Download The Pathways program emphasizes holistic sexual

Abstinence Education: An Ineffective Program that Fails to Promote Teen
Sexual Health – Lynsie Ranker
Teen Sexual Health: STIs, Teen Pregnancy and Unhealthy Relationships
Although there are minimal differences in levels of sexual activity across
developed countries, the United States continues to lead in teen pregnancy and STI
rates, making it a significant public health issue1. An estimated 30% of teenage girls will
become pregnant at least once prior to age twenty.2 Additionally, half of all new sexually
transmitted infections are contracted by youth ages 15-24 even though they only
represent a quarter of the total sexually active population.1 Teens are also more likely
than adults to engage in sexual intercourse without protection and to have multiple
sexual partners.3
Unsafe sexual practices among teens can lead to long term health, economic,
psychological, and educational consequences. Some STIs, such as human papilloma
virus, can lead to infertility, chronic pelvic pain, and cervical cancer.4 When compared to
those who delayed child bearing, studies show that teenage parents complete less
schooling.5 They are also more likely to have unstable marriages, less prestigious
occupations, and be less physically fit.5 These outcomes may be the result of early
entrance into adulthood, which causes stress and other life-long implications.5 Teen
pregnancy can also have negative consequences for the child. Girls with teenage mothers
are more likely to become teen mothers themselves.6 With the threats unsafe sexual
practices pose to the youth of our nation, it is time to address the issues surrounding the
sex education program currently supported by the federal government—that of
Abstinences-only until marriage education (AOE).
1
AOE: The Current Sex Education Model
In 2009, it was estimated that the federal government spent $175 million on
programs supporting AOE.7 By federal requirement, these programs must knowingly
withhold information from students regarding contraceptive options.7 Issues
surrounding birth control, condoms, and other methods cannot be mentioned in the
programs unless the program is citing the failure rates associated with these various
contraceptive options8. In 2010, Congress decreased funding for such programs by
eliminating funding from the Community-Based Abstinence Education (CBAE) grant
program and the abstinence-only-until-marriage portion of the Adolescent Family Life
Act (AFLA).9 In spite of the funding decrease, programs still receive an estimated $33
million in funding as of 2011 and AOE continues to be taught in classrooms throughout
the country.10
Evaluations of abstinence-only programs have found little evidence to show they
are effective at delaying initiation of sex, and some data suggest such programs are
actually harmful to teen sexual health.7 One study found that due to a $5 million
abstinence-only program in California, there was actually an increase in the number of
teens engaging in sexual intercourse.11 Furthermore, there is not a great deal of
evidence that pledging abstinence actual delays initiation of sexual activity. Data
suggest that many teens who intend to remain abstinent fail to do s0.12 Studies even
show those abstainers who become sexually active use condoms less frequently when
compared to those who did not pledge abstinence.12 The inefficacy of these programs
and the possible risky sexual behaviors associated with such programs detract from the
effort to solve the sexual health problems of this nation’s youth. Programs that promote
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abstinence as the only option create unintended backlash, fail to address the diversity
within the classroom, and ignore the holistic definition of sexual health.
Critique 1: AOE generates psychological reactance among teens
The theory of psychological reactance refers to a phenomenon that occurs when
individuals perceive a threat to their freedom. When told what not to do, or what they
cannot have, the person immediately develops urges to obtain whatever is being
withheld. Since Brehm first proposed the theory in 1966, a great deal of research has
been done on psychological reactance, including differences among age groups.13 It has
been found that adolescents experience particularly high levels of psychological
reactance.14 Abstinence-only education, as the name suggests, limits the rights of teens
to make choices regarding sex, thus taking away personal freedom. By doing so,
programs make having sex, or even the choice to have sex, more desirable and valuable
to those being told to abstain. The mechanisms by which AOE generates reactivity in
teens is through the dominance of the messenger, the explicitness of the message, and
the lack of reason and support.
Programs championing abstinence are delivered by dominant messengers. First,
there is the government and the schools, which openly support AOE. The concept of
these establishments telling teens what is and isn’t socially acceptable is likely to
generate reactance. An example of reactance to the establishment can be seen in
adolescent response to laws regarding underage drinking, where teens openly disobey as
a way to re-establish their personal freedom. Indeed, studies have found that teen
drinking increased after the legal drinking age was increased to twenty-one, suggesting
psychological reactance as a possible reason for the backlash.13 Besides the overarching
dominance of the establishment, teens are also likely to respond negatively to classroom
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messengers. These are typically teachers, nurses, or other health educators who, as
authoritative figures, can stimulate reactance in youth they are messaging to just by
virtue of their role. This is similar to the psychological reactance to parental figures.15
AOE programs are also intentionally explicit. Under these programs, abstinence
is the only option teens have when confronted with sex, and these programs make this
abundantly clear to teens through the name AOE and through the avoidance of
disseminating information regarding safe sex and contraceptive use. This perceived
coercion can generate reactance similar to that generated by teen anti-smoking
campaigns. Youth were found to respond negatively to such blatant messaging that try
to influence them to behave a certain way14
Lastly, the AOE suffers from a lack of reason and support, which further aids in
generating reactance. Examination of programs has shown they often contain
intentionally misleading, and sometimes even false, information. In fact, a study by the
minority staff of the Committee on Governmental Reform of the US House or
Representatives reviewed thirteen abstinence education curricula for scientific accuracy
and found that eleven of the thirteen contained false or distorted information about
reproductive health.8 These inaccuracies included information regarding the efficacy of
contraceptives and the risks of abortion.8 Several of the curricula referenced the efficacy
of condoms protecting from STIs and pregnancy at 31%, which is false as condoms can
be 99% effective when used properly.16 Additional analysis by Lin and Santelli of three
abstinence-only curricula revealed messaging that condoms fail to protect individuals
from HIV when research indicates they can help protect against STIs.17 AOE programs
also contain inaccuracies regarding risks associated with abortions.8 These false
statements can be misleading and confusing to adolescents. The danger posed by these
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unreasonable arguments is that the lack of strong evidence to support abstinence can
induce anger and negative thoughts in teens. This response stems from feelings of
intrusiveness, as well as the ability of adolescents to easily refute false or distorted
claims put forward by health educators.18 One study regarding the role of reasoned
arguments in reactance found a difference in negative responses based on how strong or
weak the reasoning was supporting the threat to freedom.19 Those who were exposed to
a weak message reported more negative thoughts regarding the threat compared to
those who received a well supported, strong message.19
Reactance is an important issue to consider when developing any health
campaign, particularly when it is a persuasive health campaign for teens. AOE risks a
boomerang effect, where teens may turn to sexual activity to restore their freedom. This
may be a reason for the ineffectiveness of many AOE programs.16 A successful sexual
health campaign must provide accurate information about abstinence through a nondominant messenger without appearing explicitly coercive.
Critique 2: The single-minded message of AOE ignores diversity
The United States is a melting pot, and school classrooms are no different. In any
given classroom there is a mix of genders, sexual orientations, cultural values, and racial
groups. AOE programs do not acknowledge the diverse backgrounds of students and
fail to combat disparities that lead to different sexual health outcomes. Any diversity
that is mentioned is often wrought with stereotypes and possible inaccuracies.20 In
AOE, there are examples of gender stereotyping, lack of sensitivity to socioeconomic
status, and many other failures in diversity education.4 Below are two specific examples
of how AOE largely ignores diversity, specifically in sexually active youth and
homosexual youth.
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The main message of abstinence intrinsically leaves out those students who are
already sexually active. This is a major part of the teen population, as half report having
had sexual intercourse, and 34% report having sex in the last three months.21
Abstinence programs cannot meet the needs of these already active adolescents.
Sexually experienced teens need to be given the skills and resources to make healthy
sexual choices. This includes access to reproductive health services and information
regarding contraception. Currently, AOE programs champion the statement that
abstinence is “the only certain way to avoid” sexual health issues like STIs and
pregnancy.7 This message may aid teens who are not sexually active, but for those who
are already having sex, this message can send the impression that contraceptives like
condoms are ineffective. Furthermore, the AOE approach informs these teens that they
have done something wrong instead of teaching them to take control of their sexuality
and handle their choices regarding sex in a way that promotes their emotional and
physical wellbeing.
AOE curricula also fail to address the sexual health of teenagers who do not
identify themselves as heterosexual or who question their sexual identity (GLBTQ
youth). An estimated 2.5% of high school youth identify themselves as gay, lesbian or
bisexual.22 Additionally, approximately 10% of adolescents question their sexual
identity. 7 AOE classes largely ignore the topic of sexual preference, and only discuss
homosexuality during conversations surrounding HIV/AIDs transmission.7
Furthermore, these programs often portray homosexuality as a deviant, unnatural
behavior. These portrayals may promote stereotyping and homophobia. According to
the federal guidelines outlining AOE, heterosexual intercourse, in the context of
marriage, must be emphasized as the only context for a healthy sexual relationship.8
6
This requirement completely leaves out the potential for healthy homosexuality. Also,
for those individuals living in states that do not allow same-sex marriage, they can never
look forward to a sexual relationship with their partner in the context of marriage. This,
along with the AOE message, may lead to the unrealistic interpretation that homosexual
teens should commit to lifelong abstinence causing these teens to dismiss the idea of
abstinence entirely. Differences in sexual preferences among youth need to be
acknowledged, as the current curricula could lead to homophobia. Internal and external
homophobia puts GLBTQ youth at risk for numerous health problems, including
suicide, HIV infection, substance abuse, and feelings of isolation and loneliness.7
AOE is singular in its message and does not foster and promote discussions that
acknowledge diversity within the classroom. Some students, not just those outlined
above, may end up feeling alienated by such programs. The inability to identify with any
of the views expressed in the classroom means youth are less likely to engage and
benefit from an abstinence-only message. Sexual health programs should celebrate
diversity and acknowledge differences without judgment. They should provide students
with the ability and the resources to seek out and explore their sexual identity in a safe
and healthy manner.
Critique 3: AOE does not consider a holistic definition of teen sexual health
AOE focuses on the decision of whether or not to initiate sex and thus focuses on
only one aspect of sexual health. It assumes that low sexual health comes only from the
consequences of sex. As such, the only way to assure absolute sexual health is to not
have sex. This narrow view does not allow for the consideration that many things
influence sexual health and subsequently fails to acknowledge those threats to healthy
sexuality. This current definition of sexual health is not holistic enough and needs to be
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expanded to show that sexual health goes beyond the absence of negative biological and
psychological effects of unsafe sex.
Under AOE programs “good” sexual health is considered the absence of sex.
However, sexual health is much broader. According to Robinson’s holistic definition,
sexual health includes personal, interpersonal and cultural factors.23 On a personal
level, obtaining sexual health means emotional well being and a well developed selfidentity, self-respect, and self-esteem.23 On an interpersonal level, the individual must
also be in healthy relationship with partners, or potential partners, such that one may
become emotionally and/or physically intimate. This requires open communication
regarding sexual boundaries and desires.23 Lastly, this holistic definition of sexual
health requires that the individual acknowledge sexuality as something positive and life
enhancing as opposed to damaging.23
According to this holistic definition of sexual health, the AOE program fails to
promote true sexual health on the personal level. For example, it does nothing to
promote emotional wellbeing. A study by Sabia found that females who engage in sexual
activity in adolescence are much more likely than their virgin counterparts to suffer
from depression.24 However, an alternative study suggests that sexually experienced
teens over the age of fifteen have higher self-esteem than their inexperienced peers.25
Issues such as low self-esteem are concerning as they have been found to correlated with
higher sexual risk taking behaviors such as not using contraception.26 Thus, promoting
positive self-concepts and self-esteem are important in order promote sexual health.
Beyond the individual level, AOE does nothing to promote sexual health in
relationships. The only interpersonal communication it focuses on is how to say no to
sex. This does nothing to educate teens about healthy romantic relationships or how to
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best communicate with their partner about their sexual boundaries and desires. An
estimated 55% of all US adolescents have experienced a romantic relationship in the
past eighteen months, emphasizing the need to explore how relationship dynamics can
affect sexual health behaviors.27 Studies on adolescent relationships have found that
those who have only recently met their partner are less likely to use contraceptives
compared to those who have been dating their partner for an extended time.27
Additionally, knowing one’s partner on a friendship level prior to a romantic
relationship was found to increase the likelihood that the individual would abstain from
sexual intercourse.27 Conversely, those who just met their partner are less likely to
discuss STIs and the need for contraceptive use with their partner.27 Understanding
adolescent relationships is an important part of promoting sexual health since a great
deal of communication regarding sexual boundaries and safety happens in the context of
these relationships.
On a broader level, AOE promotes negative thoughts regarding sexuality that are
detrimental to teen sexual health. AOE communicates that sex outside of heterosexual
marriage is deviant and harmful behavior.4 Yet, even when asking teens to choose
abstinence, sex should still be communicated as a positive and deeply intimate
experience that everyone, at some point, deserves to have. Adolescence is a time of
emotional and physical development which often includes exploration of sexual
identity.16 During this critical time, negative messaging surrounding sex may lead to
negative attitudes toward and general discomfort with personal sexuality. This is seen in
comparing US teens to their Dutch counterparts. Dutch teenagers report that their first
sexual experiences were wanted, fun and well-timed.20 American teens on the other
hand, are much more likely to say they wished they had waited longer even though the
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timing of initiation of intercourse between the two groups was comparable.20 This
suggests that Dutch adolescents feel they are entitled and free to explore their sexuality
without feelings of guilt or shame. This study also suggests American teens are being
adversely effected by negative messaging surrounding sexual activity. Bombarding teens
with the concept that sex is a deviant act may lead to negative feelings regarding sexual
intercourse and intimacy that can affect their current and future relationships.
AOE hits at only one aspect of sexual experience and thus cannot encourage and
promote healthy sexuality. Future sexual education programs need to focus on this
holistic view that the AOE currently ignores. In order to promote healthy choices and
avoidance of risky sexual behaviors, programs must promote personal sexual health on
more than just a physical level.
Intervention: Pathways to Sexual Health
The aforementioned flaws in AOE warrant a change in federally funded sexual
education programs. For this reason I propose a school-based sexual-health program
focusing on encouraging teens to build skills allowing them to make healthy life choices
and that focuses on encouraging the exploration of personal identity and building selfesteem. The program, entitled Pathways to Sexual Health will be based on the premise
that there are a diversity of opinions regarding sexuality that can exist in concert to
promote improved sexual health for all teens. This program will start in middle school
and run through high school in order to promote development of long-term healthy
practices. It will be run in a fashion similar to the Peer Health Exchange
(peerhealthexchange.org) where information regarding health is disseminated by
undergraduate mentors who reflect the diversity of the students with which they are
speaking and who will not be seen as authoritarian educators. The program will deal
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with a broad range of subjects in a scientifically accurate manner while fostering open
communication through peer discussion. Some of the topics covered will include:

The realities of abstinence - how to make the choice and stick with it

The risks of unprotected sex and other sexual activities

Romantic relationships – how to know if you are in a healthy relationship, avoid
abusive relationships and communicate sexual boundaries to your partner

The truth about contraceptives – what works and what doesn’t

Diversity education – acknowledging and celebrating diversity in fellow students

Self-esteem, personal identity and taking control over your sexual health

Personal mental health - acknowledging that a healthy lifestyle goes beyond
physical health

Access to resources – reproductive health services, contraceptives, relationship
counseling, and psychological counseling.
The main goal of the program is promoting emotional and physical sexual health for all
students regardless of their personal choices surrounding sexual activity.
Response to Critique 1: Reducing the potential for psychological reactance
First, it should be noted that this is a federally funded program. Unlike before
where the government was funding AOE and stimulating reactance in teens, it is
believed that federal support for a “right to choose” program will not illicit a negative
response from teens. The government dominance previously portrayed in the persuasive
messaging supporting only one correct choice is no longer threatening to a teen’s
personal freedom to choose their own sexual path.
11
Perhaps most important for deflecting reactance is the fact that the program’s
main messaging surrounding sexuality comes from peer mentors instead of adult health
educators. Mentor relationships between young adults and teens have historically
proven effective. The similarity will encourage candid conversations regarding sexual
health and a more open forum for communication. In the United States, programs with
a youth-mentoring component have shown greater reductions in initiation of drug and
alcohol use.28 This success can be transferred to sex education. One study of a youth-led
HIV prevention program in Zambian schools found that students who had a peer
mentors were less likely to have had sex in the year post-intervention.29 Furthermore,
those who participated had greater HIV and reproductive health knowledge and lower
levels of stigma regarding HIV than their peers who did not have a youth-led
intervention.29 The increased efficacy of these programs is likely due to the reduced
resistance from having the messenger be similar to the teen as opposed to a figure they
feel is asserting dominance and removing their freedom.
It is important to note that the program also works to reduce reactance through
reduced explicitness and the use of reasoned arguments. As mentioned in Critique 1,
these are the other two factors that contribute to reactance. The program reduces
reactance to explicitness through reduction in perceived coercion. The hope is that
students will still choose abstinence, but this preferred outcome is no longer the sole
message being presented. Additionally, the program will place specific emphasis on
providing scientifically accurate data. Unlike current AOE curricula, 80% of which has
been shown to contain inaccurate information16, this program emphasizes the right of
teens to knowledge and transparency regarding sexual health. Adolescents are less likely
12
to reactive negatively to persuasive arguments regarding abstinence and safe sex if the
arguments are sound and accurate.
Response to Critique 2: Celebrating and encouraging diversity rather than
ignoring differences among teens
The Pathways program epitomizes diversity in name, structure and content.
First, the name of the program hints at the many different paths to sexual health.
Second, the structure of the program which is led by peer mentors will reflect the
diversity of racial, cultural, socioeconomic and sexual identities that are also present in
the school. By encouraging a wide variety of undergraduate students to participate in
the mentor program it can be assured that teens will identify with at least one, if not
multiple mentors and hopefully desire to model their positive example in their personal
sexual health behaviors.
Perhaps most importantly, the content of the program reflects diverse opinions
and viewpoints allowing teens to seek out their own personal identity. By doing so, the
program is inclusive rather than exclusive. For example, for the half of teens that are
already sexually active, information and resources surrounding contraceptives, healthy
relationships and other issues pertinent to sexually active youth will be included in the
program. Addressing sexual health issues as they pertain to homosexuality and
encouraging discussion and exploration regarding sexual identity will similarly include
students of the GLBTQ community who were left out by AOE. Furthermore, the
program teaches teens to celebrate diversity among their peers. Acknowledging and
celebrating diversity will help improve health outcomes for those teens who were
previously being left with no support or resources to make healthy choices under a
program that did not cater to their individual needs.
13
Response to Critique 3: Promoting holistic health through application of
the Sexual Health Model
The Pathways program emphasizes holistic sexual health. As mentioned in
Critique 3, the current sex education model of AOE limits the definition of sexual health
to the absence of negative consequences of sex such as STIs and teen pregnancy. Moving
to a more holistic view of sexual health allows this program to reach beyond the sexual
act to emotional wellbeing, relationships and social health. In order to promote this
holistic view of health, the Pathways program uses of the Sexual Health Model.
The Sexual Health Model focuses on comprehensive management of all the
inputs into the system that help individuals make decisions regarding their sexual
activity and whether or not they choose to do this in a manner that promotes their own
sexual health.23 It looks at sexual health from this broader framework that identity, selfesteem, love, power and desire work to influence sexual choices.23 The theory also lends
support for the idea that unsafe sex may indicate underlying psychological issues and
behavioral patterns that should be addressed in a successful education program.23
Through the use of this approach, the Pathways program applies nine of the ten aspects
of human sexuality defined by the Sexual Health Model: talking about sex, culture and
sexual identity, sexual anatomy functioning, sexual health care and safer sex, challenges,
body image, masturbation and fantasy, positive sexuality, as well as intimacy and
relationships. It should be noted that, as this is a federally funded program, one aspect
of the model, that of spiritually, was left out from this intervention. Yet, the program
still accomplishes its goal of taking a holistic view on sexual health and prevention.
These topics embed traditional prevention strategies within the framework of holistic
14
sexual education.23 Below are a few examples of how the Pathways program applies
these topics.
The program in general promotes personal wellbeing and self-identity,
particularly the development of a sexual identity. It has been shown that an inability to
make safer sex decisions correlates with low emotional and mental health including
issues such as depression, anxiety, anger, and general feelings of unhappiness.30 The
program tries to address the issues of emotional wellbeing and personal identity
through the inclusion of such subject matter as mental health, diversity and promoting a
strong self-identity. Furthermore, the resources such as psychological counseling can
help students who are experiencing emotional health issues.
Sexual Health Model places emphasis on understanding intimacy and
relationships. The cornerstone of the model is the ability to be upfront and honest in
conversations with sexual partners regarding personal sexual values and barriers as well
as the ability to negotiate safe sex .23 As previously mentioned, this plays a large role in
adolescent sexual health as most adolescents experience romantic relationships at some
point.27 Through this program, issues of relationship and intimacy will be addressed in
a way that promotes open communication within adolescent relationships. First, the
actual topic of healthy relationships is covered in the program. Also, the mentors will be
well positioned as peers to share their own relationship experiences. Through this and
the curricula, students will gain a better understanding of the need to discuss their
personal sexual boundaries with their partner and, if they choose to be sexually active,
they will have the skills to communicate effectively to insist on the use of contraceptives.
Additionally, the resources of the program will help assist couples in making safe and
healthy decisions about their sexual relationship.
15
The program also applies the Sexual Health Model by promoting positive
sexuality. The AOE model’s messaging regarding the negative ramifications of sexual
interaction likely skew adolescent views toward sexuality in a negative direction.16
Feelings of guilt and dissatisfaction with sexual choices have been shown to plague
adolescents more often compared to their peers in sex-positive societies.20 Fisher and
colleagues found that those students with negative feeling about sexuality had lower
levels of sexual knowledge and were less likely to participate in an elective course
regarding human sexuality.31 To avoid this negativity, the overall tone of the program
promotes healthy sexual behaviors and the right to explore personal feelings regarding
sex without directly negative statements about sex. Although the risks of unsafe sexual
practices will still be covered in depth, the program has shifted to a more encouraging
tone welcoming questioning and personal reflection. Beyond the general angle of the
program towards a sex-positive tone, the program also encourages the exploration of
positive personal identities and sends the message that choosing to have sex is okay, as
long as it is done safely, through the discussions surrounding contraceptive use and the
number of resources provided to teens who decide to be sexually active. The Sexual
Health Model postulates that individual, positive sexuality will improve the ability to set
appropriate boundaries and, if sexually active, will be more likely to insist on safe sex.23
It is the hope that this intervention will do exactly that for teens who have previously
been discouraged regarding their sexuality.
Conclusion: The Road to Change
AOE education is a backwards system that does little to promote adolescent
sexual health. Yet, it continues to be supported by the US government as an acceptable
method for sexual education of adolescents. $33 million dollars a year continue to be
16
spent towards abstinence education in spite of the program’s flaws. Even when funding
was at its highest level under the Bush administration, with approximately $150 million
in annual funding, teenage sexual activity levels remained fairly stable.16 Some groups
in support of AOE have pointed to reduced teen pregnancy as a measure of success, but
an analysis by Santelli and colleagues in 2007 found that the drops in teen pregnancy
rates were mostly attributable to an increase in contraceptive use.32
Although federal funding for abstinence education has decreased under the
Obama administration, AOE continues to be the governmental standard for sex
education and increased funding for such programs is included in the Healthcare
Reform Act. Encouragingly, policy makers at the state level have begun to voice their
apprehension surrounding AOE. As of 2008, seventeen states had rejected abstinence
only federal funding in support of more comprehensive sexual education.16 Citizens are
also voicing their support. A cross-sectional study in 2006, found that over 80% of
adults support programs that promote abstinence as well as methods for helping
adolescents prevent unwanted pregnancy and STIs.33 It seems that public and political
opinion are beginning to turn toward favoring more comprehensive programs on sexual
health similar to the Pathways program described above. US citizens need to continue
to push for these types of programs in order to promote true sexual health for American
teens.
17
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