A Critique of Abstinence Only Until Marriage Education Policies and Recommendations for an Alternative Approach to Promoting Adolescent Sexual Health

Introduction
Sexually transmitted infections (STIs) among young people have been recognized as a “hidden epidemic” by the Institute of Medicine because of the ways in which STIs permeate communities yet remain largely under prioritized as an issue of concern (1). Data indicates that approximately 50% of new Human Immunodeficiency Virus (HIV) infections occur among people younger than 25 years of age. Adolescents are at particularly high risk of contracting an STI because of a range of factors. Adolescents are developmentally more prone to risk taking, and may be more willing to engage in risky sexual behavior, particularly sex without a condom. Young people are also more likely to have monogamous relationships of shorter duration, a greater number of new partners, and concurrent relationships, which increase their risk for contracting an STI (2). Finally, adolescents may be higher risk for STIs because they lack access to sexual health information, supplies, and services. Young people often rely on others (parents, siblings, grandparents, guardians) to access the healthcare system and may avoid seeking information, supplies, and/or services because of the perceived sensitive nature of adolescent sexual health.

High rates of STIs, particularly Chlamydia and Gonorrhea, are an issue of great concern to the overall health of adolescents because of the nature of these infections and the risk they pose to overall health. Chlamydial and Gonorrheal infections are largely asymptomatic, making it very difficult to diagnose adolescents unless they seek health care for other reasons (3). If a diagnosis is not made relatively early in the onset of infection, a range of health issues may surface later in life, including epididymitis, pelvic inflammatory disease, ectopic pregnancy, infertility, and increased susceptibility to infection with HIV (4). Thus, it is a public health imperative to prioritize reducing rates of STIs for the overall immediate and future health of adolescents.

Young people need access to programs and policies that enhance their sexual health. Yet, the dominant educational framework for adolescent sexual health has been abstinence-only until marriage campaigns designed and often exclusively promoted by the federal government nation-wide. These campaigns have been overwhelming ineffective at optimizing adolescent health, particularly as it relates to rates of STI infection. This paper will focus on the ways in which abstinence-only until marriage programs are based on flawed assumptions about adolescent sexual health and why they fail to protect adolescents from STIs. The main criticisms against abstinence-only programs is that they provide young people with misleading and inaccurate information, they have a high failure rate because they conflict with the normal sexual development of adolescents, and they fail to meet the needs of sexually active teens and teens identifying as lesbian, gay, bisexual, transgender or queer (LGBTQ). An alternative approach to more effectively equip young people with the information and skills they need to be sexually healthy will be addressed following the critique.

Background on Abstinence-Only Programs

Abstinence-only until marriage programs were initially introduced in 1981 as a welfare reform policy, rather than a policy advocating for the optimization of teen sexual health (5). The federal government was concerned about the teen birth rate because of the number of young, unmarried women on welfare and sought to reduce this rate by campaigns focused on the importance of abstaining from sex until marriage. The entitlement program, Section 510(b) of Title V of the Social Security Act, allocated $250 million to the states over five years, with the stipulation that states accepting 501(b) funds would be required to match every four federal dollars with three state-raised dollars for abstinence-only until marriage programs (6). Under the Bush Administration, funding for abstinence-only education programs increased tremendously. In fiscal year 2005, abstinence-only programs received $167 million from the federal government, a vast increase from the $80 million allocated in 2001 (7). States that use the federal funds are required to adhere to a strict set of guidelines when administering abstinence-only until marriage programs, and prohibit disseminating information on contraception services, sexual orientation, gender identity, and other aspects of human sexuality (8). These eight point guidelines require that abstinence until marriage be taught as “the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted infections, and other associated health problems” and that “sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects (9).” There are many flawed assumptions within the eight point mandate of abstinence-only programs, yet one consistent theme is the dissemination of misleading and inaccurate information to young people.

The Dissemination of Misleading and Inaccurate Information

In 2004, a congressional study prepared for Representative Henry A. Waxman (D-CA) found that a significant majority of materials used by abstinence-only educational programs disseminated and promoted sexual health information that was either simply inaccurate or strongly misleading. The report described how the agency responsible for granting the largest portion of abstinence-only funding, the Administration for Children and Families at the U.S. Department of Health and Human Services, does not review its grantees educational materials for scientific accuracy, nor does it require that the grantees conduct a review of scientific accuracy of their own materials (10). As such, the study found that over 80% of abstinence-only curricula used by over two-thirds of federally funded programs uses false, misleading or distorted information on anatomy and physiology, contraceptive effectiveness rates and STIs (11).

The research that abstinence-only programs misreport the effectiveness of condoms in preventing STIs, particularly HIV, is detrimental to adolescent health. Several curriculums stated that “in heterosexual sex, condoms fail to prevent HIV approximately 31% of the time (12).” Another curriculum states that “the popular claim that ‘condoms help prevent the spread of STDs,’ is not supported by the data (13).” Another inaccurately states that exposure to tears and sweat is a risk factor for HIV transmission (14). Thus, not only do abstinence-only programs falsely preach that abstaining from sexual activity before marriage is the only way to protect against STIs but they also lie to young people about important health-related information.

The impact of the lack of scientific accuracy of abstinence-only educational materials on adolescent health has been significant. A recent 2009 study concluded that adolescents who took “virginity pledges” to remain abstinent until marriage, following an abstinence-only education program, were less likely to use condoms and other forms of contraception because the program caused participants to form negative attitudes towards the effectiveness of these methods (15). This study is consistent with others in their conclusion that the misleading and inaccurate information provided in abstinence-only programs discourage safer sex practices, like condom use, when sexual activity is initiated (overwhelming outside of marriage), leading to higher rates of STIs.

High Failure Rate due to Normal Adolescent Development

Another major criticism of abstinence-only until marriage education programs is that they fail to account for the normal sexual development of adolescents and thus have a high failure rate. Adolescence is marked by several fundamental physical, psychological, and social developmental changes. In mid-to-late adolescence (14 to 18 years of age), youth are compelled to find their sexual identity through exploring sexual feelings and desires and establishing a level of comfort with their body and the physical changes they are experiencing (16). Adolescence is an important developmental stage for young people to give and receive intimate or sexual advances that will perhaps shape their future intimate and/or sexual relationships. Abstinence-only programs refuse to recognize that sexual desire is a normal aspect of development for young people and expect them to abide by an imposed moral standard, rather than take actions that are best for their overall health.

Abstinence-only is largely ineffective at keeping teens sexually inactive before marriage because most young people want to explore their sexuality before selecting a monogamous partner in marriage. A 2001 study followed youth that had taken a pledge to abstain from sexual activity until marriage over the course of six years and found that of those that had pledged to remain abstinent, 88% had had sex before marriage (17). Abstinence-only programs fail to predict adolescent sexual behavior because they falsely assume that adolescents will abstain from sexual activity if they are told of the consequences of sex outside of marriage.

This fundamental assumption of abstinence-only programs is also flawed because it conflicts with what is known about adolescent rebellion against authority and the need to establish a degree of independence. As previously mentioned, youth are more prone to risk-taking, despite any looming consequences, because their cognitive reasoning abilities have not yet fully matured. Adolescents may also be more sensitive to potential threats to their freedom, like the message to abstain from sex until marriage. The theory of physiological reactance is particularly applicable to adolescents because it posits that when people think that their freedom is being threatened in any way, they experience reactance, where they are highly motivated to restore the threatened freedom (18). Young people may actually be more likely to engage in sexual intercourse following an abstinence-only education program to restore a perceived threat to their freedom because of the program’s strong behavioral directives.

Failure to Meet the Needs of All Youth

Finally, abstinence-only programs are ineffective at adequately protecting adolescents against STIs because they completely ignore adolescents that are sexually active and those that identify as LGBTQ. Since the only protection against STIs that abstinence-only programs advocate for is to abstain from sex completely, the health needs of teens who engage in sex before marriage are ignored. Yet, the majority of high school students are engaging in sexual activity before graduation. Data from the 2007 Youth Risk Behavior Survey (YRBS) found that 65% of U.S. high school students will have had sexual intercourse by their senior year (19). Since the majority of high school students engage in sexual intercourse by their senior year, sexual health related messages need to address their needs in terms of access to sexual health supplies, like condoms, and services, like confidential testing and treatment, which abstinence-only does not.

Abstinence-only is also ineffective at protecting and promoting the health needs of LGBTQ youth, particularly as it relates to STI risk reduction. Abstinence-only programs often include stigmatizing information on homosexual behavior as deviant and unnatural. These messages can be tremendously traumatic to youth, as one in ten adolescents struggle with issues related to sexual identity (20). The homophobia that permeates American society is further perpetuated by abstinence-only programs, and contributes to homophobia related health issues such as feelings of isolation and loneliness, suicide, HIV infection, substance abuse, and violence among LGBTQ youth (21). Not only does abstinence-only label homosexual behavior as unnatural, but it also deems heterosexual marriage to be the only appropriate sexual relationship (22). This provision is additionally harmful to LGBTQ youth because they are restricted from marrying a same sex partner in most U.S. states. Thus LGBTQ youth have no method of disease prevention or health protection under abstinence-only programs and are ultimately made to feel that their sexual orientation is wrong.

Conclusion

Abstinence-only until marriage programs are overwhelmingly ineffective at protecting young people from contracting STIs because they rely on a set of false assumptions. First, abstinence-only programs assume that misleading and inaccurate information on the effectiveness of proven disease-prevention methods, like condoms, will scare adolescents into abstaining from sex. Second, they assume that adolescents can simply deny the normal development of a sexual identity that occurs and the sexual feelings and desires that drive their behaviors. Finally, they assume that adolescents are not already engaging in sexual activity and use homophobia to accomplish a discriminatory, hetero-normative agenda. There is a growing body of literature confirming that abstinence-only programs are not only ineffective, but also potentially harmful to a population that is in most critical need of reliable, creative, and theoretically based interventions that seek to optimize their health rather than restrict it.

An Alternative Approach to Optimizing Adolescent Sexual Health

While abstinence-only until marriage programs have dominated the sexual health landscape for young people over the past two decades, research proving these programs to be ineffective provides an opportunity to design new interventions. Exposing and critiquing the flawed and false assumptions of abstinence-only programs is important to understand how more effective interventions can be developed that respond to these false assumptions. The program Let’s be REAL was designed in response to the failure of abstinence-only programs and the need to provide young people with a source of comprehensive sexuality information, access to services in their local communities, and a sense of community and belonging to a group that values each and every teen, regardless of their sexual status (having sex or not) or sexual orientation. The format of Let’s be REAL will be an interactive website for teens that features the voices and stories of teens on issues related to sexual health. The site will allow young people to access information through stories and interactive features, rather than from adult lectures. The goal of Let’s be REAL is to have a place where youth can feel comfortable going to for more information about their sexual identity and health from their peers, and feel a part of a greater community. Membership to Let’s be REAL means the promise to “be real” about sexuality, and expose the truths about sexual health, as it concerns young people. The Let’s be REAL campaign will respond to the three flawed assumptions of abstinence-only by providing comprehensive sexuality information, acknowledging that sexual desires are a normal part of growing up and how to handle them, as well as an emphasis on support for sexually active teens and LGBTQ youth. The Let’s be REAL campaign will be developed with the active participation of teens and aims to inspire a movement towards getting real around sexual health for young people.

Provide Comprehensive and Accurate Information

The Let’s be REAL site will include interactive features on a range of sexual health issues that will be both non-judgmental and scientifically accurate. Sections will be designed to reach out to teens that are not engaging in sexual activity quite yet and those that are. Information on sex, delaying sex, birth control, STIs, pregnancy, HIV/AIDS, and LGBTQ issues will be included and shared from a teen’s perspective. Videos featuring stories of teens that have experienced a certain aspect of sexuality (both positive and negative) will be available. The Let’s be REAL campaign will not bombard teens with numbers and statistics on the importance of behaving a certain way. Instead, teens that are experiencing or have experienced a certain aspect of sexuality, like suspecting they have an STI, will share their story and perspective on how they felt at the time and what steps they took to resolve the issue (went to a health clinic nearby that offered free and confidential testing). The availability of stories on the site, rather than just information, will help to minimize psychological reactance among teens that might cause them to ignore or act against any overt health messages. Studies using the theory of psychological reactance suggest that reactance is minimized when those providing the information are most similar to those receiving the information (23). The stories will be told by teens from diverse backgrounds and sexual orientations so teens can more easily identify with them and the messages they share in their stories. It is of the utmost importance to the Let’s be REAL campaign that young people feel represented on the site, otherwise the goal of optimizing adolescent sexual health will not be realized.

How to Respond to Normal Sexual Desires

Let’s be REAL will recognize that forming a sexual identity and having sexual desires and feelings is a normal part of being a young person. Interactive features, such as the personal anecdotes, will be showcased again to connect with young people around the physical and emotional changes they are experiencing as they progress through adolescence. Young people need to know that the sexual desires they are feeling are a completely normal part of growing up and how to address issues of uncertainly or confusion that may arise. The stories provided will suggest other people that might also be helpful to talk to about these issues with, such as a parent, older sibling, or healthcare provider. If teens do not have a family member they can talk to about sexuality issues, a list of other resources, such as youth centers, adolescent health clinics and/or LGBTQ centers will be provided.

Emphasizing that sexual desires and questions around sexual identity are a normal part of adolescence will provide adolescents with an alternative away from abstinence-only messages that describe sexual activity as only consequence laden. Studies have confirmed that sexual health interventions that are initiated when the majority of teens are not yet sexually active (early adolescence) are more likely to be effective at motivating safer sex practices than with teens that are already sexually active (24). With this in mind, the site will not only emphasize the role sexuality plays in the normal development of teens but also feature a database of providers of sexual health information, supplies and services. Youth would ideally explore Let’s be REAL before becoming sexually active, but will of course also be tailored to teens that are already sexually active. The interactive feature will allow adolescents to enter their geographical location (Town, City, State) and be connected to a database of available services in their area. Messages ensuring patient confidentiality will hopefully encourage youth to use the services available despite perceived parental or guardian disapproval.

All Teens Can Join the Let’s be REAL Campaign

Finally, the Let’s be REAL website will feature the voices and experiences of teens from diverse backgrounds and sexual preferences to be as inclusive and user-friendly as possible. LBGTQ youth will be prominently featured on the site with stories about what it is like to wrestle with sexual identity questions and how other peers have dealt with coming out, harassment, and other LGBTQ related health issues. Since the intervention is an online website, teens who are still struggling with identity questions or who have no one else to turn to can access peer support safely and anonymously.

The voices and experiences of sexually active teens will also be prominently featured. Let’s be REAL aims to reverse the social norm that teens that are engaging in sexual activity are reckless and uninterested in their sexual health. Changing this social norm is one key goal of the campaign, as painting teens with the broad stoke of irresponsibility only further disempowers and dissolves them of taking control of their health. The theory of social expectations posits that if the social norms around an issue are tackled and changed, significant behavioral changes can result (25). While Let’s be REAL as a single intervention may not be enough to shift the social norms around adolescent sexuality, it is a step in the right direction. Implementing an intervention that places teens at the forefront and uses their voices and stories to inform and promote healthy behaviors in others has the potential to change social norms around adolescent sexual health because teens will be given the means to dictate how society interprets their sexuality.

Conclusion

Unlike abstinence-only programs, the Let’s be REAL campaign will provide youth with the scientifically accurate information they need to make their own choices about their sexuality and sexual health. Through personal stories from like-minded peers, young people will not be talked at by adults but instead will participate in a dialogue with their community. Communities of young people want real answers to complex health issues and the support they need to make the best decision that is right for them. Abstinence-only programs cloud sexual health in a fog of morality and ideology. Let’s be REAL provides teens with the control to make their own decisions, based on a full spectrum of applicable information from their peers, to ultimately optimize their health.

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4. Ibid

5. Kreinin T, Wagoner J. Toward a Sexually Healthy America: Roadblocks Imposed by the Federal Government’s Abstinence-Only-Until-Marriage Education Program. Advocates for Youth. http://www.advocatesforyouth.org/storage/advfy/documents/abstinenceonly.pdf

6. Ibid

7. Union of Concerned Scientists. Abstinence only sex education curriculum. http://www.ucsusa.org/scientific_integrity/abuses_of_science/abstinence-only-curriculum.html

8. 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. J Adolesc Health. 2006; 38: 72-81.

9. Ibid

10. United States House of Representatives Committee on Government Reform. The content of federally funded abstinence-only education programs. http://www.apha.org/apha/PDFs/HIV/The_Waxman_Report.pdf

11. Ibid

12. Ibid

13. Ibid

14. Ibid

15. Rosenbaum JE. Patient Teenagers? A comparison of the sexual behavior of virginity pledges and matched nonpledgers. Pediatrics. January 2009; 123(1): e110-e120.

16. Adolescent development. U.S. National Library of Medicine, National Institutes of Health. http://www.nlm.nih.gov/medlineplus/ency/article/002003.htm

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18. Silvia PJ. Deflecting reactance: the role of similarity in increasing compliance and reducing resistance. Basic and applied social psychology. 2005; 27:277-284.

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20. 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. J Adolesc Health. 2006; 38: 72-81.

21. Ibid

22. Ibid

23. Silvia PJ. Deflecting reactance: the role of similarity in increasing compliance and reducing resistance. Basic and applied social psychology. 2005; 27:277-284.

24. Cowan FM. Adolescent reproductive health interventions. Sex Transm Infect 2002 78: 315-318

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