The Case for a New Approach to Sex Education Mounts; Will Policymakers Heed the Message?
Abstinence-only-until-marriage education is a key component of social conservatives’ global moral and religious agenda, and the cornerstone of the Bush administration’s approach to reducing U.S. teen pregnancy and sexually transmitted infection (STI) rates. Since 1996, when a major overhaul of the nation’s welfare policy prompted a massive escalation of funding in this area, the federal government, with mandatory matching grants from the states, has spent well over one billion dollars to promote premarital abstinence among young Americans, through highly restrictive programs that ignore or often actively denigrate the effectiveness of contraceptives and safer-sex behaviors.
Fearful of being portrayed as anti-abstinence, policymakers have continued to support these rigid, ideologically driven programs even though there is clear evidence—including compelling recent evidence from a long-awaited, congressionally mandated report on federally funded abstinence-only-until-marriage programs—that they are not effective in stopping or even delaying teen sex. In fact, the federal government has been supporting and evaluating single-purpose abstinence promotion programs since the early 1980s, and there is now evidence suggesting that they may be harmful to young people in the long term. Meanwhile, there is still no comparable federal program to support comprehensive approaches that promote delayed sexual activity as well as protective behaviors for when young people do initiate sex, even though such programs have been shown to be effective at accomplishing both.
Adding to the body of evidence on sex education approaches and teen sexual behavior, three new studies from Guttmacher Institute researchers forcefully demonstrate that the current U.S. emphasis on stopping teens from having sex is out of touch with young people's lives and needs. The question that now presents itself is whether the new Congress may at long last be ready to change course and, if so, how far and how fast.
The Bush administration has recommended that a total of $204 million be spent on abstinence-only-until-marriage education in FY 2008, up from $176 million in the current fiscal year. Of that, $50 million goes automatically to the states for abstinence education programs that must conform to a highly restrictive eight-point definition enshrined in Title V of the Social Security Act. Some of the more controversial components of this definition include teaching that "a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity" and that "sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects." Because one of the planks of the eight-point definition requires funded programs to have as their "exclusive purpose" the promotion of abstinence outside of marriage, these programs are barred from providing any information that could be construed as promoting or advocating contraceptive use. In practice, programs have a choice between not discussing contraceptive methods at all or doing so in a negative manner by emphasizing their failure rates. Moreover, as of last year, state programs must now target "adolescents and/or adults within the 12- through 29-year-old age range" in their programming, signaling that the federal government will no longer allow states to use their federal funds to support programs targeting only preadolescents.
Some states have found the rules that govern the abstinence program so restrictive that they have decided to turn down the funding altogether. In March, Ohio Gov. Ted Strickland (D) announced that his administration will not reapply for Title V abstinence education funds when the current $1.6 million grant expires. Ohio joins a growing list of states—among them, California, Maine, New Jersey and Wisconsin—that have said they cannot accept the federal government's restrictions.
The lion's share of abstinence program dollars bypass state governments altogether and go directly to local organizations, including faith-based groups. Recipients of grants under the Community-Based Abstinence Education (CBAE) program must comply with the stringent rules that govern the states—only CBAE is even more rigid. Its guidelines expand on the definition of what constitutes a fundable abstinence program to 13 "themes" and expound at length on the recommended curricula content (related article, Winter 2006, page 19). CBAE is a favorite among social conservatives, and funding for the program—currently at $113 million—has risen 465% since its inception just five years ago. Indeed, all of the increases for abstinence-only education in recent years have gone to the CBAE program.
In the last few months alone, Guttmacher Institute researchers have published three studies that, when viewed together, demonstrate just how dysfunctional the U.S. government's approach to sex education is. The first, published in the December 2006 issue of Perspectives on Sexual and Reproductive Health, analyzes trends in the provision of school-based instruction about contraception and abstinence between 1995, the year before enactment of the welfare reform law, and 2002. It shows that during this period in which abstinence-only funding grew exponentially, the proportion of U.S. teens who had received any formal instruction about birth control methods declined sharply, while the proportion who received only information about abstinence more than doubled (see chart).
|MORE GETTING LESS|
|Over just seven years, the proportion of teens receiving information on birth control dropped precipitously; in its place, education only about abstinence.|
|% of teens 15–19|
Equally important, many did not get birth control information when they needed it most. In 2002, only slightly more than half of sexually experienced males and six in 10 females had received any instruction about birth control methods before they first had sex. Minority and low-income youth were especially disadvantaged: For example, only one-third of black males had received instruction about birth control prior to first sex, compared with two-thirds of their white peers. And teens living below 200% of poverty (an annual income of $34,340 for a family of three) were less likely than their higher-income peers to have received birth control education before first sex (see chart, page 4).
|NOT SOON ENOUGH|
|Black, Hispanic and low-income teens are particularly unlikely to have received education on birth control before they first have sex.|
|% of teens 15–19|
This trend is all the more disturbing considering the critical role of contraceptive use in preventing teen pregnancy. The second study, by researchers from Guttmacher and Columbia University, analyzes the relative contributions of abstinence and contraceptive use to the 24% decline in the U.S. teen pregnancy rate seen during the same 1995–2002 period. This study, published in the January 2007 issue of the American Journal of Public Health, finds that the decline occurred primarily because teens were using contraceptives better. Examining data from two rounds of a large-scale national survey, the researchers conclude that the vast majority of the decline (86%) was the result of dramatic improvements in contraceptive use, including increases in the use of individual methods, increases in the use of multiple methods and substantial declines in nonuse. Just 14% of the decline could be attributed to a decrease in sexually activity.
Not surprisingly, abstinence played a greater role among younger teens aged 15–17, but even among this age-group (in which sexual activity declined a healthy 17% between 1995 and 2002), only 23% of the decline in teen pregnancy could be attributed to decreased sexual activity. Among 18–19-year-olds, there was no change in sexual activity during this period; accordingly, the pregnancy rate decline among this group was entirely attributable to improved contraceptive use.
The third study demonstrates how unrealistic the goal of abstinence until marriage is now and has been for decades. According to the study, published in the January/February 2007 issue of Public Health Reports, premarital sex is normal behavior for the vast majority of Americans: By the time they reach age 44, 99% of Americans have had sex, 95% have done so before marriage and 74% have done so before age 20. Even among those who abstain from sex until age 20 or older, 81% eventually have premarital sex. (The typical age of marriage is currently 25 for women and 27 for men.) Further, contrary to public perception that premarital sex is much more common now than in the past, the study shows that even among women who were born in the 1940s, nearly nine in 10 had sex before marriage (see chart).
|STANDARD OF SEXUAL ACTIVITY|
|Contrary to the tenets of abstinence-only-until-marriage education, premarital sex is nearly universal, and has been for decades.|
|Note: Percentages are of Americans who had premarital sex by age 44. Source: Public Health Reports, 2007.|
What Should Be Done?
Most people would agree that teens, especially younger teens, should be encouraged to delay sexual activity. Sex among very young adolescents is frequently involuntary, at least to some degree: It may involve a partner who is substantially older, which may make it hard for such teens to resist their partner's approaches or to insist on using condoms or other contraceptive methods. Teens who have sex at a young age tend to have relatively unstable relationships and quickly acquire other sexual partners, which increases their risk of exposure to STIs. And young teenagers who get pregnant are rarely, if ever, in a position to support and raise a child.
The fact remains, however, that although only 13% of teens have ever had sex by age 15, sexual activity is common by the late teen years. By their 19th birthday, seven in 10 teens of both sexes have had intercourse. Therefore, the challenge is in helping teens, especially young teens, delay sexual initiation, while also preparing them with the information and skills needed to protect themselves and their partners when they do become sexually active.
The good news is that comprehensive sex education can assist young people in the transitions inherent in adolescence by helping them delay and prepare. According to Douglas Kirby, a senior research scientist at ETR Associates who has analyzed hundreds of program evaluations, there is strong evidence that comprehensive sex education can effectively delay sex among young people, even as it increases condom and overall contraceptive use among sexually active youth. This is in sharp contrast to what can be said about the effectiveness of abstinence-only education. A recent, congressionally mandated evaluation of federally funded abstinence-only programs by Mathematica Policy Research—conducted over nine years at a cost of almost $8 million—found that these programs have no beneficial impact on young people's sexual behavior. As Kirby puts it, we can no longer say the jury is out on abstinence-only-until-marriage programs (see box).
To the extent that they ignore contraception and the benefits of safer-sex practices generally, abstinence-only programs do nothing to help prepare young people for when they will become sexually active. And some abstinence-only programs may be doing long-term damage by deterring contraceptive use among sexually active teens, increasing their risk of pregnancy and STIs. According to research by Hannah Brückner and Peter Bearman published in the Journal of Adolescent Health in 2005, the majority of teens enrolled in grades 7–12 in 1995 who pledged to remain virgins until marriage had sex before marriage or by the time of a follow-up survey in 2001–2002. Furthermore, compared with those who never took a pledge, "pledge breakers" were less likely to use condoms and to seek testing and treatment for STIs, and just as likely to test positive for STIs.
Counter to the priorities of the Bush administration and social conservatives, most Americans believe that sex education should promote abstinence and provide information about the effectiveness and benefits of contraception. According to the results of a 2005–2006 nationally representative survey of U.S. adults, published in the Archives of Pediatrics and Adolescent Medicine, there is far greater support for comprehensive sex education than for the abstinence-only approach, regardless of respondents' political leanings and frequency of attendance at religious services. Overall, 82% of those polled supported a comprehensive approach, and 68% favored instruction on how to use a condom; only 36% supported abstinence-only education. These results are consistent with those from a range of previous surveys among adults, parents, teachers and young people.
Over the last several years, various measures have been proposed in Congress to address the disconnect between young people's need for realistic sex education and the hard-line abstinence-only approach embodied in current federal law. The more modest of these proposals have sought to curb the most grievous excesses of the current policy. One such proposal, for example, would require medical accuracy in abstinence-only educational materials, after a Government Accountability Office report raised serious concerns on that score. Another would remove the most unscientific and ideologically driven planks in the eight-point definition of abstinence education, such as the one requiring grantees to teach that sex outside of marriage is likely to be physically and psychologically harmful. As far back as 2002, Sen. Max Baucus (D-MT) proposed a "state flexibility" approach, which would give states the option of using their allotments to promote abstinence according to the eight-point definition or to teach abstinence within a more comprehensive sex education program.
Ultimately, however, most opponents of abstinence-only-until-marriage education argue that the time has come for Congress to make a more significant break from the past. In light of the changed political climate and the more robust body of research in support of a comprehensive approach, they are calling on Congress to throw its support behind the Responsible Education About Life (REAL) Act, sponsored by Reps. Barbara Lee (D-CA) and Christopher Shays (R-CT) in the House and Frank R. Lautenberg (D-NJ) in the Senate. The REAL Act would support state programs that operate under a nine-point definition of "family life education" that stands in sharp contrast to the eight-point definition of abstinence-only education. According to Lee, "We should absolutely be teaching young people about abstinence, but we shouldn't be holding back information that can save lives and prevent unwanted pregnancies."
A Sex Education Expert Discusses the State of the Evidence on Programs
For more than 25 years, Douglas Kirby of ETR Associates has studied adolescent sexual behavior and programs designed to change that behavior. In 2001, under the auspices of the National Campaign to Prevent Teen Pregnancy, he authored Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, which analyzed the impact evaluations of more than 100 teenage pregnancy prevention programs across the country that met rigorous research standards. He is currently updating this report and will publish Emerging Answers 2007 later this year.
HB: A major conclusion of your 2001 report, Emerging Answers, was that comprehensive programs that urge teens to postpone having sex but also help teens to engage in protective behaviors are effective at doing both. At the same time, the report concluded that there was no reliable evidence to support the effectiveness of abstinence-only education. Is this still true today?
DK: The evidence that comprehensive programs work has only become stronger over time. In a recent review of some 80 studies that measure the impact of comprehensive programs, two in three programs had a significant positive impact on behavior. Many either delayed or reduced sexual activity, or increased condom or contraceptive use. At least 10 interventions had long-term behavioral effects lasting two or more years; some lasted three or more years—as long as the effects were measured.
What is particularly encouraging about the evidence from these studies of comprehensive sex and HIV education programs is that when some curricula that were found to be effective in one study were implemented by other educators in other states and evaluated by independent research teams, they remained effective if they were implemented with fidelity in the same type of setting and with similar youth.
HB: As you know, opponents of comprehensive sex education argue that encouraging abstinence while promoting the use of condoms and other forms of contraception for those who are sexually active only sends a mixed message that will result in increased sexual behavior. Is there any evidence to support that fear?
DK: No, in fact the evidence is very strong that comprehensive programs do not increase sexual behavior.
HB: And what about abstinence-only programs? In 2001, you characterized the situation by saying that the "jury is out" on abstinence-only programs, even though the government already had spent almost a billion dollars on this approach and, in fact, had been funding and evaluating abstinence promotion interventions since the early 1980s. Six years later, and with many more programs evaluated and dollars spent, is the jury still out?
DK: At least with regard to the abstinence-only-until marriage programs currently being promoted under federal policy, we can no longer say the jury is out.
Until recently, there had been very few rigorous studies conducted on abstinence-only programs and even fewer studies of programs that meet the strict federal Title V requirements. The evaluation by Mathematica Policy Research changes all of that, and its importance cannot be denied. This was a rigorous, nine-year study that focused on four abstinence-only-until-marriage programs, all of which met the eight-point definition stipulated in Title V and were considered by state officials and abstinence education experts to be especially promising. The study used an experimental design and followed more than 2,000 teens—a very large sample—who were randomly assigned to a program group or a control group. Data were collected from this study sample through a series of four surveys; the most recent and final survey was completed between 2005 and 2006, four to six years after study enrollment. The response rate on this survey was very high, ranging from 80% to 84%. All in all, this was a very well done study.
The evaluation found that none of the programs had a statistically significant beneficial impact on young people's sexual behavior. In fact, I was surprised by just how flat the results were. Teens who participated in the programs were no more likely to abstain than those who did not. Those who reported having had sex did so at the same age and had similar numbers of sexual partners. The only good piece of news was that youth who participated in the programs were no less likely to use condoms or other forms of contraception.
HB: So, what about abstinence education programs more generally?
DK: First, let me be clear that, as a researcher, I am not saying that no abstinence-only program can work. What I am saying is that currently there are no abstinence-only programs with strong evidence that they actually delay sex. Thus, there is no evidence base upon which to recommend their widespread dissemination and implementation.
Also, let me say that personally, I do not oppose abstinence-only programs for some grade levels—and by abstinence-only, I mean programs that discuss abstinence without addressing contraception. In every school district, there is some grade level where very few, if any, students are having sex. At this grade level, emphasizing only abstinence—without denigrating condoms or other forms of contraception—may be appropriate.
However, I do oppose programs in schools that only address abstinence in grades where some teens are having sex. Once 10% to 20% of students in a given school district are beginning to have sex, I believe they have the right to accurate and balanced information about abstinence, condoms and other forms of contraception. Furthermore, from a public health standpoint, they should be given information, as well as the skills and access to condoms and contraception, so that they are more likely to use protection if they do have sex.
HB: In conclusion, then, given the state of the research today on the relative effectiveness of abstinence-only and more comprehensive programs, what are your recommendations for public policy?
DK: Based on the evidence to date, I would suggest that comprehensive programs be implemented broadly. There is strong evidence supporting these programs. Accordingly, we should eliminate the funding restrictions that prevent the funding of comprehensive programs that effectively delay sex among young people. After all, it makes no practical sense to fund programs that do not work and to prevent funding of comprehensive programs that actually delay sex, and increase protective behavior.
Finally, more research is needed on programs that have demonstrated that they effectively reduce sexual risk. How can we make them even more effective? How can we disseminate effective programs widely? Must these programs be implemented exactly as designed? To what extent can they be adapted for individual communities and groups of youth? The more quickly we can resolve these issues, the more rapidly we can reduce teen pregnancy and STI rates in this country.