Dr. Joseph McIlhney on Abstinence-Only Ed
POV: Tell us a little about the work that you do at your organization and your background as an in-vitro fertilization specialist. What made you decide to start the Medical Institute? When was your organization started?
McIlhaney: I'm a gynecologist with a specialty in reproductive medicine. I became aware in the mid '80s that about a third of the patients that we were bringing into our in vitro fertilization program were sterile from sexually transmitted disease (STD). So people that became sterile from their sexual activity — by which they got infected with primarily chlamydia but also with gonorrhea — most of those people would never have a chance to have a child of their own. So I wrote a 700-page book for lay women about hysterectomy and menopause and childbirth and one of the chapters was on STD.
So I started [doing interviews], because of the book and other books that I wrote. I got on national radio and national TV multiple times and then we'd get flooded with phone calls. Most of my physician friends, most of my patients and certainly most parents didn't really have any information about the problem of STD. There was a lot of information about non-marital pregnancy, particularly teen pregnancy, but almost nothing about STD. And so because of this and the flood of questions we'd get every time I would talk about this on the media, I finally had to make a decision.
Reproductive medicine is a highly demanding practice. People that are seeing you for it are spending a lot of money, a lot of time and a lot of emotion, and you can't compromise them. By this time I'd put together a set of about 100 slides that was very graphic showing diseased genitalia and so forth. I thought we could write about each of those slides and start a little organization to make these available to people, and then I could get back to my practice. I didn't want to go around being the big guru talking about this all over the country. So we opened the office.
Instead of that taking the pressure off in 1992, it made us look like we were [the] experts about the problem of STD. And we even got more calls. I'd put together an advisory board of primarily medical school professors from around the country, because I knew I didn't want to do this by myself . [and] in 1995 a couple of them said, "You need to quit your practice and do this full time." At first I was terrified of that but pretty soon my wife and I realized that this was what I was supposed to do. And so I left my medical practice and started being involved full time with the organization in early 1996.
POV: What are the goals of the Medical Institute?
McIlhaney: [The board] made the decision at that time that it was going to be a medical and a scientific organization. And [that] we would follow the data wherever it went. But we were going to be more than just information [providers]. We were going to be very much like a good physician — that is, we were going to advocate for the healthiest life for people. And that's really the guidance for our organization in that we're saying, "Okay, here's the data but we're going to give you guidance for making the healthiest decision you can for your life." Our goal is to see a dramatic drop in the instance of and prevalence of STDs, of HIV and of non-marital pregnancy.
POV: And how successful, over the past 10 years or so that the Medical Institute has been in existence, have you been in achieving that goal?
McIlhaney: I wouldn't say that we're the only group or maybe even the primary group, but I think we have contributed to bringing the problem of STD to the attention of the American public. HIV has done its own thing, because it's such a dramatic disease. Teen and adolescent non-marital pregnancy issues have been discussed in society, but I believe that one of the things that we have helped bring to the attention of the American people has been the problems of STD and the damage they cause — and also their incredible prevalence. We have an epidemic. So I think that the first thing that we wanted to and do want to continue to accomplish is bringing that [fact] to the attention of people. It wasn't there back in the late '80s when we started the work.
I think that we still are a long way from people facing the reality of the association of these diseases with behavior choices, but I do believe that we have the attention of a lot of people now. The group I'm still most concerned with [is parents]. There are a lot of parents that don't yet have the picture of how common STD are and how different the world is now than it was when they grew up.
Today there are about 1 in 4 adolescents infected with STD. Back in the days that [today's]parents were growing up in — say, the '70s — only about 1 in maybe 40 or 50 adolescents was infected with an STD. Back then there were only two diseases that were of great concern to us and both of those were treatable with penicillin — syphilis and gonorrhea. Today there are, according to the Institute of Medicine and our own data, there are over 25 STD that have become diseases to be concerned about. Parents today have not quite gotten the fact that if their kids are involved sexually they're in a world of disease that's much more dangerous than it was for them back when they were younger.
POV: What is your position on abstinence-only, abstinence-plus and comprehensive sex education in America's high schools? What type of sexuality education would you recommend?
McIlhaney: Our thought is that what we should have programs that work. I won't just say any program that works, because that program has to be evaluated in different ways. But the first and the fundamental issue is, does a program work? For example, if I was talking to Shelby, I'd say, "Okay Shelby, now I know that you mean well" — and I believe she does, from what you've described and from what I've read about the movie — "Now I want you send me a program, a model of a program or a curriculum, that has shown an appreciable decline in STD rates and non-marital pregnancy rates, since that's what you want."
That being said, what she'll find is that comprehensive sex-ed programs, are not among the [programs] that have ever lowered HIV rates, STD rates or non-marital pregnancy rates — except for one program in New York (Children's Aid Society-Carrera), which did it by becoming basically mothers to the girls in the program there. This program was able to get the girls in to get their Depro-Provera shots every three months. That's the only program that's lowered pregnancy rates in the country that's based on a comprehensive approach, the kind of thing that [Shelby's] advocating.
So what we say and what I believe is that if that's so and those are the programs that have had the majority of the money, the best teachers, the best curriculum writers, the best researchers for years, is that they basically have all failed. In fact, most of them haven't even measured the pregnancy rates and STD rates. And if that's so then it's only good wisdom to try something different. And the obvious other direction to go is in the direction of abstinence education.
We don't like the term abstinence-only because we believe it's a pejorative term. It's sort of saying, "Well, these are just stupid programs that are denying kids information." Well, that's just flat out not true. If you look at most of the new abstinence education programs, they're actually more comprehensive than most of the comprehensive programs are as far as the information they provide.
POV: We interviewed Dr. Douglas Kirby and he said that he feels that there haven't been enough studies of abstinence-only, or abstinence, programs to know whether they work. Would you agree with him?
McIlhaney: There are two [studies] that have been published in peer-reviewed literature and there's another one coming out about the Best Friends program — it's been accepted by a peer-reviewed journal [Adolescent & Family Health] and it will be coming out pretty soon. [See related links.] There's a program in a county in Georgia that has had a 47% decrease incidence of sexual intercourse among the kids and a program in Amarillo, Texas that has had a measurable decline in pregnancies. So there are abstinence programs that are beginning to show some real appreciable impact, an impact that has never been shown by comprehensive sex ed programs. And I think we need an open mind to see what these programs actually show us.
POV: Dr. Kirby's study, Emerging Answers concluded that several comprehensive sex ed programs had a positive impact on teen behavior. What would be your response to that?
McIlhaney: Well, anyone can set their own standards for what they want to look at, which is what he did. There are lots of other ways to evaluate than the evaluation standards that he set. He set good high standards but the particular design of the program or the evaluation that he was looking at, there are other types of evaluations that are equally legitimate that he ignored.
POV: What do you consider to be appropriate evaluation standards? In other words, by what standards would you assert that a program is successful? What would be your standards?
McIlhaney: Appreciable and practical declines in pregnancy rates. Most of the time, sex ed programs are brought in because prgnancy rates are too high and STD rates are too high. I would like to see appreciable declines in teen pregnancies, the number of kids with STDs, and also a decline in the number of kids having sexual activity, so that a parent can say, "they told me the pregnancy rates are too high here. I can send my girl or my son to this rogram and be fairly well assured that they will have a good chance of not getting involved sexually and not getting pregnant or not getting a disease."
POV: How would you define an "appreciable decline"?
McIlhaney: Okay, I would say where you see a 50 percent drop in pregnancy and disease. And I would think ultimately the goal for all of us in this country ought to be an 80 percent decline. I think that's achievable, but it would only happen in a community where the whole community surrounds the children and their families to support those choices.
For instance, there's a program that was done in Denmark, South Carolina that was funded by the Office of Adolescent Pregnancy Prevention, the OAPP, by a guy that was a comprehensive sex ed-oriented person, Murray Vincent, but because OAPP was an abstinence program, he saw a pot of money and designed a program that was abstinence-based. Now, Dr. Kirby denies that it was an abstinence program because there was a nurse in the high school that was recommending condoms and giving out condoms but he personally told me way back in the early days of our argument about this that he didn't really think it made any difference whether she was there or not in his eventual outcome because pregnancy rates weren't going down until he came in with his program.
Vincent's program is a program of the kind that I would advocate, that I would say is probably going to be the most successful. He got a whole community — the churches, the newspapers, the healthcare providers, the teachers and the parents — all on board with saying to young people, "You should not be having sex as a young person — as a young unmarried person. You just shouldn't be doing that." And that was the message in the whole half of the county where he did his program. Everybody got on board. The instance in pregnancy in that part of the county dropped dramatically in comparison to the other half of the county and to the counties that were surrounding. So as an organization, we believe that the solution to this is where everybody in a community — and perhaps even everybody in the whole country — is associating sexual behavior with risk behavior for kids, as they should.
I don't know if you're familiar with the fact that when kids are involved in one risk behavior, they're more likely to be involved in other risk behaviors. There are good studies that show this. The risk behavior that is the most risky for the most kids right now is sexual behavior. Yet, when communities are talking about risk behavior it's so easy for them to leave the sexual behavior out and only track drugs or tobacco use or violence. We believe that the data's pretty clear that until all the risk behaviors are being impacted, including sex for kids, that we're really not going to have success with all the other behaviors.
POV: I'd like to follow up on your comments about "abstinence programs being more comprehensive" than comprehensive programs. What do you mean by that?
McIlhaney: I think the first thing is that there is a misunderstanding about the funding for — for example, the Title Five programs — that are federally funded programs. That is, that they can't talk about contraceptives. They can talk about them, which means telling people what they are and how they work. It's just that they can't promote them. But, and I think this is appropriate personally, they are to tell people the true failure rates of them. And there is absolutely no evidence that telling young people the failure rates of condoms and contraceptives causes them not to use them. [Critics] will say that if you tell them that they won't work, then they won't use them. Well, there is no data to show that at all.
We have not seen, as a matter of fact, a single comprehensive sex ed program that gives accurate data about the effectiveness of condoms and the failure rates of condoms. That is where I think that the abstinence programs are more comprehensive than the comprehensive programs, because they are actually more truthful. The kids need to know what they can and cannot expect from condoms. As a matter of fact, it's real easy to tell. That's what's so confusing about it when they won't do it. If condoms are used 100% of the time, condoms reduce the risk of HIV by 85%. If they are used 100% of the time they reduce the risk of common diseases for kids, for example, herpes and syphilis and gonorrhea and chlamydia by about 50%. And as far as HPV goes, there is no evidence that condoms reduce the risk of HPV infection at all. It is the most common viral infection. There is one study that came out last year that showed there is some decreased incidence of HPV for guys, but it is only a study. Most studies show no decreased risk of infection from HPV even when condoms are used every single time.
Except for herpes and HIV, if condoms are not used 100% of the time, there is no evidence that they provide any risk reduction at all for things like chlamydia — which is, for a reproductive medicine guy like I am, the most horrendous disease a woman can get, because it is what is associated so much in fertility. STD are the most common reason for infertility in America today.
And by the way, most of those studies on condoms were only carried out for a year or two. So if a kid at 16 starts having sex, they usually are not going to stop. They'll then have sex, you know, off and on for the next few years, of which, as time goes by, there probably is a higher failure rate of condoms in college as young adults if they continue the sexual behavior.
We really do have this epidemic. So we believe that for their best health, young people shouldn't be involved sexually. It's just like we recommend that they not be using drugs. And that, obviously applying to the homosexual youth too, that they shouldn't be involved sexually either as far as their health is concerned. We're talking pure health, not morals or values here, but just as far as their health is concerned.
POV: What advice would you give to parents?
McIlhaney: Well, first I would want them to be aware of how much disease there is among the adolescent population. If your kid starts getting sexually involved, among that group of kids that are doing that, there is a lot of disease and the child probably will ultimately get infected with one of these things.
Most kids do not even know what the values of their parents are or what is expected of them in the area of risky behavior. They pretty well know it about tobacco and drugs, but they don't know it about sex. It's just as important for parents to communicate their values about this. Parents need to make clear what they expect the kids to do and not do in this area.
The Adolescent Health Study — the biggest study ever done on adolescent behavior in America — showed that kids who are most likely to avoid risky behaviors, were those who had a good connectiveness with their parents. And connectiveness was defined very clearly. The fact that the parents were there when the kids got up in the morning, they were there when they came home from school, they were there with them for meals in the evening and they were there when they went to bed.
So I would advocate that parents do that with their kids. Be there with them. Communicate your values and what you expect, and then support your kids in making good decisions. Then applaud them.
Joe S. McIlhaney, Jr., MD, is a board-certified obstetrician/gynecologist who resides in Austin, Texas, with his wife, Marion. In 1995, he left his private practice of 28 years to devote his full-time attention to working with the Medical Institute for Sexual Health, a non-profit medical/educational research organization he established in 1992. In December 2001 Dr. McIlhaney was appointed to the Presidential Advisory Council on HIV/AIDS, and he is currently serving as an active participant.