Why Promoting Abstinence-Only-Until-Marriage Is Not The Right Solution For Fighting The STD Problem Among American Adolescents - Andrea Niederhauser

The Center for Disease Control and Prevention (CDC) estimates that out of the 19 million new STD infections that occur every year, approximately half of them affect sexually active adolescents between 15 and 24 years (1). Furthermore, the CDC identified “sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV)” (2) as one of the six leading causes of morbidity and mortality among adolescents. This is reason enough to consider STD-infections among adolescents as a major public health issue and to examine the main prevention and intervention activities which target this problem.

In 2004, President Bush incorporated the STD problem among adolescents in his State of the Union Address and declared that “Each year, about 3 million teenagers contract sexually-transmitted diseases that can harm them, or kill them, or prevent them from ever becoming parents. In my budget, I propose a grassroots campaign to help inform families about these medical risks. We will double federal funding for abstinence programs, so schools can teach this fact of life: Abstinence for young people is the only certain way to avoid sexually-transmitted diseases”(3). This quotation demonstrates that the government is of the opinion that STDs and other health threats due to sexual behavior can be effectively prevented through the promotion of sexual abstinence.

First started in 1981, federal funding for abstinence-only-until-marriage programs has currently reached up to 176 million dollars annually (4). However, while the government continues to pour money into these educational programs, more and more studies show that the abstinence-only approach to STD prevention is not successful. Programs which promote abstinence-only-until-marriage fail in preventing STD-infections among adolescents for three main reasons; they consider sexuality as inherently problematic, they neglect the fact that imposing a normative behavior on teenagers can be counterproductive and they don’t take into account the various social and cultural norms which influence the sexual behavior of adolescents.

Definition and prevalence of STDs among adolescents

The term Sexually Transmitted Disease (STD) refers to a number of diseases, including Chlamydia, Gonorrhea, Genital Herpes and Syphilis, which are passed on from one person to the other through any sort of direct sexual contact. One particularity of STDs is that they are often asymptomatic; as a result, the diseases can be present and transmitted without the knowledge of the infected person and measuring the prevalence of STDs in a population can be imprecise or inadequate. STDs can be diagnosed through blood tests or a culture and can be treated with antibiotics. Having an STD can be a major health threat; it can damage the female reproductive organs and lead to infertility, cause genital infections and can be passed on to a baby during pregnancy or birth (5).

Estimates for the year 2000 suggest that out of a total of 18.9 million new STD infections, 9.1 million or 48% occurred among young people aged 15 to 24 (6). A recently released CDC study found that one in four, or 26% of all American teenage girls aged 14 to 19 have at least one STD (7). For that reason there is no doubt that STD infections among adolescents are a major public health threat and need to be addressed as such.

The flaws of the abstinence-only-until-marriage concept

The American government realized already in 1981 that sexual health problems among American teenagers are a growing public health concern. As a consequence, the Regan administration decided to address the crisis through the promotion of sexual abstinence as the only way to avoid negative health outcomes and established the Adolescent Family Life Act in order to promulgate this concept (8). As mentioned in the introduction, President Bush has carried on with this ideology and has even strengthened the federal stance on the topic by steadily increasing the annual funding into abstinence-only programs.

In 2007, the US government has allocated a total of $176 Million into three separate abstinence-only programs; the Community-Based Abstinence Education Program, the Social Security Act, Title V, Section 510 education programs and the Adolescent Family Life programs (9).

The Social Security Act, Title V includes a list of the eligibility criteria for programs to receive funding. It defines abstinence education as “an educational or motivational program” which “(A) has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity; (B) teaches abstinence from sexual activity outside marriage as the expected standard for all school age children; (C) teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems; (D) teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity; (E) teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects; (…)” (10).

This quotation gives an idea of how the government conceptualizes abstinence and sexuality. Sexual activity and marriage are strongly tied together; (heterosexual) marriage is defined as the norm of human relationships and sexual intercourse is expected to exclusively take place within the boundaries of this social institution. In addition to that, premarital sexuality and adultery are condemned as problematic and harmful. Throughout the paper, we will see how this understanding of sexual activity and abstinence is one of the main reasons why abstinence-only programs cannot be successful in preventing STDs among adolescents.

Sexuality as a deviant behavior

One of the principal flaws of the abstinence-only programs is the assumption that the rate of STDs can be decreased by preventing youth from engaging in sexual intercourse. However, sexual activity is a crucial part in the life of teenagers and cannot simply be eliminated.

“What we believe sexuality is, or ought to be, structures our responses to it (11)” Jeffrey Weeks writes in his book on sexuality. The author argues that a belief that accepts sexual activity only within the boundaries of social institutions such as heterosexuality, family and marriage and otherwise blames it to be harmful and disruptive and in need of strict regulation, can be called an absolutist position (12). Accordingly, the US government has clearly adopted an absolutist position in regard to teenage sexual behavior. Sexual activity is perceived as “likely to be harmful”, point proven by the high STD prevalence among adolescents (along with teenage-pregnancy and HIV-infections). By consequence, the logical response appears to be the suppression of such harmful behavior and the promotion of sexual abstinence.

While the federal government clings to this essentialist concept of sexuality, it neglects the fact that various social processes in Western cultures over the last four decades have brought by a new understanding of sex. The use of contraceptives allowed women to have more control over the outcomes of sexual intercourse and increased sexual activity outside marriage. The weaker commitment to authorities such as religion and the higher individualism and self-reliance emphasized the idea of personal liberation and sexual fulfillment (13). Finally, academic discourse shifted the understanding of sexuality from an essentialist to a constructivist approach, pointing out that the meaning that a society attributes to sexuality is always shaped by various social and cultural forces (14).

These examples show that American teenagers currently experience their sexuality in the midst of the tensions between the restrictive, conservative moral embodied by abstinence-only programs and the messages of a sexually liberated culture. As Lynn Ponton puts it “American teens are faced with taboo, miscommunication, and often direct prohibition that may contradict other messages they receive from the culture at large (15).

After an increase of sexual activity in the 1960s and 70s, especially among teenage girls, the number of adolescents having sexual contacts has stabilized in the last few years (16). According to the CDC Youth Risk Behavior Survey of 2005, 46% of all the surveyed 9^th through 12^th graders have had experienced sexual intercourse; 33% of them were sexually active in the three month preceding the survey (17). There has been a slight decrease in the number of adolescents who are sexually active, compared to previous years. This fact is often used as a proof of success of the abstinence-only programs. However, a national congress authorized evaluation of four abstinence-only programs concluded that abstinence-only programs did not have a significant impact on the sexual behavior of the adolescents. The findings suggested that teens enrolled in abstinence-only programs were not more likely to abstain from sex than the ones in the control group (18). The same conclusion can be found in the study of Jemmott and colleagues, which showed in a randomized controlled trial that abstinence intervention did not have a long-term effect in reducing sexual activity among the African American girls in the study (19).

The aforementioned statistics show that sexuality is a vital part in the life of almost half of the adolescent population. This is not only due to the fact that the teenage years are a period of biological “awakening”, but also because sexual behavior is a much encouraged behavior in modern society. Abstinence-only programs will continue to be inefficient because they are asking “that they [the adolescents] “just say no” to sex despite the ubiquitous message that it will transform their lives” (20). In addition to that, the negative attitude towards adolescent sexuality can result in adverse health effects, because they stigmatize the individuals who have already chosen to have sex and the ones who have already contracted an STD, as well as the homosexual teenagers who won’t be able to satisfy the “expected standard” of heterosexual marriage.

In order to address negative health outcomes related to sexual activity, public health interventions need to challenge the traditional position which labels adolescent sexuality as deviant behavior outside tolerable standards. Instead, they should accept the fact that teenagers do have sex, promote responsible sexual activity as the new social norm and engage in an open-minded and honest discussion around the topic.

Imposing a normative behavior is counterproductive

Adolescence is a period when young people are starting to detach themselves from their parental “shelter”, and when they want to take control over their lives and make their own decisions. Rather than acknowledging that young people want to decide on their own what is best for them, abstinence-only programs try to make adolescents adopt one normative behavior. This can be counterproductive, as it can provoke rebellion against the norm and encourage teenagers to engage in sexual risk behavior.

Youth does in general not appreciate when they are being told what to do (21). The more adolescents feel they are forced to do something that others believe is best for them, the more likely they will rebel against this imposed behavior. A paper on adolescent alcohol consumption for example suggests that “Drinking may become a behavior that is symbolic of defiance of authority; it may become an expression of rejection of the normative demands of the social order and of those who enforce them” (22). Rather than complying with the standards set by parents or school teachers, adolescents adopt a certain deviant behavior as a sign of rebellion against the expected norm. It can be argued that this is not only true for alcohol consumption or smoking, but also for sexual behavior. Abstinence-only programs try to tell youth what is good for them and what they should do and not do. By preaching to them which behavior is socially expected, abstinence-only programs might therefore cause adverse reactions in youth and give them incentives to adopt these “forbidden” behaviors.

In Europe, STD and HIV prevalence is a much less significant problem than in the US. One reason for this could be that in general, European countries adopt a different approach to adolescent sexuality. European sexual health interventions do not try to prevent adolescents from having sex and do not stigmatize sexuality as a problematic behavior. Instead, they acknowledge that adolescent sexuality as a vital component of their life and therefore empower teenagers to adopt a healthy and safe sexual behavior. These interventions show adolescents that they are being taken seriously and trusted to make their own, responsible decisions when it comes to engaging in sexual relations (23).

Public health interventions need to recognize that adolescents want to be capable of “thinking, feeling, and making moral decisions that are truly your own, rather than following along with what others believe” (24). Acknowledging this fact can transform sex from an act of rebellion against the social norms and expectations, and can be rather serve as a domain where adolescents can prove their autonomy and ability to make responsible decisions.

The limitations of an individual-centered approach

Abstinence-only based STD interventions can also be criticized by the fact that they attempt to change an individual’s behavior without taking into consideration the various social and cultural factors influencing and determining this behavior.

The risk of the sexual transmission of diseases is tightly linked to the frequency of unprotected sex; intervention strategies therefore need to focus on reducing this frequency. This can be done in two ways; either by promoting abstinence from any sexual contact or by promoting responsible, safe sex (25). Both approaches include a change of behavior, however, while the first one focuses on imposing a restrictive, normative behavior on the individual, the latter acknowledges the complexities of adolescent sexuality.

One traditional theory of health behavior is the Health Belief Model, which suggests that adopting or changing a certain behavior is a process of rational decision making based on the evaluation of costs and benefits (26). The abstinence-only programs can be understood in terms of this model, because they expect that teaching adolescents the harmful outcomes of sexual activity will increase the perceived susceptibility to these risk as well as the perceived severity of the outcomes; the teenagers will then conclude that the benefits of abstaining from sex are higher than the negative consequences of being abstinent and will be incentivized to restrain from sexual activity.

Studies mentioned earlier in this paper however have shown that abstinence-only programs are neither successful in reducing sexual activity among adolescents sexual, nor in reducing the numbers of STD infections among adolescents. One of the main reasons for this is that abstinence-only programs do not account for the various norms, values and expectations which inform the behavior of the adolescents and their attitude towards sexuality, but rather treat the individual as an entity detached from any social context.

Public health research has increasingly shown that human behavior is embedded in a complex environment and that a person always acts within a network of interdependent individual, cultural, socioeconomic, political and environmental factors (27).

On an individual level, factors such as the awareness and level of information about health risks can influence the decision whether or not to engage in unprotected intercourse. This is what the classic Health Belief Model and the abstinence-only programs focus on.

Most often however, this decision depends on a larger set of social and cultural factors; for example the beliefs and values attached to sexuality through religious traditions and the positive or negative messages communicated through the family, peers, teachers and the media.

Pressure from peers or the media can be especially important in influencing adolescent sexual behavior. Peer pressure can be defined as a “subjective experience of feeling pressured, urged, or dared by others to do certain things” and can lead teenagers to willingly or reluctantly do some actions sanctioned by the group as a whole, because of the need for popularity, conformity and integration (28). A study among 1011 black and white middle-school kids showed furthermore that mass media had an important influence on the attitude of adolescent towards sexual as well. The media was found to be a major source of information for adolescents and, mostly depicting risk-free, recreational and non-married sex, often in contrast with the values taught at school or in the family (29).

On an even more fundamental level, sexual behavior can also be influenced by socioeconomic and structural factors. Financial reasons might restrain adolescents from accessing health care and confidentiality reasons or distrust in the system can be other reasons why adolescents would not seek out for care or counseling when needed (30).

While abstinence-only campaigns often treat adolescents as a monolithic, white, middle-class, heterosexual group (31), statistics also show that females and members of minority groups are disproportionately higher affected by STDs (and other sexually related health problems) than others. Unfortunately there are not many estimates on adolescents; however the currently released CDC study indicates that teenage girls are much more affected by STDs than men and that the rates are highest among African American girls (48% compared to 20% among white and Hispanic girls) (32). Racial disparities in health are associated with lower socio-economic status, poverty and poor education, but also with different cultural understandings and personal experiences of racism and discrimination (33). In relation to sexual behavior, research has for example shown that living in impoverished, racially segregated neighborhoods can be conducive to adolescent sexual risk behavior, because “in these neighborhoods, positive adult role models and adult supervision are scarce, and youth sexual activity may be considered normal and not an obstacle to future attainment” (34).

These findings suggest that interventions - such as the abstinence-only programs – which try to apply a one-size-fits-all solution to individual risk behavior, do not understand the fundamental factors which influence this behavior and do not acknowledge the complex web of interactions which govern the actions and decisions of the individual; therefore they will not be likely to provoke any change in behavior.

All these different points show that the decision of an adolescent to engage in (risky) sexual relations is influenced by a very complex set of factors and cannot be solely understood on an individual level. Rather than concentrating on preaching abstinence, STD interventions need therefore to embrace a comprehensive approach to teenage sexuality. Rational-empirical interventions are crucial in order to make sure that adolescents receive accurate information on the possible health threats of sexual intercourse, that they have the opportunity to evaluate strategies to avoid these risks and that all teenagers have equal access to condoms and STD screenings. However, public health interventions have to go beyond this level in order to understand the social context within which adolescents are socialized, the norms, expectations and pressures with which they are confronted in their daily social interactions and the fundamental structures which influence and determine their decisions.

Synthesis

Abstinence-only programs are not an effective strategy to prevent STDs among adolescents. They consider sexuality as harmful and uniquely acceptable within the boundaries of heterosexual marriage. Adolescents who cannot or do not want to comply to this standard, either because they already had sex, are sexually active or are homosexual are thereby stigmatized and deprived from vital information on alternative strategies how to avoid or treat STDs. In addition to that, abstinence-only programs try to regulate sexual behavior by telling adolescents what is good for them; an approach which likely can cause rebellion and higher risk behavior among adolescents. Lastly abstinence-only programs consider sexuality as a biological drive which can be suppressed through the will of the individual. However, it does not acknowledge that changing behavior is more than just a pure individual act of will and that behavior is often determined by larger social and cultural factors, such as socio-economic status, family processes and peer-pressure.

References

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2. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance– United States, 2005. Surveillance Summaries, MMWR 2006;55(No. SS-5), page 1.

3. http://www.whitehouse.gov/news/releases/2004/01/20040120-7.html; accessed on 3/12/2008

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5. http://www.cdc.gov/std/; accessed on 4/2/2008.

6. Weinstock H., Berman S. and Cates W. Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health 2004:36(1), p. 6-10

7. http://www.cdc.gov/stdconference/2008/media/summaries-11march2008.htm#tues1; accessed on 4/2/2008.

8. Perrin, K. and Bernecki DeJoy, S. Abstinence-Only Education: How We Got Here and Where We're Going. Journal of Public Health Policy, 2003:24(3/4), p. 445-459.

9. http://www.siecus.org/policy/SpecialReports/Alabama_Report.pdf; accessed on 4/2/2008.

10. http://www.socialsecurity.gov/OP_Home/ssact/title05/0510.htm#ft19; accessed on 3/19/2008.

11. Weeks, J. Sexuality. 2^nd ed. New York: Routledge, 2003, p. 105.

12. ibid. p. 105-106.

13. Joyner K. and Laumann, E.O. “Teenage Sex and the Sexual Revolution”. In: Laumann E.O. and Michael R.T (Eds). Sex, Love and Health in America. Chicago: The University of Chicago Press, 2001, p. 41-71.

14. Weeks, J. Sexuality. 2^nd ed. New York: Routledge, 2003, p.20.

15. Ponton, L. The sex lives of teenagers : revealing the secret world of adolescent

boys and girls. New York: Dutton, 2000, p.4.

16. Moore, S., Rosenthal, D. and Mitchell A. Youth, AIDS and sexually transmitted diseases. London: Routledge, 1996.

17. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, 2005. Surveillance Summaries, MMWR 2006;55(No. SS-5).

18. Mathematica Policy Research Report http://www.mathematica-mpr.com/publications/pdfs/impactabstinence.pdf; accessed on 2/20/2008.

19. Jemmott, J. B. et al. Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents. A Randomized Controlled Trial. JAMA, 1998:279, p. 1529-1536.

20. Irvine, J. M (Ed). Sexual cultures and the construction of adolescent identities. Philadelphia: Temple University Press, 1994.

21. Hicks, J. The strategy behind Florida's "truth" campaign. Tobacco Control 2001:10, p. 3-5.

22. Norman, A.C. Alcohol and Adolescent Rebellion. Social Forces 1967:45(4), p. 542-550.

23. http://www.advocatesforyouth.org/publications/european.pdf, accessed on 4/10/2008.

24.http://www.ianrpubs.unl.edu/epublic/pages/publicationD.jsp?publicationId=54; accessed on 4/13/2008.

25. Jemmott, J. B. et al. Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents. A Randomized Controlled Trial. JAMA, 1998:279, p. 1529-1536.

26. For a discussion of the Health Belief Model see for example

Edberg, M. Essentials of Health Behavior. Social and behavioural Theory in Public Health. Sudbury: Jones and Bartlett, 2007, p.35-38.

27. Edberg, M. Essentials of Health Behavior. Social and behavioural Theory in Public Health. Sudbury: Jones and Bartlett, 2007, p.35-38.

28. Santor, D.A., Messervey, D. and Kusumakar, V. Measuring Peer Pressure, Popularity, and Conformity in Adolescent Boys and Gils: Predicting School Performance, Sexual Attitudes, and Substance Abuse. Journal of Youth and Adolescence, 2000:29(2), p. 163-182.

29. Ladin L’Engle, K., Brown J.D. and Kenneavy K. The mass media are an important context for adolescents’ sexual behavior. Journal of Adolescent Health 2006:38, p. 186-192.

30. American Social Health Association, State of the Nation 2005: Challenges

Facing STD Prevention Among Youth – Research, Review, and Recommendations, Research Triangle Park, NC: ASHA, 2005.

31. Irvine, J. M (Ed). Sexual cultures and the construction of adolescent identities. Philadelphia: Temple University Press, 1994.

32. http://www.cdc.gov/stdconference/2008/media/release-11march2008.htm; accessed on 3/12/2008.

33. SB721 Course Readings from March 27^th 2008.

34. Ramirez-Valles J., Zimmerman, M.A, Newcomb, M.D. Sexual Risk Behavior among Youth: Modeling the Influence of Prosocial Activities and Socioeconomic Factors. Journal of Health and Social Behavior, 1998:39(3) p. 237-253.