Advocates Call for a New Approach After the Era of ‘Abstinence-Only’ Sex Education

Heather D. Boonstra, Guttmacher Institute
Reproductive rights are under attack. Will you help us fight back with facts?

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In the weeks since he was sworn into office, speculation has continued around the new directions in which President Barack Obama, with the help of a more supportive Congress, might take the country. For opponents of sex education programs that focus exclusively on abstinence, there is already a feeling of the beginning of a new era. Under the Bush administration and with the strong support of congressional social conservatives, "abstinence-only-until-marriage" emerged as the sanctioned approach to reducing U.S. teen pregnancy and sexually transmitted infection (STI) rates. Since 1996, well over $1 billion in federal and mandatory state matching grants has been spent 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.

At long last, however, the tide seems to be turning. Over the last several years, the case against abstinence-only education has mounted. Continued funding for federal abstinence-only programs was hotly debated during a hearing held before the House Committee on Oversight and Government Reform in April 2008. At this first-ever congressional hearing to examine the effectiveness of abstinence-only education, social conservatives were on the defensive against a wealth of evidence that such a highly restrictive educational approach does not work to stop or even materially delay teen sex. A panel of public health experts, including representatives of the American Public Health Association, the Academy of Pediatrics and the Institute of Medicine, testified that there is no evidence base to support the current massive federal investment in abstinence-only programs.

Later that year, Congress rejected President Bush’s request for yet another significant increase for the abstinence-only program and declined to give it any increase. Now, opponents of abstinence-only education are taking the next step, calling on the Obama administration and Congress to end federal funding for such programs entirely. Instead, they say, policymakers should throw their support behind a more comprehensive approach to sex education that genuinely addresses the reality of young people’s lives—education that helps youth to delay sexual activity, even as it equips them with the information and skills they will need to behave safely and responsibly when they do begin to have sex.

The Rise of Abstinence-Only Programs…

Only a few decades ago, debate over sex education focused on whether public schools had a role at all in educating children and young people about sex-related matters or whether parents should be the sole transmitters of sexually related values and information to their children. However, as the level of concern over teenage pregnancy—and later AIDS—increased, so did public support for sex education in schools. Over a few years in the 1970s and 1980s, the number of states that had policies requiring or encouraging the teaching of sex education grew rapidly.

As a matter of law, abstinence-only programs are required to promote ideas that are at best scientifically questionable and to withhold health- and life-saving information.

Having lost the debate over whether there should be sex education in schools, groups that once opposed school-based programs moved to a new strategy—one aimed at limiting the content of programs to the promotion of premarital abstinence. In 1981, the first grants for what later came to be called "abstinence-only" programs were authorized under the Adolescent Family Life Act (AFLA). Sponsored by congressional family planning opponents, AFLA was promoted as a "family-centered" alternative to contraceptive counseling and services to teenagers; instead, this program’s stated goal was to promote premarital "chastity and self-discipline."

Although AFLA has supported hundreds of relatively small teenage pregnancy prevention programs over the years (as well as programs providing support for pregnant and parenting teens), its total funding for abstinence-only education—currently at $13 million—has never been large. However, a lasting contribution of the program was the early development under its auspices of so-called fear-based sex education curricula that use scare tactics about such things as STIs and the failure rates of condoms and have become models for abstinence-only programs nationwide. The "real" money for abstinence-only programs came after 1996, the year in which social conservatives in Congress quietly inserted authorization for a new program into massive legislation designed to overhaul the nation’s welfare system. Title V of the Social Security Act includes an ongoing guarantee of $50 million annually to the states; because states must spend $3 for every $4 they receive, the total amount spent pursuant to this program became almost $90 million annually overnight. To qualify for funding, abstinence-only programs must adhere to the requirements of a rigid eight-point definition, including barring teachers from discussing contraceptive methods or safer-sex practices, other than to emphasize their shortcomings, and requiring them to teach that "sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects" (see box).

Abstinence-only Education, as Defined by Current Federal Law Sex Education, as Defined by the Responsible Education About Life Act
According to Title V of the Social Security Act, an eligible abstinence education program is a program that According to the Responsible Education About Life Act, a sex education program is a program that
A) has as its exclusive purpose, teaching the social, physiological, and health gains to be realized by abstaining from sexual activity; (1) is age-appropriate and medically accurate;
B) teaches abstinence from sexual activity outside marriage as the expected standard for all school age children; (2) stresses the value of abstinence while not ignoring those young people who have had or are having sexual intercourse;
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; (3) provides information about the health benefits and side effects of all contraceptive and barrier methods used—
(a) as a means to prevent pregnancy; and
(b) to reduce the risk of contracting sexually transmitted disease, including HIV/AIDS;
D) teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity; (4) encourages family communication between parent and child about sexuality;
E) teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects; (5) teaches young people the skills to make responsible decisions about sexuality, including how to avoid unwanted verbal, physical, and sexual advances and how to avoid making verbal, physical, and sexual advances that are not wanted by the other party;
F) teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society; (6) develops healthy relationships, including the prevention of dating and sexual violence;
G) teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and (7) teaches young people how alcohol and drug use can affect responsible decision making; and
H) teaches the importance of attaining self-sufficiency before engaging in sexual activity. (8) does not teach or promote religion.

…And the Evidence Against Them

From this considerable base, federal funding for abstinence-only programs accelerated under the Bush administration, especially since the creation in 2000 of a third funding stream also tied to the eight-point definition, the Community-Based Abstinence Education (CBAE) program. Yet, even as funding increased, so did evidence that the approach is ineffective. Ironically, early emanations came in a report issued in 1996, the same year Congress created the Title V abstinence program. An often underemphasized fact about the earlier AFLA program is that it technically is a "demonstration" effort, mandated to test and evaluate various program interventions. The report, conducted by a team of university researchers and entitled Federally Funded Adolescent Abstinence Promotion Programs: An Evaluation of Evaluations, concluded that "the quality of the AFLA evaluations funded by the federal government vary from barely adequate to completely inadequate." Moreover, the researchers said, they were aware of "no methodologically sound studies that demonstrate the effectiveness" of abstinence-only curricula.

Over the next decade, however, several well-designed studies began to suggest just how difficult it can be for people to practice abstinence consistently over time. Notable among these is a series of studies examining the effectiveness of virginity pledges, which are the centerpiece of many abstinence education programs. The most recent study, published in the January 2009 issue of Pediatrics, found that teens who take virginity pledges are just as likely to have sex as those who do not, but they are less likely to use condoms or other forms of contraception when they become sexually active.This study builds on past research showing that although virginity pledges may help some teens to delay sexual activity, teens who break their pledge are less likely to use contraceptives, are less likely to get tested for STIs and may have STIs for longer periods of time than teens who do not pledge.

A major bombshell dropped two years earlier, however, when a systematic look at the federal abstinence-only effort concluded in 2007 that none of the programs it evaluated were effective in stopping or even delaying sex. The study, mandated by Congress and conducted by Mathematica Policy Research over nine years at a cost of almost $8 million, was initially criticized because it did not look at a nationally representative sample of abstinence-only programs. Instead, it closely examined four programs considered by state officials and abstinence education experts to be especially promising. Even so, after following more than 2,000 teens for as long as six years, the evaluation found that none of the four programs was able to demonstrate a statistically significant beneficial impact on young people’s sexual behavior. Individuals who participated in the programs were no more likely to abstain than those who did not.

The Mathematica findings were in keeping with those of another comprehensive review of sex and HIV education programs published later that year. Conducted by Douglas Kirby for the nonpartisan National Campaign to Prevent Teen and Unplanned Pregnancy, Emerging Answers 2007 concludes that despite improvements in the quality and quantity of evaluation research in this field, "there does not exist any strong evidence that any abstinence program delays the initiation of sex, hastens the return to abstinence, or reduces the number of sexual partners."

On top of this, abstinence-only programs have been sharply criticized by leading medical professional organizations for being, by their very nature, antithetical to the principles of science and medical ethics. As a matter of law, abstinence-only programs are required to promote ideas that are at best scientifically questionable, and to withhold health- and life-saving information; as such, they may not credibly assert that they are "medically accurate" (see box). Little wonder, then, that leading health professional groups—including the American Medical Association, the American Academy of Pediatrics, the Society of Adolescent Medicine, and the American Psychological Association—have raised serious ethical concerns about U.S. support for such programs. "Governments have an obligation to provide accurate information to their citizens and to eschew the provision of misinformation in government-funded health education and health care services," says the American Public Health Association in its policy statement on abstinence-only education. "While good patient care is built upon notions of informed consent and free choice, [abstinence-only education] programs are inherently coercive by withholding information needed to make informed choices."

Toward a More ‘Common Sense’ Approach

As the evidence base against abstinence-only programs grew, so did the number of states that decided to opt out of the TitleV program.To date, 23 states and the District of Columbia have declined to apply for the annual abstinence education grants set aside for them under Title V (see map, page 10). The number of adolescents living in those states is substantial: Nearly 14 million young people aged 12–18—46% of those nationwide—reside in states that have passed up abstinence-only funding.

Twenty-three states and the District of Columbia are no longer accepting funds under the Title V abstinence-only education program.
Source: Sexuality Information and Education Council of the United States, 2009.

In 2007, policymakers on Capital Hill at long last signaled that, at the very least, the era of big increases for abstinence-only education was over. After many years of expansion, Congress rejected the Bush administration’s recommendation to increase funding for CBAE by $28 million and instead kept its funding for FY 2008 unchanged at $176 million. But the major reversal of political fortune for abstinence-only education came with the 2008 election cycle. President Obama entered the White House with a strong record of support for what he calls "common sense approaches" to preventing unintended pregnancy and HIV, namely "comprehensive sex education that teaches both abstinence and safe sex methods."

Advocates for more comprehensive sex education are now looking to the president and Congress, whose leadership in both houses is dominated by social progressives, to make a more significant break from the past. In light of the wealth of evidence that abstinence-only programs have no beneficial effect on young people’s sexual behavior, they are calling on policymakers to stop funding abstinence-only programs altogether and, going further, to create a new funding stream to support programs that are more comprehensive in scope.

Focusing on more comprehensive approaches is both good policy and good politics. It is good policy because it is based on scientific considerations and takes into account the reality of teens’ lives. In sharp contrast to abstinence-only programs, there is strong evidence that more comprehensive approaches do help young people both to withstand the pressures to have sex too soon and to have healthy, responsible and mutually protective relationships when they do become sexually active. According to Kirby in Emerging Answers 2007, "two-thirds of the 48 comprehensive programs that supported both abstinence and the use of condoms and contraceptives for sexually active teens had positive behavioral effects." Many either delayed or reduced sexual activity, reduced the number of sexual partners or increased condom or contraceptive use. "What is particularly encouraging," said Kirby in a 2007 interview, "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."

Changing course is good politics, because it is in sync with what Americans say they want for their children....There is far greater support for comprehensive sex education than for the abstinence-only approach.

Changing course is also good politics, because it is in sync with what Americans say they want for their children. 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.

As a practical matter, advocates for comprehensive approaches are looking to the Responsible Education About Life (REAL) Act as a model for federal sex education policy in the future. Introduced in slightly different forms in past years and reintroduced in 2009 in the House and Senate respectively by Rep. Barbara Lee (DCA) and Sen. Frank Lautenberg (DNJ), the REAL Act sets out a broad alternative vision for how U.S. policy might best meet the needs of young people. As currently drafted, the bill would authorize at least $50 million annually for five years to support state programs that operate under an eight-point definition of "responsible education," which stands in sharp contrast to the eight-point definition used for the federal abstinence-only funds (see box, page 7). Similar to the abstinence-only approach, however, REAL provides a set of principles to guide the content of programs, but leaves curriculum development to local communities.

Of course, passage of the REAL Act is just one step in the larger campaign to support comprehensive sex education. Because sex education programs are guided by policies at multiple levels, from school board policies to city health department regulations to national and state-level laws, policies at each level need to support more comprehensive approaches. And because the REAL Act would direct its funds to state governments, questions remain about funding for Community-Based organizations and whether some states will decline to apply for the annual comprehensive sex education grants—as many have done under the Title V abstinence program. Moreover, policies and funding must be accompanied by efforts to address a host of other needs, including for teacher training, model programs, community assessment tools and program evaluation. Nonetheless, the leadership of the federal government in making sure that young people have the information and skills they will need to make healthy choices about sexual behavior—as teens now and as tomorrow’s adults—is critical. In this respect, there is widespread agreement that improvement is both possible and imperative.

What Is ‘Medical Accuracy’ in Sex Education?

A number of reports have examined the medical accuracy of federally funded abstinence-only programs. According to a 2004 congressional review conducted by the minority staff of the House Committee on Government Reform, 11 of the 13 most popular abstinence-only curricula were rife with medical and scientific inaccuracies. For example, many grossly underestimated the effectiveness of condoms, made false claims about the risks of abortion or offered misinformation on the incidence and transmission of STIs. Two more recent reviews by the Government Accountability Office found similar problems, faulting the government for not keeping closer tabs on the medical accuracy of grantees’ educational materials.

Apparently responding to these charges, the 2007 program guidelines for the CBAE program created a new requirement specifically pertaining to medical accuracy. "This is a welcome development," says John Santelli, department chair and professor of clinical population and family health at the Mailman School of Public Health, Columbia University, in an interview for this article. "But the fact that abstinence-only programs are required by law to provide biased information and withhold positive information about contraception raises serious questions about the ethics of these programs." Santelli continues: "If adolescents are sexually active—or will be shortly—they need information to protect their health and lives. Where there is a need to know, medically incomplete is medically inaccurate."

Recognizing the importance of scientifically grounded health policies, Santelli suggests in a 2008 American Journal of Public Health article a definition of medically accurate information that incorporates an understanding of the scientific process. Medically accurate information, he says, is information "relevant to informed decision-making based on the weight of scientific evidence, consistent with generally recognized scientific theory, conducted under accepted scientific methods, published in peer-reviewed journals and recognized as accurate, objective and complete by mainstream professional organizations.…The deliberate withholding of information that is needed to protect life and health (and therefore relevant to informed decision-making) should be considered medically inaccurate." Santelli contends that each state and the federal government should adopt requirements for medical accuracy in health education. Although definitions will not end attempts to manipulate health policy-making, "they provide a clear standard in refuting such attempts."

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