A Critique of an Abstinence-Only Until Marriage Sex Education Program in Reducing Teen Pregnancy in Mississippi - Ogechi Emereum

Beating the drum of abstinence in a culture that promotes sex in social networking, media and everything else is bound to fall on the deaf ears of adventurous teenagers. Is it really enough to tell our teens to just wait? With increasing numbers of early sexual debut in adolescents across the nation, and with very few reliable interventions that address this, more adolescent are prone to early sexual debut without proper understanding of safer sex methods and contraceptive options. This has lead to an increased number of teen pregnancies in the USA.

Teen pregnancy, defined as pregnancy in a female aged 15-19 years, has been a huge public health issue in the USA. Teen pregnancy also has several health, economical and political implications to mother, child and society. Some of these outcomes include an increase in prenatal adverse effects such as low birth weights, complications during delivery, which are expensive to treat, teen mothers have an increased risk of developing sexually transmitted infections including HIV and teen mothers and fathers are more likely to drop out of school, engage in risky behaviors that can affect employment opportunity and social class in future. (1)

According to the CDC, in 2009, approximately 410,000 births occurred among teens aged 15--19 years, with the national teen birth rate as 39.1 births per 1,000 females. This represents a 37% decrease from 61.8 births per 1,000 females in 1991 and currently the lowest rate ever recorded. State-specific teen birth rates also vary from 16.4 to 64.2 births per 1,000 females and are currently highest in southern states. (2)

Based on this statistics and with the Bush administration in power at this time, the decline was attributed to abstinence based programs. The principal rationale for abstinence is that it provides the only absolute protection against teen pregnancy and sexually transmitted diseases. In addition, programs that emphasize only abstinence as a means of birth control may be seen as sending a more consistent message to adolescents involved in sexual decision-making. (3)The federal government heavily invested in funding these programs, they also created state policies and agencies that were geared towards promoting abstinence programs across the nation. The Adolescent Family Life Act (AFLA), the Title V abstinence-only until-marriage program, and the Community-Based Abstinence Education (CBAE) grant program were created under the Bush administration. In 1996, Congress added Section 510 to Title V of the Social Security Act. This allocated $50 million per year from 1998 through 2002 to fund state programs providing abstinence education. (4) Since then, more than $1.5 billion dollars in both federal and state matching funds has since been used for abstinence-only-until-marriage programs.(5) However, despite this decline and funding, the USA still has nine times the rate of teen pregnancy compared to other developed nations.(6)

This increase in funding lead states like Mississippi whose teen birth rate is amongst one of the highest in the nation to also adopt abstinence only until marriage programs. In an attempt to curb this high birth rate amongst teenagers, the Mississippi Department of Human Services (MDHS) incorporated abstinence only programs. The programs that have been widely available in Mississippi have been mostly geared towards abstinence only. These programs follow the Title V requirements which include:

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

Ø Teaches abstinence from sexual activity outside marriage as the expected standard for all school-age children.

Ø 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.

Ø Teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity.

Ø Teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects.

Ø Teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents and society.

Ø Teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances.

Ø Teaches the importance of attaining self-sufficiency before engaging in sexual activity. (7)

However despite implementation of these programs into schools across the state, Mississippi teen birth rate is still currently at 65.7 per 1000 births, according to the CDC.(8)

“JUST WAIT”- is one of the several types of abstinence only until marriage programs that has been implemented into middle and high schools across the state. According to the MDHS, “JUST WAIT”- abstinence until marriage program was designed as a “resource of technical support for communities who desire to address this issue (meaning teen pregnancy) at the local level”.(9) The program delivers its messages of abstinence-only by using public service campaigns such as billboards, printed media, public service announcements via radio and television. Several ads put out by JUST WAIT are based on portraying premarital sex as a thing of shame, fear and would cause severe harm.(10)

An example of such message can be seen in one of the ads titled “In the Heat of the Moment”. This ad focuses on portraying the live of a teen called Stephanie. She tells a story, “Basketball was my big thing. I had a chance to play ball for college”. She describes the mistake she made in choosing to have sex with her boyfriend. “He told me that I wasn’t going to get pregnant, and he wasn’t going to get me pregnant. He’s full of it. It’s like [getting pregnant] snatched all that out from under me.”(10)

Based on messages such as that mentioned above, it is obvious that the JUST WAIT Program is bound to fail in its message of abstinence. The goals of this program appear to be based on the Health belief model (HBM). It assumes that by just educating teens on the potential unpleasant outcomes of unplanned teen pregnancy, teens will make a rational decision to abstain from engaging in premarital sex. However, by applying the HBM, the program fails to account for other factor that influences a teen’s behavior. It also does not take into account how attitudes and beliefs may affect uptake of a behavior, and assumes that adopting a health behavior is rational. Kirby D. , in his report to the National campaign to prevent teen and unwanted pregnancy, states that “There are many factors in young people’s lives that affect their sexual behavior, for example, their own sexual drive and desire for intimacy, their family’s values, their friends’ values and behavior, their own attitudes and skills, the media, the monitoring of young people by their community, and opportunities for the future in their community”.(11)

The JUST WAIT program has also failed in the manner in which it delivers it intervention to teens. The program conveys the message of abstinence by instilling a sense of fear about potentially negative outcomes of teen pregnancy. They also portray premarital sex as a thing of shame and a sure way of developing an unhealthy relationship. It has done so in a manner that does not inform its target on all the possible methods of preventing teen pregnancy. The program puts out billboard ads that read messages such as one which shows a photograph of a pregnant female torso, and reads that “A teen parent is usually a single parent- CHOOSE ABSTINENCE.” (10) The program has failed in its use of “Health Communication message”. According to McGuire, “If you frighten the audience, be sure to give them a relatively easy way to alleviate the treat. If you make your audience anxious without a way of reducing the anxiety, they will block out the message – or do the behavior you don’t want them to do (engage in premarital sex) more often.”(12)

Another way in which the “JUSTWAIT” program has failed is its use of gender and sexuality stereotyping. Most of the ads and messages portray young men as attackers, one ad shows the image of a Valentine heart with the words “I Love You” inscribed on it. The accompanying text states, “If he really loves you, he can wait.”(10) . This further reinforces male stereotyping. Sandra Berm in 1981 introduced the Gender schema theory to try to explain how gender stereotyping occurs.(13) This theory suggests that “children learn how their cultures and/or societies define the roles of men and women and then internalize this knowledge as a gender schema, or unchallenged core belief. The gender schema is then used to organize subsequent experiences. Eventually, children will incorporate their own self-concepts into their gender schema and will assume the traits and behaviors that they deem suitable for their gender”.(14) The probable unintended outcome of putting out such messages is that, young males will take on the norm deemed suitable for their gender and would not benefit from the abstinence only message.

The curriculum of the JUST WAIT program was evaluated in a study carried out by the Sexuality Information and Education Council of the United States (SEICUS) and Planned Parenthood. The study found that the program distributes the "ASPIRE: Live your life. Be Free" classroom curriculum. They found that the curriculum contained incorrect teen-health statistics and cites a "biased" activity called the "Cookie Exercise," which is used in the Just Wait program to teach students how easily STDs are transmitted. The exercise involves having four students spit a chewed-up Oreo cookie into a cup of water and then swap cups with other students, while a fifth student receives a clean cup of water. The instructor then asks the students which cup of water they'd rather drink. According to the lesson, the four students represent sexuality activity while the fifth represents purity. "The messages of this exercise are clear," The SIECUS report states. "Young people who have had sexual intercourse are dirty; they are the equivalent of spit."(15) .

This misrepresentation of belief to get teenagers to abstain from sexual activity has several implications on a teenager. Not only does it not provide accurate information on sexual relationships, it does not provide information to help teens understand that there are other ways to prevent pregnancy and STDs outside of abstinence only.

The program has also failed in its lack of accommodation for already sexually active teens. 13% of teens in the USA have ever had vaginal sex by age 15, sexual activity is common by the late teen years. By their 19th birthday, seven in 10 teens of both sexes have had intercourse.(16) This is a significant number of already active teens and cannot be overlooked. Teens who are already active may presume that since they have already done it and nothing happened, they most likely will continue. By not providing theses teens with adequate information on safer sex method and contraceptive options, the rate of teen pregnancy will continue to rise.

Finally studies such as those done by Kirby et al which assessed available school-based abstinence-only programs in the US, he found that none of the three abstinence-only programs was effective in producing a statistically significant impact on sexual behaviors in program participants relative to comparisons.(17) In a paper by Debra Hauser that looked at the impact of five years of abstinence-only programs, she noted that not only was there no evidence of long term impact of these programs on attitudes and intentions, they show some negative impacts on youth's willingness to use contraception, to prevent negative sexual health outcomes related to sexual intercourse after being exposed to the program.(18)

Based on this body of evidence, it is obvious that implementation of just abstinence only programs in Mississippi is a sure way of failing to reaching the goal to reduce teen pregnancy by one third in 2015. A shift to a more comprehensive and inclusive sex education and training is a better and proven approach to address the issue of teen pregnancy in the state.

Program Recommendation- Community and School- Based Comprehensive sex education

Although I do not argue that abstinence should not be included in the sex education training for teenagers in middle and high school, it will be more intuitive to implement a more comprehensive approach. An intervention that includes a school based comprehensive and multicomponent education in abstinence and contraception education as a method of behavioral risk modification, will decrease teen pregnancy rates and sexual risk taking behaviors that put teens at risk for STDs and HIV. The primary aim of this program will be to reduce sexual debut in school students and also to address students who are or aren’t already sexually active by educating and providing them with adequate and accurate information about the use of contraception and safer sex practices.

The intervention would include a school based curriculum that is made up of courses on sex education, skills about abstinence as well as communicating accurately about the options for safer sex practices (availability and instructions on use of contraceptive methods). The curriculum would also be addressed not only to heterosexual couples but should also provide information for students with other types of sexuality. The aim of this curriculum is to provide students with options so that they are aware of possible solutions that are available to them in a manner that does not use fear or shame tactics.

In addition to a school based curriculum, peer resources that are aimed at reinforcing what is taught in the class room would also be readily available and provided by other peers, community centers and public health advocates. Activities such as publishing articles in the school newspaper, organizing public speakers and special assemblies, distributing media materials (e.g., posters, buttons, and t-shirts), conducting small-group discussion sessions, and organizing social networking programs that addresses a comprehensive approach to sex education should be established. Content of education should be regularly evaluated for appropriateness, accuracy and up to date information and providers should undergo periodic evaluation to determine if they are competently trained to provide the information and teach student skills in an appropriate manner.

Several studies on comprehensive sex education programs such “SAFER CHOICES” have shown that compared to abstinence only programs, there was effective in reducing important risk behaviors for HIV, other STDs, and pregnancy and in enhancing most psychosocial determinants of such behavior.(19)

Proper implementation of a comprehensive sex education will work over the less intuitive abstinence only program because, teens are provided with accurate and adequate methods of avoiding teen pregnancy. It doesn’t bridge the fundamental human right to provide complete and accurate information as does the “JUST WAIT” program. A more comprehensive program does not seek to tell its audience what to do or that having sexual relationship is harmful and bad. It will address the problem of assuming that by just telling teen to abstain from sexual activity alone we eliminate the problem.

This comprehensive approach is not based on the HBM, but rather takes account of other factors that might affect a teen’s decision to practice safe sex when it is need, factors such as social environment and self-efficacy as seen with the social learning theory. The theory has been used to design health education programs by incorporating a concern for environment, people, and behavior Social Learning Theory provides a framework for designing and implementing comprehensive behavior change programs.(20) Because of the environment, media, social networks a teenager might be in, he/she may be more prone to engaging in sexual activities, without prior knowledge and understanding of other safe sex methods, they are likely to engage in risky behavior. Also since the comprehensive program incorporates family, community and peers group in advocating for teaching safer sex methods, teenagers in social networks will tend to model behavior to how others in their social networks behave. It also provides information for not only heterosexual teens but also address the sexual needs of teens with other sexuality and beliefs.

By providing a health message that does not instill fear and shame to its audience, the comprehensive sex education program will work better than the JUST WAIT program. The comprehensive approach understands the effect of psychological reactance. Whatever freedom is threatened, whether it be the possession of a choice alternative or the adoption of a particular position (in this case abstinence), the resulting reactance leads to increased perceived attractiveness of that option.(21) Teenagers especially are more likely to engage in an activity when they are told not to do so.

The comprehensive sex education also introduces the appropriate use of social marketing theory to promote safe sex practices. In a paper by Messer et al., who reported on a successful teen pregnancy prevention program, states that “social marketing campaign is an innovative approach to combating teen pregnancy. It is critical for adolescents to know the consequences of sexual activity. It is also important, however, for adolescents to feel supported as they make healthy choices. Because adolescents are powerfully influenced by their peers in regard to risk taking and sexual decision making, creating a shared social norm among the students within a school or is an innovative approach to assisting adolescents in making healthy choices.

In conclusion, sex education is a sensitive and controversial topic to address in public health, as shown in numerous researches, just preaching abstinence only has been proven to fail in this society. In order to address the high teen birthrate in Mississippi, there has to be a shift from the use of abstinence only programs such as “JUST WAIT” to use of a more comprehensive sex education program that not only encourages abstinence, but also provides adequate, accurate information needed by teen to make less risky behaviors that could result in teen pregnancy.

References

1. StrategiesForAdolescentPregnancyPrevention.pdf. http://www.acog.org/departments/adolescentHealthCare/StrategiesForAdolescentPregnancyPrevention.pdf.

2. Vital Signs: Teen Pregnancy --- United States, 1991—2009. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6013a5.htm?s_cid=mm6013a5_w.

3. Thomas MH. Abstinence-based programs for prevention of adolescent pregnancies: A review. Journal of Adolescent Health. 2000 Jan;26(1):5-17

4. Social Security Act §510. http://www.ssa.gov/OP_Home/ssact/title05/0510.htm.

5. Felicia Brown-Williams, Jennifer Heitel Yakush. Sex Ed in Mississippi: Why “Just Wait” Just Doesn’t Work | RHRealityCheck.org. http://www.rhrealitycheck.org/blog/2010/01/28/sex-ed-mississippi-why-just-wait-just-doesn%E2%80%99t-work.

6. United Nations Statistics Division - Demographic and Social Statistics. http://unstats.un.org/unsd/demographic/products/dyb/dyb2006.htm.

7. Frequently Asked Questions About the Title V Abstinence Education Program Abstinence Education Program. http://www.sexrespect.com/FundInfo.html.

8. Center for Disease and Control MMWR. http://www.cdc.gov/mmwr/pdf/wk/mm60e0405.pdf.

9. Mississippi Department of Human Services. http://www.mdhs.state.ms.us/ea_justwait.html.

10. Sex Education in Mississippi--Why “Just Wait” Just Doesn’t Work.pdf. http://www.siecus.org/_data/global/images/Sex%20Education%20in%20Mississippi--Why%20%27Just%20Wait%27%20Just%20Doesn%27t%20Work.pdf.

11.Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001.

12. McGuire, W.J., Input and Output Variables Currently Promising for Constructing Persuasive Communications. In Rice, R. & Atkin, C. (Ed.). Public Communication Campaigns. 3rd Ed. 2001. Mead, George Herbert (1934). Mind, Self and Society. Ed. University of Chicago

13. Bem, S. L. Gender schema theory: A cognitive account of sex typing. Psychological Review 1981, 88, 354–364

14. Gender - Gender Roles And Stereotypes - Theory, Family, Development, Women, Theory, Fulfill, Children, Development, and Eagly. http://family.jrank.org/pages/686/Gender-Gender-Roles-Stereotypes.html.

15.Sex Ed Advocates Attack “Just Wait” - Noise - Jackson Free Press: Jackson, Mississippi. http://www.jacksonfreepress.com/index.php/site/comments/sex_ed_advocates_attack_just_wait/.

16. Abma J C et al., Teenagers in the United States: sexual activity, contraceptive use, and childbearing, National Survey of Family Growth 2006–2008, Vital and Health Statistics, 2010, Series 23, No. 30.

17. Kirby D, Short L, Collins J, Rugg D, Kolbe L et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports 1994; 109 (3):339-360.

18. Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact. http://www.advocatesforyouth.org/publications/623?task=view.

19. Coyle K, Basen-Engquist K, Kirby D, Parcel G, Banspach S, Collins J, et al. Safer choices: reducing teen pregnancy, HIV, and STDs. Public Health Rep. 2001;116 Suppl 1:82-93.

20. Perry, Cheryl L.; Baranowski, Tom; Parcel, Guy S. Glanz, Karen (Ed); Lewis, Frances Marcus (Ed); Rimer, Barbara K. (Ed). How individuals, environments, and health behavior interact: Social learning theory. Health behavior and health education: Theory, research, and practice. Health behavior and health education: Theory, research, and practice, The Jossey-Bass health series (pp. 161-186). San Francisco, CA, US: Jossey-Bass,1990

21. Brehm J. "Psychological Reactance: Theory and Application, in Advances in Consumer Research Volume 16, eds. Thomas K. Srull, Provo, UT : Association for Consumer Research. 1989; Pages: 72-75.