Challenging Dogma


...Using social sciences to improve the practice of public health

Thursday, April 19, 2007

Abstinence Only Education: The Idealistic Oblivious and The Realistic Obvious- Sarah J. Betstadt

“Is There an Unconscious Conspiracy Against Teenagers in the United States?” Victor Strasburger wonders, in a thought provoking commentary in the journal, Clinical Pediatrics (1). He mentions several aspects of adolescent life that are often criticized, yet ineffective interventions exist to change these behaviors. An example of just such a “conspiracy” is abstinence-only education. Abstinence-only education is the only type of education publicly funded in schools. However, as Strasburger points out, the average American teenager sees more than 14,000 sexual references on TV each year. More than 75% of primetime shows contain sexual content, yet only 14% of the sexual references mention risks or responsibilities (1). Although popular culture bombards US adolescents with sexuality, they are shielded from basic information on how to protect themselves from the highest rates of unplanned pregnancy, HIV and sexually transmitted infections (STIs).

US Teenagers are Having Sex and Participating in Other Risky Behaviors
According to the Alan Guttmacher Institute, the US has one of the highest teen pregnancy rates in the developed world: twice that of England, Wales and Canada, and almost eight times that of the Netherlands and Japan (2). Almost nine million new STIs occurred in teen and young adult populations, much higher than our European counterparts. Although US levels of teen sexual activity are similar to those in Europe, Americans are more likely to have shorter relationships and are less likely to use contraceptives (2). Furthermore, estimates suggest that 50% of new HIV infections occur among people younger than 25years, with 25% of infections occurring among adolescents aged 22 years or younger (3).

Sexual activity is not limited to intercourse alone. Risky sexual behaviors such as mutual masturbation and oral sex may also expose adolescents to STIs and HIV. Although some adolescents may make “virginity pledges” they may still be participating in other sexual behaviors. To these adolescents, virginity is defined as never having had vaginal intercourse (4). Adolescents who have made virginity pledges demonstrated a delayed sexual debut (on average 18months) but reported lower frequency of condom use at first intercourse. Pledgers were also more likely to substitute oral and/or anal sex for vaginal sex, and had the same rates of STIs as nonpledgers (4).

A study done in an urban LA county high school, grades 9-12, in April of 1992 revealed that 47% of the students were virgins, and virginity declined with grade (from 63% for 9th grade to 34% of 12th grade) (5). The same study reported that 35% of virgins had engaged in one or more genital sexual activities: 29% of virgins had engaged in masturbation of a partner of the opposite gender, and 31% had been masturbated by a partner of the opposite gender. Ten percent had engaged in heterosexual cunnilingus, 9% had engaged in heterosexual fellatio with ejaculation, and 1% had engaged in heterosexual anal intercourse. Among virgins who had engaged in fellatio with ejaculation, only 6% had used a condom every time and 86% had never used a condom (5). High school students may have defined themselves as abstinent, but clearly they could benefit from comprehensive sexual education that would protect them from contracting STIs due to their risky sexual behaviors.

The Ineffectiveness of the Federal Abstinence Only Sex Education Plan
There are three federal funding sources for abstinence only education: the Adolescent and Family Life Act (AFLA), Section 510 of the Welfare Reform Act in 1996, and Community Based Abstinence Education through Special Programs of Regional and National Significance (SPRANS) (6). These government funded programs must fulfill eight specific criteria. Programs must:
1. As its exclusive purpose, teach the social, psychological, and health gains to be realized by abstaining from sexual activity;
2. Teach abstinence from sexual activity outside marriage as the expected standard for all school-age children;
3. Teach that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, STDs, and other associated health problems;
4. Teach that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexuality;
5. Teach that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects;
6. Teach that bearing children out of wedlock is likely to have harmful consequences for the child, the child’s parents and society;
7. Teach young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and
8. Teach the importance of attaining self-sufficiency before engaging in sexual activity.

Implementation of federally funded programs precludes mentioning contraception and other forms of birth control or protection, unless it is to mention specific contraceptive limitations (6). Currently there are no nationally funded comprehensive sexual education programs that include education about contraception and STI prevention in addition to abstinence. During the Bush administration, funding for SPRANS programs, which must explicitly teach all eight of the abstinence-only criteria, increased from $20million dollars in fiscal year 2001 to $104million dollars in fiscal year 2004 (6).

Funding for abstinence-only education began in 1981, but these eight points are not likely to benefit teens that are already sexually active. The federal abstinence-only program equates sex with the institution of marriage. In 2002 a woman’s median age for first intercourse was 17.4 years while her median age at first marriage was 25.3 years. In the same study, a man’s median age at first intercourse was 17.4 years and his median age at first marriage was a 27.1 years (7). There is a much smaller time difference in the median ages of first intercourse and marriage reported in the 1970s. How can the federal government believe that an intervention of waiting to have sex until marriage will work when the evidence shows that young adults are not waiting until they get married to have sex? This intervention then, does nothing at all to teach sexually active young people to protect themselves from unplanned pregnancy and STIs.

The federal funding for abstinence-only education attempts to utilize The Theory of Planned Behavior (8). This theory states that attitudes about a behavior, in conjunction with perceived societal norms and self-efficacy, or the belief that an individual has the ability to change, determine behaviors. The abstinence-only program is a failed intervention because teens in the United States do not perceive the social norm that sex and sexuality is in the context of marriage. Even the media promotes sex outside of a monogamous construct! As exhibited by the statistics on teen pregnancy and STIs, certainly teen attitudes about sexual behavior are NOT to wait until marriage. Whether or not teens have self-efficacy, the abstinence-only federal plan is a failed intervention because US teens do not have the same perceived norms or behavioral attitudes that the model is based on.

Understanding the Initiation of Adolescent Sexual Behavior
While the abstinence-only sex education model preaches the benefits of waiting for marriage for sexual activity, it does nothing to examine (other than mention that drugs and alcohol may increase vulnerability) the reasons that adolescents are sexually active. Neither does this model provide tools for already sexually active adolescents to protect themselves.

Buhi et al. examined sixty-nine published studies (from 1996-2005) that attempted to determine the factors that predicted/explained adolescent’s sexual behaviors and intentions (9). Buhi et al. used the eight factors from a consensus from the National Institute of Mental Health (NIMH) to categorize variables that might function as primary determinants of any given health behavior. These eight determinants are: intention (or commitment to performing a behavior), absence of environmental constraints, necessary skills, a positive attitude toward performing the behavior, social normative pressure to act, consistency between the behavior and the person’s self-image, positive emotional reactions to the behavior, and confidence in the performing the behavior under different circumstances. NIMH postulate that these factors “determine” whether a given individual will engage in a specific health-related action. Variables from each study reviewed by Buhi et al. were categorized under one of these eight determinants.

The three most “stable” predictors of sexual activity in the studies included in this review were intention, perceived norms, and an environmental constraint variable- time home alone (9). Teenagers perceived norms are most likely to come from their peers’ sex behaviors and attitudes, as well as parental attitudes towards sex. We know that teenagers in the US are sexually active and thus peer behaviors are likely to demonstrate this. Also time home alone with the opposite sex (or being home alone without a parent) was associated with increased sexual activity and early initiation of intercourse. Public health interventions should then focus on these factors that may cause initiation of adolescent sexual activity, not abstinence-only education. An intervention may focus on increasing after school programs for teens that would otherwise be unsupervised, or changing what adolescents think are the societal norms for sexual behavior.

The abstinence-only education plan also fails because it does not consider basic physiology. Adolescents are going through puberty and physiologically are preparing themselves for sexual behavior and procreation. We can illustrate this physiologic need for sexual behavior by Maslow’s Hierarchy of Needs (10). The theory proposes that basic physiologic needs, including food, water and sex need to be fulfilled before a person can move to higher levels of existence, such as self-esteem and morality. Therefore, it would seem that sexual behavior is a part of the maturation process. It is a societal responsibility, then, to provide adolescents with the tools to keep them safe through this time of exploration. Maslow posits that sexual behavior is a part of the foundation for a higher mentality. In many ways, the relationships and experiences that teenagers have allow them to move to higher levels of maturity.

Innovative and Effective Interventions
According to the Alan Guttmacher institute, only 35 states have laws mandating sex education or HIV/AIDS education. These laws are usually general and thus many policies are made at the local level. Perhaps a national plan for more comprehensive sex education, which would include information on contraception, STI prevention as well as abstinence, would be more effective at addressing our dilemma of unsafe adolescent sexual activity. The government in the United Kingdom implemented a national campaign in 1998-1999 to address the problem of teenage pregnancy. This campaign had four major components: a national media awareness campaign, coordination of national and local agencies to promote the campaign, better prevention of teenage pregnancy through improvements in sex education and access to health services, and finally a program for teenage parents to return to education, training or employment (11).

Pre- and post-intervention data showed that the under age 18 conception rate fell by 2% between 1998 and 2003 (95% CI 1.8-2.2). Although this is a modest decrease, the largest change in the number of conceptions was greater in deprived and more rural areas, likely the areas that would benefit most from this intervention (11). In this case, the Agenda Setting Theory proved to be effective for this intervention (12). A national campaign promoted on television in the United States would definitely get attention from adolescents but would also likely involve parents. The US is a society that is heavily influenced by the media yet we seldom see a condom commercial or reproductive health service announcement, other than late at night. Discussion of sexuality is stigmatized in the US and perhaps parents are unaware of the statistics of adolescent sexual behavior. Pre-test data from parents attending an adolescent sexual activity workshop showed that many adults themselves have incorrect information about risks of STIs and pregnancy, especially among teenagers (13). A United States national media campaign could be used to educate adolescents on safe sex or contraception or inform adults of the magnitude of teenage sexual activity. This has been proven effective in other countries such as the UK.

Perhaps the best place for sex education to occur is not in a public place such as the classroom. Adolescents may be afraid to ask questions because of embarrassment or feeling different from their peers. An internet site for sex education was developed in China to assess changes in attitudes, knowledge and behavior after viewing the materials in the website during a ten month time period (14). The website included pages on reproductive health and sex knowledge, ten minute educational videos, information on where to access reproductive health care, ways to email health professionals, and a place where young people could post questions for their peers. Compared to the control group that did not have access to this website, the intervention group had higher median scores of overall knowledge significantly different from the control group, although the baseline scores were not significantly different (14).

In our increasingly technological society, teens may be very receptive to an internet educational tool. They could get answers to sexual questions privately as well as locate reproductive health services. The US government should certainly stop spending money on a program that promotes abstinence until marriage, when data shows that most adolescents are already sexually active by the time they leave high school. This money may be better spent on a media campaign proclaiming the dangers of unprotected sexual behavior or a media campaign directing adolescents to a web site.

Conclusion
Adolescents in the United States are already sexually active yet the government continues to fund only educational programs that encourage them to wait until marriage. Clearly teenagers, who are heavily influenced by peer behavior, are not going to feel that this is a realistic behavior. Instead, they need tools to prevent unplanned pregnancy and prevent STIs and HIV. While the media continues to display irresponsible sexual behavior, it is underutilized to promote a discussion in our society of what adolescent sexual behavior is taking place and what can be done to make it safe. Ideally, as our government suggests, adolescents would delay sexual activity until they have the means to deal with the consequences. Realistically, adolescents are sexually active now and unless they are provided with the knowledge and resources to manage their choices, society will continue to deal with the unfortunate repercussions.

References
1. Strasburger V. Is There an Unconscious Conspiracy Against Teenagers in the United States? Clinical Pediatrics. 2006; 45: 714-717.
2. Allan Guttmacher Institute. Facts on Sex education in the United States. Washington, DC: Allan Guttmacher Institute. http://www.guttmacher.org/pubs/fb_sexEd2006.html.
3. Santelli J. et al. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health. 2006; 38: 72-81.
4. Bleakley A. et al. Public Opinion on Sex Education in US Schools. Arch Pediatric and Adolescent Medicine. 2006; 160: 1151-1156.
5. Schuster M. et al. The Sexual Practices of Adolescent Virgins: Genital Sexual Activities of High School Students Who Have Never Had Vaginal Intercourse. American Journal of Public Health. 1996; 86: 1570-1576.
6. Bleakley A. et al. ibid.
7. Santelli J. et al. ibid.
8. SB721 Class Website. Theory of Planned Behavior (http://en.wikipedia.org/wiki/Theory_of_planned_behavior).
9. Buhi E. et al. Predictors of Adolescent Sexual Behavior and Intention: A Theory-Guided Systematic Review. Journal of Adolescent Health. 2007; 40: 4-21.
10. SB721 Class Website. Maslow's Hierarchy of Needs (http://en.wikipedia.org/wiki/Maslow).
11. Wilkinson P. et al. Teenage conceptions, abortion and births in England, 1994-2003, and the national teenage pregnancy strategy. The Lancet. 2006; 368: 1879-1886.
12. SB 721 Class Website. Agenda-Setting Theory (http://en.wikipedia.org/wiki/Agenda-setting_theory).
13. Sulak P et al. Analysis of knowledge and attitudes of adult groups before and after attending an educational presentation regarding adolescent sexual activity. American Journal of Obstetrics and Gynecology. 2005; 193: 1945-1954.
14. Lou C-h. et al. Can the Internet Be Used Effectively to Provide Sex Education to Young People from China? Journal of Adolescent Health. 2006; 39: 720-728.

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