–55.3) Race/ethnicity White 76.7 69.4 (60.2–77.2) 75.1 (69.3–80.2) 78.2 (74.4–81.6) Black 14.0 19.2 (12.8–27.8) 16.4 (12.0–21.9) 12.5 (10.2–15.2) Other 9.3 11.4 (6.8–18.6) 8.5 (5.5–13.0) 9.3 (7.1–12.0) Household income quartile (per year)a $20,000 23.7 36.9 (28.4–46.3) 24.9 (20.5–29.9) 21.4 (18.6–24.6) $20,000–39,999 27.0 23.0 (17.1–32.5) 32.6 (27.0–38.8) 25.6 (22.4–29.1) $40,000–74,999 27.3 18.2 (12.4–25.9) 24.3 (20.0–29.2) 29.7 (26.7–32.8) $75,000 21.9 21.9 (13.7–33.1) 18.2 (13.8–23.6) 23.3 (19.8–27.1) Residencea Metropolitan, central city 53.3 39.0 (27.4–52.1) 53.4 (44.9–61.6) 55.3 (48.7–61.7) Metropolitan, not central city 27.0 26.8 (17.6–38.5) 24.7 (19.2–31.2) 27.9 (22.9–33.5) Not metropolitan 19.7 34.2 (21.2–50.1) 22.0 (14.6–31.7) 16.8 (11.2–24.5) Nonintact family unitab 41.3 53.8 (43.5–63.8) 36.9 (31.1–43.1) 41.2 (37.7–44.8) a Design-based Pearson 2 test for difference between categories significant at p .05. b Intact family unit defined as adolescent residing with the same two biological or adoptive parents from birth until age 18 years or living on own. 346 P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351 median age was 17 years; 76.7% were of white ethnicity and 14.0% black. Household incomes less than $40,000 per year were reported by half (50.7%) of the participants. The majority of respondents resided in a central city (53.3%), and 41.3% of respondents reported a nonintact family unit. Overall 9.4% of participants reported that they had not received any sex education, whereas 23.8% reported abstinence-only education and 66.8% comprehensive sex education. Univariate analysis of sociodemographic characteristics revealed significant differences between type of education received with respect to age, income, residence, and family unit intactness. Generally individuals receiving no sex education tended to be from low-income nonintact families, black, and from rural areas. Participants reporting abstinence-only education were typically younger and from low-to-moderate–income intact families, whereas adolescents reporting comprehensive sex education were somewhat older, white, and from higherincome families and more urban areas. Initiation of sexual activity Almost half of respondents (46.3% of males and 45.7% of females) reported having engaged in vaginal intercourse by the time of the survey. In univariate analyses (Table 2), respondents who were older, black, from a lower-income household, resided in a noncentral city metropolitan area, and came from a nonintact family unit were significantly more likely to report ever having engaged in vaginal intercourse, whereas those who had received any type of formal sex education were less likely to report this (p .05 for all). After adjustment for oth
er significant predictors of engaging in vaginal intercourse (age, race, gender, and family intactness), abstinence-only education was not significantly associated with an adolescent ever engaging vaginal intercourse (ORadj  .8, 95% CI  .51–1.31, p  .40), whereas comprehensive sex education was marginally associated with reduced reports of engaging in vaginal intercourse (ORadj  .7, 95% CI  .49–1.02, p  .06). Table 2 Characteristics associated with report of ever engaging in vaginal intercourse among heterosexual adolescents aged 15–19 years reporting on sex education (none, abstinence-only, or comprehensive) in the 2002 Cycle 6 of the National Survey of Family Growth (NSFG) Characteristic Ever had vaginal intercourse: Never had vaginal intercourse: p** Univariate Multivariate†† Weighted % (95%CI) Weighted % (95%CI) OR (95% CI) OR (95% CI) Sex education No sex education 11.5 (8.9–14.7) 7.6 (5.5–10.4) .06 (Ref) (Ref) Abstinence-only sex education 22.6 (19.1–26.5) 25.0 (21.6–28.7) .60 (.39–.92)* .82 (.51–1.31) Comprehensive sex education 66.0 (61.6–70.2) 67.4 (62.9–71.5) .65 (.45–.95)* .70 (.49–1.02) Age (mean  SE) 17.6 (.06) 16.6 (.06) .001§§ 1.79 (1.58–2.02)‡§ 1.91 (1.67–2.18)‡ Gender .83 Female 47.1 (42.4–51.8) 47.7 (43.9–51.6) (Ref) (Ref) Male 52.9 (48.2–57.6) 52.3 (48.4–56.1) 1.02 (.81–1.29) 1.07 (.81–1.40) Race/ethnicity .001 White 73.2 (68.6–77.4) 79.6 (75.5–83.2) (Ref) (Ref) Black 18.5 (14.6–23.0) 10.3 (8.2–12.8) 1.95 (1.46–2.61)‡ 1.86 (1.35–2.58)‡ Other 8.3 (6.1–11.4) 10.1 (7.5–13.5) .90 (.59–1.37) .85 (.53–1.37) Household income quartile (per year) .02 $20,000 27.6 (24.2–31.2) 20.5 (17.6–23.7) (Ref) $20,000–39,999 25.2 (21.6–29.1) 28.4 (24.8–32.3) .89 (.81–.98)*¶ $40,000–74,999 26.7 (23.2–30.6) 27.9 (24.7–31.4) $75,000 20.6 (17.1–24.5) 23.2 (19.7–27.1) Residence .002 Metropolitan: Central City 48.1 (41.7–54.6) 57.6 (50.4–64.5) (Ref) Metropolitan: Not Central City 31.8 (26.5–37.7) 23.0 (18.2–28.5) 1.66 (1.28–2.16)‡ Not metropolitan 20.0 (13.5–28.7) 19.4 (13.1–27.8) 1.24 (.89–1.72) Nonintact family unit‡‡ 49.3 (44.9–53.6) 34.5 (30.4–38.8) .001 1.85 (1.42–2.40)‡ 2.29 (1.67–3.13)‡ CI  confidence interval; OR  odds ratio. OR is significant at * p .05, † p .01, ‡ p .001. § OR represents increase in risk for each additional year. ¶ OR represents increase in risk for each additional income quartile. ** Design-based Pearson’s 2 test for difference between categories unless otherwise specified. †† ORs adjusted for all variables in the column. Further adjustment for income and residence did not appreciably change the estimates for type of sexual education and thus were not included. ‡‡ Intact family unit was defined as residing with the same two biological or adoptive parents from birth until age 18 years or living on own. §§ p Value obtained by design-based t test P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351 347 Pregnancy Among all respondents, 7.3% reported a pregnancy, although this was more common among females (10.2%) than males (4.7%) (p .001). In univariate analyses, increased odds for teen pregnancy were significantly associated with older age, black race, lower household income, noncentral city metropolitan residence, and nonintact family unit status (p .05) (Table 3). In multivariate analyses adjusting for age, gender, race, income, residence, and family intactness, abstinence-only sex education was not significantly associated with reported teen pregnancy when compared with no sex education (ORadj  .7, 95% CI  .38–1.45, p  .38). However adolescents who reported having received comprehensive sex education were significantly less likely to report a teen pregnancy compared with those who received no sex education at all (ORad j  .4, 95% CI  .22–.69, p  .001). The causal pathway intermediary of birth control use at last sexual intercourse was also associated with a decreased likelihood for reported pregnancy (ORadj  .3, 95% CI  .13–.48, p .001), adjusted for the same characteristics as teen pregnancy. Finally, when comparing adolescents who reported receiving a comprehensive sex education with those who received an abstinence-only education, comprehensive sex education was associated with a 50% lower risk of teen pregnancy (ORadj  .5, 95% CI  .28– .96, p  .04). Previous STD diagnosis Few adolescents (3.4%) reported any prior STD diagnoses, and previous STD diagnoses were twice as common among females (4.8%) as among males (2.1%). In univariate analyses, increased likelihood of STD diagnosis was also significantly associated with older age, black race, and coming from a nonintact family unit (Table 4). However in multivariate analyses adjusted for age, gender, race, and family intactness, neither abstinence-only nor comprehensive sex education were significantly associated with risk for STD when compared with no sex education (ORadj  1.7, 95% CI  .57–4.76, p  .36; and ORadj  1.8, 95% CI  Table 3 Characteristics associated with report of teen pregnancy among heterosexual adolescents ages 15–19 years reporting on sex education (none, abstinenceonly, or comprehensive) in the 2002 Cycle 6 of the National Survey of Family Growth (NSFG) Characteristic Ever had teen pregnancy: No teen pregnancy: p** Univariate Multivariate†† Weighted % (95% CI) Weighted % (95% CI) OR (95% CI) OR (95% CI) Sex education .003 No sex education 19.4 (13.2–27.4) 8.6 (6.6–11.0) (Ref) (Ref) Abstinence-only sex education 27.1 (17.7–39.1) 23.6 (21.1–26.4) .51 (.27–.98)* .74 (.38–1.45) Comprehensive sex education 53.5 (42.3–64.5) 67.8 (64.3–71.1) .35 (.21–.60)‡ .39 (.22–.69)‡ Age (mean  SE) 17.9 (.11) 17.0 (.04) .001§§ 1.72 (1.46–2.02)‡§ 1.87 (1.57–2.24)‡§ Gender .001 Female 66.5 (54.6–76.5) 45.9 (42.7–49.1) (Ref) (Ref) Male 33.5 (23.5–45.4) 54.1 (50.9–57.3) .43 (.26–.70)‡ .44 (.26–.74)† Race/ethnicity .002 White 66.7 (56.7–75.4) 77.4 (73.9–80.6) (Ref) (Ref) Black 26.4 (18.6–36.0) 13.1 (10.7–16.0) 2.34 (1.49–3.67)‡ 1.28 (.81–2.03) Other 6.9 (3.0–15.3) 9.5 (7.4–12.0) .85 (.35–2.07) .72 (.28–1.85) Household income quartile (per year) .001 $20,000 46.6 (37.6–55.9) 21.9 (19.4–24.7) (Ref) (Ref) $20,000–39,999 25.7 (19.1–33.7) 27.2 (24.2–30.3) .59 (.46–.74)‡¶ .69 (.53–.89)†¶ $40,000–74,999 15.4 (9.4–24.1) 28.3 (25.9–30.8) $75,000 12.3 (6.9–20.9) 22.6 (19.7–25.9) Residence .001 Metropolitan, central city 38.5 (28.7–49.4) 54.4 (48.0–60.7) (Ref) (Ref) Metropolitan, not central city 43.6 (33.8–53.9) 25.7 (21.3–30.8) 2.39 (1.51–3.79)‡ 1.83 (1.15–2.91)* Not metropolitan 17.9 (10.3–29.4) 19.8 (13.7–27.9) 1.27 (.71–2.28) .88 (.47–1.67) Nonintact family unit‡‡ 64.5 (53.9–73.8) 39.5 (36.4–42.8) .001 2.78 (1.75–4.41)‡ 2.51 (1.54–4.08)‡ Birth control method at last intercourse 71.3 (61.2–79.6) 92.5 (88.8–95.0) .001 .20 (.11–.36)‡ .25 (.14–.48)‡¶¶ OR is significant at * p .05, † p .01, ‡ p .001. § OR represents increase in risk for each additional year. ¶ OR represents increase in risk for each additional income quartile. ** Design-based Pearson’s 2 test for difference between categories unless otherwise specified. †† ORs adjusted for all variables in the column except birth control at last intercourse. ‡‡ Intact family unit was defined as residing with the same two biological or adoptive parents from birth until age 18 years or living on own. §§ p Value obtained by design-based t test. ¶¶ Adjusted for age, gender, race, income, residence, and family intactness. 348 P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351 .67–5.00, p  .24, respectively). The strongest predictor for STD was nonintact family unit status; such adolescents were four times more likely to report a previous diagnosis of STD (ORadj  3.9, 95% CI  2.00–7.74, p .001). Although condom use at last vaginal sex was significantly associated with a 50% decrease in odds of reported STD diagnoses in univar
iate analyses (p  .03), after adjusting for age, gender, race, and family intactness, this was no longer statistically significant, despite a similar odds ratio (ORadj  .55, 95% CI  .24–1.20, p  .13). Discussion This assessment of the impact of formal sex education programs on teen sexual health using nationally representative data found that abstinence-only programs had no significant effect in delaying the initiation of sexual activity or in reducing the risk for teen pregnancy and STD. In contrast comprehensive sex education programs were significantly associated with reduced risk of teen pregnancy, whether compared with no sex education or with abstinence-only sex education, and were marginally associated with decreased likelihood of a teen becoming sexually active compared with no sex education. As has been previously reported [10], receipt of formal sex education was associated with important sociodemographic characteristics including age, income, and residence. In addition, we also found a strong relationship between family intactness and receiving sex education. Teens from intact families were more likely to receive formal sex education than teens from nonintact families. Furthermore approximately 10% of teens ages 15–19 years participating in the NSFG had received no formal sex education at the time of the survey; these adolescents were most often nonwhite and from low-income families. Like many other health indicators, the opportunity for formal sex education appears to vary by social strata, with disadvantaged youth being the least likely to benefit from formal programs. Table 4 Characteristics associated with report of previous STD diagnoses among heterosexual adolescents aged 15–19 years reporting on sex education (none, abstinence only or comprehensive) in the 2002 Cycle 6 of the National Survey of Family Growth (NSFG) Characteristic Reported STD diagnosis: No reported STD diagnosis: p** Univariate Multivariate†† Weighted % (95% CI) Weighted % (95% CI) OR (95% CI) OR (95% CI) Sex education .55 No sex education 6.9 (3.0–15.4) 9.5 (7.4–11.9) (Ref) (Ref) Abstinence-only sex education 19.7 (11.1–32.6) 24.0 (21.4–26.8) 1.12 (.39–3.22) 1.65 (.57–4.76) Comprehensive sex education 73.4 (59.5–83.8) 66.6 (63.0–69.9) 1.50 (.56–4.00) 1.82 (.67–5.00) Age (mean  SE) 17.6 (.15) 17.0 (.04) .001§§ 1.37 (1.14–1.65)‡§ 1.45 (1.21–1.75)‡§ Gender .03 Female 66.9 (48.7–81.1) 46.7 (43.4–49.9) (Ref) (Ref) Male 33.1 (18.9–51.3) 53.3 (50.1–56.6) .43 (.20–.93)* .47 (.21–1.06) Race/ethnicity .05 White 64.1 (49.5–76.5) 77.1 (73.6–80.3) (Ref) (Ref) Black 25.0 (15.4–38.1) 13.7 (11.1–16.7) 2.20 (1.14–4.25)* 1.67 (.85–3.27) Other 10.9 (4.9–22.5) 9.2 (7.2–11.8) 1.42 (.56–3.55) 1.49 (.58–3.85) Household income quartile (per year) .33 $20,000 31.6 (20.0–46.0) 23.4 (20.9–26.2) (Ref) $20,000–39,999 25.4 (15.8–38.1) 27.1 (24.2–30.2) .80 (.61–1.06)¶ $40,000–74,999 31.3 (17.1–50.1) 27.2 (24.8–29.7) $75,000 11.8 (5.0–25.1) 22.3 (19.4–25.5) Residence .50 Metropolitan, central city 46.7 (31.3–62.7) 53.5 (47.3–59.7) (Ref) Metropolitan, not central city 34.1 (21.6–49.2) 26.8 (22.3–31.8) 1.46 (.74–2.90) Not metropolitan 19.2 (10.0–33.6) 19.7 (13.6–27.8) 1.12 (.52–2.42) Nonintact family unit‡‡ 72.2 (58.0–83.0) 40.2 (37.1–43.4) .001 3.85 (2.00–7.42)‡ 3.93 (2.00–7.74)‡ Condom use at last vaginal intercourse 47.3 (31.8–63.3) 65.1 (61.0–68.9) .03 .48 (.25–.94)* .55 (.25–1.21)¶¶ CI  confidence interval; OR  odds ratio. OR significant at * p .05, † p .01, ‡ p .001. § OR represents increase in risk for each additional year. ¶ OR represents increase in risk for each additional income quartile. ** Design-based Pearson’s 2 test for difference between categories unless otherwise specified. Further adjustment for income and residence did not appreciably change the estimates for type of sexual education and were not included. Condom use at last intercourse was not considered in the model. ‡‡ Intact family unit was defined as residing with the same two biological or adoptive parents from birth until age 18 years or living on own. §§ p Value obtained by design-based t-test. ¶¶ Adjusted for age, gender, race, and family intactness. P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351 349 However a recent review suggests that abstinence-only programs, whether conducted in low- or middle-income settings, had similarly modest effects on risk behavior [14]. Our study is not the only recent work to suggest that abstinence-only education may not reduce sexual risk behaviors among teens. A randomized controlled trial of four federally funded abstinence programs found no significant decrease in number of partners or risk for STD and pregnancy, and no delay in sexual debut [13]. Similarly a systematic review of 13 trials found that abstinence-only programs were not associated with reductions in sexual risk behavior or in diagnosis of STDs [14]. Another review showed that all but one of 11 programs that taught about contraception resulted in no increase in sexual activity [12]. Other studies have shown that sexual activity is not increased with teaching about condoms [15] and HIV/AIDS [16]. Although one study found later sexual debut was associated with abstinence-only virginity pledging, the majority of adolescents who made virginity pledges ultimately broke their “promise” and engaged in sexual intercourse before marriage [17]. In addition the risk for STD was not significantly different between pledgers and nonpledgers, and sexually active pledgers were significantly less likely to use condoms at first sex than were nonpledgers. Similarly our data comparing abstinence-only and comprehensive education revealed no significant difference in initiation of sexual intercourse, while detecting a decreased likelihood of teen pregnancy among those who received comprehensive education. This suggests that preteens and teens who receive abstinence-only education may engage in higher risk behaviors once they initiate sexual activity. The decreased risk of teen pregnancy we observed among adolescents receiving comprehensive sex education was likely mediated by use of birth control and condoms. Considerable evidence suggests that barrier contraceptives are effective in preventing teen pregnancy and infection with sexually transmitted pathogens. Vital statistics reports from the Department of Health and Human Services show a consistent decrease in teen pregnancies as use of condoms and contraceptive methods increases [18]. Although we observed a nonsignificant reduction in STD risk associated with condom use at last vaginal intercourse, the NSFG was not designed to evaluate the effectiveness of condoms in preventing STDs, making it difficult to draw firm conclusions about condom efficacy. Furthermore adolescents who have previously received an STD diagnosis may be more likely to use condoms, but we were unable to determine whether STD diagnosis or teen pregnancy preceded use of condoms or (other) contraception. Stronger epidemiologic evidence summarized in a review of prospective studies indicates that condom use is significantly protective against several bacterial STDs including chlamydia, gonorrhea, and syphilis [19]. More recent data indicate that condoms are more efficacious than previously thought against viral STDs such as herpes simplex virus [20] and human papillomavirus [21]. Despite the protective effects of birth control and condom use, results of numerous studies assessing the association of sexual debut, frequency of intercourse, numbers of partners, or contraceptive use associated with any type of sex education have been inconsistent [11,12]. Furthermore a population-based analysis using Wave I data from the National Longitudinal Study of Adolescent Health (Add Health) concluded that offering sex education to teens had no measurable health benefits; but there were no data on whether the teens subsequently received the education [22]. In contrast we demonstrated a significantly reduced risk for teen pregnancy a
nd a marginally reduced risk of initiating sexual activity, but also showed no impact on likelihood for STD associated with either abstinence-only or comprehensive sex education. This modest effect on STD outcomes may have several explanations. First, as suggested by the strong effect of family intactness on all three outcomes examined, sexual risk behavior is likely driven strongly by parental influence [23] in addition to, or possibly more than, curriculum content. Other potential unevaluated factors include risk perception, community resources, peer influence, and media messages. A second possibility is the limitation inherent in using reported STD diagnosis as a measured outcome. Reported STD diagnoses reflect access to care and symptomatic infection, and most STDs among U.S. teens are asymptomatic [24]. The absence of a measure of laboratory diagnosed STD in the NSFG suggests our estimates of the effect of formal sex education on STD are conservative and may even be biased, although it is impossible to determine in which direction. Third, even in a large, nationally representative sample, small numbers of reported STD cases can result in low statistical power to detect associations. Other limitations make the overall interpretation of these data challenging. Although use of a nationally representative survey such as the NSFG allowed us to evaluate the effects of formal sex education in the U.S. population, and although we restricted our study population to adolescents who received formal sex education before engaging in sexual activity, the cross-sectional nature of this survey precludes any firm conclusions regarding cause and effect. Also the small number of individuals who received no sex education may have limited our power to detect smaller reductions in odds associated with abstinence-only education. Furthermore the NSFG was not initially designed to evaluate abstinence-only programs. The survey merely asked whether an individual ever participated in a formal program—a question that provides no information as to the quality, content, context, or duration of the program. The measures we created to indicate the type of sex education received can only be considered proxy measures. In addition recall or selection bias among adolescents who become 350 P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351 pregnant may have resulted in inaccurate reporting of type of sex education received. Evaluations of abstinence-only programs may also be limited by social desirability bias, as participants in these programs may be less likely to report sexual activity before marriage. A recent study found that virginity pledgers were four times more likely than nonpledgers to initially admit to sexual activity and then later to deny it [25]. Given this social desirability bias, the true difference between these programs may be greater than what we observed. Similarly recipients of abstinence-only education may be less likely to seek testing for STDs, and thus be less likely to report diagnoses than recipients of a comprehensive education. The lack of geographical measures in these data is also a limitation. A national survey of teachers providing sex education in grades 7–12 found significant differences in the content or approach of the education by geographic region [26]. Landry et al reported that teachers in the South, Midwest, and West were more likely than those in the Northeast to emphasize the ineffectiveness of birth control measures or not to cover them at all. Teachers in the South and Midwest were more likely than those in the Northeast to teach abstinenceonly education. Regrettably the public-use version of the NSFG does not provide data on region of the U.S.. Although future prospective studies expressly designed to evaluate the effects of formal sex education programs are required, these data suggest that formal comprehensive sex education programs reduce the risk for teen pregnancy without increasing the likelihood that adolescents will engage in sexual activity, and confirm results from randomized controlled trials that abstinence-only programs have a minimal effect on sexual risk behavior. To ensure better data to evaluate the effect of sex education programs in the future, national surveys should more specifically assess types of formal sex education in an effort to more clearly understand its role and effectiveness, and, to the extent possible, seek biologic specimens to ascertain current infection with sexually transmitted pathogens. References [1] Singh S, Darroch JE. Adolescent pregnancy and childbearing: Levels and trends in developed countries. Fam Plann Perspect 2000;32:14– 23. [2] Panchaud C, Singh S, Feivelson D, Darroch J. Sexually transmitted diseases among adolescents in developed countries. Fam Plann Perspect 2000;32:24–32, 45. [3] Alan Guttmacher Institute. Teenagers’ Sexual and Reproductive Health: Developed Countries [Online]. Available at: http://www. guttmacher.org/pubs/fb_teens.pdf. Accessed April 5, 2007. [4] Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: Incidence and prevalence estimates, 2000. Perspect Sex Reprod Health 2004;36:6–10. [5] Centers for Disease Control and Prevention. STD Surveillance 2005: Adolescents and Youth [Online]. Available at: http://www.cdc.gov/ std/stats05/adol.htm. Accessed May 18, 2006. [6] US House of Representatives Committee on Government Reform— Minority Staff Special Investigations Division. The Content of Federally Funded Abstinence-Only Education Programs [Online]. Available at: http://www.democrats.reform.house.gov/Documents/ 20041201102153-50247.pdf. Accessed July 15, 2005. [7] Social Security Act. Section 510 [42 U.S.C. 710] [Online]. Available at: http://www.ssa.gov/OP_Home/ssact/title05/0510.htm#fn019. Accessed April 9, 2007. [8] Office of Management and Budget, Budget of the United States Government, Fiscal Year 2005; Department of Health and Human Service [Online]. Available at: www.whitehouse.gov/omb/budget/ fy2005/pdf/budget/hhs.pdf. Accessed November 23, 2005. [9] Office of Management and Budget, Budget of the United States Government, Fiscal Year 2008; Department of Health and Human Services [Online]. Available at: http://www.gpoaccess.gov/usbudget/ fy08/pdf/budget/hhs.pdf. Accessed April 4, 2007. [10] Lindberg LD, Santelli JS, Singh S. Changes in formal sex education: 1995–2002. Perspect Sex Reprod Health 2006;38:182–9. [11] Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy (Summary). Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001 [Online]. Available at: http://www.teenpregnancy.org/resources/data/pdr/emerganswsum.pdf. Accessed April 4, 2007. [12] Bennett SE, Assefi NP. School-based teen pregnancy prevention programs: A systematic review of randomized controlled trials. J Adolesc Health 2005;36:72–81. [13] Trenholm C, Devaney B, Fortson K, et al. Impacts of Four Title V Section 510 Abstinence Education Programs [Online]. Available at: http://www.mathematica-mpr.com/publications/pdfs/impactabstinence. pdf. Accessed August 4, 2007. [14] Underhill K, Montgomery P, Operario D. Sexual abstinence only programmes to prevent HIV infection in high income countries: Systematic review. Br Med J 2007;335:248 [epub]. [15] Smoak ND, Scott-Sheldon L, Johnson BT, Carey MP. Sexual risk reduction interventions do not inadvertently increase the overall frequency of sexual behavior: A meta-analysis of 174 studies with 116,735 participants. J Acquir Immune Defic Syndr 2006;41:374–84. [16] Tremblay CH, Ling DC. AIDS education, condom demand, and the sexual activity of American youth. Health Econ 2005;14:851–67. [17] Bruckner H, Bearman PS. After the Promise: The STD consequences of adolescent virginity pledges. J Adolesc Health 2005;36:271–8. [18] U.S. Department of Health and Human Services, National Center for Health Statistics. Teenagers in the United States: Sexual Activity, Contraceptive Use and Childbearing, 2002. Available at: http://www.cdc.gov/nchs/nsfg.htm. Accessed May 30, 2006 [19] Holmes KK, Levine R, Weaver M. Effectiveness of condoms
in preventing sexually transmitted infections. Bull WHO 2004;82:454–61. [20] Wald A, Langenberg AG, Krantz E, et al. The relationship between condom use and herpes simplex virus acquisition. Ann Intern Med 2005;143:707–13. [21] Winer RL, Hughes JP, Feng Q, et al. Condom use and the risk of genital human papillomavirus infection in young women. N Engl J Med 2006;354:2645–54. [22] Sabia J. Does sex education affect adolescent sexual behaviors and health? J Policy Anal Manag 2006;25:783–802. [23] DiLorio C, Dudley WN, Soet JE, McCarty F. Sexual possibility situations and sexual behaviors among young adolescents: The moderating role of protective factors. J Adolesc Health 2004;35:528.e11–20. [24] Miller WC, Ford CA, Morris M, et al. Prevalence of chlamydial and gonococcal infections among young adults in the United States. JAMA 2004;291:2229–36. [25] Rosenbaum JE. Reborn a virgin: Adolescents’ retracting of virginity pledges and sexual histories. Am J Public Health 2006;96:1098–1103. [26] Landry DL, Darroch JE, Singh S, Higgins J. Factors associated with the content of sex education in US public secondary schools. Perspect Sex Reprod Health 2003;35:261–9. P.K. Kohler et al. / Journal of Adolescent Health 42 (2008) 344 –351 351 The author has requested enhancement of the downloaded file. All in-text references underlined in blue are linked to publications on ResearchGate.

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