Lifting the Veil: Waiting until Marriage Fails Our Youth, Minority and GLBTQ Groups, and Global HIV Efforts - Carolyn Borsch
Abstinence-only (sex) education (AOE) is a public health approach taken on by the U.S. government to combat rising rates of pregnancy and sexually transmitted infections (STI) in American youth. AOE programs have the sole purpose of promoting abstinence until marriage to adolescents and deny any dissemination of information regarding any contraceptive methods (1).
Since 1996 under President Bill Clinton and later furthered by President George Bush, there has been major expansion in federal support of abstinence only sex education and a shift towards funding particular AOE programs that restrict other information. Budgeted funding of AOE programs has increased from $60 million in 1998 to $168 million by 2005 (1). Under “Section 510” of the Social Security Act of 1996 and the Special Projects of Regional and National Significance (SPRANS), it is prohibited to disseminate information on contraceptive services, sexual orientation, gender identity, and other aspects of human sexuality. Section 510 has an eight part definition of AOE and mandates that programs have an “exclusive purpose” (1) of teaching abstinence outside of marriage. In addition, they must not mention in any way any methods of contraceptives unless it is to emphasize their failure rates. Since 1997 programs have been required to comply with Section 510 under the Adolescent Family Life Act. Any program funded by SPRANS must meet all eight components of Section 510’s definition of AOE and the program must target 8-12 year old adolescents and must not provide any information about contraceptives, even with their own non-federal money (1).
Abstinence-only sex education is a failed public health approach. While it aims to reduce unwanted adolescent pregnancies and sexually transmitted infections by delaying the onset of first sexual encounter until marriage, it really succeeds in veiling our youth to reality and obstructs their ability to make informed decisions, denying them the information necessary to protect themselves to the fullest of their ability when a sexual situation falls upon them. Abstinence Only Sex Education is a flawed public health approach for three main reasons: 1) content of said programs are incomplete and inaccurate which disadvantage minority and GLBTQ youth as well as thwarts much needed global HIV efforts, 2) it tries to model the Theory of Planned Behavior, and 3) It induces psychological reactance.
1) Incomplete and Inaccurate Information
The approach that advocates and sponsors of AOE programs often take on is that abstinence is the answer to a character flaw and is an issue of morality based on their own personal religious beliefs (1). The real problem at hand is the public health conundrum of risky sexual behavior among adolescents and the rise seen in the United States in the harmful consequences such as unwanted pregnancy and sexually transmitted infections. This is where AOE’s first flaw comes into play. Besides AOE’s overall approach to the problem, the content included in AOE programs is often incomplete, inaccurate, or down-right confusing.
The mere definition of “abstinence” in AOE programs is complex and certainly confusing when trying to discern and understand the true meaning of abstinence (12). AOE program planners and U.S. policy makers have definitions of abstinence that range from “postponing sex,” “never had vaginal sex,” to “refraining from further sexual intercourse” if already sexually experienced (1). Furthermore, other sexual behaviors—from touching and kissing to oral sex, anal sex, and masturbation—may or may not be included in the definition of abstinence (1). The variability within the definition of abstinence leave it open to interpretation for adolescence and opens them up to fail because of misunderstandings regarding what is expected when the term “abstinence” is thrown out there in the AOE curriculum.
Sexually transmitted infections are transmittable through activities other than through vaginal intercourse, such as through oral intercourse. If abstinence in a particular AOE program is taught as strictly referring to refraining from vaginal intercourse then there is still opportunity for STIs to occur through other sexual activities not explicitly covered. There is too much variability within the AOE programs and strictly limiting information will not aid in the program’s success, and certainly will not reduce prevalence of STIs.
Actual efficacy of AOE programs have been evaluated, some more rigorously than others, and some through actual scientific methods. One such astute researcher is Doug Kirby who used biological outcomes to measure efficacy of AOE programs. He measured program success by measuring rates and prevalence of sexually transmitted infections and pregnancies. He found that there was no evidence of efficacy in delaying first sexual encounter (1). Evaluations conducted by the minority staff of the Committee on Government Reform of the U.S. House of Representatives reviewed commonly used AOE program curricula for scientific accuracy. It was discovered that 11 of the 13 programs evaluated contained false, misleading, distorted information regarding contraceptive effectiveness, risks of abortion, and other scientific errors (1, 9). Many of the statistics stated by AOE program curricula developed in the 1990’s are from the 1970’s; clearly outdated. The then American Medical Association Council on Scientific Affairs (now the Council on Science and Public Health) says that major risks once associated with legal abortions have “dramatically”(9) declined between 1970 and 1990 and some curricula inaccurately describe risks of sterility, premature birth, mental retardation, and ectopic pregnancies (9). These programs also present boy and girl stereotypes as facts and blur the line between religious and scientific viewpoints (1, 9).
Another content flaw of AOE programs is that they are geared towards youth not yet sexually active and just about completely ignore the youth that are already sexually active. The adolescents already sexually active have different health needs and require more than just abstinence only information (1). Adolescents do not like to be lied to. Incomplete information is one aspect of AOE that leads to psychological reactance, which will be discussed later. Adolescents want complete and honest information regarding contraceptives, along with information regarding their legal rights to health care and reproductive services (1). Denying access either through law or through denying complete and medically accurate information that adolescents can utilize to protect themselves against unwanted pregnancies and STIs will not stop them from having sex, but it will put them at increased risk (10,11).
Cultural differences among African-American, Hispanic, and American-Indian/Alaskan Native populations compared to Caucasians, especially among girls, inherently put these groups at a disadvantage when it comes to reproductive health. Black women are nearly four times more likely to die in childbirth than white women, are an astonishingly 23 times more likely to be infected with HIV/AIDS and subsequently 14 times more likely to die from the disease (13). Comparing American-Indian/Native Alaskan women to white women, they are 5 times more likely to have Chlamydia and over 7 times more likely to be infected with syphilis (13). Among Latinas, unplanned pregnancy is twice the national average and these women have a greater risk of contracting HPV, which is commonly known to lead to cervical cancer (13). Perhaps one reason for these increased risks is the fact that more adolescent black and Latina females receive AOE versus comprehensive sex education, than their white female counterparts. With AOE, they are not taught about contraceptives that may help them prevent pregnancy, HIV, and other STIs (13). In addition, cultural and environmental factors that differentiate urban minority youth from other youth may also account for the differences seen in sexual initiation, activity, and risk perception; all factors not taken into consideration in AOE programs. Both those from the Center for Reproductive Rights and Risha Foulkes of the University of California Berkeley Journal of African-American Law and Policy agree that race is an important aspect that is lacking in AOE programs and that overall, reproductive health fails when it comes to racial disparities (13,14).
AOE has a major harmful impact on the Gay/Lesbian/Bisexual/Transgender/ Questioning (GLBTQ) community. All AOE programs are required to completely ignore any topics of sexual orientation, gender identity, and any other aspects of human sexuality (1). About 2.5% (1) of high school adolescents identify themselves as being gay, lesbian, or bisexual, and many more are uncertain about their sexual orientation. Furthermore, 1 in 10 adolescents say that they struggle with issues regarding sexual identity (1). Not only are AOE programs not permitted to discuss issues of sexual orientation and identity, they go further and stigmatizes homosexuality with HIV/AIDS and label it as deviant and unnatural behavior; they strictly promote heterosexual marriage as the only acceptable sexual relationship. This further alienates these adolescents and pushes them to the brinks of suicide, isolation, depression, violence, and substance abuse (1).
AOE policy by the U.S. government influences global HIV efforts. The President’s Emergency Plan for AIDS Relief (PEPFAR) that delivers to 15 countries in Sub-Saharan Africa, Caribbean, and Asia-all severely affected by AIDS- requires grantees to devote at least 33% of prevention spending to go towards abstinence-until-marriage programs (1). Human rights groups find U.S. government and policy a source of misinformation and censorship. This policy has reduced condom availability and access to accurate information regarding HIV/AIDS in some countries (1). The U.N. Committee on the Rights of the Child emphasize that providing children with access to adequate HIV/AIDS and sexual health information is essential in securing their rights to health and information (1). After all, it is a basic human right to have access to the highest attainable standard of health, with accurate, non-skewed information (1).
While AOE program makers and U.S. policy makers make abstinence to be a matter of moral issue rather than a public health issue, health care providers and health educators are bound by a certain ethical obligations too. These ethical obligations contradict policies that govern sex-education program curricula and seriously raise issues of ethics and concerns of human rights. The content of AOE program curricula is not only lacking in completeness, the information it does contain is not all accurate and sometimes misleading, which leads AOE programs to fail to attain their goal of reducing unwanted adolescent pregnancies and STIs.
2) Theory of Planned Behavior
Abstinence-only sex education is reasoned on the Theory of Planned Behavior (TPB). THB, first proposed by Ajzen in 1985, is an extension of the Theory of Reasoned Action proposed by Fishbein and Ajzen in 1975 (2). The theory states that behavior is guided by a multitude of elements. Intention to perform a specific behavior can be predicted from attitudes towards the behavior, subjective norms, and perceived behavioral control and these intentions along with perceived control account for considerable variance in actual behavior. Achievement of the behavior is jointly dependent on intention and behavioral control (2,3).
AOE program planners are guided by this theory. They believe that adolescents will form a negative attitude towards the behavior, sex, or a positive attitude towards the behavior of abstinence based on the knowledge that the AOE program provides them with. It then assumes that adolescents will succumb to the subjective norms; that their perceived social pressure to perform the behavior, to abstain, and this will outweigh any other pressure engage in sexual behavior. And lastly, based on TPB, AOE programs assume that the adolescent will perceive behavioral control to engage in the behavior, abstinence, or control to not engage in sexual activity (2).
One major flaw with this reasoning, which Dan Ariely would also argue, is that this abstinence-only sex education is given in the “cold” state, and that it assumes adolescents will be able to stick to their planned behavior, of abstaining from sex, when they are brought to the “hot” state and presented with a sexual opportunity. The perceived ease of performing the behavior is supposed to take into consideration past experience as well as anticipated barriers (2). AOE programs do no such thing as to prepare the adolescent for the possible situation of being presented with an opportunity to engage in sexual activity let-alone provide the adolescent with tools to disengage from a sexual situation before it’s too late or show them how to properly equip themselves to protect themselves in the event of such a situation.
Add Health’s National Longitudinal Survey of Youth found that many teens who intend to be abstinent fail to do so, and when they do initiate intercourse many fail to protect themselves by not using contraceptives or incorrectly using them (1). Bermant and his colleagues examined the virginity pledge movement. Nearly 2.5 million adolescents have taken the popularly growing virginity pledge (1). The virginity pledge is a pledge that adolescents are encouraged to take to solidify their commitment to remaining abstinent until marriage. Pledgers were more likely to delay initiation of first sexual encounter by an average of 18 months. However, 88 % of pledgers end up having sex before marriage, compared to 99% of non-pledgers who end up having sex before marriage (1). While those who made the abstinence pledge had fewer sexual partners, 0.10 fewer partners (8), they were also less likely to report seeing a doctor for an STI concern or testing. At 6 years of follow-up, the STI prevalence was similar between abstinence pledgers and non-pledgers (1,8).
Mixed with TPB lies another theory that AOE programs have failed to recognize: Theory of Optimistic Bias. Optimistic Bias is, essentially, the misperception that one is less likely than others to experience negative consequences from a particular health behavior (18) and this view is strongest in teenage years (5). A 2002 comparative study of comprehensive sex education and abstinence only sex education revealed that adolescents 15 to 17 years old hold some sort of optimistic bias regarding their own personal HIV or STI risks (7, 18). An interview with adolescents in this age group demonstrated that many of them are concerned about AIDS, but they don’t perceive themselves as being personally at risk. One in four of the sexually experienced teens said they have been tested before for HIV, and 54% said they wouldn’t even know where to go to get HIV or STI tested. Another alarming statistic brought attention by this study said that 21% of teens believe that birth control pills are somewhat or very effective at preventing HIV transmission—that can be a grave misperception (7) When adolescent succumb to their sexual desires and abandon their abstinence pledge, they not only don’t know how to protect themselves, they don’t even know the real risks they are facing.
The theory of planned behavior is an individual-level social and behavioral model applied as a group-level intervention. Adolescents have shown that they are not capable of sticking to their plan of remaining abstinent until marriage and furthermore, they are ignorant to the reality of the risk of HIV and STIs, ignorance that we have instilled and fostered. AOE neither consider all aspects of the Theory of Planned Behavior nor addresses optimistic bias, and in doing so sets itself up for added failure in its aims to get adolescents to make abstinence a planned behavior.
3) Psychological Reactance Theory
First identified by Brehm in 1981 (19), he describes the Psychological Reactance Theory (PRT) as: when your freedom or autonomy is being threatened, you feel threatened, and you immediately react to restore that freedom or autonomy by doing exactly the activity or behavior that is being threatened (19). Three components of PRT are explicitness, dominance/similarity, and reason (5). AOE programs violate all three aspects of PRT, thus inducing reactance.
First, explicitness will be examined. AOE prohibits dissemination of information on contraceptive services, sexual orientation, and gender identity. While AOE programs are not explicit when it comes to this information, it actually conceals it, AOE is very explicit about abstinence being the only acceptable choice (1). Rains and Turner who examined psychological reactance as it pertains to persuasive health communication noted that other scholars—from Brehm himself in 1966 to Burgoon, Alvaro, et al. in 2002—have linked explicitness, defined as the intent of the source is clear, to heightened reactance (15).
Second is dominance/similarity. AOE programs geared toward youth come from adult health educators. The presence of an authoritative figure such as a teacher, nurse, or any adult runs the risk of invoking negative thoughts and feelings in adolescents (6). In addition to the authoritative figure, use of language that is seen as dominant can invoke psychological reactance. Telling a youth that they “must,” “have to,” or that this is the “only way,” that this is a “serious issue” or saying “any reasonable person would agree that…” are dogmatic and controlling messages and very well may invoke unfavorable and unintended reactance (6).
Third is reason. A weak message lacking evidence or containing faulty reasoning may fuel reactance, as demonstrated by Rains and Turner (15). AOE programs (11 of 13) have been found to contain false, misleading, and distorted information about effectiveness of contraceptives, risks involved with abortions, and other scientific errors. In addition, it reinforces boy and girl stereotypes, utilizing them as scientific facts, and blur religious and scientific viewpoints (1).
Through lack of explicitness, a high presence of dominance and lack of similarity, and lack of reason, AOE programs induce psychological reactance. The programs may indeed lead adolescents to engage in the behavior that the program is explicitly trying to prevent.
It has been demonstrated that abstinence-only sex education programs are highly flawed in their construct. From outdated information to complete denial of pertinent reproductive health information, AOE programs have failed our youth, put minorities and GLBTQ youth at a greater disadvantage, and have hindered global HIV efforts, making them more vulnerable to the problem AOE is trying to lessen-unwanted pregnancy and sexually transmitted infections. Although AOE programs have good intention and are trying to battle a valid public health issue, its approach is less than adequate and is in desperate need of reform.
I propose a comprehensive sex education program that is specifically designed to address and account for the flaws of abstinence-only sex education programs that were previously mentioned. Such an approach will have three main components: 1) it will contain complete and medically accurate information regarding reproductive health, as well as address issues that revolve around sexual orientation and identity previously avoided with AOE programs, 2) it will contain strategies to address the emotions that accompany sexual arousal and 3) the comprehensive program will be conducted in a way that reduces psychological reactance. Government policy and funding must be changed from supporting AOE programs to comprehensive sex education programs and the issue of unwanted teen pregnancy and STIs need to be reframed, from a moral and religious issue to that of a public health issue.
Step 1: Addressing Content Information
It was previously demonstrated that many of the current AOE program curricula contain false and misleading information, as well as the fact that it is government policy to restrict the information that AOE programs do cover. It was also shown that the restriction of information, required under Section 510 of the SSA of 1996 and SPRANS (1), disadvantages our youth, especially minority and GLBTQ youth, and hinders global HIV efforts. In the proposed comprehensive program, complete and accurate information will be provided to all youth. The information provided will be the most up-to-date and most accurate information available per American Medical Association Council on Science and Public Health (CSAPH), a committee that provides information and recommendations on medical and public health issues (16). The comprehensive approach will not forgo recommending abstinence, but it will provide additional information necessary to aid a youth in making a complete and fully informed choice and will give them the tools necessary to protect themselves in the event they do not remain abstinent or are already sexually active.
Much of this comprehensive approach is based on the Sexual Health Model (SHM). The SHM is an approach that first starts with wholly encompassing the idea of sexual health. Sexual health as put forth by Robinson and colleagues defines it as an approach to sexuality that is obtained through accurate knowledge, personal awareness and self-acceptance; the ability to be intimate with a partner, to be able to effectively communicate with a partner about desires, concerns either about sexual function or boundaries, and to be able to act responsibly; it includes components not only of self-acceptance and respect but acceptance and respect for others who are different and the diversity seen throughout; it addresses self-esteem, personal attractiveness and competence, and freedom from sexual dysfunction, STIs, and coercion (17). Overall, sexual health views sexuality in a positive way and as an important dimension to one’s life (17). The SHM has come about from a combination of empirical and theoretical information and research. It is composed of ten components: 1) talking about sex, 2) culture and sexuality identity, 3) sexual anatomy functioning, 4) sexual health care and safe sex, 5) challenges, 6) body image, 7) masturbation and fantasy, 8) positive sexuality, 9) intimacy and relationship, 10) spirituality (17). This approach is much more extensive and thorough than the AOE approach, and will meet the needs of minority and GBLTQ youth, and will be utilized in global programs as well. Also, the SHM will combat the boy and girl stereotypes instilled by AOE programs (9). To ensure our youth have a well-balanced sexual health, all components of the SHM need to be addressed in a comprehensive sex education program.
Step 2: Addressing Planned Behavior
Although the intentions of some youth in pledging to remain abstinent until marriage are pure, the fact remains that the majority of virginity-pledgers fail to remain abstinent until marriage. The proposed comprehensive sex education program will cover strategies aimed at addressing the emotions that accompany sexual arousal and offer tips on how to avoid such situations or discuss “walking away” before the “fire of passion” can creep up on them (4).
Dan Ariely, author of Predictably Irrational: The Hidden Forces that Shape Our Decsions (4), demonstrated through experiments that rational decisions made in the “cool” state are not always the decisions that will be made once in a “hot” state. Although his studies involved college-aged kids, the same concerns are valid and applicable to younger populations. Sexual arousal can be a new and surprising event for adolescents and some may not understand or be able to cope with their emotions; discussing these situations is key in helping them understand and eventually be able to make rational (hopefully) decisions. Ariely suggests teaching teens to walk away from temptation before they are entirely consumed and can’t resist. This may be a difficult idea to accept but Ariely argues that it is easier to avoid temptation all together than having to overcome it (4). He also suggests that we must make our youth ready to accept the consequences of saying yes if/when they are caught up in the heat of passion by preparing them and equipping them with appropriate contraceptives, like condoms (4).
The issue of optimistic bias also poses a challenge. Optimistic bias often occurs as one race thinking they are at less of a risk than another race, like whites verses blacks. While certain factors may contribute to a black youth being more at risk than a white youth, it is important to convey the risks, and in an appropriate manner, tailored to the particular adolescent audience. Changing perceived peer-norms, changing sexual attitudes, and reducing perceptual optimistic bias may aid comprehensive sex education programs in reducing risky sexual behavior (18).
While addressing behavior is certainly a daunting challenge, that alone is not sufficient to ignore the issue all together. Acknowledging that sometimes even the best of intentions with planned behavior sometimes don’t always work out is critical and then equipping them with tools to prepare them for this possibility is responsible, ethical, and necessary in battling unwanted pregnancy and STIs in our adolescents.
Step 3: Addressing Psychological Reactance
One of the worse possible outcomes AOE programs face is psychological reactance; pushing the youth to do the very thing they are trying to stop. That is why it is critical to comprise and deliver the comprehensive sex education program in a way that minimizes reactance.
Explicitness is a delicate component of psychological reactance. It is important to give the adolescent full and accurate information without being forceful of them acting one way of another. Giving the adolescent the feeling of control, that they can not only control their behaviors and choose what they participate in, but that they can control their outcomes by acting responsible and/or utilizing contraceptives when appropriate, is key in reducing psychological reactance.
Comprehensive sex education led by peers or slightly older, reliable and believable, youth, who will appear less dominant, will fix the dominance/similarity aspect of psychological reactance that AOE programs created. The source of the message should be as similar to the target audience as possible (5). It is critical to avoid controlling language, allowing the adolescents to feel like they have a choice, giving impartial, objective information with non-coercive words.
If a comprehensive sex education program is upfront about its reasons and concerns, adolescent will feel less threatened and less suspicious of hidden, ulterior motives. Adolescent don’t like to be tricked and telling a youth they can’t do something elicits their biological need to be rebellious and pushes them to do the very thing we don’t want them to do.
Within months of Obama taking over the presidential office, his administration had begun providing funds for comprehensive education geared towards programs such as ones that aim to prevent teen pregnancy and focuses on boosting academic achievements, extracurricular activities and making smarter life decisions (20). Nineteen states in 2009 have used legislative money to create “medically-accurate” and “age-appropriate” public school programs (20). Although there is still a $50 million dollar line-item budget in the Health Care legislation for abstinence-only educational programs over the next 5 years (21), overall this is a step in the right direction.
To further the current movement, a sex education program that is both comprehensive in terms of promoting abstinence and safe alternatives to being abstinent as well as in terms of utilizing more than one social and behavioral model, is far more likely to be successful than traditional abstinence-only sex education programs which does not utilize social and behavioral models to its benefit. The proposed comprehensive sex education intervention will be more successful in delaying initiation of first sexual experience, not inducing it; increase knowledge and use of contraceptives when sexual activity does occur; it will address issues of sexuality—orientation and identity— in a safe, open discussion-oriented environment; and it will be applicable but adaptable to the sexual health needs of different youth populations and ages.
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