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The recent evaluation by Jemmott et al1 is a robust contribution to the literature on abstinence-based approaches for preventing sexually transmitted infections. Compared with past studies in our systematic reviews of abstinence-based interventions,2 - 3 this trial had remarkable strengths. It was the second trial to evaluate both abstinence-only and comprehensive programs and the first to find a significant long-term benefit of an abstinence-only approach. Its rigorous methods compare favorably with previous studies.
Given these strengths, we think the article should have taken advantage of the full trial design to provide pairwise comparisons among the abstinence-only, comprehensive, and safer-sex arms. The absence of direct comparisons among these approaches is a major gap, and this trial provides the first responsive long-term behavior data. An earlier presentation of these results reported some relevant comparisons,4 finding, for instance, that long-term incidence of sexual initiation among participants who were virgins at baseline did not differ significantly between the comprehensive and abstinence-only conditions (P = .07). The article classifies comparisons among active arms as post hoc, but the randomized design would support these clinically meaningful analyses as main findings.
This study would also be more applicable if results had disaggregated oral, anal, and vaginal sex. Because virginity and abstinence are often linked to vaginal sex alone, assessments limited to “intercourse” can obscure important risks. A national study of virginity pledge programs found that adolescents who promised to abstain from sex (pledgers) reported delaying first vaginal intercourse for several years; however, sexually transmitted infection incidence did not differ between pledgers and nonpledgers.5 The substitution of oral and anal sex for vaginal sex among virginity pledgers helped explain this result, particularly because condom use was less likely for oral and anal sex acts. Abstinence-based program evaluations should separate vaginal, oral, and anal sex, and nuanced reporting is essential for interpreting results.
Summarizing past evaluations in our systematic review, we identified 13 abstinence-only program trials (n = 15 940) that consistently suggested that there was no effect on sexually transmitted infections, pregnancy, or sexual behaviors.2 The pairwise comparison reported here, based on 183 participants who were virgins at baseline and assessed at 24-month follow-up, demonstrates a unique effect on sexual initiation. This program also differs from previous abstinence-only approaches. However, incorporating these results in our review may not have changed our overall interpretation of study findings. The field would benefit from more specific assessments of sexual behavior, and this study could make a pivotal contribution by directly comparing abstinence-only, comprehensive, and safer-sex approaches.
Correspondence: Dr Underhill, Department of Community Health, Brown University, Box G-S121-4, Providence, RI 02912 (kristen_underhill@brown.edu).
Author Affiliations: Department of Community Health, Brown University, Providence, Rhode Island (Drs Underhill and Operario); and Department of Social Policy and Social Work, University of Oxford, Oxford, England (Dr Montgomery).
Author Contributions:Study concept and design: Underhill, Montgomery, and Operario. Acquisition of data: Underhill. Analysis and interpretation of data: Underhill, Montgomery, and Operario. Drafting of the manuscript: Underhill, Montgomery, and Operario. Critical revision of the manuscript for important intellectual content: Underhill, Montgomery, and Operario. Administrative, technical, and material support: Underhill. Study supervision: Underhill, Montgomery, and Operario.
Financial Disclosure: None reported.
Funding/Support: This letter received no external funding. Dr Underhill is supported by grant 5T32AA07459-24 from the National Institutes of Health, a Ruth L. Kirschstein National Research Service Award.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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