Abstinence, Sex And The Illusion Of Self-efficacy: Criticisms Of The Texas Power2Wait Program – Carrina A. Burke

The latest data on teen and unplanned pregnancy published in 2005 states that the national teen pregnancy rate is 40.5 percent (1). Among the fifty states and the District of Columbia, Texas has the third highest teen pregnancy rate at 61.6 percent, behind only New Mexico and the District of Columbia (1). Despite this, Texas receives almost $17 million annually in government funding that is specifically allocated to abstinence education in the state’s public school systems (2). Abstinence education, by definition “teaches abstinence from sexual activity outside marriage as the expected standard for all school age children and stresses the social, psychological, and health benefits of abstinence” (3). There are many abstinence programs supported by the Texas Department of State Health Services, one of the largest being the website Power2Wait.com. Abstinence programs like Power2Wait.com are less successful at preventing teen pregnancy than comprehensive sexual education programs because the programs focus the intervention at the individual level, do not provide strategies for the individuals to refuse sex if they are in “the heat of the moment,” and do not consider the multiple facets of sexuality while ignoring comprehensive sexual education.

Texas Power2Wait Program
According to the Texas Department of State Health Services, the Power2Wait program is “an abstinence-centered education program designed to offer guidance to school districts, communities, and parents to reduce the need for future family planning services for unwed minors” (4). The program offers kits, pamphlets and CD-ROMs to school districts that are specifically tailored to grades 4 through 12. The main goals of the program are to decrease teen pregnancy, teen STIs, teen abortion rates, teen dropout rates and teen “interest in future orientation” (4). In addition to targeting teens, the program targets parents, offering strategies on how to talk to teens about waiting until marriage to have sex with their sister websites Power2Talk.org and Poderdehablar.org (Spanish).
The Power2Wait program uses four intervention strategies to reach its target population. The first strategy is to provide education resources through the websites Power2Wait, Power2Talk and Poderdehablar, and through publicity tool kits provided to schools and community groups (4). The kits include interactive video games and card games. The second strategy is to provide assistance to local teen pregnancy prevention consortiums whose goals are to create community infrastructures and apply for funding opportunities to address teen pregnancy (4). The third intervention strategy is to “coordinate the Texas Youth Leadership Clubs by providing training and guidance for youth leadership clubs including the use of curricula, communication via a bi-monthly news letter, Texas Youth Leadership Club member T-shirts, and an annual Youth Leadership Summit” (4). The fourth strategy is to continue programming for abstinence education activities, including workshops and awareness presentations available through Education Service Centers around the state of Texas (4).
The main marketing tool of the Power2Wait program is the Power2Wait.com website. The website is composed of six sections: Stories, Media, Love.Sex.You, Things 2 Do, Games and Resources. The “Stories” section provides seven testimonials from teenage men and women about why they are waiting to have sex. The “Media” section offers a free MP3 download of an abstinence-themed hip-hop song and a short music video. In the “Love.Sex.You.” section, there is information about relationships, pregnancy, sex, and self-esteem issues commonly faced by teens. The “Things 2 Do” section offers alternative activities to do instead of having sex. Finally, the “Resources” section provides a list of websites addressing the topics of abstinence, STIs and HIV, teen pregnancy and relationship abuse.

CRITIQUE OF POWER2WAIT
The Flaw of Individual Responsibility
The main message of the Powe2Wait.com website is that “you” (the individual) must be in control of when you decide to have sex. The website says, “Only you choose what’s right for you. Your parents can love you. Your teachers can advise you. Your friends can give their opinion. But you are ultimately responsible for you” (5). The intervention was created using individual-level theories of behavior, specifically echoing the Health Belief Model and the Theory of Reasoned Action.
The Health Belief Model and the Theory of Reasoned Action were developed to explain health-related behavior at the individual level (6). According to the Health Belief model, before an individual performs a behavior, she weighs the perceived benefits and the perceived barriers of the behavior. Within the perceived benefits, there are perceived susceptibility and perceived severity of the behavior. In the case of the abstinence message of Power2Wait, the behavior is sex before marriage and the perceived susceptibility is the probability of becoming pregnant (if female) or impregnating someone (if male). The Health Belief Model only considers the individual’s perception of the behavior. The Theory of Reasoned Action goes a step further and accounts for social norms (6). The individual weighs the outcome expectancies and the beliefs of others about the behavior before performing the behavior. The outcome expectancies are determined by the individual’s attitude toward the expected outcome and the importance of the outcome to them. The beliefs of others are weighted by who is expressing the belief and how important to the individual is that person’s or group’s opinion.
The two main problems with using individual-level theories of behavior when teaching abstinence to prevent teen pregnancy are that the theories assume rational behavior and do not consider context. The entire basis of the Power2Wait internet campaign is that with self-esteem and good morals, abstinence can be achieved (5). The intervention assumes the fundamental attribution error, which attributes all behaviors performed to character and does not consider context into the equation (7). Teens know that unprotected sex leads to pregnancy while surfing the internet and listening to a lecture in class, but in the context of an intimate setting, the behavior may be performed anyway.

In the Heat of the Moment
The Power2Wait program emphasizes that self-esteem is the key to maintain abstinence throughout adolescence (5). The website provides broad, albeit vague advice on how to build self-esteem. However, the self-esteem building is not related directly to waiting to have sex. The website offers advice like, “Practice being assertive in everyday situations. If your order is wrong at a restaurant, ask to have it fixed. If someone calls you by the wrong name, correct it” (5). Similar advice is offered for dealing with peer pressure, with adages like: “Keep working on your confidence and practice speaking up for yourself. Maybe even come up with a few excuses, ways to get out of things that make you feel uncomfortable” (5). The major problem with this method of maintaining abstinence is that the program does not provide effective, concrete strategies on how to say “no” to sex once in a sexually charged situation. Without methods to diffuse a sexual encounter, maintaining abstinence relies solely on self-efficacy.
Another individual-level behavioral theory, the Theory of Planned Behavior includes self-efficacy into the model. The Theory of Panned Behavior, like the Theory of Reasoned Action, assumes behavioral intention is the most important determinant of behavior (8). In addition to the components of the Theory of Reasoned Action, the Theory of Planned Behavior includes perceived behavioral control, which is an individual’s perception of how much control she has over a behavior. The self-esteem level of a person is directly related to that person’s belief that she can control her behavior in certain situations. The problem with this theory is that, as with the Health Belief Model and the Theory of Reasoned Action, it assumes rational behavior. It also assumes that an individual has self-control and that all behaviors are planned. The Power2Wait website even mentions this flaw when addressing experiencing sex for the first time: “A lot of teens that have sex explain their decision by saying, ‘It just sort of happened’” (5). The admission that the initial sexual act was not planned undermines the entire intervention strategy of bolstering self-efficacy because it does not provide self-efficacy strategies for when sex happens “in the heat of the moment.”

Beyond Babies
The ethical debate regarding abstinence-only education programs is rooted in the individual right to health information. The Power2Wait program is supposed to be implemented in addition to the current sexual education curriculums in the school system. However, depending on the county and district, there may not be any additional comprehensive sexual education. The Power2Wait website does not offer any comprehensive information of sexually transmitted diseases or contraceptives. The website has an “STI Library,” where is provides definitions of the most common STIs, in addition to teen pregnancy statistics. It also provides a link to the Center for Disease Control website and the phone number for the STD and AIDS hotline under the “Resources” section.
In a survey of non-married, heterosexual adolescents ages 15-19, the sexual health risks were compared between participants who received comprehensive sex education and those participants that received abstinence-only or no sex education, those who received comprehensive education were significantly less likely to report teen pregnancy (9). Furthermore, comprehensive sexual education was not associated with increased sexual risk or STD reports (9). By not providing information on contraceptive use, the intervention assumes: 1) the individuals receiving the intervention have self-control, and 2) the individuals perceive the susceptibility and severity of the behavior outcome (pregnancy, HIV) as too high to rationally perform the behavior. In a meta analysis of four abstinence education programs, there was no significant difference between program groups and control groups on the rate of unprotected sex (10). This aspect of the intervention, in addition to the individual-level focus and the failure to provide “say no” strategies and to account for context, is also based on the tenets of the Health Belief Model, the Theory of Reasoned Action, and the Theory of Planned Behavior.

PROPOSED CHANGES TO POWER2WAIT
Moving From “I” to “We”
As discussed previously, there are many limitations to creating an intervention that takes place at the individual level. If an abstinence intervention could be focused on a group level, it would be more successful at conveying the message. In economics, there is evidence to suggest that people exhibit “herd” behaviors when it comes to investment recommendations and portfolio management (11). Reputational herding in economics is said to take place “when an agent chooses to ignore his or her private information and mimic the action of another who has acted previously” (11). It is commonly accepted among most teens that everyone is having sex in adolescence. However, according to a recent poll, in reality 87 percent of 13-16 year olds are abstaining from sex (12). By shifting the focus of the internet campaign from the individual to the 87 percent majority, it would make teens more aware that everyone is, in fact, not having sex. In addition to focusing on the majority of teens not having sex, creating a formidable brand will further strengthen the message. Advertising theory states that there are three constructs to advertising: the promise, the support, and the core values (13). The Power2Wait website already has all three components. The promise is that if you abstain from sex you will not become pregnant, and you will be able to achieve your dreams. The website supports the promise with the stories of abstinence teens. The core value of the Power2Wait program is independence.
Another change that can be implemented to move from the individual to the group is by involving a larger demographic. A main message of abstinence education (by law) is to abstain from sex before marriage. Evidence suggests that this has a potentially negative effect on teens who are gay, lesbian, bisexual, transgendered or questioning (14). Many states have implemented laws outright banning same sex marriages, and the alternative of a lifetime of abstinence is extremely unrealistic. By changing the message from abstinence until marriage to a more general message, it will reach a larger demographic of teens.

Effectively Saying “No”
Another problem with Power2Wait is the deficit of strategies advising teens on how to stop sexual advances when in a sexually charged situation. The Power2Wait website offers suggestions on how to get out of uncomfortable situations, but it quite vague as to what are those situations. It is also vague as to whom which the advice applies. A better approach would be to offer gender-specific advice on how to diffuse sexually vulnerable situations by applying the Theory of Gender and Power. The Theory of Gender and Power focuses on women’s risk and states that there are three major structures that characterize the gendered relationships between men and women: the sexual division of labor, the sexual division of power, and the structure of cathexis (14). According to theory, women who are younger than 18 years of age, having limited access to STD/HIV education, experience an individualistic family dynamic, and have conservative cultural norms have higher risks of STD and HIV infection (14). By applying the three structures of the theory, Power2Wait can compose a set of strong messages for young women who want to abstain from having sex during adolescence.

Abstinent, But Why?
It was previously discussed that studies have found that comprehensive sex education does not lead to an increase in sexually risky behavior or in STD incidence (9, 14). Therefore, inclusion of comprehensive sexual education to support the current emphasis of abstinence would be beneficial to the intervention. However, the Section 510 of the 1996 Social Security Act states that abstinence education is defined as a program which “has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity”(14). Despite this, the Power2Wait program can still convey a successful message of abstinence if it utilizes a comprehensive approach to the sexuality of its target population.
An approach to integrate multiple facets of sexuality into abstinence education is to follow the Sexual Health Model. The Sexual Health Model is composed of three tenets: 1) key characteristics of an established sexological approach to comprehensive sexuality education, 2) literature-based recommendations for culturally specific, relevant, normative models of sexual health derived from the target community’s experience, and 3) qualitative and quantitative research on the sexual attitudes, practices, and risk factors of various populations, as well as their context for safer-sex decision making (16). By considering the background of the target population of Power2Wait (i.e. Texas teenagers), the program can focus the abstinence message instead of the current vague messages and testimonials currently emphasized. The Sexual Health Model addresses ten issues relating to the sexuality of a population. Though all of them will not be discussed here, there are four that are relevant to the message of abstinence: 1) culture and sexual identity, 2) positive sexuality, 3) intimacy and relationships, and 4) spirituality (16). Power2Wait can address these issues that are specifically relevant to teens who abstain from sex, and therefore, can create a stronger message as to why to abstain, and more importantly, how to abstain under varying amounts of social pressures and in different environments.

Waiting For Change
The Texas Power2Wait Program is an individual-focused intervention promoting abstinence to prevent teen pregnancy. It states that abstinence is achieved through building self-esteem and maintaining self-control. However, it does not provide concrete advice on how to maintain abstinence in actually sexual situations, and does not take into account the contextual nuances and different environments of their target population. The Powe2Wait program can be improved by focusing the intervention at the group level, by offering advice based on gender and relationship theory to diffuse sexually charged situations, and by creating intervention strategies that integrate specific sexuality issues relating to the teen population.

REFERENCES
1. The National Campaign to Prevent Teen and Unplanned Pregnancy. Teen Pregnancy and Birth Rates in the United States December 2007. Washington D.C. http://www.thenationalcampaign.org/national-data/pdf/STBYST07.pdf.
2. Biel L. Abstinence Education Faces an Uncertain Future. The New York Times. July 18, 2007. http://www.nytimes.com/2007/07/18/education/18abstain.html.
3. Kim,C & Rector, R. Abstinence Education: Assessing the Evidence. The Heritage Foundation. April 22, 2008.
4. Texas Department of State Health Services. Texas Power2Wait Program. Austin, TX: Texas Department of State Health Services. http://www.dshs.state.tx.us/abstain/default.shtm.
5. Power2Wait.com. You. http://www.power2wait.com/#/love_sex_you/.
6. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. American Association of Occupational Health Nurses 1991; 39:128-135.
7. SB721 Class Notes. Types of Irrationality. September 17, 2009.
8. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp 9-21.
9. Kohler PK, Manhart LE, & Lafferty WE. Abstinence-only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy. Journal of Adolescent Health 2008; 42:344-351.
10. Trenholm C, Devaney B, Fortson K, Clark M, Quay L, & Wheeler J. Impacts of Abstinence Education on Teen Sexual Activity, Risk of Pregnancy, and Risk of Sexually Transmitted Diseases. Journal of Policy Analysis and Management 2008; 27: 255-276.
11. Sornette D. Why Stock Markets Crash: Critical Events in Complex Financial Systems. Princeton, NJ: Princeton University Press, 2003, pp 91-114.
12. MSNBC. Nearly 3 in 10 young teens ‘sexually active’. January 31, 2005. http://www.msnbc.msn.com/id/6839072/.\
13. SB721 Class Notes. Alternative Models: Advertising Theory. October 15, 2009.
14. Santelli J, Ott MA, Lyon M, Rogers J, Summers D, & Schleifer R. Abstinence and Abstinence-only education: A Review of U.S. Policies and Programs. Journal of Adolescent Health 2006; 38:72-81.
15. Wingood GM, DiClemente RJ. The Theory of Gender and Power: A Social Structural Theory for Guiding Public Health Interventions. Emerging Theories in Health Promotion Practice and Research:Strategies for Improving Public Health. San Francisco, CA: Jon Wiley & Sons, Inc., 2002, pp. 313-346.
16. Robinson BE, Bockting WO, Rosser BRS, Miner M, Coleman E. The Sexual Health Model: Application of a Sexological approach to HIV Prevention. Health education Research 2002; 17:43-57.