Challenging Dogma

Monday, May 7, 2012

Abstinence-Only Education: Why It Doesn’t Work And Should Be Replaced With Group-Based Comprehensive Education – Andrea Fantegrossi

Introduction: Abstinence-Only Education - Current Intervention

            Teen sex continues to create a number of ongoing concerns in our society.  Teen pregnancy and Sexually Transmitted Infections (STIs), such as HIV/AIDS, are prevalent concerns in many communities.  In fact “the United States ranks first among developed nations in rates of both teenage pregnancy and sexually transmitted diseases” (2).  Of note, 39% of all new HIV infections in 2009 were from people aged 13-29 (15).  Also importantly, “in 2010, 367,752 infants were born to women aged 15-19 years” (16). Many communities continue to use abstinence-only education programs to address these concerns.  Over 1.5 billion dollars have been invested in abstinence-only education programs since 1997 (22).  These existing programs encourage youth to refrain from sexual activity in general rather than outlining specific ways in which the risks can be minimized while engaging in this behavior, such as by using condoms (7).  The focus of abstinence-only programs is to “promote abstinence from sex…do not teach about contraception or condom use…cites sexually transmitted diseases and HIV as reasons to remain abstinent” (14). However, there is a growing body of evidence indicating that these abstinence-only programs are ineffective.  For instance, one study found that abstinence-only education has a positive correlation with teen pregnancy (2).  The ineffectiveness of abstinence-only education is particularly pronounced when it is compared to comprehensive education.  One study found that youths who received education on both abstinence and birth control were more likely to engage in healthy sexual behaviors, such as using condoms at sexual initiation, than their peers who received abstinence-only sexual education (3).  This study indicates that abstinence-only education is harmful to youth, as it does not provide the education necessary to lead to preventative measures.  While issues of teen pregnancy and STIs are ongoing concerns in our society, it is imperative that a more effective model be created in order to combat these issues.  In the following pages, I will explore the varying flaws with the abstinence-only approach and propose an intervention to address the existing flaws and improve upon sex education for youth.
Flaw #1: Abstinence-Only Education Is Likely to Invoke Psychological Reactance
            The abstinence-only education programs are reflective of the Health Belief Model, which dictates that people will base their behavior off of the perceived benefits/risks associated with a certain behavior (11).   As such, abstinence-only education does not entertain the reality that teens, among other people, are heavily influenced by the way in which the message is given – perhaps even more so than the message itself.  Part of the failure of abstinence-only education is likely due to psychological reactance, which is a phenomenon that exists when an individual feels that his or her freedom is being threatened and results in the individual ignoring the message being given.  One experiment that explored this phenomenon used a shopping website to track psychological reactance in users who received personalized shopping recommendations.  The study found that those consumers who were told that three types of personal data would be used when forming recommendations were less likely to use the recommendation services in comparison to those who were told that only one type of data would be used when forming recommendations (4).  As this experiment demonstrates, people did not want too much of their personal information to be used for recommendation purposes, as it limits the freedom of the consumer to receive a broader range of potential recommendations.  Instead, using too much personal data when creating recommendations results in a narrow snapshot of items the individual may like.  Another experiment studied participants who were given a text to read on how to conserve energy in a washing machine in comparison to participants who were given this text in addition to a picture of a robotic agent or film clip of a robotic agent.  The researchers hypothesized that, as robotic agents may be able to persuade people’s beliefs in the future, people would be more aversive in the picture and film clip conditions outlined above.  The researchers found that those participants who were in the film clip or picture conditions exhibited more psychological reactance than did the control group, which saw the text only (5).  Additionally, in one experiment, researchers tracking teen relationships found that the biggest predictor of relationship longevity was the degree to which the young people’s parents disapproved of the relationship.  Evidently, young people were much more likely to stay together when their parents were not in favor of the relationship (23).  Per the aforementioned experiments, people have an aversion to being controlled and will disregard the message being given if they feel that their freedoms are being threatened.
            These results have important implications regarding abstinence-only sex education.  As noted above, people who feel that their freedom is being threatened are less likely to be responsive to the message being given.  The abstinence-only curriculum indicates that youth should not be having sex in general, and the freedom to engage in new and exciting behaviors is being stripped from youth with this message.  Abstinence-only sex education does not give youth a choice regarding sexual decisions.  For instance, “”, a website that was created with the purpose of helping parents talk to their kids about sex, includes different approaches to talking to youth at difference ages and genders regarding avoiding sex.  When talking to a 13-15 year old girl, the website includes the dialogue, “Sex is a bad idea right now” (1).  This direct effort to manipulate youth into thinking a certain way has the strong potential to create huge levels of psychological reactance in young people.  Evidence has shown that youth have especially high levels of psychological reactance when they are being told not to do something by someone who has participated in the behavior themselves (23).  Bristol Palin, who gave birth as an unmarried teen, is an advocate for abstinence-only education.  Palin has been quoted as saying “…I do think it’s realistic.  It’s the hardest choice, but it’s the safest choice” (6).  Palin’s campaign to promote sexual abstinence is likely to contribute to the psychological reactance youth experience due to abstinence-only sex education.  Abstinence-only education is likely to create psychological reactance in young people due to the aforementioned factors, and it’s important that this reality be addressed in designing future sex education campaigns.
Flaw #2: Abstinence-Only Education makes the assumption that youth will accurately understand the risks associated with sex
            Abstinence-only education fails to teach students about different methods of contraception and safe sex, such as condom use.  Instead, these education programs simply encourage youth not to engage in sexual activity by educating youth on risks involved with sex, such as pregnancy and the transmission of STIs (7).  The Health Belief Model, on which abstinence-only education is based, posits that “the individual’s perceived susceptibility to a health threat” is one of the major factors in healthy behavior change and activity (11).   
            A study conducted by Henry A. Waxman found that the abstinence-only education curriculum was distorting data in order to scare youth into not having sex.  For instance, the Waxman study found that one curriculum advised students that “the typical failure rate for the male condom is 14 percent in preventing pregnancy”.  In reality, while “couples have a 15 percent chance of experiencing a condom failure over the course of the year” with typical use, the failure rate is 2-3 percent when condoms are consistently and perfectly used (7). 
            The scare tactics being used by abstinence-only educators may likely not be having the effect intended, as abstinence-only educators fail to take into account that people do not accurately assess the chance of bad things happening to them, which is called “optimistic bias”.  For instance, despite national efforts to educate the public on the dangers of smoking, one study that assessed smokers’ perceived risk of cancer and heart attack found that only 29 percent of participants felt that they had a higher chance of having a heart attack in their lifetime and only 40 percent of participants felt that they had a higher chance of having cancer in their lifetime than other people of the same age and sex (8).  One further study examines the attitudes of 11-14 year olds in their beliefs of what their chances are in developing skin cancer.  While more than half of the participants reported that they engage in tanning, most participants reported feeling that they are less likely than their peers to develop skin cancer later in life (9). 
            A further psychological construct, the Illusion of Control, provides additional evidence for the fact that people do not accurately assess risk.  As this construct dictates, people tend to think that they have more control over situations than they actually do.  One study hypothesized that participants would be more likely to bet more while engaging in a non-competitive task when the other participant (a confederate) appeared to be an awkward individual rather than a confident individual.   The researchers posited that, even though physiological responses, a non-competitive measure, were being tested, the degree to which the participants would bet against an awkward versus a confident confederate would be a reflection of the amount of control the participant felt he or she had versus the opponent. The results held true to the hypothesis, and participants on average betted more against the awkward confederate than the confident confederate (18).  This experiment demonstrates that humans tend to feel that they have more control over situations than they actually do.
            As the aforementioned studies demonstrate, those who engage in risky behaviors such as smoking and tanning do not fully appreciate and understand the negative consequences associated with these behaviors.  Youth who are having sex, in turn, are likely not to fully appreciate the risk involved with sexual behavior.  As such, outlining and underlining the risks associated with sexual behavior, as abstinence-only educators do, will not necessarily mean that young people will internalize these risks and understand the chances of these risks happening to them. Furthermore, young people may feel that they have more control over a situation than they actually do, further undermining interventions that underline the risks associated with certain behaviors, such sexual activity.
Flaw #3: Abstinence-Only Sex Education Fails to Acknowledge Social Expectations Which Dictate Human Behavior
            The Health Belief Model, on which abstinence-only curriculum is based, makes the assumption that individuals will make decisions on their own that will dictate their behavior, and does not take into account group behavior (11).  Abstinence-only sex education fails to take into account the extent to which teens are influenced by their peers, and are likely to emulate their behavior.  One study found that 1 and 3 boys between the ages of 15 and 19 feel pressured to have sex.  The same study indicates that, while 63% of participants reported that waiting to have sex is a good idea, most participants did not wait (10).  As this study demonstrates, the pressure to conform to the social norms as outlined by one’s peers can be more powerful than the will to act in accordance with one’s own beliefs.   Social Expectations Theory posits that people take into account the expectations of others when engaging in human behaviors.  The social nature of human behavior is likened to a baseball team, where “If each player simply decided what he or she wanted to do and acted independently, few games would be won” (13).  One study of sexual behavior in South Africa, where AIDS is particularly rampant, found that peer pressure experienced by both sexes played a role in sexual activity.  These results illustrate the reality that peer pressure minimizes the efforts to educate youth on the delay of sexual activity and abstinence from sex, among other messages (12). 
            Another study gave participants the task of identifying which line, of three, was the identical line to another line in question.  A number of confederates would voice their answers in advance of the subject’s answer.  When the confederates noted that a clearly different-sized line was identical to the line in question, the subject emulated the responses of the confederates over one third of the time.  In the control condition, the subjects did not hear the answers of confederates before giving an answer, and answered correctly in essentially every instance (17).  Thus, even when the behavior in question is discordant with the subject’s beliefs, people will continue to emulate the behavior of others. 
            Abstinence-only sex education intervenes at the individual level without taking into account the social aspects of behavioral change, which, as the research indicates, is an important aspect of human conduct.  Abstinence-only education does “not acknowledge that many teenagers will become sexually active” (14).  Through not acknowledging the evidence that teens will have sex in general, Abstinence-only educators in turn ignore the reality that teens are likely to be influenced by others having sex.  Through the failure to take the former reality (the prevalence of teen sex) into account, the existing education program cannot address the aforementioned latter reality (teens’ inclination to emulate the behavior of their peers).  This is harmful, as a meaningful and effective intervention should address the reality that social interactions do play a meaningful and lasting role in determining human behavior.
Intervention – Comprehensive Sex Education through TV
            I propose that the intervention be changed in order to address these flaws.  While current sex education takes place in schools, sex-education would more effectively be built into the plot lines of popular, youth-based TV shows.  In fact, data have indicated that “the average American child consumes more than six hours of media each day, combining and often multi-tasking with television, the internet, video games…” (25).  As such, creating a television-based campaign to address the issues associated with sexual activity would be an effective way to infiltrate the homes and minds of young people.
            Under the proposed intervention, existing TV shows with high youth viewership would be paid to infiltrate certain messages into their plot lines.  The TV shows in the proposed intervention would feature characters aged 13-19. Comprehensive sex education would be provided to viewers in part through the dialogue between the characters.  Additionally, the characters on the TV shows would attend sex education classes, where information would be provided to the characters, and thus the viewers, in greater depth.  For instance, the characters may put condoms on bananas in these classes in order to demonstrate how condoms are used.  The characters would also receive information regarding the prevalence and transmission of STIs such as HIV/AIDS, herpes, Chlamydia, and gonorrhea.  Viewers would be informed of the negatives and positives of different methods of contraception, or lack there of, through the experiences of the characters.  While some characters would use contraception and avoid certain negative consequences such as pregnancy and the spread of STIs, other characters would opt not to use protection when having sex, and still others would opt not to have sex at all.  The experiences of the characters would be reflective of the decisions they make regarding sexual activity and their methods of contraception and STI protection. Characters that don’t use contraception effectively, or at all, would address the consequences on the TV show.  For instance, a character that doesn’t use condoms may become HIV positive and/or pregnant.  Viewers would see, first hand, the risks involved with making certain decisions regarding sexual activity. 
            The TV shows would exemplify characters that make an array of decisions regarding sexual activity.  One qualitative research finding is that participants reported having less ideal virginity-loss experiences than are displayed in popular movies (19).  The proposed intervention would not seek to idealize sexual initiation.  In contrast, the intervention would provide well-researched plot-lines, depicting the realistic results of teen decisions regarding sex.  
Intervention Address Flaw #1: Deflecting Reactance
            While abstinence-only education is likely to create reactance, the proposed intervention would avoid this phenomenon.  Studies have shown that people are less likely to exhibit psychological reactance when the messenger is more similar to the person being persuaded.  One study found that participants who reviewed persuasive texts were more likely to agree with a communicator who was indicated as being more similar to the subject, such as by sharing a birthday with the subject, than a communicator who did not share any similarities.  This held true in both low and high threat conditions (20).  The messengers in the proposed TV shows in this intervention would be teens.  The teen characters would be weighing decisions regarding contraception use and whether or not to have sex.  The target audience, also teens, would not be prone to exhibit psychological reactance, as that the messengers would be similar to them.  This differs from conventional, classroom based sex education, where the messenger is typically an older individual than the teens.
            The TV shows in this intervention would further avoid creating psychological reactance because viewers would be shown that there are a number of options that one can make regarding sexual activity.  No option would be restricted, as is the case in abstinence-only education.  Rather, the potential consequences of these decisions would be thoroughly outlined in plot lines.  As previously noted, psychological reactance stems from people feeling as if their freedom is threatened.  As such, restoring choice is a way to combat this psychological construct.  Studies have shown that psychological reactance can be lowered or avoided when people are given a choice.  For instance, one study found that subjects will be more compliant with medical treatment when they perceive choice within the treatment setting (21).  The proposed intervention would give young people the freedom to make their own informed choices regarding sexual activity.
Intervention Address Flaw #2 – Acknowledging that youth may have sex and preparing them for it
               Given the evidence that people do not accurately assess risk, it’s important to acknowledge the reality that people will likely engage in risky behavior.  One study found that smokers believe that 42% of smokers in general will develop lung cancer, which is far higher than the true percentage of smokers who actually get this type of cancer.  The same population of smokers, however, reported that their own risk of developing lung cancer as compared to the rest of the population is 29% (23).  This result is reflective of the aforementioned optimistic bias.   This finding indicates that, even when people are aware of the risks involved with certain behaviors, they are not likely to understand their own risk.  As this intervention plans to teach comprehensive sex education through the characters’ experiences, it will address this flaw in the existing abstinence-only education programs by preparing youth for the inevitability that not all teens will abstain from sex.  Characters will use and discuss different methods of birth control such as condoms.  The pros and cons of different types of contraception will be worked into the dialogue of the television campaign so that youth become cognizant of their options.  For instance, an episode could include a character debating whether or not to use an intrauterine device (UTI) or condoms.  While the effectiveness of pregnancy prevention could be outlined for UTI use, the lack of prevention of STIs would be made evident to viewers, as well.
                        It has been documented that comprehensive sex education has resulted in declined rates of STIs and pregnancy, delayed sexual initiation, and increased use of contraceptives (22).  These results have been replicated in a number of trials.  For instance, a study found that group based comprehensive sex education “was found to be an effective strategy to reduce adolescent pregnancy, HIV, and STIs” (26).  Comprehensive sex education programs work because they acknowledge the reality that teens will often not entirely abstain from sex.  As humans do not always accurately understand the risk of certain behaviors to themselves, comprehensive sex education will provide young people with the tools to protect themselves if and when they do engage in sexual behavior.  
Intervention Address Flaw #3 – Shaping Social Expectations
                        The proposed intervention will address social change at a group level rather than an individual level.  As Social Expectations Theory dictates, people’s behavior is dictated by the expectations of others.  In one experiment that supports this theory, participants were asked what they felt the most important problem was for the country.  Participants were given five choices.  When participants were asked this question privately, only 12% responded to indicate that “subversive activities” were the leading threat to the country.  However, when asked in a group setting in which all other members of the group indicated that “subversive activities” were the biggest threat to the country, a whopping 48 percent of participants gave the same response (17).  As this study indicates, humans will conform.  Addressing this reality is important in designing an intervention.  Humans are likely to have their opinions, and thus, actions, shaped others.
                        Research has shown the television shows have been shown to shape societal attitudes.  In one such instance, British television shows, which make reference to the class-system on a regular basis, are noted as having influenced social attitudes regarding the class system in Slovakia once British television became popular in the country (24).  The proposed intervention would create television shows that would shape societal attitudes toward sexual behaviors, and certain behaviors would be normalized through this intervention, such as condom use.  In the proposed intervention, characters would typically use birth control and other forms of protection when they have sex.  As discussed previously, if the characters don’t use a condom, the negative results associated with this risky behavior would also be readily apparent.  One such example might be the characters’ contraction of HIV/AIDS.    In turn, young viewers would try to conform to the social expectations as dictated by this intervention.
Abstinence-only sex education in an unrealistic attempt to address sex with young people and should be replaced for a more progressive, group-based intervention.  Abstinence-only sex education creates psychological reactance in youth, makes inaccurate assumptions regarding one’s ability to accurately assess risk, and fails to address the issue at a group level.  In contrast, the proposed intervention addresses these flaws and is the superior campaign.  The more traditional models of sex education must be replaced with far-reaching campaigns that would prevent psychological reactance, provide youth with the tools and education needed to prevent pregnancy and the transmission of STIs, and alter social expectations.  The proposed television intervention will achieve these goals and create a realistic way for youth to understand their choices regarding sexual behavior through a compelling and enjoyable medium.

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