HANDOUT for OPPOSITION to HB 1178 and SB 5314 (revised)
Prepared by:
Sharon Quick, MD, FAAP
Assistant Clinical Professor
University of Washington School of Medicine
Member of American College of Pediatricians, ASA, AAP, CMDA
Email: quicksm@u.washington.edu
SUMMARY:
DISCUSSION (numbers correspond to summary points above):
1. There are a couple ways in which the term “medically accurate” can be interpreted. In a broad sense it describes something as being medically sound and not containing misinformation. Kids are bombarded every day from every direction—television, radio, internet, magazines and interaction with their friends—about the subject of sex. Much of that information is erroneous and dangerous to their health. As a pediatrician I strongly support providing them with information that is current and medically sound.
The term “medically accurate” is also used in a more technical way. Scientists describe whether a particular research study was valid—was the analysis, reporting and use of data in accordance with objective scientific methods? Are the conclusions replicable and has this been demonstrated by other studies? Are there conflicting studies? Sometimes the research points to a clear stand on an issue. For example, Thalidomide taken by pregnant women has a definite association with limb reduction of her child in utero, and no physician would recommend that drug to a pregnant patient.
Other times, the results of studies are not conclusive, as is the case of some of the medical literature relevant to sex education. The interpretation and analysis of these studies are further complicated by the influence of psychological, sociological and moral factors. “Medical accuracy” in Sec. 2, part (1) of this bill is defined more by the source of the information rather than by a full scientific evaluation of a study and related literature. Let me provide an example that might show how it could bear on the legislation at hand.
The American Psychological Association published an article in their scientific journal in which it was proposed that adult-child sex with a “willing” child should not be classified as abuse.1 According to the definition in this bill this study could be declared “medically accurate,” because it was published in a well-known professional organization’s peer-reviewed journal. However, there are other studies which have demonstrated opposing findings. The U.S. Congress unanimously denounced the authors’ conclusion in this study.2
While I respect the government of this state I am uneasy about giving it license to determine which studies should be emphasized in the sexual education of our children. Because interpretation and analysis of scientific studies in this field are subject to bias, an agenda could be advanced knowingly or unknowingly under the guise of this bill’s definition of “medical accuracy,” depending on the selected arbiter. I would rather see the curriculum-choosing process remain at the local level, where parents in conjunction with local health care professionals can have greater input in choosing their own source of sex education.
2. It is not scientifically accurate to quote studies that support one’s position and ignore similar studies with different results. House Bill 1178 is scientifically inaccurate in statements made under Sec. 1, parts (2) and (3). Not all studies looking at the outcomes of comprehensive sexuality education show positive changes in the behavior of teens, as implied in part (2) of this bill. While it is beyond the scope of this handout to give an exhaustive review of this topic, Dicenso et al3 and Kirby et al4 contain findings opposing the statement in part (2).
Sec. 1, part (3) proposes a causal relationship between sex education and both teen pregnancy rate and incidence of STDs that cannot be definitively supported by existing data. It is true that sex education is being provided in most schools and it is true that there has been a decline in the teen pregnancy rate, but whether the former has caused the latter to some degree cannot be determined with the data currently available. Increased abstinence and increased use of contraception have been touted (in varying degrees) to account for the decline in the teen pregnancy rate,5 but there is no consistent relationship between sex education and those parameters in the literature. It is also unclear how much of an effect sex education has on reducing the incidence of STDs.
3. There is no consensus in the literature for effectiveness of either abstinence-only or comprehensive sex education on outcome measures of pregnancy and STDs. Many abstinence programs stress relationships and self-esteem issues which are vital to helping teens cope with pressure to become involved in high-risk behaviors. There is at least one study showing that an abstinence-only program can decrease the percentage of students who are sexually active and decrease the numbers of sexual partners.6 An abstinence-only message must be provided as an option for school districts; this bill appears to eliminate that option by requiring curricula to include the “latest medical information that cite failure and success rates of condoms and other contraceptives in preventing pregnancy, AIDS, and other sexually transmitted diseases.” Who is going to decide how extensive this medical information must be? Will there be a mandate to instruct children on condom use and/or to provide condoms? Medical information and the decisions made from that data rapidly change. How often must “approved” curricula be updated? Can a school or a curriculum provider be held legally liable for providing medical information that is “out of date” and possibly dangerous to students?
4. Perhaps the greatest fallacy is that similar legislation (RCW 28A.230.070) has been enacted for the purpose of providing “medically accurate” HIV/AIDS curricula, but the law has effected censorship of curricula rather than medical accuracy. The office on AIDS under the auspices of the Department of Health (DOH) was deemed arbiter of “medical accuracy” of proposed HIV curricula. The criteria the DOH uses to ensure “medical accuracy” of curricula is derived from guidelines published by the Center for Disease Control (CDC) in 1988.7 The CDC has not published a more current version of these guidelines. Medically inaccurate information was found upon perusal of two different DOH-approved curricula:
KNOW8
1. Curriculum says: Nonoxynol-9 spermicide is recommended in addition to condoms to decrease the risk of HIV.
Reality: Nonoxynol-9 is no longer recommended for this purpose. Recent studies have found this spermicide to be ineffective in providing any protection against gonorrhea, chlamydia, or HIV.9 Nonoxynol-9 has been found to be associated with a slight increase in genital ulcers in one study,10 and frequent use of this product may result in genital inflammation which can actually increase a woman’s susceptibility to becoming infected with HIV.11 At the time this curriculum was written, the data was not as definitive as it is now.
NOTE: The WA State DOH continues to recommend use of latex condoms and spermicide with Nonoxynol-9 on a printable pamphlet found on their website. See Appendix. If the WA State DOH cannot keep up to date, can they be expected to supervise curricula for “accuracy”?
2. Curriculum: Correct and consistent use of latex condoms is said to prevent chlamydia, gonorrhea, hepatitis B, syphilis, trichomoniasis, and bacterial vaginosis.
Reality: Correct and consistent use of latex condoms will at most reduce the risk of some of these diseases to various degrees. The most current research does not show that Trichomonas vaginalis or human papillomavirus (HPV) transmission is reduced even with 100% condom use. There may, however, be some reduction in the risk of genital warts in men and cervical neoplasia in women (both associated with HPV) provided by condom use.12, 13
11/12 F.L.A.S.H.14 –Quite a few inaccurate or misleading items discovered; only those pertaining to HIV education are mentioned here:
1. Curriculum: Dental dam recommended to “cover the labia and clitoris or the anus during oral sex…..a condom can also be cut to form a dental dam.” (p. 259) On p. 276 an illustration of cutting a condom to make a dental dam is shown.
Reality: There is no data to support the safety or effectiveness of dental dams or cut condoms for oral sex and these techniques should not be recommended in any curriculum. A search on 1/27/03 on PubMed for “dental dam and contraception” yielded 0 results. A search on the same site for “dental dam” yielded 404 entries, none of which related to the use described above. The FDA states under Sec. 872.6300 that the classification of a rubber dam “does not include devices intended for use in preventing transmission of sexually transmitted diseases through oral sex.” Likewise a search on 1/29/03 on PubMed for “condoms” and a few other terms revealed no studies on the effectiveness of cut condoms for oral sex, nor was approval for use of cut condoms found on perusal of the FDA’s website.
2. Curriculum: Page 355 shows 3 definitions of sexual abstinence. #3 is defined as no vaginal, oral, or anal intercourse but sexual touch to orgasm is included. On page 258 an example is given of a teen couple who have been sharing genital touch without oral, anal, or vaginal intercourse. The text states that there is only a remote chance, if one had cuts or sores on his or her hands which were contaminated by semen, vaginal fluid or menstrual blood, of acquiring HIV. It goes on to say that “most physicians would tell them not to worry.”
Reality: Genital touch without any type of intercourse is NOT abstinence because transmission of STDs can occur. The teens mentioned in the example may have only a small chance of acquiring HIV, but the risk of becoming infected with other STDs (syphilis, herpes, hepatitis B, HPV, etc.) remains. This type of behavior is not healthy for an unmarried couple. There is evidence that infection with some STDs can increase the risk of acquiring HIV infection; the authors of one study stressed the need for HIV containment strategies to be promoted in conjunction with containment programs for other STDs.15
If both approved and (presumably) not approved curricula have inaccuracies, then this law has only served to CENSOR curricula. The proposed bill may produce similar results.
REFERENCES
1. Rind B, Tromovitch P, Bauserman R. A meta-analytic examination of assumed properties of child sexual abuse using college samples. Psychol Bull. Jul 1998;124(1):22-53.
2. H. Con. Res. 107; 1999.
3. DiCenso A, Guyatt G, Willan A, Griffith L. Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials. Bmj. Jun 15 2002;324(7351):1426.
4. Kirby D, Brener ND, Brown NL, Peterfreund N, Hillard P, Harrist R. The impact of condom availability [correction of distribution] in Seattle schools on sexual behavior and condom use. Am J Public Health. Feb 1999;89(2):182-187.
5. Mohn JK, Tingle LR, Finger R. An Analysis of the Causes of the Decline in Non-marital Birth and Pregnancy Rates for Teens from 1991 to 1995. Adolescent and Family Health. In press 2003.
6. Shuey DA, Babishangire BB, Omiat S, Bagarukayo H. Increased sexual abstinence among in-school adolescents as a result of school health education in Soroti district, Uganda. Health Educ Res. Jun 1999;14(3):411-419.
7. Guidelines for effective school health education to prevent the spread of AIDS. MMWR Morb Mortal Wkly Rep. Jan 29 1988;37 Suppl 2:1-14.
8. OSPI. KNOW HIV/STD Prevention Curriculum; July 1997.
9. CDC. Nonoxynol-9 spermicide contraception use--United States, 1999. MMWR Morb Mortal Wkly Rep. May 10 2002;51(18):389-392.
10. CDC. CDC Recommendations for Preventing Sexual Transmission of HIV and other STDs. CDC Update. April 7 1997:2.
11. Nieburg P. Open Letter from the CDC, National Center for HIV, STD, and TB prevention April 23 1997.
12. National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services. Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention July 20 2000.
13. Fitch JT, McIlhaney JS, Adam MB, Hager WD, Zanga JR. Sex, Condoms and STDs: What We Now Know: The Medical Institute for Sexual Health; 2002.
14. Reis E. Family Life and Sexual Health for Grades 11 & 12; 1992.
15. Beck EJ, Mandalia S, Leonard K, Griffith RJ, Harris JR, Miller DL. Case-control study of sexually transmitted diseases as cofactors for HIV-1 transmission. Int J STD AIDS. Jan-Feb 1996;7(1):34-38.