Challenging Dogma - Spring 2011

Friday, May 6, 2011

A Critique of Abstinence-Only Sex Education- Gina Foianini

Currently, in the United States half of all pregnancies to women age 18-19 are unintended. [1] In addition to this, STD prevalence is highest among youth aged 15-19. This population acquires nearly half of all new STD cases but only accounts for 25% of the sexually active population. [2] Sex education is a preventative public health intervention aimed at reducing both teen pregnancy and STD transmission among young people.

Sex education generally falls into two main categories: 1) abstinence-only education, and 2) comprehensive education. Both types of sex education focus on changing behavior. As opposed to comprehensive sex education, which teaches contraception as a way to avoid pregnancy and STI transmission, the message of abstinence-only education is to abstain from any sexual activity until marriage. Abstinence-only programs provide limited information about contraception, mainly pointing out it's ineffectiveness. [3]

As defined by Title V of the Social Security Act, abstinence-only education teaches that sexual expression outside of marriage will have harmful social, psychological, and physical consequences. It teaches one set of morals based on the idea that the only place for sexual activity is within “a mutually faithful monogamous relationship in the context of marriage.” [4]

Abstinence-only education has been supported federally since 1982, when it was originally funded despite the fact that it is not backed by public health or social science research. Abstinence-only education continues to be funded, although it has still not been proved to be effective at reducing STD transmission rates or rates of teen pregnancy. [5] Sexual education is an ongoing debate among parents, health care providers, educators and politicians in the U.S.

Abstinence-only sex education is an intervention is based on the Theory of Planned Behavior, which is based on the assumption that human behavior is reasoned and planned in advance. This theory separates attitudes from intentions. It identifies intentions as deriving from both a person’s attitudes toward a behavior and from their perception of the subjective norms associated with the behavior-what people think of the behavior. It identifies intentions instead of attitudes as being more predictive of actual behavior. [6]

The Theory of Planned Behavior also identifies subjective norms and self-efficacy as factors that influence behavior. [6] Based on this assumption, abstinence-only sex education attempts to change attitudes about sex assuming that if a person’s friends or peer group also values abstinence, the person will be likely to avoid sex until marriage. This intervention has not been effective in reducing the negative health outcomes associated with unprotected sex. The following critique aims to address the potential reasons for this ineffictivity.

The first major flaw of abstinence-only sex education as an intervention is that it assumes that intention leads to behavior, and that people move from one to the other in a rational manner. The intervention is based on the idea that sexual behavior is a result of a rational and reasoned decision-making process. Based on the assumption that people move from intention to behavior in a rational manner, abstinence-only education works to change intentions but doesn’t acknowledge other factors that impact behavior. It also doesn’t take into account that the factors which drive teens’ sexual behavior can cause their decision-making process to be anything but rational.

Abstinence-only education assumes that if people intend to stay abstinent, they will stay abstinent. Because of this assumption, the intervention does not take into account the power of visceral influences or the possibility that decisions about sexual behavior are not made in a rational manner. However, there are many other factors that come into play that affect behavior, especially sexual behavior.

Abstinence-only education doesn’t acknowledge the impact of gut reactions and emotional drives on sexual behavior. Decisions about sex are sometimes explained as being out of one’s “control.” The concept of visceral influence on behavior is used to explain the feeling of loss of control.

According to Loewenstien, sexual desire is a visceral factor, meaning it is a psychological state driven by pleasure, which affects the desirability of a good or action. Loewenstein explains that visceral influence impact behavior by blinding a person to all other goals aside from obtaining the object or behavior of desire. The second implication of visceral factors is that they cause a person to forget their impact in the future or in the past, when they are in an un-aroused state. [7]

In his book Predictably Irrational, Dan Ariely examines this phenomenon through his study of decision-making under sexual arousal. Ariely suggests that people have different decision-making processes whether they are in a “cold state”, or a “hot state”, meaning un-aroused vs. aroused. His research suggests that no matter how “good” a person’s intentions are when they are outside of a sexual situation, when they are driven by passion and arousal, the concept of right and wrong is abandoned. His study of the sexual behavior of male students at Berkley demonstrated the impact of passion on behavior. This impact was so strong that his subjects were willing to risk exposure to sexually transmitted disease. [8]

Abstinence-only education doesn’t acknowledge the impact of visceral factors on decision-making. Because of this, the intervention is limited in its effectiveness in protecting teens from the negative health outcomes of unprotected sex. By assuming that intent is predictive of behavior, the intervention only focuses on changing intentions. Because of the impact of visceral influences, or factors that drive behavior in the “heat of the moment,” focusing on changing intention alone is not enough to change behavior. This focus also doesn’t adequately prepare teens for situations that can arise due to irrational decision-making.

There are serious public health implications in relying on a model emphasizing intention as the drive behind sexual behavior. Because abstinence only education doesn’t acknowledge that intentions to stay abstinence can be impacted by powerful visceral drives, teens can find themselves in a dangerous situation. Without knowledge on how to have safe sex, they can be left without the knowledge about how to protect themselves. By only working on the level of intent we are wasting our time and effort, because intent isn’t the main determinant of behavior.

The second major flaw in abstinence only education is that it doesn’t account for important contextual factors in one’s life that also affect decision-making. By assuming that intent is the main predictor of behavior, this intervention discounts the impact of the important environmental factor of gender. Abstinence-only education simplifies sexual activity and doesn’t acknowledge gender roles and their impact sexual decision-making among teens.

The impact of gender on sexual decision-making is detailed in the Theory of Gender and Power. In sexual relationships, women often have less power than men. Because of this, they have unequal power in making decisions regarding sex. According to the Theory of Gender and Power, these gender inequalities come from 3 structures: 1) the sexual division of labor, 2) the sexual division of power, and 3) cathexis, or norms in society that reinforce behavior. [9] Gender roles, and the complex imbalance of power they create, have implications for teen sexual behavior that is not addressed by abstinence-only education.

Abstinence-only education doesn’t account for the effects of gender on sexual relationships, and it assumes that self-efficacy is the same for women as it is for men. It doesn’t take into account how gender affects decision-making. Because of power structures, women don’t have as much self-efficacy in making decisions about safe sex. According to Wingood, women often don’t believe they can negotiate safe sex. This can lead to an increase in sexual risk factors for women. [9]

Abstinence-only education doesn’t address gender roles and power inequalities, and ignores the impact of gender on sexual decision-making. It is limited in its effectiveness because it doesn’t take into account gender-based differences in self efficacy. Abstinence-only education sees men and women as equal and doesn’t focus on the struggles that women face in making healthy decisions about sex. Abstinence-only education doesn’t focus on improving women’s self efficacy in order to avoid unsafe sexual situations.

According to Wingood, women have gender- specific health risks and are more vulnerable to sexually transmitted diseases. The social structure and its power imbalances lead to different risk factors for women and men, and increases women’s vulnerability to adverse outcomes of unprotected sex. [10] Prevention interventions need to address women’s specific health risks to ensure that women are getting the help they need to stay healthy.

Women have a role in promoting and encouraging safe sex, but they need the tools to do so. Abstinence-only education doesn’t acknowledge the fact that women need different tools than men in order to keep themselves safe, and so therefore doesn’t provide these needed tools. Gender roles and norms are deeply entrenched in society, and relationships between men and women are nuanced and complex. Although it is difficult to change these norms, prevention approaches that don’t address these issues are limited in their scope. We need an approach that addresses women’s specific risks, asks more appropriate questions, and creates opportunities for prevention.

The third major flaw in abstinence-only education is that it threatens teens’ sense of freedom in making autonomous decisions about sex. The implication of this threat to freedom is explained by the Psychological Reactants Theory. This theory posits that when people perceive that their personal freedoms have been threatened they experience reactance. Motivated by this reactance and the desire to restore their freedom, they will choose to adopt the behavior that they are told not to do. [11]

How this effects adolescents is clear. According to Hong, reactance is higher among younger people and reaches a peak in late adolescence. [12] This has implications for sexual education aimed at adolescents. Miller’s study on the causes of teen smoking found that psychological reactance was a prominent predictor of teen smoking initiation. [13] Because of this, we can assume that psychological reactance caused by the taking away of sexual freedoms will have a similar result.

Abstinence-only education takes away sexual freedom from teenagers, as well as the freedom to learn about sex as a healthy part of life. In addition to this, it takes away their freedom to use contraception. Even if teens don’t necessarily want to be sexual, just the fact that the choice is taken away from them will cause reactance. According to the theory, reactance causes the person experiencing it to engage in the behavior we are trying to avoid, in this case having unsafe sex.

According to class notes, dominance is a factor that influences reactance. The more dominance that people experience, the more likely they are to be reactant. Abstinence-only education can be seen as dominance because it imposes a set of moral values that don’t necessarily apply to everyone. This kind of dominance and imposition of core values will only make teens react more, especially teens who hold different core beliefs.

Based on this theory, abstinence-only education can be ineffective because reactance can cause teens to have unprotected sex in response to the perception that their sexual freedoms are being taken away. This not only limits the effectiveness of the intervention, but could actually cause an increase in the negative health outcome of unsafe sex. Based on Psychological Reactants Theory, abstinence-only interventions could actually be a risk factor for sexually transmitted infection and unwanted pregnancy.

Based on these three flaws, a new approach to the prevention of STDs and unintended pregnancy among teens is needed. My proposed intervention, titled My Body, My Choices, addresses all of the issues outlined above. This new intervention is a form of comprehensive sexual education to be delivered in a school setting. The intervention is based on a peer model and incorporates Motivational Interviewing to motivate safe sex behavior.

By not acknowledging the power of visceral influences on sexual behavior, abstinence- only interventions leave teens unprepared in sexual situations. A comprehensive approach to sex education which teaches both abstinence and provides information about contraception will ensure that if an adolescent finds themselves in a sexual situation, they will be prepared and have the tools they need to make the situation safe. The sexuality education programs proven to be most effective are programs which send a clear message about both abstinence and the use of contraception to reduce unintended pregnancies and STI transmission. [13]

My Body, My Choices will teach abstinence as an option, but it will also focus on being prepared to make healthy sexual choices and practice safer sex. It will focus on preparation in two ways, by teaching about contraception and by talking about visceral influences like passion and arousal and their impact on decision-making. Incorporating the topics of arousal and pleasure into sex education will better prepare adolescents for the reality of sexual experiences, and therefore increase the likelihood that they will make good decisions under difficult circumstances.

The Sexual Health Model shows the importance and impact of incorporating the issue of pleasure into sex education interventions. By talking about the reasons people have sex, we can help adolescents better understand their sexual behavior. A better understanding of sexual behavior promotes safe and healthy sexual practices. The Sexual Health Model views sex from a positive perspective and assumes that when people are aware of sexual pleasure and how it affects them, they are more capable of setting sexual boundaries. [14] My Body, My Choices will incorporate the topic of pleasure to help adolescents be more prepared and better equipped to practice safe sex.

The second flaw of abstinence-only education is that it doesn’t acknowledge the impact of gender on sexual behavior. To address this issue, My Body, My Choices will focus on the empowerment of women in sexual situations. The intervention will utilize peer models to teach negotiation and communication skills to young women. By using women as peer models, the men in the class will see women as strong, independent and capable partners. The potential impact of this would be a change in the social structure and gender norms that cause women to be more vulnerable to sexual risks.

For the women in the class, having another women acting as a peer model will increase their self-efficacy to set sexual boundaries, to negotiate safe sex and to walk away from a situation that is unsafe. Modeling Theory attempts to explain how people acquire new forms of behavior. The model assumes that individuals model other peoples’ actions and responses when addressing problems in their own lives. According to the theory, if the observer identifies with the model and sees the model as worth of imitation, he or she will be more likely to adopt the same behaviors and responses. [15]

The implications of this approach can be seen in an HIV prevention intervention based on the Theory of Gender and Power. This intervention utilized peer modeling of condom use and negotiation skills to strengthen women’s control over their sexuality. This intervention was successful in increasing both self-efficacy and self-esteem. In addition to this, women in the program demonstrated a greater commitment to changing their behaviors in order to practice safe sex. [9]

By using the peer-model framework, My Body, My Choices will aim to improve the self-efficacy of the women students in the class to avoid unprotected sex. Peer modeling also has the potential to impact gender stereotypes and change how men in the class view their female peers. Through this approach we can focus on changing social norms about sex and gender in the adolescent environment.

The third flaw of abstinence-only education is that it causes reactance in adolescents. In order to reduce reactance, My Body, My Choices will give back some of the freedoms that abstinence programs take away. By giving teens the option of having sex and showing them healthy ways to do so, the intervention will be less likely to cause reactance. The intervention will focus on empowering adolescents with choices and providing them the information they need to make choices about safe sex.

Another way the My Body, My Choices Intervention will counter reactance is by utilizing Motivational Interviewing as a tool to motivate students to practice safe sex. Motivational Interviewing is an intervention that is student-centered and non-judgemental. It focuses on facilitating behavior change from within as opposed to imposing values from the outside. [16] This intervention will use Motivational Interviewing to explore the reasons for sexual behavior in adolescents and to explore how the consequences of unsafe sex would affect the student’s life and future goals.

Motivational Interviewing works by evoking knowledge that students already have, instead of imposing knowledge from the outside. The technique can decrease dominance caused by the imposition of beliefs from outside of the student, which can lead to greater reactance. Abstinence-only education teaches a set of core values which don’t always align with the core values of every student. By engaging in Motivational Interviewing, students can explore their own beliefs and how those beliefs impact their sexual behaviors.

Silvia identifies “interpersonal similarity” as another means of reducing reactance. According to this principle, the more a person relates to the communicator and identifies with them, the more likely they are to comply with what that person is saying. Interpersonal similarity also works to increase the credibility of what that person is presenting or communicating for the person receiving the communication [11] Based on this principle of similarity, My Body, My Choices will use peers instead of instructors for the Motivational Interviewing component of the intervention as students are more likely to relate to their peers.

Barnet’s study on adolescent contraceptive behaviors tested the impact of a motivational interviewing intervention aimed at preventing repeat births to adolescent mothers. The intervention group engaged in a 20-minute motivational interviewing session to encourage contraceptive use. Motivation Interviewing in this study lead to a reduction in births among adolescent mothers. [17] This study shows the potential of Motivational Interviewing to impact sexual behavior, specifically among adolescents.

Abstinence only sex education is a deeply flawed approach to the prevention of STI transmission and unintended pregnancy among adolescents. The approach is based on the false concept that intention leads to behavior and, therefore, focuses on changing intent alone without consideration for other factors. Abstinence-only education doesn’t acknowledge how gender affects sexual decision-making. It treats men and women the same when it comes to their sexual risk and ability to make decisions about sex. Because of psychological reactance, abstinence only education has the potential to cause adolescents to experiment with unsafe sex.

My Body My Choices is a dynamic approach to sex education that addresses all of these flaws. Comprehensive education avoids reactance by giving students back their freedom of choice. Using women as peer models for how to negotiate safe sex with a partner will work towards changing gender stereotypes and empowering women to take a more active role in their sexual health. Finally, by utilizing Motivational Interviewing as a tool to combat reactance, students will have the opportunity to explore their own sexual beliefs with their peers. My Body, My Choices has the potential to motivate adolescents to value safe sex practices by acknowledging the reality of their environment and their own motivations to be healthy and safe.

1. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 National Survey of Family Growth. National Vital Health Stat 2005;23(25):12.

2. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. 2004:36(1):6-10.

3. Kholer, P, Manhart, L, Lafferty, W. Abstinence-only and comprehensive sex education and the inititation of sexual activity and teen pregnancy. Journal of Adolescent Health. 2008; 42 344-351

4. Section 510(b) of Title V of the Social Security Act, P.L. 104-193

5. Howell, M, updated 2007 by Keefe, M. The history or federal abstinence-only funding. Website, Advocates for Youth. Accessed online via Last updated July 2007

6. Edberg, M. Essentials of Health Behavior Reader. Sudbury, Ma: Jones and Bartlett Publishers, 2007. p142

7. Loewenstein, G. Out of control:visceral influences on behavior. Organizational Behavior and Human Decision Processes. 1996; 65 (3) 272-292

8. Ariely, Dan. Predictably Irrational:The Hidden Forces that Shape Our Decisions. New York, New York: Harper Collins, 2008.

9. Wingood, Gina M., DiClimente, Ralph J. “The Theory of Gender and Power: a social structural theory for guiding public health interventions.” Social and behavioral sciences for public health Course Packet

10. Wingood, G, DiClemente, R. Application of the theory of gender and power to examine HIV-related exposures, risk factors and effective interventions for women. Health Education and Behavior. 2000; 27 (5) 539-565

11. Silvia, Paul J. Defliecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. 2005. Basic and Applied Social Psychology. 27(),

12. Hong, Sung-Mook, et all. Psychological reactance: effects of age and gender. 2001. The Journal of Social Psychology. 134(2). 223-228.

13. Miller Claude H., et al. Identifying Risk Factors for initiation of adolescent smoking behaviors: the significance of psychological reactance. 2006. Health Communication. 19(3), 241-252.

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