Challenging Dogma - Spring 2008

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

Sunday, April 20, 2008

Abstinence-Only Programs: Unrealistic Idea or Stagnant Programming? – Marie A. Liles

Abstinence-only programs and comprehensive sex education have become a controversial topic for school administrators and public health officials across the United States. Abstinence, once popular in the 1950s, has become a damning word in the new millennium. To most people, it seems unrealistic to believe that people could, let alone would, remain sex-free until marriage. Despite this dissension, the federal government financially sponsors abstinence programs for the public school systems in Texas, New Mexico, and other states throughout the country. In order to receive the funding, the curriculum must adhere to the federal guidelines found in Section 510 of Title V of the Social Security Act. These guidelines are referred to as the A-H guidelines that define the merit of any abstinence-only program and are listed in Table 1 found in the Appendix.
Despite the federal approval behind these programs, data have repeatedly shown that abstinence-only programs have mixed results in preventing teens from engaging in sexual intercourse. The question then becomes what is wrong with these programs. This critique is meant to convey that abstinence-only programs have become ineffective not because the idea of abstaining from sex until marriage is unrealistic but because these programs do not accurately assess or respond to the needs of their ever-changing target audience. There are three arguments revolving around this opinion, each tackling a defining characteristic of the majority of present-day abstinence-only-until-marriage programs: (1) Abstinence-only programs address the feelings, norms, and attitudes of the teenagers of a more conservative climate like the 1950s, (2) Abstinence-only programs use their value structure inappropriately, and (3) Abstinence-only programs mimic the factual rundown structure of comprehensive sex programs.

Argument #1: Programs only address the norms, attitudes, and feelings of teenagers of a more conservative era.
When the country made the shift from the open liberal direction of the Clinton Administration to the stuffy conservative methodology of the Bush Administration, the sexual education curriculum underwent a series of drastic changes as well. According to an article by the Committee on Oversight and Governmental Reform, Congress, under the Clinton Administration, allocated grants to the Department of Human and Health Services (HHS) and other organizations for the scientific study of the true effectiveness of abstinence-only education (1). Just as the HHS devised a plan using concrete outcome measures to test overall effectiveness, the Bush Administration revamped the outcome measures into weak measures with little to no scientific validity. The committee highlights that the outcome measures went from being able to track proportions of the program participants that engaged in sexual activity to simply tracking attendance in programs (1-2), Programs have been developed based on a third-party perception of teen attitudes towards sex and sexual issues. Theory of Reasoned Action. Guideline F stresses the importance that abstinence-only programs instill an understanding of how out-of-wedlock pregnancies can “have harmful consequences to the child, the child’s parents and society”. This guideline tries to establish a perceived norm to the participants of abstinence-only programs. If one was to add to Guideline F to the government’s own view of the attitudes teens have regarding sex, then, in the eyes of program creators, the abstinence-only programs will inspire teens to intend, and therefore, remain abstinent. It is perhaps obvious to now see how this mindset of abstinence-only programs is modeled in the style of the Theory of Reasoned Action, claiming that attitudes and perceived norms influence someone’s intention and his/her subsequent action in doing a behavior.

However, there are several drawbacks in using this model. The Theory of Reasoned Action’s reliance on the idea that intention will lead to a long-term, sustainable change in behavior has been proven in other scenarios. Also, the model relies on the assumption that individuals make rational choices. Perhaps if teenagers were not the target population for the abstinence-only programs, that assumption might prove correct. However, teenagers, by nature, are irrational. They are subject to making irrational choices about sexual behavior regardless of the attitudes or the perceived norms. If one were to keep in mind the structure of the Theory of Reasoned Action, one would assume that if teenagers were rational, they would have already understood the perceived norms and attitudes regarding sexual issues and chosen to abstain without the need of abstinence-only programs.

A supporter of this methodology for teaching abstinence-only programs would perhaps cite a study among Korean college students that tests the effect of the elements of the Theory of Planned Behavior as predictors for premarital sex. The Planned Behavior theory is a close analogue of the Theory of Reasoned Action that includes an self-efficacy as a factor that impacts behavior. In this study, both male and female college students ages 18 to 25 were asked a series of questions regarding how beliefs and perceived beliefs impacted their practice, or lack thereof, of premarital sex. The results found that among female students premarital sexual attitudes and norms were significant predictors of the intention of engagement of premarital sex. For males, attitudes, norms, and abstinence self-efficacy were significant predictors to the intention of engagement of premarital sex (1152-1154). Despite these findings, there is still truth in the argument that abstinence-only programs, as they are designed and implemented now, seem to only be applicable to a much more conservative audience. The study population for this study is older than the target audience of American abstinence-only programs (1155). There is also a huge difference between the Korean and American social structure (1155-1156). The Korean culture has more of a collective viewpoint toward society than the individualistic approach of the United States. In the Korean setting, society’s perceived norms of premarital sex would have a greater impact on the person’s intention to behave than in a setting that prides itself on the rights and free decisions of the individual. Also, this again only address a person’s intention and does not always translate into a long-sustainable behavior. Abstinence-only programs need to focus their scope on the United States teenage demographic.

Instead of using the perceived attitudes of teens raised in conversative environments as the basis for modeling abstinence-only programs, there should be more attention directed to the actual attitudes of teens in today’s U.S. society. Both abstinence-only and comprehensive sex education programs compete for the same demographic: high school teenagers. Recently, research has shown that high school students may not be the best age group in which to start sexual education. In a study released from San Diego State University and presented on NBC San Diego, the average age for sexual intercourse among teenage girls dropped from age 19 in the 1950s and the 1960s to age 15 in the later 1990s. Fifteen is the average age of most freshman in high school. So, by the time sexual education becomes available in most public high schools, the abstinence message no longer applies to those teens. In the documentary, Abstinence Comes to Albuquerque, the secretary of the New Mexico Department of Public Health states what the true benefit of an abstinence program that included those missing key concepts could mean when she says, “…I’ve got the third-grade-year-old girl who already has seen that sexual behavior of pregnancy is the norm in their family in 7th, 8th, and 9th grade. I’ve got to get to that young person early”. This quote illustrates a family cycle that abstinence-only programs just do not address in any of their programming. The program neglect cultural differences in defining sex as well. A study entitled, “Sexually Abstinent African American Adolescent Females’ Description of Abstinence”, examined how the definition of “having sex” varied among teens. Oral-genital contact as well as anal intercourse was defined as a sexual act but considered as “having sex” and would therefore be considered as being abstinent (234). This sample only deemed vaginal intercourse as “having sex”. Abstinence-only programs seem to never incorporate these differing definitions of sex into its programming nor do they attempt to address them in programming.

Argument#2: Abstinence-only programs use their value structure inappropriately.
Abstinence-only programs are selling a product called values and morality to teen participants. However, the approach being used is far from effective. In a study called “A Review of 21 Curricula for Abstinence-Only-Until-Marriage Programs”, an evaluation of the effectiveness of the programs was done on 21 abstinence-only programs in Texas, one of the few states standing in approval of the abstinence-only programs. The evaluation included how well each program fits the A-H federal guidelines for abstinence programs, the program’s overall characteristics, key concepts that are related to abstinence content, etc.. These concepts can be found in Table 2 in the Appendix. While most programs score very well in structurally following the federal guidelines, most fell short of the key concepts that are what abstinence-only programs and defenders of the programs claim to foster (94). These concepts are the values program coordinators claim to instill in every lecture. These concepts are the take-home messages that they profess make a more fulfilling sexual experience after marriage. These concepts are the values supporters assert will inspire generations to have a higher standard for sex. And yet repeatedly, each program falls short of effectively communicating these life-changing messages. From these findings, an assumption can be made that these programs cling tight to guidelines but loosely tie themselves to the value structure they claim to instill. By doing so, the programs fall short in really addressing the true issues regarding teenage sex. They fail in contextualizing the risk factors of underage sexual intercourse. Programs refuse to ask why some teens are even engaging in sexual behaviors. They make no inquiry where teens may have been sexually abused, whether family structure models early age pregnancies, etc. Perhaps if one were to ask these questions and others like it, one would see either strengths or weaknesses that can linked to feelings, emotions, and situations that could be addressed by or found in the masked values of abstinence.

Critics of the programs state that the teachers and curriculum designers use fear tactics to attach to sex. The most colorful example would be one highlighted by the Sexuality Information and Education Council of the United States (SIECUS) Public Policy Office in its investigation regarding abstinence-only programming. The statement reads, “The first player spins the cylinder, points the gun to his/her head, and pulls the trigger. He/she has only one in six chances of being killed. But if one continues to perform this act, the chamber with the bullet will ultimately fall into position under the hammer, and the game ends as one of the players dies. Relying on condoms is like playing Russian roulette” (1). Me, My World, My Future, the abstinence-only program that used the Russian roulette analogy, was evaluated in the above mentioned study and was given the highest score (score=5) on following federal guidelines, but a significantly lower score (score=3) on addressing those key concepts discussed earlier. Another statement cited in the investigation is this one made by another program called Sex Respect: “These are simply natural consequences. For example, if you eat spoiled food, you will get sick. If you jump from a tall building, you will be hurt or killed. If you spend more money than you make, your enslavement to debt affects you and those whom you love. If you have sex outside of marriage, there are consequences for you, your partner and society”(2). These statements do not change behavior. In fact, it is more likely that teens will commit the undesired behavior in sheer defiance (Abstinence Comes to Albuquerque) .

The programs have used a highly warped brand of framing theory in these statements. For example, the Russian roulette scenario posed in the Me, My World, My Future attempt to compare using condoms and becoming pregnant or infected with a STI to possibly being killed in a game of Russian roulette. Aside from the accuracy, or lack thereof, of the comparison, the message tries to apply an emotional value, the value of sexual intercourse within the context of marriage, to the person’s intellect. The statement made by Sex Respect does the same thing as the Me, My World, My Future statement but adds something even more sinister. The frame, whether intentional or not, make a very derogatory message to those who have already had sex whether by choice or by force. It suggests that it is natural for those who have had sexual intercourse to expect some type of punishment for past indiscretions. Some might adopt the attitude that since they will be punished for past sexual experiences, no matter the circumstances, it makes no difference whether the person continues to engage in risky sexual behaviors.

Argument #3: Abstinence-only programs mimic the factual rundown structure of comprehensive sex programs.
Abstinence-only programs are presented in a similar fashion as comprehensive sex education. Comprehensive sex education programs have a very procedural element to their messages because they are simply sharing facts and proper techniques for sexual relations and actions. Abstinence-only, on the other hand, is supposed to be inspiring values, the reasoning behind the factors for choosing to abstain from sex, and therefore should be presented conceptually. Abstinence-only programs try to present mathematical figures and graphs, which have nothing to do with the belief/value structure. The programs give rundown lists of the reasons why abstinence is a better choice and causes the public’s doubt about the accuracies of its information. Too many abstinence-only programs focus on rational decision via talking to the individual’s mind, which only works for programs that impart mainly fact. Though program directors may say that abstinence until marriage is the best way to avoid unplanned pregnancies and STIs, an individual’s main drive to remain abstinent from sexual acts is found in the person’s values and beliefs. Josie Weiss et al., in their article, mentions an interesting definition when evaluating another study. In an independent Canadian study, pathologizing sex, or explaining sex as “ a pathological process associated with potential disease, distress, and a personality weakness but without any emotional or positive aspects included” (Weiss 452) was one of the two elements study participants found to be a hindrance in understanding their own sexual behavior. The definition fit the conflicting message of abstinence-only programs. Sexual education via abstinence-only programs, in practice, give a biological look at sex while, on paper, say that it is supposed to provide an emotional look at sex. This atmosphere of non-consistency of mission statement and action is just one more problem that has led to the non-adherence of abstaining from sexual intercourse.

In conclusion, abstinence-only programs do have a place in society, just not as they are now. The abstinence-only programs have yet to realize and take action on the disconnect between their message and the teens they ware trying to serve. Gone are the times of blind following to protocol or social climate. The teens of yesterday are not the teens of today. If abstinence-only programs are ever to succeed, they must meet the needs of new populations of teens at their level. Abstinence-only programs need to target younger groups in various family structures and ethnic backgrounds so that the value system has a much more inclusive feel to teens. Currently, program coordinators insist on mentioning the external factors that undermine abstinence-only programs, but fail in the implantation of changing internal factors. It is the opinion of this reviewer that abstinence-only programs will work with higher efficacy if curriculum developers as well as governmental officials revamped their programs to fit a newer generation.


Table 1: The federal guidelines for abstinence-only programs funded by the U.S. government

A. The curriculum must have an exclusive purpose of teaching the social, physiological, and health gains to be realized from abstaining from sexual activity.
B. The curriculum teaches abstinence from sexual activity outside of marriage as the expected standard for all school-aged children.
C. The curriculum teaches that the sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems.
D. The curriculum teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity.
E. The curriculum teaches that sexual activity outside the marriage is likely to have harmful psychological an physical effects.
F. The curriculum teaches that bearing children out of wedlock is likely to have harmful consequences for the child, the child’s parents, and society
G. The curriculum teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances.
H. The curriculum teaches the importance of attaining self-sufficiency before engaging in sexual activity.

Table 2: Key Concepts Addressed in “A Review of 21 Curricula for Abstinence-Only-Until Marriage Programs”
Key concept #1: Character Formation
· Identification and definition of values, acting on values, goal-setting and decision making
Key concept #2: Human Development
· Includes but not limited to body image, body appreciation, and human sexuality as well as self-esteem
Key concept #3: Relationships
· Love, friendships, purpose and responsibilities of dating, marriage, parenthood
Key concept #4: Family
· Benefits of family, changes within family, roles and responsibilities
Key concept #5: Sexual Behavior
· Sexual urges and desires, abstinence, masturbation, fantasy noncoital sexual behaviors/shared sexual behaviors, intimacy, fidelity, human sexual response
Key concept #6: Sexual Health
· Sexual activity and contraception, sexual activity and pregnancy, sexual abuse, substance abuse , sexual activity and sexually transmitted diseases, emotional and psychological health, abortion
Key concept #7: Society and culture
· Sexuality and law, diversity, sexuality and the media, sexuality and society, sexuality and religion, sexuality in the arts
Administration for Children and Families. Guidance Regarding Curriculum Content.
Washington, D.C. United States Department of Health and Human Services. FY 2006.

Cha ES et al. Evaulating the Theory of Planned Behavior to explain intention to engage
in premarital sex amongst Korean college students: A questionnaire survey. International Journal of Nursing Studies. 2007. 44:1147-1157.

Committee on Oversight and Government Reform. The Effectiveness of Abstinence-
Only Education. Washington, D.C. Politics and Science: Investigating the State of Science Under the Bush Administration.

Haglund K. Sexually Abstinent African American Adolescent Females’ Descriptions of Abstinence. Journal of Nursing Scholarship. 2003. 35:3 231-236.

NBC San Diego. Study: Girls Having Sex At Age 15 (News Report). Aired Oct 4, 2005.

Sexuality Information and Education Council of the United States (SIECUS) Public Policy Office. Policy in Their Own Words. Washington, D.C.: Sexuality Information and Education Council of the United States (SIECUS).

Stuart C. Abstinence Comes to Albuquerque (Documentary). 2006.
Weiss JA. Let us talk about it: Safe Adolescent Sexual Decision Making. Journal of the American Academy of Nurse Practitioners. 2007. 19:450-458.

Wilson KL et al. A Review of 21 Curricula for Abstinence-Only-Until-Marriage Programs. Journal of School Health. 2005. 75:90-98

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