Challenging Dogma

Friday, April 27, 2012

Teenage Pregnancy and Sexual Transmitted Disease Intervention Backfires: A Critique of Abstinence-Only Sexuality Education — Taylor Ngo


Unplanned pregnancy among adolescents is a multifaceted issue posing challenges for the adolescents, their families, and society. The trend of adolescent pregnancy has significantly declined over the past three decades in many developed countries, however the United States still experiences the highest adolescent pregnancy rate compared to its counterparts. In 2000, there was an estimated 70 teens that became pregnant for every 1000 teenage females in the U.S. In contrast, there were 40 teenagers that became pregnant for every 1000 teenage females in Japan and most Western countries and only 12 teens became pregnant for every 100o teenage females in the Netherlands (1). Currently, the live birth rate among adolescents in the U.S. is disproportionately higher than in the other developed countries with an estimate of 39 live births per 100o teens in a year, while it is 4 live births per 1000 teens in the Netherlands and approximately 5 to 9 per 1000 teens in Japan and other Western European countries (2). Despite the trend of declining unintended adolescent pregnancy, this remains a major public health problem. Adolescent pregnancy is often associated with low birth weight, premature infants, and high neonatal death rates. Further complications include poor maternal weight gain and increasing sexual transmitted diseases (STDs) (3). Psychological implications include poor academic performance, persistent poverty, and repeat pregnancy (3, 4). The children born to adolescent mothers have increased risk for reduced cognitive development and often display behavioral disorders leading to school interruption. They also have a high risk of becoming teen-age parents themselves (3, 4).

Because of the social and economical problems associated with adolescent sexuality, promoting responsible sexual behavior is an essential public health focus. The federally funded abstinence-only sexuality education programs were initiated in 1981. The purpose of these programs is to advocate abstinence as a sole means in preventing pregnancy and STDs among adolescents. Its core values are limited to “chastity” and “self-discipline” (5). Despite the increasing for abstinence-only sex education to over 100 million dollars a year between 2002 and 2009, there is a lack of evidence supporting the effectiveness of this particular intervention. States practicing abstinence-only sex education including Louisiana, Arkansas, Arizona, and Mississippi had the highest rate in teen pregnancy in 2000. States that covered abstinence as well as other methods of prevention such as contraception in their sexuality education programs include Vermont, Washington, New Jersey, West Virginia and South Carolina had the lowest rate in teen pregnancy (5). The idea of abstaining from sexual intercourse to prevent pregnancy and sexual transmitted infections is theoretically a perfect solution. Although critics often refer to abstinence as ideological and religious beliefs, it is very similar to the Health Belief Model (HBM), which states that people are likely to perform a behavior if they think that they are susceptible to the disease, their health outcome is severe if they get the disease, and their perceived barriers are low (6). The abstinence-only approach assumes that teens are rational, that their abstinence intention and behavior are directly associated with their perceived susceptibility and severity to pregnancy and STDs. While the HBM is effective in a one-time decision process, it is not appropriate for complex sexual behaviors (7). By telling the teenagers to abstain completely from coitus until marriage, the intervention neglects to account for the teenagers’ reactance to the command, ignores normal human needs, and fails to promote healthy sexual behaviors by withholding information.

Sexual Education Teaching Abstinence as only Option Induces Psychological Reactance in Teenagers

The psychological reactant theory first described by Jack Brehm, demonstrates abstinence-only education to prevent adolescent pregnancy and STDs has evoked the opposite effect. According to the psychological reactance theory, when an individual perceives that his or her personal freedoms (for example the liberty to smoke or have sex) are threatened or reduced, the individual becomes emotionally aroused. This arousal is a psychological state called reactance, which motivates the individual to re-establish the threatened or eliminated freedom (8,9). Literature shows that the importance of the freedom to the individual (8,9), the dominance or forcefulness and the explicitness of the message (8,9,10) are the major factors associated with increased reactance.

The importance of the personal freedom is directly proportional to the reactance (8,9). In other words, the more important the behavior is to the individual, the greater the magnitude of the reactance. A large population of Americans initiates sexual intercourse during their adolescence and very few abstain from sexual intercourse until marriage (11). More than 42% (4.3 million) of female teenagers and 43% (4.5 million) of male teenagers have had sexual intercourse between 2006 and 2008. Of these, 13% of females and 15% of males had their first sexual intercourse before the age of 15 (12). These statistics suggest that sexual intercourse is the social norm among American teenagers. To the sexually active adolescent having sex is part of his or her identity. To some adolescents, abstinence-only education can be interpreted as a threat to their most important personal freedom. Those who have not engaged in sexual activity might interpret the abstinence-only message as a way in which their freedom of choice is being taken away from them. As a result, sexual activity becomes much more appealing for both sexually active and sexually inactive teens, contradicting the original intent of abstinence-only education. It creates a powerful social incentive for adolescents to perform the forbidden behaviors.

Research has shown that explicitness and dominance of the messages heighten reactance of the recipients (8,9,10). The more plain the message’s intent, the more reactance the recipients will induce. Likewise, dominance—the extent to which the message reveals the authoritative nature toward the recipients, the more dominating the message or the messenger is to the recipients, the more reactance the recipients would arouse (10). The messages of abstinence are often very explicit and dominating. For example, “abstinence is the only choice”, “say no to sex”, and making them take pledges by swearing that they will not have sex until marriage. Additionally, abstinence-only is hierarchical where adults such as teachers, nurses, and government officials are the ones who deliver explicit abstinent messages to students. Adolescents are at the development stage where some would dismiss or even defy authoritative figures. This trait, compounded with the explicit and dominating messages from an adult that arouse the students’ reactance, makes it more attractive for them to perform the risky sexual behaviors.

Abstinence-only Sex Education Neglects Basic Human Needs

To encourage adolescents that abstinence is the “expected standard” outside of marriage is to completely neglect one of the most basic physiological needs of humans. Abraham Maslow’s hierarchy of needs theory posits that human beings are motivated by deficiency needs and that the lower needs must be satisfied before the higher needs can be tackled. Deprivation needs include physiological —hunger, thirst, sleep, and sex; security and safety; belonging and love; esteem which must be satisfied before an individual is ready to achieve the highest level of needs—self-actualization or self-fulfillment. Behavior at this stage is motivated by the individual’s desire for personal growth rather than by deficiencies (13). The feeling of belonging to a group is part of human emotional needs, especially during adolescence. They have a strong desire to belong and be loved. According to Maslow’s theory, in order to fulfill their desire for love and belonging, adolescents will do the very thing that abstinence-only tells them not to—have sex.

In agreement with Maslow’s theory of needs, literature illustrates that the process of sexual maturation starting between 8 to 10 years old is a part of the normal developmental process (1,4). During adolescent years, the majority of teens is sexually matured and may be capable of sexual activities. Society, however, often prefers not to accept this fact of life. It offers very little support and often condemns sexual behaviors among teens. Sexual initiation for most Americans begin during adolescence where the median age for women is 17.4 and men is 17.7 years. The age of first marriage is 25.3 for women and 27.7 for men (11). According to the abstinence-only approach, most Americans, not just teens have to wait until they are well into their adulthood to have sexual intercourse. And, if they get a divorce, they have to refrain themselves from sex again. This method is proven to be extremely impractical for pregnancy and STIs prevention and it is against human nature and our physiological needs.

Abstinence-only sex education intentionally ignores the sexual health needs of the gay, lesbian, bisexual, transgender and questioning (GLBTQ) youths, which consists of 2.5% of the student body across the country. It supports exclusively the heterosexual relationship. By teaching “faithful and monogamous relationship is the expected standard of human sexual activity” in the marital context it discriminates against the GLBTQ teens. While it is unrealistic to encourage teens to abstain from sexual intercourse until marriage, it is more problematic for these GLBTQ teens. Except for Massachusetts and a few other states that legalized same sex marriage, abstinence means that it is a lifetime commitment for teens in other states since one of elements of the abstinence-only is to promote “the expected standard” of abstinence happens outside of marriage. These teens have to live as asexual organism for the rest of their life.

Abstinence-only Sex Education Fails to Promote Healthy Sexual Behavior

Abstinence-only sex education provides nothing but unrealistic ideas about healthy sexual behaviors. It disseminates inaccurate and misleading scientific information about sexual health. For example, one program informed students that sweat and tears are the factors for HIV transmission (14). Others misrepresented the effectiveness of condoms against STDs and unintended pregnancy by inflating the failure rate of condoms against HIV infection to 31% and that pregnancy occurs in one out of seven times the couples used condoms (14). This type of distorted information is very dangerous to the adolescents and public health. By concealing and misrepresenting scientific knowledge, it confuses and misleads adolescents. This method only steers adolescents away from practicing healthy sexual behaviors and therefore fails to protect them and the public from sexual transmitted diseases and unintended pregnancy (14).

Promoting sexual intercourse is for marital, monogamous, and hetero relationships and that it is “expected standard of human sexual activity” deprives adolescents of scientific knowledge to make responsible choices for their own sexual health (5,11). A simplistic approach to a complex behavior simply leads to failure. By teaching children that abstaining from sexual intercourse is “the only way” to avoid out-of-wedlock pregnancy and STDs and provides no other alternatives of protection and disease prevention, in actuality completely ignores the protection of children’s sexual health (5,11). While it is theoretically correct that if one does not have sex she will not get pregnant or contract STIs, but she has to abstain from sexual needs 100% of the time for this method to be effective. As many teenagers fail to abstain from sexual intercourse, the abstinence-only is proven not 100% effective (11). Additionally, adolescents represent 25% of sexually experienced in the United States but accounts for nearly 50% of the new STD cases reported in 2010 (15). Sexual intercourse is accompanied with considerable risks of unintended pregnancy and STIs. By not teaching the right way to better sexual health, the abstinence-only programs will lead to an increase in STI cases in the future.

“True Love Wait” movement was another form of refraining from having sexual intercourse until marriage. It encouraged teens to virginity pledge. Two years since its inception in 1993, 12% (2.2 million) of adolescents have taken the pledge (16). Using data surveyed from the National Longitudinal Study of Adolescent Health (Add Health) Brückner and Bearman illustrated that virginity pledge was ineffective in reducing STIs. The STI rate was not statistically different between the pledgers and nonpledgers. Although pledgers had fewer years of sexual activity and few partners, the majority of them became sexually active before marriage. They were less likely to use condoms at their first sexual activity, more likely to substitute oral/anal for vaginal sex, and less likely to seek care for STI related diseases. These findings suggested that adolescents at are at increased risks for STIs and STDs (16) and once again demonstrates that abstinence-only fails to promote healthy sexual behavior and to educate and equip teens with the necessary information and means to make informed decisions to protect themselves from unintended pregnancy and sexually transmitted diseases.

Comprehensive Sex Education Intervention

Abstinence-only sex education has proven to be ineffective against unintended pregnancy and STDs among American adolescents. A new comprehensive sex education is needed to rectify the situation. A study using data from the National Longitudinal Study of Adolescent Health, found a significant association between condom use at sexual debut and the probability of subsequent condom uses (17). Adolescents who used condoms at their sexual debut were more likely to engage in protective sexual behaviors as long as 6.8 years after the sexual debut compared to those who did not. They also were only half as likely to contract STDs (17). Considering this, it is imperative to teach all forms of safe-sex practices. In view of the finding that more than half of a million adolescents begin their sexual debut before 15 years of age (12), a comprehensive sexual education program should be implemented as early as the fifth grade and should evolve into a more extensive sexual education over time. The intervention discussed in this paper will likely to be most effective for high school teenagers. In this comprehensive sex education, we would address the specific flaws of abstinence-only sex education mentioned in previous sections. The strategies for the comprehensive sex education will include components specifically address each flaw of the abstinence-only programs. The three components consist of safe-sex messages to teens in a manner that does not induce reactance; the nature of sexuality; and provide accurate information and teach safe sex practice. The purpose of this intervention is to appropriately guide adolescents to healthy sexual behaviors in order to prevent unintended pregnancy and STDs. We hope that this intervention will better prepare teens to lead a better and healthier life.
Reduce Psychological Reactance

One of the major reasons that the abstinence-only programs failed in preventing pregnancy and STDs was the psychological reactance among adolescents. Forbidding adolescents from sexual behaviors only pushes them to restore their freedoms by engaging in sexual activity, the opposite of the intended outcome. Research has shown that successful social influences that do not threaten important freedoms (9,18) and similarity of the messengers can reduce resistance and increase compliance (18). In order to reduce reactance among adolescents, the new program will frame the teaching messages in the way that they will reinforce the beliefs, attitudes, and values of the adolescents rather than confronting them. Offering them choices of prevention such as contraceptives and condoms and encouraging them to be responsible for themselves and the ones they care about will maximize their perception of free choice. This will make them feel like they are in control of their own life and will increase the likelihood that they will comply.

To further maximize compliance, perceived peers rather than powerful and authoritative figures will be designated as the communicators. For example, young adults (less than 24 years old) that have experience with adolescent pregnancy and STDs could serve as guest speakers. These invited speakers should be people that the students feel that they can relate. Teens are more likely to listen to their friends rather than powerful and authoritative figures. This approach will provide communicators that the students will find likable and credible, resulting in increased compliance. While the content of the messages should be informative, it is crucial that they are not dominating or threatening. If the adolescents perceive that the message is less threatening they will be more likely to approve of the message and will listen. The way to make teenagers feel less threatened is to have a small group discussion led by the invited speakers. This approach will serve as a positive reinforcement and will be much more effective at creating compliance.

Address the Normative Nature of Sex

Unlike the abstinence-only approach, part of the comprehensive sex education program will address the biological process of human development in terms of sexuality and needs. It will emphasize that sexuality is a natural and healthy part of living, a natural process of becoming an adult, and that everyone is sexual (19). It is crucial to make teens view themselves as unique and worthwhile individuals and that having sex should not be associated with their identity but rather being humans. Research has shown that using descriptive norms has successfully changed the perception of a population by changing the people’s perception about the numbers of others that engage in the activity (20). In this particular situation, we should inform the adolescents that there are more than 50% of teens in the country that do not have sexual intercourse (12). Instead of following the other group of sexually active teens to fulfill the desire to belong and to be loved, they may choose to follow the other group. It is also important to address specific sexual health needs of GLBTQ teens in a manner that avoids negative labeling.

Promote Healthy Sexual Behavior with Accurate Information

Using scare tactics by providing false scientific information, promoting chastity pledges, and showing the moral ways to pregnancy and disease prevention is unethical and leads to the irreversible damage. Many would agree that young teenagers should delay having sexual intercourse. This new program will not dismiss the importance and effectiveness of being abstinence to young teens and will address risks associated with sexual intercourse. The program will provide fully accurate and up-to-date information regarding the effectiveness of current contraceptives and condoms as well as inform of new methods to prevent pregnancy and STDs as they become available. Our objective is to prepare every adolescent, regardless of sexual identity with scientific information so they can make informed, healthy, and responsible decisions to protect themselves from unintended pregnancy and STDs in the event that the abstinence is not sustained. In addition, the new program will be thorough and transparent in educating adolescents about the risks associated with sexual behaviors, respecting the diverse values and beliefs about sexuality, and the importance of making responsible sexual decisions.

We will design a study to examine the effectiveness of the program after two years and make necessary changes to ensure that the program meets the needs of all teens across the country.


The abstinence-only sex education is based on moral values and is solely geared toward educating teens to abstain from sexual intercourse, makes it ineffective to prevent teenage pregnancy and STDs. The new comprehensive sex education will be much more effective. In combination with scientifically accurate information and social and behavioral research, this new intervention approach will be more successful.


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