Challenging Dogma


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

Sunday, April 22, 2007

Abstinence-Only Programs: Failure to Consider Self-Esteem and the Possibility of Sex Lead to No Decrease in Sexual Activity-Nicole Prestiano

INTRODUCTION
Abstinence-only education (AOE) programs are an ineffective way to reduce adolescent pregnancy rates and rates of sexually transmitted diseases (STDs). Programs that teach abstinence-only rely on the health belief model which, when applied to abstinence programs, relies on the idea that an adolescent will look at his or her perceived susceptibility to becoming pregnant or contracting an STD and the perceived severity of these conditions and will weigh them against the barriers to staying abstinent and the perceived benefits of abstinence. This weighing leads to intention of staying abstinent and ultimately, abstinence (6).

This model is unrealistic in that there are many other factors that influence an adolescent’s decision to become sexually active, and this decision may not be a rational one at all. Many adolescents “choose” to become sexually active because they are looking for something. Oftentimes something is missing from their home or social life that causes them to have low self-esteem and seek out “love” and attention. This may result in an irrational decision to become sexually active to fill this void. Therefore a rationally based model to deter adolescents from sexual activity would be ineffective. Furthermore, abstinence-only education also fails adolescents that are already sexually active at the onset of abstinence-only education and leaves them without the knowledge or tools to practice safer sex. Lastly, youths may feel as though complete abstinence is unattainable and therefore may not try to abstain at all. This is based on the self-efficacy theory in that people are more willing to adopt a certain behavior if they feel that that behavior is attainable. Adolescents will put less effort into staying abstinent because they feel that ultimately they will not be able to stay abstinent until marriage (5)

BACKGROUND
In the United States 800,000 adolescents become pregnant each year, 80% of these pregnancies unintended. Furthermore, more than half of the estimated 19 million STDs contracted in the United States each year occur in adolescents and young adults under the age of 25. Abstinence-only education is a publicly supported intervention aimed at reducing these rates. While a concrete definition of abstinence does not exist, the goal of abstinence-only education is to delay sexual intercourse until marriage. Federally mandated abstinence-only education programs in the United States define abstinence in a moral and culturally specific way. Federally funded programs that teach abstinence require that abstinence education “teaches that a mutually faithful monogamous relationship in context of marriage is expected standard of human sexual activity.” Another important clarification is that while advocates of abstinence only education programs are usually concerned with issues such as character or morality, often based on religion or moral beliefs, health professionals view abstinence as a behavioral decision that is associated with health (5).

SELF-ESTEEM AND SEXUAL BEHAVIOR
Abstinence-only programs often overlook the real reason why teens are getting pregnant. A study by the American Journal of Maternal and Child Nursing looked at teen perspectives on adolescent pregnancy and prevention. When asked to list the top four reasons why teens became pregnant, the need for somebody to love, to be close to, to be wanted or needed and to get attention because it is “cool to be pregnant,” made the list, along with denial of risks and lack of responsibility. The pregnancy prevention programs that most teens thought would work best-addressed issues such as the emotional aspects that are associated with sexual behavior. They were also interested in programs that increased peer and parent-child communication on sexual issues (1).

AOE programs do not address the adolescent experience and focus on individual choices. There are environmental pressures and stresses on teens that affect their “choice” to be come sexually active. Programs that aim to reduce teenage pregnancy rates and STD infections need to address these issues on the community level, not just individual level. They also need to help teens to deal with these social pressures and their own personal self-esteem issues while giving them the knowledge and tools necessary to prevent pregnancy or infection if they do become sexually active.

Trends are important in the rates of teen pregnancy. Social and environmental factors including poverty and social disorganization – not having a stable residence, put a teen at higher risk of becoming pregnant. Teens with divorced parents or who have poor parental support and parents who have lower expectations for them also are more likely to be sexually active (2). This is because teens with poor home lives tend to have a lower amount of self-esteem. Adolescents who do not feel loved at home may go out looking for it elsewhere, often resulting in sexual behavior. They may feel that becoming sexually active will fill the void inside of them. They may also feel that they are not worth waiting for and therefore may give into the pressures of having sex in order to keep their partner. AOE programs often fail to address these issues and look at the decision to be come sexually active as an individual one. If these issues of self-esteem are not addressed adolescents will not only continue to become sexually active, but also will practice unsafe sexual behaviors because of a lack of self-worth.

UNPREPARED WHEN SEXUALLY ACTIVE
While abstinence-only education has been described as the only way to fully protect against pregnancy and STD’s, in practice this intervention offers little protection (5). Many teens fail to remain abstinent because most of the issues for why teens ultimately choose to become sexually active are not addressed in AOE. Merely being told to remain abstinent or taking vow to stay abstinent does not affect an adolescent’s issue with self-esteem and self worth. It is ultimately this lack of self-esteem that often affects decisions to become sexually active. It is the lack of self-worth that is associated with risky sexual behaviors. Data suggests that when teens that have been given abstinence-only education do become sexually active they often fail to protect themselves through the use of contraception. The reason for this is two-fold. First, when adolescents have a low sense of self worth they may not feel that taking the extra steps required to protect themselves would be necessary because they are not concerned with their own well-being. Furthermore, there is a lack of comprehensive sexual education, which would stress the importance of condoms and birth control in AOE, and therefore teens that would otherwise protect themselves would be left without the tools.

Abstinence only-programs also ignore adolescents who are already sexually active at the beginning of intervention. This group of teenagers needs to know the facts about sexual health and the availability and use of condoms and contraceptives. They also need to know how to access reproductive health services (3). Teens that are already sexually active may also have issues associated with self-esteem and self-worth that affect their decision to remain sexually active and/or practice risky behaviors. AOE education fails these teens because they do not addresses these adolescents own self-esteem issues and the complicated emotions associated with being sexually active. Furthermore AOE may add to risky behavior because a sexually active teen that is in AOE may feel like a failure for becoming sexually active, further reducing their self-esteem.

AOE AND THE GAY/LESBIAN/QUESTIONING COMMUNITY
Abstinence-only education can have extremely negative impacts on homosexual adolescents. It is estimated that 2.5% of high-school students identify themselves as gay, lesbian or bisexual. Abstinence-only education fails these youths in a number of ways. First, one in ten adolescents struggle with issues of sexual identity. This struggle becomes even more difficult when teens are told that their sexual preferences and feelings are immoral and unnatural. This may add to the occurrence of self-esteem issues and risky sexual behavior. Furthermore, the prevalence of HIV is extremely high in the gay community. Not promoting the need for condom use and emphasizing the risk of STD’s could do the homosexual adolescent community a huge disservice and leave a large proportion of them at risk (5).

A third reason how abstinence-only education negatively affects homosexual adolescents has to do with the concept of self-efficacy. If a person does not feel that a certain behavior is attainable, they may not try all-together (7). Most abstinence-only education programs teach that a person should abstain from sexual activity until marriage. For the gay and lesbian community marriage is often not an option. Furthermore the religious idea of the union of marriage is commonly employed. The gay and lesbian communities often feel rejected by the church. In addition, if a homosexual adolescent feels that the union of marriage is unattainable they may feel that there is no way they could abstain from sexual activity forever, and are likely not to try at all.

THE IMPORTANCE OF FRAMING
The way to solve a problem is determined by how the problem is framed. Proponents of AOE feel that the problem is that teens are having sex. Therefore, in their minds, an abstinence-only model would be effective because the only issue to deal with is the “choice” to have sex. People that feel that underage sexual activity is the major problem would be opposed to looking at strategies to prevent early pregnancy or sexually transmitted diseases such as birth control and condom use. They would feel that allowing such interventions would involve first admitting that these activities are acceptable, which is against their moral beliefs. If one feels that underage pregnancy and STDs are the problem then interventions that include birth control, condom use and possibly some abstinence counseling would be appropriate. Others feel that teenage parenthood that should be addressed and these interventions would include the ones listed above and possibly abortion services. Intervention strategies come from how the issue is framed (2).

A more correct framework would suggest that adolescent issues with self-esteem, self-worth and self-confidence are the real problems and issues such are teenage sex and risky sexual behaviors are associated with these underlying self-esteem issues. The only way to really solve the problem from this framework would be to work on building self-esteem and self-confidence in adolescents. It would also focus on the social pressures on teens to become sexually active and the environmental factors such as poor home lives that are associated with low self-esteem. AOE that deals with an individual choice to become sexually active would likely fail because oftentimes this “choice” is not an individual level choice and many outside pressures come into play. Even programs that frame the issue around contraception availability and use and those that address teenage parenthood issues will likely fail because underlying issues of self-esteem are not addressed.

WHERE TO GO FROM HERE
It may not be easy to convince those that believe that teenage sex is the only problem that intervention programs must first focus on self-esteem issues and then on pregnancy prevention and STD control. However, the truth of the matter is that the interventions that reach the most people are federally funded. Sexual education that addresses both the real reason why teens become sexually active and the tools necessary to prevent pregnancy and STDs once one is sexually active have the potential to reach millions of American youth when put into schools. Furthermore, if family planning organizations received more funding they would be able to offer more services and be more widespread (4). Evidence already exists that abstinence-only programs are not very effective on delaying sexual activity. Furthermore, even when sexual activity is delayed, it is rarely delayed until marriage. This means that adolescents are becoming sexually active and lack the tools necessary to practice safer sex, such as condom and birth control use (3). This evidence must be used to re-frame the issue from teenage sexual activity to emotional issues associated with sexual activity along with teenage pregnancy and contraction of STD’s. An effort should also be made to include adolescent perspectives on pregnancy and STD prevention when structuring an intervention.

REFERENCES
1. Aquilino, M et al. Adolescent Pregnancy: Teen Perspectives on Prevention. The American Journal of Maternal/Child Nursing July/August 2000; 25(4):192-197.
2. Card, J. Teen Pregnancy Prevention: Do Any Programs Work? Annual Review of Public Health May 1999; 20: 257-285.
3. Eisen, M et al. Evaluating the Impact of a Theory-Based Sexuality and Contraceptive Education Program. Family Planning Perspectives Nov-Dec 1900; 22(6): 231-271.
4. Hwang, A. et al. Family Planning in the Balance. American Journal of Public Health January 2004; 91(1):15-18.
5. 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.
6. Wikipedia Health Belief Model.
7. Wikipedia Self-efficacy.

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