Challenging Dogma - Fall 2009

Thursday, December 16, 2010

A Critique on Abstinence-Only Sexual Education –Stephanie Horton

The federal government has been supporting abstinence programs since 1981 when the Adolescent Family Life Act was implemented, but since 1996, there have been major expansions in federal support for abstinence programming and a shift to funding programs that teach only abstinence and restrict other information (1). In fact, federal funding for abstinence-only programs has increased from $60 million in 1998 to $168 million in 2005 (1).
Abstinence, as defined by policy makers, is not often clearly defined. In behavioral terms, abstinence is defined as “postponing sex” or “never had vaginal sex,” or refraining from further sexual intercourse if sexually experienced. Other sexual behaviors may or may not be considered within the definition of “abstinence,” including touching, kissing, oral sex, mutual masturbation or anal sex (1). Abstinence, according to government policies and local programs, is often described in ethical terms, using phrases such as “chaste” or “virgin” and framing abstinence as a positive attitude or commitment. A study by Goodson et al. found that abstinence-only educators in Texas and the youth in abstinence-only programs defined abstinence in moral terms, such as “making a commitment,” and “being responsible” (2). Overall, the term is often confusing and loaded with insinuation, which adds to the controversy it bares in abstinence-only sexual education programs.
While many schools in the United States provide sexual education consisting of both education about abstinence as well as other forms of birth control and sexually transmitted infection (STI) prevention, a number of curriculums in the U.S. continue to employ “abstinence-only” sexual education. Under the Welfare Reform Act Title 5 Section 115, abstinence-only sexual education must teach that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, STI, and other associated health problems, and no other form of sexual education is permitted (1). In Corpus Christi, Texas, the Communities In Schools (CIS) program implements abstinence-only programs that target the prevention of teenage pregnancy and premarital sexual activities by using three components including case management, curriculum, and parental involvement (3). The curriculum, called Choosing the Best, and its educational materials taught to adolescents 12-18 years old are consistent with Title 5 Section 115 Federal Guideline in that it teaches abstinence only. This program serves the following school districts in Texas: Corpus Christi Independent School District, Flour Bluff Independent School District, Tuloso-Midway Independent School District, Calallen Independent School District, West Oso Independent School District, Gregory-Portland Independent School District and Sinton Independent School District (3). Students enrolled in schools in these districts will receive the abstinence-only sexual education, which does not include education about contraceptive use and does not provide guidelines on how to practice safe sex.
This abstinence-only sexual education program is flawed in three major ways. First, abstinence is not 100% effective in preventing pregnancy or STIs as many teens fail in remaining abstinent. Secondly, the current federal approach focusing on abstinence-only raises serious ethical and human rights concerns. Finally, the implications of abstinence-only programs on the gay, lesbian, bisexual, transgender (GLBTQ) population may have adverse and potentially fatal outcomes. This paper aims to critique the abstinence-only sexual education public health initiative and will provide an alternative strategy for a sexual education curriculum for adolescents aged 12-18 years old.

Abstinence is not 100% Effective
It is not only misleading, but also potentially harmful to imply that abstinence from sexual intercourse is fully protective against pregnancy and sexually transmitted infection. This concept confuses theoretical effectiveness with actual practice. In other words, abstinence is not in fact 100% effective, because those who take a vow of abstinence often fail. In fact, most Americans initiate sexual intercourse during their adolescent years, the mean age for females being 17.4 and for males 17.7 (4.). Moreover, some STIs may be spread via other forms of sexual activity, such as kissing or manual or oral stimulation (1). The most useful data in understanding the efficacy of abstinence come from the National Longitudinal Survey of Youth (Add Health), which examines virginity pledgers and their adherence to abstinence (5-6). This data suggests that many teens who intend to remain abstinent, fail to do so, and that when abstainers do initiate intercourse, many fail to protect themselves with contraception (5-6). The study conducted a 6 year follow up during which the authors found that the prevalence of STIs was similar among those who took the abstinence pledge and those who did not (6). Therefore, pledging abstinence is not necessarily a 100% effective measure, and in fact, those who do not receive information about contraception but are educated on abstinence-only are actually put at increased risk.
In 2006, the Academy of Pediatrics released a position statement on sexual education. This statement concludes that adolescents are constantly exposed to sexual messages in the media, including social networking sites, television, movies, magazines and internet sites. The paper explains that American children and teenagers spend more than 7 hours per day with a variety of different media that contains sexual messages (7). According to the authors, the most recent studies on adolescent sexual behavior and media influences have resulted in four main conclusions: 1) Listening to sexually degrading lyrics is associated with earlier sexual intercourse, 2) Black female teenagers’ exposure to rap music videos or X-rated movies is associated with the likelihood of multiple sexual partners or testing positive for an STI, 3.) Teenagers whose parents control their TV-viewing habits are less sexually experienced, and 4.) Exposure to sexual content in the media is a significant factor in the intention to have sex (7). All adolescents are exposed to this type of media. Therefore, those who are receiving abstinence-only education are put at a disadvantage, because as the Add Health data suggested, teens rarely remain abstinent and if they did not previously receive education about other forms of contraception, they are less likely to protect themselves during sexual activity.

Abstinence-only Education is Unethical
It is a paradoxical observation that while abstinence education is often based on morality, the current federal approach on abstinence-only education is ethically flawed. The U.N. Committee on the Rights of the Child has emphasized that children’s right to access adequate sexual health information is essential to securing their rights to health and information (8). Therefore, since the federal approach to abstinence-only education prevents sexual education about contraceptive use as well as gay sexual education, it can be concluded that abstinence-only programs violate basic human rights. This type of sexual education does not provide the full spectrum of information that adolescents, and all people, have the right to learn. If a student in one of the Texas school districts under the abstinence-only curriculum desires knowledge about contraceptive use or safe sex practices, that student has to seek educational material out of the school. Not only will these children feel moral conflictions but often these adolescents will be unaware of the resources available as they are only being taught one form of sexual behavior: 100% abstinence from sex.
Governments have an obligation to provide accurate information to their citizens, and by omitting an important part of sexual education, the abstinence-only program outlined by the federal government is putting thousands of students at risk. If the adolescent is not equipped with the proper tools to protect himself/herself, the teachers of that adolescent have perpetrated a serious ethical injustice.
An international treaty called The International Covenant on Economic, Social and Cultural Rights specifically outlines the obligation of the government to provide its citizens with the information necessary for the “prevention, treatment, and control of epidemic…diseases,” such as HIV/AIDS (9). In additional to this international call for ethics, the United National Guidelines on HIV/AIDS and Human rights also provides guidance, “ensure that children and adolescents have adequate access to confidential sexual and reproductive health services, including HIV/AIDS information, counseling, testing, and prevention measures such as condoms” (10). The abstinence-only education programs are directly going against this guidance by not educating students about condom use and other preventative measures.

Gay Lesbian Bisexual Transgender (GLBTQ) Population and Abstinence-Only Education

Abstinence-only sex education has the potential to have profound negative effects on adolescents of the GLBTQ population. As many as 1 in 10 adolescents struggle with sexual identity and abstinence-only classes are likely to ignore the needs of this population, as homosexuality is often stigmatized and viewed as deviant behavior in this curriculum (1, 11). Therefore, it is important to consider the effects of homophobia, which include health problems such as suicide, feelings of isolation and loneliness, HIV infection, substance abuse, and violence among GLBTQ youth (1). It is not far-fetched to conclude that abstinence-only problems may indirectly cause these feelings and/or conditions in the GLBTQ adolescent student.
Under the federal requirement of abstinence-only education, emphasis must be placed on heterosexual marriage only and is defined as the only appropriate context for a sexual relationship. Lifelong abstinence as an implied alternative, therefore, holds this group of youth to an unrealistic standard which is extremely contrasting to that of their heterosexual peers. Not only does it put “moral” stress on these students, but it may teach them that their feelings toward sex are ethically wrong or even “grotesque,” and in some cases, sacrilegious.
Those youth who live in the school districts in Texas where this abstinence-only program is being implemented are put at risk for these potentially fatal consequences which result from the nature of abstinence-only sexual education.

A Flawed Social Behavioral Model

The Theory of Planned Behavior (TPB) behavioral model is a good tool to use when understanding the flaws of the abstinence-only education programs. This model explores the relationship between behavior and beliefs, attitudes, and intentions. The most important determinant of behavior according to this model is behavioral intention, which is influenced by a person’s attitude toward a behavior and by beliefs about whether individuals who are important to that person approve or disapprove of the behavior. This model also includes perceived behavioral control, meaning it assumes the person believes he/she has control over his/her behavior (12). The concept of perceived behavioral control is similar to the concept of self-efficacy. It describes an individual’s perception of his/her ability to perform the behavior and his/her control over the opportunities, resources, and skills necessary to perform that behavior. This is believed to be a critical aspect of this behavioral model (13).
This theory can be applied to the goals of abstinence-only programs. These programs assume that adolescents will remain abstinent because 1.) Their attitudes and beliefs can be molded so that they feel abstinence is the only accepted form of sexual behavior, and 2.) They care deeply about the approval of their peers, parents, and teachers. The abstinence-only sexual education guidelines also assume that if adolescents receive education about abstinence-only, they can be influenced to perceive strong control over their own behavior, which has been shown to have an influential effect.
This theory, as well as this curriculum plan, has limitations. First, the theory does not allow for decisions to change based on context and environment. In other words, students who receive abstinence-only sexual education may be influenced one way or another depending on their environment, such as sexual messages in popular media as The Academy of Pediatrics pointed out (7). Without acknowledging this fact, abstinence-only seems like it would work. However, realistically, these students are not likely to remain abstinent, and if they do not receive education about safe sex, they are more likely to suffer the consequences of unprotected sex compared to their counterparts who receive complete sexual education (4).
TPB assumes that behavioral intention will lead to the behavior, but it does not consider the time between the behavior intention and the actual behavior (12). In other words, the abstinence-only program does not consider the time between the adolescent’s intention to behave a certain way and the actual way the adolescent behaves. As seen in the Add Health data, often adolescents who take the virginity pledge fail to remain abstinent (5). This is a major limitation in this type of sexual education and can be seen clearly when TPB is applied.
This type of sexual education assumes that behavior is rational and static, a major limitation that is also seen in TPB. Adolescents are constantly changing, and their values are constantly molding. In their state of growth, behavior and attitude are anything but rational and static. Emotions are often elevated in these individuals, and so we cannot assume that when faced with the decision to remain abstinent, these adolescents will behave in the way they have been taught. This theory and plan simply ignore the adolescent’s feelings of rebellion and curiosity, thereby putting them at serious health risk. If these students learn nothing but abstinence as a form of sexual protection, they are not equipped with all the materials to keep them safe from the consequences of risky sexual behavior.

Proposal for National Comprehensive Sexual Education

A safer, more reasonable and realistic approach to sexual education is a standardized comprehensive sexual education curriculum implemented nationally. This curriculum will include the following topics: abstinence, puberty and the changes that occur, contraceptive use, where/how to obtain contraceptives, instruction on condom use, access to condoms, information on “how babies are made,” sexually transmitted infections, abortion, masturbation, homosexuality and sexual identity, oral sex, and a complete guide to resources available to help students practice safe sex.
Comprehensive sexual education should be available to all adolescents age 12 to 18 in all schools. The curriculum should cover each year these adolescents are in school and should remain current in its information and delivery. These programs should provide clear definitions of abstinence free of propaganda. This type of sexual education will make all sexual health information available to adolescents through the school system and will not discriminate based on sexual identity.
Public polls have expressed a need for a national comprehensive sexual education curriculum. These polls suggest that while abstinence is certainly a favorable behavior goal for adolescents, there is strong national support for education about contraception and for access to contraception for sexually active adolescents (14-15). More specifically, data from these polls found that 90% of parents believe it is very or somewhat important that sex education be taught in school, and only 15% of parents wanted an abstinence-only form of sexual education. 99% of parents polled believed that it was appropriate to provide high school and middle school students with broad information on sexual issues, including STI, the physiology of pregnancy and birth, having intercourse at an older age, making responsible sexual choices based on individual values, how to use and where to get contraceptives, abortion, masturbation, homosexuality, oral sex, and 71% of parents believe that teens should be able to obtain birth control pills from clinics and doctors without parental permission (15).
Over 800,000 adolescents become pregnant each year, and 80% of these pregnancies are unintended and/or end in abortion (16). In addition to these compelling statistics, an estimated 18.9 million STIs occur each year in the United States, and almost half of these cases occur in adolescents and young adults under the age of 25 (17). Long term consequences of STIs can include infertility, tubal pregnancy, fetal and infant demise, chronic pelvic pain, and cervical cancer (17).
The statistics and polls mentioned are compelling to say the least. They not only demonstrate a need for a national curriculum of comprehensive sexual education, but also a widespread acceptance of sexual education among parents. As stated, only 15% of American parents want abstinence-only sexual education (15). That means that 85% of American parents are supportive of sexual education that includes a comprehensive overview of all available safe sex practices. Therefore, a national standardized program would be well received and would prevent teens from engaging in risky sexual behaviors.
Two recent systematic reviews examined the evidence supporting abstinence-only programs and comprehensive sexual education programs. Both of these reviews demonstrated that comprehensive sexuality education effectively promoted abstinence as well as other protective behaviors among adolescents. Both reviews found no scientific evidence that abstinence-only programs demonstrate greater efficacy in delaying initiation of sexual intercourse. Therefore, a comprehensive sexual education program would not sacrifice any benefits that are believed to exist in abstinence-only programs.
Although federal abstinence-only education funding language requires teaching that sexual activity outside of marriage is likely to have harmful psychological and physical effects, there is no scientific evidence suggesting that consensual sex between adolescents is harmful. There are no reports in the scientific literature that address whether the initiation of adolescent sexual behavior itself has an adverse impact on mental health (1). Therefore, it is not unreasonable to question the government’s focus on abstinence-only education programs. This emphasis on abstinence-only is not just ineffective, but it may also be harmful to other public health efforts such as family planning programs and HIV prevention efforts. A comprehensive approach to sexual education would actually enhance these programs and would not discriminate against GLBTQ youth the way abstinence-only programs do.
Not only will national comprehensive sexual education provide teens with the necessary tools to prevent unwanted pregnancies and sexually transmitted diseases, but it will also allow parents to trust that their children are receiving complete educations through the school system. U.S. adolescents will have the knowledge they need to practice safe sex, and through the scientific literature discussed in this paper, it can be concluded that comprehensive approaches to sexual education do not lead to earlier initiation of sexual behavior. In fact, they have been shown to delay sexual behavior similar to or even more so than abstinence-only programs.
It is strongly suggested that Title 5 Section 515 of the Welfare Act be amended to recommend comprehensive sexual education to all U.S. adolescents through the education system. By doing this, we will protect our adolescents from harmful sexual consequences. A comprehensive sexual education is more ethical, more effective, and less discriminatory than an abstinence-only program, and in this free country where we strive to fulfill the rights and needs of our citizens, it is the only appropriate form of sexual education for our nation’s children and adolescents.


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2. Goodson P, Suther S, Pruitt B, Wilson K. Defining abstinence: views of directors, instructors, and participants in abstinence-only until marriage programs in Texas. J Sch Health 2003;73(3):91-96

3. Communities in Schools Website. Accessed on December 4, 2010

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8. Committee on the Rights of the Child. General Comment No. 3 (2003a) HIV/AIDS and the rights of the child, 32nd Sess. (2003), para. 13. 2003.

9. International Covenant on Economic, Social and Cultural Rights. Adopted December 16, 1966, entered into force January 3, 1976, GA Res. 2200A (XXI), 21 UN GAOR, 21st Sess., Supp. No. 16, at 49, UN Doc. A/6316 (1966)

10. United Nations. Report of the International Conference on Population and Development (Cairo, 5-13 September 1994). New York; 1994. Report No.: A/Conf.171/13.

11. Kemper ME. Toward a Sexually Health America: Abstinence-Only Until Marriage Programs that Try to Keep Our Youth ‘Scared Chaste’. New York, NY: Sexuality Information & Education Council of the United States, 2001.

12. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. National Cancer Institute Website 2005;2:9-21. Accessed on December 6, 2010.

13. Refugee Well Being Website. Health Promotion and Disease Prevention: An introductory Article. Accessed on December 6, 2010.

14. Albert B. American Opinion on Teen Pregnancy and Related Issues. Washington DC: National Campaign to Prevent Teen Pregnancy 2004.

15. Dailard C. Sex education: politicians, parents, teachers, and teens. Issues Brief 2001;2:1-4.

16. Henshaw SK. U.S. Teenager Pregnancy Statistics with Comparative Disease Surveillance, 2003. Atlanta, GA: U.S. Department of Health and Human Services, 2004.

17. Weinstock H, Berman S, Cates W. Sexually Transmitted Diseases among American Youth. Perspective on Sex and Repoductive Health. 2004;36:6-10.

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