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Abstinence Sex Education
In recent years there has been discussion about what form sex education should take, and the advantages and disadvantages of adopting an abstinence based approach as an alternative to a more comprehensive approach. Despite recent changes in public policy within the United States which has seen a cessation of federal funding for abstinence only programmes of sex education,1 programmes of this kind continue in both the USA, other parts of the developed world and are even expanding in some of the countries most affected by HIV and AIDS because of funding made available through the PEPFAR (President's Emergency Plan For AIDS Relief) programme.2
What is an abstinence based approach to sex education?
An abstinence based approach to sex education focuses on teaching young people that abstaining from sex until marriage is the best means of ensuring that they avoid infection with HIV, other sexually transmitted infections and unintended pregnancy. As well as seeing abstinence from sex as the best option for maintaining sexual health, many supporters of abstinence based approaches to sex education also believe that it is morally wrong for people to have sex before they are married. Abstinence approaches are represented in programmes such as Aspire3 and True Love Waits 4 (both developed in the US), which aim to teach young people that they should commit to abstaining from sex until marriage.
Although not all abstinence education programmes are the same, they share the fundamental purpose of teaching the social, psychological, and health gains to be realised by abstaining from sexual activity. As such, abstinence education tends to include the following teaching objectives, which are derived from a definition given in Federal Law in the United States:5
- Abstinence from sexual activity outside marriage is the expected standard for all school age children
- Abstinence from sexual activity is the only certain way to avoid out of wedlock pregnancy, sexually transmitted diseases, and other associated health problems
- A mutually faithful, monogamous relationship in the context of marriage is the expected standard of sexual activity
- Sexual activity outside the context of marriage is likely to have harmful psychological and physical effects
- Bearing children out of wedlock is likely to have harmful consequences for the child, the child’s parents, and society
- How to reject sexual advances and that alcohol and drug use increases vulnerability to sexual advances
- The importance of attaining self sufficiency before engaging in sexual activity
How does this differ from comprehensive sex education?
The main difference between abstinence based and comprehensive approaches to sex education is that comprehensive approaches do not focus either solely or so closely on teaching young people that they should abstain from sex until they are married. Although comprehensive approaches do explain to young people the potential benefits of delaying having sex until they are emotionally and physically ready, they also make sure that they are taught how to protect themselves from infections and pregnancy when they do decide to have sex. In the UK, this approach has been taken by the organisation Apause, which includes the postponement of first intercourse as part of their wider school-based Sex and Relationships Education programme.6
Descriptions of what programmes of comprehensive sex education comprise are contained in guidelines produced by SIECUS (Sexuality Information and Education Council of the United States) and UNESCO.7
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.8
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.9 One example of an abstinence plus approach is the US developed Reducing the Risk.10 The RISK approach comprises of a 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.
So why is there so much disagreement?
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.
Moral and religious views
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.11 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.
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.12
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.13 14 15 16 They argue that without access to information about all aspects of sex and sexuality making these decisions freely is impossible.17 While they think that it is important that sex education is sensitive to faith issues, they assert that sex education should not be based on any set of specific religious values.18 19
Different ‘problem’, different ‘solution’
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.20
But which method of sex education is best?
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.21 There is good evidence, from reviews of studies and studies of programmes implemented in the US, UK and other European countries and countries in Africa and Asia, that comprehensive sex education can reduce behaviours that put young people at risk of HIV, STIs and unintended pregnancy.22 23 24 25 26 27 28 29 30 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.
“Studies have repeatedly shown that comprehensive sex education does not lead to earlier onset of sexual activity”
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 so it is not possible to infer whether they work or not from the research reports.31 32 33 Several academic reviews suggest that abstinence only programmes generally have no effects on young people’s sexual behaviour. In just a few cases abstinence only programmes may encourage young people to delay first sexual intercourse in the short-term. Worryingly, some of these studies also suggest that compared to other young people those who do receive abstinence only programmes may be less knowledgeable about STDs and less likely to believe that condoms provide effective protection against them.34 35
What does research 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.
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. 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.36 In addition, the majority of young people who take abstinence pledges 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.37 38
In April 2007 the results were published of a Congressionally mandated evaluation of federally funded abstinence based programmes in American schools.39 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 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."40 Nevertheless the authors stressed the lack 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.
Assessing the effectiveness of abstinence plus sex education programmes, in comparison to abstinence only programmes, is hampered by the lack of academic reviews. However, one recent and very robust review suggests that neither are very effective and that there are good grounds for believing that failure to provide young people with information about contraception prevents them from knowing about facts which have the greatest potential to protect them against pregnancy and STDs.41
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.42 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.43
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.44 45 46 47
The criticisms leveled 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.48 49 50 51 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.52
In contrast, those criticisms leveled 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.53 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.54
Is it realistic to encourage abstinence until marriage?
The premise on which abstinence based sex 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.55 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.56 57 Data on young people’s sexual lifestyles and behaviour from countries in the developing world where HIV is most prevalent also suggest that advice to abstain from sex until marriage may be wildly out of step with accepted cultural norms.
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.
Which view is in the ascendancy?
There is no doubt that abstinence based approaches gathered political and financial support in the United States during the early 2000s when they were strongly associated with the moral and religious inclinations of the Republican Party and the Presidency of George W. Bush.58 Indeed, more than 80% of the $1.5 billion spent on abstinence education since 1982 was spent under the Bush administration,59 with the 2007 budget granting approximately $204 million to abstinence only education programmes.60
However, the Obama administration has withdrawn Federal support for abstinence only programmes within the United States.61 The budget plans for 2010 have proposed that over $100 million will be directed to teenage pregnancy programmes which have been shown to be evidentially effective.62
The effect that the change in policy in the USA will have on sex education in countries severely effected by HIV and AIDS which receive funding via PEPFAR is not yet clear. When PEPFAR was reauthorised in 2008, the requirement that a third of funds allocated to HIV prevention be spent on abstinence only programmes was replaced with the requirement of a written report to Congress if less than a half of HIV prevention funds are spent on abstinence only sex education. Although the effects of this change in legislation remain to be seen, HIV and AIDS organisations have argued that it sustains a bias towards abstinence only programmes in countries which receive PEPFAR funding.
In the UK, 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.63
What is the current situation with abstinence based sex education in the US?
The impact of the radical shift in public policy in the United States away from abstinence based sex education is yet to be determined. However, the current position seems to be one in which abstinence education has become somewhat entrenched in some states.
A survey in 2009 found that while 21 states and the District of Columbia mandate that public schools teach sex education, many more spell out requirements on how the topics of abstinence and contraception should be dealt with in the context of any teaching. The survey found that in general there was a greater tendency to require that abstinence be stressed than that programmes cover contraception.64
In contrast to this trend, some states seem to have been actively engaged in consolidating comprehensive provision and an increasing number have chosen not to receive federal funding for abstinence based sex education.65
Is abstinence education supported by young people, parents and schools?
Surveys of teachers, parents and young people consistently show that abstinence based sex education has little widespread public support. State based studies, such as a survey of parents in North Carolina and another in Minnesota conducted in 2005 and 2006-7 respectively, show an overwhelming majority supporting the provision of sex education via schools and that it be comprehensive.66 67 These results support evidence gleaned in previous studies which have found overwhelming support for sex education in school and little local controversy about its provision and organisation within schools.68
In the UK an even greater proportion of parents and young people support comprehensive approaches to sex education.69 70 Young people want AIDS education in school and want to be informed of the facts that will enable them to make their own informed decisions.71 72
Why is the debate about abstinence education important in terms of HIV/AIDS prevention?
Globally, the greatest HIV and AIDS burden falls on young people. Sex education is recognised as a major component of HIV prevention targeting young people; what form it takes and whether or not it works impacts directly on the HIV risk to which they are exposed.73 74 75 AIDS education for young people is a crucial factor in determining the extent to which they are at risk of HIV infection.
With considerable amounts of money continuing to be dedicated to abstinence only programmes under the President's Emergency Plan For AIDS Relief, abstinence education is being promoted in some of the countries worst affected by HIV and AIDS. This raises a number of concerns about whether this is an appropriate approach in contexts where HIV is very prevalent and sexual intercourse before marriage is widespread, and, particularly, whether such programmes will withhold accurate information about condoms.
All the evidence clearly shows that the best way to progress HIV prevention through sex education is through comprehensive programmes. Despite generating considerable debate and political support, particularly in the United States, abstinence education represents, primarily, a minority moral movement rather than an effective response to the sexual health needs and behaviour of young people.
As the experiences around the world demonstrate - a good example of which can be found in Uganda - what works in terms of sex education for HIV prevention is a comprehensive approach that is sensitive to the needs and experiences of particular groups. For unmarried, sexually active young people abstinence messages are not effective, whereas promoting faithfulness to one partner, condom use and abstinence is effective. Abstinence messages work to some extent for younger sexually inactive people, but they need to have information about contraception and risk-reduction behaviour for when they do decide to have sex. Everyone has the right to the information that can enable them to protect themselves against HIV infection - it is neither Christian nor moral to refuse them.
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