Last summer, then-Surgeon General David Satcher drew the ire of White House officials with the release of his long-awaited Call to Action to Promote Sexual Health and Responsible Sexual Behavior. Citing research findings on the effectiveness of various program interventions, the Satcher report stresses the importance of sex education that balances encouragement of abstinence for young people with assuring "awareness of optimal protection from sexually transmitted diseases and unintended pregnancy, for those who are sexually active...." Satcher's conclusion is echoed in Healthy People 2010, the Department of Health and Human Services' set of official national goals for improved public health, which emphasizes the need to reduce teenage pregnancy and sexually transmitted disease (STD) rates in part through comprehensive sex education programs.
Endorsing sex education that includes information about condoms and contraceptive use to avoid STDs and unintended pregnancy along with positive messages about the value of delaying sexual activity is hardly a radical idea. Indeed, it is the position of the nation's leading medical, public health and educational organizations. Moreover, the overwhelming majority of Americans support this type of sex education. In a 1998 poll conducted by the Kaiser Family Foundation and ABC Television, 81% of adults said that sex education programs should teach both abstinence and pregnancy and STD prevention; only 18% thought programs should teach only abstinence.
Nonetheless, the exclusive promotion of abstinence is the sex education policy that prevails at the federal level. Currently, three separate programs support the most restrictive abstinence-only approach—an approach that requires condemnation of sex outside of marriage for people of all ages and allows no teaching about contraceptive methods beyond failure rates. For the current fiscal year, federal spending earmarked for this type of abstinence education totals $102 million. And the Bush administration has announced that it wants more, a $33 million increase for FY 2003 ("Abstinence Promotion and Teen Family Planning: The Misguided Drive for Equal Funding," TGR, February 2002, page 1).
Advocates of a more comprehensive, or "abstinence-plus," approach to sex education have long noted that the effectiveness of the abstinence-only approach has not been demonstrated. But as a practical matter, there has been no alternative policy proposal for these advocates to rally around. Legislation introduced in the House of Representatives in December 2001, however, sets out an alternative vision for how U.S. policy might best meet the needs of young people.
The Need for Action
In the United States, as in other developed Western countries, the majority of adolescents become sexually active during their teenage years. Roughly two-thirds (63%) of U.S. teens have had sexual intercourse by their 18th birthday. But while this level of sexual activity is hardly unique among developed countries, teens in the United States do have uniquely higher rates of unplanned pregnancy. Despite significant reductions in the U.S. teen pregnancy rate over the last decade or so, nearly 900,000 teenagers still become pregnant each year—and almost four in five (78%) of these pregnancies are unintended.
Research conducted by The Alan Guttmacher Institute between 1998 and 2001 indicates that U.S. teens are more likely to become pregnant because they are less likely to use any contraceptive method than young people in other developed countries and are also less likely to use methods that in actual use have the highest effectiveness rates, such as the pill ("Teen Pregnancy: Trends and Lessons Learned," TGR, February 2002, page 7). In 1995, one in four American adolescents did not use any method at first intercourse, and one in five were not currently using any method.
Fewer than one in five adults say that sex education programs should teach only about abstinence.
Teen STD rates in the United States are also high. Every year, roughly four million teens acquire an STD. Young people aged 15-19 account for one-third of all gonorrhea and chlamydia cases in the United States. On average, two young people in the United States are infected with HIV every hour of every day. Racial and ethnic minorities have been disproportionately infected with STDs, especially HIV/AIDS. For example, although blacks represent less than 16% of the adolescent population, they account for nearly half of all reported adolescent AIDS cases.
Preventing pregnancy and STDs among teenagers, therefore, is a major public health priority—and the role that sex education can play in achieving this goal is a question of major importance. Research has demonstrated that program interventions that urge teens to postpone having intercourse but also discuss contraception can be effective in helping teens delay sexual activity and increase contraceptive use when they do become sexually active. At the same time, most abstinence-only programs and strategies have not been proven effective in delaying teens' sexual initiation or in reducing the frequency of intercourse and number of sex partners. Indeed, recent evidence suggests that these programs and strategies—including virginity pledges, which have been shown to help some teenage girls postpone intercourse for up to 18 months—may actually increase young people's risk of pregnancy and disease by deterring the use of contraceptives, including condoms, when they become sexually active.
Heeding the Evidence
Based on this research and the realities of teen sexual activity in the United States, a broad constituency of child development, education, health care, and youth-serving agencies is committed to assuring that more comprehensive sex education is provided to young Americans. To date, well over 100 organizations—including many of the most prominent medical, public health and educational associations in the United States—have signed on to a statement to demonstrate their support (see box). Calling abstinence "a key component of sexuality education," the statement contends that, "Society should encourage adolescents to delay sexual behaviors until they are ready physically, cognitively, spiritually, socially and emotionally for mature sexual relationships and their consequences." At the same time, the statement asserts, "Society must also recognize that a majority of adolescents have become involved in sexual relationships during their teenage years. Scientific research indicates that comprehensive approaches to sexuality education can help young people postpone intercourse and use contraception and STD prevention."
|SELECTED MEDICAL, PUBLIC HEALTH AND EDUCATIONAL ORGANIZATIONS SUPPORTING COMPREHENSIVE SEXUALITY EDUCATION|
|American Academy of Child and Adolescent Psychiatry
American Academy of Pediatrics
American Association for Health Education
American Association of Family and Consumer Sciences
American Association of School Administrators
American College of Nurse-Midwives
American College of Obstetricians and Gynecologists
American Counseling Association
American Medical Association
American Medical Women's Association
American Nurses Association
American Psychiatric Association
American Psychological Association
American Public Health Association
American School Health Association
Association of State and Territorial Health Officials
Federation of Behavioral, Psychological and Cognitive Sciences
National Alliance of State and Territorial AIDS Directors
National Association of County and City Health Officials
National Association of School Psychologists
National Center for Health Education
National Council on Family Relations
National Education Association
National Medical Association
National Mental Health Association
National Organization on Adolescent Pregnancy,
Parenting and Prevention
National School Boards Association
Society for Adolescent Medicine
|Source: Sexuality Information and Education Council of the United States.|
Several recent studies and surveys suggest that sex education that includes information about both abstinence and contraception also has strong support among teachers and parents, as well as among teens themselves ("Sex Education: Politicians, Parents, Teachers and Teens," TGR, February 2001, page 9). A study published in Family Planning Perspectives in 2000 reports that more than nine in 10 public school teachers believe that students should be taught about contraception. According to interviews conducted for the Kaiser Family Foundation in 2000, parents overwhelmingly want schools to do more to prepare their children for "real life." More than eight in 10 believe sex education courses should discuss the use of birth control, including condoms. Three-quarters say abortion and sexual orientation should be discussed in a "balanced" way that presents different views in society. Kaiser-sponsored research also indicates that teens want more information about sexual and reproductive health issues than they are currently receiving in school.
Putting It Together
The Family Life Education Act, according to its original cosponsors, Reps. Barbara Lee (D-CA) and James Greenwood (R-PA), sets out a vision of U.S. sex education policy that is research-based and that has the support of medical, public health and educational organizations, as well as the American people. The bill would authorize $100 million annually for five years to support state programs that operate under a nine-point definition of "family life education programs" that stands in sharp contrast to the eight-point definition of an "eligible abstinence education program" that now governs federal support in this area (see box).
|SEXUALITY EDUCATION, AS DEFINED BY THE FAMILY LIFE EDUCATION ACT||ABSTINENCE EDUCATION, AS DEFINED BY CURRENT FEDERAL LAW|
|According to the Family Life Education Act, a program of family life education is one that:
1) is age-appropriate and medically accurate;
2) does not teach or promote religion;
3) teaches that abstinence is the only sure way to avoid pregnancy or sexually transmitted diseases;
4) stresses the value of abstinence while not ignoring those young people who have had or are having sexual intercourse;
5) provides information about the health benefits and side effects of all contraceptives and barrier methods as a means to prevent pregnancy;
6) provides information about the health benefits and side effects of all contraceptives and barrier methods as a means to reduce the risk of contracting sexually transmitted diseases, including HIV/AIDS;
7) encourages family communication about sexuality between parent and child;
8) teaches young people the skills to make responsible decisions about sexuality, including how to avoid unwanted verbal, physical, and sexual advances and how not to make unwanted verbal, physical, and sexual advances; and
9) teaches young people how alcohol and drug use can affect responsible decisionmaking.
|According to current law, an abstinence education program eligible for federal funding is one that:
A) has as its exclusive purpose, teaching the social, physiological, and health gains to be realized by abstaining from sexual activity;
B) teaches abstinence from sexual activity outside marriage as the expected standard for all school age children;
C) teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;
D) teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity;
E) teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects;
F) teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child's parents, and society;
G) teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and
H) teaches the importance of attaining self-sufficiency before engaging in sexual activity.
|Source: The Family Life Education Act.||Source: U.S. Social Securit Act, Sec. 510 (b)(2).|
Funding under the Family Life Education Act also could be used to carry out "educational and motivational activities" that would teach young people about human physical and emotional development, promote male involvement in decision-making and help young people develop self-esteem and healthy attitudes about body image, gender roles, racial and ethnic diversity, sexual orientation and other issues. The legislation provides for both national and state-level evaluations of the programs' effectiveness in helping young people delay the initiation of sexual intercourse, preventing teen pregnancy and STDs, and increasing contraceptive knowledge and use among teens who are sexually active.
Into the Fray
Not only has the president proposed a major increase in funding for abstinence-only education for the upcoming fiscal year, but social conservatives have made abstinence-only education a major priority as Congress prepares to reconsider the 1996 welfare law, which houses the eight-point definition that governs all three federal abstinence-education programs.
Advocates of more comprehensive sex education hope that the arrival of the Family Life Education Act on the scene will help them stave off efforts to extend and expand the reach of federal abstinence-only policy. By setting out a vision of responsible sex education for the future, they hope it will highlight for policymakers that the current policy is highly restrictive, censors information about contraception and is out of step with what research has shown to be effective and what most Americans say should be taught. "Denying our sons and daughters the information they need to protect their health and their lives is not only naive and misguided," said Rep. Lee in a recent press statement, "[it is] irresponsible and extremely dangerous....We can't risk our children's future by not fully educating them about their options."
Because the Family Life Education Act would require that funded programs provide information about contraception as well as encourage abstinence, its sponsors and supporters hope it will help policymakers voice their opposition to the strictest form of abstinence-only education while still remaining supportive of abstinence messages. Over time, they hope it will help redirect the federal government's sexuality education spending toward more comprehensive models with demonstrated effectiveness in helping young people both delay having sex and protect themselves when they eventually do become sexually active.