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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 2 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 3 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 4 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. 5 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 7 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 8 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 9 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 10 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 References 1. Singh, S., Darroch, J.E. & Frost, J.J. Socioeconomic disadvantage and adolescent women’s sexual and reproductive behavior: the case of five developed countries. Fam Plann Perspect 33, 251-258, 289 (2001). 2. Kirby Emerging answers 2007: Research findings on programs to reduce teen pregnancy and sexually transmitteddiseases. (2007).at <http://www.thenationalcampaign.org/EA2007/EA2007_full.pdf> 3. Weinstock, H., Berman, S. & Cates, W., Jr Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health 36, 6-10 (2004). 4. Santelli, J. et al. Abstinence and abstinence-only education: a review of U.S. policies and programs. J Adolesc Health 38, 72-81 (2006). 5. Taylor, J.L. Midlife Impacts of Adolescent Parenthood. J Fam Issues 30, 484-510 (2009). 6. Woodward, L.J., Horwood, L.J. & Fergusson, D.M. Teenage pregnancy: cause for concern. N. Z. Med. J. 114, 301-303 (2001). 7. Ott, M.A. & Santelli, J.S. Abstinence and abstinence-only education. Curr. Opin. Obstet. Gynecol. 19, 446-452 (2007). 8. Waxman The Content of Federally Funded Abstinence-Only Education Programs. United States House of Representatives Committee on Government Reform-Minority Staff. (2004).at <http://www.csulb.edu/~nmatza/powerpoint/HSc411BAssign/Course%20Docs/Abst inence%20Only/abstin.only.wax2007.pdf> 9. SIECUS House Zeros out Existing Abstinenc-Only Funding; Invests in EvidenceBased Prevention Efforts. (2009).at <http://www.siecus.com/index.cfm?fuseaction=Feature.showFeature&featureID=17 86> 10. US Department of Health and Human Services Abstinence Grants. (2011).at <http://www.hhs.gov/news/press/2010pres/09/teenpregnancy_abstinencegrants.ht ml> 11. Haffner, D.W. What’s wrong with abstinence-only sexuality education programs? SIECUS Rep 25, 9-13 (1997). 12. Bearman, P.S. & Brückner, H. Promising the Future: Virginity Pledges and First Intercourse. American Journal of Sociology 106, 859-912 (2001). 13. Allen, D.N., Sprenkel, D.G. & Vitale, P.A. Reactance theory and alcohol consumption laws: further confirmation among collegiate alcohol consumers. J. Stud. Alcohol 55, 34-40 (1994). 14. Miller, C.H., Burgoon, M., Grandpre, J.R. & Alvaro, E.M. Identifying principal risk factors for the initiation of adolescent smoking behaviors: the significance of psychological reactance. Health Commun 19, 241-252 (2006). 15. Driscoll, R., Davis, K.E. & Lipetz, M.E. Parental interference and romantic love: the Romeo and Juliet effect. J Pers Soc Psychol 24, 1-10 (1972). 18 16. Duffy, K., Lynch, D. & Santinelli, J. Government Support for Abstinence-OnlyUntil-Marriage Education. Clin Pharmacol Ther 84, 746-748 (2008). 17. Lin, A.J. & Santelli, J.S. The accuracy of condom information in three selected abstinence-only education curricula. Sexuality Research and Social Policy 5, 56-69 (2008). 18. Dillard, J.P. & Shen, L. On the nature of reactance and its role in persuasive health communication. Communication Monographs 144-168 (2005). 19. Chen, H.C., Reardon, R., Rea, C. & Moore, D.J. Forewarning of content and involvement: Consequences for persuasion and resistance to persuasion. Journal of Experimental Psychology 523-541 (1992). 20. Schalet, A.T. Beyond abstinence and risk: a new paradigm for adolescent sexual health. Womens Health Issues 21, S5-7 (2011). 21. CDC Sexual Behaviors - Adolescent and School Health. (2009).at <http://www.cdc.gov.ezproxy.bu.edu/HealthyYouth/sexualbehaviors/> 22. Garofalo, R., Wolf, R.C., Kessel, S., Palfrey, S.J. & DuRant, R.H. The association between health risk behaviors and sexual orientation among a school-based sample of adolescents. Pediatrics 101, 895-902 (1998). 23. Robinson, B.B.E., Bockting, W.O., Rosser, B.R.S., Miner, M. & Coleman, E. The Sexual Health Model: application of a sexological approach to HIV prevention. Health Educ Res 17, 43-57 (2002). 24. Sabia, J.J. & Rees, D.I. The effect of sexual abstinence on females’ educational attainment. Demography 46, 695-715 (2009). 25. Haffner, D.W. Toward a new paradigm on adolescent sexual health. SIECUS Rep 21, 26-30 (1993). 26. Rosenthal, D., Moore, S. & Flynn, I. Adolescent self‐ efficacy, self‐ esteem and sexual risk-taking. Journal of Community & Applied Social Psychology 1, 77-88 (1991). 27. Kaestle, C.E. & Halpern, C.T. Sexual Activity Among Adolescents in Romantic Relationships With Friends, Acquaintances, or Strangers. Arch Pediatr Adolesc Med 159, 849-853 (2005). 28. Sipe, C.L. Mentoring programs for adolescents: a research summary. J Adolesc Health 31, 251-260 (2002). 29. Denison, J.A. et al. Do peer educators make a difference? An evaluation of a youth-led HIV prevention model in Zambian Schools. Health Educ Res (2011).doi:10.1093/her/cyr093 30. Ross, M.W. Psychological determinants of increased condom use and safer sex in homosexual men: a longitudinal study. Int J STD AIDS 1, 98-101 (1990). 31. Fisher, W.A. et al. Students’ sexual knowledge, attitudes toward sex, and willingness to treat sexual concerns. J Med Educ 63, 379-385 (1988). 32. Santelli, J.S., Lindberg, L.D., Finer, L.B. & Singh, S. Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. Am J Public Health 97, 150-156 (2007). 33. Bleakley, A., Hennessy, M. & Fishbein, M. Public opinion on sex education in US schools. Arch Pediatr Adolesc Med 160, 1151-1156 (2006). 19