AMA Journal of Ethics^®

Today's kids are inundated with sex. There is nudity on the Internet, sex in the movies, and intimations of sex in popular music. All schools and teachers face the problem of how to help these kids grow into sexually healthy adults by encouraging safe behaviors without stepping on the toes of their parents. Two types of sex education programs have evolved in response to this challenge—abstinence-only sex education and abstinence-plus (sometimes called "comprehensive") sex education.

How the Curricula Differ

The 2 types of curricula share the same strong message: the only sure means of avoiding teenage pregnancy or sexually transmitted diseases (STDs) is abstinence. Where they differ is whether or not they include discussion of contraception. Joe McIlhaney, Jr, MD, of the Medical Institute for Sexual Health, is a prominent spokesman for abstinence-only programs. He explains that the only information these programs provide about contraception is its failure rates.¹ In the mind of an adolescent, critics say, this equates to saying about contraceptive devices, "they don't work, therefore don't use them." In most schools, though, abstinence-only education means "we definitely won't talk about contraception."

A Boom in Abstinence-only Programs

In 1996, President Bill Clinton signed into law the "welfare reform act," which appropriated $50 million in funds for school-based sex education programs that focused exclusively on abstinence as a means to prevent pregnancy and STD transmission. Since then, there has been an influx of published curricula as federal funding for abstinence-only education has shot up: $80 million in 2001, and $167 million in 2005. President Bush's proposed 2006 budget appropriates $206 million for these programs.² This is exciting news for most districts; it equates to free teaching materials. Yet any school choosing the "abstinence-plus" format will not receive any of this federal money.

Problems with Current Studies of Abstinence-only

After the initial funding boom many states instituted a variety of abstinence-only programs, prompting myriad studies to assess the effectiveness of the curricula. Advocates for Youth compiled evaluations from several states after the first 5-year funding cycle came to a close. Their conclusion was that the programs implemented showed "little evidence of sustained (long-term) impact on attitudes" toward sex.³ They also asserted that the evaluations showed "some negative impacts on youth's willingness to use contraception, including condoms." The curricula evaluated in the Advocates for Youth study, as well as other abstinence-only material, face a huge limitation: none has been around long enough to show evidence of success in delaying sexual initiation among youth.

A second problem in determining which format is more successful is that the 2 types of curricula are not being compared to each other in any studies. Dr. McIlhaney's studies publicize success with the abstinence-based programs, but typically the abstinence-only curricula are being compared to simple abstinence lectures.¹ Studies have found that 1 year later, students who experienced the curricula have a significantly better understanding of the importance of abstinence than students who received the lecture. That should go without saying.

States are saying "No" to abstinence-only curricula.

Douglas Kirby, PhD, an authority on abstinence-plus sex education, has reviewed research on a wide range of curricula. He identifies 10 common characteristics of effective sex education programs.⁴ My home state of Washington has chosen to base its Guidelines for Sexual Health Information and Disease Prevention on these distinctive attributes. Washington is one of many states that encourages its schools to adopt a more comprehensive approach to sex education and, in so doing, to forgo the federal funding available for implementing abstinence-only curricula. This particular subject area is the only one that is state-mandated; the law states that all schools shall provide "the minimum requisites for good health including the beneficial effect of physical exercise and methods to prevent exposure to and transmission of sexually transmitted diseases."⁵ The state further identifies guidelines for human immunodeficiency virus (HIV) education in The Acquired Immunodeficiency Syndrome (AIDS) Omnibus Act. This law requires that all students, beginning no later than the fifth grade, must receive education on the dangers of AIDS, its transmission, and its prevention.⁶ The state provides HIV education curricula for grade levels 5-12 and requires that school districts either use it or develop their own and get it approved for medical accuracy by the state Department of Health Office on HIV/AIDS.⁷

How a District Decides What to Teach

The number of different-but-really-the-same curricula available is overwhelming. Many districts decide to reuse a previously adopted health textbook (which may be from 2002 or may be from 1993, depending on appropriation of funds). There are also supplemental materials available from acne and feminine product companies; they provide fun, puberty-related materials with their corporate name plastered on them (a form of free advertisement). Some parents are uncomfortable having their children learn about sex in school, so most districts offer parents a way to "opt out" on behalf of their child. One district I worked in allowed a parent group to choose abstinence-only curricula and find community members to deliver it to students during the school day. Other districts leave it up to the individual schools to decide what to teach.

In my district, there is a small high school with a high pregnancy rate. The health teacher told me that, when he was hired, the principal gave him the health textbook and told him to teach whatever he wanted to—except for the parts about the reproductive system. That administrator's discomfort with the subject has contributed to life-changing events for many families in our community.

Tips for Physicians

Physicians can greatly assist in teaching sex education by helping parents out of their denial. I believe that at each yearly physical exam during the adolescent years the physician should hand the parent a brochure about sex: how to talk about it, the rates of sexual behaviors based on age, and possible warning signs of sexual activity. Simply having such materials on a stand in the lobby does not help. No child wants to be seen with a parent who picks up that brochure, and not all parents realize they need to have that conversation with their child. If the physician sends a message to the parent with the kid present, no one can hide the elephant in the room.

What I Have Seen as a Teacher

Some of the abstinence-only studies show promising findings when, one year later, middle school students still have positive attitudes about remaining abstinent.⁸ What they don't have are the responses from these same kids when they are juniors in high school. As the pressures to be sexually active increase, attitudes change. I have had discussions with quite a few middle school kids who believe they are safe because they are "virgins." What they fail to understand, and what must be taught to them and their parents as early as the 8th grade is that you don't have to have sexual intercourse to be infected by an STD. Every time I teach about STDs to a new group of 8th graders, I see looks of fear upon the faces of some of the girls. These looks give them away.

Today's kids are having sex. We cannot control the sexual pressures they face, but we can shape their response to those pressures. We can do so by providing them with factual information about the transmission, progression, and prevention of sexually transmitted diseases. Their bodies are being run by that drill sergeant of a pituitary gland, and the hormones are completely in charge. If we don't fit in a few facts about the risks of following the sexual desire portion of these hormones, then we are doing a great disservice to these children and to our society.