Conservative, Ideological thinking or public health intervention?: missing the whole scope, a critique of the “Abstinence-Only” program- Jamila Gales

Preventing teen pregnancy, the spread of STD’s and other dangerous sexual behavior amongst youth, is a major public health concern today. Most adults, parent and educators, support the idea of abstinence from sexual activity for school-age children and young adults as a means of prevention. The concept of abstinence being taught as a measure of prevention, must be done in a accurate context, and along with other preventative methods that can also help keep active teenagers safe. As stated in Kaisers article, “The public supports a broad sex education curriculum that stresses abstinence as the best way to avoid unintended pregnancy and sexually transmitted infections (STIs), but that also conveys complete and medically accurate information about contraception and condoms.” (8). The “abstinence-only-until-marriage programs”, are currently being taught in many schools, but only addresses the abstinence part as an appropriate approach to sexuality education, particularly for younger children. The program does not provide adolescents additional information they need to stay healthy.

Federal support of such programs began in 1982 with a limited pool of funding through the Adolescent Family Life Act. Beginning in 1996, funding for abstinence-only and abstinence-only-until-marriage programs also referred to as abstinence-only, grew exponentially with the enactment of welfare reform (16, 7). Despite strong public preferences, the federal government has invested more than $1.5 billion in state and federal dollars since 1997 into prescriptive abstinence-only and abstinence-only-until-marriage programs, which have been reported to be ineffective and misleading to youth. (11).

As a bases for funding, federally funded abstinence-only-until-marriage education programs must adhere to a strict eight-point definition. Requirements for funded programs teach, “exclusive purpose of teaching the social, psychological, and health gains to be realized by abstaining from sexual activity.” (7). Amongst other things they are required to teach that “It is expected for people to abstain from sexual activity outside of marriage, abstinence is the only certain way to avoid out of- wedlock pregnancies and STIs, Harmful physical and psychological effects are associated with sexual activity outside of marriage and that Only one form of familial structure. (7).

The eight-point definition, (found in Appendix A), fails to have public health and social science research as its base. Instead, one can argue that the requirement points are more based on political, religious and conservative attitudes and opinion rather than the public health needs of teenagers and young adults who are both sexually active and inactive. In contrary to the goal of any comprehensive sexuality education programs/ interventions that aim to educate and promote people to practice healthy and responsible sexual behavior, many aspects of these 8 point definitions are in opposition to those goals. Some aspects of the 8 requirements are not objectionable and have a great bases for a great intervention however, others run counter to public health findings and needs, and the realities that today’s young people face daily. (7). The 8 point definition requirements that all abstinence only programs must adhere to can be found in appendix A of this paper for your review. This paper will critique and discuss 3 aspects of the “abstinence-only-until-marriage programs” that make the program ineffective and suggest methods of improving them.

One reason the “abstinence-only-until-marriage” programs are failing is federal requirement B. This requirement aims to teach “that abstinence from sexual activity outside marriage is the expected standard for all school age children.” (16). Unfortunately in the year 2010 and for the past two decades this has not been a reality for youth. Public health statistics show that “sexual behavior amongst American teenagers is almost universal. Eighty-five percent of young adults ages 18 to 24 and 56 percent of adolescents ages 15 to 17 reports having “been with someone in an intimate or sexual way (including but not limited to intercourse).” (15). Data from the 2007 Youth Risk Behavior Surveillance System of the U.S. Centers for Disease Control and Prevention (CDC), reports that, 48 percent of all high school students and 65 percent of high school seniors report having engaged in sexual intercourse. (4). Another survey of college students reported that 80 percent of students 18 to 24 years of age had engaged in sexual intercourse. (19)

The social norms approach, which has been used to counter misperceptions of social issues, has been applied here but unfortunately in the reverse manner. (12). The Abstinence only programs use this theory in the sense that it implies that the norm is that most teenagers do not engage in sexual activity before marriage. The truth is that more teens than reported are participating in sexual activity pre marriage, making the idea of abstinence before marriage the misperceived norm. The truth is teens are having sex and it needs to be addressed in order to promote the reality of these behaviors, along with preventive methods.

Additional studies further contradict this definition point that abstinence from sexual activity is an expected standard or norm for today’s youth. These studies suggest that even those young people who remain virgins during their teen years engage in some forms of sexual behavior. For instance, of the teens that took a pledge to remain virgins until marriage, 13% of virgins who took a pledge reported engaging in oral or anal sex compared to 2% of virgins who did not take the pledge. (3).

Within this definition, and the whole 8 point standard, it fails to include all the variable definitions of sexual activity. Oral sex, anal sex and other methods of avoiding vaginal penile intercourse is a common practice amongst youth to maintain the set idea of virginity. In the Lindberg article, it is states, “Although non-coital sexual acts—such as oral and anal sex—are common, little research has systematically studied these behaviors among adolescents. Anecdotal evidence, however, has led to a concern that today’s teens are engaging in oral and anal intercourse more than teenagers in the past, that they are responding to increasing pressures to remain abstinent by engaging in oral and anal intercourse as a way to stay “technical virgins,” and that they view oral and anal sex as less risky than “real” sex. (9). Without clarification, educational information and identification of the various sexual behaviors through the “abstinence only until marriage” program and other programs that address adolescent sexual behavior it can appear to encourage the idea that alternative sexual behavior is less risky and less dangerous and is ok to practice because intercourse that does not break the hymen of the female is ok and does not interrupt virginity. Without information on these alternative sex methods, youth are also not learning adequate information on the risks of those behaviors.

The fact is that these alternative sexual behaviors may reduce the risk of teen pregnancy, but do not prevent the spread of disease. This way of thinking needs to be a major public health focus within this “abstinence only” program, to educate and inform the youth on the risk of these behaviors as well. If the youth see these alternative sexual behaviors as acceptable and desirable because it still fits within the context of the defined ‘abstinence”, they will continue to practice them.

According to the theory of reasoned action, If a person believes that performing a given behavior will lead to on the whole positive outcomes, then s(he) will hold a favorable attitude toward performing that behavior. On the other hand, a person who believes that performing the behavior will lead to mostly negative outcomes will hold an unfavorable attitude. (5). As it pertains to the “abstinence only” program, teenagers and young adults who are already sexually active may feel a sense of rebellion against this programs ideas and have a negative attitude towards conforming to them because it is too late for them to produce the positive outcome suggested by this program. At young ages, people tend to be rebellious by nature as it is, so when they feel outcaste and looked down upon by “society” they may actually perform more risky behavior. This theory also addresses attitudes adolescents may have about alternative sexual activity, participating in activities other than vaginal-penile intercourse. The youth are seeing these alternative sexual behaviors as socially accepted and desirable, because they do believe that the outcome is positive in that they are still technically “virgins” and according to the “abstinence only until marriage” definitions, they are still practicing abstinence.

The self efficacy portion of the Health belief model would be an ideal way to effectively promote safer sexual practices amongst youth, including abstinence. The Self-efficacy concept originally developed by Albert Bandura, addresses a person's confidence in her/his ability to successfully perform an action required to manage prospective situations. (12). We use this model by, informing the youth that they can remain abstinent, and even with prior sexual experience, abstinence can be an adopted behavior for them as well. This will promote a sense of self responsibility and efficacy that the goal is attainable. With the re-evaluation the guidelines of the 8 point definition of the “abstinence only before marriage” program, a clear point can be made to the youth that abstinence from all sexual behavior is the desired outcome, however those that have participated in sexual activity before marriage have the ability to start abstaining now and or perform the efficient acts to be safe. This will encourage students and young adults that this is an obtainable goal for them.

Another major reason for the failure of the “abstinence only before marriage programs” is lack of essential information along with false, misleading and distorted information being delivered though curricula. Investigations by the minority staff of the House Government Reform Committee reviewed 13 commonly used abstinence-only curricula taught to millions of school-age youth. The study concluded that two of the curricula were accurate but that 11 others, used by 69 organizations in 25 states, blurred religion and science, and contained unproven claims and subjective conclusions or outright falsehoods regarding the effectiveness of contraceptives, gender traits, and when life begins. (18). Among the misconceptions and outright falsehoods was information that suggested: A 43-day-old fetus is a "thinking person.”, HIV can be spread via sweat and tears, Half of gay male teenagers in the United States have tested positive for HIV, Pregnancy can result from touching another person’s genitals, Condoms fail to prevent HIV transmission as often as 31 percent of the time in heterosexual intercourse, Women who have an abortion "are more prone to suicide, And as many as 10 percent of women who have an abortion become sterile. (18). The program also fails by excluding essential information from the youth on safer sex practices, HIV transmission and how to protect themselves if they decide to become sexually active. By not providing this information the abstinence-only-until-marriage programs leave a gap in knowledge and provide misinformation which leave the youth a higher health risk.

With the main goal of promoting preventative, healthy behavior, any public health issue and public health based program should make all health options a focus point of the program. Perhaps the Problem here is that this program is more concerned with the conservative view and old religious based practices, and is instead failing to include the public health aspect into it’s guidelines. Being that this program is a government based program, the “Government has an obligation to provide accurate information and to eschew the provision of misinformation. Such obligations extend to state-supported health education and health care services.” (19). One can argue that withholding essential information from youth at risk and giving false information on preventive methods is a violation of their rights. “By providing misinformation and withholding accurate information that youth need to make informed choices, abstinence-only-until-marriage programs violate youth’s basic human right to sexual health information, are ethically unsupportable, and inherently coercive.” (19). It is the ethical and moral responsibility for all health officials and educators to produce accurate information and statistics. People have a right and should be provided with the most accurate health information in order to take personal responsibility for good health behavior. These programs are limiting information on contraceptives, testing and other preventive and safe health behaviors available to them.

The truth is teenagers and young adults are participating in sexual behaviors that place them at risk for unintended pregnancy and STDs and more. By failing to be realistic about the real facts and behaviors, prevention of undesirable behavior, in this case abstinence will be unlikely. The federal definition of abstinence-only-until-marriage education program guidelines prohibits any discussion of contraceptives (except failure rates), pregnancy- and disease-prevention methods other than abstinence. (19). This information limitation is problematic and exclusive of sexually experienced adolescents. There is no context for this group of sexually active teens, within this program, that address the reproductive health needs distinctly different from the needs of sexually inactive youth. This needs to be addressed.

According to Seigel by focusing on total risk elimination rather than a more reasonable and attainable risk reduction strategy, the message lays out unrealistic goals and essentially sets the stage for the individual to fail (14). For teens that have already engaged in sexual activity, they may view them-selves as unworthy or as failures, and may result in increased undesired behavior. The goal of any public health based intervention/ program should never alienate any individual to the point of increased negative behavior. Based on the communication theory, utilizing a message that instills a sense of fear and dread in the audience has the exact opposite effect that it intends, and in opposition to the goal, it completely turns the recipient off from hearing the message. (10). This program promotes the idea of negative outcomes to people participating in out of marriage sex which is false and instills fear, not change.

Measures should be taken within the “abstinence-until marriage programs” to educate the youth that if they have already participated in, have thoughts of and or feel pressure to engage in sexual behavior, there are safe measures that can be taken. It is also important to remind youths that they can speak to knowledgeable adults about thoughts and behaviors without being judge or held to the strict 8 points of the abstinence until marriage program. Without blaming involved, the promotion of self efficacy, self worth, self esteem, are great focus points for allowing these young adults to assume responsibility for their actions whether that be by abstaining or using the proper contraceptives. The goal of the “abstinence only-before marriage” program is to prevent teenage pregnancy and sex. The program needs to adopt 8 more guidelines in preventive methods to address those youth that are not abstaining. It’s a new world and society from the 1980’s; the programs and interventions for youth should reflect that revolving change.

As a third means of by which the “abstinence only until marriage” programs are failing is that it discriminately presents one family structure as morally correct and beneficial to society, therefore excluding other types of families. Federal Requirement F “…teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society.” In any given classroom, group, and society, there are likely children of never-married or divorced parents. Does this requirement aim to suggest that these students and their families are aliens to society? Another case may be adopted children or children of gay, lesbian, Tran gendered and bisexual parents who face legal limitations with marriage. Making implications to these youth that their families are not normal or may be unworthy and the cause of societal problems will likely alienate them and will in return cause negative feelings about themselves and their families. Negative feeling about oneself and origin can cause increased risk-level behavior.

With the abstinence before marriage programs promoting marriage as the only acceptable family structure, it puts down the choice of many people to be single and or live in nontraditional arrangements. Despite the message of abstinence-only-until-marriage programs that marriage is the expected standard of human behavior, individuals should have the right to decide if marriage is an appropriate or desirable choice for them. “The number of Americans who are unmarried and single has been growing steadily in recent years, reaching 89.8 million in 2005, and including 41 percent of all U.S. residents age 18 and older. In 2005, 55 million households were headed by unmarried men or women -- 49 percent of households nationwide; and 12.9 million single parents lived with their children. Nearly 30 million people lived alone (26 percent of all households), up from 17 percent in 1970. Forty percent of opposite-sex, unmarried-partner households included children.” (17),

Within the same scope, abstinence-only-until-marriage programs also discriminates the LGBTQ youth. It does so by setting marriage as the only endpoint of sexual abstinence, which for many LGBTQ youth, is not a possibility because of laws. It also allows sex to fall in the context of penile-vaginal intercourse without regard to sexual orientation, which excludes an entire portion of today’s youth that are identifying with LGBTQ identities at earlier ages. These youth are also adapting to the older influences of the LGBTQ lifestyles and participating in sexual activity earlier, and at a higher rate. Many outside factors such as molestation, rape and other outside factors are also more, are identified in the LGBTQ youth, therefore adding another social aspect the program fails to take into consideration. This group also is a high risk group for HIV and Aids and this program needs to address this portion of education as well, in a accurate manner. “Non-heterosexual youth are more likely to have had sexual intercourse, to have had more partners and to have experienced sexual intercourse against their will than heterosexual adolescents, putting them at increased risk of STIs including HIVinfection.” (6).

For LGBTQ teens and for those struggling with their sexual orientation or sexual identity, the abstinence only-until-marriage approach can seem more harmful than good. With this programs ideological, religious base, conservative views, this program and many others typically teach students that homosexuality is deviant and immoral. It also promoting marriage as a strictly heterosexual institution can consequently, ignore the emotional and health needs of LGBTQ youth. (6).

The program would need to implement the idea promoting self esteem, diversity and inclusiveness, instead of discriminating, alienating and labeling. According to Labeling theory, the labels applied to individuals influence their behavior. Those who are labeled in a certain way actually take on the characteristics of those labels and live up to them as a self-fulfilling prophecy. (1). Labeling youth and or their family that are nontraditional as deviant, negative to society and unacceptable is destructive. By labeling the youth that may be participating in non traditional sexual acts, can also be destructive. By labeling these youth as “abnormal” or non-moral, it may result in them feeling defeated and unable to live up to the stipulations of the “abstinence before marriage” program and those rules set by a heterosexual, traditional society.

Public health can create a change in teenage and young adults sexual activity by shifting the attention from the current unrealistic message of “abstinence only before marriage”, toward the more proactive approach of addressing today’s reality as it pertains to traditional families, sexual orientation and sexual behavior of teenagers. Developing environments, education and guidelines that promotes social support and social networks could aid in prevention of teenage sex, teen pregnancy, STD and other negative sexual behaviors. Producing additional guidelines to the 8 points that must be followed to get federal funding, to include non traditional families and sexual orientation may increase the effectiveness of the program.

In conclusion, these requirements laid out by the government, conservatives and non public health officials, are based on the assumption that not just people, but teenager and young adults will make rational decisions. This Health belief model influenced aspect of the program intends to inform young adults that if they remain abstinent until marriage, they will not be susceptible to teenage pregnancy, std’s and other sexually based risk. What happens after marriage, if there is infidelity? Is this suggesting that married people do not face these adversities and problems? A married teenager giving birth is still teenage pregnancy. According to the HBM internalizing this susceptibility and potential severity, will show the young adults the benefit in remaining abstinent?, how will they know what the true implications of “abstinence” means if it is not defined thoroughly? How are they being presented with the benefits of remaining abstinent when the program does not include essential information on preventative practices, and does not include new sexual practices being used by youth today to adhere to the overall goal and pressure of being abstinent , yet still participating in sexually risky behavior by other means of sexual activity. This theory along with this program fail to acknowledge the outside obstacles teenagers and young adults. The program and theory fail to acknowledge various outside factors such as peer pressure, rape/molestation victims who may feel unworthy of identifying with “virginity” aspect, social factors and much more.

This program completely relies on the expectation that people make rational decisions. The fact is that people, especially teenagers do not always have rational behavior. The theory of reasoned Action which was designed to explain not just health behavior but all volitional behaviors, takes into consideration outside obstacles, which is apart if the HBM and could be applied to this program. (13). Considering an abundant number of teens have had sex, even when encouraged not to, sex education needs to be driven by public health principles and not ideology. The fact remains, sex education should continue to promote abstinence as the best option for teens. But given that so many young adults are not abstaining from sex, programs have an obligation to help teens understand the risks and responsibilities that come with sex. Statistics continuesly indicate that adolescents have a tremendous unmet need for information related to sexuality, contraception, STIs, and making sexual decisions. Government-sponsored programs need to fill this information gap, not cause it to worsen.

Appendix A:

Table I.1. A-H Definition of Abstinence Education

A. Have as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity B. Teach abstinence from sexual activity outside marriage as the expected standard for all school-age children C. Teach 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. Teach that a mutually faithful, monogamous relationship in the context of marriage is the expected standard of sexual activity E. Teach that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects F. Teach that bearing children out of wedlock is likely to have harmful consequences for the child, the child's parents, and society G. Teach young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances H. Teach the importance of attaining self-sufficiency before engaging in sexual activity

Source: Title V, Section 510 (b)(2)(A-H) of the Social Security Act (P.L. 104-193).

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13. Siegel lecture, Spring 2010.

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16. Title V, Section 510 (b)(2)(A-H) of the Social Security Act (P.L. 104-193).

17. United States Census Bureau. Special edition, unmarried and single Americans week, Sept. 17-23, 2006. Press Release August 10, 2006. www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/007285.html, Accessed April 23, 2007.

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