Challenging Dogma - Spring 2008

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

Saturday, April 19, 2008

Abstinence-Only Education Receives an F for Failure – Maggie Heimann

Sex is cool. This is the message that adolescents hear whenever they open a magazine, turn on the TV, or talk to their friends. The advertising and marketing strategists use this message because it sells their products. The unfortunate result is a culture that places a high value and excitement factor on sex. With this social norm in place, adolescents engage in sexual activity at a younger age to be cool, among other reasons. To combat the prevalence of adolescent sexual activity, the federal government places a priority on abstinence-only sex education. Through the use of the Health Belief Model, federal government decided that abstinence-only sex education is the best way to decrease the incidence of adolescents initiating sexual activity before marriage. Although abstinence-only programs are the national standard for sex education in the United States, the nationally funded high school programs ineffectively attempt to achieve their goal of delaying sexual activity until marriage in high school teenagers.

Unfortunately the most recent statistics surrounding adolescent sexual behavior and teenage pregnancy negate the belief that abstinence-only programs might be working. According to the 2005 Youth Risk Behavior Survey 46.8% of teens had ever engaged in sexual intercourse with 6.2% having their first experience before 13, 33.9% currently sexual active, and 14.3% having four or more partners (1). These statistics show that there is still a large percentage of the adolescent population engaging in sexual behavior. The percentages could be even greater because this survey is self reported. Sexual intercourse could mean something different to each youth who completes the survey. Adolescents could be engaging in all kinds of sexual activity that they do not consider to be intercourse and/or risky. While the percentage of teen births has been dropping since 1991, the decline slowed considerably in 2004 and 2005. The percentage was also still fairly high in 2005 at 40.5 per 1,000 live births (2). This excludes the percent of adolescents who became pregnant but did not give birth. Teen pregnancy rates are also reported as declining although true rates cannot be determined because the reported rates are based on birth and abortion rates with miscarriages not reported (2). Nevertheless the statistics show that the rates are still very high despite the sex education offered to adolescents.

These statistics suggests that the current sex education programs are not effective in altering adolescent behavior. If abstinence-only education’s goal is to delay sexual activity among adolescents until marriage, then the programs have yet to reach that goal. The federal funding through Title V Section 510 of the Family Planning Act is earmarked only for abstinence education programs (3). Interestingly enough, those states that utilize the monies to fund their abstinence-only programs have the highest rates of adolescent sexual activity (1,4). A disconnect between the proscribed sex education programs and the actual sexual behavior of adolescents exists through the continuation of abstinence-only education. A major reason for this is that the Health Belief Model (HBM) is used as the theatrical model in several public health initiatives.

Like Oil and Water: Abstinence-Only Education and the Health Belief Model Do Not Mix
The standard abstinence-only education program is based on the HBM which is not successful in changing sexual behavior, especially in teenagers. The HBM bases change in health behavior on an individual, rational level. The concept behind the model says a person will change their behavior if they believe they are susceptible to a severe enough disease to avoid as long as the benefits of changing their behavior outweigh the costs or barriers. From here, the person demonstrates the intention to change their behavior to avoid the disease and eventually does so (5). The interventions that use this model often constitute educational programs like abstinence-only education. The idea is to change the individual adolescent’s sexual behavior intentions.

The HBM, as applied to sexual behavior, does not take into account all the factors considered when making decisions as well as it does not consider the irrationality of the adolescent mind. Several studies discuss the limitations of the HBM. One study by Salazar mentions two important limitations: little accountability of variance in attitude and belief based behaviors and the assumption that people highly value their health (6). The variance in behaviors among adolescents and adults is vastly different as well as the variance among adolescents and their peers in their attitudes toward sex. Adolescents also still believe in the idea that nothing bad will happen to them which includes consequences from unprotected intercourse. Another study notes that the HBM does not allow for the relationship of health status combined with social structures (7). The model does not consider any environmental factors such as the social norms adolescents buy into such as “everybody’s doing it” and “having sex is the cool thing to do”. The HBM is purely based on the belief that if an adolescent learns about the severity and their susceptibility to the consequences of premarital sex along with the knowledge of the benefits to postponing sexual intercourse outweighing the costs of engaging in sexual behavior, they will intend not to have sex.

The federal funding and several of the state programs are set up with this belief and model in mind. Title V Section 510 of the Social Security Act passed through Congress in 1998 with $50 million dollars earmarked a year for abstinence-only programs (3). The provisions for the federal funding promote the HBM precepts as to what to teach in the programs. Two specific sections require the state programs to “[have] as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity” and to “[teach] that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects” (3). These two sections demonstrate the desired purpose to teach the benefits and harms of not abstaining from sexual activity in order to promote adolescents to change their behavior from sexual to abstention.

The provisions are carried out in the state through the programs set up with the funding. For example, Texas has the Abstinence Education Program which contracts out to 38 education providers including community-based, faith-based, schools and health departments. The programs are abstinence-only and geared toward “at-risk” youth, parents and health professionals (8). When looking at statistics, Texas does not have any comparable statistics across the state for any sort of decline in sexual activity or rate of STDs. The birth rate among 13-17 year olds decreased very slightly from 29.5 per 1,000 in 2001 to 26.6 per 1,000 (9). Yet the number of adolescents engaging in sexual activity will not correlate with birth rates. Florida, another state participating in the federal funding, set up a website devoted to abstinence and funds organizations throughout the state to teach abstinence-only education. The website boasts that teens respond positively to statements on surveys that indicate they plan on waiting until marriage to have sex and young people who have sex could mess up their future (10). However agreeing to those statements in a survey and actually participating in abstinence behavior are two entirely different things.

The HBM works nicely in theory alongside abstinence-only education. The federal government and some state governments agree with this model and its individual level rationality. Neither the model nor the governmental agencies have thought about the actual individuals and their developmental stage as to how they will interact with this rational, individual belief system.

Reinforcing Adolescent Social Norms Rather Than Changing Them
Abstinence-only education does not excel in altering adolescent social norms, but rather reinforces those already in place. Adolescents place high value on group opinions as they move from literal thinking to abstract thinking as well as from relying on parents for information and guidance to their peers. They feel the need to fit in with those around them (11). In a survey by the Kaiser Family Foundation, 60% of adolescents and young adults thought that delaying sexual activity was a “nice idea, [but] nobody really does” (12). For most, adolescence turns into a time of rebellion and experimentation. They are more apt to indulge in risk-taking behavior for a number of reasons and in conjunction with a number of factors (13). A combination of rebellion against authority figures and a need to fit in with their peers means adolescents experiment with more risky behaviors like engaging in sexual activity. Within the sexual behavior sphere, adolescents are transitioning toward adulthood which includes sexual activity (11).

Sexual activity in establishing relationships is one characteristic of becoming an adult in Western culture and social norms emphasize it (11). Adolescents are surrounded by images that reinforce their sexuality. They see these images on a daily basis and they talk about them with their friends. However they are taught in school not to pay attention to the images and to wait to explore their sexuality. Whether subconsciously or consciously, they come to the conclusion that sex is cool and they can use it as a method of rebellion. Combining the social norm that being normal means fitting in with this message creates an environment where adolescents need the slightest push to engage in sexual behavior. At that point, it is unlikely that teaching abstinence-only education will make much of a difference in changing their behavior. This is most especially true in high school.

By the time that adolescents get to high school, the social norms about sexual behavior are fairly ingrained in their culture. Studies show that any sort of abstinence education has a greater chance of working only with adolescents who have not engaged in sexual activity (14). One study, in particular, found that the younger the adolescents were when taught safer sex education with abstinence incorporated, the more likely they were to maintain abstinence longer. Those who were already sexual active or older were much less likely to start or continue abstention (14). Abstinence-only programs in high school fail at their primary goal of stopping sexual activity, especially when faced with highly visible sexuality in the US culture. As stated earlier, the culture that adolescents are exposed to carries a message of hyper sexuality. Movies and television shows create adolescent characters that have sex on screen without being married. A mixed signal gets sent to adolescents who are being told in school that they should not be having sex, but society views sex among adolescents as an acceptable practice. Without abstinence-only programs addressing this contradiction, they cannot succeed in stopping adolescent sexual activity.

Adolescents Are Still Having Sex
Since implementing the abstinence-only education programming as the national standard, little or no change occurred in the overall rates of adolescents having sex. The final report on the impact of the Abstinence Education Programs concluded that no change occurred over at ten year period. This report came from an outside agency, completed at the request of the federal government. The main finding was “youth in the program group were no more likely than the control group youth to have abstained from sex and, among those who reported having had sex, they…had initiated sex at the same mean age” (15). Furthermore, they had poor perceptions on condom and contraception use to prevent STIs and pregnancy. They did not know if they worked or not (15). The most interesting part of the report came from conclusion. The authors found that even programs in middle school did not effectively promote abstinence later on in high school and peer support did not continue past the programs either (15). This suggests that abstinence-only education missed an extremely important component in successfully teaching adolescents to not engage in sexual activity.

The national report garners support from other studies that compare abstinence-only programs with abstinence-based or safer sex education programs. One review analyzed 12 studies that looked at the effects of school-based abstinence programs. The conclusion showed a very small effect of these programs on abstinent behavior, mostly through parental involvement and for females (16). Another review differentiated between abstinence-only and abstinence-plus programs, noting that abstinent adolescents are a sizable minority. The conclusion of this review was that no current program showed a significant positive impact on promoting abstinent behavior (7). Some had a positive impact on attitudes, but as discussed before, there is a large gap between intention and behavior. Both of these review encouraged abstinence and safer sex programs as a combination for more success (7,16).

Therefore, abstinence can be effective, but not by itself. While a sizable minority, approximately 49% in 2007, of adolescent practice abstention, the majority are sexually active (15). The previous percentage is also only an estimate and the actual numbers could be much higher. Not to mention that most surveys and measurement tools take into account sexual activity as vaginal intercourse, but there is an array of risky sexual behavior besides the usual measurement. Adolescents may be engaging in oral or anal intercourse while thinking they are maintaining abstinence because they are not having vaginal intercourse. The social perception of engaging in sex is having vaginal intercourse so many adolescents could factually say they have not had sex when they might actually be sexually active. Abstinence-only education perpetuates this perception by not teaching about the risks of engaging in any manner of sexual behavior. By concentrating on the traditional method of sex, abstinence-only education puts adolescents at risk of contracting STIs through oral or anal intercourse instead of vaginal intercourse. The solution to this is to teach adolescents comprehensively about sex while maintaining abstinence from all sexual activity as the 100% safe sex practice.

Abstinence-Only Education Is Not a Valid Solution – So What Is?
The evidence against the effectiveness of abstinence-only education continues to grow. Not only that, but states are now starting to reject the Title V abstinence funding because they feel it is too restrictive on the type of sex education they can teach to their adolescents. As many as 16 states, mostly in New England and the West, have rejected the funding (4). The reasons for this can be very complex. However the crux of the matter is that abstinence-only education does not effectively change adolescent behavior toward sexual activity. Using the HBM presents too much of a rational approach to changing health behavior that never takes into account the mental development of the targeted population. Adolescents need a reason to rebel against engaging in sexual activity, not a reason to continue to rebel by having sex. Not only that, but adolescents need to know how to properly proceed with safer sex if they decide to engage in sexual activity. Every study on sex education programs agree that safer sex and abstinence programs effectively promote positive sexual behaviors (7,14,16). In order to decrease the number of adolescents having sex, the government and all education programs need to teach that sex is not cool.

1. Center for Disease Control and Prevention. 2005 Youth Risk Behavior Surveillance Survey. Atlanta: Center for Disease Control and Prevention.
2. U.S. Department of Health and Human Services, National Center for Health Statistics. National Vital Statistics Report. Atlanta: Center for Disease Control and Prevention.
3. US Government. Title V Section 510 of the Social Security Act. Washington DC: Social Security Act.
4. Allen D. Lecture slides from Reproductive Health Advocacy. Boston: Boston University School of Public Health. 2008.
5. Rosenstock IM. Historical Origins of the Health Belief Model. Health Education Monographs. 1974; 2: 328-335.
6. Salazar MK. Comparison of Four Behavioral Theories. AAOHN Journal 1991; 39: 12-135
7. Thomas MH. Abstinence-Based Programs for Prevention of Adolescent Pregnancies. Journal of Adolescent Health. 2000; 26(1):5-17.
8. State of Texas website. Abstinence Education Program. Austin: Department of State Health Services.
9. State of Texas website. Texas Vital Statistics 2001 and 2004. Austin: Department of State Health Services. and
10. State of Florida website. Abstinence Education Program – It’s Great to Wait. Tallahassee, FL: Florida Department of Health.
11. Bonino S, Cattelino E, Ciairano S. Adolescents and Risk: Behaviors, Functions and Protective Factors. New York: Springer; 2005.
12. Hoff T, Greene L, Davis J. National Survey of Adolescents and Young Adults:Sexual Health Knowledge, Attitudes, and Experiences. Menlo Park, CA: Henry J Kaiser Family Foundation; 2003.
13. Romer D, editor. Reducing Adolescent Risk: Toward an Integrated Approach. Thousand Oaks, CA: Sage Publications; 2003.
14. Aten MJ, Siegel DM, Enaharo M, Auinger P. Keeping Middle School Students Abstinent: Outcomes of a Primary Prevention Intervention. Journal of Adolescent Helath. 2002; 31(1):70-8.
15. Trenholm C, et al. Impacts of Four Title V, Section 510 Abstinence Education Programs. Princeton, NJ: Mathematica Policy Research, Inc; 2007.
16. Silva M. The Effectiveness of School-Based Sex Education Programs in the Promotion of Abstinent Behavior: a Meta-Analysis. Health Education Research. 2002; 17(4):471-81.

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