Challenging Dogma - Spring 2008

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

Wednesday, April 23, 2008

Abstinence is Not the Answer- Rachel Oppenheimer

Abstinence from sexual intercourse in an effective behavioral strategy for preventing sexually transmitted infections and unwanted pregnancy among adolescents and adults (11). Abstinence is often not clearly defined in behavioral terms, nor is the term used consistently. Abstinence may be defined as postponing sex or never engaging in vaginal sex or refraining from further sexual intercourse if sexually experienced. Abstinence is also frequently defined in moral terms, using language such as chaste or virgin, and framing abstinence as an attitude or a commitment in addition to a behavior (7). Abstinence-only education programs adopt a moral definition of abstinence, requiring that abstinence education “teaches that a mutually faithful monogamous relationship on the context of marriage is the expected standard of human sexuality” (12). Supporters of the program are aware that there are other ways to prevent teen pregnancy, but believe the only method that comes with a foolproof guarantee is abstinence (8). Opponents of abstinence-only programs counter that teens are going to have sex, and not teaching the merits of condoms and other contraception increase the risk of pregnancy and disease (8). While abstinence from sexual intercourse represents a healthy choice for teenagers, few Americans remain abstinent until marriage, including those who never marry, and many who initiate sexual intercourse and other sexual behaviors as adolescents. Abstinence only education is ineffective in encouraging teens to practice safe sexual behaviors. Abstinence-only education programs fail to consider important social and behavioral factors such as the social networking theory, and fail to grant students the right to make an educated, informed decision.
The human right to health information about sex
Access to complete and accurate HIV/AIDS and sexual health information is a basic human right and is essential to realizing the human right to the highest attainable standard of health (6). Governments have an obligation to provide accurate information to their citizens and abstain from misinformation (6). Abstinence-only education programs provide incomplete and/or misleading information about contraceptives, and are often insensitive to the actual behaviors of sexually active teenagers. Abstinence-only education does not provide adequate information about sexual health to students. By teaching them simply to abstain from all sexual behavior, they are not given the information about what to do when they do engage in sexual activity. There is no harm in teaching abstinence, and it should be the primary message of sexual education as it is the only absolute way to prevent pregnancy and STDs. However, the damage lies in the teaching of abstinence-only that denies students medically accurate information about how to protect themselves, which is harmful and unethical. In a nationwide survey conducted by the Kaiser Family, considerable gaps in teens’ knowledge were revealed. The survey found that many teens hold misconceptions and harbor unnecessary and unfounded fears: such as the belief that contraception can cause infertility or birth defects. Nearly 20 percent of surveyed teens underestimated the effectiveness of the contraceptive patch or ring, and over 25 percent believed that emergency contraception causes abortion. Few teens understood the effectiveness of the male condom in preventing STDs, and HIV. In addition, over 25 percent of the teens did not know that oral contraception provides no protection against sexually transmitted diseases. The study found that on average, youth answered only about half the questions correctly regarding the health consequences of STDs from abstinence-only education (1). The current abstinence-only programs provide students with distorted, deceptive, and incorrect information about sex, pregnancy, and contraception (7). Students have a human right to gain information that enables them to make an informed decision about sex. A recent Congressional committee report found evidence of major errors and distortions of health information in common abstinence-only curricula. Eleven of the thirteen curricula examined contained false, misleading, or distorted information about reproductive health, including inaccurate information about contraceptive effectiveness and risks of abortion. The report also found that several of the curricula for public schools handle stereotypes about girls and boys as scientific fact and blur religious and scientific viewpoints (12). A more comprehensive approach to risk education should be implemented. Abstinence should be part of health education programs that provide adolescents with complete and accurate information about sexual health. Concepts about healthy sexuality, sexual orientation and tolerance, personal responsibility, risks of HIV and STD/STDs and unwanted pregnancy as well as access to reproductive health care, and the benefits and risks of condoms and other contraceptive methods should all be addressed in a comprehensive sex education program.
Abstinence–only education fails to consider the social networking theory and discriminates against groups of youth.
Abstinence only education fails to address the multitude of social groups in middle school and high school, and the fact that an adolescent’s social group can have great influence on their decisions and actions. More than a quarter (29%) of teens 15-17 report feeling pressure to have sex from their peers (9). An adolescents’ intention does not always reflect behavior. It may be a teen’s intention to abstain from sex, but in a situation with peers especially those in which drugs and/or alcohol are involved their intentions may be forgotten or blurred by impairment (11). The CDC youth risk behavior surveillance summary from 2003 reports that one-quarter of sexually active 9-12th grade students report using alcohol or drugs during their most recent sexual encounter. Males (30%) are more likely than females (21%) to report having done so. In this situation it is imperative that they have the appropriate education to help them make informed decisions and protect themselves. Almost one in 10 young people reported having sex while under the influence of alcohol and later regretting it and 10% reported having had unsafe sex (1). Among 15-27 year olds, 51 percent say that they are personally concerned that they might “do more” sexually than they planned because they were drinking or using drugs (9). Adolescents are often reluctant to acknowledge sexual activity, and seek out contraception, or discuss sexuality. Abstinence-only programs do not provide a much-needed forum in which sexually active adolescents can address critical issues such as safer sex, the benefits of contraception, legal rights to health care, and ways to access reproductive health services (10). Instead, abstinence-only programs allow for discussions only within the narrow limits developed by conservatives in congress (1). For gay, lesbian and bisexual teens and for those struggling with their sexual orientation or sexual identity, the abstinence-only-until-marriage approach is actually harmful. In these programs, marriage is promoted as a much-desired heterosexual association. Abstinence-only programs ignore the emotional health needs of lesbian, gay, bisexual, and transgender youth, demeaning them while giving them a discouraging choice: deny your homosexuality or remain celibate forever (2). Despite the message of abstinence-only-until-marriage programs that marriage is the expected standard of human behavior, individuals should have the right to determine if/or when marriage may be an appropriate or desirable life choice for themselves. The number of Americans who are unmarried and single has been growing steadily in recent years. In 2005 89.8 million individuals were unmarried, unmarried men or women headed 55 million households, and 12.9 million single parents lived with their children. Nearly 30 million people lived alone and forty percent of opposite-sex, unmarried-partner households included children (1). The message of abstinence-only-until-marriage has become an out dated vision as evidence shows that single living as well as homosexuality has become more socially acceptable. However, federally funded abstinence-only-until-marriage programs further discriminate against gay, lesbian, bisexual, transgender and questioning youth, as federal law limits the definition of marriage to heterosexual couples (12). These populations have proved to be in need to sex education as well. In 2000, adolescents ages 13-21 accounted for 25% of newly reported HIV infections (9). By teaching adolescents that sex is to be had between two heterosexual, married individuals, the country is ignoring the concerns and needs of millions of citizens and ignoring their need and desire for accurate information about sex.
Abstinence-only-until-marriage as a method of birth control and STD prevention is ineffective
Compared to older adults, adolescents are at higher risk for acquiring sexually transmitted diseases because they are more likely to have multiple sexual partners and have less information about their sexual encounters. The Adolescent Women Reproductive Health Monitoring Project was established in 1999 to monitor STD prevalence and reproductive health measures among adolescent women. In 2002, results from the screening project identified a median Chlamydia prevalence of 13.2% and a median gonorrhea prevalence of 4.3%. These results show that abstinence only education is failing to decrease the occurrence of STDs. The first national study in the U.S. of two common sexually transmitted diseases (HPV and Chlamydia) among girls and young women has found that one in four are infected. About nineteen million new sexually transmitted infections occur each year among all age groups in the U.S. (2). These high sexually transmitted infection rates among young women are clear signs that new ways to reach those most at risk must be developed. This study emphasizes the need for real, comprehensive sex education. The national policy of promoting abstinence-only programs is a $1.5 billion failure, and teenage girls are paying the real price (2). Although abstinence until marriage is the goal of many abstinence policies and programs, it is proven that few Americans wait until marriage to initiate intercourse. Recent data indicate that the median age at first intercourse for women is 17.4 years, whereas the median age at first marriage is 25.3 years (5). For men, the corresponding median age at first intercourse is 17.7 years, whereas the age at first marriage is 27.1 years (5). The consequences of the early age of sexual intercourse results in high pregnancy rates. Each year, approximately 750,000 to 850,000 teenage women in the US experience pregnancy, 74-95 percent of which are unintended (1). Advocates of abstinence-only education do not believe that STDs and pregnancy are the only negative consequences of early sexual intercourse, and suggest that psychological harm is a consequence of sexual behavior during adolescence. There is no scientific data suggesting that consensual sex between adolescents is harmful. While it is thought that mental health problems are associated with early sexual activity, studies suggest that sexual activity is a consequence, not a cause, of these mental health problems (12). While health professionals often are primarily concerned with the serious consequences of sexual behavior, it must also be recognized that sexuality is integral to human nature and has many positive mental and health consequences. Two recent reviews have evaluated the evidence supporting abstinence-only programs and comprehensive sexuality education programs designed to promote abstinence (9,10). Neither review found scientific evidence that abstinence-only programs demonstrate efficiency in delaying initiation of sexual intercourse. Similar research on teens taking virginity pledges show that failure rates of the pledge are very high especially when biological outcomes such as STDs are considered (3).
While abstinence is a healthy choice for adolescents, abstinence only education should not be the only sex education students receive. Due to the fact that abstinence-only education does not promote social and cultural sensitivity to gay, lesbian, bisexual, and transgender youth, a more effective health education curricula must incorporate these lessons. Similarly, government policy about sexual and reproductive health education should be science based. While these programs should promote abstinence as a way to reduce sexual risk, these evaluations should utilize research methods and should assess the behavioral impact as well as STD and pregnancy outcomes. In conclusion, the current U.S. federal law and guidelines regarding abstinence-only funding are ethically flawed and interfere with basic human rights. They represent the opinions of religious or conservative lawmakers rather than the scientific evidence available. Using public funds to promote religiously based concepts violates the separation of church and state. These programs must be replaced with funding for programs that offer comprehensive sex education, which is realistic in its behavior expectations and based on scientific health care standards.
1. (2008) .Abstinence only until marriage programs: ineffective, unethical, and poor for health. Advocates for Youth.
2. Altman, L.K. (2008, March13). Sex infections found in 1 in 4 teen girls. U.S. study finds that among infected, 15% have more than 1 disease. International Herald Tribune, p. C9
3. Bruckner H, Bearman PS. After the Promise: the STD consequences of adolescent virginity pledges. J Adolesc Health 2005; 36:271-8.
4. Coates, T. Science vs. assumption in public health policy: abstinence alone not the answer. (2004, May 25).
5. Fields, J. Martinez GM, Mosher W, Dawson BS. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002. National Center for Health Statistics; 2004. Report No.:24.
6. Freedman LP. Censorship and manipulation of reproductive health information. In: Sandra Coliver, ed. The Right to Know: Human Rights and Access to Reproductive Health Information. Philadelphia, PA: University of Pennsylvania Press, 1995:1-37.
7. Goodson P, Suther S, Pruitt BE, Wilson K. Defining abstinence: views of directors, instructors, and participants in abstinence-only-until-marriage programs in Texas. J Sch Health 2003; 73(3):91-6
8. Helman, S. State to push abstinence in schools. (2005, December 21).,
9. Kaiser Family Foundation, National Survey of Adolescents and Young Adults: Sexual Health Knowledge, Attitides, and Behaviors, May 2003.
10. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington DC: national campaign to prevent teen pregnancy, 2001.
11. Manlove J, Romano-Papillo A, Ikramullah E. Not Yet: Programs to Delay First Sex among Teens. Washington DC: National campaign to prevent teen pregnancy, 2004.
12. Santelli, J, Ott, M.A., Lyon , M, Rogers, J, & Summers, D (2006). Abstinence-only education policies and programs: A position paper on the society foradolescent medicine. Journal of Adolescent Health. 38, 83-87.
13. U.S. Government. Separate Program for Abstinence Education, SEC. 510 [42 U.S.C. 710]; 2005.

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