Challenging Dogma - Spring 2009

Friday, May 1, 2009

The Fight Against Teen Pregnancy in the U.S.: A Critique of Abstinence-Only Sex Education Based on Social and Behavioral Theory - Karen Campbell

The United States has the highest rates of teen pregnancy and births in the developed countries (2). Thirty-four percent of women become pregnant at least once before the age of 20, which averages 820,000 pregnancies a year (10). Eight out of ten of these events are unintended and 79 percent are to unmarried teens (10). Although the amount of teen pregnancy has decreased since 1991 when incidences of teen pregnancy was at the highest peak since 1980, the decline in events began another incline in 1996, making this an issue that still needs the implementation of an effective intervention. (5)
Bearing a child as a teen can have negative affects on the child, mother, and father (2). Teen mothers are less likely to complete high school and more likely to live in poverty (6). These mothers are less likely to receive prenatal care and gain appropriate weight which heightens the risk for birth defects (6).
Under the Bush Administration, federal funding for abstinence-only, or abstinence until marriage programs rose significantly with the hope to decrease teen pregnancy as well as other negative outcomes of risky sexual behavior. The goal of these programs is to target premarital sex as the causal behavior for unintended teen pregnancy among other negative outcomes that correspond with sexual activity. The federal government spent approximately $170 million in 2005 towards abstinence based programs, which is more than twice the amount spent in 2001 (14). These programs focus on an “exclusive purpose of teaching the social, psychological, and health gains” by abstaining from sexual activity and that abstinence outside of marriage is the “accepted standard for all school aged children” (13). However, a focus on strictly teaching abstinence can be dangerous when it is presented as the sole choice and where health information on other choices is restricted (11). Theoretically abstinence is the most protective form of contraception however in actual practice abstinence often fails to protect against teen pregnancy (11).
Although risky sexual behavior can have many negative outcomes, it is important to teach adolescents ways in which to protect themselves if the teen chooses not to be abstinent. In European countries, the rates of sexual activity are very similar to that in the United States; however the US has a much higher rate of teenagers who become pregnant (2). Due to the severity of teen pregnancy rates in the US, abstinence based programs need to be revisited in order to present a more effective intervention. This paper will critically analyze the failure of abstinence-only sex education programs in the US by examining the use of fear tactics in a public health intervention, the focus on the individual as opposed to a multilevel based model, and the issue of social norms and the negative stigma on the open communication of sexually based questions and concerns in adolescents.
The Health Belief Model and the use of Fear tactics in a Public Health Intervention

Abstinence based education curricula mirrors traditional public health models such as the Health Belief Model. The main focus of abstinence programs is to highlight the health gains by abstaining from sexual activity outside of marriage by teaching the harmful psychological and physical effects of having sex (10). The goal of this program is to lower risky sexual behavior which can lead to teen pregnancy and other negative outcomes such as sexually transmitted infections. The emphasis on negative consequences of sexual behavior can be identified as a factor in a conceptual model such as the Health Belief Model.
The Health Belief Model is based on the individual cognitively analyzing the perceived susceptibility, severity, benefits, and barriers of an action (9). The emphasis of the negative outcomes of sexual activity before marriage can be benchmarked into the weighing of perceived severity and perceived susceptibility in the Health Belief Model. For example, according to Representative Henry Waxman’s analysis of these education curricula, one program teaches that a pregnancy occurs one out of every seven times a couple engages in sexual behavior with the use of a condom (14). This statement emphasizes the degree to which the individual feels that they will be at risk for the health outcome or in this case, pregnancy. Another program highlighted by Waxman includes in the curriculum that in heterosexual sex, the popular claim that condoms help prevent the spread of Sexually Transmitted Infections is not supported by data and that condoms fail to prevent HIV approximately 31% of the time (14). The above information translates to the individual that despite using contraception such as a condom, they are still at high risk for negative outcomes.
Another factor that is present in the Health Belief Model and is included in abstinence-only programs is perceived severity. For example, one curriculum states that 5% to 10% of women who have legal abortions become sterile and that “premature birth, a major cause of mental retardation, is increased following the abortion of a first pregnancy” (14). This lesson emphasizes the severity of pre-marital sex to the individual. I would also argue that the lesson from these negative teachings highlights the perceived benefits of abstinence. All programs are required to include that abstaining from sexual activity will bring many health benefits as it is the only option to prevent pregnancy and other negative health outcomes such as Sexually Transmitted Infections that are highlighted (10).
Not only do the above lessons contain false, misleading, and distorted information about reproductive health (14), this curriculum focuses on fear tactics to encourage youth to not engage in pre-marital sex. Behavioral theory suggests that fear-arousing messages can be ineffective (3). In a systematic review of randomized controlled trials on unintended pregnancies, adolescents were interviewed regarding their suggestions on how to improve sex education programs (7). This feedback on the current curriculum even included that sex education should be more positive with less of an emphasis on scare tactics (7). The goal of using a model such as the Health Belief Model would be that with the knowledge of the perceived severity, perceived susceptibility, and perceived benefits of abstinence will allow the individual to make a rational decision to not have premarital sex. The use of scare tactics is based on the assumption that individuals will change their behavior based on the portrayal of a negative outcome (6). This line of thinking correlates with the basic view of the Health Belief Model that behavior is based on a rational decision making process. This is not always the case. Many experts have come to the conclusion that programs that rely on fear tactics are “difficult to execute and rarely succeed” (6). It is further argued that risky behavior can often be attractive to adolescents which will then actually attract this age group to a behavior (in this case, premarital sex), therefore making the behavior more difficult to change (6). Extending even more upon the point that scare tactics may only be increasing the behavior of premarital sex, because the emphasis is only focused on negative knowledge and a measured concept, these programs than contribute to the limited understanding (12) of sexual behavior in adolescents. Therefore, if the individual is in fact attracted to the idea of a risky behavior (premarital sex), they will not have the knowledge regarding the efficacy of contraception use while engaging in sexual activity.
The Focus on the Individual and the Linear Correlation Between Intention and Behavior

Abstinence-only programs focus on the rational decision making of the individual. The curriculum is designed to provide information for the student so they can weigh the benefits and barriers of participating in pre-marital sex. This information (if valid) can be beneficial; however there are many limitations that can be attributed to this model of intervention as it only focuses on the individual.
A strong limitation is that there is no consideration of attitudes, beliefs and emotion (9). For example, when in a state of arousal, because of the strong emotional and physical energy, the rational teachings of “just saying no” usually do not apply (1). At this point, emotion will have a stronger effect on behavior then any planned intention regardless of the dangers that apply (1). In order to address the physical state of arousal, education should focus on methods on how to deal with emotions that occur during arousal, and not just walking away from them (1).
In addition, this model of intervention does not consider any factors that can be attributed to the community or the environment (9). Many factors have an effect on the individual, and these factors are crucial to include in a public health intervention. For example, Mark Edberg highlights that “given the broad and often complex relationship among school, family, and community, the potential kinds of useful information are diverse” (9). As abstinence-only programs currently only incorporate the decision making process of the individual, many beneficial factors are ignored. Issues such as social norms in the community, the environment, race, gender, class size and drug use are all issues that have an effect on adolescent behavior (9). Specifically in terms of drug use, studies have shown that programs that reach out to also prevent drug abuse along with social resistance skills have been successful (7).
Another issue with the Health Belief Model is that there is a direct correlation between intention and behavior. The abstinence-only model follows the linear decision making path that if the individual has enough information regarding the negative outcome and high susceptibility of these outcomes while engaging in premarital sex and understands the benefits of not having premarital sex, then they will have no intention of participating in this behavior, and therefore chose to be abstinent. This assumes that behavior is always planned. The assumption of planned behavior is apparent in the mechanistic, linear format of this particular model (9). The presence of habit and emotion are not incorporated, as there is the assumption that there is a linear thought process involved in each decision (9). This again does not account for any outside factors from the environment, community, or even emotion that can affect a behavior.

The Affect of Negative Stigma on Social Norms
As highlighted earlier as an issue that can affect an individual’s behavior, social norms are a very important factor in planning a health intervention. Edberg defines social norms as “customary codes of behavior in a group or culture” (9). These norms can vary in many different settings, so it is important to adjust specific programs to fit the needs of the target community. An example of a social norm in a community may be that you do not disrespect your elders. This is a guide on how to behave (not respecting your elders), as well as an affirmation of the route from where the social norm comes from (that it is not right to disrespect your elders) (9). In addition to social norms existing in a community, stigmas can also exist. Unlike social norms, stigmas are not defined rules, but negative actions that are considered “disgraceful” (8) in that community. Stigma can be associated with a negative label upon a certain behavior.
The negative emphasis that is being put on sexual activity by abstinence only programs aid in creating a social norm as well as a negative stigma in that community. Both stigma and social norms need to be considered in creating an intervention to a certain community; however both of these unique factors are not included in abstinence-only based programs. For example, if adolescents are repeatedly taught that sex in wrong, this creates a negative stigma towards those who participate in premarital sex. It also creates a barrier to communication regarding sexual issues, in which it is a social norm to not discuss sexual issues.
The lack of communication regarding sexual issues poses a serious threat to sexual health. In an investigation observing abstinent girls in an urban setting, there was a significant finding that open communication between mothers and daughters regarding sex had a strong influence on the adolescents choosing to stay abstinent (3). If abstinence based programs continue to rely on fear tactics alone, then the valuable resource of open sexual communication may not only be lost, but also develop into a social norm that this subject should not be openly discussed.
Another social norm that abstinence-only programs incorporate is stereotyping gender roles. Many curricula often incorporate the roles of men and women in successful relationships by defining that women need financial support, and men need domestic support (14). Another program states that women care less about their achievements and should judge their success on their relationships, while men judge their success on achievements (14). Another program includes that men are “sexually aggressive and lack deep emotions”, while women need affection and conversation (14). This line of teaching proposes a social norm that women are weaker, and need male support. This may also place a negative stigma upon girls that tend to be more independent, and men that tend to be more emotional.
Including any form of lesson that suggests women should be dependent on men is also very dangerous. In the same investigation observing abstinent girls in an urban setting, there were also significant findings that an emphasis on future achievements, independency and choices had a strong influence on the adolescents choosing to stay abstinent (3).
Abstinence-only sex education was put into place to decrease teen pregnancy and other issues associated with risky sexual behavior. The program identifies pre-marital sex as the main cause of these issues as well as incorporates modeling traditional heterosexual relationships as an example of an acceptable lifestyle. Unfortunately, the execution of this intervention uses techniques that are ineffective.
The use of scare tactics and the extreme focus on premarital sex as an unacceptable and harmful behavior is not only an unsuccessful method of intervention, but also uses false information as statistical fact. As stated before, facts such as a pregnancy occurs one out of every seven times a couple engages in sexual behavior with the use of a condom, that “5% to 10% of women who have legal abortions become sterile,” and that “premature birth, a major cause of mental retardation, is increased following the abortion of a first pregnancy” are included in abstinence-only curricula (14). According to obstetrics textbooks, fertility is not altered by abortion and no results have been shown to have an on effect low birth weight in later pregnancies (14). Also, in terms of condom use, failure rates for perfect use are 2-3%, and for typical use it is 15% (14). It can be argued, that if more attention is focused on teaching students how to correctly use contraception methods, then the failure rates would decrease. Currently, there are no abstinence-only programs that provide information on how to choose an appropriate method of birth control, and use it effectively (14).
The extreme focus on the individual also weakens the intervention. There is no focus on outside factors such as gender, race, socioeconomic status and social norms, which are all factors that have an effect on human behavior. Factors such as social norms can cause an individual’s decision making process to be irrational, and this specific program only focuses on a rational decision making process. This program also teaches social norms that enforce traditional stereotypes; such as women are weaker than men, in the curriculum (14). This type of lesson does not only force a certain view of traditional relationships on individuals it may not apply to, but it also can work against the actual message of abstaining from sex before marriage. Studies have shown that girls who are more independent and value their choices and futures are more likely to choose abstinence than other girls (3).
The issue of teen pregnancy in the US is severe, and needs to be addressed. Unfortunately, abstinence-only sex education is ineffective, and is forced on millions of adolescents each year (14). In order to create an intervention that will produce a positive outcome, many modifications to the current curriculum need to be addressed. Although abstinence in theory is the best method of contraception, it is important to teach abstinence in addition to other methods of birth control and how to protect oneself against unplanned pregnancy. Other factors such as future planning, self confidence, emotions, and alcohol and drug prevention need to be incorporated as well. Each program must also focus on more than just the individual, and also be modified to fit the social norms of the community that it is reaching out to. Finally, the extreme negative emphasis on premarital sex needs to be eliminated. In the event that an adolescent is not abstinent, it is essential to sexual health that they know how to not only use an appropriate method of contraception, but know how to discuss these options with their partner. Open communication about sexual issues is essential, and needs to be accepted.
The Fight Against Teen Pregnancy in the United States: A Proposal to transform Abstinence-Only Sex Education Based on Social and Behavioral Theory

In order to see positive results in a Public Health campaign regarding the rates of teen pregnancy in the US, many changes need to be made to the current abstinence- only based curriculum. As highlighted in the previous critique, methods such as fear tactics, focusing on the individual, and creating negative social norms has not only hindered the effort to lower teen pregnancy rates, it has actually contradicted the teachings of abstinence. For example, by using fear tactics as a method of teaching this emphasizes that the target behavior is unacceptable. Risky behavior can often be attractive to adolescents which will then attract this age group to a behavior (in this case, premarital sex), therefore making the behavior more difficult to change (6). In order to create a program that will yield positive effects, education in schools must be altered to eliminate the use of fear tactics, a strict focus on the individual, and the creation of negative social norms.
We first must build a health education program that is mandated in schools and includes all aspects attributed to sexual health. Currently, 21 states do not require sexual education in public schools, including the State of Massachusetts (20). Health education should be required, and should also start at an early age. The average age of sexual initiation is 13.8 years (15), so it is crucial that this curriculum be initiated before the participants initiate sexual intercourse. This health program in schools should be year round and should start as soon as the child begins schooling. Specific issues that can affect sexual health such as alcohol consumption, future planning, communication, and contraception should be addressed in addition to biological functionality of the reproductive system. In order to take the necessary steps to prevent teen pregnancy the abstinence-only curriculum needs to be revised. This proposal will define ways to educate youth in a health education class that occurs yearly from age 5-18. This will focus specifically on sexual issues and contraception use and opening the lines of communication in a multilevel model by eliminating the use of fear tactics, individually based models, and the creation of negative social norms that currently exist in abstinence-only programs.
Education of all Methods of Contraception, including Abstinence (age 10-18):

Abstinence in theory is the best method of contraception, and should be included while teaching methods of contraception. However, if the adolescent chooses to engage in sexual activity, all methods of contraception should be taught so that the individual is fully educated on how to protect themselves accordingly. As teens that use condoms at first sexual intercourse are 20 times more likely to use protection in future sexual acts and the average age for sexual initiation is 13.8 years (15), contraception education should be initiated at age 10. This will allow adolescents who do engage in sexual intercourse at an early age to have the tools to properly administer their preferred method of contraception, and will increase the likelihood that they will continue to use methods of protection.
Starting at age 10, students will begin receiving education in health class with an exclusive focus on contraception methods including the correct efficacy rates, and how to use each method. All classes will need to incorporate statistical evidence and percentages (such as thirty-four percent of women become pregnant at least once before the age of 20, and 79 percent are to unmarried teens (10)), ways in which infections can be prevented (such as using different methods of contraception), and how to administer contraceptives along with efficacy rates.
All methods of contraceptives should also be brought to class so that students can learn what they look like, and how to recognize each method. In an investigation that surveyed 1,373 British teens, many teens that had engaged in sexual activity stated that they had used a condom, however either administered the condom after intercourse had already initiated, or removed the condom before intercourse was complete (16). This is not only an unsuccessful method of protection but “the reduced effectiveness of condoms as a method of sexually transmitted disease prevention when used incorrectly may result in users losing confidence in what should be a highly effective method (16).”
The basic format of the abstinence-only education based solely on the Health Belief Model does address the benefits of abstinence; however the use of fear tactics and negative emphasis does not allow the student to be educated on all options. Adolescents who do chose to become sexually active will not have the appropriate tools to stay protected against unwanted pregnancy and sexually transmitted infections. Not only can this lack of education have negative outcomes like unwanted pregnancies, but the loss of confidence in what should be a highly effective method can then affect the choices that the individual makes in future sexual acts (16).
Taking the Focus off of the Individual and Incorporating Irrational Factors (age 5-18)

Abstinence-only programs focus on the rational decision making of the individual, however, decision making is not always rational. Many factors such as emotion, attitudes, the community, and the environment can all interrupt the line between intention and behavior (9) and these factors are not included in the abstinence-only curriculum. In order to design a program that does not rely on rational decisions, each school year will begin with an evaluation of the community.
As Mark Edberg highlights, “given the broad and often complex relationship among school, family, and community, the potential kinds of useful information are diverse” (9). As issues such as social norms in the community, the environment, race, gender and class size can affect adolescent behavior (9) these factors need to be evaluated on a yearly basis so that issues that are specific to that community can be incorporated. For example, one of the most prevalent risks associated with drug and alcohol use in teens is engaging in risky sexual behavior (19). As this is a known risk factor of unprotected sex, the levels of alcohol and drug use in the specific community can be evaluated. The severity of this issue can then be incorporated into the health curriculum. The same method can be applied to other factors that may be prevalent in the community that need to be addressed.
Emotion and biological functionality are also important factors that are not addressed in abstinence based programs. Arousal, peer pressure, and curiosity are all emotions that may not be present when rationally thinking about engaging in sexual activity, however can arise in other situations. In order to address these emotions and physical states, the health curriculum must include methods on how to address emotions, and alternative methods of dealing with them as opposed to acting on impulse. For example, addressing the existence of arousal should be tied together with contraception education so that adolescents understand that if you are in a state of arousal, and are about to engage in any type of sexual activity, it is important to be prepared with the choice method of contraception, and understand the emotions that will be present.
It is important to include the functionality of reproductive organs as well in teaching emotion. Arousal for example, can be taught as an emotion; however it is important for the adolescent to fully understand the physicality of sexual acts. Sex education needs to start when a child begins to have curiosity about his or her body which starts at a very young age (18). Incorporating different organs and their roles in the body should start at age 5 and continue through age 18. Starting with explaining the presence of different body parts at a young age, as well as encouraging young children to ask questions regarding their curiosity is important so that the child does not learn at an early age that it is not appropriate to ask questions regarding this topic. Sexual development such as puberty should then be incorporated and eventually sexual health (i.e. self breast exams, STI Information, the importance of getting checked for STI’s etc). One way to monitor specific topics that need to be addressed is by including surveying each class during the yearly community review. The survey will inquire what type of topics the student wishes to learn next year, and if they have any specific questions that they would like to have addressed. These questions can help to evaluate where these groups of students are in their sexual development, and then be incorporated into the curriculum.
Opening the lines of communication (age 5-18)
Open lines of communication between adolescents and parents is extremely important. According to the Centers for Disease Control and Prevention (15), findings from a collection of interviews with 372 sexually active adolescents in New York, Alabama, and Puerto Rico established that parent-adolescent discussions about condom use before the initiation of sexual intercourse greatly increased the percentage of adolescents who used condoms for their first intercourse (15). Adolescents who did choose to use condoms at first intercourse were also 20 times more likely to use condoms in subsequent acts (15).
Currently, the negative emphasis that is being put on sexual activity by abstinence-only programs is creating a social norm as well as a negative stigma in that community that can hinder communication lines between adolescents, their teachers, parents and peers. Lifting the extreme negative emphasis on intercourse will help to change the social norm in the community that sexual activity is not appropriate to discuss; however open communication regarding sexual issues needs to be a prominent theme in school education.
Healthy relationship and communication training needs to be incorporated into the curriculum. It is important that adolescents understand how to communicate with their partners about their own needs, as well as with their peers, and parents. Included in communication and healthy relationship training, self confidence should be emphasized. It is important that students learn to build healthy relationships with not only their peers, partners, and parents, but also with themselves. All students should receive training on the values of future achievements, independency and choices as the importance of these factors can yield significant results on the individual making healthy choices (3).
Opening lines of communications with adolescents and their parents can be difficult but it is important that the student has a relationship with an adult that they feel that they can trust. In order to open up these lines of communication, each year the student will need to interview and adult of their choice on the topics learned in class. This will help the adolescent learn how to communicate with adults about sexual and health topics, as well as build a relationship with this contact. The strength of this relationship is crucial so that if the student ever has questions, or needs to talk to someone about sexual issues, they have confidence that there is someone they can go to.
Abstinence-only sex education was put into place to decrease teen pregnancy, however the intention of education in general is to prepare youth with the skills they need for the future (17). Fear based abstinence teaching not only is not helpful to youth after the age of 18, but it also does not incorporate information based teaching so that students can apply the information later in life (17). This method also does not take into consideration community factors which have a strong impact on behavior. For example, abstinence-based programs enforce that unmarried people should remain abstinent, but this does not take into account the fact that the median age of first marriage is continually rising (17).
In order to see positive results on the fight against teen pregnancy, a program must be designed that starts at an early age and continues until the student graduates. Students must be educated on all methods of contraception, as well as the reproductive system. Multilevel factors such as the community and the environment must be incorporated so that the program can successfully relate and apply to the participants. Evaluating the community issues on a yearly basis is essential because if there are existent factors that are not addressed, the intervention may not have any positive effect. Finally, communication regarding sexual issues between students, teachers, peers, partners and adults must be accepted. It is essential that students feel that they can talk about issues, and develop communication skills that allow them to address their own needs. With these established skills, students should be able to make healthy decisions with future goals in mind as they leave schooling and move into the working world or higher level education.

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