What is the current situation with abstinence education in the US?

Despite federal financial support the picture of what takes place in schools and colleges across the United States is difficult to piece together since most policies on sex education are decided at state level and even then school districts may enjoy a considerable degree of latitude to determine exactly what form provision takes within this policy context.

However, a survey in 1999 found that all school districts with a sex education policy required that abstinence be taught and around 4 in 5 required that it be promoted as the best option for young people. About 35% not only required abstinence to be covered but either did not allow discussion of contraceptives or allowed discussion only of their failure rates. The other 51% required that abstinence be taught as the preferred option, but also allowed discussion of contraception as an effective means of protection. Only 14% had a policy of teaching abstinence as part of a comprehensive programme.

Recent research has suggested that while overall abstinence education continues to grow in influence, some states are actively seeking to consolidate comprehensive provision. As of May 2007, ten states had chosen not to receive federal funding for abstinence education 62. New York followed suit in September 2007.

Which view is in the ascendancy?

There is no doubt that abstinence-based approaches have gathered political and financial support in the United States where they have become strongly associated with the moral and religious inclinations of the Republican Party and the Presidency of George W. Bush 54 55.

As a result, the current situation is that of the $1.5 billion spent on abstinence education since 1982 more than 80% has been spent under the current Presidency 56. Approximately $204 million was granted in the President's 2007 Budget to abstinence-only education programmes 57.

The bulk of this funding has been available annually since 1996 when an amendment to health and welfare legislation affecting support to families initiated an annual cycle of federal funding to abstinence education 58. From this point funding became available to states if they matched the Government grant with some money of their own. This money then became available to organisations through several funding strands if they agreed to use it for work that meets the following eight characteristics defining abstinence education as that which:

* Has as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity;
* Teaches abstinence from sexual activity outside marriage as the expected standard for all school-age children;
* Teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;
* Teaches that a mutually faithful, monogamous heterosexual relationship in the context of marriage is the expected standard of human sexual activity;
* Teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects;
* Teaches that bearing children out of wedlock is likely to have harmful consequences for the child, the child's parents, and society;
* Teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and
* Teaches the importance of attaining self-sufficiency before engaging in sexual activity.

The situation is the UK is rather different in that abstinence education has no support in public policy and receives no funding from government, although there is an expectation that sex educators in schools will emphasise the potential benefits of delaying or abstaining from sexual activity alongside providing information about contraception, sexual health services, sexuality and gender issues 59.

So can we decide whether one approach is better than the other?

It is very important to note that debates about research into the effectiveness of different types of sex education, and criticisms of the extent to which programmes contain factual inaccuracies and are guilty of stereotyping, do not always represent objective attempts to weigh the evidence that these studies have produced. While the debate between supporters of both approaches has populated these areas of difference it is not in pursuit of a resolution of their differences but rather a definitive answer that suits their moral agenda. There is no doubt that, whatever evidence is assembled, people who hold particular strong moral views are unlikely to give up supporting their preferred approach regardless of whether it works or whether someone else thinks it presents a distorted picture of the facts.

What is the difference in the content of abstinence-based and comprehensive programmes of sex education?

Another way in which the debate gets framed is in relation to differences in beliefs about what the 'real facts' are that young people should be presented with in the context of sex education. Many supporters of abstinence-based sex education say that comprehensive programmes are too positive about the protective potential of contraceptives and understate their failure rate and the risks of contracting HIV or another STI 37. In addition, they criticise programmes of comprehensive sex education for placing too little emphasis on abstinence and sending young people a mixed message by referring both to abstaining from or delaying when they first have sexual intercourse, and the benefits of using contraception.

Some reviews of abstinence -based programmes suggest factual inaccuracies.

For their part critics of abstinence-based programmes have said that they are too negative about the effectiveness of contraception and sometimes include inaccurate information about failure rates. Proponents of abstinence-based approaches have been accused of overstating condom failure rates, exaggerating the risks of infection with HIV and other STIs, reinforcing gender and sexuality stereotypes, and presenting sex and sexuality in an overly negative way.

The criticisms levelled against comprehensive programmes of sex education are difficult to sustain because research suggests that in practice many sex educators are very concerned not to present sex in too positive a light and tend to avoid coverage of sensitive and potentially embarrassing subjects like homosexuality and abortion. Young people consistently report that the underlying message is that they should not have sex. Moreover, much of the evidence for the ineffectiveness of condoms and other contraceptives cited by critics of comprehensive programmes is highly suspect, being based on poor quality research or the outcome of a partial reading of its results.

In contrast, those criticisms levelled at abstinence-based approaches do seem to have a firmer foundation. Some reviews of programme materials suggest factual inaccuracies - such as massively overestimating the prevalence of HIV and STIs and the failure rates of condoms when properly used - are common. These reviews have also shown that these programmes tend to project stereotypes about gender, repress information about positive aspects of sexual relationships, and overstate the emotional risks and dangers associated with sex.
Is it realistic to encourage abstinence until marriage?

The premise on which abstinence education is founded - that it is reasonable to wait until marriage before having sex for the first time and then be faithful to that one partner for life - may well be unrealistic for many young people because it fails to reflect the nature of modern, industrial societies in which people marry later in life, if at all. And with the high frequency of breakdown in marriage, people are very likely to have several sexual partners over their lifetime. Across the US, the UK and the rest of Europe data on sexual lifestyles consistently show that the age at which people first marry has risen to around 30 years old and that about a fifth of marriages end in divorce or separation within five years 50 51. Yet while the age at which people marry has risen, the age at which they first have sexual intercourse has been falling to around 16 years old, and a diminishing minority of people report that their first sexual partner was also their marriage partner.

But which method is best in sex education?

One of the ways in which the debate between supporters of abstinence and comprehensive approaches to sex education has been framed is in terms of which is the most effective.

Although at first glance the evidence can seem confusing, with claims coming from both groups about the proven effectiveness of programmes embodying their values, when only the most reliable studies are taken into account the position is clear 20. There is good evidence, from studies of programmes implemented in the US, UK and other European countries and countries in Africa and Asia 21 22 23 24 25 26 27 28, that comprehensive sex education can reduce behaviours that put young people at risk of HIV, STIs and unintended pregnancy. Studies have repeatedly shown too that this kind of sex education does not lead to the earlier onset of sexual activity among young people and, in some cases, will even lead to it happening later.

In contrast there is no such robust evidence for the effectiveness of abstinence education. Almost all the studies that have claimed to show any positive outcomes are not well-enough designed to sustain these claims 29 30 31 so it is not possible to infer whether they work or not from the research reports.
So, what does the research evidence show about the effects of abstinence-based approaches?

The research that is available currently shows at best mixed outcomes for abstinence-based approaches to sex education, benefiting some young people in the short term but placing them at greater risks later. For example, two studies suggest that for some young people making pledges to abstain from sexual intercourse until marriage does lead to delay in the timing of their first sexual intercourse. But these young people tend to hold strong religious beliefs and enjoy being an exclusive group among peers who do not take abstinence pledges. As the researchers note this means that pledging abstinence is not appropriate for young people who do not hold strong religious views and, moreover, if lots of young people are involved in making pledges (as using abstinence education as a method of sex education requires) the sense of being special will be dissipated 32. In addition, while an abstinence pledge may work for some groups of young people as a way of delaying when they have sexual intercourse, the majority still have sex before they are married and when they do they report using condoms less often than 'non-pledgers' and are more likely to substitute anal or oral sex for vaginal sexual intercourse 33 34.

In April 2007 a company called Mathematica Policy Research published the results of a Congressionally mandated evaluation of federally funded abstinence-based programmes in American schools 35. The investigation, which looked at four programmes offering a range of settings and strategies, found that rates of abstinence and unprotected sex in students who took part in the programmes were virtually identical to rates among students who had been randomly assigned to not take part. The ages at first sexual intercourse were also nearly identical, as were the numbers of sexual partners. It appears that the programmes had no impact on how the students behaved.

With regards to HIV prevention, a systematic review of all relevant studies 36, published in October 2007, concluded, "Evidence does not indicate that abstinence-only interventions effectively decrease or exacerbate HIV risk among participants in high-income countries; trials suggest that the programs are ineffective." Nevertheless the authors stressed the paucity of robust data and the need for more rigorous trials. They noted that most studies have been conducted among American youth, which may limit the generalisability of their findings.

So why is there so much disagreement in sex education?

Despite the similarities in some of the things that supporters of abstinence-based and comprehensive approaches believe about sex education and what it can achieve in terms of young people's sexual health, it is probably overly optimistic to think that it is possible to build consensus on a single approach. This is because these superficial similarities mask profound differences in the values and attitudes which inform the views of supporters of abstinence-based and comprehensive sex education.

Many supporters of abstinence-based sex education have a background in or connection to Christian organisations that have strong views about sex and sexuality. Not only do they often believe that sex should only take place in the context of marriage, but some are also opposed to same-sex relationships and abortion 10. As a result of the strong faith basis for their beliefs about sex, supporters of abstinence education see the main objective as being to equip (and encourage) young people to refuse or avoid sex altogether, and they may exclude from their programmes any other information that they believe conflicts with this view. This may result in an abstinence-only course failing to include basic information about what activities transmit HIV and how such transmission can be avoided.

As a result of the strong faith basis for their beliefs about sex, supporters of abstinence education see the main objective as being to equip (and encourage) young people to refuse or avoid sex.

Even where supporters of abstinence-based sex education disavow a strong religious basis for their beliefs about what young people should be taught, they often highlight issues about fidelity to one partner, and reject provision of information about steps young people can take to protect themselves against disease and unintended pregnancy because they argue that to do so sends a mixed message 11.

In contrast, most supporters of comprehensive sex education regard having sex and issues to do with sexuality as matters of personal choice that should not be dictated by religious or political dogmas. Working from an understanding of human rights, which means that people are entitled to access information about matters that affect them and the decisions that they make, they see sex education as being about providing young people with the means by which they can protect themselves against abuse and exploitation as well as unintended pregnancies, sexually transmitted diseases and HIV/AIDS 12 13 14 15. They argue that without access to information about all aspects of sex and sexuality making these decisions freely is impossible 16. While they think that is important that sex education is sensitive to faith issues, they assert that it should not be based on any set of specific religious values 17 18.

These fundamentally different views about sex and sexuality mean that supporters of abstinence-based and comprehensive approaches to sex education see the 'problem' of what to do about young people and sex quite differently and therefore reach quite different conclusions about the 'solution'. If, as supporters of comprehensive sex education tend to believe, the underlying premise of sexual health interventions is to meet social and utilitarian ideals then the solutions that are proposed are more likely to include earlier and more comprehensive sex education, more liberal abortion laws and freely available contraception. By contrast if, as supporters of abstinence-based approaches feel, the underlying motive has a strong religious dimension then the solutions are more likely to revolve around abstinence campaigns and be characterised by reluctance to promote contraception 19.

Can abstinence-based and comprehensive approaches to sex education be combined?

Some people have argued that is it possible to combine the main elements of both comprehensive and abstinence-based approaches to sex education in one approach. These people point out that supporters of both abstinence-based and comprehensive approaches share the view that sex education plays an important role in HIV prevention and both approaches emphasise the potential benefits of delaying having sexual intercourse in terms of helping young people avoid HIV, other STIs and unintended pregnancies. On the basis of this it has been argued that abstinence-based and comprehensive approaches can be reconciled into one inclusive approach which is sometimes called abstinence-plus

In abstinence-plus sex education, although the main emphasis is on abstaining from sex as the preferred choice of protection, young people are also provided with information about contraception and disease prevention so that they can protect themselves when they do become sexually active 6. Abstinence-plus approaches include programmes such as the Reducing the Risk and APAUSE (Added Power And Understanding in Sex Education) which have been developed in the US and UK, respectively 7 8 9. Both these programmes comprise school-based curricula which explicitly emphasise that students should avoid unprotected intercourse, either by not having sex or (for students who choose to have sex) by using contraceptives.