Abstinence and Teenagers: Prevention Counseling Practices of Health Care Providers Serving High-Risk Patients in the United States

Although the average age at first intercourse in the United States, at 17, is similar to that in other industrialized countries, U.S. rates of teenage pregnancy and STD are significantly higher and contraceptive use far lower than in those other nations.1,2 The U.S. government has promoted abstinence-only sex education programs for adolescents, which teach abstinence as the only way to prevent pregnancy and HIV and other STDs. A series of legislative and funding mechanisms in the past 15 years has supported abstinence-only education over comprehensive sexuality and contraceptive education, and a growing proportion of adolescents have received abstinence-only education.3,4 The newly signed health care reform law allocates $75 million for evidence-based sex education programs, and more than three times more, $250 million, for abstinence-only-until-marriage programs for teenagers.5 However, several rigorous studies have proven abstinence-only education to be ineffective at reducing sexual risk behaviors and outcomes, although one recent study did show some effect for young students in sixth and seventh grade.6–9 The scientific literature has also shown that a more comprehensive approach to educating adolescents about sexuality, which includes dispensing condoms and contraceptives, is superior to abstinence-only education at reducing sexual risk behavior.10,11 Although abstinence-only policies reigned mainly in the educational realm, they have also extended into health care services over the past decade. Title × guidelines since 2004 have encouraged providers to teach adolescents abstinence until marriage in addition to contraception and safer sex practice options.3,12 Funding decisions on abstinence and policies on Title × guidelines, however, are under scrutiny.13 Health care providers play a valuable role in educating their patients, and accuracy and completeness of information are the accepted standards in medicine.14 Clinicians are held to professional standards involving medical and public health ethics, and are guided by professional health organizations. Guidelines in preventive medicine for HIV, other STDs and unintended pregnancy support the delivery of needed services, including counseling on condom and contraceptive use.15,16 Although recognition of evidence-based medicine has been increasing, wide variation exists in medical practices; often, the provider’s judgment is a component in determining patient care.17 Few studies have assessed the practices of health care providers regarding abstinence counseling for adolescents within the one-on-one patient visit, although results from a recent survey of pediatricians show that 62% discuss abstinence with adolescent patients at preventive care visits.18 Abstinence-only counseling is a charged topic in policy and health funding settings, and to understand the public health implications, it is important to examine how health care providers approach it in serving teenagers who are at the highest risk of unintended pregnancy and HIV and other STDs. The objectives of this study were to gather qualitative data on provider perspectives on such patients’ needs, and on whether, when and with which patients they discuss abstinence. We also looked at the content, context and framing of this topic within the visit. We tried to understand the meaning and utility of abstinence counseling for health care providers in serving their patients, as well as the role of professional judgment and scientific evidence in guiding provider practices in this area.