Monday, May 20, 2013

A Critique of Abstinence-Only Education Programs in the U.S. – Amanda DiPaolo

Adolescents and teens that are sexually active or engage in risky sexual behavior are at a high risk for unintended pregnancy, HIV and other sexually transmitted diseases (STDs). In 2011, nearly 330,000 babies (8.4% of all births) were born to teen mothers who were 15 -19 years of age, representing a birth rate of 31.3 births per 1,000 women in this age group (1,2).  Furthermore, nearly half of all reported STDs are among individuals aged 15-24 years (2).  In an effort to mitigate the social and economic impact of these outcomes, education-based interventions targeting young people are supported by the federal government. 
Multiple types of interventions have been implemented in schools around the country to help prevent or reduce risky sexual behavior among young people. In addition to comprehensive sexual education, some states receive funding for abstinence-only education under the Federal Title V Maternal and Child Health program. The current funding level for abstinence-only education under Title V is $50 million annually for FY2011 - FY2014 (2). Unfortunately, evaluations of abstinence-only courses and curriculums have failed to show evidence of reducing the likelihood for teens to become sexually active or use contraception (4 - 7). A prominent study conducted by Mathematica Policy Research Inc. concluded that abstinence-only program participants had just as many sexual partners as non-participants and had sex at the same median age as non-participants.  Contraception use was also just as likely among program participants compared to non-participants (4).
This intervention critique aims to highlight three basic weaknesses inherent in the general approaches of abstinence-only education programs funded under Title V.  At the core of these criticisms are three fundamental deficits.  First, these programs undermine the impact of societal messages about sex delivered via the media such as television/movies, music, the internet and magazines; this is important, as the media is a powerful tool for influencing youths’ beliefs (attitudes and subjective norms) about sex.  Second, while these approaches teach youth to avoid situations that can lead to sex, they are less likely to focus on the difficulties of making good decisions when they are already in a physical situation.  Finally, in many cases, educators and curriculum developers have neglected to consider that the use negative messaging (scare tactics and “slut-shaming”) to promote abstinence may cause adverse effects among youth. Such tactics may have little impact on teens that desire autonomy or to rebel against authority and can promote risky behavior.  In the same vein, these methods may be considered offensive and turn participants off to the entire program.
Critique argument 1: The impact of the media
The media plays a huge role in framing how people think about sex and offers an unrestrained resource for social learning. It serves as a “super peer” to   adolescents (especially young girls) by teaching them how to behave in romantic contexts and sexual situations (8,9). Essentially, the media provides young people with skewed perceptions of sex and normative sexual behavior – this may involve promoting overestimations of the frequency of sex and unrealistic expectations or scenarios (10).  The conclusions which youth draw about sex based on their exposure to the media are in line with the theory of cognitive heuristic availability.  This theory provides that individuals will often make judgments or generate biases about the frequency of events according to data that has limited validity (11).
Unfortunately, a review of abstinence-only education requirements does not show that these programs are directly required to address the impact of the media (12). While some programs have included education pieces that address the effects and inaccuracies of sexually driven media, many popular programs (FACTS,  Promoting Health Among Teens! Abstinence-Only,  Making a Difference) do not emphasize sex in the media leaving major gaps in the curriculum (13-15). 
Portrayals of sex and sexuality in the media are continuing to increase. In 1988, researchers estimated that teenagers viewed nearly 15,000 sexual references, innuendos or jokes on television alone (1).  More recently, the Kaiser Family Foundation estimated that the number of sex scenes on TV nearly doubled from 1998 to 2005 (17).  This influence is overwhelming when we also consider the impact of sex-related material on the internet and in magazines.  Research has shown that higher exposure to sexual media is directly correlated with more frequent sexual behavior and higher likelihood of teen pregnancy (18).   Since environmental factors are playing such a significant role in shaping youths’ beliefs about sex, abstinence-only programs that do not directly address this influence are pointless, to some extent.  To be effective, these programs must attack skewed perceptions about sex at their root cause.  Without ultimate control over what this “super peer” is teaching teens about sex, it is important that educators help teens become well-equipped to separate reality from the glamorized untruths projected by the media.
Critique argument 2: Decision-making in context
Many abstinence-only education programs have segments dedicated to decision-making; however, these portions of the programs do not address decision-making in context.  In fact, most of the discussion centered on decision-making is fact-based and describes the potential outcomes or consequences of making certain decisions. Some programs merely provide participants with a laundry list of statistics describing rates of STDs and unwanted pregnancies in hopes that this will help guide better decision-making (13). In a “cold” or rational state it is plausible that understanding “the facts” will help teens view abstinence as an important way to promote healthy future relationships and avoid unwanted pregnancy or disease. What this fails to do, however, is provide participants with practical tools for actually making tough decisions when they are in the “heat of the moment”, or “hot” states. This is especially important since research has shown that individuals are less inclined to think responsibly and rationally when aroused (19).  
Ariely’s concept of hot vs. cold is an important point to consider. In some cases, curricula will focus on making decisions to avoid sexual situations and advances, but less information is provided on decision-making in the “heat of the moment” a much more sensitive, yet relevant topic. This includes the decision to be prepared and use protection.  Of course, the goal of abstinence-only education is to promote abstaining from sex until marriage. However, statistics have shown that program participants are still engaging in sexual activity at similar rates compared to non-participants and they are doing so with little to no accurate knowledge of how to protect themselves (3, 20).  This lack of knowledge in conjunction with a lack of understanding of how hormones and emotions can inhibit one’s ability to make good judgments is a dangerous combination.  As a result, it is no surprise that numerous reports have cited abstinence-only states as having the highest rates of teen pregnancies and rising rates of STDs (21, 22).
Critique argument 3: The use of shame and scare tactics
Many abstinence-only education curricula tend to focus on the emotional drivers that influence teen sex such as the need to feel accepted or loved.  In addition to helping participants understand these feelings, programs use scare tactics or so-called “slut-shaming” methods to deter youth from wanting to have sex.  For example, a well-known abstinence-only lecturer, Pam Stenzel, admittedly employs negative messaging throughout her program in order to scare students about sex (23).  Other curricula include activities to portray how sexual promiscuity will cause an individual to lose value in the eyes of their future spouse.  The Choosing the best PATH curriculum has utilized the following activities:
“Mint for Marriage”
·      An unwrapped peppermint patty is passed from student to student. 
·      Each student is asked to hold it, examine it (maybe smell it) and then pass it to their neighbor.
·      After the patty is passed around the room, the instructor offers it to the class to see if anyone wants it.
·      The instructor asks the class “why is this peppermint patty no longer appealing?” invoking the response that “it’s gross and nobody wants it anymore.”
·      The instructor then ties the activity to the idea that “no one wants food that has been passed around and neither would you want your future husband or wife to have been passed around.”
 “A Rose with No Petals.”
·      The instructor holds up a rose and notes how beautiful it is, before passing it around to the class.
·      Each student is asked to pull a petal from the rose before passing it on to the next person.
·      When the rose is nothing more than a stem, it is passed back to the instructor.
·      The instructor then asks “how much value does the rose have now?”(24)
While meant to illustrate the value of virginity, it is hard to deny other ways of interpreting these activities.  A main concern would be encouraging feelings of shame which may inhibit sexually active teens from having conversations about safe sex or getting tested for STDs. 
There are two main issues with using negative messaging in abstinence-only education curricula. First, research has shown that scare tactics can have adverse effects by inducing rebellious behavior.   In a study of Scared Straight, an intervention designed to prevent youth from engaging in criminal activity, researchers found that the program was not effective at deterring criminal behavior, and in some cases, even promoted it by inducing rebellious actions (25). Secondly, “slut-shaming” can facilitate bullying or promote poor self-esteem (especially in young girls that have already been promiscuous) which may lead to further risky sexual behavior (26).  This tactic generally enforces the idea that individuals who have sex before marriage are bad, dirty people.  Students have publicly voiced complaints about the use of “slut-shaming” messages implied by motivational speakers aiming to promote abstinence (27).  Overall, negative messaging has been shown to work against the goals of abstinence-only education.
Proposed Alternative Interventions - Recommendations
The proposed intervention would be a focus on three core areas in order to boost the effectiveness of abstinence-only education programs.  Rather than designing an entirely novel intervention strategy, the proposed idea will build on and modify the existing approach. Therefore, the following guidelines should be incorporated into the existing requirements for approved programs under the Title V grant program.
1.    Each curriculum will have one segment dedicated solely to exploring the most important drivers of what shapes our beliefs and values about sex.  This can be in conjunction with modules regarding peer pressure; however, there must be particular and sufficient coverage on media literacy and the effects of sexual media.
2.   While abstaining from sex will continue to be the core message of abstinence-only education, further requirements should include that portions of each curriculum should address safe-sex practices. 
3.   Programs and instructors will be restricted from employing extreme tactics that could potentially inflict emotional harm and incite adverse reactions.
These recommendations will bolster abstinence-only education programs by ensuring that the curriculum addresses key facets of sexual behavioral learning.  Additionally, the programs will be more suited to meet the full needs of participants by taking a more realistic approach which considers a broader set of decisions teens will face regarding sex.  Moreover, the recommendations will ban harmful practices that have been linked to promoting bad self-esteem, poor learning outcomes and rebellious attitudes.
Articulation of the proposed intervention: Supporting argument 1
According to the Theory of Reasoned Action, both subjective norms and attitudes towards a behavior contribute to behavioral intention. Abstinence-only education has not been proven to change teens’ attitudes and values towards premarital sex; however, movies, music and other media have been shown to significantly influence these attitudes.  In order to address a major disparity in abstinence-only education, programs will be required to include modules on media literacy and the effects of sexual media.
A recent study of over 900 adolescents who underwent media literacy training provides sound evidence for this recommendation.  Pinkleton et al indicated that “participants who received media literacy training better understood that media influence teens' decision making about sex and were more likely to report that sexual depictions in the media are inaccurate and glamorized” (28). By helping teens recognize the sexual fallacies projected by the media, they will be less inclined to form distorted subjective norms about sex. Furthermore, the study cited that participants who took part in the training were more likely than the control group to believe that other teens practice abstinence.  The experimental group also reported a greater ability to resist peer pressure. Overall, the study provided solid evidence of how media literacy can positively influence teens’ beliefs about sex and logic-oriented decision-making process. 
In another study, a teen-led media literacy curriculum targeted primarily to middle school students was evaluated at 22 school and community sites.  The program helped to correct media-driven misperceptions that overestimated sexual activity among teens as the result of cognitive heuristic availability.  Participants were also less likely to expect social benefits from having sex or engaging in sexual behavior.  These results further enforce the promise of using media literacy training to influence or reshape adolescents’ attitudes and beliefs about sex. Requiring such training as part of abstinence-only education would provide participants with a “cognitive framework necessary to understand and resist the influence of media on their decision making concerning sex” (29).
Articulation of the proposed intervention: Supporting argument 2
Despite the overarching purpose to promote abstinence, programs need to include a safe-sex module.  The current model for abstinence-only education is unrealistic because it does not consider that irrational behavior will still occur and many teens will still choose to have sex.  It is essentially a Health Belief Model-based approach. Basically, by only focusing on decision-making as a means to prevent sexual activity, the approach ignores an entire portion of its audience – adolescents that will still have sex or are currently sexually active. It is important to remember that for multiple Title V abstinence-only programs, control and program group youth reported similar rates of sexual activity (4-7).  Therefore, a safe-sex module that covers the use of contraception and birth control should be required as part of approved curricula.  More importantly, this learning segment should also describe how emotional physical states affect our ability to make decisions. Specifically, participants should be exposed to the concept of hot vs. cold decision-making to further understand how their physiological responses to sexual stimuli will significantly impact their decision-making ability. 
Of course, it may take some persuading to include a “safe sex” module into an abstinence-only curriculum.  However, highlighting the scientific basis for irrational decision-making would help to make a strong case. Social Cognitive Theory is considered more advanced in comparison to the Health Belief Model because it considers irrational behavior as it contributes to irrational decision-making.  Requiring a safe sex component of the curricula will enable abstinence-only education programs to become better aligned with more modern (accurate) theories of social and behavioral processes.  
Articulation of the proposed intervention: Supporting argument 3
Based on the risks involved with negative messaging, programs that include scare tactics and so-called “slut-shaming” should not be funded under Title V. Instead, more evidence-based methods should be employed. One particular approach that has been correlated with the lowest risk for STDs is the promotion of self-efficacy. In fact, perceived self-efficacy, or a belief in one’s ability to exert control over his or her sexual behavior, has been identified as one of the best predictors of sexual risk-taking (30). At the risk of leaning towards a comprehensive strategy, self-efficacy skills should be taught for both abstinence and safe sex.  More specifically, sexual self-efficacy skills may include how to negotiate sexual activity and/or use contraception such as condoms or birth control (31).
By removing negative messaging from abstinence-only curriculums, a more conducive environment for promoting self-efficacy can be developed. Further research is needed to develop more concrete recommendations regarding which types of self-efficacy skills are most effective.
Abstinence-only education is not working and evidence highlighting its flaws far outweighs the evidence-base for supporting its effectiveness.  Upon applying well-known social behavioral theories, it is clear that gaps in abstinence-only education programs are creating barriers to preventing unwanted pregnancies and the transmission of STDs. Therefore, enhanced curriculum guidelines should include required media literacy training as this type of intervention has shown to directly influence adolescents’ attitudes and beliefs about sex. Additionally, ensuring that curriculums provide a broader approach to decision-making is critical. Learning about decision-making beyond the context of abstinence is important because teens are more likely to make irrational decisions in sexual situations. Also, restricting the use of negative messaging tactics is necessary to create a positive environment where more effective educational methods, such as self-efficacy training, can be implemented. 
Overall, applying these intervention strategies to the current framework for abstinence-0nly education will increase the effectiveness of these programs.
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