Abstinence-Only Education: Possibilities for Implementing Advertising Theory – Catherine Diamante

The Bush administration fostered a dramatic increase in federal support for abstinence-only sexual education programs from approximately $80 million under the Clinton administration to $176 million in 2007. Over $1.5 billion has been spent on abstinence-only education programs. In order to receive federal funding, an abstinence education program is one that:

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

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

C. teaches 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. teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity;

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

F. teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child's parents, and society;

G. teaches young people how to reject sexual advances and how alcohol and drug use increase vulnerability to sexual advances; and

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

Despite extensive funding and support for abstinence-only education, it has failed to garner significant results. Abstinent-only sex education has ultimately failed to significantly delay sexual initiation or reduce the rates of pregnancy and sexually transmitted infections (STIs) among teens (1).

An evaluation of four abstinence education programs found that between adolescents and teens receiving abstinence only education or no sexual education, there was no significant difference in rates of sexual abstinence, number of sexual partners, contraceptive use, pregnancies, births, or STIs (1). In addition to impact on sexual behavior, this study found that none of these programs had any effect on alcohol or marijuana use, which is a target included in federally funded abstinence education programs. Despite these failures, abstinence only education continues to receive extensive funding and support. As a public health intervention aimed at altering behaviors, abstinence only education can be evaluated as a failed execution of both the Health Belief Model and Theory of Reasoned Action/Theory of Planned Behavior.

Reliance of Abstinence-Only Education on the Health Belief Model

The Health Belief Model (HBM) posits that health related behavior is motivated by four factors:

1. perceived susceptibility,
2. perceived severity,
3. perceived benefits of an action, and
4. perceived barriers to taking that action.

The HBM involves a person weighing the benefits of an action against the barriers to the action, leading to intention then execution of that intention, while assuming a certain amount of self-efficacy. Abstinence only education plays upon the perceived susceptibility and severity of the negative consequences of sex to its students.

Condom use is mentioned only in terms for failure rates, emphasizing the susceptibility of teens to become pregnant or transmit STIs. This is done in hopes of convincing them that the only truly safe option is abstinence. However, in practice, this appears to have little effect on the actual sexual habits of teens. Not only is susceptibility to condom failure exaggerated, but some programs resort to misinformation in order to affect behavior (2). In addition to exaggeration of condom failure, some curricula state that HIV and other pathogens can “pass through” latex condoms, making them ineffective. Such scare tactics are a demonstration of taking the HBM to the extreme, giving extraordinary weight to the perceived susceptibility and severity of negative consequences of sex.

These types of tactics and misinformation are not limited to transmission of STIs. One program states that pregnancy can result from merely touching another person's genitals (1). This type of misrepresentation not only exaggerates perceived susceptibility and severity, but also serves to diminish the potential benefits of engaging in sexual activity.

This also extends to the presentation of abortion as a possible consequence of pre-marital sexual behavior. Programs have been found to use inaccurate or out of date information concerning the risks of abortion, such as sterility, premature birth, ectopic pregnancies, and the effect on the psychological state of the woman. While the American Psychiatric Association found that an abortion has no independent effect on psychological well-being over time (3), some abstinence-only programs incorrectly state that “following abortion, women are more prone to suicide (2).” Again, abstinence only education exaggerates negative risks and consequences to sway behavior.

Despite these attempts to manipulate the perceived susceptibility and severity of negative consequences of sexual behavior, the failure of abstinence only education is still dependent upon and has the same weaknesses of the fundamentals of the HBM. The programs largely focus on the individual and assume him to make rational choices based on the information given. This weakness is perhaps exasperated by the fact that abstinence only education is aimed at adolescents and teens, who may not act as rationally as desired due to their still developing minds and bodies.

Reliance of Abstinence-Only Education on the Theory of Reasoned Action/Theory of Planned Behavior

The Theory of Reasoned Action postulates that behavioral intention results from weighing an individual's attitude towards a behavior against his perception of the subjective norms associated with the behavior. The individual's attitude towards the behavior is broken down into the expected outcomes of the behavior and whether this outcome is positive or negative; and the subjective norms come from the individual's belief about what others in his social group will think about the behavior and his motivation to conform to these social norms. The Theory of Planned Behavior, in addition to these concepts, incorporates the idea that the individual has some level of perceived behavioral control, in which control beliefs, which are about factors that will make it easy or difficult to perform some action, are coupled with perceived power, which refers to the power of the control beliefs.

Some aspects of abstinence only education take an approach based on the Theory of Reasoned Action to affect the perception of social norms in order to discourage pre-marital sex. One method of achieving this is via reinforcing gender stereotypes and presenting them in such a way to promote abstinence until marriage. These stereotypes tend to reinforce the perception that girls are weak and in need of protection that can only be found within marriage (2). This can alter one's perception of subjective norms, creating a false belief as to how the individual's social circle will react to engaging in sexual activities. These stereotypes aim to make sexual activity before marriage more socially unacceptable than it may actually be within the student's social circle. Altering this perception could theoretically direct behavior towards abstinence. However, this is not the case, as abstinence only education has not been found to significantly affect teens' attitudes towards sex (4).

An exception to this lack of change may be found in the development of negative attitudes towards using contraceptives and condoms. In a 2000 poll, 66% of teens said they would feel suspicious or worried about their partners past at the suggestion of condom use, 49% would worry that the partner was suspicious of them, and 20% would feel insulted (5). This perception serves only to reduce condom use while having no effect on maintaining abstinence, undermining the goals of abstinence only education.

Like the Health Belief Model, the Theory of Reasoned Action is dependent upon individuals making rational decisions which is not likely to occur when attempting to change teens' personal and social perceptions of sex.

The Theory of Planned Behavior incorporates control beliefs and perceived power into the Theory of Reasoned Action. In terms of abstinence-only education, these may be affected to the point of increasing sexually risky behavior. Exaggeration of STI transmission rates and contraceptive and condom failures may result in an individual feeling very low perceived power in controlling the consequences of sex. While this may lead to abstinent behavior, it can also potentially lead to engaging in risky sexual behaviors with the perception that there is no effective method of reducing risks.

Unintended Consequences of Abstinence-Only Education

In terms of altering social norms within the Theory of Reasoned Action, one notable consequence of abstinence only education is the use of virginity pledges as a means of engaging community support for abstinence. While this may at first appear to be a more effective method than simply relying on each individual to make a reasoned choice for abstinence, there are some unintended results. Abstinence only education focuses mainly on the consequences of vaginal intercourse, and in doing so usually neglects to adequately address the risks of oral and anal sex. In “preserving virginity” by refraining from vaginal sex, some experiment with oral and anal sex instead. Because these are not addressed as fully as vaginal sex, teens may not know the risks associated with these activities, which, in the case of anal sex, carries a higher risk of STIs (6, 7).

Another unintended consequence of virginity pledges may be decreased use of contraceptives or condoms after sexual debut (7). Even as sexual debut is delayed, 88% of those pledging virginity until marriage did engage in vaginal intercourse before marriage. At first vaginal intercourse, pledgers were found to be less likely to use a condom. In cases where oral and/or anal sex are used in substitution for vaginal sex, condom use was virtually non-existent in oral sex and lower in anal sex than vaginal. The combination of misinformation of contraceptive and condom efficacy combined with neglect of oral and anal sex undermines the intention of abstinence only education and virginity pledges to reduce pregnancy and transmission of STIs.

One major area of neglect within abstinence only education is the neglect of homosexual sex, particularly among men. Homosexuality is largely ignored by abstinence only education except in the context of HIV transmission. While HIV rates among teenagers overall is exaggerated in abstinence only programs, it is especially so among homosexual male teens where, in one program, it is implied that 50% of homosexual male teens are HIV positive (2). This presentation serves to stigmatize gay men and can undermine the practice of safe sex among gay teens. This continued stigmatization may lead some homosexual teens to engage in risky heterosexual activity to assert themselves as straight. A random sample of sexually active youth in Massachusetts revealed that gay adolescents had more sexual partners, more frequent use of substances before engaging in sex, and higher rates of pregnancy than other youths (8).

Conclusion

Abstinence only education has failed in the United States as a means of effectively reducing rates of pregnancy and STI transmission among adolescents. Much of abstinence only education is grounded in individual models of health behavior, namely the Health Belief Model, Theory of Reasoned Action, and Theory of Planned Behavior. Because of this, the failure of the programs tend to align with the inherent weaknesses of these models. Abstinence only education assumes rational behavior in teens where it has no basis to do so and consistently relies on actions of each individual to produce a significant result.

Abstinence only education fails to effectively utilize the Health Belief Model in that it is unable to effectively affect abstinent behavior by presenting information about the perceived susceptibility and severity of the negative consequences of sexual activity. This is in spite of pervasive exaggeration of these consequences and minimization of the efficacy of contraceptives and condoms. In this case, scare tactics are used to strengthen the power of abstinence only education, but it does not appear to add efficacy to the intervention.

In terms of the Theory of Reasoned Action and Theory of Planned Behavior, abstinence only education seeks to alter the individual's attitudes towards sexual behavior as well as the perception of how such behavior is viewed within the social circle. Again, abstinence only education fails to effectively alter these views and perceptions in such a way as to significantly alter sexual behavior in the long term. As with its reliance on the Health Belief, abstinence only education utilizes scare tactics in trying to alter personal attitudes and subjective norms as well as reinforcement of gender stereotypes.

Unfortunately, there are some unintended consequences to implementation of abstinence only education which serve to undermine its goals. Where it fails to change attitudes towards sexual behavior among teens, it does seem to build negative attitudes towards the proper use of condoms and contraceptives. In addition to this, neglect and misrepresentation of homosexuals and homosexual sex in the abstinence only curriculum has served to marginalize and stigmatize homosexual teens. This can lead to higher rates of risky sexual behavior among these teens, further undermining the goals of an abstinence only education.

Abstinence only education has failed to decrease rates of teen pregnancy and STI transmission in the long run. Instead of decreasing these, it has instead reinforced negative gender and sexual orientation stereotypes as well as poor sexual habits among its students. Abstinence only education is a failed public health intervention grounded in the individual-based models of the Health Belief Model, Theory of Reasoned Action, and Theory of Planned Behavior.

Alternatives to Abstinence Only Education

While states continue to implement abstinence only education in order to remain eligible for federal funding, they have proven to be a poor method of reducing rates of teen pregnancy and STI transmission. Sex education should be reformed as a whole to include elements from the social sciences and ensure that youth are not given false or misleading information in order to achieve a greater affect.

Ensuring Accuracy of Information

Perhaps the easiest area to improve sex education is in expanding its scope and ensuring that all of the information in programs is correct. One significant consequence of misinformation is the stigmatization of homosexuals and homosexual behavior. As this stigmatization seems to encourage heterosexual promiscuity in gay youth, removing it may be enough to reduce the disparity in pregnancy and STI transmission between homosexual and heterosexual youth (8). For both homosexual and heterosexual youth, sex education needs to address oral and anal sex as fully as vaginal intercourse, especially as these activities can be use in lieu of vaginal intercourse with their own sets of risks.

In the classroom setting, accurate information and practical skills should be given in a straightforward manner. While this may not ultimately have any real effect on whether or not one chooses to have sex, it can effect the efficacy of protected sex practices. Understanding how to properly use contraceptives and condoms can play a major role in preventing unwanted pregnancies and STI transmission when a student chooses not to be abstinent. These practical skills in conjunction with effective campaigns for protected sex outside of the classroom can have an effect on the overall rates of teen pregnancies and STI transmissions.

Using the Social Sciences in Sex Education

A 1995 review of sexual education programs associated nine identifiable features associated with programs that successfully achieved delays in first intercourse and/or increased the use of contraception or condoms:

1. Social Influence Theory, Social Learning Theory or Cognitive-Behavioral theories of behavior underpinned the interventions;
2. the programs were focused on the specific aims of delayed intercourse and protected intercourse;
3. the interventions were at least 14 hours in length or there was work in small groups to optimize the use of time in shorter programs;
4. a range of interactive activities such as role-playing, discussion, and brain-storming were employed such that participants personalized the risks and were actively involved in the process of developing strategies;
5. clear statements were given about the outcomes of unprotected sex and how those outcomes could be avoided;
6. the social influences of peers and media to have sex or unprotected sex were identified, and strategies to respond to and deal with such pressures were generated;
7. there was clear reinforcement of values supporting the aims of the programs and development of group norms against unprotected sex relevant to the age and experiences of the participants;
8. programs included activities that allowed participants to observe in others, and rehearse themselves communication and negotiation skills yielding greater effectiveness in achieving delays in initiation of intercourse or protected sex; and
9. there was effective training for those leading interventions (9).

The most notable difference between these characteristics and abstinence only education is the focus on delayed intercourse and protected intercourse rather than abstinence until marriage. In dealing with sexual intercourse, delaying initiation and engaging in protected sex is more likely to be measurably successful than in promoting abstinence until marriage. With few exceptions, people will inevitably have sexual intercourse. Because of this, relying on abstinence as a means of pregnancy and STI transmission control will unavoidably fail. Education about protected sex is simply a more practical route to achieving this end.

Implementing Advertising Theory In Sex Education

Traditionally, sex education programs address one of two groups: those that are sexually active and those that are not. Instead, youth can be divided into four groups: those who do not anticipate having sex within a year (delayers), those who anticipate having sex within a year (anticipators), those who have had one sexual partner (singles), and those who have had multiple partners (multiples) (10). Using these more focused divisions, educators and the media can perhaps utilize advertising theory to their advantage. While the core values of youth can arguably be determined as a whole, negotiating the differences between these groups can be addressed in order to successfully induce them to practice protected sex as much as possible. For example, in those that are already sexually active, it is too late for abstinence, and proper contraceptive and condom use needs to be emphasized. Between delayers and anticipators, the anticipators have been shown to have an increased tendency towards risky behavior and looser ties to family, school, and church. These core differences should be addressed and can make sex education more effective.

Advertising theory can be used in sex education to manipulate how youth view sex in itself and their own relationship with sex. While students should not be explicitly separated into these groups, sex education programs, especially among older teenagers, should include elements that appeal to each of these. Likewise, media campaigns should also directly address each of these groups. As the “Truth” anti-smoking campaign appealed to the values of honesty and rebellion, sex education campaigns should also aim to address the core values of its audience. These could potentially include honesty and rebellion, as well as self-respect, love, lust, or other values.

One example of a campaign utilizing advertising theory is the Trojan's “Evolve” campaign (11). This campaign equates men seeking sex with pigs until they obtain a condom, at which point they become attractive sexual partners. It makes it seem as though getting sex will be impossible until a condom is present. Among teenagers and young adults who are sexually active, this campaign appeals to vanity and the pursuit of sexual relationships within the group. Additionally, it stigmatizes unprotected sex between non-married partners, as the men pursuing unprotected sex are depicted as filthy pigs. While the “Evolve” campaign was designed to sell condoms, it is fulfilling one of the goals of sex education: increased use of contraceptives or condoms.

Similarly, media campaigns can be developed that address the values of delayers and anticipators to either encourage continued delay of sex or preparedness to engage in protected sex. As the “Evolve” campaign may not be effective in swaying the behaviors of these groups, campaigns directed at them will likely have little effect on those who have already engaged in sexual intercourse.

MTV's “Staying Alive” campaign addressing the global impact of HIV/AIDS aimed to increase awareness and preventative behavior, reduce stigma and discrimination, an empower young people to take action (11). This campaign involved several public service announcements (PSAs), a website linked to MTV.com with resources and information, a documentary aired on MTV about young people living with HIV/AIDS, and concerts held on World AIDS Day. The PSAs were found to be the least effective element of this campaign, and the documentary the most effective. The documentary and its focus on young people created a situation for the audience, young people themselves, to empathize and become emotionally involved with the subjects. Again, like the “Truth” campaign, the message against unprotected sex came from peers rather than some emotionally removed authority figure.

Sex education should include more than class time in school, where information will by default come from an authority figure. While information can be given via this avenue, changing attitudes in youth about sex and its consequences should come from peers.

Conclusion

Perhaps the first issue to address in current sex education is the validity of the information being given to youth. As misinformation and the lack of certain information in abstinence only education programs can lead to negative unintended consequences, providing this information in a straightforward manner can perhaps mitigate some of these consequences.

Outside of a classroom based program, media can be used to affect the sexual attitudes and behaviors of youth. In particular, advertising theory can be used to address youth as a whole as well as subdivisions of youth with respect to their sexual status and beliefs. Within these media based campaigns, it is imperative that they appeal to some core value of youth or subdivision of youth in order to encourage either delay of sexual initiation or protected sex. While in classroom based programs, youth are being told how to behave by authority figures, usually of a different age group, media campaigns have the ability to convey information though peers with whom youth can relate and empathize, perhaps increasing their efficacy.

References

1. Trenholm, C., et al. Impacts of Four Title V, Section 510 Abstinence Education Programs: Final Report. Washington, DC: Mathematica Policy Research Inc., 2007.
2. Waxman, H. The Content of Federally Funded Abstinence-Only Education Programs. Washington, DC: United States House of Representative Committee on Government Reform – Minority Staff Special Investigations Division, 2004.
3. Edwards, S. Abortion Study Finds No Long-Term Ill Effects on Emotional Well-Being. Family Planning Perspectives, 1997.
4. Hauser, D. Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact. Washington, DC: Advocates for Youth, 2004.
5. Henry J. Kaiser Family Foundation. Safer Sex, Condoms, and “The Pill”: A Series of National Surveys of Teens About Sex. Menlo Park, CA: The Foundation, 2000.
6. Connolly, C. Teen Pledges Barely Cut STD Rates, Study Says. The Washington Post. Washington, DC, 2005.
7. Bruckner, H and P. Bearman. After the promise: the STD consequences of adolescent virginity pledges. Journal of Adolescent Health 2005; 36: 271-278.
8. Blake, S. et al. Preventing sexual risk behaviors among gay, lesbian, and bisexual adolescents: the benefits of gay-sensitive HIV instruction in schools. American Journal of Public Health 2001; 91: 940-946.
9. Kirby, D. A review of educational programs designed to reduce sexual risk-taking behaviors among school-aged youth in the United States. Santa Cruz, CA: ETR Associates, 1995.
10. Finger, W. Sex Education Helps Prepare Young Adults. Adolescent Reproductive Health 2000: 20.
11. Brown, J. ed. Managing the Media Monster: The influence of media (from television to text messages) on teen sexual behaviors and attitudes. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy, 2008.