Challenging Dogma - Fall 2011

Friday, December 23, 2011

Abstinence-Only-Until Marriage Youth Sexual Health Education: A Theory-Based Criticism and an Alternative Model – Sarita Sonalkar


By the age of 19, seven in 10 adolescents have had intercourse. This rate is similar to that reported in other developed nations, but the rates of teen pregnancy, births, and abortions in the United States are among the highest in the developed nations (1). Sexually transmitted diseases (STDs) disproportionately affect adolescents, with the highest age-specific chlamydia and gonorrhea rates occurring in women aged 15-19 years (2).

Both unintended pregnancy and sexually transmitted infections have disturbing public health consequences for teens. Women with unintended pregnancy are at risk for unintended childbearing, which is associated with adverse maternal behaviors and child health outcomes, including inadequate or delayed initiation of prenatal care, smoking and drinking during pregnancy, premature birth and lack of breastfeeding, and negative physical and mental health effects on children (23). Gonorrhea and chlamydia are associated pelvic inflammatory disease, potential fatal ectopic pregnancy, and infertility. Finally, young adults aged 13-29 accounted for 39% of all new HIV infections in the United States in 2009 (2).

Adolescents who have accurate knowledge about abstinence and contraception are more likely to delay initiation of sexual activity, or to use condoms and other contraceptive methods when they do become sexually active (4). Given the potential adverse outcomes of risky sexual behaviors in teens, sexual health education has been incorporated into many U.S. schools. However, little is known about the scope and content of this education. In a survey of a representative sample of sexual health education teachers in Illinois (as a case study for the U.S.), 50% of Illinois sex education teachers used an abstinence-only-until-marriage curriculum (10). This is in contrast to what is termed a “comprehensive” curriculum, in which both abstinence and safe sexual practices are taught. The integral components of comprehensive sexual health education are not defined and vary by organization, but general agreement exists that adolescents should be provided at minimum with medically accurate information about abstinence, contraception, HIV/AIDS, and other STDs (10).

Comprehensive sex education is supported by U.S. health professionals, and by most U. S. adults (4,5), but is being increasingly replaced by abstinence-only education (24). Since 1996, over one billion dollars have been invested by the U.S. federal government and individual states to support abstinence-only-until-marriage” education programs. To qualify for government funding, these programs must adhere to an 8-item definition of abstinence as outlined below (7, 14):

A. “Have as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity

B. Teach abstinence from sexual activity outside marriage as the expected standard for all school-age children

C. Teach 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. Teach that a mutually faithful, monogamous relationship in the context of marriage is the expected standard of sexual activity

E. Teach that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects

F. Teach that bearing children out of wedlock is likely to have harmful consequences for the child, the child’s parents, and society

G. Teach young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances

H. Teach the importance of attaining self-sufficiency before engaging in sexual activity”

Despite the extensive funding these programs have received, research has shown that these programs do not affect initiation of sex, age of initiation of sex, abstinence in the previous 12 months, number of sexual partners, use of condoms, use of contraception, frequency of unprotected sex, pregnancy rates, birth rates, or STD rates (8,9). On the other hand, comprehensive programs have shown strong evidence of positive effects on behavior including delaying the initiation of sex, reducing frequency of sex, reduced number of sexual partners, increased condom use, increased contraceptive use, or reduced risky sexual behavior (4).

Social and behavioral sciences models may be applied to more deeply understand the causes for the failure of abstinence-only education. Described in this paper will be a critique of abstinence-only education based on the social and behavioral science model of psychological reactance theory, as well the argument that these programs are often unethical and discriminatory. Furthermore, these critiques will then be utilized to design a model for an improved sexual educational program.

Psychological reactance theory and abstinence-only education

When people think that a freedom is being threatened, they experience a motivational state called reactance, which is aimed at restoring the threatened freedom. The intensity of reactance has been found to be a direct function of the magnitude of the threat upon the freedom, the number of free behaviors jeopardized, and the value placed upon them (15).

These concepts were described by Brehm in 1966 as part of the Psychological Reactance Theory (11). The theory states that each person believes him or herself to have a set of “free behaviors” in which he or she could partake. Reactance plays a role in improving the appeal of a threatened or eliminated freedom. In addition, it may protect the capacity to elect not to do something. Thus, coaxing or persuasive attempts to do the threatened task are often met with greater resistance (15). Finally, Brehm also clarified a relationship between reactance theory and the concept of control. Control was defined as “the ability to affect the probability of occurrence of a potential outcome. To the extent that one has this ability, one has a freedom…[this]definition of ‘control’ is equivalent to that of ‘freedom’ as used in reactance theory.” Thus, if something threatens control, freedom is threatened.

The specific curricula for abstinence-only programs vary greatly. However, the basic principles of this education as outlined above provide a framework for how abstinence-only education is delivered. When adolescents hear messages of abstinence as an “expected standard” their reaction based on psychological reactance theory is to do just the opposite of that standard. In addition, the fear-based messages of “harmful psychological and physical effects” of “out-of-wedlock” children and “sexual activity outside the context of marriage” would also elicit reactance (7).

A California abstinence-only education program called “Free to Be” was reviewed and criticized by the Public Health Institute, in part because of messages of fear when addressing the issue of teens’ choice to engage in sexual activity. Exaggerated negatives were attributed to premarital sexual activity and methods to reduce risk of pregnancy and STDs. In one activity entitled “The Bridge,” teens who choose to become sexually active are crossing a shaky bridge with rocks below displaying the words “sad,” “lonely,” “stress,” “guilt,” “feel used,” “lose goals,” and “parents disappointed” as what seem like inevitable outcomes (16). These types of messages are clearly threatening and coercive, and are likely to meet resistance by adolescents.

Finally, most sexual education programs are administered by adult educators. In a 2008 survey of Illinois sexual education programs, 97.4% were adults over the age of 24. In a 2005 article, the concept of deflecting reactance through interpersonal similarity was described and studied. In this article, similarity reduced perceptions of threat, even when the communicator was highly threatening. Thus, these educators by the nature of their age difference compared to adolescents, may heighten baseline reactance that students have harbored from the education curriculum itself (10).

This reactance is likely to lead to pursuing sexual activity as the opposite of the given message of abstinence, without the benefit of accurate information on contraception and STI prevention that would be afforded by comprehensive sexuality education.

Abstinence-Only Education: Content flaws

Sexual health educators have a basic duty, at minimum, to provide medically accurate information about abstinence, contraception, HIV/AIDS, and other sexually transmitted diseases (10). Without provision of this information, adolescents are in fact at higher risk of adverse outcomes. In the California “Life Choice.Healthy Futures” curriculum reviewed by the Public Health Institute, multiple inaccuracies in information were discovered. For example, multiple infections were misclassified as sexually transmitted when in fact, they are not. In some cases, the primary route of transmission of infection was disregarded, as in campylobacteriosis and salmonellosis, which are food-borne infections. Bacterial vaginosis, and vulvovaginal candidiasis are listed as sexually transmitted, which is simply false. Misleading information is given regarding human papillomavirus (HPV) in that it is reported to “have no cure” and “can lead to death.” In fact, HPV is often self-limited in young women, and has excellent cure rates with routine preventive care (16).

The curriculum relies on misleading information about the effectiveness of condoms in preventing STDs. It describes 2001 report from the National Institute of Allergy and Infectious Diseases that states that there is “insufficient evidence” to draw definite conclusions about the effectiveness of the latex male condom in reducing the transmission of most common STDs. However, although this report concluded that the available information was inaccurate, it focused on the need for more well designed studies. Since that time, evidence has shown that condoms are highly effective at reducing STD risk if used correctly.

The curriculum also provides misleading information regarding the effectiveness of condoms in preventing pregnancy. The report cites only typical use failure rates of condoms (15%) without providing the context of perfect use failure rates of 2%. Only 34% of all sexual education programs (including comprehensive programs) teach the proper use of condoms, and it is highly unlikely that this particular program would teach condom-use skills to adolescents. Thus, the program likely does not attempt to improve proper use of condoms in adolescents. The “Live Choice.Healthy Futures” curriculum omits all medically accurate information the effectiveness and safety of FDA-approved contraceptive methods.

Finally, contraceptive efficacy statistics are most commonly divided into “perfect” and “typical” use failure rates (17). Although it is prudent to supply adolescents with typical-use statistics for all methods, no “typical-use” efficacy is provided for abstinence. This is in part because no research has assessed this. However, abstinence-only curricula fail to teach even the concept that abstinence also has a failure rate. If abstinence is promoted as a contraceptive method, adolescents should receive information, at least conceptually, about typical adherence to the method and its efficacy.

The medical inaccuracies in the abstinence-only curriculum can be viewed as stemming from a desire to implement the Health Belief Model. These incorrect medical facts play into teens perceptions of susceptibility, severity, benefits of abstinence, and barriers to abstinence (18). These are individual-level concerns, and thus are not likely a deep effect on teens decisions regarding initiation of sexual activity, as opposed to the effect of peer and other social interactions. However, inaccurate medical information is unethical and immoral in the context of a public health intervention. In fact, young people who took virginity pledges in the context of an abstinence-only program were one-third less likely to use contraception when they did become sexually active, than peers who had not pledged. In addition, those who took virginity pledges had the same rate of STDs as those who did not pledge, because of decreased condom usage and decreased STD testing and treatment (16).

Abstinence-only-until-marriage: discrimination and marginalization

A true public health intervention aims to improve health for the entire targeted population, and school-based sexual education is no exception. The definition for abstinence as stated by the Title V Social Security Act definition includes the statement that “Teach that a mutually faithful, monogamous relationship in the context of marriage is the expected standard of sexual activity” (14). This stipulation is deeply discriminatory to those who may not have the right to marry such as lesbian, gay, or transgender youth. In addition, marriage may not be considered an ideal goal for all adolescents, and should not be stated as a moral standard. This language alienates youth from nontraditional families or those with divorced, widowed, or unmarried parents, and excludes gay and bisexual youth. Finally, it causes mistrust and vilification of siblings or friends who may have initiated sexual intercourse. Thus, a large portion of students will find that this education is not realistic or relevant to their lives, and may even serve to fracture current important relationships in their lives. Mistrust in an intervention based on discrimination is unlikely to foster any positive outcome of the intervention.

In summary, abstinence-only education is a flawed public health concept based on the following three issues:

1) Promoting abstinence is likely to result in psychological reactance.

2) Misinformation in an educational curriculum is unethical, likely to result in decreased trust, and poorer health outcomes.

3) Discrimination against sexual minorities and students without married parents harbors poor trust in these groups, thus negating potential positive effects.

Alternative Intervention – General Concepts

Abstinence-only curricula addressed above fail, at their core, to trust the students that they are attempting to educate. By failing to acknowledge basic facts about teens (that is, that most of them initiate intercourse), failing to provide accurate education, and by conveying messages of fear, shame, and guilt for who they are (sexual beings), these programs are not truly speaking to adolescents. Comprehensive sexual education curricula are certainly a solution, but as in abstinence-only curricula, there is great variation in the content and delivery of programs. In an evidence-based review of effective sexual education programs, the following common characteristics were identified (21):

1) A clear message that using contraception consistently and carefully is the right thing to do, as opposed to simply laying out the pros and cons of different sexual choices.

2) Sufficient length of a program (longer than a few weeks)

3) Leaders who believe in the program and have adequate training

4) Active engagement of participants with personalization of information

5) Addressing of peer pressure

6) Building of communication skills

7) Reflective of the age, sexual experience, and culture of young people in the program

Beyond the above characteristics, this program should be based in theory, and should take into account the goals and values of its target population. Finally, a sexual education program should be standardized in order to allow for program evaluation, while still having the ability to be culturally competent.

The content of this program would span over multiple grades with monthly mixed-methodology and interactive sessions addressing age-appropriate material including basic reproduction, sexuality, self-esteem, empowerment, sexually transmitted disease prevention, and contraception. Sessions would have some didactic components, but always involve either small group sessions for discussion or hands-on interactive exercises and field trips.

Alternative Intervention – Incorporating Psychological Reactance Theory

One alternative model for a comprehensive sexuality education program would be implemented using a peer education program. Peer educators would be trained as leaders in sexuality education. These educators would be motivated high-school students who are seen as role models, and would be selected either if they volunteered, or if teachers recruited them. These peer leaders would undergo a rigorous and defined for-credit summer or after-school curriculum prior to starting as leaders in their school system. This “teacher training” would be for course credit, and designed and run by health teachers, nurses, local reproductive health experts including clinicians, and educational experts.

Psychological reactance theory states that persuaders are more effective when they avoid threatening persuasion tactics. These concepts are addressed in the alternative model by the use of positive and non-threatening messages. Positive messages include the ideas of trusting relationships, communication, sexual satisfaction (with or without intercourse), and the benefits of condom and birth control usage. Rather than disseminating fear-based messages about sexual activity, condom usage, and contraception, this program would embrace sexuality as a normal part of adolescence and work within that framework to promote condoms and hormonal contraception as positive. Students should be given information as to where to receive contraceptive methods, ideally, on a school campus clinic. As one module of the program, students should be taken on a tour of this clinic, meet friendly clinic staff, and be assured of confidentiality of care in order to dispel fears or apprehension in seeking care. By creating an atmosphere that sexuality can be fun, healthy, and responsible (rather than creating an atmosphere of judgment), students are more likely to adhere to recommendations.

Also determined to be part of psychological reactance, interpersonal similarity improves the influence of the persuader. The use of well-trained peer leaders rather than adult teachers would help to diffuse reactance that can be bred by non-similarity (20).

Alternative intervention: Medically accurate, and ethically sound

A comprehensive sexual education program should be designed in a multidisciplinary fashion by expert educators, public health professionals, and medical professionals to provide accurate, up-to-date information, and should ideally be peer-reviewed in both the educational and medical communities.

Public health interventions are more effective if they speak to the core values of the population they are trying to reach. Given what we know about the lack of effect of graphic and fear-based messages to prevent smoking, it is unlikely that fear-based messages of sexually transmitted diseases will influence adolescents to abstain or use condoms. Secondly, based on the law of small numbers, although students may overestimate overall risks of contracting STDs, they are unlikely to believe that they themselves are at risk. Regardless, it is important to provide basic information on how to recognize and treat STDs, and which STDs are treatable with antibiotics (such Chlamydia), and which ones can be managed but have no definitive cure (such as herpes and HIV).

More important to medical accuracy is the reinforcement of behaviors to prevent STDs and pregnancy. This would be done by having condoms readily available to take home, and by allowing students to touch, play with, and practice using them properly on models, thus removing some of the taboo from their use.

Alternative model - Nondiscriminatory

The alternative model would not discuss concepts of marriage as the ideal framework for sexuality. This is unrealistic and not in accordance with teen and adult life. Instead, the alternative model would incorporate the Sexual Health Model, which incorporates 10 key components thought to be essential to healthy human sexuality: talking about sex, culture and sexual identity, sexual anatomy and functioning, sexual health care and safer sex, challenges to sexual health, body image, masturbation and fantasy, positive sexuality, intimacy and relationships, and spirituality (22). These emotionally mature concepts would better taught via college-aged students rather than high school students. In this framework, discussions of healthy relationships including same sex relationships can be discussed. Thus, this intervention would not marginalize the very common sexual relationships that occur outside of marriage. In fact, this curriculum would teach adolescents about the wide gamut of healthy sexuality and foster tolerance and respect for peers.

In conclusion, sexuality education needs to take into account the values and lifestyle of the students it is trying to teach. In the current form of abstinence-only-until marriage education, the only values that are being incorporated are those of conservative politicians. Educational programs should not have stipulations and rules outlined by the government, even if they are government-funded. Those people who are best suited to design public health programs are those with experience with young people and public health and medical professionals. Sexuality education should enforce positivity and peer role models, and be medically accurate, culturally competent and ethically sound. In an alternative and improved model for sexuality education, the youth are the focal point.


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14. Title V. Section 510 (b) (2) (A-H) of the Social Security Act (P.L. 104-193).

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24. Lindberg, L.D. et al. Changes in Formal Sex Education 1995-2002 Perspectives on Sexual and Reproductive Health 2006; 38:182–189.

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