Vested interests

At a Westminster Sexual Health Policy Forum earlier this week (click here), many speakers claimed that Sex and Relationship Education (SRE) had a firm evidence base for preventing unwanted pregnancy. I wonder.

In 2002 a BMJ review of randomised trials (click here) suggested that many types of sex education did not prevent unwanted pregnancy.  More recently, the latest Cochrane review (click here) concluded that mixed interventions (education and contraceptive promotion) may reduce unintended pregnancies, but that the trials had methodological weaknesses. Besides the usual problems of small size and lack of registration, trials in this area typically relied on self-reported outcomes. Even apparently hard self-reported endpoints such as unintended pregnancy or abortion are susceptible to bias; abortions may be concealed, and judging if a pregnancy is wanted is subjective.

In 2000 UK experts recognised that better trials were required. They should be of cluster design to avoid contamination, and the primary outcome should be both unambiguously bad, namely abortion, and collected in unbiased fashion by record-linkage, rather than self-report.  The UK Medical Research Council funded two such trials.

The SHARE trial, registered here in 2000, studied pupils attending non-denominational secondary state schools in Tayside and Lothian. The intervention group got the SHARE (sexual health and relationships) programme which had all 10 characteristics identified by experts as necessary for effectiveness – five days teacher training followed by 10 pupil sessions at ages 13-14, and 10 more at age 14-15.  Controls got their school’s usual sex education.  Only two control schools demonstrated condom use and none taught negotiation skills for sexual encounters. The planned sample size was 24 schools, 7,200 pupils, 3,400 per arm. The primary endpoint was terminations by age 20 assessed from abortion registration statistics.  The final results are here.  There were no significant differences in terminations by age 20 per 1000 pupils (127 SHARE v 112 control; difference 15, 95% CI −13 to 42). i.e. there were non-significantly more terminations among pupils who got the best possible teacher-led sex education.

The RIPPLE trial was registered here, also in 2000. Classes of pupils aged 13–14, either received peer-led sex education by older pupils aged 16-17 (the intervention group), or the usual teacher-led sex education (controls). Twenty seven schools and 9,000 pupils were studied.  The primary endpoint was again termination of pregnancy by age 20 assessed from abortion registration statistics.  Final results here. Exactly five percent of girls had abortions in each group. The odds ratio (OR) adjusted for randomisation strata was 1.07 (95% CI 0.80–1.42, intervention v. control). i.e. peer-led sex education had no effect  on abortions.

My efforts to draw the meeting’s attention to these results were met by silence – like the man in the Bateman cartoon. Sex educationalists have a vested interest and no longer talk about these trials. For them sex education is obviously good, so trials which show it doesn’t work must be wrong.  The rest of us, who have to pay for their ineffective and possibly harmful programmes, and who care about really reducing unwanted pregnancy, should look for another approach.

One other lone speaker spoke up for programmes to help parents deliver the sex education. That sounds a good idea. Let’s evaluate it.

Jim Thornton

For Why doesn’t sex education work? click here.