To Wait Or Not To Wait: A Critique Of Why Abstinence-Only Sex Education in the United States Does Not Work- Keerthi Chandrasekaran

Teenage sexual behavior has always been an issue of major concern. According to recent data from the Guttmacher Institute, nearly 46% of US teens between the ages of 15-19 have had sex at least once (1). In addition, nearly 800,000 women of the same age range become pregnant each year and of the 18.1 million cases of sexually transmitted infections (STI’s), roughly 48% of them belong to men and women between the ages of 15-24 (2). Even in comparison to other developed nations, the US leads with a teenage birth rate of 52.1 per 1,000 births, which is almost four times higher than the average teenage birth rate of the entire European Union (3). In addition, 60% of teenage girls who gave birth before age 18 drop out of high school and those who do not receive their high school diploma or GED by the age of 20 are more likely to live at the poverty level for the rest of their lives (4). These shocking statistics show that there is a need for a better public health intervention in order to reduce the instance of unsafe teenage sexual behaviors including teenage pregnancies and STI’s.
Current public health interventions are based around sex education programs in middle schools and high schools, with nearly 89% of 7th-12th graders receiving sex education at least once during their schooling (5). Sex education programs generally follow one of two paths: comprehensive education or abstinence only education (6). Comprehensive sex education programs focus on the benefits of abstinence and contraception as well as how to avoid STI’s and teen pregnancies. These types of programs are supported by national organizations such as the Society for Adolescent Medicine (7), and the American Public Health Association (8), who recognize that teens will have sex regardless of what an authoritative figure (or anyone for that matter) tells them. Therefore, these programs aim to educate teenagers on safe sex methods, while teaching them how to deal with difficult or uncomfortable situations when it comes to sex (9). On the other hand, abstinence-only programs focus solely on abstinence and exclude any other types of sexual and/ or reproductive health education such as contraceptive use including birth control or condoms. Abstinence only education teaches teenagers that abstinence is the only 100% foolproof way of preventing unwanted pregnancies and sexual transmitted infections. It also focuses on the “social, psychological, and health benefits” of abstaining from any sort of sexual behavior. Abstinence only education programs receive support from a wide variety of sources ranging from religious groups/ organizations to the US Federal Government (5).
Despite this wide range of support, abstinence only education programs fail on several levels. Abstinence works in theory, but in practice is extremely difficult for teenagers to do, especially when peer pressured by their significant other and/ or friends to have sex. In addition, abstinence only education does not provide teenagers with any sort of education for when they encounter an uncomfortable sexual situation (10). In addition, research has shown that abstinence only programs are ineffective at reducing teenage pregnancy and the incidence of STI’s. In fact, teens exposed to abstinence only education programs were just as likely to have sex and were more likely to engage in unsafe sex practice such as not using a condom, having sex at a young age, having multiple partners, etc (11).
Since these current methods are ineffective, one can look to the social and behavioral sciences as well as the field of developmental psychology in order to find a more creative and practical solution to this growing problem. Through an in-depth analysis of current abstinence only education programs, one can see how truly ineffective and unappealing such programs are to teenagers. In order to get teenagers to change their unsafe sex behaviors, new interventions need to focus on what teenagers value and use those core values to convince teens to not engage in sex at such a young age. Additionally, we need to implement the successes of current comprehensive sex education programs into abstinence only programs, so that adolescents can make well-informed decisions about their sexual behavior.
How Do Teens Perceive Risky Sexual Behaviors?
Most of the sex education programs available to teens utilize the Health Belief Model. The model works on an individual level and states that in order for a person to make a behavior related change, the individual must be able to perceive the susceptibility and severity of their negative health behavior. If the person weighs the perceived benefits of a behavior change with the perceived barriers of implementing such a change, then they can make an informed decision that will dictate the appropriate behavior (12). Although the model allows for the individual to make a completely rational and calculated decision, it fails to take into account social, cultural, and/or environmental influences (13). In addition, the model relies heavily on an individual’s “perception” of the situation, which varies dramatically from person to person.
Abstinence only education follows the Health Belief Model, since the programs assume that teens perceive their susceptibility and severity of unsafe sex consequences in the same way that adults do. In other words, abstinence only education assumes that teens believe that they are at a high risk of contracting STI’s and having unwanted pregnancies and would therefore avoid having sex at all. However research suggests the opposite; teens often underestimate the risk of unsafe behaviors, especially when it comes to sex (14). From a developmental standpoint, adolescence is characterized by a heightened sense of egocentrism. Teens often believe that they are invincible and unsusceptible to any sort of harm, which is why they engage in risky behaviors (15). In addition, abstinence only education presumes that teens will easily overcome the perceived barriers to abstaining from sex, such as not caving to peer pressure and ignoring the influence of the media in its portrayal of sex.
From this psychological standpoint, one can see that abstinence only education fails to take into account the perspective of the individual teenager. The Health Belief Model makes too any false assumptions regarding the decisions and subsequent behaviors that teens will make. Also, the model assumes a sort of “vacuum” where teens are free from societal and cultural influences. Abstinence only educational programs need to revamp the psychological approach they are based on, in order to create a more effective intervention.
Why the Lecture?
Another critique of abstinence only education is the “authoritative” voice it uses. These programs often deliver their message by lecturing adolescents on why they should abstain from sex. The programs do not offer any other options and assume that teens will follow their message through intimidation and fear of contracting STI’s or becoming pregnant. Contraceptive use is rarely mentioned and if it is, then it is usually mentioned as an ineffective method (6). Also, these lectures are often delivered by parents, teachers, leaders of a religious organization, and/ or other adult figures who may not be easily relatable to teenagers (10).
The problem with this authoritative voice is that teenagers hate being told what to do. Their rebellious nature causes them to turn against anyone who impedes their freedom. From a developmental point of view, teens are at a stage in their life when they are trying to develop their own independence and prove that they can take care of themselves (15). Since abstinence only education programs lecture teens on exactly what to do, teens look at these programs as a threat to their freedom and ability to make their own decisions. In additions, teens develop extremely close relationships with their peers who they share common interests with and who are more likely to understand their emotional state. They are less likely to listen or connect with their parents or educators who they have far less in common with (16).
In order to correct this problem, advocates of abstinence only education programs need to deliver their message in such a way to captivate a teenage audience. It would also be of use to employ a messenger that is relatable to teens, so that teenagers would be more likely to listen to the message. The last thing a teenager wants is a lecture about health risks that they barely perceive or think they are susceptible for from a person who they cannot relate to.
The Assumption of Morality
Several abstinence only education programs are supported by a wide range of religious organizations for their emphasis on purity and morality. Many religions find abstinence to be the only type of sex education that agrees with their religious beliefs, especially that of no sex before marriage. There is also a strong belief that morality alone will prevent teenagers from engaging in any type of behavior that would taint their purity (6). These beliefs have gone beyond places of worship to national organizations such as True Love Waits (http://www.lifeway.com/tlw/), which uses a written pledge (17) and the Silver Ring Thing (http://www.silverringthing.com/home.asp), which uses a silver finger ring inscribed with Biblical verses (18), to serve as a vow to remain celibate until marriage.
With no disrespect to any religious beliefs, one may argue that morals alone cannot prevent risky teenage sexual behaviors. Research shows that several of these pledges have been proven to be inefficient. Teens who commit to an abstinence pledge or oath end up delaying their first sexual initiation by a mere 3 years (9). In addition these same teens are also more likely to engage in unsafe sex practices (ex. not using a condom or using birth control) and are more likely to contract STI’s and HIV/AIDS, most likely to their lack of knowledge and education on the topic (19).
In addition, the period of adolescence is characterized by a period of continuous identity and personality development. Lawrence Kohlberg, a prominent developmental psychologist, classifies adolescence as a stage of “Conventional Reasoning,” where teenagers abide to certain moral standards; however they are the standards of others, such as their parents or family members (20). Teenagers are still struggling to develop their own personal and moral codes and may blindly take the view of their parents or family members simply to please them. In terms of abstinence pledges or receiving abstinence-only education, teens may not fully agree with the ideas being presented, but may go through such pledges to satisfy their parents or other important figures in their lives. This lack of true commitment actually makes it harder for teenagers to stay motivated and follow through with their intended promise.
From these examples, we can see that abstinence pledges may end up doing more harm than good. Therefore there is a strong need to revamp the current approach to abstinence only education in order to get teenagers motivated enough to change their negative behaviors and unsafe sex practices. Rather than using morality alone, public health interventions should perhaps take a holistic approach and use other values in tandem with morality to appeal to adolescents.

A New Approach to Sex Education
As one can see, current sex education programs that revolve around abstinence-only education are failing. In order to fix this problem, I propose a new intervention that will help adolescents realize the consequences of their risky sexual behaviors. This new intervention will utilize peer groups where teenagers can talk to each other about sex and its consequences. These groups will create a forum for discussion where teens can safely confide in their peers about the pressures of having or not having sex. Each peer group will have a peer leader who is responsible for facilitating discussions and creating a safe environment for teens to speak to each other. The peer leader should also integrate information such as how to use contraceptives and how to say no to having sex into these discussions. In addition, the peer groups can add a personal touch by bringing in “guest speakers” such as teen moms or teens who contracted STI’s to talk to teens about their experiences with unsafe sex practices.
The idea behind this new intervention is that instead of having parents or educators lecture teens on what to do, let teens decide for themselves. By laying out the facts and engaging in conversation with their peers, adolescents will learn how to make appropriate decisions regarding sex. The discussions will help them learn from each other’s success and mistakes and will also help them realize that the consequences of practicing unsafe sex have an immediate impact on them. Teenagers would be more willing to undergo this sort of sex education program since they are working with their peers who they easily relate to. In addition, peer groups will help give teenagers an identity since they have committed to the groups through their own will. Finally, peer groups will help teenagers look at the options that they have if they find themselves in an uncomfortable sexual situation.
How Do You Get Teens To Listen?
Instead of relying on the Health Belief Model, the new intervention is based around the Theory of Psychological Reactance. This theory is based on the idea that people have adverse emotional reactions when their sense of freedom is being taken away (21). This is the reasoning behind why people hate to be told exactly what to do; they want the ability to freely make their own decisions without being manipulated in any way. In order to decrease reactance and make it work in public health, we need to stop telling people what to do and restore that sense of freedom that was previously taken away. The simplest way to deflect reactance is to develop a line of communication that does not tell the audience exactly what to do. This can be accomplished by delivering the message from multiple sources and from messengers that are extremely similar to the recipient. The more the recipient of the message can relate to the messenger, the more likely they will agree with the message being presented and the less reactance they will have against the message (22).
Contrary to the Health Belief Model, the Theory of Psychological Reactance does not make any assumptions about perceived susceptibility or severity of disease. It recognizes that teenagers may succumb to peer pressure and uses that fact to its advantage. The proposed intervention uses the Theory of Psychological Reactance by changing the source of the message. Instead of relying on educators or parents, the use of peer groups and leaders relies on teens themselves to spread safe sex practices to this specific population. By diffusing the message through similar messengers, such as peer leaders, teenagers are more likely to listen to the proposed message since they relate to the messenger, thus decreasing reactance. In addition, since current approaches take away teenager’s freedom and subsequent ability to make their own decisions, the use of psychological reactance will help restore that freedom. Instead of making teens feel like their being manipulated, peer groups will allow for discussion which will help adolescents feel like they are in control of the situation. The more they feel manipulated, the less likely teens will listen to the message and the more likely they will rebel against it. However, if you offer teenagers more options, then they are less likely to feel like their personal freedoms are being threatened (15).
Stop The Lectures
The proposed intervention is unique in that it essentially turns the table on teens; instead of lecturing teens and threatening their sense of freedom, it shows them how the consequences of their unsafe sex behaviors will ultimately lead to the loss of their own freedom by removing the authoritative voice. Peer groups could bring in “guest speakers,” such as teen moms and teens who have been infected with STI’s or HIV/AIDS to share their experience with others. Teens would be able to interact with these speakers and could see first-hand what the consequences of unsafe sex are. In essence, adolescents can see how taking care of a baby or managing a chronic STI or even HIV/AIDS will impose on their freedom to live life on their own terms. This approach may work better with teenagers since it allows them to make their own decisions based on the information presented. It puts the individual teenager back in control of the situation since they are not necessarily being told what to do.
A perfect example of this type of intervention is being done by the Candies Foundation (http://www.candiesfoundation.org/us.html). The goal of this foundation is educate the public about the consequences of teenage pregnancies. Through various media campaigns and celebrity sponsors, the foundation has been successful in reaching millions of teens all across the United States. In particular their television and print ads literally focus on how the consequences of teen pregnancy take away one’s freedom to live life. One particular ad features a picture of a baby stroller underneath a slogan that reads “Not what you had in mind for your first set of wheels, huh?” (http://www.candiesfoundation.org/print.html). The ads are generally endorsed by celebrities who teenagers have deemed as “cool” such as Fergie, Usher, Hayden Panettiere, Fall Out Boy, Ciara, and Hilary Duff among others (22).
The success of the Candies Foundation is attributed to its smart advertising and use of the Theory of Psychological Reactance to show teens how their freedom is being taken away. Although this particular ad campaign uses fear, it does so in an extremely subtle way. By getting rid of the authoritative voice and showing teens the consequences of unsafe sex practices, these new interventions can teach teenagers that the decision of whether or not to practice unsafe sex is ultimately theirs. In addition, the Candies ad campaign and other similar types of ads that appeal to teenagers diffuse the voice of authority and make it possible for teenagers to make informed decisions that they will commit to.
Teens Will Listen To Each Other
Abstinence pledges and oaths often do not give teens the opportunity to talk about any questions they may have regarding sex and sexual behaviors. In addition, studies have shown that teens are more likely to talk to their peers then their parents or teachers about sex (24). Keeping this in mind, the proposed intervention employs the use of peer groups or peer leaders to carry its message. Open discussions will allow teens to freely voice their opinion and ask questions without having to worry about being reprimanded. Teens can discuss issues such as how to deal with the pressure to have sex and ways to say no to sex. This new approach may work better than previous approaches since teens are more likely to talk to each other since they are more comfortable with each other. Also this approach works in terms of the Theory of Psychological Reactance since the messenger (peer leaders) are similar to the recipients (other teenagers), thus decreasing the amount of reactance. Teens are more likely to listen to each other then they are to parents, teachers, and/ or other adults since they share common interests, values, and goals with their peers (16).
In addition, the use of peer leaders and peer groups will allow teenagers to commit to a group. In essence this is a form of branding which helps teenagers form an identity. Branding is a common marketing technique that uses a set of associations to sell a product. In public health, branding can be used positively to define a healthy behavior, thus allowing adolescents to feel like they are a part of something (25). In terms of sex education programs, peer groups will allow teenagers to commit to a cause and self-identify with a group. Since teens are so easily influenced by their peers, if they see that one of their own friends is part of a cause, they are more likely to support and take part in that same cause (16).
The Future of Abstinence-Only Education
Despite being the only foolproof way to avoid unwanted pregnancies and the contraction of STI’s and HIV/AIDS, abstinence-only education has proven to be extremely ineffective among the teenage population. Current abstinence-only education programs are modeled around the Health Belief Model which assumes that teenagers have perceived the severity as well as their own personal susceptibility to unsafe sex practices as a serious threat to their future. In addition, abstinence-only education uses an authoritative voice such as a parent, educator or other significant adults in a teen’s life, to lecture adolescents on the benefits of abstaining from sex. Lastly, several of these programs assume that teenagers will blindly take and follow through with abstinence pledges and oaths. These current methods do not take into account the teenager’s perspective on sexual behavior nor do they allow for adolescents to express their own opinions on the matter.
In order to make abstinence-only education more effective, public health campaigns need to restructure their approach. The previously outlined new intervention, improves upon the fallacy of past sex education programs by utilizing peer groups to promote its message. Instead of using the Health Belief Model, the new intervention is developed around the Theory of Psychological Reactance and Branding. Both are powerful marketing techniques that target the core values and beliefs of teenagers. These theories allow for teenagers to make their own decisions without being forced to comply with anyone else’s ideas. In addition, since adolescents are more likely to listen to each other rather than their parents or educators, both theories allow for the implementation of peer groups where teens can talk to each other about the pressures of having or not having sex. These peer groups also allow adolescents to make a commitment and become part of a group thus giving teens an identity and voice for expression.
As one can see, there are several options that are readily available to the public in order for communities to improve the effectiveness of sex education. If directors and educators of sex education programs learn to target the core values and ideas that are important to adolescents, then they will be remarkably successful in getting this specific population to change their unhealthy behaviors. Also, by employing the help of organizations like the Candies Foundation as well as the use of popular celebrities, it is possible to get teenagers to change their behavior, which at the very least entails practicing safer sex methods if not abstinence. The more effective these programs are in motivating and capturing the attention of adolescents, the more likely they will have success in making a difference in their lives.

References
1. Abma JC et al., Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002, Vital and Health Statistics, 2004, Series 23, No. 24.
2. “Facts on American Teen’s Sexual and Reproductive Health.” Guttmacher Institute: Home Page. Jan. 2010. http://www.guttmacher.org/pubs/FB-ATSRH.html#1
3. A League Table of Teenage Births in Rich Nations. United Nations Children’s Fund, 2001. http://www.unicef-irc.org/publications/pdf/repcard3e.pdf
4. National Campaign to Prevent Teen Pregnancy Why it matters: Teen pregnancy and education. (2007). http://www.teenpregnancy.org/
5. Sex Education in the U.S.: Policy and Politics. Kaiser Family Foundation, Oct. 2002. http://www.kff.org/youthhivstds/upload/Sex-Education-in-the-U-S-Policy-and-Politics.pdf
6. Kohler, Pamela K. et al. "Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy." Journal of Adolescent Health 42 (2008): 344-51. http://www.planetwire.org/files.fcgi/7689_Ab_Only_Ed_Kohler_.pdf
7. "Society of Adolescent Health and Medicine." SAHM | Home. http://www.adolescenthealth.org/Overview/2264.htm
8. APHA: American Public Health Association. 03 Dec. 2010. http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1334
9. Harris, Mary Beth, and Jane G. Allgood. "Adolescent Pregnancy Prevention: Choosing an Effective Program That Fits." Children and Youth Services Review 31 (2009): 1314-320.
10. Santelli, J., M. Ott, M. Lyon, J. Rogers, D. Summers, and R. Schleifer. "Abstinence and Abstinence-only Education: A Review of U.S. Policies and Programs." Journal of Adolescent Health38.1 (2006): 72-81.
11. Trenholm, Christopher, et al. Impacts of Four Title V, Section 510 Abstinence Education Programs. Publication. Mathematica Policy Research, Apr. 2007. http://www.mathematica-mpr.com/publications/PDFs/impactabstinence.
12. Rosenstock, Irwin M. "Why People Use Health Services." The Milbank Quarterly 44.3 (1965): 94-127.
13. Thomas, L. "A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education." Journal of Professional Nursing 11.4 (1995): 246-52.
14. Cohn, Lawrence D., Susan Macfarlane, Claudia Yanez, Walter K. Imai, and Et Al. "Risk-perception: Differences between Adolescents and Adults." Health Psychology 14.3 (1995): 217-22.
15. Santrock, John W. "Physical and Cognitive Development in Adolescence." Life-span Development. Boston, MA: McGraw-Hill Higher Education, 2009.
16. Maxwell, Kimberley A. "Friends: The Role of Peer Influence Across Adolescent Risk Behaviors."Journal of Youth and Adolescence 31.4 (2002): 267-77
17. "LifeWay: True Love Waits®." LifeWay | Biblical Solutions for Life. LifeWay Christian Resources of the Southern Baptist Convention, 2001. http://www.lifeway.com/tlw/
18. The Silver Ring Thing. 1995. http://www.silverringthing.com/home.asp
19. DiCenso, Alba. "Interventions to Reduce Unintended Pregnancies among Adolescents: Systematic Review of Randomized Controlled Trials.” Child: Care, Health and Development 28.6 (2002): 533. British Medical Journal. http://www.bmj.com/content/324/7351/1426.full
20. Kohlberg, Lawrence. "The Claim to Moral Adequacy of a Highest Stage of Moral Judgment." The Journal of Philosophy 70.18 (1973): 630-646. http://www.jstor.org/stable/pdfplus/2025030.pdf
21. Hammock, Thomas, and Jack W. Brehm. "The Attractiveness of Choice Alternatives When Freedom to Choose Is Eliminated by a Social Agent1." Journal of Personality 34.4 (1966): 546-54.
22. Dillard, J. P., & Shen, L.. On the nature of reactance and its role in persuasive health communication. Communication Monographs, 72 (2005): 144–168.
23. The Candie's Foundation, 2001. http://www.candiesfoundation.org/index.html
24. Whitaker, D. J., and K. S. Miller. "Parent-Adolescent Discussions about Sex and Condoms: Impact on Peer Influences of Sexual Risk Behavior." Journal of Adolescent Research 15.2 (2000): 251-73.
25. Grier, Sonya, and Carol A. Bryant. "Social Marketing In Public Health." Annual Review of Public Health 26.1 (2005): 319-39. http://www.annualreviews.org/doi/pdf/10.1146/annurev.publhealth.26.021304.144610