Moral Imposition and Perverted Science: The Problem of Abstinence-Only Sex Education in the United States--Amanda Trainor

Each year in the United States, about 750,000 adolescent females become pregnant, 20,000 young people are newly infected with HIV, and nearly four million new STI infections occur among 15- to 19-year-olds (1). There are roughly 400,000 teen births every year in the United States, with about $9 billion in associated public costs (13). U.S. teens account for about 71 percent of all teenage births occurring in all developed countries. While some gains have been made in the area of teen pregnancy in recent years, matters have backslid; for the first time in more than a decade, the U.S. teen pregnancy rate rose in 2009 (13). Since 1996, the majority of federally funded interventions for teen pregnancy and transmission of STIs have been abstinence-only sex education programs.

Abstinence-only interventions should be abandoned for the following reasons: 1) the rational for abstinence-only education is grounded in moral and spiritual beliefs, not in a social/behavioral theoretical framework; 2) abstinence-only education actively encourages negative health outcomes because it disparages and withholds factual scientific information about contraception and disease protection; 3) abstinence-only education is not significantly effective at preventing teen pregnancy or the spread of STIs among teens. These three main failings of abstinence-only education can be mitigated by the adoption of comprehensive and ‘abstinence-plus’ (11) sex education programs, which 1) are grounded in scientific evidence and reasonable social/behavioral theoretical frameworks, 2) show positive results in reducing unsafe sexual behaviors that result in teen pregnancy and STI transmission, and 3) do not withhold information or offer false information about safer sex practices.

Background of Abstinence-Only Sex Education in the US
Controversy over if and how sex education should be part of the US public school curriculum is certainly nothing new, and the notion that if sex is discussed, the message should be abstinence-only hearkens back to the 1960’s (4). Most relevant to today’s cultural moment, though, is how federal abstinence-only funds began flowing into states for school curriculums in 1996. Quietly tacked onto welfare reform was $250 million payable over the next five years for abstinence-only education. Under President George W. Bush, funding continued and increased; by 2003 alone, government spending on such chastity focused education reached nearly a billion dollars, and continued to increase through his next term (4).

If a state or school wanted a slice of this funding, they had to develop and implement a sex-education curriculum that adhered to eight strict points mandated by the Bush Administration under Title V of the Social Security Act. Known as the “A-H” points, demands included that the curriculum must “have as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity”, that “abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems”, that “marriage is the expected standard of sexual activity” and that “sexual activity outside the context of marriage is likely to have harmful psychological and physical effects” (3).

1. Abstinence-Only Education Relies on Spirituality and Moralizing, not Social/Behavioral Theories
The “A-H” points which define federally acceptable abstinence-education, and the curriculums designed around those points, seem to be based not on peer reviewed social/behavioral theoretical models—but on the spiritual and moral world-views of the persons who were given authority to conceive, implement, and fund abstinence-only sex education programs (4). Consider the following example. During his first term, then-President Bush appointed a woman named Pam Stenzel to an influential task force at the Department of Health and Human Services which was charged with designing and implementing abstinence education guidelines. For Stenzel, social/behavioral theories and scientifically rigorous research are the not the foundations on which to build an education program. The reason why society should not condone pre-marital sex? Because, she says, it is “stinking, filthy, dirty, rotten sin” (4). Stenzel continues:

What [they] are asking is does [abstinence-only education] work. You know what? Doesn’t matter. Cause guess what. My job is not to keep teenagers from having sex. The public schools’ job should not be to keep teens from having sex. Our job should be to tell kids the truth! People of God...commit yourself to truth, not what works! I don’t care if it works, because at the end of the day I’m not answering to you, I’m answering to God. . . AIDS is not the enemy. HPV and a hysterectomy at twenty is not the enemy. An unplanned pregnancy is not the enemy. My child believing that they can shake their fist in the face of a holy God and sin without consequence, and my child spending eternity separated from God, is the enemy. I will not teach my child that they can sin safely (4).

Unfortunately, Stenzel and her cohort are not teaching only their own children, but millions of American young people who deserve sex education based on empirical evidence, not moral zealotry. While it may be possible to frame various abstinence-only curriculums as having some connection to industry-accepted social/behavioral theories, the attitude that Stenzel exemplifies is one of obsession with personal beliefs about spirituality and morals.

2. Abstinence-Only Education Withholds and Disparages Lifesaving Information
Perhaps the most egregious flaw of abstinence-only education is that it withholds and disparages lifesaving information about safe sex practices (1, 4, 9, 10, 11, 16). Even without invoking God or personal morals, it is fair enough to say that abstinence really is the safest sexual practice, but it is inevitable that not everyone will abstain until marriage. For the young people who choose not to abstain, accurate information about contraception and STI protection is essential. Abstinence-only education denies students that information. Furthermore, abstinence-only education has not been shown to significantly succeed in its mission to convince young people to abstain until marriage (1, 9, 10, 11, 12, 13). Troublingly, studies have shown that even when abstinence-only education succeeds in delaying the onset of teen sex, it also increases the risk of teens choosing to not use condoms or other contraception when they do have sex (4).

A closer look at how the Title V funds are deployed in schools and in other abstinence-promotion initiatives reveals how science is twisted to meet a political and ideological agenda that risks the health of young people. Title V funded programs are forbidden to even mention birth control (10), except to disparage birth control methods and highlight (often falsely) their failure rates (10). Take the use of condoms, for example—a widely available, relatively inexpensive, simple, and highly effective method of reducing pregnancy and a host of STIs. Abstinence-only curriculums have stated that not only do condoms not protect against pregnancy, HIV or other STIs, but that they have been linked to cancer (16). One abstinence curriculum manual says that having sex with a condom is like a game of Russian roulette, stating that “there is a greater risk of a condom failure than the bullet being in the chamber” (4).

Outside of school, young people seeking resources for responsible sexuality and reproductive health may find themselves still blocked by the deployment of Title V through support of initiatives beyond the classroom. These funds have been used for Crisis Pregnancy Centers— facilities that masquerade as health clinics, but offer few health services, offer no contraceptive counseling, and give visitors false information, such as stating that abortion leads to cancer and mental illness. Abstinence advocates—many of the same individuals appointed to abstinence-only education development positions under the Bush administration—led the effort to block FDA approval of a vaccine for Human Papilloma Virus (HPV) in 2006 (16, 4). Abstinence proponents argue that “giving the HPV vaccine to young women could be potentially harmful, because they may see it as a license to engage in premarital sex” (4).

3. Abstinence-Only Education Does Not Significantly Reduce Pregnancies or STI Transmission Among Teens
The sexual behavior among teens exposed to abstinence-only curriculums offer little support for continuing to pour money into these scientifically invalid programs. Take the state of Texas, for example. In 2009, Texas reported the third-highest teen birth rate in the country and the highest rate of repeat teen births (15). It also leads the nation in the amount of government money it spends on abstinence-only education. Resultantly, some school districts in the state are now shifting away from that approach, admitting that it simply doesn’t seem to be working out as their teen births climb.

Numerous studies predicted what Texas is experiencing: that abstinence-only education isn’t the solution for protecting teens against the health risks of sex. A congressionally mandated report on federally funded abstinence programs in 2007 (11) found that none of four abstinence programs evaluated showed a significant positive effect on sexual behavior among youth. Many federally funded abstinence-only programs include having students take “virginity pledges”, vowing to abstain from sex until marriage. But studies have found that those who pledge abstinence do not have intercourse at lower rates than those who do not pledge, nor do they have lower rates of pregnancy and STIs (2). Based on interviews with more than 20,000 young people who took virginity pledges, one study found that 88 percent of them broke their pledge and had sex before marriage (2). A January 2009 study in Pediatrics (14) found that religious teens who take virginity pledges are less likely to use condoms or birth control when they become sexually active, and just as likely to have sex before marriage as their peers who didn't take pledges.

Recently, abstinence-only education advocates expressed satisfaction (5) at the publication of a 2010 study by Jemmott et al (9) which suggested that abstinence education could delay the initiation of sexual activity among very young teens and pre-teens. However, there are several reasons why this study does not detract from evidence that rigid abstinence-only-until-marriage is an ineffective method of sex education. For example, the study’s generalizability is likely limited, given that the sample group was relatively small and included only African-American students in grades 6 and 7 (5, 9). Furthermore, the study would not have met many of the A-H definition (3) points that define the restrictive federal criteria for abstinence-only funding (5). Furthermore, the study avoided many of the hallmark pitfalls of abstinence-only education: it was theory-based (the study drew from research on the population and behavior change theory, which helped the researchers address participant’s motivation and build skills to pursue abstinence) (9), it was not moralistic (9), it did not disparage or mislead students about the effectiveness of birth control (9), nor did it insist that sex outside of marriage was likely to have harmful physical and emotional side effects (5).

What Really Works? The Case for Comprehensive and Sex Education
The Jemmott study is important because its program is the first abstinence-only intervention to demonstrate positive impact in a randomized control trial (5). It had a significant impact in delaying sexual initiation among participants, so it adds useful new information and ideas for what does work in sex education. But it does not contradict the strong body of evidence that rigid abstinence-only-until-marriage programs are generally ineffective. Rather, it adds valuable evidence to the effect that “abstinence-plus” (11) education—that is, education which discusses the merits of abstinence, while also offering factual, comprehensive information on options for birth control and STI protection—is a far superior model. Not all of the students who participated in the Jemmott study remained or will remain abstinent until marriage. About one-third of students who had not had sex when they started the abstinence-only program had initiated sex at the two-year follow-up (9). The study demonstrates that while it is possible and important to delay sexual initiation, it is equally incumbent upon educators to prepare students for the time when they do become sexually active, which more than two-thirds will have done by age 19 (5).

1. Comprehensive Sex Education Is Backed by Theory, Not Spirituality or Morality
Like the Jemmott study, comprehensive and abstinence-plus sex education programs fairly admit that abstinence is an option for young people, and that it is an effective way to completely avoid any risk of pregnancy or STIs. However, they also stress the importance of using protection if and when teens do choose to have sex, and they do not rely on falsified science claims or moralistic threats against teens’ physical and emotional well being if they choose to have sex out of wedlock. This model for education is supported by the social/behavioral theory of harm reduction (6). Harm reduction theory explicitly recognizes that a certain number of people in a given population will engage in risky and potentially harmful behavior, and thus proposes that people should be given the information they need to make an informed decision about those risks and how to manage them (6).

2. Comprehensive Sex Education Does Not Withhold Information or Present False Information
Examples abound of comprehensive curriculums that accurately offer all available information about sexual behaviors. The model presented by publications of the Illinois Campaign for Responsible Sex Education is an excellent example; in its 2007 review (8) of comprehensive curriculums available for use in Illinois, it defines comprehensive sex education as curriculum that contains a strong abstinence message in addition to age-appropriate, medically accurate information on basics of reproduction, human development (puber¬ty), contraceptives and other barrier methods, HIV/AIDS, sexually transmitted infections (STIs), sexual orientation and gender, communication and behav¬ior skills, information about access and/or condom availability, decision-making, values and responsi¬bility, and self-esteem and body image.

This holistic approach does not prevent young people from accessing knowledge that can protect them when they do choose to become sexually active. Rather than withholding information, it offers a factually robust, socially contextualized option for teaching about sexual behaviors, associated risks, and risk prevention strategies. Incorporating lessons on skills like decision-making and communication—which are useful in non-sexual life encounters as well—can help young people negotiate better sexual health outcomes for themselves and their partners.

3. Comprehensive Sex Education Shows Positive Outcomes Evidence
A 2007 report (11) by non-partisan organization The National Campaign to Prevent Teen and Unplanned Pregnancy looked at 48 comprehensive sex education programs—programs that supported both abstinence and the use of condoms and contraceptives for sexually active teens—and found that the overwhelming majority had positive behavioral effects (11).

None of the programs the study examined hastened the initiation of sex or increased the frequency of sex. The study found that comprehensive programs had positive effects on both genders, for all major ethnic groups, for sexually inexperienced and experienced teens, in different settings, and in different communities (1, 11).

In 2008, another non-partisan organization, Advocates for Youth, reviewed existing comprehensive sex education programs to assess their significance and outcomes (1). Of 26 effective programs focused on teens, 23 included comprehensive sex education as at least one component of the program. Among the accomplishments, 14 programs demonstrated a statistically significant delay in the timing of first sex; 13 programs showed statistically significant declines in teen pregnancy, HIV, or other STIs; 14 programs helped sexually active youth to increase their use of condoms; 9 programs demonstrated success at increasing use of contraception other than condoms; 13 programs showed reductions in the number of sex partners and/or increased monogamy among program participants; and 10 programs helped sexually active youth to reduce the incidence of unprotected sex (1).

New Administration, Old Patterns: Obama Renews Abstinence-Only Funding
In the face of such evidence that abstinence-only education programs pale in usefulness to their comprehensive counterparts, it would seem logical to invest federal dollars into what works. Public opinion surveys reveal that Americans view abstinence and contraceptive education as complementary, and that even though there is great support among parents and teens that delaying sexual activity is beneficial, receiving accurate, honest information about contraception and disease protection is essential(12).

In December of 2009, President Obama moved toward elimination of federal abstinence-only funds by signing an appropriations bill that ended federal funding for existing abstinence-only-until-marriage programs, to be supported by more than $114 million in federal funds-- $75 million of which would go toward replicating comprehensive sex education and teen pregnancy prevention programs that have been thoroughly evaluated and provide the strongest evidence of success, while $25 million will go to other promising new programs (12).

But Obama’s plan was undermined. Also in December, Sen. Orrin Hatch, R-Utah, successfully included an amendment to the final version of health care reform that Obama signed to restore $50 million a year in abstinence-only state funds for another five years (13). In this case, the strong scientific evidence pointing towards the value of comprehensive sex education and away from the failed efforts of abstinence-only education has been trumped by politicized values—and the health of America’s young people is the losing party.


REFERENCES

1. Advocates for Youth. http://www.advocatesforyouth.org

2. Corrina H. What's the Typical Use Effectiveness Rate of Abstinence? January 29, 2010. From: Scarletteen.com http://www.scarleteen.com/blog/heather_corinna/2010/01/29/whats_the_typical_use_effectiveness_rate_of_abstinence

3. Evaluation of Abstinence Education Programs Funded Under Title V, Section 510: Interim Report. http://aspe.hhs.gov/hsp/abstinence02/

4. Goldberg M. AIDS is not the enemy: Sin, Redemption and the Abstinence Industry (pp. 134-153). In: Goldberg M. Kingdom Coming. New York, NY: W.W. Norton & Company, 2006.

5. The Guttmacher Institute. Review of New Study on a Theory-Based Abstinence Program. Guttmacher Advisory, February 2010. http://www.guttmacher.org/media/evidencecheck/2010/02/03/EvidenceCheck-Jemmott-Study.pdf

6. Harm Reduction Coalition. Principles of Harm Reduction. New York, NY: Harm Reduction Coalition. www.harmreduction.org.

7. Hauser D. Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact. 2004
http://www.advocatesforyouth.org/index.php?option=com_content&task=view&id=623&Itemid=177


8. Illinois Campaign for Responsible Sex Education. Curriculum Content Review: An in-depth look at sex education curricula in use in Illinois Classrooms. 2007. http://icah.org/sites/icah.org/files/docs/Sex%20Education%20Curriculum%20Content%20Review%2007_0.pdf


9. Jemmott III J et al. Efficacy of a Theory-Based Abstinence-Only Intervention Over 24 Months: A Randomized Controlled Trial With Young Adolescents. In: The Archives of Pediatrics and Adolescent Medicine. 2010;164(2):152-159.

10. Joffe C. Dispatches From the Abortion Wars. Boston, MA: Beacon Press, 2009

11. Kirby D et al. Emerging Answers 2007: Research Findings on Programs
to Reduce Teen Pregnancy and Sexually Transmitted Diseases. From: The National Campaign to Prevent Teen and Unplanned Pregnancy. November 2007. http://www.thenationalcampaign.org/EA2007/EA2007_sum.pdf


12. Krisberg K. Teen pregnancy prevention focusing on evidence: Ineffective abstinence-only lessons being replaced with science. From: The Nation’s Health, American Public Health Association. April 2010. http://thenationshealth.aphapublications.org/content/40/3/1.1.full

13. Landau E. $250 million for abstinence education not evidence-based, groups say. From: CNN.com. March 31, 2010. http://edition.cnn.com/2010/HEALTH/03/31/abstinence.education/index.html?hpt=T2

14. Rosenbaum J. Patient Teenagers? A Comparison of the Sexual Behavior of Virginity Pledgers and Matched Nonpledgers. In: PEDIATRICS Vol. 123 No. 1 January 2009, pp. e110-e120.

15. Terkel A. Texas schools move away from abstinence-only education: We don’t think it’s working. From: ThinkProgress.org. September 28, 2009. http://thinkprogress.org/2009/09/28/texas-contraception/

16. Valenti J. Full Frontal Feminism. Berkeley, CA: Seale Press, 2007.