Monday, December 20, 2010

Say No to Just Saying No: Why Abstinence Only Sex Education is Flawed – Ashley Bourland

Sex education programs exist in the United States to prevent teen pregnancy and sexually transmitted infections, including HIV. Sex education programs that solely promote messages of “abstinence only” and “abstinence until marriage” are fundamentally flawed. These programs have been taught to teens for decades and are still strongly supported by federal monies in spite of public support for more comprehensive sex education (1). A comprehensive approach to sex education would be much more appropriate and beneficial to America’s teens.

Sexual Activity in U.S. Teens
The median age of first sexual intercourse for women in the United States is 17.4 years old, while the median age at first marriage is 25.3 years.(2,3) For men, the median age of first sexual intercourse is 17.7 years old and age at first marriage is 27.1 years old.(2,3) Based on this evidence, it is clear that U.S. teens are having sexual intercourse.

Importance of Sex Education for Teens
Sex education for teens is important for two main reasons – preventing unwanted pregnancy and sexually transmitted infections (STIs). According to reports published by the Guttmacher Institute in 2006, there are more than 750,000 teen pregnancies each year of which 82% are unintended.(4) Overall, teen pregnancy rates had been declining for the last decade in the U.S., however, the rate increased by 3% in 2006 and 4% in 2009.(4,5) These rates are twice as high as those in Canada and England and eight times as high as in Japan and the Netherlands.(4)
Approximately nine million new STIs are diagnosed in teens and young adults annually.(6) Chlamydia and gonorrhea are the most commonly acquired STIs and can easily be treated with antibiotics.(6) In 2008, 15-19 year-old girls and 20-24 year-old young women had the highest rates of gonorrhea (636.8 and 608.6 cases per 100,000 females, respectively) than any other population.(7) If left untreated, STIs can lead to pelvic inflammatory disease and, in severe cases, sterility.(7)

History of Abstinence Education in the United States
There are different definitions of “abstinence” such as “never had vaginal sex” or “postponing sex”.(8) Government laws and policies may refer to “abstinence” as “being moral” or “chaste”.(8) For the purposes of this critique, “abstinence” means abstaining from sexual intercourse.
Abstinence education first began receiving federal funding in 1981 through the Adolescent Family Life Act (AFLA).(9) Despite lawsuits, issues of unconstitutionality (10,11) and minimal proof of efficacy (10-12), abstinence only programs are still funded by federal monies today. Programs, like the Adolescent Family Life (AFL) Demonstration and Research program and the Title V State Abstinence Education Grant Program, are awarded millions of dollars to help abstinence education (12); the AFL program received more than $16.6 million in funding in fiscal year 2010.(9) The Title V State Abstinence Education Grant Program, which is run through the Administration for Children and Families (ACF)/Family and Youth Services Bureau (FYSB), accepts annual grant application for programs that support abstaining from sexual activity until marriage with a focus on those groups that are most likely to bear children out-of-wedlock.(13) States are always welcome to procure other funding without limitations on the type of sex education that can be offered, however, federal funding is tempting.

Social Science Theories Behind Abstinence Only Education
The most common social science theories behind abstinence only education (AOE) interventions are the Health Belief Model (14) and the Theory of Reasoned Action (15). Interventions utilizing the Health Belief Model propagate the message that sex is harmful and therefore should be avoided (16), while interventions utilizing the Theory of Reasoned Action propagate the message that society will look down on you for having sex and that sex before marriage is immoral (17,18). These messages that sex is both dangerous and immoral are the prolific in AOE programs. Print ads are designed to scare teens away from sex.(19)

Why is Abstinence Only Sex Education Flawed?
The main fault with only promoting abstinence in sex education is the simple fact that one needs to abstain from sex for this method to be effective. In the U.S., 46% of all 15-19 year olds have had sex at least once in their lives.(6) Therefore, despite abstinence only education programs, teens are having sex. Furthermore, research has shown that once teens who are only taught abstinence become sexually active, they are less likely to use contraception to prevent pregnancy and STIs.(8) The following paragraphs present an analysis of three specific flaws in abstinence only sex education in the U.S.

Argument #1: “Don’t Tell ME What To Do”
The primary flaw with abstinence only education (AOE) is based on Brehm’s Psychological Reactance Theory (20) which states that people do not like being told what to do and will fight for their freedom if they feel it is threatened. AOE provides only one choice – no sex until marriage – thereby eliminating a person’s freedom to make any other choice. Studies have shown that attaching a threatening message to a behavior (e.g. “sex is bad for you”) or prohibiting someone to engage in that behavior (e.g. no sex until marriage) can have the opposite effect, causing that person to want to engage in that behavior even more.(21) A person will want what they cannot have and want to do what they have been told they cannot do. Other examples of this behavior can be found during the Prohibition Era when alcohol was legally banned; bootleggers made millions of dollars during that time making and selling “home-made” alcohol because Americans wanted the products that were banned by their government.(22)
One can also use the Advertising Theory to expand on this flaw in AOE. The strength behind Advertising Theory’s effectiveness is the emphasis on a core value when supporting a behavior; in this case, rebellion.(23,24) Americans have many core values including love, health and family; teens are more likely to value control in their lives. Therefore, when teens perceive a loss of control, such as when they are told not to engage in any sexual activity, they are apt to rebel. Telling someone to abstain from a certain behavior is ineffective because it is in our nature to dislike being told what to do.

Argument #2: Misinformation in Abstinence Only Education
The next flaw in abstinence only education programs is that the information presented excludes other safe sex methods and often misrepresents these methods in an effort to promote abstinence. In 2004, the minority staff of the Committee on Government Reform of the U.S. House of Representatives reviewed 13 commonly used abstinence only sex education curricula; in their published results, they found that 85% of the programs contained incorrect or misleading scientific information regarding reproductive health.(7) Some reports contained exaggerated failure rates for contraception while others blended scientific and religious information. This misinformation is both unethical and promotes institutional discrimination against teens who have sex. By only presenting only one option – abstinence – sexually active teens are not given the tools and information they need to ensure their health and safety. According to the Oxford Dictionary, the definition of discrimination is “the unjust or prejudicial treatment of different categories of people or things, especially on the grounds of race, age, or sex”.(25) Abstinence only programs are subconsciously discriminating against teens who engage in certain behaviors. This discrimination leads to higher rates of unintended pregnancy because teens’ ages 15-19 years are twice as likely to become teen mothers if they do not use contraception during their first sexual intercourse.

Argument #3: American Attitudes Towards Sex
Historically, abstinence only sex education has close ties to conservative religious beliefs.(8,10,11) The U.S. is a mix of political and social views, however, there is a general perception that the U.S. is less liberal or accepting of sexual activity than other European countries.(19) Despite using sex to sell everything from clothing to hamburgers, the general message is that sex is shameful. This attitude creates a self-perpetuating cycle of Americans believing they should be uptight and embarrassed about sex and then they become uptight and embarrassed about sex. This cycle is described in the Labeling Theory (26) and creates a social atmosphere where abstinence only sex education is encouraged. We, as a society, have created a taboo around sex and abstinence only education amplifies that taboo. This taboo leads teens to be more secretive when engaging in sexual behavior. Teens that are not taught any other option besides abstinence are less likely to use contraception if they become sexual active. These teens are also less likely to report STIs to a doctor.(8) Society has created an environment where sex is acceptable in advertising, but not in real life, which presents a confusing and seemingly hypocritical model for teens. Teens question why one minute sex is glorified in movies and television and the next minute they are told to abstain from sex until marriage.
Sex is more socially acceptable in other European countries, such as the Netherlands.(6) Sex is still used to sell products, as it is one of the most important core values present in Advertising Theory, however the stigma surrounding sex is diminished. Safe sex ads are commonplace in mainstream media and unabashedly promote condom use. Dutch teens are also more likely to be prepared for safe sex by carry condoms in their wallets.(19) Despite the greater social acceptance of sex in the Netherlands, the teen pregnancy rate is eight times lower than in the U.S.; an atmosphere of social support for sex and safe sex behavior leads to teens acting more responsible about sex as well as lower rates of unintended pregnancy and STIs.(6)
Americans may be concerned that the Dutch attitudes towards sex are glorifying sexual behavior, however, research has clearly shown the opposite to be true.

Alternative Intervention for Safe Sex Education
As stated above, the three main flaws with abstinence only education are as follows:
1) People do not like being told what to do
2) It is unethical and discriminatory for abstinence only education to withhold or misrepresent information about reproductive health.
3) Abstinence perpetuates the view that sex is taboo in the U.S.

Intervention #1: Comprehensive Sex Education
The main purpose of a sex education program is to reduce the number of unintended pregnancies and sexually transmitted infections in teens.(12) The efficacy measure for most sex education programs is time to first sexual intercourse; a program that delays or prevents first intercourse is considered to be efficacious.(10,11,27) A comprehensive sex education program that includes several safe sex methods, including abstinence, would be most successful for U.S. teens.(28,29) In one cross-sectional survey, 82% of respondents were in favor of a comprehensive sex education program that taught both abstinence and other safe sex methods.(1)
The program must be presented in a way that does not dictate safe sex methods, but offers multiple choices and gives teens the control of which methods they choose to use. Programs are most often presented in schools because students are a captive audience.
The program would need the following components: 1) background data, 2) presentation of safe sex methods, 3) demonstrations of these methods and 4) personal stories.
• Background Data: Accurate information should be presented on different types of sexual behavior, such as the definition of oral sex vs. vaginal sex. Data should also be presented regarding sexual trends in teens so that participants can rely on scientific data instead of their perceptions of others’ behaviors. Data should be obtained from unbiased, peer-reviewed sources such as scientific journals. Data should also be presented on body image and masturbation.
• Safe Sex Methods: Multiple safe sex methods should be presented including: 1) abstinence from sexual behavior, 2) male and female condom use, and 3) oral contraceptives.
• Demonstrations: Safe sex methods should be demonstrated by the teacher and practiced by the students. For example, teens should be taught how to recognize, open and apply a male condom to a banana. This hands-on experience is vital and often missing from sex education programs.
• Personal Stories: As stated in Advertising Theory, personal stories have a greater impact than statistics.(26) Stories should be presented from members of the community who are HIV positive or unwed teen mothers.
To further enhance the information presented in the sex education program, an optional evening seminar will be offered at the beginning of each semester to parents in the community. The seminar will be held at the school. The school principal and school psychologist will be present; this will demonstrate the school’s support for the program. The seminar will be run by the sex education instructors. A summary of the entire comprehensive sex education program will be presented to parents including any hand-outs that students will receive. Parents will be given ample time to ask any questions about the program, methods or materials. This seminar will both help to reinforce the lessons learned in the program as well as get the parents involved in their children’s lives. Research has shown that more time with a parent leads to teens postponing first sexual intercourse.(30)

Intervention #2: Ensuring Accurate Data on Reproductive Health
In order to ensure that accurate scientific information is being used in sex education programs, there needs to be a two-tiered oversight process. The first tier involves the source of the data used in the education program. Sex education programs should be a public health issue, not a moral or religious issue, (8,30,31) therefore these data should be selected by a committee of medical professionals from peer-reviewed research journals.(32,33) The committee will determine what data can be used, such as accurate rates of STIs or teen pregnancy. The committee should also re-review the scientific data every two years.
The second tier of oversight involves the development of the comprehensive sex education curriculum itself. The materials used in the curriculum will be selected from the medical professional committee-approved data. A Curriculum Board should be convened to design and write the curriculum for each school district; this level is most appropriate as sexual health issues may vary across school districts. The Board members should be selected from local parents, teachers and medical professionals from the community. By involving these three groups, the schools will be incorporating the views of the community and thereby strengthening the program. Before designing the curriculum, each Board should assess the specific sexual health issues in their district through focus groups. This approach is based on Social Marketing Theory and the subsequent curriculum and intervention can be tailored to that school district’s needs.(34) For example, Boston schools may need to emphasize more HIV prevention education, while Gloucester schools may want to emphasize teen pregnancy prevention.(35) These issues can be more closely addressed when personal stories are presented in the curriculum.
Prior to implementation, each Board’s curriculum must be approved by a state governing board. This state board will be looking for the following components of the program:
1) Accurate scientific data
2) Overview of multiple safe sex methods
3) Demonstrations of safe sex methods
4) Personal stories from community members
These curricula will be made available to the public so that parents and other community members are aware of what is being taught in schools.

Intervention #3: Changing the Taboo About Sex in the U.S.
Changing social attitudes regarding sex is a complicated task. This intervention proposes to address this issue at the individual and group level. This intervention would need to create a positive attitude surrounding sex and promotion of safe sexual behaviors.
There is no requirement for teachers to become certified before teaching a sex education class. This can lead to an awkward atmosphere in the classroom as these teachers will unknowingly bring with them the social attitudes of sex in America. In this intervention, teachers would be required at attend a one-day training session so that they can become certified not only in the sex education curriculum, but also methods for teaching the curriculum. You wouldn’t jump out of an airplane without a licensed instructor, so why would teens receive important information about their sexual health and behavior from someone without any training. This training would act to break the cycle of uncertified instructors bringing societal attitudes and bias into the classroom.
At the group level, this intervention would need to introduce a different way of viewing sex in America. Safe sex ads in the Netherlands abandon the scare tactics and present behaviors, such as condom use, in a straightforward light. These ads create a positive attitude and label for safe sex and sex overall without being raunchy. Again using the Labeling Theory, American ads need to present this same positive label about sex and safe sex methods. For example, a series of ads showing teens carrying condoms in their wallets or backpacks can use the evidence that perceived norms can affect sexual behavior in a positive way.(8) Research has shown that teens who believe their peers are having sex have a higher intention to have sex themselves.(8) This theory can be used for condom use; if teens see more ads of teens with condoms, they will believe that more teens are using condoms and this will increase their intention to use condoms themselves.

Sex education programs that solely promote messages of “abstinence only” and “abstinence until marriage” are fundamentally flawed. Comprehensive sex education programs are more appropriate for teens. These programs need to be taught in a way that presents multiple safe sex methods without dictating to teens, as teens are apt to rebel when they sense their control is being taking away from them. Sex education curricula need to be based on accurate medical data and developed with the input of parents and community members. Lastly, in an effort to change the social taboo regarding sex in America, teens need to see more ads encouraging condom use. This multi-faceted approach can help improve the sexual health of teens in the U.S.


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