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, “Power2Talk.org”, 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.

Conclusion

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.

References

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The United States Government Should Stop Funding Abstinence Only Programs, Particularly the Choosing the Best Programs – Jen Jorgensen

Introduction

            In the United States, teen pregnancy and the rates of sexually transmitted infections among young persons aged 15-24 years remain as two important public health problems.  Although the teen birth rate has been on a general decline especially over the last several years, the rate remains high at 34.4 births per 1,000 (1).  This rate keeps U.S. teen birth rate as one of the highest rates among other industrialized nations (2).  Teen birth rates vary significantly across states (3) with rates highest in the South and Southeast (4).  Furthermore, disparities continue to exist as the teen birth rates for Hispanic and non-Hispanic black teenagers remain more than double that of white teenagers (3,5).  Fifty-nine percent of pregnancies in 15-19 year–olds in 2008 ended in birth and 26% in abortion (5).  Based on these statistics, there is not doubt that teen pregnancy remains as a public health problem especially when considering the elevated health risks for teen mothers and their infants.

            Similar to teen birth rates, rates of sexually transmitted infections (STIs) among U.S. adolescents are higher than in most other industrialized countries (6).  Despite accounting for only 25% of the sexually experienced population, young people aged 15-24 years will acquire nearly 50% (9.1 million) of the 18.9 million new cases of STIs each year (7).  Unlike teen pregnancy, the rates of STIs, particularly Chlamydia, gonorrhea, and syphilis, have increased in this population over the past several years (8).   Sexually transmitted infections not only have reproductive health sequelae, but they also affect the psychological health of those infected and present considerable economic burdens.  In light of these high rates and associated risks, the prevention of STIs among adolescents and young adults is an imperative public health matter.

            In attempts to reduce teen pregnancy rates and STIs rates among adolescents, U.S. public schools have instituted sex education programs.  Until recently, most programs used were those that taught abstinence-only and in fact many states mandate abstinence-only sex education for schools holding the belief that sex education including safe sexual practices sends a mixed message to students and promotes sexual activity (9).   The U.S. Federal Government, seemingly agreeing with this view, promoted abstinence-only education by placing restrictions and regulations of federal funding that allowed only for abstinence-only programs; specifically the government began several initiatives such as the Title V, Section 510 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (10).  When the federal funds for abstinence-only education expired in June 2009 and Congress approved a new evidenced-based Teen Pregnancy Prevention Initiative, advocates for removal of abstinence-only education began to think the federal government was finally moving in the right direction.  However, despite the overwhelming evidence that abstinence-only education programs are ineffective (11,12), the funding was restored and increased to include a mandatory $250 million abstinence-only fund in September of 2009, through an amendment of the Senate Finance Committee’s health-reform legislation (13).

            This paper will critically examine one of the most widely used sets of abstinence-only sex education programs, Choosing the Best.  We will examine three aspects of the program that will help to explain why this program is ineffective; many of the arguments we will make can be extrapolated to other programs and will also explain why the federal government should stop wasting taxpayer money on hopeless programs.   Next, we will provide alternatives and possible solutions for each aspect based on social behavior theories and prior research. 

Choosing the Best Programs

            Choosing the Best offers abstinence-centered sex education curricula through 3 different middle school programs for grades 6-8 and two high school programs for grades 9-10 and 11-12.  Each program consists of video vignettes, real life case studies, role-plays, interactive exercises and small-group discussions.  Discussions are lead by teachers. Programs range from 5 to 8 lessons long; a teacher using the provided materials conducts each lesson.   According to the founders, Choosing the Best programs are based on three learning theories: experiential learning theory, social learning theory and cognitive learning theory.  This paper will focus on the program for 8^th grade, Choosing the Best LIFE.  This is an 8-session curriculum that “helps communicate, dynamically and positively, the value of committing to abstinence.” The videos are intended to lead naturally to a discussion lead by the classroom teacher (14).

Criticism 1: Telling adolescents they should remain abstinent invokes reactance and leads to the opposite behavior

            The theory of psychological reactance posits that people have a set of actions or free behaviors that they are aware of, believe they have the ability to perform and feel they can engage in at the moment or in the future (15).  The ability to engage in sexual activity is one such free behavior for adolescents and adults alike.  If a person believes that a freedom is threatened, he will experience reactance, a motivational state aimed at restoring the threatened freedom, as a combination of anger and negative cognitions directed at the offending stimulus and/or it’s source (15, 16, 17).  When formulating the theory, Brehm observed that free behaviors could vary in significance and importance. Therefore, he hypothesized that the strength of psychological reactance is a function of the degree of threat directed at the perceived freedom and the level of importance that an individual assigns to the particular freedom (15).  By telling adolescents they must remain abstinent, Choosing the Best LIFE program is invoking psychological reactance.  Furthermore, the psychological reactance is likely to be extremely strong for two reasons: psychological reactance peaks during adolescence (18) and more importantly, freedom of sexual choices is highly valued among adolescents. 

            The theory of psychological reactance states that individuals experiencing reactance are motivated to restore their threatened freedom by performing the forbidden behavior or by resisting the behavior being advocated, a “boomerang effect” (19).  Not only are adolescents going to react with anger and negative perceptions to the abstinence-only message of the Choosing the Best LIFE, but also they will engage in the unwanted behavior, sex and completely reject abstinence.  The program does not address methods of safe sex, such as condom use; as a result, adolescents will engage in riskier sexual behavior when rebelling against the program to restore their freedom.  Psychological reactance has been shown to predict risky sexual behavior in young adults aged 18-25 (20); given that reactance peeks in adolescence, we can conjecture that reactance will also predict risky sexual behavior in adolescents.  Others have found that individuals will restore freedom through more indirect, vicarious forms such as performing an alternative but similar behavior to the one threatened or derogating the source (21).  Given this fact, adolescents may choose sexual activities, such as oral sex and mutual masturbation, other than sexual intercourse in order to rebel.  By not addressing these types of sexual activity as alternative options to sexual intercourse, Choosing the Best LIFE program may falsely lead adolescents to believe that there are no other options to sexual intercourse to quell their sexual urges.  Also, adolescents may think that there are no risks of sexually transmitted infections when engaging in these behaviors, as the program did not address them. 

Criticism 2: Videos used by the program focus on negative consequences of engaging in sexual activity

            An essential tool of the Choosing the Best LIFE is videos of teenagers or young adults discussing their experiences of the session’s topic; videos are described as focusing on the negative outcomes of sex.  For example, the “Sex, STDs and Honesty” session begins with a video that introduces students to the consequences of STDs, “Sex, Alcohol and Respect” session opens with a video of teens sharing their painful stories of mixing alcohol and sex and “Sex, Pregnancy, and Responsibility” focuses on a real-life teen couple’s struggles with unintended pregnancy.  This focus on negative consequences of sexual activity in flawed for two reasons. 

            First, by focusing on negative aspects the videos’ messages will instill fear and alarm in adolescents watching the video. Communication theory has found that using a fear-instilling message has the opposite effect of what it intends (22).  In other words, the receiver will be turned off from hearing the messages and accepting the content or advice.  When adolescents are watching the video discussing the struggles of unintended pregnancy, it is likely they will feel dread and in order to avoid that feeling, they will shut themselves off to hearing the underlying messages and advice.  The message of abstinence-only will not be received nor will any other advice the program has to offer.      Second, by focusing on the negative consequences of sexual intercourse, Choosing the Best LIFE is utilizing the Health Belief Model to change adolescents’ behavior.  According to the Health Belief Model (HBM), people examine their perceived susceptibility to a poor health outcome and the perceived severity of consequences.  Next, individuals weigh the benefits and risks of each option to rationally decide on which option is the best (22).  By examining the risks and negative consequences of sexual intercourse, the program is trying to provide students with information so that they may weigh the risks and logically choose abstinence. 

Reliance on the HBM to change adolescent sexual behavior is flawed for several reasons.  First, HBM assumes that all individuals highly value health (23).  Health is not as important to adolescents as is fitting in and being accepted by their peers.  Therefore, if their peers are engaging in sexual intercourse, adolescents are more likely to engage in sexual intercourse to fit in despite the potential risks.  Second, Choosing the Best LIFE relies on perceived susceptibility, as the HBM does, to push benefits and risks analysis to in favor of abstinence.  However, research of smokers has shown that people tend to rate their susceptibility of to disease lower than their peers’ susceptibility to disease (24).  People tend to over estimate the probability of good things happening to them while underestimating the probability that bad things will happen to them (25). 
Adolescents may watch the program’s videos thinking the whole time that will never happen to me and completely disregard the videos’ message.  Lastly, the HBM has been shown to poorly predict several behaviors such as sexual activities and addictive behaviors in which people often act irrationally.  HBM assumes that people act rationally; this is particularly not true with adolescents, as they often have not developed the cognitive ability to weigh risks and benefits.  

Criticism 3: Choosing the Best is incorrectly and ineffectively using Social Learning Theory

            According to their website, Choosing the Best LIFE utilizes social learning theory to develop the program’s tools and activities.  Unfortunately, they incorrectly and inefficiently implement the theory.  Social learning theory holds that there is an interactive triangle between individuals, their environment and their behavior and that modeling is an important component of the learning process (26).  Individuals observe a behavior taking place and then go out to adopt similar behavior, to simply put it.  One sessions of Choosing the Best LIFE is focused on choosing abstinence; again it begins with a video of teens sharing their reasons for choosing abstinence.  The video utilizes teens to provide peer role models that emulate the desired behavior.  An important factor in adopting modeled behavior is credibility of the model (27).  According to social learning theory, in order to be a credible role model the individual must have high status within the peer group (25).  The Choosing the Best LIFE abstinence video is using teens that are clearly not even in the peer group of the adolescents engaged in the program let along having high status within the group.  It is very possible that adolescents in the program might view these teens as unpopular or not cool.  Social learning theory states that in order to function as role models, adolescents would need to be able to observe peer role models practicing the healthy behavior (28).  If their peers are having sex, it is more likely that they will have sex regardless of watching a video with teens that choose to remain abstinent. 

            Furthermore, after watching the videos all discussions are led in some form by teachers.  To follow with social learning theory, the discussions should be led by adolescents within the group.  By using peers the program could reinforce the modeled behavior of abstinence from the video.  However, instead the program relies on teachers to facilitate discussion; adolescents will view the message as coming from their teacher and not a peer.  Anti-drug campaigns, such as D.A.R.E., have shown that using teachers led initiatives are ineffective (29).   Therefore, teacher led discussions on choosing abstinence are likely to be ineffective.

            Social learning theory is also used ineffectively when adolescents in the Choosing the Best LIFE program are asked to engage in role-play.  This role-play is meant to provide another model of behavior emulate as well as provide self-efficacy when making sexual behavior choices.  One may practice saying no to sex and it will likely be rather easy in a “cold” state, meaning a non-aroused state.  However, adolescents may find it difficult to use the skills learned in a “cold” state while in a sexually aroused or “hot” state.  In fact people in a “cold” state are more likely to believe they are in control of their behavior.  A study of sexual arousal found that men overestimate the degree to which they will be able to control their behavior (30).  By having adolescents engage in role-playing while in the cold state, Choosing the Best LIFE falsely leads adolescents to believe they will have greater control in the heat of the moment.  Replicating the intense feelings and sense of arousal at the time just before sexual behavior is difficult if not near impossible to do and is not appropriate for a school setting; therefore, role-playing may not be an effective way to increase abstinence among adolescents.

A Possible Solution: “Free to Be You”

            Aspects of social learning theory can be used to effectively teach sexual education to adolescents.  This paper will purpose a comprehensive sexual education program, Free to Be You, which incorporates aspects of social learning theory, social norms theory, and the sexual health model.  By using aspects of marketing theory, the program will extend outside of the classroom to a Free to Be You movement that promotes safe sex behavior and open discussion of sexuality and sex.  The ultimate goal of Free to Be You is to increase safe sex practices that would lead to decreased rates of teen pregnancy and sexual transmitted infections amongst adolescents.

            Prior to beginning, Free to Be You will conduct research be going into the field and interacting with adolescents.  Detailed information on the adolescent lifestyle, what they value and what they aim to achieve will be collected.  Data on the current sexual behaviors of adolescents will also be collected in order to establish current social norms.  It is commonly known that as soon to be adults, adolescents value autonomy and freedom; to start, Free To Be You will focus on these strong core values in its’ marketing campaign.  Lastly, observation of peer groups will help the program to identify peer-leaders and role models.

Defense 1: Comprehensive sexual education will provide adolescents with alternative sexual behaviors and using peers to discuss these behaviors will reduce psychological reactance

            As discussed, providing abstinence only education will lead adolescents to engaging in sexual intercourse or other sexual behaviors via attempts to restore their freedom and the “boomerang” effect.  As a comprehensive sexual education program, Free to Be You will present adolescents with information regarding several different types of sexual behaviors and safe ways to engage in those behaviors; this will include abstinence but will go far beyond that.  The sexual health model consists of ten components that are essential aspects of healthy human sexuality, many of which influence safe sex behaviors.  One component of the model focuses on normalizing masturbation and fantasy, which next to abstinence is the ultimate in safe sex (31). Free to Be You will incorporate this component to present adolescents with other safe ways to fulfill their sexual urges and desires.  By removing some of the stigma surrounding masturbation, masturbation can become a part of sexual behavior that can decrease the pressure to engage in sexual intercourse (31).   A study of African American women found a positive relationship between positive attitudes toward masturbation and positive attitudes toward condom use (31).  By presenting various sexual behaviors as different options, Free to Be You will provide adolescents with the ability to make their own choices and therefore, will evoke less psychological reactance as adolescents’ freedom and autonomy are not being threatened.

            Free to Be You may be perceived as telling adolescents what to do when making the point that condoms should be used during all sexual behaviors with penetration; adolescents may feel their freedom is being threatened and develop reactance as a result.  Studies have shown that people interpret threatening actions as less threatening when those actions come from similar people; in fact, similar people can persuade others to comply with a behavior even in the face of threats (32).  In order to decrease psychological reactance surrounding condom use, Free to Be You will use peer leaders, who use condoms themselves or understand the significance of using condoms, to lead discussions on the importance of condom use for safe sex (see defense 3 below for more on peer leaders).  Since these peer leaders will be adolescents themselves from the same school, adolescents in the program will feel very similar to and like the peer leaders and as a result, will be less threatened by messages to use condoms.

Defense #2: Focus on positive sexuality by creating a movement that adolescents will want to join

            Rather than focusing on the negative consequences that may result from sex, the Free to Be You will focus on the positive aspects of sexuality.  Two important components of the sexual health model are comfort in talking about sex and positive sexuality.  The model assumes that when people are more comfortable with their sexuality and can comfortably talk about sex they will be more able set appropriate boundaries for safer sex (31).  Free to Be You will focus on increasing adolescents’ comfort with discussing sex.  The program will encourage adolescents to explore and embrace their sexuality; this will encourage a positive view on different preferences rather than ignoring them as abstinence only programs do. The program will equip adolescents safe ways to explore their sexual desires that can lead to positive outcomes – such as mutual masturbation; this will help adolescents to realize that there is a way to satisfy their needs that does not have negative results.  By increasing adolescents’ comfort with speaking about sex and sexuality, Free to Be You will also increase their comfort with talking about safe sex boundaries.

Free to be You recognizes that adolescents may not value their health too highly and therefore, the health belief model may not be the best behavioral model to base the program on, as abstinence-only programs focusing on negative consequences are.  Adolescents strongly value autonomy, freedom and fitting in with social circles.  Therefore, the program will combine aspects of social norms theory and marketing theory with the program’s positive view of sexuality.  Social norms theory states that adolescents’ sexual behavior is influenced by their perceptions of the sexual behaviors of their peers.  These perceptions are often misconstrued with over emphasis of risky sexual behavior (33).  Therefore, if adolescents believe that their peers are having sex, then they will engage in sex.  If they believe their peers are using condoms, then they too will use condoms.  Free to Be You will use its research to determine what the current social norms are of the adolescents taking part in the program.  These social norms will be used to create a movement via a media campaign that highlights the positive and safe sexual practices of adolescents.  For example, the campaign may use a poster saying x% of your friends are using condoms – Join them!  By focusing on what adolescents are currently do, Free to Be You will work to change adolescents’ misperceptions of the sexual behaviors of their peers. Also, the campaign will encourage adolescents to join the rest of their peers, something that they value.  Marketing theory states that individuals are more likely to use a product or become part of movement if it offers a brand that promises something that they value strongly (34).  By allowing adolescents to become more like their peers, Free to Be You appeals to adolescents’ desire to fit into social circles.  Furthermore, providing options from which adolescents can choose provides freedom and autonomy. 

A second aspect of the media campaign and movement will include an interactive website.  The website will contain the current social norms of the group focused on safe sex behaviors and encourage students to become part of the movement.  There will also be a blog portion that highlights stories of different adolescents in the program that chose safer sex behaviors.  The stories will mainly focus on the success of the adolescents and the autonomy they have in choosing what they do in and outside of school – for instance, one might be the quarterback on the football team, another the class president.  These stories will incorporate how the adolescent engages in safe sexual behaviors – or even how they might be waiting for the right person – and how those behaviors allow him to maintain his freedom.  Adolescents will then be encouraged to share their own positive stories and post questions to others.  The ultimate goal of the media campaign is create a brand, Free to Be You, that is all about freedom of choice when it comes to safe sex practices.

Defense #3: Free to Be You will use social learning theory effectively by using credible role models as peer educators and leaders of the movement

            Social learning theory can be applied to sexual education by using peer educators to serve as role models.  Peer educators can talk about how they use condoms and other ways they practice safe sex becoming role models for others.  It is important that these peer educators be credible among their peer group as asserted by Social Learning Theory (26).  Free to Be You will observe the social dynamics of the adolescents who will partake in the program to identify and recruit individuals with a high status in the peer group; this will ensure that credible role models are obtained.  Prior studies have shown that popular-opinion leaders in communities were effective peer leaders because of their status within the community (28).  Similarly, Free to Be You believes that these high status individuals will be effective peer educators.  Also, by using peer educators from the adolescents’ actual social group it is more likely that these individuals will have similar or the same cultures as most other adolescents at a particular school. Cultural sensitivity is an important part of the sexual health model.  The sexual health model asserts that the cultural meaning of sexual behaviors should be taken into account because that meaning may drive unsafe or safe sex (31). Therefore, peer educators will help to incorporate specific cultural aspects of sexual behaviors into the program.

These high status individuals will be involved in the program from the beginning and will actually be the ones starting the Free to Be You movement.  They will be trained as peer educators and given the skills to speak about the current sexual practices and social norms of the group.  These individuals will be the initial stories featured on the blog portion of the website.  A flash mob of the school cafeteria done by the high status individuals will be used to raise awareness and start the movement.  The flash mob will dance and wear T-shirts with the movement name Free to Be You on it.  At the end, they will hold up posters with either facts of the current social norms (x% use condoms etc) or Free to Be You’s web address.

Conclusion 

            In closing, it is clear that abstinence-only sexual education programs are fraught with problems and challenges, only a few of which have been described here.  These programs do not adequately or effectively use behavioral theories to change the sexual behavior of adolescents.  The U.S. Federal Government should solely fund comprehensive sexual education programs and drop all funding for abstinence-only programs. Comprehensive sexual education programs that choose behavioral models applicable to sexual behavior and effectively incorporate those models do have the potential to significantly change the sexual behavior of adolescents.  Free to Be You as described here incorporates aspects of multiple behavioral models in order to develop a more encompassing program that promotes positive views of sexuality and safe sex.  It uses components of marketing theory to present the program in a way that is more inviting and attractive to adolescents.  Sexual education in the U.S. should move toward a similar program.

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