Challenging Dogma - Fall 2011

Wednesday, December 28, 2011

Abstinence-Only vs. Comprehensive Sexual Education Efficacy in Reducing Teenage Pregnancy Rates in the United States—Lauren Dustin

Teenage Pregnancy Rates in the U.S.

Teenage pregnancy is a public health issue that affects every individual in a community. In 2006, 750,000 teenage girls, aged 15-19, became pregnant. Having a child during teenage years carries many emotional, physical, and financial costs to the parents and community. Teen childbearing costs $9 billion to taxpayers annually, and teen birth rates in the U.S. are up to 9 times higher than most other developed countries. (1) Teens get most information about sex and pregnancy prevention from their school curriculum. About 70% of school districts teach comprehensive sex education that includes information on the risks of sexually transmitted diseases, unintended pregnancies, contraception methods, and abstinence, while other schools teach abstinence-only curriculums. Between the years of 2006-2008, most teens had received information about most of these topics; however, about one-third of teens had not received any formal instruction about contraceptive methods and use. (2) In 2009, there were 39.1 births per 1,000 women aged 15-19, marking an historic low with a decline of 37% from the peak rate of 61.8 in 1991. (3) Although the rate of teenage pregnancy has been steadily declining, there is still a lot more work to be done in finding the most effective educational program.

How Teen Pregnancy is Currently Addressed

Sexual health education is handled in varying ways throughout our nation’s schools. About 35% of school districts in the U.S. believe in abstinence-only education that does not provide any additional information on other methods of prevention from STDs and pregnancy. Discussion of contraception is either prohibited completely, or only permitted in order to emphasize its ineffectiveness. The remaining school districts use comprehensive sex education programs sometimes referred to as abstinence-plus programs. These programs teach abstinence as the most effective method, but also include information and resources on other effective measures of prevention. There have been some shifts in which programs schools prefer, and the biggest change in sex education policies has been toward more schools using abstinence-plus policies. (4)
Abstinence-only education is based on the belief that young men and women are unable to develop committed, loving relationships, and that this leads to childbearing out-of-wedlock. These programs focus on how to develop loving and enduring relationships first before sexual activity. Supporters of abstinence-only programs argue that teaching teenagers about contraception implicitly encourages sexual activity. (5) So instead, abstinence-only education teaches that abstinence is the only way to avoid STDs and pregnancy, and every other method is ineffective. Most programs focus on instilling moral or religious values rather than providing accurate health information. Evaluation of abstinence-only programs found no delay in first sex and analysis of federally funded programs were even found to contain false, misleading, or inaccurate information about reproductive health. (6)

Supporters of comprehensive sex education or abstinence-plus programs say that it may not be reducing sexual activity in teens, but it is teaching them how to do it safely in order to prevent negative outcomes. About half of all teens ages 15-19 are sexually active, and a sexually active teen that does not use contraception has a 90% chance of becoming pregnant within one year. (2) This type of program recognizes the inevitability that most teens are going to be sexually active at some point during their adolescence, and their aim is to prepare them to make healthy and informed choices about contraception. A national survey revealed that 78% of parents of teenagers agree and believe that their children should learn about birth control and safer sex in school. Many medical organizations such as the Institute of Medicine, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American Academy of Pediatrics also support the inclusion of contraceptive information with abstinence education to prevent teen pregnancy and STDs. (7)

There is no evidence to date that abstinence-only education delays teen sexual activity. However, research shows that abstinence-only strategies may deter contraceptive use and increase a teen’s risk of unintended pregnancies and STDs. (2) A study that compared abstinence-only and abstinence-plus education found that programs offering contraceptive education significantly influenced students’ knowledge and use of contraception methods. The study also found that abstinence-plus education led to increased contraception use by teens at follow-up compared to abstinence-only education. In addition, the use of abstinence-plus programs did not lead to an increase in sexual activity by teens, as mistakenly believed. (7) Evaluations of comprehensive sex education show that they do not increase rates of sexual initiation, they do not lower the age of first sex, and they do not increase the frequency of sexual activity or number of partners. In fact, teens who receive comprehensive sex education have a lower risk of pregnancy than those who receive abstinence-only or no sex education. (8)

New studies have shown that an increase in contraception use, not abstinence, is responsible for the decline in teenage pregnancy rates. According to the Guttmacher Institute, “86% of the decline can be attributed to the use of contraception, while only 14% can be attributed to abstinence.” (9) To reduce rates of teenage pregnancy, programs need to either improve contraceptive behaviors, reduce teen sexual activity, or both. Prohibiting contraceptive education in school-based programs keeps the very information that may have the greatest potential to decrease pregnancy rates from the people who need it the most. However, community attitudes towards teenage sexuality, rather than evidence-based interventions, greatly impact the acceptance of publicly funded school-based sex education programs. (7)

Government funding and policy-making by Congress, and individual state governments provide the basis for which type of education is used in certain school districts. In December 2009, Congress replaced the rigid Community-Based Abstinence Education Program with a new $114.5 million teen pregnancy prevention program to support evidence-based interventions and created the five-year Personal Responsibility Education Program (PREP). Its purpose is to educate adolescents on both abstinence and contraception, and to prepare them for adulthood by teaching subjects such as healthy relationships, financial literacy, and decision-making. Congress also renewed the Title V abstinence-only programs for another five years to provide funding to schools that choose to promote abstinence. (3)

Critique of Abstinence-Only Sexual Education Programs

Although abstinence-only education has not been proven to be effective or ineffective in preventing teen pregnancy in the United States, we can see how these programs have failed to apply social science theories correctly and are flawed in three fundamental ways.

The first major flaw in abstinence-only education programs is that it takes freedom and control away from teenagers when it comes to making decisions about sexual activity. Abstinence is stressed as the only effective method to prevent STDs and pregnancy, and teens are simply told to abstain. There is no information given about other methods of contraception so teens are not even given a choice to make, it is made for them. This type of program fails to consider the Theory of Psychological Reactance and how people react to their freedom being threatened or taken away. The theory says that when a person feels their freedom is being threatened, they experience reactance, a motivational state aimed at restoring the threatened freedom. (10, 11) In other words, they react by doing the negative behavior they are told not to do. When a teen is not given the freedom to make their own choices about sexual activity and contraception and they are simply told not to have sex, they will act out by doing the opposite of what they are told. Since abstinence-only programs do not provide information about contraception, these teens are at a greater risk for STDs and pregnancy because they are less likely to use any form of contraception when they do engage in sexual activity. (7)

Another flaw in abstinence-only education is the use of an improper communicator. These programs use adults, specifically teachers, to convey the message of abstinence as the only option. Teachers are the dominant player in the student-teacher relationship and their dominant and explicit messages can evoke increased psychological reactance. (11) Abstinence-only programs do not take into account the importance of similarity that is stressed in the Communication Theory, and that is also used as a way to reduce reactance and increase compliance. Teenagers who find it hard to relate to adults teaching them about abstinence will resist the very message. One of the most important aspects of the Communication Theory is the use of a messenger that is as similar as possible to the target audience. (12) The use of similarity has been found to reduce reactance and increase compliance. In a study done by Silvia, results showed that similarity increases liking and positive forces towards compliance while reducing negative forces toward resistance. Similarity also increases the communicator’s credibility and reduces the perceived threat to freedom. (10) Teachers and other adults may be the most practical communicator for school-based education, but in reality they are the least similar to the target audience and most likely to evoke reactance.

The last flaw of abstinence-only sex education is that providing inaccurate information or withholding information about contraception is morally and ethically wrong and unsafe. Abstinence is often presented as the moral choice for adolescents contemplating sexual activity. However, the current federal approach to supporting more funding for abstinence-only education raises serious human rights concerns. Access to complete and accurate sexual health information has been recognized as a basic human right and essential to make critical health decisions regarding sexual activity and the prevention of STDs and pregnancy. Abstinence-only programs are problematic because they withhold information and promote sometimes questionable and inaccurate opinions rather than facts. This threatens the fundamental human rights to health, information, and life. (13)

This flaw is a result of the incorrect usage of the Consumer Information Processing Model. This model explains that information is a necessary tool in health education; however, it is not sufficient for knowledge in general. Consumers, or students in this case, tend not to engage in extended searches for information. Therefore, if information about safe sex practices is not given to them in a structured way, they will most likely not seek it out themselves and this puts them in danger of contracting an STD or becoming pregnant if they do not know how to protect themselves. The Consumer Information Processing Model also states that before people will use health information it must be: available, seen as useful and new, and presented in a friendly format. This is where abstinence-only programs are flawed. They do not provide the new, useful, and necessary information in the first place, and the information they do provide, sometimes inaccurate, is not presented in a friendly way. (14)
Without complete and accurate information about sexual health and contraception, teens are unable to make a fully informed decision regarding sexual activity and STD and pregnancy prevention. In fact, teens who only receive abstinence messages face a greater risk of contracting an STD or becoming pregnant because they do not possess the necessary resources on other methods of contraception. (7)


The actual causes of teenage pregnancy are not fully understood, but public health professionals would likely argue that a lack of information is a main reason. Teens that are not getting information about contraception and other prevention resources are at an increased risk for negative consequences because they are not informed or prepared to make these important decisions in a safe way. As discussed, abstinence-only sex education programs may be the least effective way to reduce teenage pregnancy rates because they are severely flawed. The explicit, forceful, and dominant messages portrayed by abstinence-only educators are the definition of what evokes psychological reactance in teens. When teenagers are told simply not to do something, they perceive their freedom to be threatened and they react to gain back that freedom by doing that behavior. This is the opposite of what abstinence-only programs want. Additionally, the use of a dissimilar communicator only heightens reactance and resistance to the abstinence-messages. People respond well and tend to comply with the beliefs and messages of a person who is most similar to them, often regardless of how threatening the message is. Lastly, the use of abstinence-only sex education in schools is morally and ethically wrong because they withhold crucial information that can be considered a basic human right in the context of making sexual health decisions. Teens need to be given the information that is new and useful to them because they are likely not going to seek out the information themselves. All of these flaws create inefficiencies that can severely hinder any possible progress made towards lowering the rate of teenage pregnancy.

New Theories

Using the social and behavioral theories previously discussed in the correct way along with several new theories will help to create a new and more effective sexual education intervention. These theories keep the target audience in mind and they recognize the need to reduce reactance in order to be successful. The new intervention will be comprehensive to include information not only about abstinence as the most effective method of STD and pregnancy prevention, but also additional information on other methods of contraception and how to use them.

Limiting Psychological Reactance & the Illusion of Control

Instead of using forceful abstinence-only messages, sex education programs should give the freedom of choice. Don’t tell teens what to do (abstain from sex), tell them what they can do instead (use protection if they become sexually active). Psychological Reactance can be a risk factor for initiation of the negative health behavior so it is important to limit reactance in order for an intervention to be successful in achieving its goal. One way to limit reactance to an intervention is to measure it before starting by finding out if the campaign would elicit reactance in the target audience. Public health professionals can do this through pilot studies or through questionnaires given to teens to assess their attitudes towards abstinence-only versus comprehensive abstinence-plus programs. To avoid reactance we need to know what elements can lead to it. Explicitness, dominance, and reason are three items that can influence reactance. The more explicit or forceful a message is, the more it evokes psychological reactance. When a communicator is perceived to have dominance over the message recipient, this increases reactance as well. However, when reason or support is given for the claim, this is likely to reduce perceived threats and reduce reactance. (11)

The Illusion of Control Theory explains that people value control over their lives or events that happen to them most when they have ownership over that behavior. If public health professionals were to use an intervention that sells control rather than takes it away, this would be accepted much more readily by our target audience. To give teen’s ownership over their sexual health decisions they will value their sexual health and choices they make much more, and this will lead to more informed choices about sex and contraception. The Illusion of Control Theory can also be used to decide when to intervene on a behavior. Intervening during the hot state (when someone is thinking about sexual activity or is already sexually active) will have the greatest effect on helping teens develop realistic plans for sexual activity and the use of contraception. (15)

Communication Theory & the Use of Similarity

The school setting is the most common place where teens learn about sex, both from their teachers and their peers. It is a logical strategy that the adults or teachers of the school system are the ones who educate teens about sex, but perhaps using a more similar messenger would have an additional impact on lowering the teen pregnancy rates. In addition to adults teaching sex education in the classroom, peers can be used to convey messages and information to other teens about contraception and pregnancy prevention in other settings through various forms of media. Interventions can use peers from the same school who are around the same age or even a celebrity who is of similar age.

The Communication Theory and study done by Silvia explains that the most important part of effective communication is to use a messenger that is similar, well-liked, and attractive to the target audience in order to increase compliance and reduce psychological reactance. The messenger should also deliver non-threatening information, unlike the messages in abstinence-only programs. (10, 12) Teens should be given the freedom of choice and control over their sexual health. Using similarity will help to balance positive and negative forces of compliance and reactance and give teens the confidence and freedom to make their own decisions about their sexual health. Providing the resources will enable them to make safer choices and help to decrease the teen pregnancy rate.

Bringing About Change with the Agenda Setting Theory

To learn from the flaws of abstinence-only programs and to eventually eliminate these programs all together I would propose using the Agenda Setting Theory. This theory is based on the idea that there is a public agenda, and it consists of what people are talking about and what people are interested in at that specific moment in history. If you can get people to think and talk about your issue, it will be a part of the public agenda and it will be much easier to have an impact on the public health issue. Public health professionals can use this theory to get people to realize the flaws with abstinence-only programs and why comprehensive programs can be more effective and safer for teens. This would tie in very well with the use of a media campaign targeting teens because often times the media dictates the public agenda. (12)

New Intervention

The first strategy towards creating a more effective sexual education intervention program that reduces the rate of teenage pregnancy in the U.S. would be to make all education programs comprehensive. I believe having comprehensive sex education as the primary form would be the most effective in increasing contraception use, and reducing STDs and pregnancy rates in teens age 15-19 as previously supported. (7) Information about safe sex and contraception is critical to teenagers who are faced with decisions about sexual activity. To withhold this information puts them at greater risk for negative consequences. The new intervention will offer control and freedom to the teenagers so as to not threaten them and evoke psychological reactance. Instead of explicitly stating that abstinence is the only way to go, the new intervention will feature other choices for contraception and prevention, in addition to abstinence. This has shown to be more effective in increasing the use of contraception, which in turn leads to a decrease in pregnancy rates. (9) The most effective curriculum-based programs have focused on a specific behavior, such as using contraception, and provide the basic information, not too much detail . They are age appropriate and based on theoretical approaches; they address peer pressure, and teach skills in problem-solving and decision-making to prepare students for difficult life choices they will encounter. Teaching basic life skills along with sex education has shown to be effective in increasing knowledge and changing attitudes and behavior towards contraception. (16, 17)

To give teens the freedom to choose how they handle their sexual health may not be enough to achieve the overall goal of reducing teen pregnancy. For this reason, the new intervention will also add another communicator to the program who is more similar to the target audience to deliver messages to teens. On top of the comprehensive school curriculum, the program will feature media ad campaigns emphasizing safe sex and “the choice is yours” type statements. The campaign will be marketed like a mass movement, urging teens to join the “Safe Sex” movement by choosing to abstain or use contraception, and realizing they have the freedom to choose and they have control over their sexual health decisions and the consequences of those decisions. By joining a movement, this will make the teens feel like they truly are in control and they will not feel threatened to obey abstinence-only messages. These messages will be delivered by someone who is familiar and similar to the target audience. Studies by Silvia show that similarity increases compliance and decreases resistance. This will have the greatest effect on getting teens to use contraception in order to reduce the teen pregnancy rates. (10, 12) Teens can relate to someone who is most similar to themselves, and this is not going to be the teachers or adults in a school. A peer-to-peer media campaigns will be a more effective element to the comprehensive sex education already in place.

The intervention will feature positive and freedom enforcing messages on posters throughout the schools, on computers, on school news broadcasts, on local television, and social networking websites. The campaign will say things like “Safe sex is sexy”, “The choice is yours, own it” and other positive, non-dominant messages. Teens say that they would prefer to get information about sex from their parents, but more than half of them report getting information about sex, birth control, and pregnancy from television shows, movies, and magazines. (18) Because teens most often learn about sex through these channels of communication, using magazines and local television would successfully reach the target audience. The messages will be created and delivered by peers and persons who are the most similar to the target audience such as students from the same school. The combination of control and the use of a similar communicator will greatly reduce reactance and increase compliance. (10)


Although many school-based and community interventions have been used to try to reduce the rate of teenage pregnancy in the U.S., most have been ineffective. The designs of abstinence-only programs are especially flawed because they evoke psychological reactance from the dominant and forceful messages they portray. They fail to provide the necessary information about contraception that teens need in order to make safe decisions about their sexual activity. Teens that do not receive information about contraception are at an increased risk for getting and STD or becoming pregnant. Educational programs that are comprehensive in nature and include information on both abstinence and other methods of prevention, as well as teach important life skills, are the most successful at increasing knowledge and changing attitudes and behavior. Teens respond best and tend to comply more with messages that use a communicator that is most similar to them. Interventions that take advantage of similarity effectively limit reactance while increasing compliance. This will have a positive effect on reducing the teen pregnancy rate in the U.S. The first step in creating a more effective sexual education program for all school districts to use is to get this issue on the public agenda through the use of the media. This intervention will depend on public support and community acceptance in order to be successful, and this will be the most difficult element to achieve.

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