Thursday, May 6, 2010

A Critique of Abstinence-Only Education and A Prop

Teenagers who engage in unprotected sexual activities face immense risk to their physical reproductive health, as well as to their social and emotional well being (1). Annually, over 800,000 adolescents become pregnant; 80% of these pregnancies are unintended (2). In addition, adolescents have the highest age-specific risk for many sexually transmitted infections (STIs), with 25% of new HIV infections occurring in adolescents under the age of 22 (2). In regards to physical health, long-term consequences of STIs can include infertility, tubal pregnancies, fetal and infant death, chronic pelvic pain, and cervical cancer (2). In addition to the adverse physical and emotional consequences for teen mothers, the offspring of adolescents often perform more poorly on indicators of health and social wellbeing than children of older mothers (2). The US continues to have a higher teen pregnancy rate than other developed countries, and despite its recent decline, the rate has decreased less rapidly than other countries during the last thirty years (3). In addition, despite adolescents initiating sexual intercourse at an earlier age than in years before, the prevalence of adolescent condom utilization has not increased since 1999 (3). Teen pregnancy and STI transmission is an important public health issue, not only for the directly affected adolescents, but also for society at large. Although abstinence-only education has been promoted as a successful intervention addressing teen pregnancy and STI transmission, this paper will provide a critique of abstinence-only education and argue that abstinence-only education is not meeting its intended goals. Instead, I will propose an improved comprehensive sexual health counseling program to address adolescent sexual behavior.
In 1981, the Adolescent and Family Life Act (also known as the chastity act) was enacted as a response to the social and economic problems resulting from risky adolescent sexual behavior (3,4). In addition, the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 occurred as part of a larger change to welfare policy that was prompted by national declines in marriage and an increase of births outside of marriage (3,4). As a result, in 1996, there were major expansions in federal support ($50 million dollars) for programming that supported abstinence-only education, and that restricted comprehensive sexual education (2). The funds were administered by the federal Maternal and Child Health Bureau at the department of Health and Human Services under title V of section 510 of the Social Security Act (welfare reform) (2). In addition, in 2000, the Community-Based Abstinence Education Project was funded through the Maternal and Child Health Block Grant for Special Projects of Regional and National Significance (SPRANS) (2). Programs funded under section 510 and SPRANS prohibit disseminating information on contraceptives and sexual orientation (2,4). In fiscal year 2005, federal funding for abstinence-only education programs rose to $168 million, the highest it had ever been (2).
Abstinence-only programs funded under SPRANS and section 510 must target 12-18 year olds, they cannot provide information on contraception or safe sex practices (even with private dollars), and they must teach all 8 elements shown in the table below (1):

Abstinence-only education is approached from both, the public health perspective, and from a moral and religious perspective. Those using the public health approach promote abstinence as a means to prevent teen pregnancy and STI transmission, while those using the moral lens place abstinence within the foundation of personal responsibility, commitment, and character development (5). Federal regulations for abstinence-only education funding have an inherent moral basis, requiring that abstinence-only education teach that, “a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity” (1). One primary definitional issue is that abstinence-only education programs are meant to prevent the initiation of “sexual activity”, but what constitutes sexual activity, what are teens expected to abstain from? For example, possible definitions of abstaining from sexual activity include postponing sex, never having vaginal intercourse (until marriage), as well as abstaining from touching, kissing, mutual masturbation, oral sex and anal sex (2). Overall, the intent of abstinence-only education is to discourage teens from initiating sexual activity so as to reduce the number of sexual partners and reduce their exposure to STIs and the risk of pregnancy (6). There are two main methods through which abstinence-only education programs are conducted; one is school-based sexual education, and the other is the “pledge” movement (7). The pledge movement was started in 1993 by the “True Love Waits” campaign. By 1995 2.2 million adolescents (12% of all adolescents) had taken pledges to abstain from sex until marriage (7). The successes and failures of the pledge movement will be addressed in greater depth below.
Critique 1. “Readiness”: Sexual Behavior as a Rational and Planned Act.

One primary flaw of abstinence-only education is that it assumes that adolescent sexual behavior is a planned and rational act. Abstinence-only education has, ingrained in it, an assessment of an adolescent’s “readiness” to engage in sexual activity (5). The individual’s level of readiness is determined by their personal characteristics, their relationship characteristics, as well as a balance of health, family and social risks (5). Using readiness as one element in sexual behavior decision-making is appropriate, however abstinence-only education ignores the fact that adolescents may (and often do) engage in sexual activity without necessarily being “ready” (5). The idea of readiness looks very similar to the Health Belief Model. When applied to abstinence-only education, the Health Belief Model states that adolescent sexual abstinence or sexual activity is the outcome of the individual’s: 1) perceived severity of the consequences of sexual activity, 2) their perceived susceptibility to those consequences, 3) the perceived benefits of abstinence, 4) the perceived barriers to abstinence, and 5) their self efficacy, or self-confidence, in abstaining from sexual activity (8). Under the lens of the Health Belief Model, abstinence-only education assumes that after weighing the risks of sexual activity with the benefits of abstinence, an adolescent will rationally plan to abstain from sex. However, adolescent sexual behavior is often sporadic and unplanned (5). Teens’ sexual decisions are often related to other distal factors such as family/peer relationships, interpersonal conflicts, insecurity/low self esteem, and other factors that extend beyond their personal beliefs regarding sexual activity (3). This idea parallels that of the social ecological model. The social ecological model states that health behavior is influenced by intrapersonal factors, interpersonal processes, institutional factors, community factors and public policy (9). Many teens do not have the tools to navigate the diverse social situations and environmental factors that lead them to unplanned or irrational sexual activity. For example, one evaluation of an abstinence-only program found that the program did not have an effect on the participants’ confidence to avoid risky sexual situations, which are precisely the type of situations when an unplanned sexual act may occur (6). Furthermore, more than 2/3 of teens believe that just teaching teenagers to say “no” to sex is not an effective way to teach sexual education (3). In addition, abstinence-only education promotes the idea that adolescent sexual behavior is always bad, and that a rational decision-maker would abstain from sexual activity until marriage. However, sexuality is integral to human nature, and it does have many positive effects on adolescent mental health (1). There is no scientific data suggesting that consensual sex between adolescents is harmful, as long as they take all necessary steps to ensure that they are engaging in safe sex (2).
Lastly, abstinence-only education is an intervention that assumes all adolescents are the same, with the same set of risk factors that they must consider in planning their decision to abstain from sex. However, studies of interventions to delay the initiation of sexual activity have found vast differences in outcomes between males/females, older/younger adolescents, sexually experienced/inexperienced, etc. (5). Males and females may need different sexual education messages and a different set of skills to use when making decisions around sexual activity (5). Abstinence-only programs often ignore adolescents who are sexually experienced, yet this group of teens still needs access to complete and accurate information regarding reproductive health services, contraception, and abortion (2). Adolescents engaging in the riskiest sexual behavior are often initiating sexual behavior at a young age, an age where they may not have the emotional development/maturity to rationally weigh the social-emotional risks/benefits of sexual activity. While younger adolescents are still going through a cognitive transition and developing their decision-making and interpersonal skills, older adolescents are more easily able to talk about a sense of self-respect, self-assurance and they are less susceptible to peer pressure and social norms (5). All programs funded under 510 and SPRANS must teach the same 8 components of abstinence-only education, and they must target 12-18 year olds; however 12 year olds will be in a very different place than 18 year olds in terms of socio-emotional development and the shift to rule-based moral reasoning (5). For all of these reasons, the use of the health belief model in abstinence-only education will not be effective as it is currently applied to improve sexual health outcomes for adolescents.
Critique 2. Does the Intervention Actually Improve Adolescent Sexual Health?

With over a hundred million dollars being poured into abstinence-only education programs, it is critical that we assess whether or not there is any scientific evidence to support this type of sexual health education. Though abstinence is 100% effective in preventing teen pregnancy (you can’t get pregnant if you aren’t having sex), in actuality, abstinence often fails to protect against pregnancy and STI transmission because abstinence is often not maintained (1). In 2002, the CDC identified five “programs that work” with evidence to show the programs’ effectiveness in reducing unsafe sex practices; strikingly no abstinence-only education program was included as an effective intervention (3). An assessment of school-based sexual education programs (using nationally representative data) found that abstinence-only programs had no significant effect in delaying sexual activity or in reducing the risk for teen pregnancy and STI transmission, while comprehensive sexual education programs were significantly associated with reduced pregnancy rates (10). In addition, a randomized control trial of four federally funded abstinence-only education programs found no significant decrease in the number of sexual partners, in the risk for STI transmission or pregnancy, and in the delay in the initiation of sexual activity (10). Among 17-19 year olds, the recent decline of pregnancy risk is entirely attributable to increased contraceptive use, and among 15-17 year olds, 75% of the decrease in pregnancies is due to the improved use of contraceptives (11). On the other hand, studies on adolescents who have taken virginity pledges show that pledge failure rates are very high (1). Although abstinence-only pledgers may initiate sex later than others, they report a lower frequency of condom use at first sexual intercourse, and those who choose not to engage in intercourse often substitute unprotected oral or anal sex (7). In addition, pledgers often underestimate their personal risk for infection because they are not properly educated about what protects them from the transmission of STIs. Pledgers are also less likely to be tested for STIs, or to have ever seen a doctor for their sexual health (7). Much of the disparity in health services utilization by pledgers is due to the immense stigma surrounding sexual activity, and the fear that if a pledger’s sexual behavior is exposed then they may be expelled from the program (12). Because abstinence-only education restricts the distribution of information on safe sex resources, Add Health data has shown that many teens that fail to remain abstinent also fail to protect themselves when they do initiate intercourse (13,14). Not only is their a lack of evidence supporting the success of abstinence-only education, but furthermore, the absence of contraceptive education and reproductive health counseling may place these adolescents at a higher risk for STDs once they initiate sexual intercourse because they will not have the information they need to engage in safe sex practices (6,14).
Critique 3. What Does the Public Want?

The final critique presented in this paper explores whether or not abstinence-only education programs actually reflect the sexual health needs and wants of the public. Famous for it’s success, the “Truth” campaign looked to youth to design an effective public health intervention. The Truth campaign empowered youth who said that they did not want to be told what to do, they wanted the facts to make an educated decision about their own health behavior (15). The same approach could be effective for adolescent sexual behavior, and in looking at public voice, it is important to take into consideration the point-of-view of adolescents, parents, and sexual health educators. Seventy-five percent of adults and 81% of teens want adolescents to receive more information about both abstinence and contraception (11). In addition, 92% of people in the United States feel that sexual education should tell young people who are sexually active to use contraception, and 83% of people believe that teens should receive information about safe sex practices even if they are not yet sexually active (3). Data from a national poll of middle school and high school parents found that: 15% of the parents wanted abstinence-only education, 91% thought it was appropriate to provide information regarding how to make responsible sexual choices based on individual values, 86% wanted adolescents to have more information on how to use and where to get contraceptives, 85% approved information on abortion, and 73% wanted sex education to include same sex sexual education (11).
In addition, many people think that abstinence-only education is inherently unethical and coercive because abstinence-only educators provide misinformation and withhold information that is needed to make safe and well-informed sexual choices (1). A Congressional Committee Report on abstinence-only education found significant errors and distortions in the abstinence-only curriculum, including inaccurate information about contraceptive effectiveness and the risks of abortion (1). In addition, teachers and students are often censured for discussing or responding to questions about certain sexual health topics; in 1999 one quarter of sex education teachers said they were prohibited from talking about contraception (1). Furthermore, abstinence-only education discriminates against LBGT (Lesbian Bisexual Gay Transgender) youth by limiting the definition of marriage to heterosexual couples, by focusing sexual education on heterosexual intercourse, and by stigmatizing homosexuality as deviant and unnatural (1). Not only is this ethically wrong, but this approach ignores the 2.5% of high school youth who self-identify as LGBT (1). As evidenced by national polls and surveys, abstinence-only programming does not reflect the needs and wants of the American public, and in addition, its method of sexual health education is considered unethical and coercive.
Recommended Intervention: School-based Individual Sexual Health Counseling

Ninety-five percent of all children ages 5-17 years old are in school; therefore, school-based programming serves as an efficient and far-reaching method through which to deliver adolescent health promotion (3). In particular, a study done by the Kaiser Family Foundation found that schools fall second to parents in teens’ sources of information about sexuality (3). In developing an effective sexual health intervention, studies have found that successful programs provide accurate information in an informal and personalized way, use interactive activities, address environmental factors and social pressures surrounding sexual activity, and provide messages that are appropriate for the adolescent’s age, gender and sexual experience (3). In addition, the CDC’s report of sexual education “Programs That Work” indicated that successful strategies for sexual education include large/small group discussions, involvement of the student’s parents, role playing, simulations, videos, homework on local sexual health resources, school-wide health promotion, and experiential exercises (16).
I am proposing a school-based sexual health-counseling program that will be conducted on an individual basis with each student in 7th through 12th grade. Each student will meet with a trained sexual health educator three times per year. All students will be encouraged to participate in the program, though parents may choose to have their child opt-out. The sexual health educators will be as diverse as possible in regards to language, culture and sexual identity so as to make the students feel comfortable engaging in an open and honest discussion about sexual health. The one-on-one counseling sessions will be complemented by a series of classroom activities and large group discussions. The curriculum for the counseling sessions will include discussion surrounding the risks and benefits of sexual activity, what is considered “healthy” sexual behavior, information on abstinence, contraceptives and abortion, and local sexual health resources and services.
To address critique 1, the main goal of the one-on-one sexual health counseling sessions is for the sexual health educator and the student to work together in creating an individualized “reproductive health plan”. Reproductive health plans have recently been introduced in the field of preconception health, and are used to develop reproductive life planning tools that respect variations in age, literacy, and cultural/linguistic contexts (17). Though this model still uses “planning” as a means of sex education, it does so under the assumption that unplanned and irrational things will undoubtedly happen, and the reproductive health plan will serve as a tool through which to navigate those circumstances or look to local resources for help. When developing their reproductive health plan, each student will discuss and write down what they envision for their future in regards to sexual activity. For example, the student will write down when they want to have sex (today, tomorrow, next year, next partner, marriage, etc.). However, because the reproductive health plan assumes that unplanned activities may occur, the student will also discuss and write down action steps to help them navigate unfamiliar or uncomfortable situations where they could see a risky sexual activity occurring. The student and the educator will role-play various circumstances to practice using the action steps, and they will develop personalized tools that can be used to help the student make the best sexual behavior decisions possible. In addition, the student and the educator will discuss the outcomes of irrational decisions, and brainstorm local resources and services as well as personal supports the student can turn to for help. The student and educator will also discuss the student’s capacity to access those resources, and problem-solve the challenges that may arise in regards to money, transportation, stigma, etc. In order to secure a support system for the student, the student must identify a “caring adult” whom they can go to for sexual health advice (parent, teacher, counselor, etc.), and together they must complete an assignment mapping out five sexual health services/resources that could be helpful for that adolescent.
The curriculum of the one-on-one sexual health counseling will be personalized to meet the individual needs, wants and experiences of each adolescent. For example, the age of the student will be taken into consideration during discussions of social interaction, decision-making, and personal responsibility. These topics are highly influenced by the maturity and cognitive development of the adolescent, and therefore the conversations should be tailored to each student’s developmental level. The sexual experience of the student will be discussed but no assumptions will be made on their sexual future. For example, abstinence-only education programs view abstinence as an “all or nothing” approach, and therefore completely ignore students who have already engaged in sexual activity that is considered “irreversible” (5). For this program, the reproductive health plan that is created for each student does not have to be influenced by the student’s past behavior; any inexperienced student can decide that they want to have sex for the first time, and any experienced student can decide they would like to try abstaining from sex. In addition, this program will not just view sex as an unhealthy behavior, and should a student decide they want to have sex in the near future, the educator will work with the student to ensure that the student understands what healthy relationships and healthy sexual activities are, and what practices to use to make sex safe. Lastly, LGBT students will work with the health educator to address the individual student’s health behaviors, and to identify local resources/services that may specifically support the LGBT community.
In regards to critique 2, it is difficult to predict whether or not this particular program will have a successful effect of improving the sexual health of adolescents. However, based on the research that has already been done (and was previously discussed in this paper), the model of comprehensive sexual education that will be used for this program has proven to be much more successful than abstinence-only sex education. Vital statistics reports have shown that there is a decrease in teen pregnancies when there is an increase in the use of condoms and contraceptive methods (10). Therefore, all students in this program, regardless of whether or not they are sexually active, will learn about contraceptives and safe sex practices. Some abstinence-only supporters argue that teaching students about safe sex practices will actually encourage them to engage in sexual activity however, a recent review showed that, all but one of 11 programs that taught about contraception resulted in no increase in sexual activity (10,18,19). As previously discussed, many previously abstinent adolescents who engage in unsafe sexual behavior do not seek medical advice because of the stigma associated with sexual behavior. However, because this program will conduct sexual education in a one-to-one setting, it is predicted that students who are engaged in risky (unsafe) sexual activity will have a safe and comfortable space through which to talk about that behavior and seek help. In addition, many abstinent adolescents do not have an accurate idea of their personal risk in regards to sexual activity, and therefore this program will seek to give a more complete and accurate education of sexual health, and will not withhold information or distribute misinformation related to sexual health.
Lastly, addressing critique 3, in order to meet the needs and wants of the students this program will serve, a school-wide needs assessment will be conducted prior to program implementation. The needs assessment will look at the school’s most prominent areas of concern regarding sexual health (pregnancy rates, STI transmission, rape, abuse, etc.). In addition, a school-wide survey will be distributed to all students inquiring about their questions and concerns around sexual health. As a result, the curriculum of the classroom-based element of the program will be tailored to address the specific health outcomes that are of concern for the school, and the most areas of student interest that are most widespread. In addition, the relationship between the student and the health educator should be dynamic and mutually reciprocal so as to encourage a constant flow of questioning/answering throughout every counseling session.
In light of the physical, socio-emotional, and societal consequences of teen pregnancy and adolescent STI transmission, sexual health education in the United States must be prioritized as a critical area of public health promotion. Though abstinence-only education has received extensive public and private support, it can no longer be thought of as the best intervention for protecting the sexual health of adolescents. Abstinence-only education is largely ineffective because 1) it does not account for irrational and unplanned sexual behavior, 2) it does not personalize sexual education to the diversity of adolescents it targets, 3) it does provide adequate and accurate sexual health information necessary for teens to know in order to protect themselves from unsafe sex practices, and 4) it is not providing the sexual health education that teens, parents and educators thing is important. Overwhelmingly, studies have found that, when compared to comprehensive sex education, abstinence-only education is not working to prevent teen pregnancy or the transmission of STIs. By implementing the one-on-one sexual health counseling program, the flaws of abstinence-only education will be remedied through the use of individualized sexual health counseling, which incorporates an education of safe sex practices, and reflects the sexual health concerns of the adolescent public.


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