Changing emphases in sexuality education in U.S. public secondary schools, 1988-1999.

CONTEXT: Since the late 1980s, both the political context surrounding sexuality education and actual teaching approaches have changed considerably. However, little current national information has been available on the content of sexuality education to allow in-depth understanding of the breadth of these changes and their impact on current teaching. METHODS: In 1999, a nationally representative survey collected data from 3,754 teachers in grades 7-12 in the five specialties most often responsible for sexuality education. Results from those teachers and from the subset of 1,767 who actually taught sexuality education are compared with the findings from a comparable national survey conducted in 1988. RESULTS: In 1999, 93% of all respondents reported that sexuality education was taught in their school at some point in grades 7-12; sexuality education covered a broad number of topics, including sexually transmitted diseases (STDs), abstinence, birth control, abortion and sexual orientation. Some topics--how HIV is transmitted, STDs, abstinence, how to resist peer pressure to have intercourse and the correct way to use a condom--were taught at lowergrades in 1999 than in 1988. In 1999, 23% of secondary school sexuality education teachers taught abstinence as the only way of preventing pregnancy and STDs, compared with 2% who did so in 1988. Teachers surveyed in 1999 were more likely than those in 1988 to cite abstinence as the most important message they wished to convey (41% vs. 25%). In addition, steep declines occurred between 1988 and 1999, overall and across grade levels, in the percentage of teachers who supported teaching about birth control, abortion and sexual orientation, as well as in the percentage actually covering those topics. However, 39% of 1999 respondents who presented abstinence as the only option also told students that both birth control and the condom can be effective. CONCLUSIONS: Sexuality education in secondary public schools is increasingly focused on abstinence and is less likely to present students with comprehensive teaching that includes necessary information on topics such as birth control, abortion and sexual orientation. Because of this, and in spite of some abstinence instruction that also covers birth control and condoms as effective methods of prevention, many students are not receiving accurate information on topics their teachers feel they need.

Sexuality education in fifth and sixth grades in U.S. public schools, 1999.

CONTEXT: While policymakers, educators and parents recognize the need for family life and sexuality education during children's formative years and before adolescence, there is little nationally representative information on the timing and content of such instruction in elementary schools. METHODS: In 1999, data were gathered from 1, 789 fifth- and sixth-grade teachers as part of a nationally representative survey of 5,543 public school teachers in grades 5-12. Based on the responses of 617 fifth- and sixth-grade teachers who said they teach sexuality education, analyses were carried out on the topics and skills sexuality education teachers taught, the grades in which they taught them, their teaching approaches, the pressures they experienced, whether they received support from parents, the community and school administrators, and their needs. RESULTS: Seventy-two percent of fifth- and sixth-grade teachers report that sexuality education is taught in their schools at one or both grades. Fifty-six percent of teachers say that the subject is taught in grade five and 64% in grade six. More than 75% of teachers who teach sexuality education in these grades cover puberty, HIV and AIDS transmission and issues such as how alcohol and drugs affect behavior and how to stick with a decision. However, when schools that do not provide sexuality education are taken into account, even most of these topics are taught in only a little more than half of fifth- and sixth-grade classrooms. All other topics are much less likely to be covered. Teaching of all topics is less prevalent at these grades than teachers think it should be. Gaps between what teachers say they are teaching and teachers' recommendations for what should be taught and by what grade are especially large for such topics as sexual abuse, sexual orientation, abortion, birth control and condom use for STD prevention. A substantial proportion of teachers recommend that these topics be taught at grade six or earlier. More than half (57%) of fifth- and sixth-grade sexuality education teachers cover the topic of abstinence from intercourse--17% as the only option for protection against pregnancy and STDs and 40% as the best alternative or one option for such protection. Forty-six percent of teachers report that one of their top three problems in teaching sexuality education is pressure, whether from the community, parents or school administrators. More than 40% of teachers report a need for some type of assistance with materials, factual information or teaching strategies. CONCLUSIONS: A large proportion of schools are doing little to prepare students in grades five and six for puberty, much less for dealing with pressures and decisions regarding sexual activity Sexuality education teachers often feel unsupported by the community, parents or school administrators.

Abstinence promotion and the provision of information about contraception in public school district sexuality education policies.

CONTEXT: For more than two decades, abstinence from sexual intercourse has been promoted by some advocates as the central, if not sole, component of public school sexuality education policies in the United States. Little is known, however, about the extent to which policies actually focus on abstinence and about the relationship, at the local district level, between policies on teaching abstinence and policies on providing information about contraception. METHODS: A nationally representative sample of 825 public school district superintendents or their representatives completed a mailed questionnaire on sexuality education policies. Descriptive and multivariate analyses were conducted to identify districts that had sexuality education policies, their policy regarding abstinence education and the factors that influenced it. RESULTS: Among the 69% of public school districts that have a district-wide policy to teach sexuality education, 14% have a comprehensive policy that treats abstinence as one option for adolescents in a broader sexuality education program; 51% teach abstinence as the preferred option for adolescents, but also permit discussion about contraception as an effective means of protecting against unintended pregnancy and disease (an abstinence-plus policy); and 35% (or 23% of all U.S. school districts) teach abstinence as the only option outside of marriage, with discussion of contraception either prohibited entirely or permitted only to emphasize its shortcomings (an abstinence-only policy). Districts in the South were almost five times as likely as those in the Northeast to have an abstinence-only policy. Among districts whose current policy replaced an earlier one, twice as many adopted a more abstinence-focused policy as moved in the opposite direction. Overall, though, there was no net increase among such districts in the number with an abstinence-only policy; instead, the largest change was toward abstinence-plus policies. CONCLUSIONS: While a growing number of U.S. public school districts have made abstinence education a part of their curriculum, two-thirds of districts allow at least some positive discussion of contraception to occur. Nevertheless, one school district in three forbids dissemination of any positive information about contraception, regardless of whether their students are sexually active or at risk of pregnancy or disease.

PIP: Descriptive and multivariate analyses were conducted to identify districts that had sexuality education policies, their policy regarding abstinence education and the factors that influenced it. A nationally representative sample of 825 public school district superintendents or their representatives completed a mailed questionnaire on sexuality education policies. Results revealed that 69% of public school districts have a district-wide policy to teach sexuality education, of which 14% have a comprehensive policy that treats abstinence as one option for adolescents in a broader sexuality education program; 51% teach abstinence as the preferred option for adolescents, but also permit discussion about contraception as an effective means of protecting against unintended pregnancy and disease; and 35% teach abstinence as the only option outside of marriage, with discussion of contraception either prohibited entirely or permitted only to emphasize its shortcomings. A growing number of US public school districts have made abstinence education a part of their curriculum; however, two-thirds allow at least some positive discussion of contraception to occur.

Age differences between sexual partners in the United States.

CONTEXT: Researchers have examined the age of partners of young women at first intercourse and of young women who have given birth, but little is known about the age of partners of young women in current sexual relationships or young women who have had an abortion. METHODS: Data from the 1995 National Survey of Family Growth (NSFG) were used to examine age differences between women and their current partner and women's use of contraceptives at last intercourse, by marital status and by the age difference between women and their partner. Data from the NSFG and the 1994-1995 Alan Guttmacher Institute Abortion Patient Survey, with supplemental information from other sources, were used to estimate 1994 pregnancy rates for women by their age and marital status, according to the age difference between the women and their partner. RESULTS: Among all sexually active women aged 15-44, 10% had a partner who was three or more years younger, 52% a partner who was within two years of their age, 20% a partner who was 3-5 years older, and 18% a partner who was six or more years older. In contrast, 64% of sexually active women aged 15-17 had a partner within two years of their age, 29% a partner who was 3-5 years older, and 7% a partner who was six or more years older. Among women younger than 18, the pregnancy rate among those with a partner who was six or more years older was 3.7 times as high as the rate among those whose partner was no more than two years older. Among women younger than 18 who became pregnant, those with a partner who was six or more years older were less likely to have an unintended pregnancy (70%) or to terminate an unintended pregnancy (21%) than were those whose partner was no more than two years older (82% and 49%, respectively). Among women younger than 18 who were at risk of unintended pregnancy, 66% of those who had a partner who was six or more years older had practiced contraception at last sex, compared with 78% of those with a partner within two years of their own age. Young women who were Catholic and those who had first had sex with their partner within a relatively committed relationship were less likely to be involved with a man who was six or more years older than were young women who were Protestants and those who first had sex with their partner when they were dating, friends or had just met. Young women who had ever been forced to have sex were twice as likely as those who had not to have a partner who was 3-5 years older. CONCLUSION: Although the proportion of 15-17-year-old women who have a much older partner is small, these adolescents are of concern because of their low rate of contraceptive use and their relatively high rates of pregnancy and birth. Research is needed to determine why some young women have relationships with an older man, and how their partner's characteristics affect their reproductive behavior.

PIP: Data from the 1995 National Survey of Family Growth (NSFG), a nationally representative survey of 10,847 women aged 15-44 years, and the 1994-95 Alan Guttmacher Institute Abortion Patient Survey, together with supplemental data from other sources, were used to estimate 1994 pregnancy rates for women by their age and marital status, according to the age difference between the women and their partner. Among all sexually active women, 10% had a partner who was 3 or more years younger, 52% a partner within 2 years of their age, 20% a partner 3-5 years older, and 18% a partner 6 or more years older. 64% of sexually active women aged 15-17 years had a partner within 2 years of their age, 29% a partner 3-5 years older, and 7% a partner 6 or more years older. Among women under 18 years old, the pregnancy rate among those with a partner 6 or more years older was 3.7 times higher than the rate among those whose partner was no more than 2 years older. Among women under age 18 who became pregnant, those with a partner 6 or more years older were less likely to have an unintended pregnancy or to terminate an unintended pregnancy than were those whose partner was no more than 2 years older. Among women under age 18 at risk of unintended pregnancy, 66% of those with a partner 6 or more years older used contraction at most recent sex, compared with 78% of those with a partner within 2 years of their own age. Young Catholic women and those who had first had sex with their partner within a relatively committed relationship were less likely to be involved with a man who was 6 or more years older than were young women who were Protestants and those who first had sex with their partner when they were dating, friends, or had just met.

Pregnancy rates among U.S. women and their partners in 1994.

CONTEXT: When rates of pregnancy, birth and abortion are calculated only for the women involved, men's role in reproduction is ignored, resulting in limited understanding of their influence on these outcomes. METHODS: Data from the 1995 National Survey of Family Growth and from the 1994-1995 Alan Guttmacher Institute Abortion Patient Survey were combined with national natality statistics to estimate pregnancy rates in 1994 for women and their male partners, by age and marital status at the time of conception. RESULTS: Nine percent of both men and women aged 15-44 were involved in conceiving a pregnancy in 1994 (excluding those resulting in miscarriages). Pregnancy levels were highest among women aged 20-24 and among male partners aged 25-29. Men younger than 20 were involved in about half as many pregnancies as were women this age (9% compared with 18%). In contrast, men aged 35 and older were involved in roughly twice as many pregnancies as were similarly aged women (19% compared with 9%). Three out of every four pregnancies in 1994 resulted in a birth. However, 47% of pregnancies involving men younger than 18 ended in abortion, compared with about 34% of those involving men aged 40 and older. In comparison, 31% of pregnancies among women younger than 18 resulted in abortion, while 39% of those among women aged 40 and older were terminated. CONCLUSION: The overall rate at which men were involved in causing a pregnancy is similar to the pregnancy rate among women. Men are typically older than women when they are involved in a pregnancy, however. This implies that men may bring more experience and resources to the pregnancy experience.

PIP: This study examines pregnancy rates and pregnancy outcomes among US women and their male partners in 1994. Sources of data include the 1995 National Survey of Family Growth, the 1994-95 Alan Guttmacher Institute Abortion Patient Survey, and statistics records of the National Center for Health Statistics. Findings revealed that 9% of both men and women aged 15-44 were involved in conceiving a pregnancy in 1994. Pregnancy levels were highest among women aged 20-24 and among 25-29 year old male partners. In addition, men younger than age 20 and women were engaged in 9% and 18% of pregnancies, respectively. A significantly contrasting result was noted among men and women aged 35 and older; 19% of men and 9% of women were involved in pregnancies at these ages. Furthermore, the study indicated that 3 out of every 4 pregnancies in 1994 resulted in a birth. However, 47% of pregnancies involving men below 18 years resulted in abortion, compared with about 34% of those involving men aged 40 and older. In comparison, 31% of pregnancies among women below 18 years old ended up in abortion, while 39% of those among women aged 40 and older were terminated. Although there are similarities in the levels and distributions of pregnancies among both sexes, the findings indicate that among couples involved in pregnancy, it is common for men to be older than women.

The effects of pregnancy planning status on birth outcomes and infant care.

CONTEXT: The planning status of a pregnancy may affect a woman's prenatal behaviors and the health of her newborn. However, whether this effect is independent or is attributable to socioeconomic and demographic factors has not been explored using nationally representative data. METHODS: Data were obtained on 9,122 births reported in the 1988 National Maternal and Infant Health Survey and 2,548 births reported in the 1988 National Survey of Family Growth. Multiple logistic regression analyses were employed to examine the effects of planning status on the odds of a negative birth outcome (premature delivery, low-birth-weight infant or infant who is small for gestational age), early well-baby care and breastfeeding. RESULTS: The proportion of infants born with a health disadvantage is significantly lower if the pregnancy was intended than if it was mistimed or not wanted; the proportions who receive well-baby care by age three months and who are ever breastfed are highest if the pregnancy was intended. In analyses controlling for the mother's background characteristics, however, a mistimed pregnancy has no significant effect on any of these outcomes. An unwanted pregnancy increases the likelihood that the infant's health will be compromised (odds ratio, 1.3), but the association is no longer significant when the mother's prenatal behaviors are also taken into account. Unwanted pregnancy has no independent effect on the likelihood of well-baby care, but it reduces the odds of breastfeeding (0.6). CONCLUSIONS: Knowing the planning status of a pregnancy can help identify women who may need support to engage in prenatal behaviors that are associated with healthy outcomes and appropriate infant care.

PIP: The planning status of a pregnancy has been shown to influence maternal behaviors during pregnancy (e.g., smoking and weight gain) as well as pregnancy outcomes such as prematurity and low birth weight. It is possible, however, that the apparent effects of planning status actually reflect demographic and socioeconomic differences between women who plan their pregnancies and those who did not intend to conceive. This issue was explored through use of data on 9122 births reported in the 1988 US National Maternal and Infant Health Survey and 2548 births reported in the 1988 National Survey of Family Growth. In the first survey, 16% of intended births, compared with 20% of mistimed and 26% of unwanted births, had at least one negative outcome. Similarly, the proportions of infants who received well-baby care by 3 months and were breast-fed were highest when the pregnancy was intended. However, when the mother's physical and socioeconomic characteristics and the infant's health status at birth were controlled, a mistimed pregnancy had no significant effect on any of these outcomes. An unwanted birth was significantly more likely than an intended one to be associated with negative infant health outcomes when a woman's prior pregnancy experiences, physical characteristics, and socioeconomic status were controlled (odds ratio, 1.3), but the association lost significance when the mother's prenatal behaviors were considered. Unwanted pregnancy had no independent effect on the likelihood of well-baby care, but significantly reduced the likelihood of breast feeding (odds ratio, 0.6). These associations should be reassessed with more sophisticated measures and study design. However, intention status at conception does appear to represent a useful gross indicator for identifying women in need of special services and support during pregnancy.

Predicting maternal behaviors during pregnancy: does intention status matter?

CONTEXT: Women's behavior during pregnancy, which can affect the health of their infant, may be influenced by their attitude toward the pregnancy. METHODS: Multivariate analyses of data from the 1988 National Maternal and Infant Health Survey and the 1988 National Survey of Family Growth were conducted to investigate whether women with unplanned births differ from other women in their pregnancy behavior, independent of their social and demographic characteristics. RESULTS: Women with intended conceptions are more likely than similar women with unintended pregnancies to recognize early signs of pregnancy and to seek out early prenatal care, and somewhat more likely to quit smoking, but they are not more likely than women with comparable social and demographic characteristics to adhere to a recommended schedule of prenatal visits once they begin care, to reduce alcohol intake, or to follow their clinician's advice about taking vitamins and gaining weight. Social and demographic differences in these behaviors are largely unaffected by planning status, indicating that these differences are independently related to pregnancy behaviors. CONCLUSIONS: Both the intendedness of a pregnancy and the mother's social and demographic characteristics are important predictors of pregnancy-related behavior.

PIP: The hypothesis that women's behaviors during pregnancy that have the potential to influence their baby's health are influenced by their attitudes toward the pregnancy was examined through use of data from two US surveys: the 1988 National Maternal and Infant Health Survey (n = 9122 births) and the 1988 National Survey of Family Growth (n = 2586 births). Specifically, it was explored whether women with unintended (mistimed or unwanted) pregnancies make less use of prenatal care services and conform less closely to recommended practices such as those related to smoking and weight gain than women with planned pregnancies, independent of their social and demographic characteristics. Multivariate analysis indicated women with planned pregnancies were 12 percentage points more likely than women with unintended births to recognize their pregnancy in the first 6 weeks, 16 percentage points more likely to have initiated prenatal care in the first 8 weeks, and 8 percentage points more likely to have adhered to medical advice to quit smoking. Once the effects of social and demographic factors were controlled, these differences were reduced by 49%, 46%, and 32%, respectively. Contrary to expectations, once prenatal care was initiated, women with an unintended pregnancy were as likely to meet the recommended number of visits, reduce alcohol consumption, take vitamins, and gain weight per advice as women with a planned pregnancy. These results indicate a need to pay attention to social and demographic factors that contribute to late recognition of pregnancy, delayed entry into prenatal care, and continued smoking during pregnancy as well as the wantedness of the pregnancy in the design of maternal-child health programs.

Public health departments providing sexually transmitted disease services.

Results of a 1995 survey reveal that 1,437 local health departments-half of those in the country-provide sexually transmitted disease (STD) services and receive about two million client visits each year. Their clients are predominantly individuals with incomes of less than 250% of the poverty level (83%), women (60%) and non-Hispanic whites or blacks (55% and 35%, respectively); 36% of clients are younger than 20, and 30% are aged 20-24. On average, 23% of clients tested for STDs have chlamydia, 13% have gonorrhea, 3% have early-stage syphilis, 18% have some other STD and 43% have no STD. Virtually all public STD programs offer testing and treatment for gonorrhea and syphilis; only 82% test for chlamydia, but 97% provide treatment for it. Some 14% offer services only in sessions dedicated to STD care, 37% always integrate STD and other services, such as family planning, in the same clinic sessions, and 49% offer both separate and integrated sessions. STD programs that integrate services with other health care typically cover nonmetropolitan areas, have small caseloads, serve mainly women and provide a variety of contraceptives. In contrast, those that offer services only in dedicated sessions generally are in metropolitan areas and have large caseloads; most of their clients are men, and few provide contraceptive methods other than the male condom.

PIP: In 1995, the Alan Guttmacher Institute surveyed 1437 local public health departments that provide sexually transmitted disease (STD) services to determine the range of STD services. They had around 2 million clients annually. These agencies comprised 50% of all local public health departments in the US. Further analysis was limited to 587 randomly selected agencies. The health department clients tended to have incomes less than 250% of the poverty level (83%) and to be women (60%) and non-Hispanic Whites or Blacks (55% and 35%, respectively). 36% of clients were teenagers. 30% were 20-24 years old. Among clients screened for STDs, 23% had chlamydia, 13% had gonorrhea, 3% had early-stage syphilis, 18% had another STD, and 43% had no STD. 99% and 93% of all public STD control programs provided testing and treatment for gonorrhea and syphilis, respectively. 97% treated chlamydia but only 82% tested for chlamydia. 14% of all agencies always provided STD services in separate sessions. They tended to be in metropolitan areas, to serve many clients, to see about as many men as women, and to provide little contraceptive care. 37% of all agencies always integrated STD services and other health care. They tend to have small STD caseloads, to provide STD services mostly to women, and to offer contraceptive methods other than male condoms. 49% used a mix of separate STD sessions and sessions in which STD services were integrated with other services. Individuals in need of STD testing and/or treatment who lived in sparsely populated areas appeared to have a limited choice of accessible clinic-based or private providers.

Private physicians' provision of contraceptive services.

Private physicians provide family planning services to the majority of American women. According to data from the National Ambulatory Medical Care Survey, office-based physicians received on average 13.5 million visits annually for contraceptive services during 1990-1992. Private insurance was the expected from of payment for 38% of visits, while managed care covered 22% of visits, and Medicaid or another source of public assistance subsidized 12%; 22% were self-paid and 6% covered by other sources. The majority of patients who received contraceptive services gave a reason other than general family planning or care regarding a specific contraceptive as the primary purpose for their visit, although women covered by a managed care plan or through public funding were the most likely to give general family planning needs as the main reason. Women whose visit was listed as publicly funded were less likely to have a contraceptive prescribed or provided or to obtain a Pap test than were those expected to pay with private insurance.

PIP: An analysis of patient visit information drawn from the 1990, 1991, and 1992 US National Ambulatory Medical Care Surveys raised concerns that a woman's expected source of payment for services may affect the quality of her reproductive health care. These surveys, conducted by the National Center for Health Statistics, collect data from a nationally representative sample of physicians about visits to private office practices. In 1990-92, an average of 13.5 million contraceptive visits per year were made to private physicians; 94% of patients were women. A contraceptive method was prescribed at 66% of these visits. Interestingly, 81% of women and 64% of men cited a reason other than contraceptive care (e.g., physical examination or Pap smear) for the visit. Payment sources were as follows: private insurance, 38%; managed care plans, 22%; self-pay, 22%; and Medicaid and other government programs, 12%. Women whose family planning visits were covered by Medicaid were significantly more likely to be Black and under 25 years of age. The likelihood of obtaining a contraceptive method at a given visit was 33% lower among Medicaid patients than those with private insurance, while that of receiving a Pap test was 61% lower. Only 56% of publicly funded family planning visits resulted in the prescription of a contraceptive method compared with 79% of privately or self-funded visits.

How old are U.S. fathers?

One in every six U.S. birth certificates have no information on the age of the baby's father; for more than four in 10 babies born to adolescent women, no data are available on the father's age. Information from mothers aged 15-49 who had babies in 1988 and were surveyed in the National Maternal and Infant Health Survey indicates that fathers for whom age is not reported on the birth certificate are considerably younger than other fathers. In 1988, 5% of fathers were under age 20, and 20% were aged 20-24. Fathers typically are older than mothers, especially when the mothers are teenagers. Fathers who are unmarried, black or partners of lower income women are younger than other fathers.

PIP: Although current programs promoting male involvement in pregnancy and child rearing are based on the assumption that the partners of pregnant teenagers are predominantly adolescents, there is a lack of data to support this claim. In 1991, the age of father was missing from 17% of all US birth certificates, and this omission was most prevalent for births to never-married women under 20 years of age. To obtain more complete information on the age of fathers, birth certificate data were supplemented with data from the 1989-91 National Maternal and Infant Health Survey. Although paternal age was missing from 11% of birth certificates, 98% of respondents reported the current age of their infant's father. Extrapolation from this data set suggests that 5% of the fathers of the 3,898,922 live-born infants in 1988 were teenagers compared to 12% of the mothers. Among fathers who had no age listed on the birth certificate but for whom questionnaire data were available, 16% were under 20 years old compared with 3% of those for whom age was listed. Only 35% of fathers of infants born to teenagers were also under 20 years of age. Overall, fathers tended to be two years older than mothers; however, 60% of 15-17 year olds and 50% of 18-19 year olds had a partner who was three years older and 20% of all teenage mothers had a partner six or more years older. The age differential was greatest for teenage parents who were not high school graduates. These findings suggest that programs seeking to prevent teenage pregnancy or increase male responsibility for children must target older, out-of-school males as well as adolescents.

Measurement of accelerator bremsstrahlung spectra with a high-efficiency Ge detector.

A Compton spectrometer with a high-efficiency Ge detector was used to measure photon spectra from clinical accelerators. The response-function matrix for the detector system was determined using ten radioactive sources that emitted gamma rays of single energy ranging from 279-1525 keV. The system was tested by measuring the spectrum from a 60Co teletherapy machine. The energy distribution of tungsten target bremsstrahlung produced by 2.2, 2.5, 15, 20, and 25 MeV electrons in two clinical accelerators were determined. Theoretical thin-target calculations overestimate the number of photons in the high-energy regions of the spectra, as was expected. However, theoretical thick-target calculations underestimate the numbers of high-energy photons.

The application of pattern recognition techniques in the analysis of metacarpophalangeal lengths.

Pattern recognition techniques have been applied to the analysis of metacarpophalangeal lengths obtained from hand radiographs. A data base consisting of healthy subjects, and subjects exhibiting achondroplasia, Down's syndrome, and Turner's syndrome was studied. A classification technique was found which effectively separates these conditions. The technique is suitable for computer automation.