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

Introduction

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.

Conclusions

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.

REFERENCES

1.    Martinez G, Copen CE, Abma JC. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2006–2010. National Survey of Family Growth. National Center for Health Statistics. National Vital Health Stat. 2011;23(31).

2.   Solomon-Fears C. Teenage Pregnancy Prevention: Statistics and Programs.  Congressional Research Service. April 15, 2013.

3.   Centers for Disease Control. Sexual Risk Behavior: HIV, STD, & Teen Pregnancy Prevention. Atlanta, GA : Centers for Disease Control and Prevention . Atlanta,GA. http://www.cdc.gov/HealthyYouth/sexualbehaviors/

4.   Trenholm C et al. Impacts of Four Title V, Section 510 Abstinence Education Programs (final report).  Mathematica Policy Research, Inc., April 2007.  

5.    Jemmott JB, Jemmott LS, Fong GT. Efficacy of a Theory-Based Abstinence-Only Intervention Over 24 Months. Archives of Pediatrics and Adolescent Medicine 2010; 164, no. 2:152-159.

6.   Kohler PK, Manhart LE, Lafferty WE.  Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy. J Adolesc Health. 2008 Apr;42(4):344-51.

7.   Toledo, C. Abstinence-only education does not lead to abstinent behavior, UGA researchers find. UGA Today. November 29, 2011. http://news.uga.edu/releases/article/abstinence-only-education-does-not-lead-to-abstinent-behavior/

8.   Brown  J. D. , Halpern  C. T. , & L'Engle , K. L. Mass media as a sexual super peer for early maturing girls . Journal of Adolescent Health 2005; 36:420-427.

9.   Strasburger, VC. Adolescents and the Media: Medical and Psychological Impact. Developmental Clinical Psychology and Psychiatry, Volume 33.  Thousand Oaks, CA : Sage Publications, Inc. 1995.

10.             Bryant J and Oliver M.B. Media effects: Advances in theory and research. New York, NY: Routledge, 2009.

11.Tversky A and Kahneman D. Judgment under Uncertainty: Heuristics and Biases. Science, New Series 1974;185:1124-1131.

12.              Title V State Abstinence Education Grant Program Fact Sheet. Washington D.C.: Family and Youth Services Bureau. April 6, 2012. http://www.acf.hhs.gov/programs/fysb/resource/aegp-fact-sheet

13.             FACTS Curriculum. Portland, OR: Northwest Family Services. http://www.nwfs.org/empowering-youth/facts-curriculum.html

14.             Promoting Health Among Teens!-Abstinence Only Version (Overview). New York, NY: Select Media Inc. http://www.selectmedia.org/programs/phatab.html

15.Making A Difference! (Overview). New York, NY: Select Media Inc. http://www.selectmedia.org/programs/difference.html

16.             Harris L and Associates. Sexual Material on American Network Television During the 1987–88 Season. New York, NY: Planned Parenthood Federation of America, 1988.

17.             Kunkel D et al. Sex on TV 4. Washington D.C.: Kaiser Family Foundation. 2005. http://kff.org/other/event/sex-on-tv-4/

18.             Chandra A et al. Does Watching Sex on Television Predict Teen Pregnancy? Findings From a National Longitudinal Survey of Youth. Pediatrics 2008;122;1047-1054.

19.             Ariely D. Predictably Irrational : The Hidden Forces That Shape Our Decisions. New York, NY: Harper Collins Publishers. 2008.

20.              US House of Representatives Committee on Government Reforms – Minority Staff, Special Investigations Divisions. The Content of Federally Funded Abstinence-Only Education Programs. Washington, D.C. 2004. http://www.apha.org/apha/PDFs/HIV/The_Waxman_Report.pdf

21.             Ferguson D. States with ‘abstinence-only’ sex ed programs rank highest in teen pregnancies. The Raw Story. April 11, 2012. http://www.rawstory.com/rs/2012/04/11/states-with-abstinence-only-sex-ed-programs-rank-highest-in-teen-pregnancies/

22.             Nicholson, E. Faced With Rising Teen STD Rates, County Health Officials Lobbying DISD to Jettison Abstinence-Based Sex Ed. The Dallas Observer. March 19, 2004. http://blogs.dallasobserver.com/unfairpark/2013/03/teenagers_volatile_bundles_of.php

23.             Pam Stenzel: Review. Community Action Toolkit. http://www.communityactionkit.org/index.cfm?fuseaction=page.viewpage&pageid=1002

24.             Kempner M. They’re Baaaaaack: Abstinence-Only Programs Rely on Scare Tactics and Humiliation to Spread Misinformation. RH Reality Check. October 28, 2009.  http://rhrealitycheck.org/article/2009/10/28/they%E2%80%99re-baaaaaack-abstinenceonly-programs-rely-scare-tactics-and-humiliation-spread-misinformation/

25.             Petrosino A, Turpin-Petrosino C, Buehler J. “Scared Straight” and other juvenile awareness programs for preventing juvenile delinquency [Cochrane review]. In: The Cochrane Library. Issue 4. Chichester, United Kingdom: John Wiley & Sons, Ltd, 2004

26.             Ethier KA. Self-esteem, emotional distress and sexual behavior among adolescent females: Inter-relationships and temporal effects. Journal of Adolescent Health 38 (2006) 268–274.

27.             Owens E. High schoolers complain, tweet about slut-shaming during abstinence-only assembly. The Daily Caller. April 12, 2013. http://dailycaller.com/2013/04/12/high-schoolers-complain-tweet-about-slut-shaming-during-abstinence-only-assembly/

28.             Pinkleton B, Weintraub Austina E, Yi-Chun C, Cohenc M. The Role of Media Literacy in Shaping Adolescents' Understanding of and Responses to Sexual Portrayals in Mass Media. Journal of Health Communication: International Perspectives 2012;17:460-476.

29.              Pinkleton B, Weintraub Austina E, Yi-Chun C, Cohenc M,  Fitzgeraldd E. Effects of a Peer-Led Media Literacy Curriculum on Adolescents' Knowledge and Attitudes Toward Sexual Behavior and Media Portrayals of Sex. Health Communication 2008;23:462-472

30.             Bandura A. Self-efficacy beliefs of adolescents (pp. 307-337). In F. Pajares & T. C. Urdan (Eds.) Guide for constructing self-efficacy scales. Greenwich, CT: Information Age, 2006.

31.              Kali S. Van Campen  et al. “I Have What?”: How Sexual Self-Efficacy and Sexuality Education Are Associated with STD Risk in Adolescence. Francis McCelland Instisute. http://mcclellandinstitute.arizona.edu/sites/mcclellandinstitute.arizona.edu/files/I%20Have%20What%20How%20Sexual%20Selfefficacy%20and%20Sexualtiy%20Education%20are%20Associated_VanCampenToomey.pdf

Real Cost of (Ineffective) Teen Pregnancy Prevention: A critique of New York’s Teen Pregnancy Prevention Program--Caroline Kimberly

Introduction & Background

On March 3, 2013 Mayor Bloomberg, the Deputy Mayor for Health and Human Services announced the roll out of a new campaign with the goal of further reducing teenage pregnancy rates in New York City.  The campaign consists of posters in subway and bus terminals asking the question, “Think being a teen parent won’t cost you?” and of toddlers and young children saying things such as, “Honestly, mom… chances are he won’t stay with you. What happens to me?” and “Dad, you’ll be paying to support me for the next 20 years. “One depicts a toddler crying with the text, “I’m twice as likely not to graduate high school because you had me as a teen.” (1).

 The second component to the intervention is a text-based initiative in which the public can participate in learning the “real cost of teen pregnancy” through games and quizzes via text message (1). Many of the texts are just as harsh as the posters, where if you choose to follow a pregnant teenage girl, her friends call her fat at prom, she loses her best friend, and her parents kick her out of the house. New York has seen a steady increase in teenage pregnancy over the past few years and mayor Bloomberg believes that these harsh advertisements are the best way to further prevent teen pregnancy. The press release launching the new campaign outlines how the approach is meant to, “Address the issue from both an economic and social perspective, the message focuses on responsibility and the impact employment, family, education and the emotional and financial support of both parents have on a child’s well-being.” (2).

 

Overview

Incorporating texting and technology familiar to teens is increasingly being incorporated into public health interventions in addition to traditional methods in order to meet adolescents at a point they understand. Unfortunately most social media programs use Social Cognitive Theory, Theory of Reasoned Action and the Theory of Planned Behavior to reach teens and fail to realize important flaws in their design (3). New York’s new Teen Pregnancy Prevention Program falls into the same trap as most public health interventions. Specifically, the program incorrectly assumes that teens believe they are at risk of becoming pregnant and fails to acknowledge positive choices teens make by stereotyping the period of adolescence as one where you make bad choices. Finally, the intervention invokes psychological reactance in teens. By defining pre-marital sex as costly, inappropriate and shameful the intervention effectively encourages teens to take risks sexually out of defiance.

Flaw #1: Assumes teens accurately perceive risk

The intervention assumes that teens believe they are at risk of becoming pregnant, and that if they believe they are at risk, they will change their behavior. The assumption that adolescents believe they are at risk of pregnancy completely discounts the overwhelming research that teens tend to feel a sense of invincibility, which lowers perceived risk, in the realm of long-term health outcomes. Wickman, Anderson and Greenburg (2008) sought out to understand adolescent perceptions on what invincibility meant to them. As one teen put it, “somehow I think that it can never happen to me because it is (only) other people who have bad things happen….”(7).

 Almost all teens know that if they have unprotected sex, there is a chance they will become pregnant. However, as Kershaw et al (2003) write, sexual risk is not accurately perceived among adolescents, leading them to engage in what they believe is a minimal risk activity, unprotected sex. In a sample of adolescent females who had engaged in unprotected sex with more than one partner (i.e. high-risk behavior for STI infection), 65% believed that their behavior was only slightly or not at all risky (4).  Underestimation of perceived risk only increases as an individual engages in an increased number of risky interactions (6). In other words, as frequency of risky acts increases, real risk also increases, however perceived risk decreases, leaving those at the greatest risk with the greatest sense of false safety.  Those at the greatest risk therefore are the least likely to recognize these posters of crying babies as something to pay attention to. The posters are hung in very public and busy spaces, where passersby are likely to ignore the message, assuming it does not pertain to them. The texting aspect of the campaign must be subscribed to, and since many teens do not see themselves as needing a pregnancy prevention program, they will not subscribe.

Flaw #2: Stereotypes perpetuate behavior, not change it.

Society has effectively stereotyped adolescence as an emotionally taxing, physically awkward and challenging time in our lives. We are all taught that teens make bad choices, take unnecessary risks and disregard what parents tell them to do. While some of these characteristics can be accurate to some degree, the negative image placed on teenagers is detrimental to their health behavior. When we apply overarching stereotypes to any group, they are more likely to live up to, or down to, that stereotype. For example, the stereotypes exist that Asian Americans are particularly intelligent in math and science and that women are not as gifted in those subjects. After two separate groups of Asian American females were reminded of each of these stereotypes, and given an exam, participants scored relative to the stereotype they were reminded of (8). Those that had gender inequalities on their mind had lower scores than those that had ethnic differences on their minds. This simple experiment has important implications for the Teen Pregnancy Prevention Program. Constantly reminding teens of their risky health behavior stereotype may lead them to fulfill that stereotype. As one teen describes, “media focuses on the negative behaviors of teenagers and that because of an established negative stereotype, teens do not have the chance to prove themselves.” (7).

In addition, the intervention fails to address the reality that our society has effectively sexualized almost every aspect of our lives. Advertisements crowd airwaves and websites with overly sexual commercials advertising everything from deodorant to alcohol to clothing. Mass media has a large role in socialization processes of teens and has been referred to as “a sexual super-peer” in influencing teen behavioral practices and exposure to hypersexual media has a strong association with earlier initiation of sex among teens (5). The media’s role and the messages sent by the public health community are conflicting yet both shed a negative light on adolescents. Media constantly appeals to teens using sexual ads as they try to adapt to the changes in their body physically and mentally, and encourages teens to experience their sexual freedom.  At the same time adults, and public health interventions such as this remind teens of the risky decisions they make. The intervention does nothing to support teens in defining themselves as sexual beings in a healthy and supportive way, which would help them make better decisions and change stereotypes.

Flaw #3: Threatens teens’ freedom by stigmatizing deviant and ‘risky’ behaviors

The Teen Pregnancy Prevention Program paints a harsh portrait of teen mothers, accusing them of meaningfully putting children into an environment in which it is near impossible to thrive. The posters have an authoritative tone to them, stigmatizing teen parents as bad people. However the research shows that this preachy and negative stereotype approach to sharing information in reality completely shuts down teens’ willingness to listen. Negative stereotypes foster a hostile relationship between adolescents and adults, and create an “’us-against-them’” mentality (7). Hostile atmospheres in which adults try to tell teens what to do invoke strong psychological reactance in adolescents. Psychological reactance results in rebellion and pushes teens to experiment with their sexuality in an unhealthy context. Teens exhibit psychological reactance often through an, “No one can stop me,” or “I don't have to listen to anyone,” attitude, leading them to make risky choices (7).

  When the public health community victimizes and shames teen parents, we are only promoting stigmatization of adolescent sexual intercourse. Stigmatization effectively defines adolescent sex as a ‘deviant’ behavior and subsequently limits teen’s feeling of sexual autonomy. Psychological reactance theory describes how when we limit one’s behavior and remove their freedoms they are actually more likely to engage in that behavior. Psychological reactance has been shown to be an effective predictor of engaging in risky sexual behavior, more predictive than sensation seeking or consumption of alcohol or drugs (6).  Therefore it is essential to include a prevention method of reactance in public health interventions, something this campaign certainly does not do.

Proposed Alternative Intervention

Interventions to prevent teen pregnancy must be focused on the present, not the consequences that are to come down the road. We must also work to change the negative stereotypes surrounding teenagers and the choices they make by changing the discourse of how we approach understanding how adolescents make choices. Finally, we must not foster the “us-against-them” culture that ignites the desire to make the unhealthy choice. Therefore I propose a community action-based intervention that involves former teen parents, facilitates discussion and promotes a culture of empowerment and changing stereotypes. Community based interventions have shown promise in addressing health disparities in at risk populations (12).

The texting component of the NYC Teen Pregnancy Prevention Program is not a terrible idea, however it must be implemented in a less authoritative and accusatory way.  Text-based interventions allow teens to ask questions anonymously at anytime that is convenient to them. Therefore my intervention would have a component in which teens are provided with a phone number they can text any question they may have concerning sexual or health in general.

Focus on the here and now

Adolescents, and many adults are unable to act in logical ways in the present to protect from outcomes in the future. They simply do not recognize that becoming pregnant could really happen to them (8). Therefore it is essential to meet teens where they are rather than forcing them to think about a future they cannot envision. Showing teens the immediate implications, both positive and negative, of their actions allows them to contextualize the action. For example, Wickman et al (2011) found that telling adolescents not to smoke because their lungs will turn black in ten years elicits no behavior change, yet an intervention that tells teens their crush won’t want to kiss them because they smell bad will (7).

Change the discourse, creating a safe environment

Adolescents will likely conform to stereotypes even if they are shifted from negative to positive. Changing the discourse of the conversations about choices teens make eliminates that negative environment and provides adolescents an opportunity to prove adults wrong. Rather than behaviors being risky, it may be helpful to promote “exploratory or experimental” behavior within a safe context. Rather then telling teens their sexual desires are ‘bad’, change the discourse to trying to understand where they are coming from. Shifting vocabulary however must be accompanied by a shift in attitude by parents, community members and educators. Adults must be open to creating a supportive environment in which teens can learn and take calculated, educated risks within the context of a safe environment.

Safe environments in which to take risks greatly decreases the negative health outcomes associated with those risky behaviors. For example, participation in needle exchange programs as an injection drug user significantly decreases one’s risk of HIV infection (10). By eliminating a risk factor an creating a culture of measured risk we can greatly decrease teen pregnancy rates.

 Empower

Young women must be empowered and encouraged to take control of their sexuality. My proposed intervention discards telling teens what to do and instead creates a community of teens who choose to have safe sex and are comfortable in their sexuality. Goal oriented, inclusive and constructive programs reframe teen pregnancy prevention and are essential to reaching the most at-risk populations (11).  Young women must be included in discussions and accept their desire to be recognized as sexual beings. Education programs telling them what to do will not change behavior, therefore programs that include information about relationships and sexual desire and empower them to take control of those relationships and desires will have the greatest effect. “By empowering teens—especially teenage girls whose desire is often denied or stigmatized—to recognize and take control of their own desire, they will be more in control of their sexual behaviors.” (Sisson, 2011).

Conclusion

Overall the Teen Pregnancy Prevention Program is an ineffective public health intervention. The program fails to acknowledge some of the most basic characteristics and personality traits of adolescents by assuming accurate perception of risk of pregnancy, promoting negative stereotypes and disseminating information with an authoritative tone. As public health professionals we must address these faults to insure that young men and women have a safe environment in which they can make educated decisions are supported by their community in taking control over becoming sexual beings and accurately perceive risk in the short term.

References

(1) HRA- Teen Pregnancy Prevention. “Think being a Teen Parent won't Cost you?” NYC Human Resource Administration Department of Human Services.  28 April 2013. http://www.nyc.gov/html/hra/html/programs/teen_pregnancy_campaign.shtml

(2)City of New York Office of the Mayor. MAYOR BLOOMBERG, DEPUTY MAYOR GIBBS AND HUMAN RESOURCES ADMINISTRATION COMMISSIONER DOAR ANNOUNCE NEW CAMPAIGN TOFURTHER REDUCE TEEN PREGNANCY, Press Release. 3 Mar 2013. http://www.nyc.gov/html/hra/downloads/pdf/press_releases/2013/pr_march_2013/teen_pregnancy_press_release.pdf

(3)Kylene Guse, M.A., Deb Levine, M.A., Summer Martins, M.P.H., Andrea Lira, M.H.S., Jenna Gaarde, Whitney Westmorland, Melissa Gilliam, M.D., M.P.H. “Interventions Using New Digital Media to Improve Adolescent Sexual Health: A Systematic Review.” Journal of Adolescent Health, Volume 51, Issue 6, December 2012, Pages 535–543 http://dx.doi.org/10.1016/j.jadohealth.2012.03.014

(4)Kershaw, Trace S., Kathleen A. Ethier, Linda M. Niccolai, Jessica B. Lewis, and Jeannette R. Ickovics. 2003. “Misperceived Risk Among Female Adolescents: Social and Psychological Factors Associated with Sexual Risk Accuracy.” Health Psychology 22 (5) (September): 523–532. doi:10.1037/0278-6133.22.5.523.

(5) L’Engle, Kelly Ladin, and Christine Jackson. 2008. “Socialization Influences on Early Adolescents’ Cognitive Susceptibility and Transition to Sexual Intercourse.” Journal of Research on Adolescence 18 (2): 353–378. doi:10.1111/j.1532-7795.2008.00563.x.http://onlinelibrary.wiley.com/doi/10.1111/j.1532-7795.2008.00563.x/abstract.

(6)Miller, Claude H., and Brian L. Quick. 2010. “Sensation Seeking and Psychological Reactance as Health Risk Predictors for an Emerging Adult Population.” Health Communication 25 (3) (April): 266–275. doi:10.1080/10410231003698945.

(7)Wickman, Anderson & Greenburg. Mary E. Wickman, PhD, RN, Nancy Lois Ruth Anderson, PhD, RN, FAAN, Cindy Smith Greenberg, DNSc, RN, CPNP. “The Adolescent Perception of Invincibility and Its Influence on Teen Acceptance of Health Promotion Strategies”. Journal of Pediatric Nursing, Volume 23, Issue 6, December 2008, Pages 460–468 . http://dx.doi.org/10.1016/j.pedn.2008.02.003

(8)Weinstein, Neil D. 1984. “Why It Won’t Happen to Me: Perceptions of Risk Factors and Susceptibility.” Health Psychology 3 (5): 431–457. doi:10.1037/0278-6133.3.5.431.

(9)Ariely, Dan. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: HarperCollins, 2008.

(10)                 Don C Des Jarlais, PhD, Michael Marmor, PhD, Denise Paone, EdD, Stephen Titus, MPhil, Qiuhu Shi, MS, Theresa Perlis, MS, Benny Jose, PhD, Samuel R Friedman, PhD. “HIV incidence among injecting drug users in New York City syringe-exchange programmes.” The Lancet, Volume 348, Issue 9033, 12 October 1996, Pages 987–991 http://dx.doi.org/10.1016/S0140-6736(96)02536-6

(11)                 Sisson, Gretchen. “Finding a way to Offer Something More: Reframing teen Pregnancy Prevention.” Sexuality Research and Social Policy. Springer Science. 2 May 2011. http://link.springer.com/article/10.1007/s13178-011-0050-5/fulltext.html

(12)                 Heidi Hauser Green, M.S., M.L.I.S., Patricia I. Documét, M.D., Dr.P.H..”Parent peer education: Lessons learned from a community-based initiative for teen pregnancy prevention.” Journal of Adolescent Health, Volume 37, Issue 3, Supplement, September 2005, Pages S100–S107 http://dx.doi.org/10.1016/j.jadohealth.2005.05.002