Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Sunday, December 9, 2007

Abstinence-Only Sex Education: Turning the clock back on sexual health knowledge – Joyleen Ong

Teenagers face considerable risk of unintended pregnancies and sexually transmitted infections (STIs). While many experts agree on the importance of sex education in the classroom in preventing sexual risk behavior and pregnancy, the type of sex education has long been hotly debated. Two major options exist for teen sexuality education: Abstinence-only programs (AOE), as defined by federal requirements, and comprehensive programs, which promote abstinence, but also provide teens with information about contraceptive options. To be eligible for federal funding, AOE programs must meet an eight-point definition of abstinence education that promote “abstinence from sexual activity outside marriage as the expected standard” and sex education programs that promote the use of contraceptives are not eligible for funding (1).

The federal government has embraced AOE programs by expanding federal funding for them since 1996 (2). Federal funding for AOE programs has increased from $60 million in FY 1998 to $191 million in FY 2007 (3). Supporters of AOE programs argue that a sharp decline in teenage pregnancy rates in recent years is proof that the AOE programs are working. But a recent report in the American Journal of Public Health found that improved contraceptive use was the primary determinant of declining rates, not a decline in teenage sexual activity (4). And, ironically, results of a study ordered by Congress showed that the average age of first sexual intercourse and the number of sexual partners were almost identical for youth who attended AOE programs and youth who did not. So why have AOE programs been ineffective in delaying sexual intercourse or in reducing rates of teen pregnancy and STIs? Abstinence-only education (AOE) programs are ineffective because they brush over the reality that sexual abstinence is often a choice that is highly influenced by not only individual level factors, but also social factors. AOE programs also alienate many teen groups, and the scare tactics used to frighten youth into abstinence are ineffective.

AOE programs rely largely on the Health Belief Model

AOE programs fail because they rely largely upon the Health Belief Model (HBM). The HBM explains health-related behavior at the level of the individual decision maker (6). The HBM is also a rational belief model because it presumes the ability of a rational individual to be able to weigh the advantages and disadvantages of a given behavior via an objective and logical thought process (6). AOE programs attempt to provide teens with the supposed severity of not remaining abstinent and the benefits to be realized by abstaining, then expect teens to weigh the decisions rationally and without outside constraints. However, decisions about sexual behaviors do not get made in a vacuum nor are they necessarily made rationally. Social factors, such as media that is heavy in sexual content, peer relationships, fear of losing a boyfriend, and reduced family prohibitions against pregnancy, play a critical role in influencing premarital sexual relations too (7).

Obviously our current social environment does not support abstinence as evidence by pro-sex messages permeating our media, and teens that are in a period of heightened sexual, curiosity, desire and risk-taking behavior make for a captive audience. So, while AOE programs may impart knowledge about what is good or bad about abstinence and influence the intention to abstain, those intentions may not translate into behavior once outside the classroom. To be effective at changing not just teen sexual intention but also behavior, classroom instruction must factor in influences from peers, family and media.

AOE programs alienate many teen groups

Indeed abstinence may be 100% effective in preventing pregnancy or STIs, but only if teens remain abstinent. A recent national survey of all high school students reports that almost half of all high school students have had intercourse, and nearly 40 percent did not use a condom at last intercourse (8). The reality is that many teens are sexually active and denying comprehensive sexual education to sexually active teens puts a group that is already at high risk for unintended pregnancy and contracting STIs at an even greater risk. AOE programs present misleading and scientifically inaccurate information about reproductive health and contraception (9). For example, several AOE curricula exaggerate condom failure rates in preventing pregnancies, or make the false claim that HIV can “pass through” condoms (9). If youth are taught that condoms and contraceptives are ineffective, then they may be more likely to have unprotected sex. Therefore, prohibiting access to complete and accurate sexual health information may cause teens who are having sex for the first time or teens who are already sexually active to use ineffective or no protection against pregnancy and STIs. Furthermore, it is unethical to provide misinformation or to withhold complete and accurate sexual health information to coerce individuals to be abstinent.

AOE programs also alienate gay, lesbian, bisexual, transgender and questioning (GLBTQ) youth by ignoring the sexual health needs of GLBTQ youth, except when “discussing transmission of HIV/AIDS or stigmatizing homosexuality as deviant and unnatural behavior (10).” The funding requirement also defines marriage as “a legal union between one man and one woman as a husband and wife (9).” AOE programs do not educate GLBTQ youth, but instead discriminate against them and stigmatize homosexuality as immoral and a choice.

Many theorists propose that stigma at its core is a “devaluing social identity” that occurs within a social context that defines an attribute as devaluing (11). As a consequence, the stigmatized are predisposed to poor outcomes, such as poor self-esteem, academic achievement, and mental or physical health (11). AOE programs magnify the stigma towards homosexuality, and in doing so they contribute to rejection, feelings of loneliness, ostracism, and harassment by biased peers. Moreover, if the federal definition of marriage limits it to heterosexual couples, the implication is that homosexual students should either make lifelong abstinence or turn heterosexual. But both options are unrealistic expectations. Essentially AOE programs convey the message that there is no safe way for GLBTQ youth to have sex, and deny them sexual health information that could improve their sexual health.

AOE programs use scare tactics

AOE programs use a normative-re-educative approach to persuade adolescents to remain abstinent till marriage. The normative-re-educative approach is a planned-change strategy that attempts to bring about change through persuasion (12). The tools used by AOE programs to persuade abstinence include messages in curricula that emphasize the fear and shame of premarital sexual activity. For example, the AOE curriculum teaches that non-marital sex in teen years may reduce the probability of a stable, loving and healthy marriage; and that teen sexual activity is associated with decreased school completion, decreased educational attainment, and decreased income potential; and that abstinence reflects qualities of personal integrity and is honorable (1). But there is no evidence to suggest that premarital abstinence is the magic elixir to a happier, more successful life. In fact, the reality is that there are many Americans who have had or who are having premarital sex and who still lead happy, healthy lives, and many teens are likely to know such individuals, i.e. their parents. Ultimately, if there is a disconnect between the persuasive messages and reality, teens will view the fear-based messages as idle threats and overdramatized, and, therefore, ignore such messages. In a double whammy, students are not scared into remaining abstinence AND they are not taught safe sex!

Teens do not need fairy tales and scare tactics. Teens do not need to be taught intolerance of sexual orientation. Rather the lesson learned from the failure of AOE programs is that a comprehensive approach to protect teens from STIs and unintended pregnancy is needed. Schools should encourage abstinence as a healthy option for teens and also provide complete and accurate information about sexual health, including information about sexual orientation and tolerance, contraceptives, and risks of STIs and unintended pregnancies in order to empower teens to make safe decisions regarding their sexual behavior – whether that means abstaining from sex or practicing safer sex.


1. Community-Based Abstinence Education Program Funding Opportunity Description. Department of Health & Human Services Administration for Children and Families. Available at:
2. Advocates for Youth. The History of Federal Abstinence-Only Funding. Available at: factsheet/fshistoryabonly.htm
3. Budget in Brief, Fiscal Year 2007. Department of Health and Human Services. Available at:
4. Santelli JS, Lindberg LD, Finer LB, Singh S. Explaining Recent Declines in Adolescent Pregnancy in the United States: The Contribution of Abstinence and Improved Contraceptive Use. American Journal of Public Health; 2007; 97(1): 150-6.
5. Trenholm C et al. Impacts of Four Title V, Section 510 Abstinence Education Programs. Mathematica Policy Research, Inc April 2007.
6. Salazar MK. Comparison of Four Behavioral Theories. AAOHN Journal 1991; 39:128-135.
7. Perrin K, DeJoy SB. Abstinence-Only Education: How We Got Here and Where We’re Going. Journal of Public Health Policy 2003; 24: 445-459.
8. CDC. Youth Risk Behavior Surveillance – United States, 2005. Morbidity & Mortality Weekly Report 2006; 55 (SS-5): 1-108.
9. Letter to Secretary Leavitt, New Federally Funded Abstinence Programs Guidelines Based on Ideology, Not Science. Available at:
10. 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.
11. Hsin Yang et al. Culture and stigma: Adding moral experience to stigma theory. Social Science & Medicine 2007; 64: 1524-1535.
12. Siegel M. Education and persuasion versus coercian as public health approaches. The Rest of the Story: Tobacco News Analysis and Commentary (blog). May 4, 2006. Available at:

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