Statement of Joe S. McIlhaney, Jr., M.D., President, Medical Institute for Sexual Health, Austin, Texas
Testimony Before the Subcommittee on Human Resources
of the House Committee on Ways and Means
Hearing on Teen Pregnancy Prevention
November 15, 2001
Thank you, Chairman Herger and other distinguished members of this committee. I am a gynecologist who practiced clinical medicine for twenty-eight years. I had a rewarding practice of in-vitro fertilization, surgery, and healthcare for women. However, I left that practice in 1995 to spend the rest of my medical career helping women and men avoid the problems I saw every day -- problems that physicians today are seeing even more often. Those problems are non-marital pregnancy, sexually transmitted disease, and the emotional damage of inappropriate sexual behavior.
First, births to unmarried women. There were approximately 4 million births in the United States in 1999.1 Approximately 1/3 of those (1,300,000) were out-of-wedlock. Seventy percent of these were to women twenty years of age and older, but 50 percent were to mothers who were under age 20 when they bore their first child.2 These out-of-wedlock births are often disastrous for the mothers, for the children, and often for the fathers – but they are also disastrous for society. They affect poverty, child health, education, and crime.
The specific facts I will now cite come from an insightful new book, The Case for Marriage – Why Married People Are Happier, Healthier, and Better Off Financially.3
Poverty: In 1996, for example, 11.5% of children younger than 6 who lived in a married couple family were poor, compared to almost 59% of those living with a single mother.
Child health: For college-educated white mothers, being unmarried increases the risk that a baby will die by 50%.
Education: Living in a single-parent family approximately doubles the risk that a child will become a high school dropout – 29% vs. 13%.
Crime: Boys raised in single-parent homes are twice as likely to have committed a crime that leads to incarceration by the time they reach their early thirties than boys raised in the home of two biologic parents.
I could go on and on to show how dramatically the non-marital pregnancy problem has impacted almost every facet of society. We must dramatically reduce its occurrence. And we have made some progress with teen pregnancy. Prior to the government’s first legislation funding abstinence education, the Title XX program, teen pregnancy rates were skyrocketing. As a result of Title XX funding, by 1990 approximately 200 abstinence programs had been founded and implemented. Subsequently, in the early 1990s not just teen pregnancy rates, but also teen sexual activity rates began falling – together. These trends continue for teens and are most likely due in large part to abstinence promotion, which received a big boost from Title V funds made available through the welfare reform legislation of 1996.
The abstinence pledge movement is alive and well among teens and has had a powerful influence in helping them maintain a healthier lifestyle. Pledges by teens to remain abstinent have been proved by the ADD Health Study to be one of the biggest influences in a young person’s decision to delay the onset of sexual activity. ADD Health also shows that a surprisingly large number of adolescents have taken such a pledge – 10% of boys and 15% of girls. This movement was begun as the Southern Baptist True Love Waits Campaign in 1993. It has now spread to both religious and secular environments nationwide. Pledges were at first ridiculed by the scientific community – no more!
In addition to these national statistics there are studies accumulating of specific abstinence programs which are showing surprising success. These are both published and unpublished. The best known is Rowberry’s study of Best Friends. The most recent has been a report from the Monroe County, NY, Department of Health regarding the success of its Not Me, Not Now program.4 A Title XX program performed in rural South Carolina showed dramatic reduction in teen pregnancy in the 1980s.5 A Cleveland study recently showed a 2/3 drop in the onset of sexual activity of virgins and a return to abstinence by some sexually experienced students (unpublished). There are others.
Those who are attempting to discredit abstinence promotion efforts emphasize the fact that there are only a small number of studies of these programs. It is vital to remember two things about these efforts. Implementation of abstinence education is still relatively new. Additionally, it takes a lot of time, money, and expertise to evaluate abstinence promotion programs – money not made available until recently.
Let’s compare this to smoking. A brave Surgeon General in 1964 said smoking was harmful and that Americans should not smoke. No study of abstinence from smoking would have shown success in those early years. Now, thirty-seven years later, we know that adult smoking has dropped from 43% to 23%. We all praise this success. What we need to also remember about this is that smoking hardly ever hurts a teen while they are a teen – the cancer and emphysema do not usually happen for years. Sexual activity, however, often hurts teens while they are still teens with disease and/or pregnancy. We need to be as comfortable and intentional in urging them to be abstinent from sex as we are in urging their abstinence from cigarettes. And we need to be patient and unrelenting so efforts can mature.
There has been some success. Teen sexual activity has been decreasing since 1990. Today over 50 percent of students in high schools across the country are still virgins. During this same period of time teen birth rates have also declined to their lowest level in recent memory.
The chart “Out of Wedlock Birth Rates, 1980-1999” clearly suggests that abstinence efforts have played a major role in this healthy trend. Almost all efforts to encourage sexual abstinence, particularly Title XX and Title V, have been directed toward teens and, as the chart shows, that is the group in which out-of-wedlock birth rates have fallen. If these decreased birth rates were primarily due to increased contraceptive use, birth rates among unmarried women in their 20s should also have fallen because undoubtedly these groups go to the same healthcare providers and have equal access to contraceptives. It was only the age group on which abstinence efforts have been focused that has experienced not only reduced pregnancy rates, but also reduced rates of sexual activity.
This information makes it clear that Congress was wise in including Title V funding for abstinence promotion in its 1996 welfare reform legislation. The success being shown by studies of abstinence efforts, regardless of criticism of the strength of those studies, is the first beam of light showing us the way out of the dark tunnel of not only teen pregnancy, but also out-of-wedlock pregnancy for all age groups.
The goals of Title V legislation encourage adolescents to remain abstinent until marriage and TANF legislation emphasizes marriage by stating in three of its four goals, and I quote:
“2. To end the dependence of needy parents on government benefits by promoting job preparation, work, and marriage.
3. To prevent and reduce the incidence of out-of-wedlock pregnancies and establish numerical goals for preventing and reducing the incidence of these pregnancies.
4. To encourage the formation and maintenance of two-parent families.”
These messages from America’s political leadership are powerful and influential. I believe it is vital that Congress continue to help America by reauthorizing TANF and Title V abstinence efforts and also funding ongoing evaluation. Efforts to support, strengthen, and promote marriage are evolving and efforts to encourage sexual activity in only that environment are maturing. Evidence suggests these will result in greater health for all. Studies are necessary to encourage continued improvement of such efforts and to learn which are most effective for different communities.
It is of great importance to note that there is a major problem which is often conveniently and disastrously overlooked in discussions about out-of-wedlock pregnancy. That is the epidemic of sexually transmitted disease. When I gave testimony before this same committee in 1996, I highlighted those problems, and they are still with us.
Specific examples tear at our hearts.
1. In a recent study of women receiving routine gynecologic care in New Mexico, 50 percent of sexually active women between the ages of 18 and 22 were infected with human papillomavirus (HPV), the virus that causes 99 percent of all cervical cancer.9 Only a tiny fraction will get cancer, but will one of these be your daughter? And, between 4,000 and 5,000 American women a year are dying from this disease – more than die of AIDS.
2. One in five Americans 12 years old and older is infected with genital herpes,10 a disease from which many suffer painful recurrences and emotional distress.
3. Approximately 6% of teenaged females attending family planning clinics are infected with chlamydia. Most have no symptoms and yet this infection can cause them to become sterile if untreated.11
When I started practice in 1968, there were two major sexually transmitted diseases that worried us. Now there are over twenty-five such diseases and many more people infected. In the 1960s 1-in-47 sexually active teens was infected with an STD. Now it is 1-in-4.12
The reason we must include the problem of sexually transmitted disease when we talk about out-of-wedlock pregnancy is that the same risky behaviors are responsible for both. But the contraceptive techniques most reliable for preventing pregnancy, DepoProvera and oral contraceptives, provide no protection from STD transmission. So we therefore must not focus our efforts on reducing pregnancy alone. We must include reducing STD also.
The obvious question then is “Don’t condoms make sex safe enough?” A major NIH panel considered the world’s data about this subject. The report was published this year. This scientific panel found the following: If used 100 percent of the time, condoms reduce the risk of HIV by 85% and of gonorrhea for men by 47% to 75%. However, for the most common STD (HPV) they provide no protection from infection. For the other diseases there is just not enough data to say whether protection is provided by condoms or not.
Unfortunately, sex is sexist. It hurts women far more than it does men. I invite you to look at the diseases a moment.
In summary, all this information, in my opinion, provides credible scientific evidence showing the wisdom of Congress in passing TANF legislation and including its emphasis on two-parent families and marriage. This information also provides data showing the wisdom of including in Title V legislation funding for teaching adolescents that they should reserve sex for marriage. This is not just a moral or religious issue. Many aspects of marriage, including its very formation and dissolution, are regulated as civil matters by secular government.
For the health of individuals and of all society we need to emphasize marriage as the core issue for society and as the ultimate answer for these health problems plaguing our country and other countries around the world. A major step in accomplishing this is TANF reauthorization with additional TANF funds being earmarked for abstinence and marriage efforts which are not limited solely to the adolescent age group. In addition, TANF bonus money for decreasing out-of-wedlock pregnancies should be restricted to use for abstinence and marriage promotion, the efforts by which those states obtained the money in the first place.
Finally, Title V funds for abstinence education should not only be continued but increased. If these steps are not taken, there is significant danger that the promising trends of decreasing sexual activity and decreasing teenage pregnancies will reverse. In addition, if funds are not made available for promoting marriage and sexual abstinence until marriage for single people in their 20s, that group will continue to suffer. We need a cultural transformation regarding sexual activity for the protection of all of society. You as leaders can play a huge role in this happening.
2. Ventura SJ, Bachrach CA. Non-marital childbearing in the United States, 1940-99. National vital statistics reports; vol. 48, no. 16. Hyattsville, Maryland: National Center for Health Statistics. 2000.
3. Waite LJ, Gallagher M. The Case for Marriage: Why Married People Are Happier, Healthier, and Better Off Financially. New York: Doubleday, 2000.
4. Doniger A, Adams E, Utter C, et al. Impact evaluation of the Not Me, Not Now abstinence-oriented, adolescent pregnancy prevention communications program, Monroe County, New York. J of Health Comm. 2001; 6:45-60.
5. Vincent ML, Clearie AF, Schluchter MD. Reducing adolescent pregnancy through school and community-based education. JAMA. 1987;257:3382-3386.
6. Centers for Disease Control and Prevention. CDC Surveillance Summaries, June 9, 2000. MMWR 2000;49 (No. SS-5).
7. Mann J, McIlhaney JS, Stine CS. Building Healthy Futures, The Medical Institute for Sexual Health, 2000.
8. American Social Health Association. Sexually Transmitted Diseases in America: How Many Cases and at What Cost? Menlo Park, CA: Kaiser Family Foundation; 1998.
9. Peyton CL, Gravitt PE, Hunt WC, Hundley RS, Zhao M, Apple RJ, Wheeler CM. Determinants of genital human papillomavirus detection in a US population. J Infect Dis. 2001;183:1554-64.
10. Fleming DT, McQuillan GM, Johnson RE, et al. Herpes simplex virus type 2 in the United States, 1976 to 1994. N Engl J Med. 1997;337:1105-1111.
11. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2000. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2001.
12. Institute of Medicine. The Hidden Epidemic, Confronting Sexually Transmitted Diseases. Washington, D.C.: National Academy Press, 1997.