Challenging Dogma - Fall 2007

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

Monday, December 10, 2007

Gender and Racial Inequalities & Heterosexism: How "Safer Choices”, a Comprehensive Sexual Curriculum, Cannot Impact Everyone- Melanie Pennison

In the United States, there are two major streams of sexual education taught in the school system today: abstinence-only and comprehensive sexuality education. Abstinence only programs emphasize abstinence until marriage as the only way to prevent HIV/STDs and teen pregnancy whereas comprehensive sexual education curriculums stress both abstinence and contraceptive use as preventative measures against sexually transmitted diseases and pregnancy (1). In addition, individual states have multiple polices governing sexual education and individual school districts are left to the challenge of deciding what is actually taught in the schools (2). Therefore state laws, in accordance with individual school district policies, dictate the stream an individual school will take regarding sexual education. Furthermore, there are numerous abstinence-based as well as comprehensive curriculums from which a school can choose. “Safer Choices” is one such curriculum whose primary goals are to reduce HIV/STD and teen pregnancy rates as measured by the delay of sexual intercourse and condom use with intercourse (3). Primarily, the flaws in Safer Choices involve differential success rates based on gender and race in accordance with a heterosexist view of sexual education (4).

“Safer Choices” is a two-year comprehensive sexual education intervention published by ETR Associates and geared towards freshman and sophomores in high school. Resource allocation for the intervention comes from state and local educational agencies as well as individual schools (5). “Safer Choices” is based on social cognitive theory, social influence theory and models of school change (3). In addition, the intervention has five components that include: creation of a school health promotion council containing teachers, students, parents, administrators and community representatives, development of staff to administer the twenty session, two-year intervention, development of a peer team in charge of school events and resources related to the intervention and development of materials (newsletters, events and homework assignments) that include parents and community resources. The curriculum was first implemented in the 1993-1994 school year and the following 1994-1995 school year (3). It was this first cohort of students from twenty schools in California and Texas that was used by Coyle et al (2001) and Kirby et al. (2004) for their “Safer Choices” evaluation (3-4). The “Safer Choices” intervention is comprehensive to many of the individual and environmental factors that general high school teenagers face. However, the intervention does not take into account the unique challenges faced by three vulnerable populations, female, Black and queer youth, that allow them to be at a greater likelihood for high-risk sexual behaviors.

Gender differentials in the “Safer Choices” intervention
In a study evaluating the “Safer Choices” intervention, Kirby et al. (2004) illustrated gender differences between males and females and reported condom use. They stated that while there was no significant difference in initiation of sexual intercourse between males and females, there were statistically significant or nearly significant differences in all measures of condom use assessed including: frequency of unprotected sex, number of sex partners unprotected, condom use at last sex and contraceptive use at last sex. This lends evidence to the argument that there are social challenges faced by females that prohibit condom use and that these challenges are unrelated to sexual education.

A study conducted by Henry et al. (2007) assessing peer influences on condom use consistently found a marked decrease in condom use by female youth. One possible explanation relates to the dependence of female youth on their peers for personal validation (6). This allows young women to be more vulnerable to peer pressures, such as not using a condom. Arguably, this dependence on outside influence by females could stem from the subjugation of women into relying on other people for notions of self-image. Accordingly, female youth are more likely to have sex without a condom when the perceived cost of sex by their peers is low (6). For example, when a young woman has friends that do not see the importance of condom use, the young woman is much less likely to use condoms independent of her own perceived dangers. This effect of interdependence on one’s peers is not seen among male youth thereby solidifying the notion that female youth are more influenced by their peers than their male counterparts.

In addition to peer influence, female youth are extraordinarily vulnerable to the gender-based power dynamics that permeate our society today. Factors that contribute to a woman’s powerlessness in a relationship include decreased economic opportunities, exposure to violence, substance use and experiences of racism and oppression (7). Young women are particularly vulnerable to an increase in sexual risk behaviors when they have been victim of dating violence (8). Accordingly, adolescent girls who have been a victim of dating violence are more likely to have had unprotected sexual intercourse than those that have never experienced dating violence (8). This direct correlation between violence and sexual risk illustrates how powerlessness decreases an adolescent girl’s ability to negotiate condom use with her male partner. As a result, public health needs to address dating violence in the context of adolescent sexual health interventions because of its direct influence on risk behavior (8).

“Safer Choices” and African-American Youth
“Safer Choices” also needs to address the differences in sexual-risk behaviors faced by teenagers of color. According to Kirby et al. (2004), “Safer Choices” shows differential success rates between Black, White and Hispanic youth where Black youth had the lowest rates of success. Although “Safer Choices” did show some decrease in frequency of unprotected sex, numbers of partners unprotected, condom use at last sex and contraceptive use at last sex, none of these measures were statistically significant when compared to the group of African American youth not part of the intervention used as controls (4). Accordingly, the underlying factors that contribute to these disparities needs to be determined and addressed as a public health issue.

Hallfors et al. (2007) reports that Black young adults are more likely to acquire STDs than their white counterparts even when risk-behaviors are similar. One important finding in Hallfors et al. (2007) is that sexual mating patterns display why there is such a marked difference in STD rates in Black youth. Both Black and White youth tend to have sexual partners of the same race, yet White youth are likely to have sex with persons of the same risk group, whereas Black youth are likely to cross high- and low-risk behavior groups when choosing a sexual partner. Behaviors that put people in the high-risk group are: drug and alcohol use, unprotected sex or prior STDs (9). Therefore, “Safer Choices” needs to consider issues faced by the young African American community as a whole when addressing sexual risk taking in high school. Accordingly, it is clear that this intervention needs to tailor a program towards Black youth because a general high-school based program does not allow for these issues to be addressed in this population.

Social factors such as socioeconomic status (SES), educational level and housing quality show a correlation with health behavior and disease prevalence (10). Black households have lower income than their white counterparts of the same educational level and Black youth are more likely to live below the poverty line (10). Likewise, lower SES has also been associated with higher rates of drug and alcohol abuse that can lead to risky sexual practices (11). This lends support to the Hallfors et al. (2007) paper that illustrates that targeting individual level risk factors, such as condom use in Safer Choices, cannot fully impact the target audience when the factors that influence risky behavior work on the social level.

Heterosexism in the Safer Choices Intervention
Studies involving LGBT youth show considerable increases in levels of school victimization, family violence and societal discrimination (12). These factors tend to cause increased levels of substance abuse among queer youth that also increases their risk for unsafe sexual practices. While there was no data on Safer Choices success rates among queer youth, one could argue that any intervention that fails to address these youth specifically will not fully address the needs of the young LGBT community.

Queer youth face higher rates of school victimization than their heterosexual counterparts (13). These rates are even higher in gay males than in females, presumably mirroring societal discrimination. Consequently, the higher the level of victimization, the more likely a LGBT youth is to smoke and abuse alcohol and drugs (13). Research shows that drug and alcohol use decreases sexual restraint and leads to risky sexual practices thereby increasing the risk of HIV/STD infection (13). In addition, most gay youth feel uncomfortable socializing in an open manner and are unable to create suitable sexual relationships with their peers. The “Safer Choices” program does not take into account the social stigma associated with being LGBT. Accordingly, without the intervention addressing the needs of these students, LGBT youth are more likely to seek out high-risk sexual connections that increase the chance of HIV/STD infection (12). Gay youth are also coming to terms with their sexual identity and in doing so may deny the risks associated with sexual experimentation (12). As one can see, there are many unique social factors associated with LGBT youth that cannot be addressed by targeting individual level risk factors.

From Puritanism to Bush-ism, the repression of human sexuality in the United States is not a new phenomenon. This suppression naturally extends itself into the United States educational system in the form of inconsistency in federal policies regarding sexual education in schools. Accordingly, it is up to the individual state to form policies as to what can be taught in the schools regarding abstinence, contraception, HIV/STDs and other sexuality related topics (1).
In our society, from birth onward, people are consistently differentiated based on gender. From sex-based categorizations on birth certificates and driver’s licenses to sex-specific facilities such as bathrooms and locker rooms, separateness based on gender is ingrained from an early age. One’s gender permeates how information is received, interpreted and acted upon and for that reason, it is not surprising that female teens showed lower rates of condom use than males in the Safer Choices intervention. One theory as to why condom use is significantly lower in female youth is related to the affect peer influences have on decision-making regarding the use of condoms (6). Therefore, public health interventions need to address the social reasons that prohibit a person from carrying out healthy behaviors.

Primarily, public health needs to draw upon other disciplines when planning interventions regarding behavior change. For example, to capitalize on the influence peers have on young women, one can draw upon the discipline of sociology. One model that uses sociology to influence behavior modification is the dissemination of innovations (DOI) approach to health promotion (14). Rooted in rural sociology, this approach uses dissemination techniques to reach core members in the target audience (14). Subsequently, the health behavior of interest is adopted in the ‘early adopters’ group and later disseminates to others in the target audience (14). In our example, an influential group of junior and senior young women could act as our early adopters by influencing the freshman and sophomore girls into healthy behavioral choices. To make this possible, the older girls facilitate groups where issues are addressed and discussed outside the presence of boys and adults. This simultaneously incorporates the core teenage value of ‘fitting in’ with one’s peers while working within the peer team component of the “Safer Choices” intervention.

Racial disparities in disease prevalence has been linked to an increased risk of hypertension, cardiovascular morbidity and mortality and HIV/STD infection in African Americans (9-15). There has been much debate about whether these disparities can be attributed to individual behaviors that lead to an increased risk or social factors that reflect environmental, institutional and contextual differences between Blacks and Whites (9). Once again, public health officials need to attempt to impact both the social factors and individual behaviors that lead to risky sexual behavior. One suggestion can be aggressive community-level strategies that inform African-Americans of the high HIV/STD rates across risk factor groups (9). In addition, nontraditional locations such as churches and beauty salons can act as resource and information centers for testing and treatment services (9). This community-based strategy can be incorporated into the Safer Choices intervention within the community involvement component. Arguably, this could allow Black youth to gain a sense of camaraderie with their neighborhood and it could also educate them to the resources in their community.

Public health interventions aimed at reducing sexual risk behaviors need to be tailored to queer youth specifically as to be both developmentally and culturally relevant (12). Particularly, interventions aimed at building social support networks, self-esteem and positive identity in conjunction with individual risk factor reduction would be beneficial in the LGBT community (12). Although some sexual education programs have shown moderate successes in increasing condom use among young gay men, alternative modes of information dissemination is needed because of the high truancy rate in this population (12). Community involvement including LGBT adults sitting on the governing council as well as community activities could help queer students gain a sense of empowerment and also decrease homophobia among straight students, teachers and staff. Accordingly, public health interventions that seek to address issues in the queer community should include addressing the factors that make this group more vulnerable.

First and foremost, “Safer Choices” is a good sexual education curriculum. It is comprehensive and allows for some degree of interaction with the community. The downfalls in “Safer Choices” parallels the flaws of many public health interventions in that it fails to acknowledge the social factors that make a person vulnerable to an adverse health outcome. As a result, public health interventions that solely target individual behaviors are likely to show differential success rates in diverse communities. Although the chances of one intervention having incredible success rates in everyone is slim, there are alterations that can be made to “Safer Choices” to increase condom use in female, Black and queer youth by addressing the specific needs of each population. These populations each have unique factors that affect their health behaviors; therefore, an intervention that tackles these issues will have a greater rate of success in the individual and a larger impact on the community as a whole.

1. Ito K., Gizlice Z., Owen-O’Dowd J., Foust E., Leone P and Miller W. Parent Opinion of Sexuality Education in a State with Mandated Abstienece Education: Does Policy Match Parental Preference? Journal of Adolescent Health, 2006; 39(5):634-641

2. Keiser Family Foundation. Sex Education in the U.S.: Policy and Politics. Menlo Park, CA: Keiser Family Foundation.

3. Coyle K, Basen-Engquist K, Kirby D, Parcel G, Banspach S, Collins J, Baumler E, Carvajal S and Harrist R. Safer choices: reducing teen pregnancy, HIV and STDs. Public Health Reports, 2001; 116(S1):82-93.

4. Kirby DB, Baulmer E, Coyle KK, Basen-Engquist K, Parcel GS, Harrist R and Banspach S. The “Safer Choices” Intervention: Its Impact on the Sexual Behaviors of Different Subgroups of High School Students. Journal of Adolescent Health, 2004; 35:442-452.

5. Wang, LY, Davis M, Robin L, Collins J, Coyle K, Baumler E. Economic evaluation of Safer Choices: a school-based human immunodeficiency virus, other sexually transmitted diseases, and pregnancy prevention program. Archives of Pediatrics & Adolescent Medicine 2000; 154(10):1017-24.

6. Henry DB, Schoeny ME, Deptula DP and Slavick JT. Peer Selection and Socialization Effects on Adolescent Intercourse Without a Condom and Attitudes About the Costs of Sex. Child Development 2007; 78 (3):825-838.

7. Saunters-Philips K. Factors Influecing HIV/AIDS in Women of Color. Public Health Reports 2002; 117:S151-6

8. Silverman JG, Raj A and Clements K. Dating Violence and Associated Sexual Risk and Pregnancy among Adolescent Girls in the United States. Pediatrics 2004; 114 (2):220-5.

9. Hallfors DD, Iritani BJ, Miller WC, and Baur, DJ. Sexual and Drug Behavior Patterns and HIV and STD Racial Disparities: The Need for New Directions. American Journal of Public Health, 2007; 97(1):125-132

10. Williams DR and Collins C. Racial Segregation: a fundamental cause of racial disparities in health. Public Health Reports 2001; 116:404-416.

11. Essien EJ, Meshnack AF, Peters RJ, Ogungbade GO and Osemene NJ. Strategies to prevent HIV transmission among heterosexual African-American men. BMC Public Health, 2005; 5(3).

12.Radkowsky M. and Siegel L. The gay adolescent: stressors, adaptations and psychosocial interventions. Clinical Psychology Review, 2007; 17(2):191-21.

13. Bontempo DE and D’Augelli AR. Effects of at-school victimization and sexual orientation on lesbian, gay or bisexual youths’ health risk behavior. Journal of Adolescent Health, 2002; 30:364-374

14. Edberg M. Social, Cultural, and Environmental Theories (Part I). In: Edberg M, Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett Publishers, 2007.

15. Bosworth HB, Dudly T, Olsen MK, Voilis CI, Powers B, Goldstein MK, and Oddone EZ. Racial Differences in Blood Pressure Control: Potential Explanatory Factors. The American Journal of Medicine, 2006; 119:e9-70.e15.

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