Monday, May 10, 2010

Does Abstinence-only Education Work? – Daniel M Purnell THE PROBLEM

Adolescent sexual behavior is related to a number of public health problems, such as teen pregnancy, abortion, and STIs. The most recent research from the Centers for Disease Control and Prevention (CDC) report that nearly half of all high school students (students aged 15-19) have had sexual intercourse; and of those, 39% did not use a condom the last time they had sex (1). Earlier data had suggested that over 50% of both males and females between ages 15 and 19 had engaged in oral sex (1). 14% of all HIV/AIDS diagnoses in 2006 were in young people aged 13-24 (2). Each year, half of the approximately 19 million newly diagnosed STIs occur in people aged 15-24.4 (3). In addition, most recent teen pregnancy rates from 2006 reported nearly 500,000 births to mothers aged 15-19, the majority of which were unintended pregnancies (4). Also in 2006, adolescents aged 19 years or less underwent 116,613 abortions (5).

In light of these numerous health risks, a public health intervention to address risky adolescent sexual behavior is clearly warranted. Given the data above, it would seem the most logical solution would be to use public schools to provide all young Americans with information regarding the dangers of sex (e.g., how many teens have STIs, the probability of catching certain STIs, the financial and emotional cost of having a child, etc.) and essentially telling them to abstain from sexual intercourse until marriage and/or adulthood. Indeed, a number of these so-called abstinence-only programs (discussed in greater detail below) have sprung up around the country. In this editorial, I will argue that Abstinence-Only sex Education (AOE) fails as a public health intervention because federal policy defining AOE is based on moral values and supported by biased, poorly conducted research; because it does not take into account all of the factors that play into whether or not a teenager chooses to abstain from sex; because proponents of AOE improperly frame the issue of sexual education of adolescents; because the message is delivered only by adult teachers in an educational setting; because it ignores important teen health issues; and because it goes against what the majority of parents want for their children. I will conclude by proposing a general solution to the problem.

Federal Policy and AOE Models
AOE programs are often based on individual level health education models, which focus on education through talking about the risks of sex and values and attitudes toward sex, and assumes that when kids know how risky and harmful sex can be, they will make the choice to be abstinent. Teen-Aid, an AOE program founded in 1981, focuses on what they call “risk avoidance education” (6). Values and Choices focused on the Theory of Reasoned Action and used values-based education to change teen attitudes toward sex (7). Facts and Feelings, similar to Values and Choices, was a home-based program emphasizing values-based education at the individual level (7). Success Express, Project Taking Charge and Sex Respect all have a similar values-based, individual focus (7). However, even assuming this is a useful model for AOE (see page 4 for further discussion), current federal policy outlining criteria for these AOE programs raises a number of problems in the context of health belief and health education models.

First, a recurring theme in these policies is alleged “harmful psychological and physical effects” stemming directly from sexual activity “out-of-wedlock” (8). Yet a recent review paper by John Santelli and colleagues uncovered no studies showing a causal link between adolescent sexual activity and mental health problems (9). Any papers that do address mental health and sexual activity in this population appear to suggest that early sexual activity may be an effect of pre-existing psychological harm, rather than a cause of it (9). A review by Robert Anda and colleagues concluded that adverse childhood experiences and their subsequent effects on behavior were strongly related to age of first sexual activity (10). Related studies have yielded similar results (11-14). The policies also imply harmful psychological effects for teens who become pregnant and undergo abortions (8). Yet several studies suggest the exact opposite is the case (15-18). It is difficult to determine, in light of these findings, what facts, if any, were relied on in the development of these policies.

Second, abstinence appears to be defined in the criteria as not engaging in “sexual activity” until marriage. But there is no explicit definition of what constitutes sexual activity and, ergo, what constitutes abstinence (8). A survey conduct by Mark Schuster and colleagues suggested that adolescent beliefs and behaviors regarding what abstinence is can vary, such as whether or not oral or manual stimulation counts as a loss of virginity (19). AOE program directors and instructors also differ in how they define abstinence. A study by Patricia Goodson revealed “substantial variation” in how directors, instructors, and hence, participant youth defined abstinence (20). It would seem that before developing policy regarding how to teach abstinence to teens, it would be helpful if those involved came to an agreement on what abstinence is.

Third, there is an obvious pro-abstinence moral bias in these policies. Here, abstinence is often not discussed in the context of health, but in the context of character and moral values, often religious in nature (8). This is problematic when one considers children who have been raised with a particular set of moral values asserting that sex out-of-wedlock is common and acceptable. What would teachers following an AOE program say to them? The inherently subjective nature of moral values not only raises a serious ethical question as to whether or not it is acceptable to use them to develop nationwide policy in this context, but also raises serious doubts as to the credibility of the federal policies as a whole.

Finally, nowhere in the policies is there any indication that a discussion of healthy sexual behaviors, such as proper contraceptive use or what to do in the case of a pregnancy or STI scare, would be necessary. In fact, from the policies it appears that this information has been intentionally excluded (8). This seems to endorse the preposterous notion that the best way to reduce undesirable behaviors is to altogether avoid a discussion of those behaviors or their consequences. It is as if we were to decide that the best way to increase road safety was to never discuss what causes accidents or what to do if one occurs.

So what does all this mean for the Health Belief, Health Education, the Theory of Reasoned Action, and the AOE programs that use them? These programs, as shown, focus on risks, protective factors, and moral values-based arguments for being abstinent. They seem to assume that if teens have full knowledge of the risks of sex and are taught to be “chase” and “virginal”, they will weigh a desire for sex against the risk of disease or unwanted pregnancy, and in so doing, will choose to abstain. However, assuming these models could be successful, fundamental to their success is the veracity and general applicability of the information they teach to teens. How can one reliably or accurately weight risks and benefits in making a choice if the information one has is related to that choice is based on values-based personal biases, lies and incomplete information? Evaluations conducted on each of the aforementioned AOE programs are telling: Teen-Aid, Values and Choices and Sex Respect showed changes in attitudes in the desired direction, however say nothing about whether behavior changed, and a lack of comparison group coupled with the fact that all these studies were conducted in Utah using predominately Mormon subjects greatly reduces generalizability; Facts and Feelings showed no desired effects whatsoever at 12 month follow up, on either attitudes or behavior; Project Taking Charge appeared to increase knowledge but did not affect values or behaviors; and Success Express actually caused an increase in precoital sexual activity among participants (7). It should be noted that these evaluations suffered from a number of design flaws, such lack of a comparison group, small, non-representative study sample, and possible selection bias (7). However, two more recent reviews, one by Douglas Kirby (21), and one by Jennifer Manlove (22), which employed more stringent inclusion criteria, have been unable to find any scientific evidence that AOE programs effectively promote abstinence.

Decades ago, follow up research on the Drug Abuse Resistance Education program showed the program had failed to curb adolescent drug use (23). There is no reason to think that the same strategy will lead to a different outcome in this case.

Hot States versus Cold States

Another major problem with AOE programs and how they educate is the assumption that the choice to abstain will be made in a rational state of mind. The emotional intensity of a sexual situation compared with the relative emotional neutrality of an educational situation implies this may not be the case. A study conducted by behavioral economist Dan Ariely on a group of male students at UC Berkeley asked a series of personal questions related to sexual behavior which focused on types of sexual behavior in which students would likely be comfortable engaging. The questionnaire was administered twice, once while the students were in a non-aroused or “cold” state, and again in an aroused or “hot” state. The general goal was to determine whether level of arousal had an effect on decision making. Surprisingly, the results showed that those in a “hot” state were significantly more willing to perform all of the described sexual behaviors, even behaviors were unusual or unethical (e.g., bestiality or getting a partner drunk in order to have sex with them, respectively) (24).

The fact that different emotional states seem to affect decision-making poses a problem for AOE programs. Since all AOE programs are obviously administered to teens in a “cold” state, how effective will such educational efforts be when it matters; specifically, when an individual is in a “hot” state? In the moment, just saying no may be easier said than done.

It may be pointed out that this appears to be an indictment of sexual education in general. However, the data above studies suggests that, although decision-making was significantly affected, it was not entirely impaired (24). This seems to imply that sexual education is still to some degree useful. However, assuming that an individual will give in to desire at some point – indeed, statistically, most Americans do not wait until marriage to have sex (25-26) – such education will likely only be useful in a “hot” state if it is comprehensive in nature. Again, AOE programs (see discussion of federal policy above) are not comprehensive. Along these lines, a study by Bearman and colleagues on teens who had followed the virginity pledge movement showed that 88% ended up having vaginal intercourse before marriage in spite of their pledge (27). A related study focusing on STI-related behaviors within the same population of teens compared to teens who had not pledged abstinence showed that teens who had made the pledge were less likely to see a doctor for STI testing (28). All of this strongly suggests that many teens whose education has focused on abstinence only in many ways fare no better, and in several important ways fare worse, than teens who receive comprehensive education. Thus, while comprehensive education may still be useful, it is doubtful that the same is true for AOE.

Framing
Another significant problem, related to the moral bias issue discussed above, is how this issue is framed by researchers and advocates.

The research The research cited promoting AOE programs is often suspect. A review of AOE programs conducted by Robert Rector concludes that AOE programs do work, and cites ten AOE programs in support of this claim (29). However, six of the ten program evaluations he cites are those cited above, all of which are either unproven or have been shown to be ineffective (7). Like these six, the other program evaluations have also been criticized as methodologically flawed. A review of these programs published by Douglas Kirby for the National Campaign to Prevent Teen Pregnancy revealed that nine of them failed to show any evidence that they delayed initiation or frequency of sexual intercourse. The only program that showed any effect (a mass communications campaign called Not Me, Not Now) is still suspect because it was not possible to control for confounding factors (30). Kirby concluded that “[there] do not currently exist any abstinence-only programs with strong evidence that they either delay sex or reduce teen pregnancy” (30). Additionally, note that this study was supported by the Heritage Foundation, an institution with a strong conservative bias that advocates for public policy based on “traditional American values” (31).

The most recent study promoting AOE, published this year in February, appeared to show that AOE programs might be an important factor in “adolescent sexual involvement” (32). However, in the section describing the AOE intervention, instructors teach kids in this group to remain abstinent until they are “prepared to handle the consequences of sex”; that a “moralistic tone” is not permitted; and that the efficacy of condoms should not be questioned (32). Upon referring to the federal policies defining AOE, it becomes clear that the investigators have essentially taken a comprehensive sex education and framed it as AOE, an act which is clearly misleading and makes the results favoring AOE essentially meaningless.

The advocacy More generally, along with policymakers, advocates for AOE often frame the issue improperly. According to the Santelli review, a common argument used by proponents of AOE programs is that abstention is the only method of safe sex that is one hundred percent effective. There are several problems here.

First, recall that nearly all Americans have sex before marriage and that the goal of AOE is abstinence until marriage. Presented in this straightforward way, concluding that AOE programs are not effective appears inescapable. So how do advocates of AOE use framing to get around this fact? One way is by pointing out that evaluations of AOE programs like those mentioned above show that AOE programs are similar in effectiveness or more effective than non-AOE programs. The problem with these studies, in addition to those discussed above, is all of them assess efficacy through periodic follow up and define success by how long the teen remained abstinent (7, 32), rather than by whether or not the teen actually had sex before marriage. Framed in terms of abstinence until marriage, the actual goal of the intervention, AOE programs suddenly appear much less effective.

Another way proponents of AOE improperly frame this issue is by focusing on the simplistic and misleading statement that abstinence is one hundred percent effective and therefore better than any other form of safe sex. There are several problems here. For one thing, it is completely misleading to call abstinence “the safest sex.” The term safe sex implies sex is already happening. Presenting abstinence as safe sex is misleading, and may even be “potentially harmful because it conflates theoretical effectiveness with the actual goal of abstinence” (9). Indeed, the two reviews mentioned previously regarding the efficacy of virginity pledge movements offer support for AOE programs causing harm (27-28). However, if the issue is re-framed by comparing AOE program effectiveness in terms of those who remain abstinent until marriage and those who do not, the claims loses its credibility. For proponents of AOE programs, the more honest and complete statement appears to be that abstinence is one hundred percent effective as long as you remain abstinent. This is, of course, nonsensically circular. It would be like saying that your car brake is one hundred percent safe as long as it always works. Any public health intervention can be theoretically successful. What matters is whether or not it succeeds in practice, whether behavior has actually changed.

Summarily, it appears that opponents of AOE focus on the health problems that may result from poor sexual choices, whereas advocates frame sexual activity as the problem itself.

Other Programs
A general problem with programs seeking to educate lies with the teacher. Research by Paul J. Silva on the Concept of Psychological Reactance, which is a term denoting a rebellious reaction to a perceived threat to freedom (33), has demonstrated that the threat perceived from telling someone something which conflicts with their personal beliefs was significantly reduced when there was similarity between the speaker and the listener. In other words, who is delivering the message may be just as important as its content. There is evidence of this rebellious nature in teens. A report discussing the methods of the highly successful truth campaign against smoking showed that the main reason many teens choose to smoke is precisely because adults tell them they shouldn’t (34). This suggests that teens may be more likely to engage in behavior that adults forbid them to do. Although this can be seen as a problem for sex education in general, the fact that AOE programs can only focus on a very limited number of facts, and essentially tell teens that they shouldn’t have sex at all, makes this problem particularly difficult for AOE programs.

In reference to the aforementioned study on STI prevalence among teens who joined the abstinence pledge movement, it bears reiterating that the only major difference between teens who had made the pledge and teens who had not made the pledge appeared to be how likely they were to receive STI testing (27-28). That a program intended as a public health intervention targeted at teens might make teens less likely to seek needed medical attention is, needless to say, highly problematic.

Finally, it should also be considered what information the majority of parents want for their children. Data has consistently shown that teens’ parents overwhelmingly support sexual education programs (90%) and that, of that of those, support programs that include information on contraception (86%), abortion (85%), masturbation (77%), oral sex (72%), etc. In contrast, only 15% of those polled supported AOE (35-36).This data suggests that any sexual education program which follows an abstinence only model will not be well received by the majority of parents.

Based on the problems discussed above, AOE should be abandoned as an ineffective public health intervention and ineffective public health policy.

THE SOLUTION

In light of the nationwide, strong parental support for comprehensive sex education, in order to fight AOE and improve sex education in general, I am proposing the development of an organization consisting of parents who oppose AOE programs and support sexual education reform. They would advocate against AOE programs and in favor of sexual education reform in two ways: lobbying for policy change, and starting a national media campaign intended to raise awareness of and re-frame the problem.

Lobbying for Policy Change

Since federal policy explicitly endorses AOE, lobbying for policy change is a crucial element in the fight against AOE. If there is no clear definition of abstinence, it will be difficult, if not impossible, to effectively teach it to teens (20). If policy continues to not only permit but support programs that ignore crucial topics such as proper condom use and where to get STI testing, teens will be less likely to seek help when they need it (27-28). Without policies that are clearly written, morally neutral, and above all, based on sound behavioral health research, sex education simply will not be effective (8, 9). Finally, it has also been argued that, from the perspective of medical ethics, policies supporting AOE are unethical because they deny teenagers access to complete and accurate health information (8, 9).

Lobbying federal government for policy change would also be supported as a public health intervention by Social Expectations Theory. Social Expectations Theory, according to an article by Melvin Defleur and Sandra Ball-Rokeach concerns the norms, or general rules, of attitude and behavior that develop over time in a given group of people. Importantly, policies are identified as one source of these norms (37). Thus, efforts to change these policies would likely, over time, cause a positive change in norms related to issues of adolescent sexuality. Additionally, policy change is also important in this case because federal funding for sex education is currently tied to teaching AOE as defined in Section 510 of the Social Security Act (8). This puts any sex education program wishing to teach comprehensive education at a clear disadvantage. Lobbying for policy change would help to correct this problem.

National Media Campaign
The media can be a powerful tool for communicating a message targeted at adolescents. There are numerous examples illustrating the power of the media to bring about attitude and behavior change. Sesame Street and Blues Clues were highly successful television programs aimed at providing basic education to pre-teen children (38). The ad campaign identifying the act of pouring a Guinness beer as a ritual through the use of the slogan “perfection can’t be rushed” caused sales to skyrocket and literally saved the company (39). The most relevant example is the truth ad campaign mentioned above. Their ads ran in magazines, on television, and on the internet. A follow up evaluation revealed across the board reduction in youth smoking (34).

Since the media has been used successfully to positively affect attitudes and behavior toward all the issues above, it is reasonable to conclude that the media can positively affect teen attitudes and behavior toward sex. To accomplish this, the parent organization can develop a national, multimedia ad campaign. An example commercial of such a campaign might consist of an adolescent man and woman alternately telling a story about a recent house party they attended. They would talk about how they were about to have sex, but just before they did, the man realized he didn’t have a condom. The story would conclude with the teens ultimately deciding not to have sex. Then the man and woman would each say their name and the campaign slogan (e.g., “my name is David, and I made the right choice”). The commercial would end by flashing the campaign website name on the screen: maketherightchoice.org. This commercial would be effective for a number of reasons:

Research has shown that people respond well to the use of personal stories. When Pam Laffin, a 31 year old mother of two from Malden, Massachusetts, was dying from emphysema, the CDC and the Massachusetts Department of Public Health made a video of her story and ran it on television (40). Within hours, an anti-smoking hotline called 1-800 QUITNOW received a huge influx of callers (41). In passing the health care bill, President Obama spoke at length about Natoma Canfield, a woman who had died of cancer because she did not have adequate health insurance. His reasoning was that every reasoned policy argument had been used (42-43). Indeed, politicians running election campaigns often stick to personal stories for exactly this reason. Thus, an ad campaign consisting of attractive, trendy-looking young people talking about personal sexual situations in which they acted responsibly would therefore be much more effective than, for instance, a simple discussion of disease statistics.

This ad campaign could also have other positive affects. According to theories in marketing and advertising, any ad campaign is more effective when it sells core values that are important to its target audience (44). The positive tone of this commercial, the physical appearance of the actors, the campaign slogan, and the overall theme of personal choice exemplify known core values such as love, beauty, youth, independence, trust and control (44). Independence and control were two major core values that explained the appeal of the truth campaign (34). The slogan for the proposed commercial mentioned above also exemplifies the concept of Branding, which states that the goal of selling any product is by linking it with a particular set of important values in the mind of the consumer (44-45). Based on these theories, the message of this series of commercials is “if you make responsible sexual choices like these teens, you will feel more beautiful, more independent, and more loved.” Such advertising would counteract the message delivered by proponents of AOE by focusing on the positive aspects of sex and help to re-frame the problem by shifting the discussion from how to convince teens to stay abstinent to the idea that being healthy and safe is a way to feel independent and in control, and to feel more loved.

These commercials would also address the aforementioned psychological reactance problem by the fact that they featuring young, attractive people talking about sexual situations and feelings which are familiar to the average teen. The designers of the truth campaign interviewed adolescents about the reasons they chose to smoke prior to developing their campaign. They credit the interviews as a major factor in the campaign’s success (34). This also fits with the research on psychological reactance (33). Similarly, in developing this campaign, the parental organization could work with adolescents to develop the scenarios for each commercial in the series. Unlike AOE, this campaign would directly involve adolescents in their own sexual education, making them more likely to adopt responsible sexual behaviors.

In addressing the “Hot State-Cold State” issue, in his book, Predictably Irrational, Dan Ariely offers two suggestions: emphasizing condom use and availability, and focusing education less on biology and physiology and more on the powerful emotions that come with sexual arousal. The proposed ad campaign described could be modified to incorporate both of these suggestions. When the website name “maketherightchoice.org” appears on the screen, a voice could be added saying “visit maketherightchoice.org for more information on taking control of your sexual health and how to order condoms discreetly, online, for free.” Conversation about the emotions that accompany sexual arousal could be encouraged by modifying the commercial to feature parents and their teens. They would describe how initially they were embarrassed to talk about sex as a family, but once they did, they were glad they had. These ads would appeal to families for the same reasons the ad described above would appeal to teens.

In conclusion, it is likely that sexual health during adolescence, and the best way to teach it, will always be a controversial topic. Discussing such sensitive and personal topics with minors may conflict with deeply held religious or moral beliefs, or may simply be a source of embarrassment. However, given that as a matter of biological fact, puberty starts in most humans between the ages of ten and sixteen (46), and that this change is accompanied by sexual maturation and the capacity for reproduction (46). No policy, religion, or set of moral values can alter these simple facts. Once this happens, the only way to keep adolescents mentally and physically healthy, and safe, is to make sure they fully understand and feel comfortable with what is happening to their minds’ and bodies’, and feel personally empowered and motivated to keep themselves sexually healthy. Aggressive lobbying efforts in support of sex education programs that require full and honest disclosure, coupled with a media campaign, targeted at both parents and their teens, that identifies sexual health with love, beauty, independence, trust and control, is the best way to accomplish this.

REFERENCES
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