AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. October 2005, Volume 7, Number 10.

Op-Ed

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Teens Deserve More than Abstinence-Only Education

Adolescents should receive comprehensive sex education that includes information about both sexual abstinence and contraception.

Debra Hauser

Each and every day in the United States, some 10 000 teens contract a sexually transmitted disease [1], 2400 get pregnant [2], and, tragically, 55 contract human immunodeficiency virus (HIV) [3]. The reasons for these problems are complex and defy simplistic solutions. Yet, since 1998, the United States has spent over $1 billion in federal and state funds to support ineffective abstinence-only-until-marriage programs—programs that censor educators from providing life-saving information about the health benefits of contraception and condom use for sexually active youth. In fact, discussion of condom effectiveness within a federally funded abstinence-only-until-marriage program is restricted by federal regulation [4,5].

Support for Comprehensive Sex Education

The overly simplistic "just say no" approach to teens and sex is unrealistic and dangerous. Censoring vital information that young people need to protect their health endangers their lives. As early as September 2000, the Institute of Medicine (IOM), created by Congress to advise the nation on scientific issues, released a report calling on that very body "to eliminate requirements that public funds be used for abstinence-only education" [6]. The IOM further recommended "age-appropriate comprehensive sex education and condom availability programs in schools" to help young people reduce their risk of contracting HIV [6]. Later that same month, the Office of National AIDS Policy released a similar report, stating, "It is a matter of grave concern that there is such a large incentive to adopt unproven abstinence-only approaches. Effective programs identified to date provide information about safer sex, condoms, and contraception, in addition to encouraging abstinence" [3].

Further, the American Medical Association, American Academy of Pediatrics, Society for Adolescent Medicine, American College of Obstetricians and Gynecologists, and more than 100 other leading public health and medical institutions support a more comprehensive approach to sex education—one that includes information about both abstinence and contraception [7-11].

Concerns about Abstinence-only Education

Two recently released reports show the danger of abstinence-only programs. A 2004 report compiled at the request of Representative Henry A. Waxman (D-Calif.) found that 80 percent of the most popular curricula used by federally funded abstinence-only education programs distorts information about the effectiveness of contraceptives and condoms, misrepresents the risks of abortion, blurs religion and science, treats stereotypes about girls and boys as scientific fact, and contains basic scientific errors [12].

A report compiled by Advocates for Youth in 2004, further demonstrated the ineffectiveness of these programs [13]. Advocates reviewed all available evaluations of state-based abstinence-only programs and found that, of the 10 states with evaluations, few demonstrated any short-term benefits and none demonstrated any lasting, positive impact on young people's attitudes, intentions, or behaviors. A few programs showed mild success at improving attitudes and intentions to abstain. No program was able to demonstrate a positive impact on sexual behavior over time. Further, evaluations from Arizona and Ohio found that young people's attitudes and intentions to use contraception (or condoms) declined from pre- to post-test, indicating that abstinence-only programs may have a negative impact on young people's willingness to use contraception or condoms once they do become sexually active [14,15].

Recent evaluations of the impact of virginity pledges further demonstrate this potentially dangerous program effect. Studies published by Hannah Brückner and Peter Bearman indicate that taking a virginity pledge can help some young people to delay sexual initiation for up to 18 months. Once these young people break their pledge, however, they are less likely to use contraception or condoms, thus putting them at risk for unwanted pregnancy and HIV or other sexually transmitted diseases (STDs) [16,17].

Brückner and Bearman also found that, among sexually experienced youth, more than 88 percent of pledgers had broken their pledge and had sex before marriage. Once pledgers began to have sex, they had more partners in a shorter period of time and were less likely to use contraception or condoms than were their nonpledging peers. Rates of STDs among youth who had taken a virginity pledge varied little from rates among those who had never pledged. Further, data showed that among those who reported having only oral and anal sex, pledgers were over-represented, possibly to "keep their virginity intact" [19].

Health Benefits of Comprehensive Sex Education

For those concerned that teaching young people about contraception will induce them to have sex, research again is clear on this issue. Numerous reviews, including one by the IOM, found that programs that teach about both abstinence and contraception do not encourage sexual activity [6,18-20]. Further, the IOM report, No Time to Lose, concluded that programs that teach young people about abstinence and contraception demonstrate more success than do abstinence-only programs in delaying sexual activity among youth who have not had sex and at improving contraceptive use among teens when they do become sexually active [6]. Further, abstinence-only programs leave young people ill-equipped to make responsible decisions about sexual health or to provide informed consent for health care services.

Parents' Views

While some in Congress seem uncertain about the difference between educating young people to the importance of abstinence and limiting education to abstinence-only, parents are clear. A poll by the National Campaign to Prevent Teen Pregnancy shows that a majority of adults and teens support greater emphasis on encouraging teens both to not have sex and also to use contraception [21]. A national poll by the Kaiser Family Foundation further revealed that 85 percent of parents want schools to teach information about condoms and 90 percent want schools to teach about other forms of birth control [22]. An Advocates for Youth/SIECUS (Sexuality Information and Education Council of the United States) poll, conducted by Hickman-Brown Associates, indicated that 70 percent of adults oppose federal funding for abstinence-only-until-marriage education [23].

Lessons from Abroad

Despite almost 15 years of decline in the teen pregnancy rate (declines that began long before Congress started appropriating widespread funding for abstinence-only), the United States continues to have the highest rates of teenage pregnancy, birth, and abortion in the industrialized world and some of the highest rates of STDs [24-26]. The US has nearly 11 times the teen birth rate of the Netherlands, over 74 times the teen gonorrhea rate of France, and nearly 8 times the abortion rate of Germany [27,28]. Why are public health outcomes for teens so much better in these countries than in America? The answer is that these European countries have pragmatic, research-based policies and an open, honest approach to sex education in the home and at school [29-35]. Does all of this openness lead to promiscuity? To the contrary, European teens in these countries begin having sex at about the same time or later than do American teens. They also have fewer sexual partners and use contraception more consistently than do their American peers [36-38].

Ethical Considerations

Clearly, it is unethical to censor vital life-saving information from people who need it. Young people have the right to medically accurate, honest information about sex and sexual health. The American public wants a more comprehensive and realistic approach. Teens say they need more information about both abstinence and contraception [22]. Research shows that comprehensive sex education—education that includes information about both abstinence and contraception—is the most effective sex education for young people [39].

American teens deserve medically accurate, realistic, and honest information about sex. Anything less in the era of HIV and AIDS is not only naïve and misguided, but also irresponsible and dangerous.



References

  1. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives on Sexual & Reproductive Health. 2004;36:6-10.
  2. Alan Guttmacher Institute. US Teenage Pregnancy Statistics: Overall Trends, Trends by Race and Ethnicity and State-by-State Information. New York, NY: Alan Guttmacher Institute; 2004.
  3. Office of National AIDS Policy. Youth and HIV/AIDS 2000: A New American Agenda. Washington, DC: White House; 2000.
  4. Sexuality Information & Education Council of the United States. State Profiles: A Portrait of Sexuality Education and Abstinence-Only-Until-Marriage Programs in the States. Fiscal Year 2000 edition. New York, NY: SIECUS; 2004.
  5. Social Security Act. Pub L 104-193. Section 510(b).Title V.
  6. Committee on HIV Prevention Strategies in the United States, Institute of Medicine. No Time to Lose: Getting More from HIV Prevention. Washington, DC: National Academy Press; 2000.
  7. American Medical Association. House of Delegates. Resolution 834 (I-04). Abstinence-Only Education and Federally-Funded Community-Based Initiatives. Adopted December 2005. Available at: http://www.ama-assn.org/meetings/public/interim04/resolutions.pdf. Accessed September 2, 2005. American Medical Association Health Policy. Sexuality Education, Abstinence, and Distribution of Condoms in Schools. H-170.968. Chicago, IL: AMA, 2004. Available at: http://www.ama-assn.org/apps/pf_new/pf_online? f_n=resultLink&doc=policyfiles/HnE/H-170.968.HTM&s_t=H+170.968 &catg=AMA/HnE&catg=AMA/BnGnC&catg=AMA/ DIR&&nth=1&&st_p=0&nth=1&. Accessed September 2, 2005.
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Debra Hauser is vice president of Advocates for Youth, Washington, DC, a nonprofit organization that helps young people make informed and responsible decisions about their reproductive and sexual health.

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