Where Did The Boys Go? A Critique of Teen Pregnancy Prevention Approaches – Cynthia Schoettler

Introduction
Teen pregnancy has always been a looming and difficult issue for American Society. While the average teen birth rate has declined dramatically since the highs recorded in the 1980s, it has shown an increase in recent years (1). In fact, in 2006, over 400,000 babies were born to a teenage mother (2). This accounts for over 9% of all births in the US (3).

Teenage motherhood is not without risks both medically and socially. Medically, the outcomes are worse than babies born to women in their 20s (4) and added cost of supporting teenage parents to society, in dollars, is upwards of $16,000 per year, per child (5). Young mothers are also at higher risk of dropping out of high school and achieve lower educational attainment (6) thus limiting their own potential for growth. Additionally, the female children of teenage parents are at least twice as likely to become teen parents themselves (7), thus repeating the cycle of additional risks, costs and poor outcomes.

But, these statistics and the majority of academic literature available regarding teenage pregnancy are all in regards to young women. For example, a cursory search on PubMed, one of the major search engines for scientific and medical literature, for “teenage pregnancy, (female or girl)” yields roughly 2.6 times the number of results that “teenage pregnancy, (male or boy)” does (http://www.ncbi.nlm.nih.gov/pubmed). While this may be a reflection of the fact that in society, the onus of child rearing usually falls upon the woman, especially in cases unintended pregnancies, it neglects the biological fact that creating a traditional pregnancy requires two individuals; one female and one male. Consequently, when confronting the issue of teen pregnancy, it is crucial to acknowledge the role that young men play.

This is not to minimize the current efforts targeting the role that young women have and need to take charge of their own bodies, their futures and themselves. Keeping young women at the forefront of teenage sexual education and prevention of teen pregnancy should always remain a priority. Instead, I wish to argue that because teen pregnancy is the result of two players, neglecting one half is akin to dancing the tango alone – awkward and not nearly as effective as when done in tandem.

Nowhere is this lonely dance more apparent then in current, widely publicized campaigns to prevent teen pregnancy. Among the most common campaigns such as MTV’s 16 and Pregnant (http://www.mtv.com/shows/16_and_pregnant/season_2/series.jhtml) , StayTeen.org’s teen pregnancy page (12) and the Candie’s Foundation (www.candiesfoundation.org). The campaigns and messages are frequently lauded for being appealing to teens and for employing star power or drama to propel their message to a willing audience. They are also relatively even handed when it comes to giving out information regarding the options that teens have in both preventing pregnancy and what to do if a pregnancy occurs.

However, much like the empirical research regarding teen pregnancy, these prevention of teen pregnancy campaigns focus on targeting young women. This focus is especially surprising given that some of the drop in teen pregnancy rates in the early 2000s has been attributed to shifting sexual behaviors in adolescent males (8). In order to demonstrate how the paucity of campaigns targeting young men has not met its potential I will critique this approach through pointing out the three major fallacies of neglecting young men in teen pregnancy prevention campaigns, and then argue for the addition of a male centered campaign.


Critique #1 – Ignoring the Male Interest

One of the most widely talked about teen pregnancy public service announcements (PSAs) this spring has been Brisol Palin’s warning about teen pregnancy by the Candie’s Foundation. In this PSA, Bristol Palin talks directly about her experience and the consequences of her actions. At no point is the role of the father mentioned. Furthermore, most of the other PSAs or posters put out by the foundation feature mainly teen girls (9). This focus on young women is further evidenced in its media material where the colors are black and neon pink, the majority of spokespeople are women and the promotional T-shirt is displayed by and comes in only women’s sizes.

By ignoring the male interest through creating campaigns that feature female celebrities or PSAs that talk about the girl’s experience in such detail, the announcements might as well be talking about menstruation, dangly earrings or anything else that teenage boys typically find beyond their realm. Anyone who knows teens will be able to tell you that one of the fastest ways to be ignored is to be completely uninteresting to them and un-relatable (32). By focusing so heavily on the teen girl’s point of view or experience, the promoters of these campaigns are essentially doing just that.

Instead, the campaign needs to take a note from their own manifesto and “use celebrities that teens can relate to” (9) - male celebrities talking about the male perspective of teen pregnancy. This approach is key because despite recent movements towards gender equality, concrete gender differences regarding sexual knowledge, attitudes and behavior remain (10).

Utilizing differences to attract specific audiences is nothing new. Traditionally, marketing firms research the target audience extensively to better understand what they relate to and even more importantly, what they pay attention to. This is called “Formative Research”, and is the foundation of any successful marketing campaign (11). Yet in the teen pregnancy campaigns, this basic principal of marketing seems to be forgotten.


Critique #2 – Portrayal of the Male Role

The second area where teen pregnancy awareness and education campaigns fail is in portraying the male role. In the Candie’s Foundation campaign, the male is featured as an accessory to the crime who then disappears when the girl is handed a baby (9).

In the information regarding teen pregnancy presented by StayTeen.org, eight of the 12 facts presented focus on the consequences for teen girls. This is 75% of what was presented. For the remaining quarter, one fact talks about fathers not marrying the mother, another talks about how the male children of teen mothers are more likely to go to prison and the other two are simple statistics about teens and pregnancy in general (12). It is clear that nowhere is there any information or anecdotes about how the pregnancy was created by or affects the father of the child.

If teen pregnancy campaigns are going to engage the adolescent male through scenarios, anecdotes and information, why is there no representation of his involvement? This blatant omission of the simple biological fact that the young man was involved in creating a pregnancy is akin to pardoning him from any and all responsibility – for the act and repercussions.

The result of this omission is profound. Labeling theory tells us that creating a perception or a label of a certain demographic essentially creates a self-fulfilling prophesy – for society and especially for the labeled individual (13). Consequently, by communicating that adolescent males are exempt from responsibility for and the results of teen pregnancy, we are setting them up to believe and act so.

One very public example of this is featured in the 16 and Pregnant MTV reality show where many of the teen fathers are blatantly uninvolved (14). By placing these young men in the spotlight the show is inadvertently endorsing their behavior and furthering the reputation of teen fathers as irresponsible and irrelevant.

By widely presenting teen males as superfluous and exempt from teen pregnancy, the campaigns are essentially publicizing that the male is expected to do nothing. Because social expectations are so powerful, often acting as rules that govern the day to day functioning of society (15), these PSAs are acting to further perpetuate the exact problem they wish to solve. A result of this is that adolescent males frequently place contraceptive responsibility to females and have lower perceptions of the risk of pregnancy (16; 8).

Socially and biologically, the male exemption from teen pregnancy has many effects. Children of uninvolved adolescent fathers are more likely to drop out of school, have developmental and behavioral problems and become teen parents themselves (17). Some may argue that this may be due, in part, to the fact that teen fathers indeed are often uninvolved in the rearing and support of their children. Some statistics report that only 15% of unwed fathers provide regular support (18).

Even so, the fact of the matter is that even when disengaged, teen pregnancy does affect the father. Sullivan (19), reports that the inability to provide support in the life of their child is often viewed as a manifestation of a loss of manhood. Other studies show that teen fathers don’t necessarily view disengagement as a desirable outcome (20). Thus, in order to help stop the cycle of self-fulfilling labeling and to help better support teen fathers it is doubly important to show them exactly what their role was, how becoming a parent will affect them and how important it is for them to be involved.


Critique #3 – The Reality of Men Are From Mars

Whether it is comfortable to admit or not, there are distinct gender differences in the psychological and sexual profiles of adolescents. For example, teen boys often have less conservative attitudes about sex than teen girls (8). They also react differently to information regarding sexual health and procreation (21).

As a reflection of these differences, teen boys have been known to discontinue any use of an effective method of contraception if a current method is deemed uncomfortable (socially or physically) (22). This is worrying because some studies have shown that male methods account for half of all adolescent contraceptive use (23).

This difference likely results from the fact that adolescent males become aware of their potential to procreate at later years than adolescent females (24). This consciousness is also activated differently, through problem solving alongside the direct envisioning of of procreation (21). Adolescent females, on the other hand, become more aware of their sexuality through active experiences and often before the onset of menarche (25).

Another realm where adolescent males differ from females is in reactance to information, instructions and especially to campaigns (32). Adolescent males consistently produce higher behavioral and verbal reactance scores than their women counterparts (26). This means teen boys react less favorably when simply instructed to do something and more favorably when presented with options – much like Hutchinson et al determined when studying male awareness of sexuality and sexual situations. By ignoring these differences between the genders, potentially effective campaigns fail to meet their potential and end up impotent.


Proposed Intervention

As stated earlier, many of the current wide-reaching initiatives are lauded for being [initially] appealing to teens as a general population, for employing star power and drama to propel their message to a willing audience. Yet, they fall short in being able to specifically target the male audience, portray adolescent males as involved in the creation of a pregnancy and the aftermath and in acknowledging the fact that adolescent males view and react to sexuality and messages different from adolescent females. Therefore, I propose to add male oriented, Public service announcements, posters and information to the present teen pregnancy prevention campaigns.

For example, piggy-backing off of the Candie’s PSA featuring a passionate scene of a teen couple in a car, instead of suddenly switching to an awkward moment with a baby, the couple would be faced with what to do because the guy just found out he has no condoms. The options would be to go ahead or be a real man and pause [the tagline of the campaign] to fix the problem. A simple change such as this would address all three of the main problems of the current campaign by a) appealing to the male interest in general and in relation to sexual health by featuring a guy the viewers can relate to, b) portraying him as a responsible partner in the act and c) acknowledging his thought patterns and reactions by placing the decision in his hands.


Defense of Intervention - Marketing Techniques

Publicity campaigns for commercial products are so successful because they are able to employ the core traits of marketing theory and framing with great skill. For example, the clothing brand Abercrombie and Fitch is able to sell rather common looking T-shirts at high prices because they appeal to teenagers’ ideals of strength and independence.

Likewise, these same tools can be re-appropriated for the prevention of teen pregnancy by incorporating them into the campaigns. It is only after being able to “get under the skin of their target audience and explore the core values” (11) that one is then able to redefine the product [teen pregnancy prevention] in a way that will be able to grab attention and make the message appealing.

One way to do this for the male addition to the teen pregnancy campaign is by changing the way the information is presented. One way is to appeal to values young men embrace – such as independence or virility. For example, instead of showing an unhappy teen father alone, contrast him to an independent and sexy teen who is not a father. A different approach would be to appeal to a teen male audience would be to portray activities, such as afterschool programs that have been proven to reduce teen pregnancy and emphasize teen success (8) in a light that also would make the participant more desirable to the opposite sex.

Another way to capture the male interest would be to present the issue as something they are affected by; to make the issue of teen pregnancy relevant to the adolescent. An effective method for this would be to feature clips of real, or admired, teenage boys talking about how preventing teen pregnancy allows them to remain independent (and still be cool). By keeping the personal stories positive the campaign would help create a positive promise for the young men that they would embrace more readily (27). Similar approaches have been used in individually focused teen prevention initiatives with great success (8), but would reach a larger target audience if part of nationwide publicity campaigns.

Furthermore, as an extension of the visual support the commercials following this formula would lend to the message, the information sections of these websites would need to also appeal to male values and interest. This would mean completely re-formatting the layout. Perhaps the websites could follow the format of Sports Illustrated, AskMen.com or GQ Magazine – any site that is specifically designed for and read by this demographic.

The information given on such informative websites would also have to focus on the ways in which a pregnancy affects the male and be nuggets of information that teen boys react to. Examples include giving statistics on how there is a threat to independence and that future achievements can be thwarted by the new responsibility and financial burden of raising a child (8). This would help fix the problem that the current sites have featuring women and the color pink (one of the colors most widely associated with women and girls) or by being gender neutral and hence less interesting to boys.


Defense of Intervention – Social Influences

Focusing on the adolescent male in broad public service campaigns is especially important because one of the remaining effects of the perception that ‘boys will be boys’ is that the sexual education of teen boys is often neglected (28) and that teen boys are essentially exempted from responsibility for creating a pregnancy (18). Thus, to counteract this attitude, the campaigns need to publicly show that teen pregnancy is indeed affects young men, and as something that they can and should control.

The first step would be to reduce the optimistic bias experienced by adolescent males (8, 34) and most individuals who engage in common high-risk behaviors (29). To do this, the new male focused campaign could continue with its format of featuring relatable teens, but also feature young men who became teen fathers and the way their new responsibility has affected their lives. By engaging the audience with a compelling personal story, the consequences become less abstract and more real. As a result, teen boys would be less apt to believe that a pregnancy won’t happen to them, and will be more willing to pursue options for its prevention.

A second component to changing opinions regarding the male role in teen pregnancy would be to model safe sex or abstinence behaviors in a way that preserves the ideal of manhood. This would also remove the perception that engaging in safe sex behaviors or refusing intercourse is damaging to one’s self-image or loosing the respect of one’s peers (30). Instead, it would add the perception that [the male] taking responsibility is expected and desirable. An example of this could be a commercial asking the question “What is a real test of strength, 100 pushups in a minute or saying no to sex without condoms?” The end result of a sustained and successfully executed campaign with these components would be an eventual shift in society’s perceptions and expectations [of the guy’s responsibility] and young men would follow suit (15).

While this approach may seem far sighted and impossible in some areas given the pervasive culture of machismo in nearly every social group of teen boys, current programs already promoting this approach, such as the Young Men’s Clinic in New York City (8) have proven to be very successful. They are successful because they consistently present young men with positive role models who achieve many of the same goals as the adolescents aspire to. While not as interactive as an group specific outreach program, a national information and media campaign with the same message would begin the process of normalizing the responsible adolescent male.


Defense of Intervention – Irrational Decision Making

The current campaigns fail to address the reality of the way individuals, especially adolescent males, make decisions. For example, in the Candies campaign, one PSA beings well with a very passionate scene of a teen couple (9). While this opening is an excellent use of context by creating a hot state for the viewer, it falls short in the delivery of the message. This is because after creating the hot state, the scene suddenly changes to a cold one by cautiously presenting the guy with a baby in a pram and no information about how to prevent this reversal of situation. Based on our knowledge of how adolescent males think about procreation, the PSA would be much more effective if it continued to give its information in the hot state and presented the male viewer with a quick dilemma and subsequent solutions (21).

Tailoring the message to the way adolescent males made decisions is crucial because especially in middle adolescence, teen boys do not respond well to scare tactics and instead are pushed to take the exact risks they have been warned about (8). Therefore, by engaging the teen in problem solving and by framing the options as a choice, the campaign takes advantage of the teens’ need to make their own choices and exercise their growing ability to reason (31).

As a result of such an approach, the teens would begin to feel more involved in their own actions and in the protection of themselves and their livelihood. This is especially important because when individuals feel ownership over themselves, an object or even something as abstract as a brand, they are more willing to go to great lengths to maintain the situation (33). By creating an adolescent ownership of responsible sexuality or abstinence through the media campaign, through showing believable threats to their situation and through enabling teens to feel ownership through decision making, they will naturally be more apt to maintain what they have and stay pregnancy free.

Lastly all individuals, but especially adolescents, respond with less negative reactance and stronger agreement when the communicator is viewed as more similar to the target audience (32). So, by continuing to present popular yet relatable young men who act responsibly when it comes to sex the new campaign would garner greater credibility and allow adolescent males to take ownership over their actions because they would view their options as both desirable and reachable (33).

Conclusion

The end result of all these elements playing a role in the addition of a male oriented branch to current teen pregnancy prevention efforts would be to essentially create a sought after brand that is the responsible and involved teen male – who just happens to engage in safe sex practices or abstinence. The campaign would shift the current paradigm away from ignoring the male interest, promoting the lack of male responsibility for the creation of a pregnancy and the sequelae, and blatant lack of recognition of the male psyche. Instead, it would create an awareness of the benefits of avoiding teen pregnancy through effective marketing strategies, create favorable associations between the teen and the outcome through facilitating realistic decision making for the teen male and last but not least create loyalty to the prevention of teen pregnancy through promoting social expectations of responsibility.

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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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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.

A Critical Look at Abstinence Only Sex Education to Adolescents- Adam T. Hughes

Abstinence only sex education is currently the only federally funded approach to sex education to adolescents in the U.S. This curriculum requires school health teachers to promote abstinence as the only effective method for preventing pregnancy and sexually transmitted infections (STI’s). (1). Beginning in FY98, Title V Section 510 provided $50 million dollars in annual federal support for this type of curriculum, making it standard in most U.S schools. (14) This restricts any education around other health information or options if one chooses behaviors other than abstinence (1). The table below defines abstinence education.

A-H Definition of Abstinence Education
A. Have as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity
B. Teach abstinence from sexual activity outside marriage as the expected standard for all school-age children
C. Teach that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems
D. Teach that a mutually faithful, monogamous relationship in the context of marriage is the expected standard of sexual activity
E. Teach that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects
F. Teach that bearing children out of wedlock is likely to have harmful consequences for the child, the child's parents, and society
G. Teach young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances
H. Teach the importance of attaining self-sufficiency before engaging in sexual activity
Source: Title V, Section 510 (b)(2)(A-H) of the Social Security Act (P.L. 104-193). (14)


Controversy circles this policy as advocates of abstinence only curricula feel that sex before marriage is immoral. They also share that condoms are not an effective way to prevent pregnancy and STI’s, which put adolescents who engage in sexual activity at high risk for these outcomes. Exclusions using this approach include: condom demonstration and distribution, sexual risk reduction, and contraception options. At the time this law took effect 88.7 per 1000 women aged 15-19 in the U.S. became pregnant each year. (15) At the same time, half (9.1 million of 18.9 million) of all STI’s in the U.S. were contracted by people between the ages of 15-24. (16) Abstinence only sex education teaches teens that remaining abstinent until marriage is the only way to avoid both of these health outcomes. (3). The reason for leaving out other related health information and education is the belief that educating adolescents about things like condoms, safer sex, and contraception will encourage and enable adolescents to initiate sex before marriage (2). This approach incorporated a moral construct to sex before marriage to create the norm that connects sex with death, disease and danger (4).Currently there are many studies that claim the abstinence only approach does not effectively prevent adolescents from abstaining from sexual activity. While there are a limited number of studies that refute that claim, most are not peer reviewed or published works (2).

Abstinence only advocates, such as Concerned Women for America, point out that adolescent sex is not only about public health but morality as well. Adolescent sex, according to this organization, contributes to not only illegitimate births and AIDS, but also poverty, increase in crime, and the breakdown of the nuclear family. This idea is shared with many other organizations such as: The Eagle forum, The Family Research Council, The Heritage Foundation, The Medical Institute for Sexual Health (MISH), and many others (2). Since these advocates have been able to draw connections to all these societal downfalls, those against abstinence only sex education face a difficult battle with the conservative right.

Within the last three years, there has been a rise in publications that are finding flaws in abstinence only sex education. Many of these publications argue that this approach leaves adolescents with incomplete, even fragmented information that is inappropriate considering the high rates of pregnancy and STI’s in the U.S. (5). Conservatives and the religious right continue to advocate abstinence only education, but momentum is shifting towards comprehensive, or abstinence plus (another name for comprehensive sex education). The statistics are very uneven and compares sex initiation as a value relative to pregnancy and STI rates, which often times do not match up (6). The most effective and appropriate approach for adolescent sex education is proving to be comprehensive or abstinence plus education.


Critique 1: Leaving Adolescents Uninformed Deters Them of Vital Knowledge

Advocates against abstinence only sex education that promote comprehensive sex education, or abstinence plus, say the current approach leaves adolescents uninformed or misinformed about facts of sex and health information if they choose a behavior other than abstinence (2). Without this knowledge, they are left to navigate sexual activity without understanding ways to reduce risk of pregnancy and STI’s. If an adolescent chooses to engage in sexual behavior before marriage and had only received abstinence only education, that individual will not know how to correctly use a condom Education around these topics is incorporated in comprehensive sex education. Students who have more information have the opportunity to be prepared to handle situations they may find themselves in. (5) Also, studies show that comprehensive sex education does not promote or increase the rates of sex initiation (which is a fear among those opposed to comprehensive sex educations) and does increase teens’ knowledge of how to protect themselves (2). The same idea relates to contraception. If a young women is not empowered with all the information to make informed choices for her own sexual and reproductive health, her risk of pregnancy and STI is increased if she decides to engage in sexual behaviors.

Comprehensive sex education advocates argue that despite the idea that abstinence only education is morally correct, it is immoral to deny the human right of sexual health information (1). HIV/AIDS and sexual health information has been recognized as a human right and is essential to living the highest standard of health attainable (7) On that basis, ethical and moral standards come into question using the abstinence only approach to sexual education. This is concordant with the argument that restricting information leaves adolescents uneducated about the information needed if one chooses behaviors other than abstinence. The attempt to control behaviors in turn may just be allowing adolescents to slip through the cracks unless they follow the strict guidelines laid down by abstinence only sex education. The public health consequences of this will result in a decrease in consistent correct condom usage and lack of awareness and access to contraception. (6)

Critique 2: Attaching Moral Judgment and Stigma to Sex and Sexuality Causes Shame and Poor Self Esteem

Abstinence only sex education has incorporated a moral construct to sex before marriage to create the norm that connects sex with death, disease and danger. The message being relayed to these adolescents is fear. For example, in the abstinence-promoting evangelical educational video “No Second Chance”, the educator compare sex with Russian roulette and goes as far as saying “the only difference is, in Russian roulette you only have one in six chances of getting killed.” This actually infers that having sex is even more dangerous than a game involving a lethal weapon (4).
Using images of men dying of AIDS has also been seen as a scare tactic to delay sex until marriage. Not only does this stigmatize individuals living with HIV/AIDS, but it infers that if you have sex, you will get AIDS. This obviously and viciously stigmatizes sex. Stigmatizing sex creates a culture of shame and embarrassment around topics of sexual experiences and feelings among adolescents. There is also evidence that bible verses are used to manipulate youth that premarital sex is wrong. In a abstinence only curriculum called “Abstinence Works: A Notebook on Pre-Marital Chastity” there is a bible verse from Deuteronomy starting with “Today I set before you life or death, blessing or curse” with an image of Mother Theresa on one side and a picture of a skeleton on the other. There is clear stigma attached to premarital sex in this campaign. It attaches moral judgment in an explicit manner implying one can be as good as Mother Theresa or as bad as death (4).

Because abstinence only education is aiming at delaying sex until marriage, it not only stigmatizes sex, but sexuality as well. Under Section 510 requirements (the federal law surrounding abstinence only sex education) heterosexual marriage is exclusively the appropriate context for sexual behavior. What is a gay or lesbian adolescent in a state that does not recognize gay marriage going to walk away from this approach? Homosexuality is not explored in depth in abstinence only sex education. The only time it is addressed is when talking about transmission of HIV/AIDS (1). This not only ignores homosexuality as a lifestyle, but infers stigma to being gay is only relative to getting HIV/AIDS. Adolescents who are questioning their sexuality are not in a place to openly and affirming question homosexuality. There are silent judgments made about homosexuals in this approach to sex education. The implied expectation of LGBT adolescents is lifelong abstinence. Since sex and sexuality is an aspect of health and abstinence only education infers lifelong abstinence, this is not conducive to a healthy sexual and reproductive life for LGBT adolescents (4).

Critique 3: Media Works Against Abstinence Only Education

One of the core components of abstinence based sex education is the component of exposure. Advocates for abstinence only education argue that exposing youth to condoms, safer sex practices and contraception will condone sexual behavior. Unfortunately, this is allowing adolescents to receive a portion of their sex education from the media (9). In a study conducted by The Association for Education in journalism and Mass Communication, increasing restrictions of schools because of abstinence only education leaves adolescents to obtain much of their sexual knowledge from the media. This in turn, is informing adolescents about sex without the sexual health aspect (9). Some examples to follow illustrate the disconnect between the education adolescents receive at school and what compliment that information with from the media.

Since the current approach does not address condom usage, adolescents have received information on that from movies such as American Pie. In this movie, four friends make a pact to lose their virginity by graduation. Though condoms were seen throughout the movie by the boys, the only time a condom was shown actually attached to a sexual encounter was given to the boy by a young woman. This enhances the stereotype that contraception and safer sex is the responsibility of women only. Also, because the main character, Jim, ejaculated prematurely during sex, his prom date told him to put on two condoms so he could “last” Longer (9). This information is incorrect as it is shown that wearing two condoms at the same time increase the risk of the condom breaking (10).

Another example focuses on the media depiction of teen pregnancy. In a rapper DMX’s song Shorty was Da Bomb, he spoke about how the rubber (condom) bust. He insinuated she was a dishonest person because she said she was four months pregnant and he found out she was six months pregnant. Because of his perceived dishonesty of the girl, he abandoned her. He ended the song saying she would be ok because “Shorty [his penis] was the bomb”. This educates young men that pregnancy is the woman’s responsibility and abandoning a young woman you impregnate is acceptable, considering you are a good lover (9). These unhealthy and even inaccurate portrayals of sex in the media supplemented by restricted information by schools leave adolescents with mixed messages and unacceptable behaviors to base their decision making on. If comprehensive sex education was implemented and taught of the shared responsibility of teen pregnancy, adolescents would be able to distinguish the unhealthy portrayal of this song, without that education, this song is all they have to draw from.

A study on sex in the media done by Kaiser Family Foundation has found there is increasing evidence that exposure to sexual content on television is contributing to many aspects of adolescents sexual knowledge, beliefs, expectations, attitudes, and behaviors. (17) This points out the flaw of abstinence only education that assumes adolescents will not receive messages about premarital sex if they are not taught in the school. The same study indicates that television would be an excellent venue to socially market sexual health information in a productive manner.

Revised Approach

The strongest aspect of the approach criticized is that it promotes the one fool proof behavior that prevents pregnancy and STI’s. What the approach lacks is all the information teens need beyond abstinence education, without moral judgment and stigma. A revised approach would incorporate a three-tiered system. The foundation of this approach would be the incorporation of comprehensive sex education across all public schools in the country including a repeal of Section 510. The comprehensive sex education would still be grounded in delay of sex, but incorporate communication with sex partner, condom negotiation skills, contraception, and testing options. This approach would be supplemented by incorporating sex-positive messages in the education using the stigma/labeling theory. The third tier of this approach would be a large scale social media campaign accessible to adolescents that celebrate sex and sexuality while still providing education on the reality of decision making and consequences.

The purpose of this approach is to remove the aspects of the approach being criticized. Adolescents would receive vital health information so they are empowered to make informed choices around their own sexual and reproductive health. Sex positive messages would replace morally judging/stigmatic messages to be inclusive to all sexual and gender identities as well as decrease the taboo of premarital sex to open dialogue with adolescents. Lastly the social media campaign would be a widespread comprehensive series that would work to combat the sex messages sent to adolescents through mainstream media. The expected outcomes of this approach would be an increase in condom usage, decrease in unwanted pregnancy, and a decrease in STI rates among adolescents.

Defense of Approach 1:Incorporation of Comprehensive Sex Education

Incorporating comprehensive sex education, or abstinence, will provide adolescents with the information to make informed decisions surrounding their sexual and reproductive health. As mentioned earlier, most of the studies tracking programs that implemented this approach reported no significant increase in sex initiation (8). Using this approach, empowering adolescents with health information is not perceived as condoning rather than acknowledging the reality that some adolescents will choose behaviors other than abstinence and ensuring that they have the knowledge to make those decisions when in real life situations.

Specific topics included in comprehensive sex education would include consistent correct condom usage, condom negotiation skills, contraception options for women, contraception responsibility for males, as well as safer sex risk reduction. Condoms would be made available in the nurse’s office of schools to provide free availability for condoms. To access a condom, students would need to demonstrate correct usage on a condom demonstrator before being given condoms. School nurses would not be restricted to what information and resources they can distribute to young women about contraception and pregnancy options. All of these components would leave the adolescent with a full scope of information to aid them in decision making. Federal funding would be solely towards comprehensive sex education and abstinence only education would be stopped.

Research completed by Douglas Kirby, a respected sex researcher of ETR Associates concluded that STI/HIV education programs in the schools he studied can delay sex; reduce the frequency of sex, increase condom and contraceptive use, and decrease pregnancy or childbearing. (6) This clearly refutes the ideas attached to comprehensive sex education as “enabling and condoning”. There were also indicators that many programs that implement comprehensive sex education lack fidelity and that if funding was dispersed to ensure fidelity, sexual risk taking among adolescents would decrease. The Ideology believing that restricting information to adolescents will have better outcomes than if the information is made available is flawed based on this research.

Another study was conducted in New York City and Chicago public schools. In NYC schools, condoms were made available; in contrast, Chicago schools followed abstinence based education. The conclusions were clear. Reports of sexual activity were equal in New York compared to Chicago. New York students reported higher rates of condom usage at last intercourse as well as higher condom usage for participants who had three or more sex partners over the last six months. This points out the inaccuracy that if you give adolescents more information, rates of sexual activity will rise. (8)

Defense 2: Re-framing Sex and Sexuality

Since the years of abstinence only sex education has attached fear, death and disease to sex, a revised approach will have to work to diminish this stigma (4). Curriculums that are comprehensive sex education will also incorporate positive labels and images about sex and sexuality. This aspect of the new approach follows Howard S. Becker’s labeling theory. Becker states how people’s perceptions about something are affected by the labels or stigma that is attached to it (11). Abstinence only used this theory to attempt to scare adolescents away from pre marital sex by attaching many negative labels and stigma to sex and sexuality. This same approach would be implemented, however the labels attached to sex and sexuality would all be positive and healthy. Words such as love, compassion, commitment, sharing, and communication would replace the death, disease, and danger that preceded them. If sex is looked at in positive and healthy light, adolescents will have ownership over it versus viewing sex as deviant behavior that an adolescent must suppress. There would be no more negative imagery linked to sex to decrease moral judgment about behaviors other than abstinence. This would improve health outcomes because adolescents will not feel inhibited to communicate openly about sex which in turn would increase their knowledge about sex and safer sex options. (7)

Another purpose to using labeling theory would be inclusive and affirming to LGBT adolescents. Currently under abstinence only sex education homosexuality is only mentioned in relation to HIV/AIDS (4). That stigma coupled with the marriage only ideology indoctrinates adolescents with stigma attached to homosexuality. Ideas of freedom and individualism and choice would be attached to sexual orientation and gender identity. This would prevent the marginalization and ostracization of LGBT adolescents in school setting sex education. This affirmation could positively affect the sexual health outcomes of these individuals because, again, their choice would not be labeled as deviant behavior. This would create self esteem and an ability to communicate freely about sex and sexuality.

Defense 3: Social Marketing Campaign

Despite the incorporation of comprehensive sex and sexuality into schools, mainstream media will still be reaching individuals with unhealthy and sometimes incorrect sex messages. To make this new approach complete, the federal government also must implement a large scale media marketing campaign around healthy sex and sexuality geared towards adolescents. This campaign would be based on social marketing principles. Social Marketing goes a step beyond health promotion/education. The campaign is not simply selling the health information (12). The information that is intended to be sold is attached to “non tangibles” that connect with the target audience (13). These non tangibles are attitudes, ideas, lifestyles that are desired and reach the target audience beyond the scope of the information you are “selling”. In a sense you are selling the idea, attitude or lifestyle through buy-in of the health information.

Television is a very effective venue to run a social media campaign around sex and sexuality. (17) Extensive research would be conducted to accurately identify what non tangibles connect with adolescents. Once identified, a series would be created that targets three different cohorts among adolescents: males, females, and LGBT adolescents. These ads would run concordantly with the same television shows that project inaccurate and sometimes incorrect information. The ads would address sex in the media and “debunk” myths and misconceptions adolescents may have. The male cohort would receive messages including contraception and safer sex is not solely the woman’s responsibility. The young women’s series would incorporate messages including communicating with partners around safer behaviors and decision making. The LGBT series would be affirming of relationships and same sex relationships and include condom usage and other safer sex messages.

Conclusion

Abstinence only sex education is an outdated approach that needs revision. Some aspects of this approach are potentially damaging to certain groups among adolescents. It is unethical to withhold vital health information to a group with the idea it will prevent certain behaviors. The moral judgment and stigma that has been incorporated in abstinence only sex messages are inappropriate and inaccurate. If adolescents do not receive accurate information from appropriate sources, they are going to get the information elsewhere and that source may misinform individuals.

Incorporation of comprehensive sex education is a wise approach. Research points to no evidence that this approach increases sex initiation and sexual activity. Replacing negative messages and teaching fear with positive messages and healthy communication is an important step in revising the approach to adolescent sex education. Marginalizing populations within this group is an unhealthy approach to teaching healthy behaviors. Combating portrayals of sex in the media through social marketing coupled with comprehensive sex education and positive labeling is a healthier more appropriate direction to work towards in the years to come.

References
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2. Collins, C; Alagiri, J.D; Summers, T. Abstinence Only vs. Comprehensive Sex Education: What are the Arguments? What is the Evidence? AIDS Research Institute, University of California, San Francisco. Policy Monograph Series, March 2002.
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15. U.S. Teen Pregnancies Births, and Abortions: National and State Trends and Trends by Race, Ethnicity. Guttmacher Institute. January 2010. http://www.guttmacher.org/pubs/USTPtrends.pdf
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