Challenging Dogma


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

Monday, April 30, 2007

Let's Talk About Sex, Baby; Why Abstinence-Only Education is Failing America's Youth – Stephanie Trilling

Generations of children have gazed trustingly into their parents eyes, timidly asking the same question, "Mommy, where do babies come from?" And just as many generations of parents have been caught off guard only to sheepishly cough up a variety of ridiculous explanations. Frantic parents have come up with stories ranging from a giant flying bird that drops pink and blue wrapped babies down chimneys to the most anatomically correct medical definitions they could possibly muster. And why shouldn't parents feel uneasy when answering their innocent progeny's questions? Sexual intercourse does not only answer where babies come from, it is also answers scarier questions like, "Where do genital herpes come from?" Higher risk of teen pregnancy, abortion, and sexually transmitted infections (STIs) are only a few examples of what teenagers are up against once they start having sex. Sexual intercourse can also put people at risk for complex emotional, spiritual, and mental health consequences. Adults agree that something needs to be done, but a staunch dispute has been brewing in this country for quite some time about what the appropriate method should be.

The Debate. Typically, parents today fall into two camps, “tell ‘em how to be safe,” and “don’t give ‘em any ideas!” One hundred years ago, before the "sexual revolution," American society repressed any discussion of sexual health. Sex was something a woman found out about on her wedding night and was never to be discussed before or after for fear of offending her virginal ears with such vulgarity. Men, just as today, had a little more of an unspoken flexibility, but such things would never be revealed in a company of mixed gender. Whether it was the invention of oral contraceptives or the financial independence women gained after WWII (1), the US slowly began ridding itself of the "sex taboo". Now, as we proceed further into the new Millennium, there has been a noticeable shift in ideology, backed up by government funding, pertaining to the best way to keep kids safe from the risks associated with sexual activity. There was a time not so long ago when it was not only tolerable to teach about condoms and contraceptives, but encouraged! Now abstinence-only education reigns supreme and is the only acceptable form of sex education allowed in our nation's public schools. This paper aims at critiquing the model that this current change in educational policy and funding is based on by exploring theories from adolescent psychology as well as arguing for comprehensive sex education to be taught once again in our public schools.

The Policy. Since the turn of the century, over a billion dollars have been spent on abstinence-only programs. In 2006 the federal budget allotted $215 million dollars to abstinence-only education, jumping 15% from the year before and more than doubling the amount spent in 2001. In 1996, Title V of the Social Security Act redefined definitions of abstinence-only programming. Title V is made up of an 8-point plan for programs, teaching themes to adolescents such as sex is only acceptable within marriage and that children born out of wedlock are harmful to society (2). Title V annually receives $87.5 million from the government in funding. For every four dollars the federal government spends the states match it with three dollars. Almost every state accepts money from Title V, which means they must comply with the 8-point definition of abstinence-only education laid out in the legislature. Another federal program, Community Based Abstinence Education, spends $115 million a year on programs that adhere to Title V's 8-points. According to the SEICUS webpage under Title V, "…the discussion of abortion and contraceptive instruction are explicitly prohibited. However, the guidelines encourage teaching failure rates for contraceptives and emphasizing the inherent differences between men and women…" (3). The rest of the money spent yearly is allocated through other legislature like the Adolescent Family Life Plan, which receives $13 million dollars and whose effectiveness has never been substantiated (3).

The Reality. Teenagers have sex and teenagers get pregnant. According to a study on teenage sexuality and contraception one out of every three girls in America have had sex by the age of 16 and by 18 it's two out of every three (4). Approximately 750,000 women between the ages of 15-19 still become pregnant each year. While teen pregnancy is down by almost 30% since 1990, the United States continues to lag behind the rest of the western world. According to the Alan Guttmacher Institute, a sexually active teen that does not use contraception has a 90 percent chance of pregnancy within one year (5).

"Despite years of evaluation in this area, there is no evidence to date that abstinence-only education delays teen sexual activity. Moreover, recent research shows that abstinence-only strategies may deter contraceptive use among sexually active teens, increasing their risk of unintended pregnancy and STIs." (6).

Conservative politics are determining health education policy in this country by controlling federal money. Unfortunately the politics of this matter don’t seem to be concerned with effectiveness. SEICUS, the Sexuality Information and Education Council of the United States, supports “abstinence-based” education which places messages about abstinence in a context and allows for more comprehensive education to be covered as well. SEICUS “does not believe that fear-based, abstinence-only programs will achieve their goals.” SEICUS points to studies such as one done a failed abstinence-only program in California to back up its position. According to SEICUS, five million dollars were spent on an abstinence-only program in CA only to find an increase in the number of young people who engaged in sexual intercourse after completing the program (7).


The Reasons.
Abstinence-only education is a public health program that aims at reducing sexual health related risks by giving all public school students one message; sex is only appropriate within a marriage. The underlying assumption is that individuals make rational decisions about their sexual health. The thought process the proponents of abstinence-only education aim students to have is, “If I have sex outside of marriage I could end up pregnant or with an STI.” These scenarios, or the “perceived severity” of risks, must weigh greater on the decision-maker than the “perceived benefit” of sexual intercourse prior to or outside of marriage. Abstinence-only education creates a very high perceived susceptibility to these risks in the hopes of changing students' intentions so that they will wait until marriage for sex. This is a perfect example of the Health Belief Model (HBM). The HBM is one of the most popular models used in the field of public health today. The main critique of the model is that intention (ie: wanting to wait until marriage) doesn't always indicate behavior (8). Other things may impact a teenager’s decision on sexual intercourse, such as self-efficacy, or believing they are capable of behaving in this manner. The Social Cognitive Theory, envisioned by psychologist Albert Bandura, is another traditional behavior model used in planning public health interventions (9). While still rooted in rational thought and individual intention, it provides a more realistic approach for a public health intervention, particularly one aimed at teenagers. If teenagers were educated on methods that seem more “doable” they would have more of a chance of modifying risky behavior. Comprehensive sex education allows more options for adolescents who may not consider abstaining until marriage a realistic goal.

The Sex and the City Era:
Many adolescents don’t see abstinence as a reasonable possibility as they are products of today’s society. Turn on the TV and chances are you'll get a glimpse of our sex-crazed society within moments. Popular television series like Sex and the City, Dawson's Creek, even Will and Grace, jumble the messages that teenagers are getting at school or from their parents about acceptable sexual behavior. Teenage boys and girls are getting mixed messages about what is acceptable sexual behavior. Girls read articles from magazines like Cosmo about how to best please your man, and boys read Maxim, which is known for its scantily clad models, showcasing women as sexual objects. Choi, who critiqued the Health Belief Model as it applied to Asian and Pacific Islander American men who have sex with men, claimed that the HBM "ignores the wider social context within which an individual may be a member," (10). All of the power of decision-making is left up to the individual in this model, which can be difficult for adolescents who are particularly susceptible to pressures from their peers and the rest of the outside world to "fit in" and do what everyone else is doing. According to the Social Learning Theory, yet another public health model fashioned by Bandura, purports that humans model what they see others in their social network doing. In his famous “Bobo Doll Experiment”, Bandura found that young children were much more likely to create violent acts against a life-size doll if they first observed adults doing the same thing (11). According to this theory, teenagers are apt to model the behavior they see in characters like Carrie Bradshaw, from HBO’s Sex in the City, who has several extra-marital affairs throughout the length of the series.

The Health Belief Model and Cultural Relativity.
Another drawback to using the Health Belief Model for a sexual education program is that it assumes the target population is of the same culture; one which prioritizes health and pregnancy prevention. The United States is an incredibly diverse country and its public school students come from varying backgrounds and cultures. Abstinence only education does not account for this complex interweaving of cultural differences. By only offering one option it fails to address differing cultural norms, religious beliefs, even language barriers. It is particularly harmful for adolescents who have been brought up in cultures where talking about sex is still very taboo. These teens are even more at risk because they lose all opportunity to talk about and understand sexual health at home and at school. They have nowhere to turn for open discussion about sexual health and choices. Linda Thomas in her critique of the HBM from a feminist perspective writes,

"This paradigm has been oppressive in nature, depriving persons of value and contextual meanings which are embedded in cultural practices, skills, and languages. From the HBM perspective, persons are viewed as a collective group, confined and reduced to 'objective' data without regard for their sociopolitical and historical experiences” (12). Statistically speaking, teenage pregnancy rates around the country are higher in lower SES and minority communities. For example, black women between the ages of 15-19 have a pregnancy rate of 143 out of 1000 followed by Latina's who are at 131 per 1000 as compared to white women aged 15-19, whose pregnancy rate is at 48 per 1000 (13). Abstinence-only education, based on the HBM, is failing the minority demographic because it refuses to take into account different cultural norms. Thomas goes on to say that the HBM does not address issues such as, "social desirability and social/political barriers." Minorities have historically been at a loss for political representation in the government and still are today. This could be one reason why they have not been able to counter abstinence-only education programs, which is clearly not serving their needs as a population.

Adolescent Psychology as a Framework. A major problem with the Health Belief Model is the fact that it assumes all of human behavior is rational. Unfortunately, we do not always act rationally, especially when it comes to matters of the heart. According to Salazar in her, Comparison of Four Behavioral Theories, the HBM, "does not address the issue of coping skills. It focuses on rational, intentional behavior and does not take into account the spontaneous activity that characterizes much of human behavior"(14). This is problematic for the abstinence-only campaign seeing as sexual activity is often a spontaneous decision made in the moment. Furthermore, sexual activity can a lot of times go hand in hand with alcohol or substance use, which deters one even further from the prospect of rational decision making.

Adolescents, it has been shown, prioritize their friends and social network above most other things in their life. The Health Belief Model expects people to determine intention through rational decision making; however teenagers cannot be considered rational because of their value system. Teenagers are also prone to believing they are invincible, so the perceived threat of STIs and pregnancy may not be strong enough for them to choose the hoped for behavior, in this case, not having sex outside of marriage.

The HBM almost completely fails to take into account human psychology at all as a way to determine behavior. Abraham Maslow, one of the founding fathers of social psychology, is famous for his Hierarchy of Needs (15). Often depicted as a pyramid, the needs are stacked on top of each other from the most basic physiological to the most advanced top of the pyramid, self-actualization. The most basic needs are usually met before the higher levels can be reached, but there is room flexibility. Interestingly enough, Maslow placed sex in the most basic, deficiency needs along with the need for shelter and the need for food. This would be the physical benefits of sexual intercourse, release of endorphins and exercise. Next is the need for safety, such as security of employment or the need to feel stable in your health. The fact that sexual intimacy is on the level of a lower-order need and must be met before one can move up the pyramid to where concerns about healthcare lie proves that teenagers may not be able to rationally choose the less risky health behavior over meeting their sexual biological needs. Maslow also places the emotional connection of sexual intimacy in the third tier of the pyramid, along with social acceptance and love. If one cannot meet the needs of this level, which provides emotional well-being, the person may no longer care about meeting the needs of higher-order tiers.


"In the absence of these elements, many people become susceptible to loneliness, social anxiety, and depression. This need for belonging can often overcome the physiological and security needs, depending on the strength of the peer pressure. e.g. An anorexic ignores the need to eat and the security of health for a feeling of belonging." (15).

Rebels Without a Cause.
Adolescents, who cannot be considered rational beings, are also known for their rebellion. Erikson, a prominent psychologist, in his Theory of Socioemotional Development, claims that during the adolescent years (approximately between the ages of 13-20) teenagers enter the "Fidelity" stage (16). This stage is characterized by the struggle between finding their unique identity and fitting that into the greater, societal picture. Almost every teenager will experience some delinquency and experiment with some sort of rebellion as a way to find out who they are and where they belong in the world (16). What this means for a program like abstinence-only education is that with only one option available to teens from authority figures such as teachers or parents, they are more likely to experiment with other options. In fact, the very set up of an authority figure giving a teenager no choices is exactly a situation teenagers are drawn to rebel against. They are reaching an age where they are almost considered adults by society, and they are testing the waters and starting to exert their independence. Abstinence-only education doesn't allow them to make their own, educated decisions about their sexual health; instead it forces one down their throat. If the teen doesn't want to conform, and due to their inherent rebelliousness they many times will not, abstinence-only education leaves them without resources or tools to act in safe manner. If they are never educated about contraception or condoms, and instead only told to wait until marriage, they will be unprepared to reduce their risk if they do choose to have sex outside of marriage.

As a high school teacher, I was privy to many adolescent conversations on sex. I was walking through the hall one day when I overheard a conversation between two 14 year old girls talking about contraception in an abstinence-only public school. "I took one of Chelsea's birth control pills today so that I won't get pregnant." Had this girl been given the proper tools and resources that she would have received in a comprehensive sex education class she would have known that birth control pills need to be taken at the same time, daily, for at least a month to prevent pregnancy and even then, they will not prevent STIs or HIV.

Comprehensive Sex Education as a Solution. Although abstinence-only programs are failing our country's youth, we needn't abandon the idea of presenting abstinence as a viable option for teens. Studies have shown that teaching kids to wait until marriage can be an effective measure to delay the age of a first sexual encounter. It simply isn't a comprehensive plan that could benefit all teenagers, including those that decide to have sex, are already having sex, or are already pregnant. Abstinence-only education also leaves out sexuality education, leaving GLBTQ students, who do not have the right to legally wed in this country (except MA!), absolutely no alternative but to abstain from sex for their entire lives, which is not always a practical expectation. Advocates of comprehensive sex education encourage openness and frank discussion. Some organizations go so far as calling themselves "sex-positive" meaning that no judgment is put upon any sexual behaviors and that risk reduction is the aim or education. This type of environment would be ideal for teenagers who are eager to rebel, as a non-judgmental, open and educational atmosphere won't leave any room for them to rebel. According to Erickson, adolescents are at a stage in their development where they are coming to terms with their own individual beliefs and values. If sex education embraced and educated on everything from abstinence to sexuality teens would have a chance to assert their own values, rather than be coerced into a lifestyle they may not agree with which would lead them only to rebel against it. As Salt-N-Peppa put it over 10 years ago, it's about time we, "…Talk about sex, baby/ Let's talk about you and me/ Let's talk about all the good things and the bad things that may be/ Let's talk about sex."

REFERENCES

1.Petigny A. Illegitimacy, Postwar Psychology, and the Reperiodization of the Sexual Revolution. Journal of Social History, 2004.

2. Social Security Act, Title V Section 510 http://www.ssa.gov/OP_Home/ssact/title05/0510.htm

3. SEICUS. A Portrait of Sexuality Education and Abstinence-Only-Until Marriage Programs in the States. http://www.siecus.org/policy/states/

4.K.A. Driscoll, A.K. Lindberg. A Statistical Portrait of Adolescent Sex, Contraception, and Childbearing, 1998.

5. Alan Guttmacher Institute. Sex and America's Teenagers. New York and Washington, DC: 1994

6. Alan Guttmacher Institute. Facts on Sex Education in the United States. http://www.guttmacher.org/pubs/fb_sexEd2006.html

7. Haffner DW. What's wrong with abstinence-only sexuality education programs? SIECUS Rep. 1997 Apr-May;25(4):9-13.

8. Rosenstock I. Historical Origins of the Health Belief Model (pp. 328-335). In: Health Education Monographs VOL. 2, NO. 4

9. Bandura, A. Organizational Application of Social Cognitive Theory. Australian Journal of Management, 1998; 13(2), 275-302. http://en.wikipedia.org/wiki/Social_cognitive_theory

10. Choi M. Centers for Disease Control and Prevention. HIV Prevention Among Asian and Pacific Islander Men Who Have Sex With Men: A Critical Review of Theoretical Models and Directions for Future Research.

11. Bandura, A. Self-efficacy: The exercise of control. New York, 1997; W.H. Freeman. http://tip.psychology.org/bandura.html

12. L Thomas. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing. 1995; 11:246-252.

13. see 6

14. Salazar MK.Comparison of Four Behavioral Theories. AAOHN Journal. 1991; 39:128-135.

15. http://en.wikipedia.org/wiki/Abraham_Maslow

16. Huitt W. Socioemotional development. Educational Psychology Interactive. Valdosta, GA. 1997; Valdosta State University http://chiron.valdosta.edu/whuitt/col/affsys/erikson.html

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