Challenging Dogma - Spring 2008

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

Tuesday, April 22, 2008

The Failure of Abstinence-Only Sexual Education in Secondary Schools – Megan Edson Grandin

Over $270 million of federal funds have been dedicated to abstinence-only sexual education programs (1). Supported primarily through the Special Programs of Regional and National Significance (SPRANS), Section 510 of the 1996 Welfare Reform Act, and the Adolescent Family Life Act, these programs promote abstinence from all sexual activity as the only means of preventing pregnancy and sexually transmitted diseases (1). In order to receive federal funding, programs must adhere to strict standards, such as, “teaching abstinence from sexual activity outside marriage as the expected standard for school age children,” “teaching that abstinence from sexual activity is the only way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems,” “teaching that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity,” and “teaching that that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society” (2). These programs teach that engaging in sexual intercourse before marriage can have serious, lasting, negative effects on the mind and body (3).
Nationwide, 46.8% of students in grades 9-12 have engaged in sexual intercourse (4). Teenage pregnancy and rate of infection with sexually transmitted diseases remains a public health problem. Each year, nearly 750,000 females between the ages of 15 and 19 become pregnant (5). Nearly 25% of annual new cases of sexually transmitted diseases occur in teenagers (6). Clearly, students need to receive education on how to prevent these outcomes. However, studies have shown that, despite the amount of money spent on abstinence-only sexual education, it has little to no effect on teen pregnancy or rate of sexually transmitted diseases (1). This broad failure can be attributed to the programs’ lack of consideration of various factors that influence individuals’ decisions regarding their health.

Abstinence-Only Sexual Education Relies on the Health Belief Model
Federally funded abstinence-only programs rely on a number of traditional health behavior models to format their teachings. The Health Belief Model, widely used in public health settings, has distinct components which determine how likely people are to take actions to prevent a negative health outcome. One component is individuals’ perceived susceptibility to a health consequence, or how likely people feel that they will suffer from the outcome. Another such component is the perceived severity of the health consequence, or the degree to which individuals believe that they will suffer from the health outcome. These two components are weighed against the perceived costs of taking the action (7). The Health Belief Model dictates that these components will determine individuals’ health intentions, and that the intentions will lead to specific health behaviors (8). This model relies on the assumption that logical thought processes determine health decisions. It also relies on the hypothesis that health decisions are made on an individual level (8).
Health decisions are not always rational. While many teenagers may be well aware of the risks of sexual activity, they are not necessarily rational about their behavior. When faced with temptation, it may be difficult for teenagers to remain abstinent, despite their intentions to do so (9). In conducting research for the “Truth” anti-tobacco campaign, researchers found that teenagers’ reasons for health decisions had little to do with rational decisions, and much to do with emotions (10). In addition, many decisions regarding sexual behaviors are made under the influence of alcohol, which impairs people’s abilities to be rational. Even those with the strongest of intentions to remain abstinent can have their resistance lowered with the aid of alcohol (6).
It is also difficult to factor perceived susceptibility into this equation, because studies have shown that teenagers often have low perceived susceptibility to diseases. Although many abstinence-only sexual education programs teach about sexually transmitted diseases, many teenagers do not believe themselves to be at high risk for such diseases (11, 12). Therefore, the health belief model would not be applicable or helpful to use in this situation. Furthermore, even if teenagers know how susceptible they will be to a sexually transmitted disease or pregnancy, and how severe the disease may be, it may not necessarily matter when caught up in the moment of desire.
The Health Belief Model fails to account for other factors that affect health decisions, such as social norms (8). Many abstinence-only programs fail to consider social norms, and assume that adolescents are making decisions on an individual basis. Students are taught such lessons as, “abstinence from sexual activity outside marriage [is] the expected standard for all school age children” (2). However, nearly half of American teenagers are sexually active (4). Social networks play a large role in teenagers’ decisions to engage in intercourse (12). Through wider social networks, students see that abstinence is not, in fact, the standard. Teenagers will be much more likely to listen to their friends than to their teachers (3). Clearly, if sexual education programs are to work, they need to take these wider social networks into account. Studies have shown that in smaller, more insular communities of students, when remaining a virgin is considered to be socially acceptable, teenagers will be more likely to do so (11).
The most effective sex education programs “include activities that address social pressures that influence sexual behavior” (13). Teenagers are deluged by societal forces that use sex as a marketing tool. The media widely displays images that show that being sexually active is the social norm. Marketing campaigns that use sex to sell their products may enforce fears in teenagers that being a virgin is not the social norm. If sexual education is to make an effective, measurable impact on teenagers, it must account for the myriad factors that account for teenage health behavior (13). Adolescents do not always make rational decisions, and societal forces, such as social networks and the media, impact their health behavior more than teachers do.

Many Abstinence-Only Programs Fail to Account for Self-Efficacy
Self-efficacy refers to “individuals’ beliefs about their ability to perform the behavior of interest” (8). Many health decisions are affected by self-efficacy. If people believe that they can achieve a desired health behavior, they are more likely to take steps to achieve that desired health behavior. Conversely, if people believe that they will be unable to achieve a desired health behavior, it is much less likely that those people will even attempt the steps necessary for the behavior.
Many abstinence-only programs are taught in moral terms (9). Students are taught that those who remain abstinent are morally superior to those who are sexually active (9). This may lower the self-efficacy of sexually active teens, due to feelings of shame and embarrassment. These negative feelings may cause people to hide their behaviors, thereby leading to a lack of desire to take further preventive action. Such students are less likely to see a doctor about sexual concerns (9, 11). The students feel that they are already at risk for a disease, and that there is nothing that can be done to change that fact. Therefore, they do not make healthy decisions, and expose themselves to more of the negative consequences. One study showed that adolescents who had already engaged in sexual intercourse prior to receiving abstinence-only education were more likely to drop out of the programs. Furthermore, such programs had no measurable effect on their sexual practices (14). Conversely, higher self-efficacy is linked to higher rates of contraception use (6). When people feel more in control of their health behavior, they will be more likely to take preventive actions.
Problems with self-efficacy are also seen in homosexual teenagers in abstinence-only courses. By its definition, abstinence-only-until-marriage education implies gay and lesbian students are not part of the social norm. These educational programs teach that, “sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects” (2). However, in all but one state, homosexuals are legally unable to marry. The only option presented to gay teens is a life of abstinence, which is quite unrealistic. Homosexual teens tend to be ignored in these programs, and this exclusion creates a stigma (9). By creating this stigma, and telling adolescents that they fall outside of the social norm, it can lower their self-esteem and force them to engage in riskier health behaviors. Those who feel that their sexual practices are “unclean,” or “wrong,” may take extra steps to hide their relationships and desires. They would be less likely to seek preventive measures for fear of further stigmatization (15).
When people feel the stigma of being “different,” whether they are gay, or have already engaged in sexual behavior, their self-efficacy is affected. Students are placed at a higher risk for negative consequences. As demonstrated by studies of condom use in gay men, people need to feel in control of their bodies and lives in order to feel empowered enough to make healthy decisions (16). Many sexual education programs reflect a single view of a single kind of sexuality, neglecting alternate forms of love (9).

Messages in Abstinence-Only Curricula are Often Unclear
Messages in abstinence-only education courses are sometimes unclear. Many times, “abstinence” is defined in moral terms, and can be colored by interpretation (9). It may be difficult for teenagers to understand what they are being asked to do. In addition, some abstinence-only education classes present conflicting information. As demonstrated by the creators of the “Truth” campaign, teenagers do not respond well to being deceived (10).
One study showed that not every teenager who received abstinence-only education actually knew what “abstinence” was. When asked to define “abstinence,” answers varied depending on age, grade, school, and amount of personal sexual experience, suggesting marked confusion about the term (17). Teenagers are more likely to engage in other kinds of unprotected sexual activity when they interpret the meaning of “abstinence” as merely refraining from vaginal intercourse (9).
Numerous studies have shown that abstinence-only education lies about the effects of condom use and risks of sexually transmitted infections (1). For example, one curriculum compared condom use to playing Russian Roulette, in that there is a one in six chance that the user will be killed (18). Another curriculum states that AIDS can be transmitted via skin-to-skin contact (19). This information is blatantly false. If students do not know whom they can trust, their perceived susceptibility to pregnancy and sexually transmitted infections may be altered. Studies have shown that those who doubt the effectiveness of contraceptives will be more likely to engage in unprotected sex (20, 21).
Teenagers without accurate information are at a higher risk for sexually transmitted infections and pregnancy (9). The most effective sex education courses enforce a clear and consistent message about using contraception, as well as the risks of pregnancy and HIV (13).

Studies have shown that sexual practices adopted by teenagers have effects on their adult sexual practices (6). High school should be a time when safe sexual practices are learned, so that they may be carried into adulthood. There must be programs in place that appeal to teenagers, and will account for the differences in interpretation. Current federal policies are not working, and have been shown to have little to no effect on teenagers’ sexual practices. Before more money is spent on ineffective practices, influences that determine health behavior must be examined.
Teenagers need a clear message, presented without moral interpretation. They should be made to feel that they are capable of taking control of their own health decisions, regardless of past sexual activity or sexual orientation. At no time should teenagers be made to feel ashamed about past decisions. Most importantly, teenagers should be equipped with information that they can use to make healthy choices.

1. The Content of Federally Funded Abstinence-Only Education Programs, US House of Representatives Committee of Government Reform, prepared for Rep. Henry Waxman (D-CA), December 2004.
2. Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Pub. L.No. 104-193, 1996.
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4. Department of Health and Human Services Centers for Disease Control and Prevention. Youth risk behavior surveillance – United States, 2005. Morbidity and Mortality Weekly Report 2006;55:1-108.
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13. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: The National Campaign to End Teen Pregnancy, 2001.
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16. Siegel M. The importance of formative research in public health campaigns: an example from the area of HIV prevention among gay men (Appendix 3-A), pp. 66-69. In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett Publishers, 2004.
17. Ott M., Pfeiffer EJ, Fortenberry JD. Perceptions of Sexuality among High-Risk Early and Middle Adolescents. Journal of Adolescent Health 2006; 39(2): 192-198.
18. Roach N, Benn L. Me, My World, My Future. Spokane, WA: Teen-Aid, 1993.
19. Duran MG. Reasonable Reasons to Wait. Chantilly, VA: A Choice in Education, 2003.
20. Advocates for Youth. Toward a Sexually Healthy America: Roadblocks Imposed by the Federal Government’s Abstinence-Only-Until-Marriage Education Program. Washington, DC: Advocates for Youth, 2001.
21. Landry D, Kaeser L, Richards CL. Abstinence promotion and the provision of information about contraception in public school district sexuality education policies. Family Planning Perspectives 1999;31:280-286.

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