Challenging Dogma

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

Friday, April 27, 2007

The Failure of Abstinence Only Education Programs to Utilize Public Health Models and to Take Adolescent Mentality into Account – Gina Nota

The United States healthcare system is arguably one of the most unique in the world. It is natural that a system designed to maintain the health of many people across a wide geographical area with a variety of cultural backgrounds needs occasional reevaluation and change. One difficulty facing the United States today is the large percentage of teen pregnancies and Sexually-transmitted infections (STIs) compared to other industrialized countries (3). In 2001, the Center for Disease Control (CDC) released a document stating that 45.6% of high school students across the nation reported having sexual intercourse at least once (11). Particularly frightening is the increase in HIV infections among adolescents. People under 22 account for 25% of new HIV infections, and this number increases to 50% by age 25 (13). The use of abstinence-only programs in schools across the nation has allowed this ever-increasing problem to persist because it has failed to actually educate students on the prevention of STIs and pregnancy. Abstinence-only education programs have been shown to have little impact on delaying sexual behavior and have caused a greater hesitation and resistance to condoms and other contraceptives (5). Instead of protecting adolescents, the education program is overall detrimental as it fails to use effective public health models and to take into account the inherent difficulties of the adolescent age.
Current Programs and their Public Health Models
There are currently three arrangements for sexuality education across the country: abstinence-centered, ‘inclusive’ education, and, of course, no sex education. Abstinence-centered education focuses on refraining from sexual intercourse as the only way to prevent pregnancy and STIs with minimal, if any, mention of contraceptives (usually only failure rates (11)) or options for terminating a pregnancy (3). In addition, abstinence-centered education includes the beliefs that sexual activity outside of marriage can have a harmful psychological effect and that being in a monogamous, married state is the human sexual norm (14). ‘Inclusive’ education, as its name suggests, not only offers abstinence as a means of prevention, but also informs students of various contraceptives, their uses, and their availability. One study of 825 educational districts across all regions of the U.S. found that 57% of the districts offer abstinence-centered education, 33% have no policy, and only 10% offer a comprehensive sexual education (9). These numbers are staggering and offer insight into the ways in which the American educational system has failed its youth.
The United States government has been funding abstinence-only education programs since 1981. The program was brought into being by the Adolescent Family Life Act, which was meant to “prevent teen pregnancy by establishing family-centered programs to promote chastity and self-discipline,” (6). In recent years , Congress voted to add an additional $50 million to abstinence-only-until-marriage programs through the Maternal and Child Health Bureau of the US Department of Health and Human Services (6). These programs are based on the Health-Belief model and the Advertising Theory Model. The Health-Belief model involves the perceived susceptibility and severity of a risk and suggests that these will influence the intention of the individual and should, therefore, affect his or her behavior (4). However, this model is ineffective for several reasons, not the least of which being that a person’s intentions do not always have a direct effect on changing their behavior. In addition, for teenagers especially, the perceived risk and susceptibility may well be skewed because of their unique time of life and views of what the benefits of certain actions might include. The Advertising Theory Model includes thoughts of benefits, core values, promises, and support, which intend to influence behavior (M. Siegel, SB 721 Lecture, Feb. 1, 2007). In other words, when one is advertising a particular health program or behavior, they should prove that the benefits outweigh the difficulties, that the core values of the program are the same as the core values of society, that the promises that they are making can be realized, and that they will offer support to achieve the goals of the program. The current abstinent-only education programs fall drastically short of both these models.
Why these Models don’t work
The Health-Belief model is the most used and well-known public health model. However, it relies on a rational, adult mentality that weighs risks and benefits in a very specific way. Teenagers do not always think in the same manner as their adult counterparts, nor do they view risks in the same way or see the same things as benefits. Most adolescents do not, as is commonly believed, make irrational decisions (12). Rather, they weigh benefits and risks as opposed to automatically fearing taking risks. Benefits for a teenager may include social prestige, pleasure, or ‘fun’, and would rarely include long-term consequences (12). There are also those who participate in risky behavior spontaneously and without any consideration of risk and benefits (12). For these adolescents, most educational programs and public health theories will prove ineffective since most of their actions are not governed by reasoned thought (12). Because of the worth that adolescents place on benefits it is rare that a public health program will be able to convince them that a risk far outweighs the conceived benefits, particularly when the risks include treatable diseases, bacterial STIs, and pregnancy, and the benefits include social status and pleasure. Invoking HIV as a serious risk may work for some students, but current treatments allow HIV infected individuals to live full lives for up to two decades and therefore can easily be considered a “long-term consequence” that tends to be forgotten. For these reasons, it is practical to suspect that adolescents will engage in sexual behavior and will take risks if they are not given information on how to protect themselves. In addition, the final step of the Health-Belief Model shows that behavior is a result of intention. However, this is not always the case. Some abstinence-only programs have students sign cards pledging an abstinent lifestyle until marriage (11), a clear indication of intended behavior. The data shows that most students do engage in sexual activity before marriage, which would seem to negate the theory of intention being indicative of future behavior.
The failure of the Advertising Theory Model in this case is obvious. It has already been established that the benefits of maintaining abstinence until marriage do not outweigh the ‘benefits’ of engaging in pre-marital sexual behavior for most adolescents. In addition, the core values of the abstinence-only programs do not reflect that of our society, which is rife with sexuality in pictures, movies, music, etc. As a result, students may not think it feasible or practical to maintain an abstinent lifestyle, which tends to undermine the ‘promise’ that abstinence will help one lead a better, fuller life. Finally, it is difficult to determine what levels of support educators could offer students to help them remain abstinent.
Kirby et. al., in a study of the effectiveness of various sex education programs, showed that the programs most effective at delaying the onset of intercourse, increasing condom use, and reducing risky sexual behaviors had six common characteristics (7). Of these six, two are missing from abstinence-only programs: 1) reinforcement of age appropriate values and group norms against unprotected sex and 2) activities meant to increase relevant skills for contraceptive use and avoidance of peer pressure and confidence in said skills (7).
Models that should have been considered
There are more effective public health models that should have been used when creating a sex education program for adolescents. These include the Social Cognitive Theory, the Theory of Reasoned Action, and the Social Learning Theory. Any program considering these three theories in addition to the Health-Belief Model’s emphasis on perceived risks would, in all likelihood, be the most comprehensive and effective.
Two of the above theories address adolescents’ interaction with society. The Theory of Reasoned Action considers a person’s attitudes towards a behavior and the perceived societal norms for that behavior and states that these factors will influence one’s intentions and behavior (1). The Social Learning Theory states that what behavior an individual sees modeled will affect their own behavior (2). It is unlikely, or even impossible, for any individual to grow up in a sexless community where people, including parents, peers, and educators, are practicing abstinence. In fact, most evaluations of state sex education programs have shown that parents want more comprehensive education for their children. Up to 85% reported that they wanted schools to teach their children about condom use, 84% wished for their children to learn more about other forms of birth control, and 88% wanted schools to teach students how to communicate effectively with their partners (6). Students also wish to be made more aware of the issues at hand: in students between 7th and 12th grades, 45% want to know what actions to take in case of rape or sexual assault, 46% want to know how to deal with the emotional consequences of sexual activity and how to have open discussions with their partner, and 40% want to know how and where to get birth control (6). It must be noted that the number of students reported may well be on the low end of the spectrum because students may hesitate to tell educators about their sexual curiosity. Even so, these numbers indicate that it is likely that there is no model for abstinence in most adolescents’ lives, and that there is no perceivable norm for abstinence for students to turn into their own intentions and behaviors. These two models show, therefore, that abstinence only education has some gaping holes in theoretical efficacy (and that the theory extends into real life practice).
The Social Cognitive Theory is another model that should have also been taken into consideration. This theory indicates that the primary driving force behind a behavior is “self efficacy,” that is, how easy or feasible a person believes it is to practice that behavior (2). For teens who are already sexually active, their perception of self-efficacy in maintaining an abstinent lifestyle is null and void. Abstinence-only education programs ignore the questions these students are facing and their needs (13). In addition, it must be taken into account that there is no evidence that abstinence only education is at all effective, and that this fact is well known (6). If students are being taught using a method that science has deemed fairly ineffective and that the majority of their parents are against, it is doubtful that they will think the goals of the program are feasible. Finally, it has already been shown that there is probably a lack of effectively abstinent role models in most students’ lives. Without someone to demonstrate that it is possible to maintain such a lifestyle, it is unlikely that students will believe it to be possible.
The Life and Times of Adolescents
Teenagers are at a unique and difficult point in their lives in which they face tremendous emotional upheaval; students may be more likely to engage in risky behaviors, particularly those that authorities have warned them to avoid. What they may need is an education program that gives them the tools to protect themselves instead of ignorance. In Finland, a study showed that an increase in sexual partners and the non-use of contraceptives were both linked to self-reported depression (8). Adolescents in Finland are likely to be similar to adolescents in America, where children ages 10-14 have suicide rates of 1.3 per 100,000 and adolescents ages 15-19 have suicide rates of 8.2 per 100,000 (7). If the use of contraceptives is already hindered by the feelings of depression, then a lack of knowledge on how to effectively use them and their benefits can only further hinder their use. Ironically, while federal reports indicate that sex outside of marriage can have negative psychological effects there are no scientific data to indicate that sex between consenting adolescents is harmful, but there is a possibility that certain mental health problems cause early sexual activity (13).
The adolescent years are also a time of change and growth of adolescents’ sexual feelings (7). These feelings can be intensely pleasing and intimate or intensely disturbing in cases of exploitation and guilt. In either case these feelings and the consequences of their actions, such as STIs and pregnancy, can have immediate and long-term effects on their lives (7). Teenagers who become mothers are more likely to suffer negative social experiences and poorer health (14). This shows without a doubt that effective education programs that meet the needs of adolescents of various ages and experience levels must be established immediately in order to ensure their social, mental, and physical health.
With HIV/AIDS at epidemic proportions in the U.S. and adolescents contributing largely to the increase, it is clear that current sexual education programs offered in schools is inadequate. Laurie Zabin, a researcher and professor at Johns Hopkins School of Public Health, noted that “there is not a single scientific study that demonstrates that abstinence- only programs have done anything to cut down on teen sexual activity.” Instead, she says, “all the evidence points to the fact that programs that are comprehensive in their coverage, interactive and nondidactic in their approach, and that provide access to services not only reduce teen pregnancy, but also contribute to abstinence or at least wiser sex behavior” (11). Truly comprehensive programs begin early, even before adolescence, and give age-appropriate lessons about self-esteem, the reproductive system, healthy relationships, contraceptive use, and also abstinence (11). The more thorough and educational a program is, it becomes more likely that students will have the tools they will need when making complex decisions in their futures. To be most effective, such programs should be designed using several different public health models and theories in conjunction. Theories that might be considered ought to include self-efficacy, such as the Social Cognitive Theory; role models, as in the Social Learning Theory; attitudes and perceived norms, such as are used in the Theory of Reasoned Action; and perceived susceptibility and the severity of consequences as seen in the popular Health-Belief Model. A major step that should also be taken into consideration is moving sex education programs into other aspects of students’ lives: after school programs, the media in music and television, religious education, etc. These are all key aspects of a student’s life that affect how they think and make decisions. Further research should also be done on the effectiveness of peer-education programs in which college aged or sometimes older adolescents come into classrooms to teach sex education, and peer mentoring programs such as Big Brother and Big Sister. These peer interaction programs may reduce the influence of peer pressure on students while also decreasing their desire to rebel against “authority.” These steps and others must be taken to decrease HIV infections in teens, to combat the culture of ignorance and poor health being fostered by poor education, and to secure a future of health and prosperity through the adolescents of today.
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11. Pardini, P. (2002). Abstinence-Only Education Continues to Flourish: If half of U.S. teens are sexually active, why aren't we giving them the full story on contraception and STD prevention? Rethinking Schools Online.
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14. Wiley, D. (2002). The ethics of abstinence-only and abstinence-plus sexuality education. Journal of School Health, vol.72, 164-167.

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