Challenging Dogma - Spring 2008

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

Thursday, April 24, 2008

Failure Of The Healthy Futures Program-Grace Thiongo

Federal support for “abstinence-only” education programs has expanded rapidly. The federal government spends approximately $170 million on abstinence-only education programs. However, states are limited to spending the money on abstinence-education programs only. As a result abstinence-only education, which promotes abstinence from sexual activity without teaching basic facts about contraception, now reaches millions of children and adolescents each year in the United States. In contrast, comprehensive sex education encourages both abstinence and effective contraceptive use, which have been shown in many studies to delay sex, reduce the frequency of sex, and increase the use of condoms and other contraceptives. In addition, the abstinence-education programs, which promote sex after marriage, do not take the lesbians, gays, bisexuals and transgenders into account, who cannot get married in 49 of the 50 states. Massachusetts is among one of the states that promote the abstinence-only education curricula. Governor Mitt Romney announced in April 2006 that the state will funnel nearly $1 million in federal funds to a faith-based organization to teach abstinence to public middle school students in a dozen communities across the state [1]. This faith based organization is known as Healthy Futures.

A 2005 Youth Risk Behavior Survey [2] indicates that among Massachusetts high school students 45% ever had sexual intercourse, 34% had sexual intercourse during the past three months, 35% did not use a condom during their last sexual intercourse and 75% did not use birth control pills during their last sexual intercourse. CDC recommends better health education. A 2004 School Health Profiles indicated that among Massachusetts middle/junior and senior high schools that taught health education, 59% of them required students to take two or more health education courses, 94% taught abstinence as the most effective method to avoid STDs and 50% taught how to correctly use a condom and 40% taught the basic prevention methods of STDs.
Healthy Futures is a state- and federally-funded health program that bases its curricula on educating teens in the areas of sexuality, healthy relationships, and self-respect through arguably “medically-accurate” information and interactive skits and demonstrations. Further, it empowers teens to avoid the social, psychological and health consequences of early sexual activity and provides the skills necessary to attain abstinence before marriage [3]. Supporters of abstinence-only programs argue that they are an effective way of reducing pregnancies and reducing the spread of sexually transmitted diseases. The group, the largest of its kind in Massachusetts, was formed in September 2002 by A Woman's Concern, a pregnancy health services agency that lists its guiding principles on its website as the importance of the gospel, the sanctity of human life, and the soundness of sexual purity, marriage, and family [4]. The Healthy Futures program, a Boston-based agency, runs abstinence programs in several dozen schools across the state. The program, free to the school districts, is available to schools in 12 communities with high numbers of teen births, including Boston, Lawrence, Lowell, and Lynn [3].

Opponents of abstinence-only programs counter that teens are going to have sex anyway, and that such programs, by not teaching the merits of condoms and other contraception, increase the risk of pregnancy and disease.” The problem here is not the abstinence," said Angus McQuilken, director of public relations and governmental affairs for the Planned Parenthood League of Massachusetts, a leading provider of comprehensive sex education in the public schools [5]. ''We're doing them a disservice if we deny them medically accurate information about how to protect themselves" she says.

Healthy Futures And The Gay Community
Despite the nearly 15000 lesbian and gay teenagers in Massachusetts public high schools [6], and the growing visibility of gays and lesbians in the broader culture, few educators are willing to address homosexuality in the classroom. Advocates assert that including gay issues in sexuality education could help address heightened health risks faced by gays and lesbians due to misinformation and lack of information about safe-sex practices; emotional isolation that contributes to high suicide and dropout rates among gay teens; and widespread harassment of gay and lesbian students by their peers and teachers [7].

In a society that generally shuns from the idea of homosexual relationships and marriages, curricula that reject the idea of sexual intimacy among homosexuals ignore their need for critical information about protecting themselves from sexually transmitted diseases. The program’s objective of reducing the number of pregnancies and STDs among teens cannot be effective if a large number of teens who are vulnerable to these practices are excluded from the curricula. This ultimately undermines efforts to educate teens about protecting their health and also creates a hostile environment for gays and lesbian teens.

Stacy Weibley, a sexuality educator and public policy associate, states that teens face increased health risks, largely because of fear and ignorance [7]. In 1995, a study based on Minnesota teens published in the Journal of Adolescent Health found that lesbian and bisexual girls were more likely to become pregnant and more likely to have multiple pregnancies than heterosexual girls. In addition to the health risks, these teens can become suicidal as well. A 1995 report from the Centers for Disease Control and the Massachusetts Department of Education found that lesbian and gay youth are four times more likely than non-lesbian and gay teens to attempt suicide. And the U.S. Department of Health and Human Services has reported that gays and lesbians account for 30 percent of all teen suicides [7].
Including information about homosexuality, remains highly controversial among parents, school administrators and teachers. About 1 in 12 high school health teachers taught their classes that homosexuality is wrong in 1995, according to a survey of 211 U.S. school districts published in the Journal of School Health. LAMBDA reports that 77 percent of prospective teachers would not encourage a class discussion on homosexuality and 85 percent oppose integrating gay and lesbian themes into their existing curriculums [7].

Healthy Futures And Self-Efficacy
The curriculum teaches the adolescents and teens that abstinence from sexual activity until marriage is the expected social norm and the only manner in which to avoid sexually transmitted diseases and unwanted pregnancy. Healthy Futures plainly state in their curriculum that “sex is wonderful in the context of a faithful, lifelong relationship, which is marriage, but that there are physical and emotional risks outside of the context”. They also misrepresent the effectiveness of condoms in preventing sexually transmitted diseases and pregnancy. The curriculum teaches that the claim that condoms help prevent the spread of STDs, is not supported by the data; it also states that in heterosexual sex, condoms fail to prevent HIV approximately 31% of the time; and that a pregnancy occurs one out of every seven times that couples use condoms [3]. Abstinence-only program educators are not permitted to discuss the proper use of contraception, including condoms, as a way to reduce risk of contracting HIV or other sexually transmitted diseases.

The concept of self-efficacy based on Albert Bandura’s social cognitive theory assumes that human beings by means of self-esteem, exercise control over their thoughts, feelings and actions. This theory is rooted in a view that individuals are engaged in their own development and can make things happen by their actions [8]. Based on this ideology, the Healthy Futures curricula believe that teens and adolescents will not have sex before marriage because they are told that they should wait is being unrealistic. The virginity pledge program, strongly emphasized by Healthy Futures, encourages students to make a pledge to abstain from sex until marriage. However a study by Bearman et. al [9] found that while in limited circumstances virginity-pledgers may delay first intercourse, they still have sex before marriage and are less likely than non-pledgers to use contraceptives at first intercourse or even get tested for STDs when they do become sexually active.

Healthy Futures And Contraceptives
With only two-thirds of teens in the United States having had sexual intercourse by the time they are 18, it is vital to provide them with information to protect them [10]. Such discussions must include information on methods of reducing risks, including use of condoms and other birth control methods. While abstinence-only programs may delay sexual activity and reduce the number of sexual partners over a lifetime, abstinence-only education curricula that do not discuss contraceptive methods are placing the teens in danger of unwanted pregnancies and being infected with sexually transmitted diseases.
A study by Kirby [11] found that there is enough evidence to show that abstinence-education programs coupled with comprehensive sexual education, delay sex and reduce sexual risk among teens. It is disheartening that abstinence-only programs do not include comprehensive sex education in their curricula. According to Duberstein et. al [12] between 1995 and 2002, the proportion of adolescents who had received any formal instruction about methods of birth control declined substantially, and by 2002, one-third of adolescents had not received any advice on contraception.
Undoubtedly, the Healthy Futures abstinence-only education program presents information about pregnancy prevention and testing and treatment of STDs. However, they do so incompletely and inaccurately. For instance, a 2004 congressional report [13] concluded that many federally-funded abstinence-only curricula misrepresent the effectiveness of condoms in preventing STDs and pregnancies by exaggerating the failure rates. In particular, the Healthy Future program presents data on the effectiveness of latex condoms by using data from a 2000 workshop by the National Institutes of Health panel [14]. This program concludes that the NIH determined that there is insufficient evidence whether condoms can prevent STDs. However, looking at data from the NIH panel, they determined that the relative risk of acquiring STDs or getting pregnant decreases as condom usage increases from a relative risk of 0.006 of using a condom which then breaks, to using a condom with no break or leak at a relative risk of 0.0.

A vast majority of parents, teachers and health practitioners have been in recent years at a consensus that teens should receive complete and accurate information about abstinence and contraceptives. In a nationwide poll conducted by Kaiser Family Foundation, National Public Radio and Kennedy School of government [15], researchers found out that the majority of parents wish to a have comprehensive-based sex education curricula that cover topics such as condom use, sexual orientation and options such as abortion and adoption.
In addition, a national survey by Darroch et. al [16] that was carried out in 1999 among 7th-12th grade teachers found that 93.4% believed that sexuality education courses should cover birth control methods, 89% believed that curricula should cover factual information about abortion, 88.8% believed that the curricula should include where to go for birth control, 82% proposed that curricula should include correct ways to use a condom, and 77.8% believed that curricula should be geared towards other sexual orientations other than heterosexuals.

It is undoubtedly true that abstinence-only education programs aim to reduce the spread of STDs and unwanted pregnancies among teens. However, curricula need to further help them by giving them complete and accurate information about STDs and use of contraceptives effectively. In addition, lesbians and gays need to be taken into account as well, keeping in mind that they too are a vulnerable population and therefore their health needs to be protected as well. Lastly, the social cognitive theory only goes as far as a person’s will and strength takes them. Believing that teens will not engage in sexual practices until they are married is unrealistic particularly because of the influence of media and social networks as well.

8. Bandura, A. Self-efficacy: The exercise of control. New York. WH Freeman and Company. 2001.
9. Peter S. Bearman & Hannah Bruckner. Promising the Future: Virginity Pledges as they Affect Transition to First Intercourse 35 (2000); see also Hannah Bruckner & Peter Bearman, After the Promise: the STD Consequences of Adolescent Virginity Pledges, 36 J. Adolescent Health 271 (2005).
10. Hatcher RA et. al. Contraceptive technology, 18th rev. ed. New York: Ardent Media, 2004.
11. Douglas Kirby. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy 16 (2001)
12. Laura Duberstein et al., Changes in Formal Sex Education: 1995-2002, 38 Persp. Sex. & Reprod. Health 182, 184 (2006).
13. United States House of Representatives Committee on Government Reform – Minority Staff Special Investigations Division, The Content of Federally Funded Abstinence-Only Education Programs (2004) (hereinafter House Committee Report) Christopher Trenholm et al. Impacts of Four Title V, Section 510 Abstinence Education Programs (2007).
15. National Public Radio et al., Sex Education in America, General Public/Parents Survey (2004), available at
16. Jacqueline E. Darroch et al. Changing Emphases in Sexuality Education in U.S. Public Secondary Schools,1988-1999, 32 Fam. Plan. Persp. 204, 206 (2000).

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