Challenging Dogma - Spring 2009

Thursday, May 7, 2009

Why Abstinence-only Education Fails: A Critique from a Social Behavioral Perspective – Christine Connolly


Sexual activity during adolescence can have a myriad of public health consequences; including but not limited to increased rates of sexually transmitted disease (STD) and unintended pregnancy. In the United States, recent estimates have suggested that adolescents account for almost half of all new STD cases while only representing a quarter of the ever sexually active population (1). Although pregnancy and birth rates among girls ages 15-19 years have decreased since 1991, approximately 400,000 infants were born to mothers in this age group in 2006. More than 80% of these pregnancies were unplanned. Among developed countries, the United States has the second highest adolescent pregnancy and birth rates. (2)

To help address these issues, the United States federal government began funding programs to promote abstinence in 1982, with the passage of the Adolescent Family Life Act (AFLA). Since this time, federal funding for abstinence programs has increased; first under Section 510 of the Social Security Act in 1996 and again under the Special Projects of Regional and National Significance Community-Based Abstinence Education Program (CBAE) in 2000. In particular, passage of Section 510 of the Social Security Act was significant, as this legislation outlines an eight-point definition of abstinence; the interpretation of which has gone on to define the characteristics of programs to receive federal funding. Based on this eight-point definition (and later, on strict guidelines introduced by CBAE), funding has shifted from comprehensive sex education programs (promoting abstinence in conjunction with other health-related behaviors such as contraception use) to education programs advocating abstinence-only until marriage. Under current legislation, federally funded programs must promote only abstinence and are prohibited from disseminating information regarding contraception services, sexual orientation and gender identity, and other aspects of human sexuality. (3)(4)(5)

Despite immense funding to date ($204 million was appropriated in 2008 alone (5)), there is evidence to suggest that abstinence-only education (AOE) largely fails to reduce negative public health consequences of adolescent sexual activity. This paper will present three arguments for why AOE has failed as a public health initiative from a social behavioral perspective.

Argument 1: Intention vs. Behavior

The notion that intention leads to behavior is a common theme among traditional health behavior change models, including the Health Belief Model and the Theory of Reasoned Action. Intention is a cornerstone of many AOE programs, where it is assumed that adolescents who develop intention to remain abstinent will carry this forward behaviorally. As is the case with the aforementioned traditional models, the idea that intention (in this case abstinence) leads to behavior (forgoing sexual activity) is fundamentally flawed.

Studies have shown that intention to abstain does not always lead to abstinence behavior among adolescents. Perhaps the most straightforward evidence of this is demonstrated by AOE programs that include public virginity pledging; where adolescents publicly declare their intention to abstain from sexual activity in the form of an oral or written promise. Studies on the effectiveness of public virginity pledges have generally shown that adolescents who have pledged do not delay sexual initiation longer than their non-pledging counterparts (except in some specific social contexts). Adolescents who have pledged versus those who have not have comparable rates of STDs. Further, many adolescents go on to deny having pledged if they break their pledge. (6)(7)(8)

Perhaps this discrepancy can be explained in part by a new model of adolescent risk behavior called the prototype/willingness (P/W) model, first proposed by Gibsons and Gerrard in 1995. According to this model, much of adolescent risk behavior is unplanned and is influenced by an adolescent’s willingness to engage in a behavior. An adolescent’s willingness is function of four factors: whether the adolescent’s peers have positive attitudes toward the behavior, whether the adolescent has positive attitudes toward the behavior, whether the adolescent has engaged in the behavior in the past, and finally, whether the adolescent associates a positive social image or prototype with the behavior. In this model, an adolescent’s engagement in risk behavior is based on social reactivity. So, in a risk-conducive situation, an adolescent may react by engaging in risk behavior conditional on his or her willingness to engage in the behavior. This reaction is completely unplanned. The P/W model acknowledges the presence of intention, but views it as independent from but related to willingness. In this model, an adolescent can fully intend to abstain from a behavior (such as sexual activity), but can go on to engage in the behavior anyway if the situation presents itself and they are willing. (9)

Even if intention always led to behavior, some studies have suggested that adolescents do not consider abstinence and sexual activity to be opposing constructs. This is problematic in the context of AOE programs, as an adolescent could both intend to abstain and intend to be sexual active simultaneously. Several studies to date have shown intention to have sex to be a stable predictor of sexual activity among adolescents (10). Expanding on this, a recent study examined how adolescents think about abstinence as well as sexual activity. This study found that intention to abstain did not consistently predict abstinence or reduction in sexual behavior. In fact, the association between abstinence intention and subsequent behavior differed by an adolescent’s intention to have sex. For example, when an adolescent’s intention to have sex was positive but low, intention to abstain from sex had little impact on sexual activity. However, when both intentions to have sex and to abstain were high, intention predicted an increased likelihood of sexual activity. The authors of this study feel this could be due to a perception among some adolescents that there is a natural linear progression between abstinence and initiation of sexual behavior. When considered temporally, it is possible to have strong non-oppositional intentions regarding both. (11)

Argument 2: Perceived Susceptibility

Although discussion of contraception use is prohibited, contraception is often described in AOE programs with an emphasis on failure rates. In addition, there is no requirement for scientific accuracy in educational materials provided by AOE programs and inaccuracies often involve exaggerations of failure rates. (6)(12) When discussion of contraception is limited to downplay of possible positive health effects, AOE programs become a flawed public health approach. By limiting information and/or distorting facts, AOE programs attempt to enhance an adolescent’s perceived susceptibility to negative health outcomes. The flaw inherent to such an approach is that adolescents may not be particularly influenced by this construct in the context of risk behavior.

This effect may be particularly pronounced among young women. A study of 209 adolescent women conducted in 2003, found that the majority of participants (88.9%) perceived themselves to be at little to no risk for contracting and STD. This was despite the fact that the majority of participants (73.8%) had reported previously contracting an STD and/or engaging in risky sexual behaviors, such as unprotected sex. (13)

Perhaps this can be explained by research which suggests that adolescents (as well as adults) can exhibit unrealistic optimism regarding the development of negative health outcomes. Unrealistic optimism is a form of cognitive bias and can be defined as the tendency for individuals to perceive their risk of harm as below average as compared with others. (14) Such a bias could certainly render perceived susceptibility ineffective, given that individuals with this bias may not truly believe they are susceptible to the same negative health outcomes as other individuals.

A second explanation may stem from the fact that adolescents tend to be oriented in the present and generally do not focus on future outcomes. Adolescents tend to plan ahead, think about the future, and anticipate future consequences of their actions less than their adult counterparts. Adolescents also tend to favor small rewards delivered sooner over large rewards delivered at a later time point. These effects appear to be more pronounced in younger adolescents and decrease as adolescents move towards adulthood. (15) This is significant in the context of sexual behavior, as adolescents may not fully comprehend possible long term consequences associated with their actions. Because of this they may feel less susceptible to negative health outcomes that will not manifest until much later in life (such as the development cervical cancer from contracting HPV).

Argument 3: Unaddressed Contextual Factors

As with traditional health behavior change models, AOE attempts to cultivate health behavior change on an individual level and fails to address contextual factors that may inhibit or promote health behaviors. For this reason, AOE is a flawed public health approach, as it fails to account for contexts where it may be virtually impossible for adolescents to abstain.

For example, AOE ignores that individuals may make very different decisions in contexts that leave them in dispassionate versus aroused states. In his book, Predictably Irrational, Dan Ariely discusses an experiment he conducted where college students were asked to predict a number of decisions they would make (for example, the decision use or not use a condom) in both dispassionate and aroused states. The results of this experiment showed that students in dispassionate states were more likely to predict making rational decisions, but the same students in aroused states were more likely to predict making irrational decisions. He goes on to suggest that this phenomenon may be exacerbated in adolescents and that adolescents may not be able to resist sexual behavior once they are in an aroused state, even if they would have earlier decided to abstain. (16)

AOE ignores social contexts which may influence an adolescent’s decision to abstain. In the case of virginity pledges, pledging is at times associated with delay of first sexual intercourse among adolescents. However, this delay appears to be mediated by social contexts. In situations where too many or too few adolescents within a community pledge, pledging is not associated with delay in sexual activity. Specifically, pledging seems to work when adolescent pledging can assume a minority identity as a result of their pledge. This is a common phenomenon related to identity movements. (17) The influence of identity within a social context can also be seen in a recent study that found retraction of virginity pledges by those who had pledged previously was strongly associated with the abandonment of a born again religious identity. Together, these findings suggest that identity in social contexts may be a motivating factor for adolescents when it comes to abstinence. (7)

Further, AOE programs largely ignore the influence of family dynamics and socioeconomic status (SES) on adolescent sexual activity. For instance, multiple studies have shown greater parent-child connectedness (parental support, closeness, and warmth) is related to delay in the timing of first intercourse and reduction of sexual activity. Living with a single parent and/or having sexually active older siblings has been associated with higher rates of adolescent pregnancy. Lower SES has been associated with earlier first intercourse and lower rates of contraception use. (18)


Abstinence-only education is not flawed because abstinence is ineffective. In fact, as argued by many proponents of AOE, abstinence is the only way to completely avoid negative consequences related to sexual activity. Rather, the fundamental flaw inherent to AOE is the uncertainty around whether adolescents can successfully remain abstinent. As argued above, an abstinence-only approach may not be a realistic option for adolescents for a number of reasons. To a large extent, social factors appear to be related to whether an adolescent remains abstinent, regardless of whether an adolescent intends to abstain. In addition, AOE programs do not take into account how adolescents may cognitively process their own sexual development or risks for subsequent health issues. An effective program must acknowledge that adolescents may not be able to abstain and therefore must provide them with tools to protect themselves if they become sexually active.

A Counter-Proposal to Abstinence-Only Education

Abstinence can be used as one part of an effective strategy to avoid negative health outcomes associated with sexual activity. An effective public health intervention could utilize abstinence by incorporating it as one of several methods an adolescent could employ to avoid negative health consequences. Such an intervention could further improve outcomes by addressing fundamental flaws inherent to AOE-based interventions.

An Alternative Intervention

An alternative approach to AOE programs could consist of a hypothetical country-wide network of community-based outreach and education programs collectively called the Rainbow Project. Across the Rainbow Project network, programs would have three primary goals. First, programs would endeavor provide adolescents and their families with scientifically accurate information regarding a variety of topics related to human sexuality. Topics covered would include, but not be limited to: abstinence, effectiveness and proper use of contraception, sexual orientation, and gender identity. Second, programs would endeavor to cultivate social environments where adolescents feel supported and empowered to be responsible for their sexual health. Third, programs would endeavor to provide services designed to strengthen relationships between adolescents and their families, such as parent-child activities, parenting classes, and family counseling.

How individual programs would achieve the goals described above would be relatively flexible. Individual programs would be housed within neighborhood community centers and would receive funding to conduct community-level research to design and fine tune initiatives to fit community needs. However, despite this flexibility, a few general concepts would be implemented across the board.

Overall, programs would engage adolescents and their families both together and one-on-one. Programs would provide comprehensive sex education directly to adolescents via classes and workshops within their schools. Adolescents would also be addressed outside of their schools through after school programs and activities organized within their community. Parents and other family members would be engaged through school and community activities as well. The community center would serve as a place for impromptu contacts between programs and community members. Programs would be staffed at hours to promote accessibility, based on the needs of the community

The initiative described above would incorporate abstinence as one of many methods to be used to protect adolescents from negative health outcomes. Further, the initiative described above would address a number of flaws inherent to AOE-based programs. How the Rainbow Project would address the specific flaws discussed previously is discussed below.

Flaw 1: Intention vs. Behavior

Similar to traditional health behavior change models, AOE programs fail in their assumption that abstinence intention will lead to abstinent behavior. The Rainbow Project does not share this flaw, as it does not assume that intention leads to behavior.

Instead, the Rainbow Project arms adolescents and families with a myriad of strategies to avoid negative health outcomes related to sexual activity. In this sense, the fact that people can have a number of intentions and may only be able to translate a few into behavior is acknowledged. By providing a number of options, the Rainbow Project will give adolescents alternative strategies to use if they are unable to follow through with their initial intentions.

This could be significant in cases where adolescents may have positive intentions regarding both abstinence and sexual behavior. In such cases, adolescents would now be armed with methods to protect themselves if their intention to engage in sexual activity leads to behavior. In addition, the Rainbow Project would foster social environments where abstinence intention could lead to behavior more often. A recent study suggests that adolescents may experience negative social and emotional consequences as a result of abstaining from sexual activity. In this study, adolescents who remained sexually inexperienced over the course of the study reported having a bad reputation as a result and regretted abstaining. (19) This is significant in the context of the prototype/willingness model, where an adolescent’s willingness to engage in a behavior is based in part on whether the adolescent associates a positive social image with the behavior. The Rainbow Project will work towards changing social perceptions among adolescents by promoting positive social images related to reproductive health responsibility.

Flaw 2: Perceived Susceptibility

AOE programs are flawed when they fail to take into account that perceived susceptibility is not an effective tactic to influence adolescent behavior. The Rainbow Project improves upon this in that it does not attempt to emphasize perceived susceptibility and instead focuses on disseminating scientifically accurate information regarding contraception, as well as other aspects of human sexuality.

There is ample evidence to suggest that providing adolescents with medically accurate information about contraception is an effective strategy. Multiple studies have found that providing such information to adolescents does not encourage early sexual activity. Rather, such initiatives were found to increase contraception use among adolescents who were already sexually active. In fact, declines in unintended pregnancies among adolescent women observed in the 1990s have largely been attributed to an increased knowledge regarding and appropriate use of contraception. (20)

Providing adolescents with medically accurate information regarding contraception acknowledges the existence of cognitive bias, such as unrealistic optimism, and the tendency for adolescents to be oriented to the present rather than the future. When adolescents cannot abstain from sexual activity due to cognitive bias or lack of forethought regarding future outcomes, contraception can provide an alternative method to safeguard their reproductive health.

Flaw 3: Unaddressed Contextual Factors

AOE programs fail as public health policy as they do not address contextual factors that may influence adolescent sexual behaviors. The Rainbow Project improves upon this as it strives to address contextual factors related to sexual activity among adolescents.

First, as mentioned previously, the Rainbow Project will arm adolescents and their families with a myriad of strategies they can employ to avoid negative outcomes. This is significant in the context of decisions made by adolescents in dispassionate versus aroused states. In this context, an adolescent who has made an irrational decision to engage in sexual activity based on their physiologic state will still have options available, such as using the functional knowledge required to use contraception effectively.

In addition, the Rainbow Project will not ignore social contexts which may influence an adolescent’s decision to become sexually active. Instead, it will directly acknowledge and try to address issues within social contexts by fostering environments where adolescents are influenced to make responsible decisions regarding their reproductive health.

Further, the Rainbow Project will address issues related to family contexts by strengthening communication and relationships between adolescents and their caregivers. Strengthening both will help to alleviate negative health outcomes, as there is evidence to suggest the adolescents who feel that their parents are involved in their lives (who know where they are and who they are with) are less likely to engage in at-risk sexual activity. Further, there is evidence to suggest that positive parental influence can mediate effects of peer influence that can lead to sexual behavior. (21)


The Rainbow Project is a hypothetical intervention to reduce negative health outcomes associated with sexual behavior among adolescents. It avoids strategies employed by both traditional health behavior change models and AOE programs and instead recognizes the importance of innate human behavior, social behavior, and environmental contexts. Perhaps the most compelling strength of the Rainbow project from a contextual perspective is its emphasis on community-based research to define new and augment existing programs. It is in this way that the Rainbow Project recognizes heterogeneity between communities and will be able to better address contextual issues specific to the communities they serve.


1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2007. Atlanta, GA: National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, December 2008.

2. Centers for Disease Control and Prevention. Adolescent Reproductive Health. Atlanta, GA: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion.

3. Advocates for Youth. The History of Federal Abstinence-Only Funding. Washington, DC: Advocates for Youth.

4. Santelli J. et al. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health 2006; 38: 72-81.

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11. Masters NT. The opposite of sex? Adolescents’ thoughts about abstinence and sex, and their sexual behavior. Perspectives on Sexual and Reproductive Health 2008; 40: 87-93.

12. United States House of Representatives Committee on Government Reform. The Content of Federally Funded Abstinence-Only Education Programs. Washington, DC: Minority Staff Special Investigations Division, 2004.

13. Ethier KA. et al. Adolescent women underestimate their susceptibility to sexually transmitted infections. Sexually Transmitted Infections 2003; 79: 408-411.

14. Greening L. et al. Predictors of children’s and adolescent’s risk perception. Journal of Pediatric Psychology 2005; 30 5: 425-435.

15. Steinberg L. et al. Age differences in future orienting and delayed discounting. Child Development 2009; 80 1: 28-44.

16. Ariely D. Predictably Irrational the Hidden Forces that Shape Our Decisions. New York, NY: HarperCollins, 2008.

17. Bearman P. and Bruckner H. Promising the future: Virginity pledges and first intercourse. American Journal of Sociology 2001; 106: 859-912.

18. Miller B. Family influences on adolescent and contraceptive behavior. Journal of Sex Research 2002; 39: 22-26.

19. Brady S. and Halpern-Felsher B. Social and emotional consequences of refraining from sexual activity among sexually experienced and inexperienced youth in California. American Journal of Public Health 2008; 98 1: 162-168.

20. AIDS Policy Research Center & Center for AIDS Prevention Studies. Abstinence Only vs. Comprehensive Sex Education: What are the arguments? What is the evidence? San Francisco, CA: AIDS Research Institute University of California, March 2002

21. DiClemente R. et al. Psychosocial predictors of HIV-associated sexual behaviors and the efficacy of prevention interventions in adolescents at-risk for HIV infection: What works and what doesn’t work?. Psychosomatic Medicine 2008; 70: 598-605.

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