Challenging Dogma - Fall 2009

Monday, December 21, 2009

The Misuse of Behavioral Theory in Abstinence-Only Sex Education: Why Abstinence-Only Curriculum Fails To Prevent Sexual Activity, Pregnancy, and STI

--Emily Hyman

Abstinence-only education, which promotes abstinence from sexual activity until marriage and does not provide information on contraception besides failure rates (1), has received federal support since 1981 under the Reagan Administration. From 1996 to 2008, abstinence-only education received more than $1.5 billion through both federal and state matching funds and, during the 2009 fiscal year, more than $160 million was allocated to abstinence-only education (6).

Although national Youth Behavior Risk Surveys show that teen sexual activity decreased by 7 percent from 1991 to 2007 (2), teen birth rates increased significantly between 2005 and 2007 (3) and today, U.S. teens experience the highest birth rate and one of the highest rates of sexually transmitted infections (STIs) compared to all other industrialized nations (1). The CDC estimates that, by age 24, at least one out of every four Americans will contract an STI (4).

Clearly, effective public health interventions are needed to help lower rates of STIs and unintended pregnancies; however, abstinence-only education is not the answer. A large body of evidence consistently shows that abstinence-only education fails to reduce risky sexual behavior among teens (7), identifying few short-term benefits and no lasting, positive impact on student’s sexual behavior over time (1).

Although Obama's 2010 budget cut the Title V grant program, a major source of abstinence-only funding for U.S schools, it is necessary to examine why abstinence-only curriculum is flawed so as not to repeat these tactics in future sex education curricula.

As an example, this report will focus on “Choosing the Best,” (, a popular and widely-used abstinence-only curriculum for 6th -12th graders that has been produced since 1993 by Choosing the Best Publishing, LLC. based in Atlanta, Georgia. Using videos, case studies, role playing exercises and group discussions, Choosing the Best aims to “transform attitudes and behavior of teens about premarital sex” by showing why abstinence is “the best way to show respect for yourself and others (8).”

Choosing the Best is flawed in that it relies on behavioral science theories that are counterproductive and unlikely to impact teens abstaining from sex including: fear-based tactics which distort facts and create scenarios unlikely to repeat in a real-life situation; assumptions that teens will act rationally when making emotional decisions about sex (9); and failure to account for the power of social norms to change the context of sex. The misuse of these tactics demonstrates how Choosing the Best is not adequately preparing students to make safe decisions about sex. However, by applying modern behavioral science principles, both the methodology and content of the curriculum can be improved and made more effective.

Fear –Based Tactics

Nobel-prize winning chemist Marie Curie once said, “Nothing in life is to be feared. It is only to be understood.” Contrary to this sentiment, Choosing the Best uses techniques that may cause students to fear sex, rather than understand it. All stages of the curriculum use framing to accentuate the risk of STIs and teen pregnancy and paint a negative picture of the effectiveness of birth control, thus inciting fear or making students feel threatened.

For example, Choosing the Best presents the following statistic on virginity in their 6th grade curriculum: “Nearly 1 in 10 kids reports losing virginity before age 13.(8)” Upon reading this, a child may feel like his or her chance of losing their virginity before turning 13 is high and something to fend against. Alternately, this statistic could be re-worded to say, “Approximately 90 percent of teens have not had sex before age 13.” The latter example presents the same information as the first; however, it does not trigger fear to the extent of statistic used by Choosing the Best.

Another example of distorting facts to elicit fear can be found in Choosing the Best’s 7th- grade curriculum. The statistic states, “One in 5 Americans aged 12 and up contract genital herpes (9). In this statistic, “Americans aged 12 and up” could include any American age 12 to 100; however, 12 is the only age mentioned in the statistic and is likely to build fear among 7th graders about herpes, instead of presenting curriculum in as straightforward a manner as possible.

Although fear can serve as a powerful motivator, it may also distort the truth, as in the examples above, and skew facts to create an extreme scenario unlikely to repeat itself in a real-life situation. This distortion could make it confusing for students to make decisions about sex. Also, if students feel the message is so exaggerated that it is disproportionate to the risk, they may rebel or ignore the source of the message (similar to how youth decided to mock the anti-drug commercials with a dog as a spokesperson instead of accepting the messages as truthful).

Fear-based tactics are also used in Choosing the Best’s HIV/AIDS curriculum which shows a video where students travel to a health clinic to learn about HIV and meet with Lisa, a 33-year old woman with AIDS. In the video, students are introduced to a severely ill woman who is gaunt and visibly suffering. After describing her drug regimen and the pain she is going through, she says the following to the students:

“I don’t want you to think that 40 pills a day is going to make it go away. I am in prison and I can’t get out. There is no parole. I have been 80 lbs and bald for three years.

This will rob every dream that you ever had. It will take everything away. Do me a favor if you could just hold off and make that pact than I feel like my life on earth has been served. "

By using a severely ill AIDS patient to deliver messages about the risk of HIV-AIDS, students are likely to grasp the severity of the threat of HIV/AIDS and the deadly risks associated with unprotected sex. However, the AIDS example presented is extreme, and students are likely to remember this spokesperson as a caricature of AIDS instead of a person they are likely to come across in their own lives and social situations, leaving them unprepared to judge the risk of HIV and AIDS when people appear just as healthy and vibrant as they do. According to Nicholas Christakis and James Fowler’s study on social network theory, people are more likely to be influenced by people who resemble them. It is also possible that exaggerating the risks of a behavior could be perceived as melodramatic to program participants, causing health professional to lose credibility as kids make fun of or distance themselves from the curricula since it is difficult to relate to and easier to mock.

Assumption of Rational Behavior

Choosing the Best and abstinence-only education in general assumes students are rational, or in “cold states,” when it comes to making decisions about sex (5). Using the methodology behind the Health Belief Model, Choosing the Best provides students with a clear picture of the risks associated with sex (STDs, pregnancy, negative view of themselves) in the hopes that students will feel so threatened by these risks that, when it comes time to decide whether or not to have sex, students will view the benefits of abstinence as outweighing the consequences, and therefore, choose to abstain. In reality, decisions about sex are frequently made in hot states where the likelihood of rational decision-making quickly falls by the wayside (5).

As demonstrated in the sexual questionnaire experiment in Dan Ariely’s book Predictably Irrational, rational thinking is diminished when participants are in a hot state. The following excerpt from Predictably Irrational explains how emotions caused by sexual arousal make it extremely difficult to control ones behavior:

Many parents and teenagers, while in a cold, rational, Dr. Jekyll state, tend to believe that the mere promise of abstinence – commonly known as “Just saying no” – see no reason to carry a condom with them. But as our study shows, in the heat of passion, we are all in danger of switching from “Just say no” to “Yes!” in a heartbeat; and if no condom is available, we are likely to say yes, regardless of the dangers (9).

One example of Choosing the Best’s assumption of rational thought is the program’s use of one-on-one interviews with an assortment of students describing first-hand why they regret having sex and felt the experience was negative. These interviews are hoping to steer students towards abstinence by showing them the negative emotional consequences of sex. Similarly, in a video for 9th and 10th graders titled, “Why do I hurt inside?” students relay their experiences having sex and describe how it made them confused, used and unloved. One teenage male student tells the following story in the video:

“After the act, I felt dirty like, well, actually I felt guilty. After riding my bike back home, inside I was like… I didn’t know what happened since I had lost my virginity. All week, I had this stressful thing in my mind because I had lost my virginity. I was emotionally unstable. I couldn’t think straight. If sex was supposed to make me feel like a man, it didn’t. I took a bunch of showers and still felt dirty inside. It just makes more sense to abstain than to not abstain.”

Another teenage female has the following anecdote:

“I ended up having sex when I was in 8th grade, it was a horrible experience, I felt I lost a part of me, my identity. I was looking to him to define who I was.

Both anecdotes show how Choosing the Best is hoping to change student’s attitudes towards sex by stressing the negative emotional consequences of sex, such as feeling “dirty,” “guilty,” “emotionally unstable” and “horrible.”

As suggested by the Theory of Reasoned Action, one’s intention to act is a determinant of behavior. Intention is a function of a person’s attitudes towards the behavior and their judgment about whether the behavior is good or bad (10). By showing easily-relatable, age-appropriate students speaking candidly about how they felt remorseful, embarrassed and confused by their decision to have sex, Choosing the Best may certainly succeed in changing a student’s attitude towards sex or succeed at demonstrating how susceptible teens are to negative emotional consequences of sex, but, the question remains: is this enough to prevent sex? The answer: most likely not.

By painting sex as an unfortunate mistake made by people who are too weak to control their impulses, Choosing the Best assumes students will use rational decision-making processes when considering sex. Knowing the tremendous power arousal has to impact behavior and quickly uproot previous attitudinal preferences, it is clear that birth control methods such as condoms are essential to protecting students in the heat of the moment, when students in hot states are likely to discard messages of self-control, forget about perceived risks, and give in to emotion.

Ignoring the Power of Social Norms

Finally, Choosing the Best fails to account for the ability of social norms to impact teen behavior. Similar to the reasoning previously stated, abstinence-only curriculum does not account for the considerable social variables teens are likely to come across when making decisions about sex. Different environments, situational contexts, and peer groups will likely present teens with a variety of social norms they will need to navigate. In step with the Health Belief Model, Choosing the Best curriculum focuses on the personal orientation of an individual and their level of readiness to take action (10); however, it fails to consider how individuals will act when part of a variety of social systems. As the perceived benefits and risks of an action begin to change around an individual, i.e. if a student moves to a new school or changes friend groups, behaviors may begin to shift depending on those who surround them and those whose opinions they value. In other words, their perception of “normal” is likely to change.

Social learning theory as outlined in the book, Effects of Mass Communication (11), demonstrates the power of society and mass media to affect behavior. According to authors DeFleur and Ball-Rokeach, social learning theory explains how people acquire new forms of behavior by observing other people’s actions, and how people come to adopt those patterns of actions as personal models of response t0 problems, conditions or events in their own lives (11).

Choosing the Best tries to set social norms in their curriculum, i.e. teens that have sex will be looked down upon by their peers or sex makes teens confused. But, what if this dynamic changes when the student is in another social context and sex all of a sudden becomes something rebellious and fun teens should try. According to the social learning theory, people are likely to model their own behavior on what we see others doing and thinking.

Instructing students how to use a condom or other birth control methods will help protect teens from STDs and pregnancy in a much wider spectrum of social norms. An effective sexual education intervention needs to consider the power of social norms to dictate behavior and fluctuate throughout a teen’s life.

Proposal for Alternative to Abstinence-Only Intervention

As stated above, Choosing the Best abstinence-only until-marriage curriculum currently used in U.S. middle and high schools is flawed in that it frames information about STDs, teen pregnancy and sexual activity in negative and exaggerated ways so as to evoke fear among students. The program also assumes students will maintain rational behavior, even in the midst of emotional situations involving sex. Finally, Choosing the Best and other abstinence-only-until-marriage curriculum ignore the power of social norms to influence decisions and the likelihood that changing social norms will alter what teens consider to be acceptable or “normal” forms of sexual behavior. Using modern behavioral science theory, these three main criticisms can be addressed and both the methodology and content of the curriculum improved.

Instead of fear, inspire control

The notion that freedom is the antidote to fear is a concept that can be applied to improve abstinence-only education. As described earlier, Choosing the Best uses techniques that may cause students to fear sex, instead of understanding the nuances and complexities of adolescent sexuality. As we can see throughout Choosing the Best curriculum, birth control, such as condoms, are framed negatively to exaggerate their ineffectiveness and make teens feel that the only way to gain control of their lives and their sexuality is through abstinence. This narrow view about the consequences of sex and limited options for control distorts reality and could result in rebellion or confusion among teens. Instead, Choosing the Best should present a broad range of options available to teens to limit their risk of STIs and pregnancy and, therefore, control their destiny.

The idea of control is already portrayed positively within Choosing the Best, when the program provides teens with positive messages about relationships, such as the importance of feeling loved and respected by a partner and the importance of being in control of your body. To improve the program, these positive messages of control could be expanded upon to include information about other birth control options besides abstinence. Through this increased knowledge, teens would feel more in control of their futures and the program would be less likely to lose credibility since it would be empowering students to consider all of the options and make their own decision. To help “sell” birth control as a viable option to prevent STIs and pregnancy, advertising theory could be employed and campaign could be created around the “promise” of freedom from the risk of STIs and the security of knowing you are capable of protecting yourself from becoming pregnant (12).

Convey sex as irrational

In order to be effective, Choosing the Best and abstinence-only education curriculum in general must accept that people are not rational beings, especially when it comes to making decisions about sex. Although there is certainly value in showing students the benefits of abstinence and the risk of sex, it is unrealistic to assume that students will remain reasonable and even-keeled every time the opportunity for sex presents itself. By preparing students to make decisions about sex in a hot or irrational state, Choosing the Best would become more effective.

This could include teaching students to use birth control such as condoms, thus providing them with an option for protection, even in the heat of the moment. Second, the educational program could also include realistic, detailed stories or videos that show two people being intimate but then stopping and deciding to use protection. These videos could use humor to make them more relatable to teens but still convey the powerful emotions behind sexual behavior. Generally, abstinence-only programs could be more honest about the psychology behind sex and sexuality and explain the science behind sexual feelings and how our bodies go into overdrive during sexual experiences. Having as much information as possible to prepare students for what the experience will be like could help them prepare mentally and emotionally for what is in store and why their decisions will be so difficult to make.

Acknowledge the power of social norms

In order to prepare teens for the multitude of situations and corresponding social norms they will face throughout their lives, it will be necessary for Choosing the Best to acknowledge the strength of these unknown and changing variables and their power to impact teen behavior. Similar to the reasoning previously stated, abstinence-only curriculum does not account for the considerable social variables teens are likely to come across when making decisions about sex. Different situations, social networks and experiences will present teens with a variety of social norms they will need to navigate.

One force that is particularly good at setting social norms among today’s teens is mass media, especially television, film and radio. As described by DeFleur and Ball-Rokeach in Theories of Mass Communication, modeling theory, similar to social learning theory, presents the idea that “the acquisition of new behavior” comes “from media portrayals.” The authors go on to state that the “media are readily available and attractive sources of models” and “provide a symbolic modeling of almost every conceivable source of behavior… literature has shown that both children and adults acquire attitudes, emotional responses, and new styles of conduct from all the media, and especially from films and television.”

Therefore, if Choosing the Best and other abstinence-only programs were to create or identify a celebrity who embodied the abstinence-only values they are trying to impress upon their students, perhaps such a high-profile person in the media would have the power to override the more typical models we see constantly in the media, including stars such as Brittney Spears whose music promotes the pleasure, power and satisfaction that come from sex. Nearly every major female and male pop star popular among teens today portrays an image of being sexually active. Would it be possible for the media machine to create the same star power for someone with abstinence-only values? For instance, if Taylor Swift announced she was in favor of abstinence-only-until-marriage, many social norms among teens would undoubtedly shift towards favoring abstinence. Of course, there is great risk placing so much power on the shoulders of one high-profile model, but the ability of mass media to shift social norms and create behavioral change should not be underestimated.

In conclusion, Choosing the Best uses behavioral science theories that are ineffective at making teens abstain from sex including fear-based tactics which skew reality, assumptions that teens will act rationally when making emotional decisions about sex, and a failure to acknowledge the power of social norms to change the context of decisions about sex. By addressing these issues and accounting for the power of irrational behavior and group dynamics, Choosing the Best would be closer to becoming an effective at lowering pregnancy and STI rates among teens.


1. Advocates for Youth. Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact. Washington D.C.: Title V State Evaluations, 2008.

2. Centers for Disease Control and Prevention. Trends in HIV- and STD-Related Risk Behaviors Among High School Students --- United States, 1991--2007. Atlanta, GA.: Morbidity and Mortality Weekly Report, 2008.

3. Centers for Disease Control and Prevention. Adolescent Reproductive Health: Preventing Teen Pregnancy. Washington D.C. Centers for Disease Control and Prevention.

4. The Henry J. Kaiser Family Foundation. Fact Sheet: Sexually Transmitted Diseases in the U.S., Menlo Park, CA: 2003.

5. Inclusion Of Abstinence-Only Funding In Senate Health Reform Bill Surprises Advocates On Both Sides. Medical News Today, 2009.

6. The Sexuality Information and Education Council of the United States (SIECUS). Federal Abstinence-Only-Until-Marriage Funding. Washington D.C. SIECUS.

7. The Future of Abstinence-Only Sex Ed.

8. Choosing the Best, Inc. Curricula. Atlanta, GA: Choosing the Best.

9. Dan Ariely. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York, NY: Harper Collins Publishers, 2009.

10. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991; 39: 128-135.

11. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th Edition), Chapter 8 (Socialization and Theories of Direct Influence),pp. 202-227. White Plains, NY: Longman Inc., 1989.

12. How to build great campaigns (Chapter 5). In: Ogilvy D. Confessions of an Advertising Man. New York: Atheneum, 1964, pp. 89-103.

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