Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Wednesday, April 23, 2008

100% Effective? The Unintended Consequences of Federal Abstinence-Only Education – Kristin Semancik

Significant declines in teenage pregnancy rates occurred during the 1990s. The Centers for Disease Control and Prevention (CDC) attributed half of this decline to decreased sexual experience and half to improved contraceptive use, conservatively estimating contraception effectiveness (1). A combination of abstinence and safe sex practices education proves most effective for preventing teen pregnancy and STI-contraction (2, 3). Despite evidence of the value of teaching contraception (2), federal funding continues to support only abstinence-only education, a controversial subject that extends beyond health terms into moral territory.
Abstinence-only education drastically expanded under the Bush presidency. The federal government provided $170 million in 2005 to programs that promoted abstinence from all sexual activities until marriage, twice the amount issued in 2001 (4). According to federal guidelines, abstinence-only education programs must teach abstinence as the only certain method to prevent pregnancy and sexually-transmitted infections (STIs) (4). Programs must focus on specific concepts including the social, psychological, and health gains of abstinence; the harmful psychological and physical effects of sex outside of marriage including depression and STIs; and the detrimental ramifications of teen pregnancy for the child, the child’s parents, and society (4). Programs also must stress abstinence as the expected standard for all school age children, and marriage as the expected standard of human sexual activity (4).
On June 21, 2007, the US Department of Health and Human Services (HHS) launched its Parents, Speak Up! Campaign, an abstinence-only educational program that combines public service announcements with online resources to encourage parents to talk with their children about abstaining from sex until marriage (5). However, the Parents, Speak Up! Campaign only focuses on one influence on teenage sexual actions, parental advice. The program ignores vital influences on teen sexual behaviors and neglects significant subsets of the teenage population. The Parents, Speak Up! Campaign fails to prevent, and may actually increase the incidence of, risky adolescent sexual behavior.
Peer Influence on Teenage Sexuality
The Parents, Speak Up! Campaign encourages parents to talk to their teenagers about sex and tell them to wait to have sex until marriage (6). The federal program assumes teenagers will abstain from sex if their parents instruct them. However, most individuals first engage in sex as teenagers before marriage; for American women, the median age of the first sexual experience is 17.4 years, but is 25.3 years for the first marriage (7). Parental conversations alone do not stop teenage sexual activity (8). Although parents provide much of the education, adolescents receive information regarding sexual behavior from other sources, notably from their peers (9).
Both parents and peers impact adolescent sexual behavior (10). Current sexual education programs focus mainly on the role of parents and often neglect peer impact (10). Teenagers converse with friends about sex: almost 50% of 13-to-15-year-olds talk about sexual intercourse with their friends (11). These conversations convey perceived adolescent norms. These norms, viewed as typical behavior, guide teenage sexual decision-making. Adolescents that believe that their friends are having sex are significantly more likely to become sexually active (9, 12, 13). Friend approval correlates with increased teenage sexual activity (10). For teenagers, friends’ perceived opinions greatly influence sexual decisions and oppose parental advice.
Achieving social status, respect from one’s social group and peers, encourages adolescent sexual initiation and continuing behaviors. Adolescents that value popularity are significantly more likely to have sex at an earlier age (14). High self-esteem and good peer relations, characteristics associated with more popular adolescent groups, correlate with engaging in sex at a younger age (15). Teenage males used sex to achieve social status, because increased experience equates to “coolness” (10). Adolescents who moved often, thus lacking permanent social connections, have sex more frequently and use sex as a tool to develop friendships (14). Other ambitions and goals propagated by peer groups sometimes override the desires for popularity. Teenagers who had academically-high-achieving-peers initiated sex at an older age (14).
Adolescent sexual initiation extends beyond peer pressure. Teenage girls seek love, approval, and a sense of maturity through sexual behaviors (10). A committed relationship is a significant sexual intercourse risk factor (16). Both emotional and physical desires surround adolescent sex. Eighty-percent of females and 66% of males have sex, because they love their boyfriend/girlfriend, and eighty-two-percent of females and 89% of males have sex for pleasure (17). Peer influences diminish somewhat as the adolescents age (12); however, peer approval remains a strong factor affecting sexual behavior into adulthood (10). The federal program ignores adolescent norms by only addressing parents. Peer leaders succeed more in changing adolescent norms and attitudes about sex than adults (18). Interventions for teenage populations cannot ignore these impacts on behavior choices. Teenage sexual behavior is complex. Social conditions and teenage desires work counter abstinence-only messages by pressuring adolescents to initiate sex, limiting the effectiveness of the Parents, Speak Up! Campaign.
Ignoring Vulnerable Populations
In addition to inadequately addressing all sources of sexual information for teenagers, the Parents, Speak Up! Campaign also ignores two teenage population subsets, individuals who have had sex and homosexuals, by instructing adolescents to have sex only when married and purporting sex in the context of marriage as the only acceptable standard. Due to their inability to live up to all the standards, these groups will lack self-efficacy and consequently, will most likely reject the program in its entirety.
Firstly, the campaign does not address adolescents who have already had sex. The campaign commercials portray the child as innocent, as a parent’s “muffinhead” or “cuddlebug” (6) and fails t0 frame the conversation for parents whose children are sexually active. Parents, Speak Up! Campaign ignores a large portion of teenagers. Over ½ of teens have sex before their 18th birthday and over 80% of people in the US have sex before marriage (9). According to the campaign commercials, “success comes for those who wait”; waiting insures having an education, family, career, and happiness (6). These goals seem unattainable for teens that choose not to wait. Teenagers may not practice safe sex if they have already failed to abstain. The campaign framing ignores a large subset of the teenage population, those who have had sex, and fails to educate them about safe practices. Sexually-active teens need information regarding safe sex practices not provided by abstinence-only education (7).
Secondly, the message of abstaining from sex until marriage ignores homosexual adolescents by implying heterosexuality, further isolating them and potentially encouraging riskier behavior. About three-percent of high school students identify as gay, lesbian, bisexual, transgender, or questioning (GLBTQ) (7). Many psychological and physical consequences of sex that the federal programs seek to prevent are of particular concern for this teenage subset, including depression and STIs, but the program, to its detriment, ignores the population.
Although teen pregnancy, a focus of abstinence-only education, may not be a factor for much of the GLBTQ population, STIs, another component of abstinence-only programs, affect this population and can be transmitted through various sexual activities including oral and anal sex (6). To prevent the transmission of STI infections, successful intervention for sexual behavior change must address the particular needs of the homosexual population (19). For example, many adolescents, especially the GLBTQ population, view AIDS as a chronic condition due to recent medication improvements. This can lead to unsafe sexual practices (9); federal efforts do not address these dangerous beliefs. No component of the campaign is tailored to specifically address GLBTQ needs.
The program also has emotional ramifications for the GLBTQ teenagers. The emphasis on marriage can further stigmatize homosexuality, detrimentally impacting the GLBTQ population (7). The program fails to acknowledge the legitimacy of committed relationships within the GLBTQ population (19). GLBTQ teens already encounter social difficulties; teenagers may feel more isolated due to a perceived dearth of parental support. GLBTQ adolescents’ resulting low self-esteem leads to risk-taking, particularly unsafe sexual practices and depression (20). Education programs should not further stigmatize a vulnerable group.
The blanket message of “wait until marriage to have sex” will not accomplish the range of federal goals for the sexual activity of a diverse teenage population. Both teenagers who have already had sex and GLBTQ are especially vulnerable populations to the negative consequences of sex abstinence-only education seeks to prevent, yet the federal program ignores and further stigmatizes them.
Unsafe Sexual Activities & Abstinence
Abstinence-only education not only fails to address certain subsets of the population, but also adversely affects the sexual behavior of the targeted population. According to President Bush, abstinence is “the surest way, and the only completely effective way, to prevent unwanted pregnancies and sexually transmitted disease” (21). Abstinence is 100% effective when used perfectly, but like all methods of birth control, its actual use, everyday application, is lower than perfect use. The Parents, Speak Up! Campaign biases effectiveness by comparing perfect use of abstinence to actual use of other contraception methods (6). Research lacks a measure of typical use of abstinence.
Consistently maintaining abstinence is very difficult, especially for teenagers (21). Intention to abstain from sex does not directly lead to behavior, and teenagers often have unplanned sex even when they have pledged abstinence (7). An abstinence-only education fails to provide adolescents with tools for safe sex. The majority of teenagers have sex even when they plan on abstaining (16). Those with abstinence-only education exhibited more risky sexual behaviors than those who received comprehensive sexual education due to a lack of information on protecting themselves when engaging in sex (16). As a result, the highest rates of teen pregnancy in 2000 in the US occurred in states that focused on abstinence-only education and the lowest rates occurred in states that provided information on both contraception and abstinence (9).
Various definitions of “abstinence” further complicate educational effectiveness. The federal program aims to teach abstinence from all sexual activities (6). Many adolescents who identify as virgins define abstinence as refraining solely from vaginal intercourse, not refraining from oral and anal sex (22). The Kaiser Foundation, a reputable health organization, and Seventeen magazine, an entertainment and social information source for many teens, found that half of 15-to-17-year-olds think that virgins can have oral sex (21). In an urban high school, 35% of students who said they were virgins had engaged in mutual masturbation, oral sex, and/or anal sex (23). Older populations exhibited similar beliefs: 55% of self-reported college virgins reported having oral sex (21).
Lacking knowledge about safe sex due to a focus on abstinence-only educations, teenagers often engage in oral and anal sex without protection from STIs. Tenth graders not only reported having oral sex more frequently than vaginal intercourse, but also had more oral sex partners and used protection less frequently than with vaginal sex (9). Only 6% of self-reported teenage virgins who had oral sex always used a condom and 86% never used one (24). Although individuals will not become pregnant, STIs can be transmitted through oral sex and anal sex. Unprotected anal sex increases the risk of STI-transmission compared to vaginal intercourse (21). Oral sex spreads many STIs including herpes, hepatitis, gonorrhea, syphilis, Chlamydia, chancroid, and human papillomavirus (22). However, for some STIs, the risk of the infection declines for oral sex in comparison to vaginal intercourse transmission. The HIV virus, for instance, is rarely transmitted through oral sex, because saliva inactivates the virus (22). Although pregnancy does not occur with oral and anal sex, many of the other problems that the abstinence-only education, particularly the psychological and physical repercussions of teenage sexual activity can occur. By ignoring teens’ definitions, the program intends to teach abstinence from all sexual activities, but adolescents interpret abstinence as only pertaining to vaginal sex.
In addition to problems regarding definitions, teens frequently break abstinence vows. Abstinence-only programs therefore delay teenage sexual intercourse, not prevent it. By college, 60% of students who pledged virginity broke their pledges (7), illustrating the difficulty of maintaining virginity until marriage. Abstinence-only education typically affects adolescents’ short-term attitudes, but not long-term behavior (3). As a result, most teenagers who pledge abstinence engage in premarital sex and when they have intercourse, are less likely to use condoms and receive STI treatment (16). Abstinence-only education programs do not provide the resources for sexually-active adolescents. Teaching both abstinence and safe sex practices better equips teenagers to cope with pressures of adolescence.
Conclusion and Implications
The Parents, Speak Up! Campaign, an abstinence-only educational program, neglects important factors that impact teenage decisions and ignores entire subsets of the teenage population. The program fails to contextualize current adolescent behaviors and beliefs about sexual behaviors into its intervention. Economic, educational, familial, and social factors impact teenage sexual activity (9). Programs need careful design to address the unique, complex nature of a diverse teenage population’s sexual behaviors. Marketing solely to parents to talk to their children about abstinence is not the best use of limited federal funds
The sexual education agenda needs change. Recently, programs strongly focus on abstinence-only education, but only 15% of parents solely want abstinence taught in schools (7). However, due to the moral implications of sexual education, a small group of vocal abstinence-only education proponents can push an agenda that many do not support. They succeed, because the opposition lacks the drive to fight back. All teens face pressure to engage in sexual relations during their adolescence. The issue affects anyone who has children, who is an adolescent, and according to the government, society as a whole, which must cope with the ramifications of sexual decisions.
In 2002, abstinence-only education programs did not make the CDC’s list of “Programs That Work” to reduce adolescent risky sexual behavior (9). Federal policy should include a mix of proven effective methods, not concentrate solely on abstinence, which sounds great in theory, but lacks results in reality. From 1991 to 2003, pregnancy rates declined 27% for women ages 15-19; 86% of this decline was due to increased contraception use and 14% was due to refraining from sexual activity (2). The contraception use accounts for 100% of the decline for ages 18-19 (2). Sexual education programs that combine abstinence education with safe sex instruction do not increase sexual activity and teen pregnancy rates, and abstinence-only education has not been proven to prevent initiation of sexual activity (23). Society cannot pretend that all teenagers are abstaining from sex; teenagers need to be educated to protect themselves and others from unplanned pregnancies and unwanted STIs.
Programs that teach only abstinence fail to effectively address any and all risky teenage sexual behavior. According to 2/3 of US teens, solely teaching abstinence-only sexual education is ineffective in preventing the onset of sexual behaviors (9). Limited federal pecuniary resources should be allotted to proven comprehensive sexual education to help protect vulnerable populations and society as a whole. Compared to other developed nations, the US has the highest teen pregnancy and STI rates, rates that are declining slower than other nations (9). Other countries are more successful, and the US must look to them for guidance. The future for federal sexual education efforts remains unclear, but the 2008 elections provide an opportunity for federal policy improvements to better utilize the millions of sexual education dollars.
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