HIV You Can Live Without It

In Waco, Texas, a young African-American approached a health fair booth with the serious question, “Is it true that all Blacks will get AIDS?” He believed that AIDS is inevitable. There was a time in the HIV/AIDS epidemic that health care workers consoled themselves with the refrain, “As soon as everyone knows someone with AIDS, behaviors will change.” Actually worldwide, most everyone knows someone who has died of AIDS and behaviors have become more risky and the number of infected rises daily. If this young man and his peers believe AIDS is inevitable, they then ask, “why not behave recklessly? There is no future.” Racist rhetoric and dire statistical predictions paralyze young people rather than assisting them in making wise choices. (Misunderstanding may be even greater in foreign countries with language barriers.) Ugandans use four or five different languages.[1] For example, in Uganda, there is one traditional health practitioners for every 200-400 people, whereas the availability of trained medical personnel is typically one per 20,000 people.[2]

Where did this young man get his fearful information? From health care workers who wanted to scare him into using condoms. Health care workers in his community couldn’t believe that this handsome young man was a virgin and he said, “I want to remain pure until I get married.” They had no hope that he could control his physical urges to have sexual intercourse. Their advice to him was to wear a condom - but would they?

Training for medical professionals is to always use universal precautions – [3]wearing protective covering when contacting body fluids. “Save sex” defies all their advice to this young man.

The medical profession knows how to take care of themselves. Health care workers use universal precautions. These universal precautions[4]require wearing protective hats, goggles, masks, gown, foot covering and gloves. Yet, some medical professionals tell their sexually active patients its okay to get naked, put on one thin condom and engage in complete body contact, which includes contact with various body fluids.

The medical profession has carefully evaluated their actions and the consequences of their actions. Medical professionals undoubtedly are more frequently exposed to HIV contaminated fluids than this young man and they DO NOT consider HIV an inevitable consequence.[5] They recommend more protection for themselves, than for their young sexually active patients.

Conference of Professional Condom Promoters

Text Box: ü Knowledge
ü Hope
ü Responsible Behavior

When asked, “if you knew a person was HIV-positive would you knowingly have sexual contact with that person if you were protected with a condom?” One hundred percent of the health care providers adamantly responded, “No”. Yet, in the face of drastic consequences, public policy continues to recommend the limited “protection” provided by a condom. Health care workers arm themselves with knowledge about the modes of transmission to enable wise decisions. Hope motivates reasonable behavior and sets a responsible standard of behavior. Very few health workers contract HIV from contact with patients. However, for some minority populations who do risky behaviors, health care workers have a different prevention strategy. Since, “You cannot control your behavior, the best protection you can have is a small thin piece of latex a condom.”

The irony is that these very same uncontrollable humans are expected to consistently control their behavior as they use condoms effectively each and every time.[6]

I travel to train parents and teachers to talk to young people about relationships and responsible sexual behavior. The troubling stories I hear range from the young African-American in Texas to the African pastor in Johannesburg, South Africa who thinks his guest speaker from the UN is teaching premarital abstinence but instead is teaching condoms to his young members. It is equally as alarming as what Dr. Margaret Ongala, the health officer for Kenya, said. She pleadingly told me that even if a cure for HIV were found today it would take one hundred years to replace the resource of people lost to the epidemic. As well as the 14-year-old Idaho boy who sat next to a doctor on a ski lift at a resort, who asked, “Tell me the truth, do condoms work against AIDS? Am I still at risk if I use one?” The policies have to follow the truthful answers.

This article is a cry for consistency so that this generation can live without HIV. Condoms fail for a number of reasons, construction flaws, improper use, temperature and an increase in sexual partners.

ü The FDA allows defect rates of 4 per 1000[7] to be marketed as if they were high quality products. Although this sounds low, it may not be if you get the defective condom while engaging in sexual contact with an HIV infected person

Latex may have microscopic voids or holes, which may allow the passage of bacteria and viruses that are smaller than sperm a way of escape.

The failure rate for condoms (breakage or slippage rate) is higher than most people think. During vaginal intercourse condoms have been reported to break or slip off 14.6%[8] of the time, and a large family planning clinic found that 52% of respondents had experienced condoms bursting or slipping off in the previous three months.[9] Between male homosexuals, condoms have been shown to break/slip 7.3%[10], 8%[11], and 25.5%[12] of the time.

Condoms fail to protect when they break or slip off. Failure most often occurs when used by couples that are young, less experienced, or in those who are not cohabiting.

•Failure rates for adults who are experienced and/or mutually monogamous are 1.3%,[15] 1.9%,[16]6.7%,[17] 7.4%,[18] 8%,[19] 10.1%,[20] 11.7%,[21]12.9%,[22] and 15.1%.[23]

•When one partner had limited experience; condoms failed 6.9%[24] and 14.8% of the time.[25]

•In one study in non-cohabiting couples ages 13 to 17; condoms failed 11.5% of the time.[26]

Condoms Fail Because of Temperature

Condoms shipped to locations with hot climates must use temperature controlled shipping and storage or the condoms have even higher failure rates. They are to be stored at room temperature, 65 to 85 F degrees.[27] Most countries have temperatures ranges well beyond these limits.

Adolescent males appear to report substantially higher rates of condom use than do adolescent females. Although the 1997 Youth Risk Behavior Survey asserts that 63% of high school males report using a condom at last intercourse, only 51% of girls reported that a condom was used.[28] Given the differences in reporting between males and females, it is likely that other rates of condom use reported by males may be overestimated.

Condoms fail for adults because of familiarity in relationships. According to Ku et al only 38.9 percent of 19 year olds reported consistent use of condoms.[29][30]

Cohabitation Increases The Number Of Lifetime Partners

Dating relationships vs. marriage relationships increase the number of partners. Cohabitation increases marriage failures, which increases the potential number of partners. Increased numbers of sexual partners increases the exposure to sexual transmitted diseases including HIV. The more STD’s a person has had the more likely that the person will contract HIV. This is especially true for women under the age of 20 or prior to childbearing.[31]

Condoms Fail Because of the Immaturity of Teens and especially because of their Inconsistent Use

Teens are ineffective at using condoms each and every time for a variety of reasons.

– Casual relationships often don’t display the mutual concern for the other partner necessary for consistent use. This is the reason that contraceptive use of all kinds becomes erratic in casual relationships.

– However, as the relationship becomes more stable, couples are less likely to use a condom.[32]

– Singles have sexual intercourse in a variety of places so supplies and consistency are lacking.

– Inconsistency is a hallmark of irresponsible adults and many youth who engage in sexual activity for recreation.

– Myths about usage, amount of pleasure and levels of commitment and intimacy in relationships abound.[33]

If these individuals can’t control their sexual urges how can they be expected to control their urges long enough to obtain, carefully store and consistently use the condom?

Both condom promoters and premarital abstinence/marital fidelity promoters assume that human beings can be responsible for their bodily functions. Humans can control their urges and modify their behavior. The question is do policy makers believe that people can control their behavior --only long enough to use condoms. On the other hand, can people be expected to control their behavior in a societal context by abstaining until marriage and then maintain monogamous relationships within marriage? One prominent adolescent sexuality researcher has stated, “… it may actually be easier to delay the onset of intercourse than to increase contraceptive practice.”[34]

Premarital Abstinence and Marital Fidelity Are 100% Effective

Text Box: One prominent adolescent sexuality researcher has stated, “… it may actually be easier to delay the onset of intercourse than to increase contraceptive practice.” ? Douglas Kirby, a researcher for Planned Parenthood.”

Limiting the number of lifetime partners is a very effective prevention measure. Premarital abstinence and marital fidelity are 100% effective in preventing STD’s. Historically, cultures that expect abstinence/fidelity achieve higher levels of fidelity. Many youth who abstained during early teens become sexually active at older ages because of societal expectation to engage in sexual activity. The closer a young person gets to marriage the more likely he or she will have intercourse and society seems to condone this. Several years ago, most societies condemned this. Unfortunately, over half of all engagements are broken. This is the reason that marriage must be the standard for sexual behavior not merely monogamous relationships.[35]

The younger the age at first intercourse is associated with a greater number of partners.

Weigh the Choices

Volumes could be written about the advantages that abstinence and fidelity provides to society. Marriage increases life expectancy, sexual happiness and overall health. [39]

Advantages of Abstinence

Freedom from Pregnancy

Out of wedlock pregnancy

Abstaining teens are responsible for reducing the rates of pregnancy for all teens. Yet, even though sexually active youth used more condoms they experienced higher rates of out-of-wedlock pregnancy and STD’s. In 1996, only 40 percent of all unmarried American adults used a condom at last intercourse, and surprisingly, only 60 percent of people at high risk for HIV reported using a condom the last time they had intercourse outside of an ongoing relationship.[40]

Marital pregnancy

Public health officials generally accept a 10% annual pregnancy for couples who use condoms. Condoms worked better for married women than for their single teen counterparts. Unmarried women had an 18% failure rate per year. Condoms allowed pregnancy to occur for married women 11% annually. [41]

Freedom from Sexually Transmitted Diseases

According to the Guttmacher Institute, condom use has increased in the United States from 1988 to 1995 with the rates of usage being highest among teens aged 15-19 and younger women 20-25.[42] During the same time, rates of Chlamydia and gonorrhea have increased the most among the same age groups who used condoms the most.[43] Only two infections ‑ gonorrhea and HIV were reported to be reduced by the use of condoms. If an increase in the number of sexual partners occurs, the risk of infection increases even with the use of condoms.

Syphilis is transmitted by sores both in the genital region and in other skin areas. Of course, a condom does not cover other areas. The incidence of syphilis has risen with the increase of HIV. Syphilis unless treated satisfactorily can cause crippling and death especially to those with immune deficiencies.

Human Papilloma Virus (HPV) is an STD that is also spread by skin-to-skin contact. While condoms may reduce infection to the cervix they are not totally effective in the prevention of infection especially for genital warts or vulvar cancer. HPV is the cause for genital warts, cervical dysplasia and cervical cancer. In the US, more women die from cervical cancer than from HIV.[44]

Herpes Simplex is another virus, which is spread by skin-to-skin contact and can cause lifelong infection. The use of condoms may be ineffective in preventing the spread of this infection.

Hepatitis B is transmitted by body fluids especially semen, vaginal secretions and blood. Once again condoms may reduce but will not eliminate the transmission of the disease.

Freedom from the bother and dangers of pill, IUD, and other contraceptives[45]

The bother of using condoms is often cited as the reason not to use one. Since the condom is less effective than most other birth control devices, contraceptive users are told to use both the birth control method plus the condom to reduce exposure to disease – doubling the bother and expense.

Freedom from the pressure to marry before you're ready[46][47]

Sexual intercourse is the consummation of a commitment, even in subcultures where promiscuous behavior is prevalent. Pressure to marry stems from emotional expectations and social customs.

Freedom from abortion[48]

More than two-thirds of women seeking abortion were using contraceptives the month that they conceived.[49] The contraceptives were usually more effective than condoms. The availability and use of contraception has been shown to increase exposure and increases in the rate of unintended pregnancy. These unintended pregnancies are more likely to be aborted.

Akerlof and Murray argue that the increased availability of contraception and abortion meant that women could no longer hold the fear of pregnancy over their male partners, either to avoid sex or to elicit a promise of marriage in the event that pregnancy resulted from sexual intercourse.[50]

Freedom from the trauma of having to give your baby up for adoption

Condoms fail more often for unmarried couples making the occasion for adoption more prevalent. The adoption choice is cultural and economic but the emotions of the mother are real. She is at more risk of having to choose adoption while relying on a condom.

Freedom from exploitation of others[51]

All too often, women are coerced into sexual activity by men with the promise of protection by the use of a condom. “I’ll use a condom” is the pick-up line used since the news of AIDS broke in 1981. All too often condoms fail to protect these women. The greatest concern is the emotional consequences that impact young people in future relationships. Emotional consequences happen each and every time a sexual encounter occurs.

The truth is that abstinence-until-marriage protects, provides and is possible.

Freedom from guilt, doubt, disappointment, worry, rejection[52]

There is no condom to protect the heart. Sexual activity is about emotions that cannot be protected by a condom. Sexual activity always has an emotional consequence.

Freedom to be in control of your life

Emotional and social strings connected with sexual behavior extend beyond disease to impact the well being of families and societies. Among teens other health risk behaviors are associated with the onset of sexual activity, i.e., smoking, early alcohol abuse, illegal drug use, non-attendance at school and suicide.[53] The risks from these have life-long health consequences.

Freedom to experience fuller communication in relationships

Sexual intercourse often becomes a substitute for verbal intercourse. Getting to know someone before marriage increases the likelihood of success. Exploitative relationships or ones that lack long-term commitment impair personal growth and happiness. For young people, sexual activity often produces barriers to parent-teen communication. This communication barrier may hinder maturation and the achievement of educational goals.

Freedom to focus energy on establishing and realizing life goals

Preparing for sexual intercourse can become a pre-occupation. Especially, teens change their goals and commitment to high achievement with the onset of sexual activity. This negative impact is more serious among teen girls.

Freedom to develop respect for self

Condom education programs promote the value of being responsible and having high self-esteem but then declare that the reasons teens have sex is low self-esteem.

Freedom to have greater trust in marriage

Studies show, individuals who cohabit before they marry face a significantly higher chance of getting divorced. Estimates of this divorce risk range from 33%[54] to 48%[55].

Divorce - The presence of children is linked to a declining risk of divorce. In fact, each child a couple has reduces their risk of divorce by 20 percent[56]. Promotion of the use of condoms may bring justification to infidelity. Infidelity is the major cause of divorce. Divorce is the greatest cause of poverty for women and children.

Freedom to enjoy being a teenager, young person, a healthy citizen

Parents and teachers should be training young people about relationships and responsible sexual behavior. Their questions have to be honestly answered and the policies have to follow the truthful answers.

The truth is that responsibility demands the promotion of lifestyle practices that take individuals out of harm's way and have lifelong and societal benefits beyond reducing the incidence of AIDS. Policies that may increase the number of lifelong sexual partners have been shown to decrease condom usage and can be destructive to entire populations. These failed policies increase the number of widows and orphans.

“African quote”

Policy makers must decide whether to put their hopes in people being able to control their behavior or decide to place their confidence in condoms.

Solution -- continued condom failures or training for premarital abstinence and marital fidelity

Every parent wants his or her child to live without infection. Parents want to live to raise their child. Every major religion promotes abstinence prior to and fidelity to partners within marriage. Every government will benefit from reduced out of wedlock sexual activity and its consequences. Limiting the number of partners has a greater chance of reducing the incidence of infection than does the condom. These expectations lay in the hands of policymakers who can place their faith in condoms or people. Over time condoms can result in the annihilation of those who are sexually active with multiple partners. Can policymakers live with a 10 to 20 percent failure rate each year?[57]

A revolution may be necessary to restore societal values of marital fidelity and premarital abstinence in order to save humanity. The sexual codes that adopted sexual promiscuity have brought economic and health disasters for too families and nations.

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[1] CIA Facts Book http://www.odci.gov/cia/publications/factbook/geos/ug.html The World Factbook 2000.

In general, information available as of 1 January 2000 was used in the preparation of this edition.

The World Factbook is prepared by the Central Intelligence Agency for the use of US Government officials, and the style, format, coverage, and content are designed to meet their specific requirements.

[2] Bodeker G; A regional task force on traditional medicine and AIDS; Lancet Issue: April 8; 355(9211):1284.

[3] Centers for Disease Control and Prevention. 1997 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus. MMWR Morb Mortal Wkly Rep 1997 Jun 27;46(RR12):1-46. No abstract available.

[4] Centers for Disease Control and Prevention. Perspectives in Disease Prevention and Health Promotion Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings. MMWR Morb Mortal Wkly Rep 37(24): 377-388 Publication date: 06/24/1988.

[5] Centers for Disease Control and Prevention. Update: human immunodeficiency virus infections in health-care workers exposed to blood of infected patients. MMWR Morb Mortal Wkly Rep 1987;36:285-9.

[6] Sonenstein FL, Ku L, Lindberg L, Turner CF, Pleck JH. Change in sexual behavior and condom use among teenaged males: 1988 to 1995. Am J Public Health 1998;88:956-959. This study examines shifts in sexual experience and condom use among US teenaged males. The proportion of never-married 15-to 19-year-old males who had had sex with a female declined from 60% to 55% (P=.06). Although protective behaviors among teenagers have increased, significant proportions of teenagers—especially Black and Hispanic males—remain unprotected.

[7] Condoms and Sexually Transmitted Diseases…Especially AIDS Brochure, U.S. Food and Drug Administration — Center for Devices and Radiological Health: 6.

[8] Mok JQ, De Rossi A, et al. Infants born to mothers seropositive for human immunodeficiency virus. Lancet 1987 May 23;1(8543):1164.

[9] Mother-to-child transmission of HIV infection. The European collaborative study. Lancet 1988 Nov 5;2(8619):1039.

[10] Ades AE, Newell ML, et al. Children born to women with HIV-1 infection: natural history and risk of infection. European Collaborative Study. Lancet 1991;337:253.

[11] Ades AE, Newell ML, et al. Children born to women with HIV-1 infection: natural history and risk of infection. European Collaborative Study. Lancet 1991;337:253.

[12] Chiodo F, et al. Vertical transmission of HTLV-III. Lancet 1986 Mar 29:739.

[13] Albert AE, Hatcher RA, Trussell DJ, Bennett C. Condom use among female commercial sex workers in Nevada’s legal brothels. Am J Public Health 1995;85(11):1514-20.

[14] Rugpao S, Pruithithada N, et al. Condom breakage during commercial sex in Chiang Mai, Thailand. Contraception 1993;48(6):537.

[15] Boldsen JL, Jeune B, Madsen PC. Aspects of comfort and safety of condom. A study of two thousand intercourses among volunteer couples. Scand J Soc Med 1992;20(4):247-52.

[16] Trussell J, Warner DL, Hatcher R. Condom performance during vaginal intercourse: comparison of Trojan-Enz and Tactylon condoms. Contraception 1992;45(1):11.

[17] Russell-Brown P, Piedrahita C, et al. Comparison of condom breakage during human use with performance in laboratory testing. Contraception 1992;45(5):429.

[18] Trussell J, Warner DL, Hatcher R. Condom performance during vaginal intercourse: comparison of Trojan-Enz and Tactylon condoms. Contraception 1992;45(1):11.

[19] Richters J, Gerofi J, Donovan B. Why do condoms break or slip off in use? An exploratory study. Int J STD AIDS 1995;6(1):11.

[20] Russell-Brown P, Piedrahita C, et al. Comparison of condom breakage during human use with performance in laboratory testing. Contraception 1992;45(5):429.

[21] Richters J, Donovan B, Gerofi J. How often do condoms break or slip off in use? Int J STD AIDS 1993;4(2):90.

[22] Russell-Brown P, Piedrahita C, et al. Comparison of condom breakage during human use with performance in laboratory testing. Contraception 1992;45(5):429.

[23] Trussell J, Warner DL, Hatcher RA. Condom slippage and breakage rates. Fam Plan Persp 1992;24(1):20.

[24] Grady WR, Tanfer K. Condom breakage and slippage among men in the United States. Fam Plan Persp 1994;26(3):107.

[25] Sparrow MJ, Lavill K. Breakage and slippage of condoms in family planning clients. Contraception 1994;50(2):117.

[26] Steiner M, Piedrahita C, et al. Can condom users likely to experience condom failure be identified? Fam Plan Persp 1993; 25(5):220.

[27] Schellstede W P, Carter E J, Finger W J. The Latex Condom Recent Advances, Future Directions: Chapter 5, Standards, Specifications and Tests, chapter 5, Standards, Specifications and Tests, Copyright 1999, Family Health International. Available at http://www.fhi.org/en/fp/fpother/conom/conmon10.html.

[28] Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance-United States, 1997. MMWR Morb Mortal Wkly Rep 1998;47 (SS-3):1-92.

[29] Ku L, Sonenstein Fl, Pleck JH. The dynamics of young men’s condom use during and across relationships. Fam Plan Persp 1994;26:246-251. Though nearly 70% of 16-year-olds report consistent condom use, only 38.9 percent of 19-year-olds report the same.

[30] Sonenstein, et al. 1998. Other studies substantiate the observed decline in condom use with increasing age.

[31] Aral SO. Sexual behavior in sexually transmitted diseases research. An overview. Sex Transm Dis 1994;21(March-April Suppl):S 59-S 64.

[32] Ku L, Sonenstein Fl, Pleck JH. The dynamics of young men’s condom use during and across relationships. Fam Plan Persp 1994;26:246-251. Young men were more likely to have used a condom if they thought their partner was sexually inexperienced, and less likely to have done so if they suspected their partner was at high risk for an STD.

[33] Anderson JE, Wilson R, Doll L, Jones TS, Barker P. Condom use and HIV risk behaviors among U.S. adults: Data from a national survey. Fam Plan Persp 1999. Sixty-two percent of adults reported using a condom at last intercourse outside of an ongoing relationship, while only 19% reported using a condom when the most recent intercourse occurred within a steady relationship.

[34]Kirby D, Korpi M, Barth RP, Cagampang HH. The impact of a new curriculum on sexual risk-taking. Fam Plan Persp 1991;23:253-263.

[35] Waite L J, Gallagher M, The Case for Marriage: Why Married People Are Happier, Healthier, and Better Off Financially, Doubleday, 2000.

[36] Ho GYF, Bierman R, Beardsley L, Chang CJ, Burk RD. Natural history of cerviovaginal papillomavirus infections in young women. N Engl J Med 1998;338:423-428. Genital human papillomavirus (HPV) infection is highly prevalent in sexually active young women. An increased risk of HPV infection was significantly associated with younger age, Hispanic ethnicity, black race, an increased number of vaginal-sex partners, high frequencies of vaginal sex an alcohol consumption, anal sex, and certain characteristics of partners (regular partners having an increase number of lifetime partners and not being in school).

[37] Eng TR, Butler WT, eds. The Hidden Epidemic-Confronting Sexually Transmitted Diseases. Institute of Medicine. Washington, DC: National Academy Press; 1997. Book available online at http://bob.map.edu/html/epidemic/index/html#contents.

[38] National Center for Health Statistics. Fertility, family planning, and women’s health: New data from the 1995 National Survey of Family Growth. Vital Health Stat Series No. 23 (19). 1997.

[39]American Sociological Review. Vol. 58, 1993;210-232. Also, David B. Larson, James P. Swyers, and Susan S. Larson, The Costly Consequences of Divorce, National Institute for Healthcare Research, Rockville, Md., 1995;211-214.

[40] Anderson JE, Condom use and HIV risk behaviors among U.S. adults: Data from a national survey. Fam Plan Persp 1999.

[41] Fu H, Darroch JE, Haas T, Ranjit N. Contraceptive failure rates: New estimates from the 1995 National Survey of Family Growth. Fam Plan Persp 1999;Mar-Apr;31:56-63. In general, failure rates are highest among cohabiting and other unmarried women, among those with an annual family income below 20% of the federal poverty level, among Black and Hispanic women, among adolescent and among women in their 20s. For example, adolescent women who are not married but are cohabiting experience a failure rate of about 31% in the first year of contraceptive use.

[42] American Social Health Association. Sexually Transmitted Diseases in America: How Many Cases and at What Cost? Menlo Park, CA: Kaiser Family Foundation; 1998.

[43] Gaydos CA, Howell MR, Pare B, et al. Chlamydia trachomatis infections in female military recruits. N Engl J Med 1998;339:739-744.

[44] National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention.

http://www.cdc.gov/cancer/nbccedp/info-cc.htm, http://www.cdc.gov/mmwr/PDF/wk/mm4245.pdf

http://www3.cancer.org/cancerinfo/sitecenter.asp.

[45] Sexuality Commitment and Family, Potter and Roach, 1998, 271-272.

[46]SPECIALTY LAW - California Family Law, Bonds v. Bonds, S079760 Supreme Court of California, August 21, 2000, Citation not yet available http://mdeansutton.com/cpbonds.htm.

[47] http://www.divorcecoach.com/rightmate/preview.htm.

[48] Kost K, Forrest J. Intention status of U.S. births in 1988: Differences by mothers’ socioeconomic and demographic characteristics, Fam Plan Persp 1995;Jan-Feb;27:11-17. Although the level of unintended childbearing is high in almost all socioeconomic subgroups of women, the proportion of births that were mistimed or unwanted was 50% or more among age-groups 15-17 (78%), 18-19 (68%) and among never-married women (73%).

[49] Bankole A, Singh S, Haas T. Characteristics of women who obtain induced abortion: A worldwide review, Fam Plan Persp June 1999 Volume 25, Number 2.

[50] Does Marriage Really Make Men More Productive? The Journal of Human Resources 26-2:282-307; Akerlof GA. Men Without Children. The Economic Journal 1998;108:287-309.

[51] Schneider, JP M.D., Ph.D., Irons, R M.D. Addictive sexual disorders: Differential diagnosis and treatment. Primary Psychiatry 1998;April.

[52] Lickona, T. The Neglected Heart: The Emotional Dangers of Premature Sexual Involvement. American Educator 1994;Summer;34-39.

[53] The National Center on Addiction and Substance Abuse at Columbia University. Dangerous Liaisons: Substance Abuse and Sex. The Henry J. Kaiser Family Foundation, The Carnegie Corporation of New York. 1999. Teens who use illicit drugs are 5 times more likely to have sexual intercourse, teens who drink alcohol are 7 more likely to have sexual intercourse and teens who use alcohol are twice as likely to have had four or more sexual partners.

[54]Cherlin, AJ. Marriage, Divorce, Remarriage. Harvard University Press; 1992.

[55] Bumpass L, Sweet J. National estimates of cohabitation. Demography. 1989;24:615-625. AFDA Data Set No. 01-05 1988 National Survey of Families and Households, James Sweet, Larry Bumpass, and Vaughn Call. The National Survey of Families and Households 1988 is a national survey designed to look at the causes and consequences of changes in the American family and household structure. Bumpass and Sweet 1995 http://www.socio.com/srch/summary/afda/fam01-05.htm. When cohabitation is taken into account, about two-fifths of all women and 30% of all children are likely to spend some time in a stepfamily.

[56] Kaplan S, Lancaster, JB, Anderson, KG. Human Parental Investment and Fertility: The Life Histories of Men in Albuquerque. In: Booth, A and Crouter, A., eds. Men in Families, Mahwah, NJ: Lawrence Erlbaum Press; 1998. Fertility is linked to a declining risk of divorce. In fact, each child a couple has reduces their risk of divorce by 20 percent.

[57] Fu H, Darroch JE, Haas T, Ranjit N. Contraceptive failure rates: New estimates from the 1995 National Survey of Family Growth. Fam Plan Persp 1999;31:56-63. 13.9% for male condoms.