Joe S. McIlhaney is a board-certified OB/GYN and a member of the Presidential Advisory Council on HIV/AIDS. In 1995, he left his private practice to work with the Medical Institute for Sexual Health, a pro-abstinence medical research organization he established in 1992.

Excerpted from a longer interview by P.O.V. in conjunction with their documentary The Education of Shelby Knox. The film chronicles the debate in a conservative Christian town over sex education in its public schools.

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?

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.

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?

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 and it will be coming out pretty soon. 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.

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?

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.

By what standards would you assert that a program is successful?

Appreciable and practical declines in pregnancy rates. Most of the time, sex ed programs are brought in because pregnancy 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 program 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."

How would you define an "appreciable decline"?

I would say where you see a 50 percent drop in pregnancy and disease. 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'd like to follow up on your comments about "abstinence programs being more comprehensive" than comprehensive programs. What do you mean by 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.

What advice would you give to parents?

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.

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