Wednesday, May 5, 2010

Why Abstinence-Only Education Doesn’t Work and Why Federal Policy Needs To Change—Kelly Walker

Abstinence-only education has been federally funded under the Social Security Act since the Clinton administration passed welfare reform in 1996. Beginning in 1998, and continuing through today, $50 million a year has been dedicated to abstinence-only education programs throughout the nation that try to impress on adolescents that “abstinence from sexual activity outside of marriage [is] the expected standard for school-age children.” (1,2) Abstinence-only education is rooted in eight elements, commonly referred to as the A through H definition. Examples of some of the elements include:
• teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems
• teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity
• teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects

If states accept federal dollars to teach abstinence-only education, they must follow the A through H rules in order to be compliant with federal abstinence-only education rules. States that accept the federally funded dollars must also provide 3 dollars for ever 4 federal dollars received, nearly doubling the nation’s monetary investment in abstinence-education. (3)
Despite the heavy federal and state funding of abstinence-programs, numerous studies conducted on their efficacy have continually found that abstinence-only education has no quantifiable effect on teenage sexual behavior, and may actually increase the incidence of risky sexual behavior in adolescents. (3) Analyzing abstinence-only education through the lens of social behavioral theory can help to explain why abstinence-only programs are undoubtedly failing contemporary adolescents.

Sexual behavior is NOT rational


Most of the leading social science theories applied in public health interventions assume rationality in decision-making concerning personal health. Abstinence-only education does the same. The Health Belief model, the Theory of Reasoned Action, and the Transtheoretical model all propose a similar notion; that is, as long as someone has a positive attitude towards a behavior and believes the behavior will positively impact their life, they will carry out that behavior, as long as the benefits outweigh the costs (4). This idea has been widely criticized by today’s social scientists, who have posited that these models do not take into account an individual’s personality traits, demographic characteristics and other factors which may influence their behavior (5, 6).

The benefits of abstinence among adolescents are great—it is obviously the most effective way to completely halt the transmission of STDs and HIV, and prevent teen pregnancy completely. Unfortunately though, the decision to have sexual intercourse is one which adolescents typically do not approach by rationally weighing the costs and benefits, as described in the socio-behavioral theories above. Instead, adolescents are much more influenced by other factors, involving their peers, their environment, and their own biology. (7-10)

Adolescence is a time of tremendous change in a young person’s body. In the past most of adolescent risk-taking was attributed to new hormones flooding the body during puberty. But recent research suggests that adolescents’ inclination for dangerous behaviors actually stems from a complex combination of hormonal changes and ongoing brain development. (11) Parts of the adolescent brain which control emotional function are not completely developed by adolescence, and this can lead even intelligent teenagers to act irrationally when faced with serious, and potential dangerous sexual situations. (11)

Considering this, abstinence-only education’s focus on the rational benefits of restraining oneself from sex is bound to fail. How can adolescents possibly be expected to approach sex rationally, something that most adults can’t even do, when their brains are not fully developed, and under the influence of powerful new hormones?

No Consideration of the Environment


Another drawback of abstinence-only education is that it expects adolescents to always say no to sex in every situation. As noted above, the goal of abstinence-only education is to express to adolescents that abstinence is the only acceptable alternative to marital sexual relations. This view is extremely restrictive and fails to take into account both the immediate environment in which an adolescent may be attempting to have sex, and more abstractly, the environment of an adolescent dating relationship.

The socio-ecological model stresses the importance of considering environment when studying patterns of behavior. (12) Many people understand how physical environmental factors affect health—pollution in the air or contamination in a water supply can make people sick because of the ingestion of dangerous chemicals. But the socio-ecological model posits that health risks are also found in the social environment. (12)

In adolescence, different social environments—the high school classroom, the after-school program, the Saturday night party, or the varsity soccer game—all hold different health risks and opportunities. The common thread connecting all of these environments is the extreme influence that peers have on adolescents in any one of these environments. Adolescents examine the behavior of their peers and replicate their behavior in an effort to learn what they believe is correct socio-normative behavior. (13)

Although all adolescent behavior is somewhat influenced by peers, each adolescent is unique and friends and peers will have varying degrees of influence on each individual. A study has found that the more likely an adolescent is to peer influence, the more likely they are to participate in deviant behavior—including drug and alcohol use and risky sexual behavior. (14) Some of the risk factors that make an adolescent susceptible to peer influence are: younger age, family dysfunction, and depression. (15, 16)

Considering this fact, we can see that whether or not an adolescent is around friends at the time of risky sexual behavior, or if the potential sexual partner is someone the adolescent wants to impress, this can have a large effect on their ability to restrain from sexual contact. The sexual encounter does not occur in a vacuum, like abstinence-only education would have us believe.
Further, some teens are having sex within the environment of a healthy monogamous relationship, in which they are protecting themselves from pregnancy and sexually transmitted disease through condoms (or protecting themselves exclusively from pregnancy through another form of birth control). The 1995 Survey of Family Growth found that among teenagers who had sex prior to age 18, 52% of teens who had just met their partner did not use contraception, while only 24% of those in serious relationships did not use contraception. (17)

Although some studies link adolescent relationships to depressive symptoms (18), other surveys have found that adolescents in healthy, steady relationships have reported higher self-esteem. (19) It has further been suggested that healthy relationships during adolescence can offer opportunities for growth and fulfillment that can improve one’s health and happiness and increase resilience in later relationships. (20) If this is true, it may benefit adolescents to experiment with forming romantic relationships, and experiencing sexual intercourse, as a precursor to forming a healthy emotional and sexual relationship or marriage later on in adulthood.

Fails to promote self-efficacy


Many of the traditional socio-behavioral models include an element known as self-efficacy. Self-efficacy is defined as a person’s personal belief in his or her ability to complete an action. (4) Self-efficacy is important, because if a person has a high degree of self-efficacy they will be more likely to carry out a certain positive behavior, or at least attempt to carry it out, due to their increased confidence. Conversely, someone with a low degree of self-efficacy may put off attempting a positive change in health behaviors, because it will seem futile due to their low amount of personal self-confidence. Both the Health Belief Model and the Social Cognitive Theory include self-efficacy as an integral part of their behavior change models. (4, 21)
Albert Bandura considered self-efficacy so important that he updated his original Social Learning Theory with the addition of self-efficacy, and named it Social Cognitive Theory. Bandura posits that self-efficacy is the most important part of this model—and believes that an individual’s perceived self-efficacy has an influence on an individual’s coping behavior, level of psychological stress reactance, degree of resignation and despondency, and motivation to achieve personal or career goals. (22)

Abstinence-only programs fail to teach and promote self-efficacy to adolescents by avoiding educating young people about their options involving sexual intercourse and relationships. Because abstinence-only education stresses that abstinence is the only 100% effective way to avoid sexually transmitted diseases and pregnancy, it robs those students who aren’t practicing abstinence of self-efficacy by increasing self-doubt in their own attempts to avoid the negative outcomes of intercourse.

For example, if two adolescents are engaging in sex, but using condoms each time, they are protecting themselves at nearly the same efficacy rate as abstinence (condoms, when used correctly work 98% of the time). (23) But if these two young people are being taught at school that abstinence is the only truly effective, and truly acceptable, way to avoid negative outcomes of intercourse, then they may start to feel shame and doubt about their own personal experience with contraception and condoms.

Unfortunately, abstinence-only education not only advocates solely for abstinence, but also undermines the use of effective contraception. Since federal guidelines restrict abstinence-only education to endorsing abstinence outside of marriage, contraception is only mentioned extremely briefly and only mentioned in terms of failure rates. (24) The highlighting of negative information about condoms, the birth control pill, and other forms of contraception by trusted adults can seriously skew an adolescent’s belief in their effectiveness, and consequently, take away an adolescent’s confidence and self-efficacy concerning using contraception as a part of safe sex.

By failing to consider the absence of rationality in adolescence, by failing to consider the environment in which adolescents have intercourse, and by robbing adolescents of their self-efficacy, abstinence-only education has failed contemporary adolescents. By failing to trust adolescents to engage in sexual relations safely, the federal government has missed an opportunity to help foster healthy sexuality in the next generation of Americans.

The Solution: Comprehensive Sex Education


The best alternative to abstinence-only education is a federal policy mandating that comprehensive sexuality education be taught in classrooms across the country. Comprehensive sexuality education includes, unlike abstinence-only education, the true success and failure rates of various contraceptive devices, the endorsement of healthy relationships (even those which aren’t marriages), and the most accurate and up to date information on preventing unwanted, unhealthy outcomes of sexual activity, including sexually transmitted infections and pregnancies.

A federal policy endorsing teaching only comprehensive sexuality education would replace the Title V, Section 510 provision in the Social Security Act supporting abstinence-only education. This policy’s main purpose would be stated as educating adolescents about their sexual health and providing them with relevant tools with which to avoid possible negative outcomes of sexual relations.

Accepting the irrationality of adolescence


Unlike abstinence-only education’s supposition that adolescents should be able to use rational thought and adhere to abstinence at all times, the new federally-mandated comprehensive sexuality education curriculum instituted would acknowledge the irrationality of adolescence, as well as the irrationality of sex, and deliver its curriculum in consideration of these facts.
Adolescents, for the most part, are not able to make rational decisions due to the fact that their brain, especially their frontal lobe, is still in the midst of developing. Because of this, adolescents are far more likely to respond impulsively, rather than rationally, in emotional situations. (25) Sex, especially first time sex, would certainly be considered a highly emotional situation for an adolescent. Considering this, activities like sexual communication role plays are especially important.

Studies have shown that communication between an adolescent and a potential sexual partner is an essential part to having a safe and enjoyable sexual experience, because it allows an adolescent to better understand their potential partner’s past sexual experience, health and disease status, and desires in a sexual relationship. (26) But due to the implicit impulsivity of adolescents, this conversation is often bypassed, and adolescents increase their risk of contracting a sexually transmitted infection or getting pregnant accidentally.

Role plays are a way for adolescents to practice communicating about sex a situation which is not as emotionally charged as a true sexual experience. The Centers for Disease Control and Prevention’s list of best-evidence sexual health interventions has found that programs that include role play elements significantly influenced adolescents’ sexual behaviors. Youth that were in interventions that included role plays were found to have higher rates of condom use, lower rates of sexual initiation if they weren’t already sexually active, and lower rates of reported unprotected sex. (27) This suggests that role plays might be a mitigating factor in correcting for the irrationality of teens when it comes to sexual intercourse.

For this reason, the comprehensive sexual education program that will be federally mandated will include opportunities for adolescents to role play in order to practice the skill of negotiating with a potential sexual partner, and providing adolescents with the confidence to practice safer sex.

Considering Environmental Factors in Adolescent Sex


The suggested comprehensive sexual education programming would also be more effective than abstinence-only programming when considering environmental factors that affect adolescent sexual relations. An issue which is not touched upon in abstinence-only education, but would be included in the federally mandated comprehensive sexually education classes is the use of substances among the teenage population and its connection to sex.

According to the 2007 Youth Risk Behavior Survey, 22.5% of currently sexually active high school students had drunk alcohol or used drugs before their last sexual intercourse. (28) This suggests that for many high school students sexually activity is closely linked to substance use. This is likely due to the nervousness many adolescents experience while attempting sexual intercourse, and the ability to relax with the aid of substances such as alcohol or marijuana. It also suggests that sexual intercourse is not occurring in a vacuum, but instead in a certain environment in which adolescents can get access to alcohol or drugs, like a party.

Considering this, it is highly important that alcohol and drug information be included in the federally mandated comprehensive sexual education program. Topics which would be discussed in the curriculum would include not only statistics on substance abuse affects one’s sexual health, for example how heavier drinkers have a higher number of partners (29), but also would include a complete overview of drugs and alcohol in general. Teaching adolescents about the immediate dangers of drugs and alcohol outside of their sexual lives, and then synthesizing the information with the dangerous effects it has on their risk for sexually transmitted diseases and possible pregnancies would strengthen the argument against use at all.

Role playing would also be initiated during the drug and alcohol use part of the sexual education curriculum, and would have teenagers practice how to negotiate being offered drugs and explore what they might do if they found themselves under the influence of drugs or alcohol and being pressured to have sexual intercourse.

Promoting Self-Efficacy through Empowering Adolescents


The last and most important subject that would be addressed in the federally mandated comprehensive sexual education program is the self-efficacy of adolescents. One of the most important things that public health can do for adolescents is to support them with both relevant educational programming and with as many resources as possible to make them self-sufficient about keeping themselves healthy. This is especially true when public health is attempting to address a subject as intimate as sexual health. Adolescents faced with choices to make about their sexual habits will often make those choices alone, as the choice to have sex with someone is an extremely personal decision.

In order to make sure that adolescents make healthy decisions we have to educate them on how to have sex safely, and also to be honest about how safe each method of contraception is. The unique benefits and risks of the birth control pill, the condom, the intrauterine device or the Depo-Provera shot should all be discussed in relation to how they would work in a certain adolescent’s life. Special attention should be paid in the comprehensive sexual education program on teaching teenagers how to get and use condoms, as they are the most likely contraceptive device used during adolescent sex (with 49 percent of men, and 45 percent of women age 15-19 using condoms at their first sexual experience). (30) Programs that make this information explicit to adolescents have been shown to increase the number of students who felt confident about both obtaining and using condoms. (31) If students feel confident about their abilities concerning condoms, they are more likely to actually use them during intercourse, and subsequently less likely to experience a negative outcome related to sexual intercourse.

Conclusion


Abstinence-only education has sadly left many high school students across the country in the dark about their sexual health. By modifying federal policy to mandate comprehensive sexual education be taught in all high schools across America, we could correct information adolescents have been given about failure rates and empower them with the information they need to have safe sex. By using role plays as part of this education, we will appropriately take into consideration the irrational nature of the adolescent brain and their sexual lives. And by synthesizing alcohol and substance abuse information with sex information, we will be acknowledging the fact that adolescent sex hardly occurs in a vacuum, but instead in sometimes dangerous and emotionally charged environments. This comprehensive curriculum would serve adolescents better than abstinence-only programs that simply tell adolescents to wait; it would truly prepare adolescents to make their own decisions regarding sex, and to gain the self-efficacy to negotiate sex with a partner, understand why using substances while having sex is dangerous, and empower them to use contraceptive devices, all to the end of more emotionally and physically safer sex.

References


1. Advocates for Youth. The History of Federal Abstinence-Only Funding. Washington, DC: July 2007.
2. U.S. Social Security Administration. Compilation of the Social Security Laws. Washington, DC: January 2007.
3. Mathematica Policy Research Inc. Impacts of Four Title V, Section 510 Abstinence Education Programs. Princeton, NJ: April 2007.
4. Edberg M. (Ed.) Individual Behavior Theories (Chapter 4). Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: 2007, 35-49.
5. Poss, JE. Developing a New Model for Cross-Cultural Research: Synthesizing the Health Belief Model and the Theory of Reasoned Action. Advances in Nursing, 2001;23(4):1-15.
6. Thomas LW. A critical feminist perspective of the health belief model: implication for nursing theory, research, practice, and education. Journal of Professional Nursing, 1995;11:246-252.
7. Ott MA, Millstein SG, Ofner S and Halpern-Felsher BL. Greater Expectations: Adolescents' Positive Motivations for Sex. Perspectives on Sexual and Reproductive Health, 2006;38(2):84-89.
8. Parsons JT et al., Perceptions of the benefits and costs associated with condom use and unprotected sex among late adolescent college students. Journal of Adolescence, 2000;23(4):377-391.
9. Kinsman SB et al., Early sexual initiation: the role of peer norms. Pediatrics, 1998;102(5):1185-1192.
10. Stanton B et al., Sexual practices and intentions among preadolescent and early adolescent low-income urban African-Americans, Pediatrics 1994, 93(6, pt. 1):966-973.
11. Dahl, Ronald. Beyond Raging Hormones: The Tinderbox in the Teenage Brain. The Dana Foundation. New York, NY: 2003.
12. McMurray A. Community Health and Wellness: A socio-ecological approach. Marrickville, New South Wales: Elsevier Australia, 2007.
13. Gardner M and Steinberg L. Peer Influence on Risk Taking, Risk Preference, and Risky Decision Making in Adolescence and Adulthood: An Experimental Study. Developmental Psychology, 2005; 41(4):625-635.
14. Allen JP, Porter MR, and McFarland CF. Leaders and followers in adolescent close friendships: Susceptibility to peer influence as a predictor of risky behavior, friendship instability, and depression. Development and Psychopathology, 2006; 18:155-172.
15. Steinberg L and Monahan KC. Age differences in resistance to peer influence.
Developmental Psychology, 2007; 43(6):1531-1543.
16. Prinstein MJ, Boergers J, Spirito A. Adolescents' and Their Friends' Health-Risk Behavior: Factors That Alter or Add to Peer Influence. Journal of Pediatric Psychology, 2001; 26(5):287-298.
17. U.S. Centers for Disease Control. National Survey of Family Growth. Hyattsville, MD: 1995.
18. Monroe SM, Rohde P, Seeley JR, and Lewinsohn PM. Life events and depression in adolescence: Relationship loss as a prospective risk factor for first onset of major depressive disorder. Journal of Abnormal Psychology, 1999; 108: 606–614.
19. Samet NR and Kelly, EW. The relationship of steady dating to self-esteem and sex role identity among adolescents. Adolescence, 1987;22:231–245.
20. Karney BR, Beckett MK, Collins RL, and Shaw R. Adolescent Romantic
Relationships as Precursors of Healthy Adult Marriages: A Review of Theory, Research, and Programs. RAND Labor and Pollution. Santa Monica, CA: 2007.
21. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, NIH Publication No. 05-3896, 9-21.
22. Bandura A. Self-Efficacy Mechanism in Human Agency. American Psychologist, 1982;37(2):122-147.
23. Hatcher, RA, Trussel, J, Nelson, AL et al. Contraceptive Technology (19th ed.). New York, NY: 2007.
24. Santelli J, Ott MA, Lyon M, Rogers J, Summers D, and Schleifer R. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health, 2006;38:72-81.
25. The American Academy of Child and Adolescent Psychiatry. The Teen Brain: Behavior, Problem Solving, And Decision Making. Facts for Families Newsletter, No. 95. 2008.
26. Whitaker DJ, Miller KS, May DC and Levin ML. Teenage Partners’ Communication About Sexual Risk and Condom Use: The Importance of Parent-Teenager Discussions. Family Planning Perspectives, 1999; 31(3).
27. Centers for Disease Control and Prevention. 2009 Compendium of Evidence-Based HIV Prevention Interventions: Best-Evidence Interventions. 2009. Available at: http://www.cdc.gov/hiv/topics/research/prs/best-evidence-intervention.htm.
28. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance-2007. Atlanta, GA, 2007. Available at: http://www.cdc.gov/mmwr/PDF/ss/ss5704.pdf
29. Cavazos-Rehg PA, Spitznagel EL, Bucholz KK, Norberg K, et al. The Relationship Between Alcohol Problems and Dependence, Conduct Problems and Diagnosis, and Number of Sex Partners in a Sample of Young Adults. Alcoholism: Clinical and Experimental Research, 2007;31(12):2046-2052.
30. Abma JC, Martinez, GM, Mosher, WD., Dawson, BS. Teenagers in the United
States: Sexual activity, contraceptive use, and childbearing, 2002. National
Center for Health Statistics. Vital Health Stat 23(24). 2004.
31. Tucker JS, Fitzmaurice AE, Imamura M, Penfold S, et al. The effect of the national demonstration project Healthy Respect on teenage sexual health behaviour. European Journal of Public Health, 2006;17(1):33-41.

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2 Comments:

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