A Critique of Abstinence-Only Policy’s Culturally Biased Messages – Jenna Sandler

Despite overwhelming evidence discounting its success, Abstinence-Only education programs still receive high levels of federal funding in the United States. In the 2007 federal budget, $204 million were allocated to institutions implementing abstinence-only programming and the funds are expected to rise in the 2009 budget. (1) Additionally, states that accept these funds are required to match them by 75%. (2) Thus, an enormous sum of taxpayer dollars is being wasted on ineffective programs and would be better spent on programs that address social and behavioral contexts of sexual risk taking. In our culture, sexual activity is a topic carrying with it widespread and heated controversy. However, the reality is that nearly half of adolescents in grades nine through twelve are sexually active, (3) and one out of four teens has a sexually transmitted infection. (4) Given these statistics, 97% of Americans agree that conversations about sex must be considered a necessary part of a child’s education. (5) How such topics are taught, however, is not quite so unanimous. Fervent supporters of Abstinence-Only education represent a conservative constituency that does not realize the public health threats such programs pose to the adolescent population. (6)
To be eligible for federal funding, programs must follow the A-H abstinence education guidelines, which require the contextualization of sex within a monogamous heterosexual marriage.(4) Abstinence-only programs are deterred from teaching the use of or giving access to contraception, emphasizing instead that abstinence is the only way to protect oneself from sexually transmitted infections (STIs) and teen pregnancy. (7) The results from the Mathematica report, which conducted a federally-mandated evaluation of four Abstinence-Only programs, indicated that youth in such programs were not more likely to abstain from sex or less likely to engage in unprotected sex, as its proponents would hope. Instead, adolescents seem to be confused about the efficacy of contraception in protecting from health risks. For example, 23% of the youth who participated in the Abstinence-Only programs reviewed in the Mathematica report believed that condoms do not protect against HPV and herpes, as compared to 15% in the comparison group. (4) Such programs seem to offer no benefits in terms of sexual risk taking and critics argue that its flawed methodology may even produce harmful effects for teens.
Due to the implications of sex in the sectors of religion and morality, resistance to simply adapting new sex education paradigms to adjust for failures of current programs remains a huge barrier. Public health professionals must, however, analyze the reasons behind Abstinence-Only’s failure rather than merely repeatedly displaying statistics of teen pregnancy and STI rates to the public. The lack of cultural and social context, the over-reliance on the Health Belief Model, and the disregard of self-efficacy all contribute to adolescents ignoring the messages of Abstinence-Only.
“My mom was a teen mother and proud of it”: Abstinence-Only neglects the role of cultural and social context
The fundamental premise of abstinence-only programming, as delineated in the A-H characteristics is the promotion of sex as a behavior for heterosexual, married couples. It decries having children out of wedlock and thus, disparages single parents. (4) This strategy is likely to marginalize those who come from single parent homes, which represent 35% of children born in 2004. (2) The following excerpt from Sex, Lies, and Stereotypes, a report from Legal Momentum whose mission is to advocate for the rights of women, demonstrates the stereotypes engendered by abstinence only programs:
“The strong ideological bent of the groups designing abstinence-only programs often leads them to disseminate scientifically inaccurate and misleading information about contraceptives, STIs, and abortion in order to promote dangerous gender stereotypes, and frequently to rely on scare tactics and homophobic sentiments to convey their message.” (2)
Premarital sex is labeled as “wrong” which may decrease compassion for teens who do get pregnant or live with STI’s. (2) There is an especially significant risk for teen girls, who must live with visible consequences (pregnancy) of sexual activity and the ubiquitous social stigma perpetuated by Abstinence-Only programs. (2) Fathers of children born to teen girls are likely to be a few years older (8) and are unlikely to pay child support, and teen mothers are at an increased risk off dropping out of school and needing to be on welfare. (9) In fact, Title V, section 510 which created federal funding for Abstinence-Only programs was born out of the Temporary Assistance for Needy Families Act as a part of welfare reform, and the amount of funding for each state was determined by its prevalence of low-income children. (6) Rather than eliminating the need for welfare, Abstinence-Only programs have only perpetuated the cycle of poverty. In fact, 60% of teen mothers were already living in poverty before they got pregnant. (10) Furthermore, schools with the least resources often use Abstinence-Only programming because it is backed so heavily by U.S. government funding when the immediate support they may need is access to contraception.
For religious, white, Christian adolescents, abstinence only programs reinforce the values learned in the home and may be effective. However, for youth for whom abstinence until marriage and two parent households are not the norm, it conveys a very different message. These are the adolescents most at risk and as a result of the negligence of schools in providing contraceptive information, they are slipping through the cracks. Statistics show that 95% of Americans have had premarital sex by the age of 44, (2) demonstrating that the goal of abstinence until marriage is unrealistic and does not represent a value of the majority.
Along with adolescents from low socioeconomic status communities, African-Americans and Latinos report higher rates of teen pregnancy and STI’s. (11) The assumption that norms of marriage and sex are universal across cultures is a misconception that contributes heavily to the failure of abstinence only programs. Traditionally, in paternalistic cultures, women were not granted control of their own sex lives and were confined to abstinence whereas men were free of consequences from premarital sex. The availability of contraceptives gives women control over their own sexual risk-reduction. Dismissing condoms as an acceptable alternative represents a setback from progress and re-institutes gender inequality. (2)
Abstinence-Only programs also miss the mark for gay, lesbian, bisexual, and transgender youth (GLBT). The fundamental message promoted by such programs is abstinence until marriage, which in and of itself represents a dilemma for this youth constituency. When marriage is not a viable option for most of these adolescents, neither is abstinence. Additionally, GLBT lifestyles are condemned, with teachers required to encourage only heterosexual marriage per the federal funding guidelines. Junior high and high schools already pose problematic environments for youth exploring sexual identity, with a lack of tolerance and an unacceptability of differences, especially in this realm. By reinforcing conservative, narrow-minded thinking, abstinence-only programs arguably violate basic human rights. (2)
“Don’t have sex or else”: Abstinence-only is rooted in the Health Belief Model
Perhaps the biggest flaw characteristic of the Abstinence-Only movement is its over-reliance on the Health Belief Model. The Health Belief Model attempts to predict behavior by suggesting that perceived severity and perceived susceptibility of an outcome in combination with perceived barriers will lead to an intention that correlates with actual behavioral output. (12,22) Perceived severity refers to the individual’s beliefs about the seriousness of the consequences of a health behavior, and perceived susceptibility refers to the level at which one rates individual risk of an outcome. (12) Guided by the false assumptions of this behavior change model, programs utilize scare tactics by showing pictures of disease, by exaggerating the effects of sexual activity, and by using shame and guilt as strategies to ostracize sexually active adolescents. They teach the perception that all STI’s are life-threatening and incurable, and portray an inaccurate and misleading picture of the effectiveness of contraceptives. (2) These tactics may elicit a visceral, intense response among participants, but the effects are short-term. It sacrifices scientific rigor in an attempt to create ideological persuasive messages. (2) Furthermore, Abstinence-Only programs assume that adolescent behavior is planned and rational. It considers a scenario in which a teen is presented with the opportunity to engage in sexual activity, and relies on the teen’s ability to weigh the possible consequences of a decision and decide analytically whether or not to engage in said behavior. The reality of adolescent sexual intercourse, however, is that it occurs sporadically and inconsistently. (13) Decisions are made impulsively and, especially with sex, are influenced by emotion and physical desire in addition to cognition. Abstinence until marriage requires a long commitment of withstanding from a behavior that is an inherent act of human nature, and an intention in high school to remain abstinent until marriage is not likely to be upheld far into the future. Developmentally, the prefrontal cortex of the early adolescent brain is not fully wired for making rational decisions and as a result, behavioral decisions are overwhelmingly based on emotion. Teenagers are therefore ill-equipped to evaluate risk and reward. (14) Moreover, the choice to become sexually active is not solely an individual one -the decision involves another person. Thus, peer pressure is a strong influence on adolescent sexuality. The peer group is a fairly accurate predictor of whether one will choose to remain abstinent. (15) As such, the focus should shift toward changing social norms. By contrast, relying on the Health Belief Model confines interventions to a focus on individual processes of change. It ignores any element of social influence in behavioral decisions. (12)
The methodology of Abstinence-Only programming aims to increase students’ knowledge of the consequences of sexual activity as a vehicle for increased perceived susceptibility and severity. One study comparing a group exposed to a health belief model abstinence program to a control group found that there was no increase in abstaining from sex and no decrease in unprotected sex, additionally finding that females in the control group were better at using contraception than females in the program group. These data indicate a harmful effect of Abstinence-Only programs. (16) Even if a program communicates the negative consequences of STI’s and the challenges of teen pregnancy convincingly, perceived severity and susceptibility is of sex generally rather than unprotected sex. This is an unreasonable behavioral expectation, and once adolescents leave the classroom, they are bombarded by thousands of sexualized messages from the media and peers. During one hour of television viewing, an adolescent will see about 11 sexual acts. (6) These mixed messages create a confusing framework for decision-making. Again, the link between intention and behavior relied upon by the Health Belief Model will likely be interrupted by these clashing expectations.
“Can I do it?”: The disregard of self-efficacy
Self-efficacy has been shown to serve an important role in successful public health interventions. (23) Self-efficacy refers to “individuals' expectations about whether they can execute specific activities, which reflect their personal control over a situation.” (17) Self-efficacy of abstinence until marriage is challenging to assess because the time between adolescence and marriage is an ever increasing number of years. (18) During this period, adolescents are constructing their own moral beliefs and are undergoing monumental physical and emotional changes. The ability to abstain from sexual activity is not easy, especially for hormonally raging adolescents. By age 19, 70% are engaging in sexual intercourse. (19)
The ultimate goal of this intervention is to prevent teen pregnancy and decrease the incidence of STI’s. It is true that abstinence is the only way to 100% ensure a zero risk of these outcomes, but the lack of alternatives for those who do choose to become sexually active reduces self-efficacy dramatically. Bandura, the psychologist who developed the concept of self-efficacy, explained that self-efficacy is attained through practicing protective behaviors. Practicing sex communication with peers and parents, for instance, is a good predictor of good communication in sexual relationships.(20) Abstinence-Only programs are counterproductive to this finding, because they create a taboo around sex, causing teens to be uncomfortable talking about it.
As has been laid out in this paper, abstinence is an unreasonable goal for the majority of adolescents. Self-efficacy of protected sex, however, can be promoted through the specific instruction on how to use a condom. Coyle et al in 2001 found that “students exposed to activities that strengthen beliefs in their ability to use condoms were more likely to have protected sex.” (17) Interestingly, adolescents who are less involved in religion are more likely to use protection, most likely due to misconceptions about condom use in Abstinence-Only programs. (17) Statistics show that if condoms are used correctly every time, they work in preventing pregnancy 97% of the time but if they are used inconsistently, they fail about 10-14% of the time. (2) Abstinence-Only programs fail to explicitly teach teenagers how to correctly and consistently use a condom during every sexual encounter, and self-efficacy deflates as a result.
Conclusion
In conclusion, Abstinence-Only programs have yet to produce sound research findings that demonstrate a public health impact. With the goal of eliminating teen pregnancy and STI’s, Abstinence-Only creators were well-intentioned but created a behavior change program based on their own ideological drives rather than scientific fact. By relying on an unreasonable behavioral promise, to refrain from sex until marriage, Abstinence-Only programs not only fail to elicit behavior change but also neglect the impact of cultural and social context on sexual behavior and encourage harmful stereotypes. Definitions of marriage and sex are not universal across cultural groups, socioeconomic groups, genders, or races, and youth are likely to disregard a message that contradicts their own beliefs. In addition to its fundamental flaws, Abstinence-Only programs often implement these lessons through a combination of scare tactics and guilt and shame. Although the U.S.’s teen birth rate has followed a decreasing trend in recent years, STI rates continue to rise and the teen birth rate still remains at the top for developed nations. (2) Spending federal dollars on Abstinence-Only programs is only setting us back in improving adolescent health. Behaviors that develop in adolescence are likely to become embedded lifetime habits, so successful prevention is critical. As such, future policies should recognize the abstinence but drop the only.
Graduate and Celebrate: A Social Sciences Based Approach to Sexual Education
In recognition of the flaws embedded in the Abstinence-Only approach to teen pregnancy and STI prevention, I would argue for a policy-wide switch to a comprehensive sexual education program that gives information about sex and its consequences but also focuses on relationship communication. According to STI and teen pregnancy intervention reviews by Doug Kirby, characteristics of successful programs include an accurate portrayal of risk, opportunities to practice communication skills, staff that believe in the efficacy of the program, discussion of peer pressure, and perhaps most importantly “incorporation of behavioral goals, teaching methods and materials that are appropriate to the age, sexual experience and culture of the students.” (24)
The following proposal is based on comprehensive sexual education programs that have elicited decreases in rates of unprotected sex and teen pregnancy, and is guided by Kirby’s “10 Characteristics of Successful Programs.” (24,25) Rooted in Framing Theory, which suggests that the specific way a health behavior is presented impacts people’s choices, (26) it primarily aims to frame graduation as a high achievement (especially in schools where this might not be current perception), and to frame condom use as an important safer sex practice (instead of disparaging already sexually active teens). It would be implemented in both middle and high schools, and would include three components: education, media coverage, and celebration of graduation. This policy specifically requests that education begin in early middle school, before adolescents are making sexual decisions. (27) The education piece can be broken down further into a teacher training component, a peer education component, and a behavioral skills training component. The curriculum would include creating a teen task force of students from the area who demonstrate leadership qualities and a passion for effecting positive change. After being appointed, they would then be trained as peer educators. Teen task force students would hold weekly after-school forums where other students can express opinions, share experiences, or ask personal questions. In addition, teachers would receive additional training so that they may serve as mentors and role models to the students around the clock and be available and willing to discuss sexual health issues.
While emphasizing that abstinence is the only true way to ensure 100% protection, contraception will also be taught as an alternative. Specifically how to use contraception and where to access it will be delineated in the lessons. Students will learn about adult resources and access to appropriate care. The curriculum will utilize role-playing, interactive discussion, activities, and games. In addition to the education piece, the media will highlight the efforts being undertaken by the schools. Third, because of the inextricable link between teen pregnancy and high school dropout, graduation will be framed as a highly celebrated, momentous, and highly prized accomplishment. Schools will be encouraged to institute annual graduation celebration blowouts to reward students for their achievement.
Social and cultural context
Ignoring differences in culture within a single classroom is a fatal limitation of Abstinence-Only programming that requires awareness. The first step is to recognize that perpetuating the social norm of sex only within the context of a heterosexual marriage may be a violation of human rights. According to labeling theory, already sexually active adolescents or adolescents of single parents will be labeled as “immoral” by the existing curriculum. Once labeled as such, learned helplessness sets in and motivation to engage in protected sexual intercourse or to stop engaging in sex is diminished. As a result, these individuals become disproportionately infected with STIs or become pregnant. In order to avoid sweeping generalizations that may result in a self-fulfilling prophecy, sex must not necessarily be framed as a negative occurrence but as something that one must be prepared for. Allowing all students to feel comfortable talking about sex rather than reinforcing its current taboo status will help avoid this harmful cultural bias.
By the same token, Erikson’s psychosocial theory states that this age is the critical period for developing sexual identity. (28) Understanding that experimentation with sex is an appropriate developmental tendency, it is a public health responsibility to provide alternatives and create an environment by which risk-takers are protected from lifelong consequences. Moreover, emphasizing relationship communication and redefining relationships to include more than just heterosexual norms will decrease any stigma attached to LGBT youth while still teaching the ability to discuss safe sexual practices with a partner.
In order to delve into the cultural and social context of each community, it is important to first conduct focus groups with teens to determine the social determinants of sexual risk behaviors. (29) The teen task force is the heart of developing culturally appropriate lessons. Aside from being delivered by trusted peers who come from the same background and are part of the social network, the messages will be specific and relevant to neighborhoods and social groups. Teens will be equipped not only with a solid theoretical understanding of sexual intercourse and its consequences but of actual places within the community where condoms are available, where STI testing is done, what the policies are on emergency contraception and abortion, and who to go to if questions should arise.
Departing from the Health Belief Model
Instead of relying on individual intentions, which do not always lead to behavior change, this program addresses the social context of adolescent sexual behavior. Recognizing that not all individuals have the same values, opportunities, and experiences, the education part of the program addresses alternatives to abstinence and emphasizes relationship skill building. It aims to transform the framing of sex as negative and immoral and focus more on protection from teen pregnancy and sexually transmitted infections. By transforming the social norms surrounding high school graduation, making it highly desirable and presenting the challenges that teen mothers face, it takes advantage of the highly peer-influenced nature of adolescent behavior. (30) Ultimately, the hope is that high school graduation becomes such a desirable and expected norm that it becomes an internalized reason to avoid unintended pregnancy and a host of other risky health behaviors.
Furthermore, by taking into account the irrationality of human behavior and discrepancy between intention and behavior, this intervention program recognizes that individual beliefs about sex will change over time. Accepting abstinence until marriage as an intention at age 13 has little predictive value of behaviors at 18 or 20. Again, assessing the social context of the increasing gap between early puberty and late marriage age leads to the assumption that providing alternatives, should goals change, is imperative. Instead of utilizing the scare tactics in accordance with the Health Belief Model, this policy change would include giving accurate portrayals of risk and accurate means of protection.
The use of the media is an essential piece of this program that allows it to affect teen pregnancy and STI rates on a population wide scale. Challenging social norms within schools throughout the nation and sharing the efforts of schools within and between communities nationwide will begin to spark dialogue about teen sexual health issues. In accordance with agenda-setting theory, which suggests that the volume of media exposure on a topic increases its pervasiveness in social perceptions, the continued review of these programs in the media will begin to shift the attitudes toward both high school graduation and sexual behavior.
Self-efficacy
According to Social Cognitive Theory, self-efficacy is “a person’s confidence that he or she can perform a behavior.” (31) Solely giving students the behavioral goals is not enough. The goals must be realistic in taking into account the context of adolescents’ lives and they must be given the means to reach those goals. Instead of the unrealistic goal of abstinence, I argue that the aim for students should be to successfully graduate from high school. This is an attainable, near future, specific benchmark that employs a positive youth development approach. While not directly targeting teen pregnancy and STI infection, it does take into account the abysmal dropout rates of teenage mothers and considers the holistic context of the adolescent life. (32) Part of the intervention will include changing the social norms around high school graduation. Huge celebrations will be thrown in honor of graduates each year, with appealing advertisements around schools and communities heightening anticipation for the event. Media attention highlighting graduation and honoring graduates will accompany the celebrations.
Additionally, by giving students alternatives to abstinence, we are at least increasing their self-efficacy of consistent protection. Making condoms available and teaching students how to use them properly will increase the rates of protected sex among those engaging in sexual activity. Behavioral training, namely role playing and practicing responding to scenarios that may present themselves in real life also increases the level of self-efficacy. Having students practice discussing sex with one another will shift the connotation of sex as a taboo subject, and especially having girls practice voicing their relationship expectations will decrease the gender norms attached to sexual relationships. Actually practicing speaking the words will help students articulate their own wishes when an actual situation arises. As simple and obvious as it may seem, we would be remiss in telling students to “just say no” without having them practice. (20) Also, having them assess and evaluate their own opinions rather than just imposing one on them will empower them with the ownership of their own goals.
Conclusion
In summary, the objectives of the proposed intervention are to provide an accurate assessment of risk for STI’s and unintended pregnancy, to encourage abstinence but give adolescents resources and knowledge about contraception as an alternative, to create a teen task force of students to serve as peer educators, to institute weekly after-school teen forums facilitated by peer educators, to provide additional teacher training, to conduct culturally-appropriate lessons about self-efficacy and healthy relationships, to promote high school graduation as an extraordinary achievement, and to use media access to encourage dialogue about sexual health among and within communities. By addressing the central flaws of the Abstinence-Only approach and changing the framing of high school graduation and contraception, the enactment of this prevention program as policy will not only decrease rates of unintended pregnancy and STI’s but level the playing field for all adolescents rather than exacerbating the already remarkable disparities.


References

1. Underhill, Kristen, Montgomery, Paul, and Operario, Don. Sexual abstinence only programmes to prevent HIV infection in high income countries: systematic review. BMJ. 2007 August 4; 335(7613): 248. .

2. Kay JK, Jackson A. Sex, Lies and Stereotypes How Abstinence-Only Programs Harm
Women and Girls. Legal Momentum 2008; 76 pages.

3. Youth Risk Behavior Surveillance –United States, 2007 . Morbidity & Mortality Weekly Report 2008;57(SS-4):1–131.

4. Trenholm C, Devaney B, Fortson K, et al. Impact of Four Title V Section 510 Abstinence Education Programs Final Report. April 2007. 164 pages.

5. Sex education in America. An NPR/Kennedy/Kaiser School Poll. Feb. 24, 2004. Accessed 18 Nov 2008. .

6. Blinn-Pike, Lynn. Why Abstinent Adolescents Report They Have Not Had Sex: Understanding Sexually Resilient Youth. Family Relations, Vol. 48, No. 3 (Jul., 1999), pp. 295-301.

7. Press Release. Annenberg Public Policy Center. Accessed 18 Nov. 2008. .

8. Teen Pregnancy and the Case for Abstinence. Accessed 18 Nov. 2008. .

9. Roybal-Allard Joins in Fight Against Teen Pregnancy. Press Release May 7, 2002. Accessed 18 Nov. 2008. .

10. O’Halloran, Peggy. Pregnancy, Poverty, School, and Employment. MOAPP. April 1998. Accessed 18 Nov. 2008. .

11. Ventura, Stephanie J.; Abma, Joyce C.; Mosher, William D. Henshaw, Stanley K. Estimated Pregnancy Rates by Outcome for the United States, 1990–2004. National Vital Statistics Report. April 14, 2008. .

12. Edberg, M. Essentials of Health Behavior. Social and behavioural Theory in Public Health. Sudbury: Jones and Bartlett, 2007, p.35-38

13. Moore, Kristin A. Moore; Miller, Brent C., Sugland, Barbara W.; Morrison, Donna Ruane; Glei, Dana A.; Blumenthal, Connie. Beginning Too Soon: Adolescent Sexual Behavior, Pregnancy, and Parenthood. A Review of Research and Interventions. US Dept of Health and Health Services. .

14. Steinberg L. Cognitive and affective development in adolescence. Trends in Cognitive Science 2005 9(2):69-74.)

15. Trenholm, Christopher; Devaney, Barbara; Fortson, Ken; Quay, Lisa; Wheeler, Justin; Clark, Melissa. 
Mathematica Policy Research, Inc. “Predictors of Sexual Abstinence.” Impacts of Four Title V, Section 510 Abstinence Education Programs, Final Report. April 2007. .

16. Eisen, M., PhD, Zellman, G.L., PhD, McAlister, A.L., PhD. (1992) A Health Belief Model-Social Learning Theory Approach to Adolescents' Fertility Control: Findings from a Controlled Field Trial. Health Education Quarterly, 19(2), 249-262. <>.
17. Longmore, Monica A., Wendy D. Manning, Peggy C. Giordano, & Jennifer L. Rudolph. Contraceptive Self-Efficacy: Does It Influence Adolescents' Contraceptive Use? Journal of Health and Social Behavior, Vol. 44, No. 1 (Mar., 2003), pp. 45-60. Pub. American Sociological Association. .

18. Sussman, Marvin B., Suzanne K. Steinmetz, Gary W. Peterson. Handbook of Marriage and the Family. 2nd Ed. Pg. 386.

19. Facts on American Teens’ Sexual and Reproductive Health. Guttmacher Institute. Accessed 18 Nov. 2008. .

20. Halpern, Felsher, Bonnie L. Halpern-Felsher, Rhonda Y. Kropp, Cherrie B. Boyer, Jeanne M. Tschann, Jonathan M. Ellen. Adolescents' self-efficacy to communicate about sex: its role in condom attitudes, commitment, and use. Adolescence, Fall, 2004.

21. Lizarraga, Kelly. Brindis, Claire. Advancing the adolescent reproductive health policy agenda: issues for the coming decade. Journal of Adolescent Health, Volume 31, Issue 6, Supplement 1, December 2002, Pages 296-309.

22. Rosenstock, IM. Historical Origins of the health belief model. Health Education Monographs 1974; 2:424-428.

23. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.

24. Kirby, Doug (2007). Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy.

25. Science and Success, Second Edition: Sex Education and Other Programs that Work to Prevent Teen Pregnancy, HIV and Sexually Transmitted Infections Advocates for YouthWashington DC, 2008. 128 pages. .

26. Framing and Framing theory. Accessed 10 Dec 2008. .

27. Children ‘need sex advice sooner.’ BBC News. 18 Oct 2006. .

28. Erikson’s Psychosocial Theory. .

29. Luquis, Raffy R., Erica Garcia, & Darlene Ashford. A Qualitative Assessment of College Students’ Perceptions of Health Behaviors. American Journal of Health Studies; 2003, Vol. 18 Issue 2/3, p156-164, 9p.

30. Joshi, S. Does peers’ sexual behaviors affect adolescents’ sexual behaviors? Nursing Campus Maharajgunj. Accessed 10 Dec 2008. .

31. Mark Edberg. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Barlett Publishers, 2007. Pg. 54.
32. Catalano RF, Hawkins, JD, Berglund ML, et al. Prevention science and positive youth development: competitive or cooperative frameworks? Journal of Adolescent Health 2002; 31(6 Suppl): 230-239. .