Challenging Dogma

Friday, April 27, 2012

The Efficacy of Abstinence-Only Sex Education and Virginity Pledges on Preventing the Spread of STI’s – Megan McFadden

Sexually Transmitted Infections as a Public Health Issue

Sexually transmitted infections (STIs) have become a public health problem that too often goes unaddressed because of the sensitive nature of the issue. According to the Center for Disease Control and Prevention’s 2010 surveillance on STIs, there are about 19 million new infections every year in the United States (1). STIs affect people of all ages but are more prevalent in young people between ages 15 and 24 because of biological and behavioral susceptibility. The CDC found that although young people only make up 25% of the sexually active population, approximately half of new STIs occur in the young population (1). STIs can lead to long-term and serious health complications, especially if undetected or untreated (1). In order to prevent the spread of sexually transmitted infections and subsequent complications interventions should be tailored to the adolescent population who are most susceptible.

Abstinence-Only Education and the Virginity Pledge

Sex education in schools is the current approach used in the United States to prevent STIs; however, there is long-standing controversy surrounding what type of sex education is most effective. In general, sex education in the United States can be defined as either comprehensive sexual education or abstinence-only sexual education (2). Comprehensive sexual education teaches abstinence but includes education on other birth control and STI protection methods. Abstinence-only education presents abstinence until marriage as the only effective method of birth control (2). Federal funding for abstinence-only education programs had been around since the 1980’s but increased in 1996 with Section 510 of the Social Security Act and again in 2000 with the Special Project of Regional and National Significance (SPRANS) (3). In order to receive funding from the government, a sexual education program must meet the eight criteria outlined by Section 501, which assures the programs main purpose is to promote abstinence (3).
One such abstinence-only program conducted by the Southern Baptist Church initiated the Virginity Pledge in 1993 as part of youth education. A virginity pledge is an oral or written promise to abstain from sexual intercourse until marriage. The virginity pledge was picked up by other programs and spread so that in 1995, approximately 12-13% of American adolescence had taken a pledge (4). The pledge program created an unofficial identity movement for teens that boomed within the first couple years of implementation. Teenagers who took the pledge were found to have a delayed transition to first sex, less sexual partners, and less cumulative exposure than teenagers who did not take the pledge within the first year of pledging (4).

Despite this supposed success of the pledge, research by Rosenbaum done in 2009 shows that the virginity pledge tends to fall apart after the first year. When asked five years after being exposed to the virginity pledge, not only did half of the “pledgers” disaffiliate after the first year, but over 80% of subjects denied ever having taken the pledge (5). Teenagers who had taken the pledge were less likely than teenagers who had not to use condoms or other forms of contraception to protect themselves from STIs or pregnancy (5). Hannah Brucker and Peter Bearman’s research on the same sample pool revealed that STI rates did not significantly differ between those that had pledged and those that had not (4). Adolescents who take a virginity pledge are not likely to remain abstinent until marriage and lack the education to protect themselves from STIs when they eventually do have intercourse. In the end, the virginity pledge ends up making teens more susceptible to the harmful consequences of sexual intercourse including sexually transmitted infections.

Virginity Pledges and the Psychological Reactance Theory

Abstinence-only education and virginity pledges are clearly flawed in creating lasting interventions that prevent STIs and pregnancy in young adults. The gaps in abstinence-only education programs and the eventual rejection of the abstinence promise by the majority of adolescents can be partially explained by the psychological reactance theory. Jack Brehm’s research in the 1960s explains how individuals whose freedoms have been threatened will react by restoring those freedoms (6). A free act is a behavior that is realistically possible at a given time, including the freedom to choose one option over another (6). A teenager loses a certain freedom of choice when he or she is only given one option for conducting his or her sex life. According to the psychological reactance theory, teenagers given abstinence-only education will be denied freedom of choice and will attempt to restore freedom by having sex.

Adolescents are highly motivated to react against abstinence-only education because threats to sexual behavior imply threats to other similar behaviors. Brehm describes how the implication principle can strengthen psychological reactance to behavioral freedoms tied to other freedoms (7). Threatening the freedom to engage in sexual intercourse threatens all other sexual acts, as well as related “forbidden” behaviors. Teaching teenagers that sex is off limits may imply that less harmful behaviors such as oral sex, kissing, groping, or even holding hands are off limits as well. The message of abstinence-only education lumps sexual behavior into the same category as other taboo behaviors that often cause reactance in teenagers such as alcohol, tobacco, and drug use. The combination of many implied threats creates a greater degree of psychological reaction to the implicate threat (7). Abstinence-only education programs are particularly evoking of the psychological reactance theory because of the general feeling of threat they impose upon teenagers enrolled in the program.

The virginity pledge is less offensive to Brehm’s theory because an individual has the option to decline the pledge. However, the psychological reactance theory explains why most individuals do not adhere to the pledge for more than a year. Brehm suggests that the magnitude of reactance to a threat varies based on a number of variables, including the importance of the behavior threatened and the degree to which the individual has the freedom to begin with (6). Both these variables are inevitably going to shift in response to sexual activity as an individual moves through adolescence. The importance of sex as a free behavior to a teenager will most likely increase as he or she gains more experience; and sex may not be a free behavior at all for a young teenager who has not yet hit puberty. Adolescents who had a low degree of reactance when agreeing to sign the pledge could easily develop a higher degree as they age and will attempt to restore their freedom by having intercourse. “Pledgers” who experience a delay in reactance are at risk for STIs when they eventually use intercourse to rebel. Comprehensive sexual education is necessary to protect the young population who react against the virginity pledge from the harmful consequences of unprotected sex.

Ineffectiveness of an Intervention in the Cold State

Instantaneous or gradual psychological reactance is not the sole underlying explanation for the ineffectiveness of the virginity pledge for long-term prevention. Both proprietors and participants of the virginity pledge make the unrealistic assumption that decision-making capacity is consistent between the environments in which the pledge is signed and the environment in which first sex is encountered. Making such an assumption is detrimental to the long-term success of the virginity pledge. The two contrasting environments can be classified based on George Loewenstein’s research from 1996 as hot and cool states (8). Visceral factors such as hunger, thirst, sexual desire, and pain are the primary drives that define a “hot state;” when an individual is in a “cool state,” visceral drives are satisfied (8). Drive states and visceral factors have a profound effect on decision-making, behavior, rationality, and even egocentricity (8). Loewenstein found evidence that decisions made during hot states are generally more instinctual and less rational because of the overwhelmed need to satisfy the acting visceral drive (8). Any individual could easily ignore previous decisions made in a cool state when he or she is overwhelmed with a desire that needs to be satisfied instantaneously.

Sexual desire is the visceral factor that influences adolescent behavior in the context of the virginity pledge. When a teenager is presented with the pledge, he or she is presumably sitting amongst peers and adults in a structured environment and therefore in a cool state in terms of sexual desire. A teenager who decides to sign the virginity pledge will do so in a state that promotes rational decision-making and clarity (8). In contrast, when a teenager is presented with the opportunity to lose his or her virginity, he or she will likely be in a hot state of sexual desire and arousal. Decisions made while in a hot state are more likely to be impulsive and often uncharacteristic of the individual making the decision (8). The validity of the virginity pledge is highly subject to falling apart once adolescents experience the visceral state of sexual arousal. Abstinence-only education does not equip young adults with the knowledge of safety precautions to take if they break their promise during a hot state.

In addition to the disparity between decision-making capacity in hot and cool states, individuals have been found to make poor predictions of actions performed in a hot state. Research done by Dan Ariely and George Loewenstein in 2006 concluded that people are unable to anticipate how a state of sexual arousal will affect his or her behavior (9). Male college students in a cool state were unable to predict their own answers to future questions pertaining to arousal and risky sexual behaviors asked during a hot state. Subjects were 25% more likely to decline using a condom while in a hot state than in a cool state (9). The inability to predict decision-making in a hot environment explains why such higher percentage of “pledgers” engaged in premarital sexual relations despite their intentions to refrain. The discrepancy between hot and cool states also helps to explain why “pledgers” are less likely to use protection against STIs and pregnancy than “non-pledgers.” A pledger is essentially unaware of the decisions he or she will make when faced with the prospect of first sex and therefore will not prepare to take the proper precautions. A lack of education combined with ignorance about future decision making increases the chances that a pledger with contract an STI.

Negative Consequences of Normalizing

Not only does the virginity pledge lack lasting success because of individual behavior such as reactance and drive states; the pledge is also unable to change group behavior. The virginity pledge was initially successful because it created an “identity movement” during the first couple years of implementation. Adolescents who took the pledge became part of a trendy subculture in which they could identify with other peers who had pledged. Merchandise, music trends, websites, and chat rooms all stemmed from the popularity of the virginity pledge making abstinence the “cool” thing to do (10). The virginity pledge appeared to be a successful tool to prevent premarital sex because of the initial boom in popularity; however, as mentioned earlier, the majority of pledgers eventually break their promises. The sheer popularity of making the promise actually contributed more to the pledge’s downfall as an intervention rather than its success.

Trends such as the virginity pledge come about largely because of social influence on behavior. In 1956, Solomon Asch’s research revealed that people altered their judgments, attitudes, and behaviors based on the behavior of other’s around them. Asch found that an individual is more likely to give an incorrect answer to a simple question when he or she observes another individual giving an incorrect answer (11). People are inclined to copy those around them regardless of whether they share the others’ beliefs. Asch observed the social phenomenon that explains the snowball effect created by the virginity pledge or anything else that could be considered a trend. Numerous other experiments evolved from Asch’s findings that continue to reinforce the fact that people will conform a social norm in almost any circumstance (12). Theoretically, the virginity pledge would be positively impacted by conformity because the number of pledgers would increase as teens copied each other by signing. However, if teenagers are only signing the pledge because of social influence, they will not take the pledge seriously and will most likely break their promise when faced with first sex. Teens following the trend will not make informed decisions about first sex and therefore will not likely protect themselves from STIs.

Proposed Intervention for the Prevention of STIs

The standard alternative to abstinence-only sex education is known as comprehensive sex education. As mentioned earlier, comprehensive sex education includes education on all methods of contraception including abstinence, condom use, and modes of protection against both STIs and pregnancy (2). Comprehensive sex education should be implemented in all schools over abstinence-only education, but a sexual education program may not be enough to provide teenagers with all necessary resources to practice sex safely and responsibly. A comprehensive sexual education curriculum should be combined with a sexual health peer mentorship program to further prevent harmful consequences, such as STIs, that could result from irresponsible sexual intercourse.

Ideally, sexual education should be part of eighth grade and high school curriculum for a quarter of each school year. The lesson plans will be changed each year so that they are specifically tailored to the needs of each age group. Overlaps in lessons are inevitable and necessary to reinforce important topics and ensure that students receive the full scope of the education. Sexual education can be conducted during physical education time; students will be excused from P.E. for a quarter of each year to attend. Sex education will be conducted in a classroom setting where a qualified instructor will teach sexual anatomy, contraceptive methods, and other topics in a factual and objective manor without imposing any certain beliefs on the student. The goal will be a comprehensive education on safe sex, not just imposing a particular belief structure of any kind.

In addition to classroom instruction, each student has the option to seek an older, same-gender “sexual health mentor.” Students will have the opportunity to apply to be mentors as they enter ninth grade and will be required to commit to the position until twelfth grade. Mentors will be trained to help students with sexual health issues, specifically focusing on how to say no and how to protect themselves from STIs and pregnancy. Students enrolled in sex education will be provided with a way to discretely schedule an appointment with a mentor either during lunch period or after school. A comprehensive program with mentorship availability will give teenagers the knowledge and support to either remain abstinent until marriage or have safe, responsible sex.

Decreasing Reactance through Options and Similarity

Abstinence-only education is subject to a high degree of reactance from young adults because the program threatens so many freedoms. In contrast, through sexual education students are able to maintain their own beliefs while gaining the knowledge to support whatever decision they make in regards to their sex life. The information presented in the classroom setting will be provided in an entirely objective manner so that students will not feel as if they are being told what to do and may apply the knowledge however they see fit. Curriculums will be altered each year to take into account the changing importance of sex as a freedom for each age group. Peer mentors can reduce reactance even further through the interpersonal relationship the mentor will build with the younger student. A peer mentor will be able to understand his or her mentee’s beliefs (i.e. whether or not they intend to have premarital sex) on a personal level and conduct counseling in a way that affirms these beliefs. Both classroom instructors and mentors will make students feel as though they are being heard and eliminate or decrease psychological reactance.

Giving students more options for sexual activity may not be enough to decrease reactance if the options are coming from an authority figure. The peer mentorship program will provide an outlet for students who do not feel comfortable speaking with a teacher about their sex lives. In 2005, Paul Silvia conducted several experiments involving psychological reactance and interpersonal similarities. Silvia found that simple similarities such as gender, birthday, and first name decreased feelings of threat a subject felt towards the individual administering an essay that threatened attitudinal freedom (13). The degree of psychological reactance will be minimized when students are able to hear messages about sexual behavior from individuals who are of the same gender and of similar age based on Silvia’s findings. Mentors will be following their mentee throughout the school years so they will be able to alter counseling based on the changing degree of reactance a mentee may experience. The proposed approach to sexual education should be able to eliminate psychological reactance almost entirely through a combination of factors.

Realistic Acknowledgement of the Hot State

Unfortunately, the decision to refrain from intercourse, even if made under the best and well-informed intentions, does not necessarily mean an adolescent will refrain. Comprehensive sexual education presents abstinence as a viable option to prevent oneself from STIs and pregnancy. A teenager may choose to remain abstinent after hearing the facts in a cool, rational state. That teenager may later find him or herself in a hot state and choose to engage in intercourse despite original intentions. Either the classroom instructor or the peer mentor must be realistic in explaining potential environments where students might be unable to say no. People in general are unable to predict how they will behave when sexually aroused and ignorance is amplified for young adults with little sexual appearance (9). Students must realize they may be unable to follow through on intentions because of the overwhelming nature of sexual desire.

The proposed curriculum must include strategies to prevent adverse effects of somewhat unintentional first sex. Both the classroom curriculum and mentor training will include strategies on avoiding situations that will unleash visceral desires for both males and females. Strategies for effectively saying no to a partner must also be taught while again reinforcing that saying no may be more difficult in a future environment. The nature of comprehensive sexual education includes information on adequate protection against STIs and pregnancy but should reinforce safety precautions that can be taken “just in case” (i.e. keeping a condom on your person). These combined elements of the proposed intervention will help teenagers protect themselves from STIs despite the potential influence of a hot state.

Preventing the Start of a Trend

The virginity pledge is somewhat unique from other public health interventions in that the pledge will not benefit from becoming a social norm. Asch found that people are very susceptible to changing both their beliefs and behaviors to conform to a social norm (11). Abstinence is a personal decision that requires a strong belief and a fair amount of hard work. A teenager who chooses to pledge solely because of social influence will not follow up on the promise and eventually transition to first sex before marriage. A “non-pledger” is more likely than a “pledger” to protect him or herself from STIs and pregnancy because the individual anticipates having sex (5). Teens will be better protected from STIs if they make an individual decision in regards to sexual behavior based on realistic intentions instead of just following their peers.

The private nature of the proposed peer mentorship program will prevent sexual decisions from becoming trendy to reduce outside influences on teenager’s decisions. Students will be able to sign up for mentor appointments online to ensure complete discretion and eliminate fear of judgment from other students. The mentors will be trained to avoid influencing their mentees as much as possible and encourage independent decision-making. The mentors will also be required to sign a confidentiality agreement to further cut down on social interaction that could alter counseling or decision making. Social influence can be detrimental to sexual health because sex is a highly individualized decision. A teenager is more likely to take precautions against contracting an STI if they are in control of their sexual decision-making.

Comprehensive Sexual Education as an Effective Intervention against STIs

Although the United States federal government has been funding abstinence-only education in schools since the 1980’s, sexually transmitted infections continue to spread through adolescent populations. The virginity pledge was implemented in 1993 to further promote abstinence in teens and was seemingly successful in doing so after the first few years of implementation. The sudden success of the virginity pledge did not continue due to several sociological factors. Virginity pledges and abstinence-only education invoke psychological reactance from teens because teens are likely to feel a threat to both implied and implicate freedoms. Abstinence-only education and the virginity pledge do not take into account the discrepancy in decision-making capacity when teenagers are in hot vs. cool states. Finally, the virginity pledge decreased in validity when it became a social norm amongst teens. The combination of flaws in the intervention resulted in an increased susceptibility for “pledgers” to contract sexually transmitted infections.

Comprehensive sexual education combined with a peer mentorship program should be implemented in public schools throughout the United States to prevent the spread of sexually transmitted infections. The program will reduce psychological reactance by providing teens with options for conducting their sex lives and increasing interpersonal similarity between the students and the messenger. Classroom instruction and mentors will realistically address decreased decision-making capacity that may occur during hot states and provide students with strategies for avoiding and managing such a state. Sexual beliefs will not become a trend because of the personal nature of the peer mentorship relationship so students can make individualized decisions. By controlling for each sociological factor, the proposed intervention will decrease the rate of sexually transmitted infections amongst young adults in the United States.

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