Challenging Dogma - Fall 2008

Thursday, December 18, 2008

Abstinence Education: A Critique and Alternative Approaches for Improvement – Kathy Zheng

The United States spent about $1 billion dollars on abstinence education between 1998 and 2007 (1). The goal of this campaign, as promoted by President George W. Bush beginning in 2001, is to decrease the incidence of teenage pregnancy and sexually transmitted diseases through the promotion of abstinence among unmarried individuals. The Department of Health and Human Services established the website “” as part of the campaign. Its main purpose is to provide information for parents about how to talk to their children about abstinence. However, despite the widespread efforts of the government and the vast funds that have been dedicated, the abstinence campaign has not been successful. Studies show that in areas where abstinence education is explicitly promoted in schools, the rate of sexual activity among teens increased after completion of the education program (2). The number of pregnancies among teens who participated in the abstinence only programs also increased (3). Thus, it is clear that abstinence-only education programs have fundamental flaws. While some of the flaws are rooted in the theoretical basis from which the program is designed, others are in reference to the audience in which the program is directed towards. Several criticisms of the approach, specifically the use of the website, as well as suggestions for the improvement of the intervention are presented here.
Criticism 1 – Theoretical Basis
It is evident that the abstinence-only education programs are based on several traditional models of health behavior. These models include the Theory of Reasoned Action (TRA) and the Health Belief Model (HBM). emphasizes the importance of parents communicating to their children their desire for them to abstain from sex until marriage (4). The argument is that children who understand their parents’ desire for them to abstain are more likely to do so. One of the facts that the website encourages parents to share is “Do you know that, according to one survey, two-thirds of teens who have had sexual intercourse wish they had waited?”
This approach is clearly modeled after the TRA because it aims to change a person’s attitudes towards a behavior and present abstinence as a socially desirable and acceptable behavior. One major criticism of this approach is that it is an individual level intervention. This is paramountly inappropriate for interventions dealing with teenage pregnancy and STDs because neither is individually acquired. Another argument to this approach is that it assumes that individuals will systematically weigh the benefits (100% prevention of pregnancy and STDs) and public perception and naturally arrive at a mathematical conclusion to abstain. Thus, is fundamentally arguing that is it a lack of knowledge and input that contributes to premarital sex. This is exceptionally unreasonable given the major emotional and hormonal input in a teenager’s decision to have sex.
Abstinence-only education is primarily a data based intervention. Proponents often cite statistics about the rate of STD transmission among the sexually active and unmarried (4). They frequently use data about the higher incidence of poverty among unmarried women who get pregnant as a tool to discourage sex before marriage. To its credit, presents some information about contraception other than abstinence. However, its merits are quickly abated when upon closer inspection, one notices that the failure rates of each form of contraception is prominently noted. This presentation clearly highlights the viewpoint of the website about abstinence rather than encourage the discussion of its alternatives.
The approach is also based on the HBM. The severity of the consequences of premarital sex and the susceptibility of a person to those consequences are presumed to be the main driving force behind the decision to abstain. Studies have shown that “knowledge of consequences” is the third most often cited reason for the use of abstinence education (5). Interventionists must trust that the teenager will view this information as dangerous enough to abstain from sex. However, it would not be prudent to assume that the teenager would then naturally make the rational decision. Adolescence is characterized by risk taking and rebellion (2). Therefore, a conscious effort by the teenager to act against the rational decision would be more likely. This model also creates an individual level intervention and this is inappropriate because sexual activity is generally not an individual level action. Furthermore, abstinence-only sex education assumes that the decision to have sex is made inside a vacuum, that is, without social or environmental determinants or influences. This is inappropriate because an adolescent’s decision to have sex is well-known to be influenced by the pressures or actions from others. Finally, abstinence-only education based on both the TRA and HBM assume that the adoption of abstinence is planned. This does not take into account the spontaneous nature of teenage activities, especially those sexual in nature (6).
One alternative model of health behavior that may explain the failure of abstinence-only education is Stigma or Labeling Theory. This theory argues that when people are labeled as a particular type of person, there is a self-fulfilling prophecy. If a teenager has already had sex and plans to continue having sex, the only advice the website gives to parents is to continue talking to the teenager and have her visit a health care provider. Although, there is information on the website about birth control, as mentioned, there is no information about how to speak to teenagers about using them. Thus, if the teenager is already sexually active, Labeling Theory suggests that teenagers may view themselves as being beyond the scope of abstinence-only education, and therefore may reject sex education altogether. The intervention does not comprehensively address the needs of this population and teenagers may continue with their unsafe sexual practices because there then appears to be no reasonable alternative. In fact, teenagers who find that they are unable to abstain may experience shame (2). This could lead to the teenagers being secretive about their sexual practices and discourage them from seeking out advice about ways to prevent pregnancy and STDs.
Criticism 2 – Contextual/Ecological Factors
As mentioned, abstinence-only education based on the traditional health behavior models is an individual level intervention. Despite the fact that actions to protect oneself from teenage pregnancy or STDs may be individual in nature to a certain extent, interventionists may not be able to act without knowing the context of the problem. There may be higher level factors that abstinence alone cannot reasonably address and they may be the fundamental causes of why a teenager is engaging in risky sexual practices.
One risk factor for such practices may be the community one interacts or lives within (7). For example, if the community is one where most residents are of low socioeconomic status, parents may work more than one job that requires long hours. assumes that parents have the time to maintain a continuous dialogue with their teenagers about the risks of sex. Their argument is that this dialogue is most influential for a teenager’s decision to abstain from sex. However, if the parents are unable to devote the time, does not offer an alternative solution to the problem.
Areas of low socioeconomic status may also be deprived of recreational activities associated with the community, church, or school for adolescents. Research shows that adolescents who participate in these activities are less likely to engage in risky sexual behavior (8). Abstinence-only education does not address the possibility of this deprivation of social activities and thus ignores the higher order contextual risk factors associated with the initiation of sex among adolescents.
The individual level intervention fails to address the influence of the media in a teenager’s decision to have sex. Images of sex are pervasive in the media and research shows that teenagers exposed to those images on television are more likely to have their first sexual experience sooner (9). However, the study also shows that the effect of sex in the media can be countered by parents watching television with their children and sharing their beliefs about safe sex. This would also assume that the parents can devote the time to partake in such activities. If this assumption is incorrect, then the influence of the media can be substantial.
Criticism 3 – Social and Cultural Factors
Abstinence-only education fails to address the social and cultural differences of teenagers and their families. A lack of understanding of these differences may lead to teenagers feeling marginalized and unworthy. In addition, an intervention that does not reasonably and comprehensively address alternatives to abstinence greatly limits the context in which the intervention can be presented, and context is of primary concern when approaching a subject that is culturally sensitive such as sexual activity.
There are cultures that practice family silence about topics relating to sex. For example, Choi et al states that “Asian families are not able to acknowledge sexual identity” (7). suggests that sexual abstinence by teenagers can be achieved mainly through dialogue with parents about the risks of sex. If sex is a taboo subject within a culture, then this dialogue is not possible. As a result, the underlying message propagated by the campaign would be inapplicable to the Asian population. Moreover, since the website does not comprehensively address alternatives to open discussions about abstinence and sex, teenagers may develop repressed sexual urges that may encourage them to seek out sex, safe or not (7).
In addition to racial differences, studies also show that there are gender differences with respect to adolescent attitudes about sex. Girls have more negative perceptions about the benefits of sex and less negative perceptions about pregnancy as compared to boys (10). does not address gender differences with their approach. The assumption is that both girls and boys would be equally receptive to the messages presented by the website. Since the research shows that there is a gender difference in sexual attitudes, the approach is unreasonable.
Abstinence-only education also fails to address the sexual practices of those for whom marriage may not be an option. The intervention operates under the assumption that its entire audience will eventually enter into a mutually faithful, monogamous relationship in the context of marriage (11). This approach discriminates against the gay, lesbian, and transgender youth (12). Marriage may not be possible for these individuals due to government policies. Therefore, abstinence-only education interventions either do not condone sexual activity for these people or they feel that this group is unworthy of safe sex intervention. The concept of worthiness is one that is often cited in support of sexual abstinence for teenagers (13). If teenagers who are gay, lesbian, or transgender do not abstain before marriage because marriage is unlikely, then they may develop a feeling of unworthiness if exposed to the abstinence message. In reference to Labeling Theory as discussed, this feeling may lead them to continue with unsafe sexual practices and may even exacerbate the problem.
As shown, there are many fundamental reasons for the failure of the abstinence-only campaign to fight pregnancy and the spread of STDs among adolescents. It is evident that the failure is unrelated to the lack of funding, but rather it can often be attributed to the lack of understanding of its audience. In addition, it can be seen that the traditional health behavior models inadequately address issues with significant social and emotional components that may also happen to be culturally sensitive. As a result, a more comprehensive and less contextually restrictive approach to the problem is warranted.
Alternative 1 – Predictable Irrationality and Alternative Health Theories
The abstinence-only campaign based on the traditional health belief models does not account for the irrationality of teenage behaviors and decisions. Therefore, an alternative intervention is suggested where there is no assumption of a rational decision on the part of the teenager to abstain from sexual activity and the basis for the intervention will be an alternative health behavior model. Studies show that among individuals aged 10 to 24 years old, 47.8% were sexually active in 2007 (14). About half of teenagers do not remain abstinent despite the campaign. Studies show that comprehensive sex education programs that include promoting methods of safe sex do better to reduce the number of partners, improve condom use, and reduce pregnancy among teenagers compared to abstinence-only education programs (15-16). These comprehensive programs are critical because they address the needs of teenagers who are already sexually active.
One suggested alternative health theory to use as a basis for an intervention is Marketing Theory or the Social Marketing approach (17-18). Unlike the TRA and HBM, Marketing Theory is a group level intervention because it does not seek to target each individual separately. The issue of preventing teenage pregnancy and STDs lends itself better to a group level intervention because of the social and peer influences associated with sexual decisions. Also unlike the TRA and HBM, this theory does not present the negative consequences of sex, but rather the positive outcomes of safe sex. Advertising Theory, which is a subset of Marketing Theory, argues that interventionists should first identify teenagers’ aspirations. The promise of a teenager’s fulfillment of those aspirations if they adopt safer sexual behaviors can be made through visual representations in the media.
Interventionists should look to the success of popular clothing brand campaigns for ways to market aspirations to teenagers. The television, billboard, or magazine advertisements for these clothing brands often do not even need to rely on a presentation of the product to be effective. Rather, the aspirations being presented may include teenagers being perceived as physically attractive, popular, independent, etc. Therefore, it is reasonable to assume that the same formula can be effective for a safe sex campaign. Commercials and print advertisements portraying attractive and popular teenagers in relatable yet glamorized settings could be presented along side messages promoting condom or contraception usage.
Alternative 2 - Addressing Higher Level Factors
As mentioned, the United States spent about $1 billion between 1998 and 2007 on abstinence education (1). There is clearly no lack of available funding for sex education. The issue is then to find better a way to utilize those resources to produce lower incidences of teenage pregnancy and STD infections. A criticism of the initiative is that it does not address the possibility of the deprivation of social activities within neighborhoods of low socioeconomic status. A lack of participation in recreational activities associated with the community, church, or school is a risk factor for engaging in risky sexual behavior among teenagers (8). Therefore, a successful intervention must do more than address the risk factors association with teenage pregnancy and STD transmission; it must also address the risk factors associated with risky sexual behaviors. The recommendation is to allocate some of the resources reserved for sex education towards funding for increased after-school activities or community recreational activities geared towards teenagers. also fails to address the influence of the media. However, an intervention based on Marketing Theory utilizes the influence to its advantage. If studies show that teenagers exposed to sex in the media are more likely to have their first sexual experience sooner, or media campaigns such as Florida’s “truth” initiative are able to decrease the incidence of teenage smoking by 7.4% in 30 days, then it is reasonable to believe that the media can also be a powerful tool to influence teenagers to adopt safer sexual practices (9, 19). Therefore, increased funding for recreational activities for teenagers in conjunction with the use of a Marketing Theory-based media intervention would have improved success over the campaign.
Alternative 3 – Cultural Competence and Social Awareness
In addition to community based programs to intervene where parental involvement may be limited, programs should also be established to provide support to parents who are able to take an active interest in their children’s sexual wellbeing. Addressing the social and cultural factors that limit the success of the campaign requires the establishment of such programs.
It is important to recognize culture as an important predictor of sexual initiation among teenagers. Although the relationship between culture and attitudes towards sex in the United States has not been fully explored in the literature, a study performed in the United Kingdom shows that an open dialogue about sex within Chinese families was uncommon often due to the language and cultural barriers between the UK-born teenagers and the China-born parents (20). Although abstinence-only education may seem inappropriate given that half of all United States teenagers have sex, it is important to note that the a generalized comprehensive sex education program may also be inappropriate for families of cultural backgrounds with conservative views about sex.
It is important for interventionists to recognize that some cultural views about sex may be more conservative than mainstream views (20). One approach would be to dedicate funds to establish community programs to teach parents how to overcome language, cultural, and generational barriers to effectively convey their own attitudes about sex. These programs should be led by individuals who have the same cultural backgrounds as those being served because there will be an intimate awareness of what is and is not appropriate. Another approach would be to produce television and print campaigns to air on foreign language channels and publications. These foreign language campaigns could show images of happy families and healthy teenagers with the message that effective culturally appropriate communication about sex could lead to these aspirations. In addition to comprehensive sex education programs directed towards teenagers who choose not to abstain, these approaches could show cultural groups how to give parental support to those teenagers who do abstain because of their own beliefs without feeling alienated by mainstream views.
The lesbian, gay, bisexual, and transgender (LGBT) community is one where abstinence education is inappropriate, for reasons described above. A feeling of worthiness should be reinforced within this community despite the fact that sexual activity occurs outside of marriage. Television and print campaigns, such as those previously suggested, can be tailored to present positive images of LGBT teenagers more prominently. Another direction campaigns geared toward LGBT’s can adopt is to make methods of safe sex provocative and fun. For example, there are condom commercials which show the sexual attractiveness of a man who has a condom to women. The same types of commercials can be produced showing LGBT couples.
Lastly, an important consideration for both the use of media and community programs for an intervention is gender differences. Studies have shown that girls and boys have differences in their perceptions about sex (10). As a result, interventionists should produce one set of media campaigns geared toward girls, such as portraying aspirations of being respected by peers for being sexually responsible, and another gears towards boys, such as portraying the independence one could have if one was not burdened by the responsibility of early fatherhood.
Ultimately, the use of the media as well as establishing community programs to address higher order societal risk factors for teenage pregnancy and STD transmission are improvements upon the current interventions adopted by the government. A government campaign to battle teenage pregnancy and STD transmission has the unique advantage of not being limited by funding, as public health initiatives tend to be. Public health professionals should look to successful marketing campaigns for commercial goods aimed at teenagers for inspiration on how to design a successful safe sex campaign. The funding is available for interventionists to purchase the same expensive air time slots as consumer product companies buy. Perhaps the unorthodox approach of marketing safe sex as a product rather than as a behavior is one that teenagers will finally respond to.
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