Abstinence and abstinence-only education: A review of U.S. policies and programs

doi:10.1016/j.jadohealth.2005.10.006

Journal of Adolescent Health

Volume 38, Issue 1, January 2006, Pages 72-81

https://doi.org/10.1016/j.jadohealth.2005.10.006 Get rights and content

Abstract

Abstinence from sexual intercourse is an important behavioral strategy for preventing human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), and pregnancy among adolescents. Many adolescents, including most younger adolescents, have not initiated sexual intercourse and many sexually experienced adolescents and young adults are abstinent for varying periods of time. There is broad support for abstinence as a necessary and appropriate part of sexuality education. Controversy arises when abstinence is provided to adolescents as a sole choice and where health information on other choices is restricted or misrepresented. Although abstinence is theoretically fully effective, in actual practice abstinence often fails to protect against pregnancy and STIs. Few Americans remain abstinent until marriage; many do not or cannot marry, and most initiate sexual intercourse and other sexual behaviors as adolescents. Although abstinence is a healthy behavioral option for teens, abstinence as a sole option for adolescents is scientifically and ethically problematic. A recent emphasis on abstinence-only programs and policies appears to be undermining more comprehensive sexuality education and other government-sponsored programs. We believe that abstinence-only education programs, as defined by federal funding requirements, are morally problematic, by withholding information and promoting questionable and inaccurate opinions. Abstinence-only programs threaten fundamental human rights to health, information, and life.

Section snippets

Methodology

We began with a literature search using Medline and Google Scholar but also collected publications and reports by communicating with a broad range of scientists and policymakers. We also actively monitored newspaper reports and internet list serves between January 2004 and July 2005 for the release of new studies or reports. Although we relied primarily on peer-reviewed sources for key scientific information, policy-relevant information and viewpoints about AOE are often available only from

Definitions of abstinence

Abstinence, as the term is used by program planners and policymakers, is often not clearly defined. Abstinence may be defined in behavioral terms, such as “postponing sex” or “never had vaginal sex,” or refraining from further sexual intercourse if sexually experienced, i.e., ever had sexual intercourse. Other sexual behaviors may or may not be considered within the definition of “abstinence,” including touching, kissing, mutual masturbation, oral sex, and anal sex. Self-identified “virgins”

Initiation of sexual intercourse and marriage

Although abstinence until marriage is the goal of many abstinence policies and programs, few Americans wait until marriage to initiate sexual intercourse. Most Americans initiate sexual intercourse during their adolescent years. Recent data indicate that the median age at first intercourse for women was 17.4 years, whereas the median age at first marriage was 25.3 years [4], [5] (Figure 1). In 1970, the time between first intercourse and first marriage was considerably shorter. For men in 2002,

Physical and psychological health outcomes for adolescent sexual behaviors

Initiation of sexual intercourse in adolescence is accompanied by considerable risk of STIs and pregnancy. Adolescents have the highest age-specific risk for many STIs [6], and the highest age-specific proportion of unintended pregnancy in the United States [7]. The United States continues to lead the developed world in adolescent pregnancy rates [4]. Over 800,000 adolescents become pregnant each year, 80% of these pregnancies are unintended, and many of these end in abortion [8]. An estimated

Public support for abstinence and comprehensive sexuality education

Public opinion polls suggest strong support for abstinence as a behavioral goal for adolescents [29], [30]. These polls also indicate strong support for education about contraception and for access to contraception for sexually active adolescents.

Data from a recent nationwide poll of middle school and high school parents found overwhelming support for sex education in school; 90% believed it was very or somewhat important that sex education be taught in school, whereas 7% of parents did not

Current federal policy and local programs

Although the federal government began supporting abstinence promotion programs in 1981 via the Adolescent Family Life Act (AFLA), since 1996 there have been major expansions in federal support for abstinence programming and a shift to funding programs that teach only abstinence and restrict other information [31], [32], [33]. These expansions include Section 510 of the Social Security Act in 1996, which was part of welfare reform, and Community-Based Abstinence Education projects in 2000,

Evaluations of abstinence-only education and comprehensive sexuality education programs in promoting abstinence

To demonstrate efficacy, evaluations of specific abstinence promotion programs must address methodological issues including (1) clear definitions of abstinence (as discussed above), (2) appropriate research design, (3) measurement issues including social desirability bias, and (4) the use of behavior changes as outcomes [38]. Evaluations should also consider the use of biological outcomes such as STIs, in addition to behavioral measures. Experimental and quasi-experimental research designs can

Concepts of efficacy for abstinence in preventing pregnancy and STIs

Abstinence from sexual intercourse has been described as fully protective against pregnancy and sexually transmitted infections. This is misleading and potentially harmful because it conflates theoretical effectiveness with the actual practice of abstinence. Abstinence is not 100% effective in preventing pregnancy or STIs as many teens fail in remaining abstinent. Moreover, some STIs may be spread via other forms of sexual activity, such as kissing or manual or oral stimulation. In addition to

Impact of abstinence-only policies on comprehensive sexuality education

Health professionals, who often encounter patients who lack basic information about human sexuality, have strongly supported comprehensive sexuality education, including information about contraception and STI prevention [53], [54], [55].

Although comprehensive sexuality education is broadly supported by health professionals, increasingly, abstinence-only education is replacing more comprehensive forms of sexuality education. In Texas, for example, the Texas Board of Education has decided to

Impact of federal abstinence policies on pregnancy and HIV prevention programs

Federal and state governments provide support for family planning programs, which are available to adolescents through Title X of the Public Health Service Act. Title X program guidelines stress that abstinence should be discussed with all adolescent clients. Starting in the FY 2004 service delivery grant announcements, Office of Population Affairs announced that program priorities for Title X grantees would include a focus on extramarital abstinence education and counseling, increasing

Abstinence-only education and sexually active youth

Programs geared to adolescents who have not yet engaged in coitus systematically ignore sexually experienced adolescents, a group with specific reproductive health needs and who often require more than abstinence education [67]. Sexually experienced teens need access to complete and accurate information about contraception, legal rights to health care, and ways to access reproductive health services, none of which are provided in abstinence-only programs.

Abstinence-only education and GLBTQ youth

Abstinence-only sex education may have profoundly negative impacts on the well-being of gay, lesbian, bisexual, transgender and questioning (GLBTQ) youth. An estimated 2.5% of high school youth self-identify as gay, lesbian or bisexual, and more may be uncertain of their sexual orientation [68]. However, as many as 1 in 10 adolescents struggle with issues regarding sexual identity [69]. Abstinence-only sex education classes are unlikely to meet the health needs of GLBTQ youth, as they largely

The human right to sexual health information

Paradoxically, although abstinence is often presented as the moral choice for adolescents, we believe that the current federal approach focusing on AOE raises serious ethical and human rights concerns. Access to complete and accurate HIV/AIDS and sexual health information has been recognized as a basic human right and essential to realizing the human right to the highest attainable standard of health [73]. Governments have an obligation to provide accurate information to their citizens and

Ethical obligations of health care providers and health educators

We believe that patients have rights to accurate and complete information from their health care professionals and that health care providers have ethical obligations to provide accurate health information. Health care providers may not withhold information from a patient in order to influence their health care choices. Such ethical obligations are part of respect for persons [81] and are operationalized via the process of providing informed consent. Informed consent requires provision of all

Summary and authors’ commentary

Although abstinence from sexual intercourse represents a healthy behavioral choice for adolescents, policies or programs offering “abstinence only” or “abstinence until marriage” as a single option for adolescents are scientifically and ethically flawed. Although abstinence from vaginal and anal intercourse is theoretically fully protective against pregnancy and disease, in actual practice, abstinence-only programs often fail to prevent these outcomes. Although federal support of

Acknowledgments

We would like to thank the following people for their insightful comments on early drafts of this review article: Sarah Brown, Jonathan Cohen, Cynthia Dailard, Jennifer Hirsch, Barbara Huberman, Doug Kirby, Rona Peligal, Vaughn Rickert, and Tony Tate.

References (81)

R.F. Anda et al.
Adverse childhood experiences and risk of paternity in teen pregnancy
Obstet Gynecol
(2002)
V.I. Rickert et al.
The relationship among demographics, reproductive characteristics, and intimate partner violence
Am J Obstet Gynecol
(2002)
R. Haskins et al.
Abstinence education and welfare reform
Child Youth Serv Rev
(1997)
H. Bruckner et al.
After the Promisethe STD consequences of adolescent virginity pledges
J Adolesc Health
(2005)
C.D. Brindis et al.
Adolescents, health policy, and the American political process
J Adolesc Health
(2002)
M.A. Schuster et al.
The sexual practices of adolescent virginsgenital sexual activities of high school students who have never had vaginal intercourse
Am J Public Health
(1996)
P. Goodson et al.
Defining abstinenceviews of directors, instructors, and participants in abstinence-only-until-marriage programs in Texas
J Sch Health
(2003)
Social Security Act: Title V: Maternal and Child Health Services Block Grant. Separate Program for Abstinence Education
(2005)
J. Abma et al.
Teenagers in the United Statessexual activity, contraceptive use, and childbearing, 2002
Vital Health Stat 23
(2004)
J. Fields
America’s Families and Living Arrangements2003
(2004)

Sexually Transmitted Disease Surveillance, 2003

(2004)

The Best IntentionsUnintended Pregnancy and the Well-Being of Children and Families

(1995)

S.K. Henshaw

U.S. Teenager Pregnancy Statistics with Comparative Statistics for Women Aged 20–24

(2004)

H. Weinstock et al.

Sexually transmitted diseases among American youthincidence and prevalence estimates, 2000

Perspect Sex Reprod Health

(2004)

P. Donovan

Testing PositiveSexually Transmitted Disease and the Public Health Response

(1993)

J.W. Curran et al.

Epidemiology of HIV infection and AIDS in the United States

Science

(1988)

P.S. Rosenberg

Scope of the AIDS epidemic in the United States

Science

(1995)

Youth & HIV/AIDSAn American Agenda

(1996)

L.A. Valleroy et al.

HIV prevalence and associated risks in young men who have sex with men

JAMA

(2000)

Heterosexual Transmission of HIV—29 states, 1999–2002

MMWR

(2004)

Sex and America’s Teenagers

(1994)

US House of Representatives, Committee on Ways and Means, Democrats. Steep decline in teen birth rate significantly...

M.A. Koenig et al.

Coerced first intercourse and reproductive health among adolescent women in Rakai, Uganda

Int Fam Plan Perspect

(2004)

Y.W. Chen et al.

Mental health, social environment, and sexual risk behaviors of adolescent service usersa gender comparison

J Child Fam Stud

(1997)

L.F. Woodward et al.

Early conduct problems and later risk of teenage pregnancy in girls

Dev Psychol

(1999)

N.E. Adler et al.

Psychological factors in abortiona review

Am Psychol

(1992)

N.E. Adler et al.

Abortion among adolescents

Am Psychol

(2003)

L.S. Zabin et al.

When urban adolescents choose abortioneffects on education, psychological status, and subsequent pregnancy

Fam Plann Perspect

(1989)

W.J. Quinton et al.

Adolescents and abortionare minors at greater risk?

Psychol Public Policy Law

(2001)

J. Chang et al.

Pregnancy-related mortality surveillance—United States, 1991–1999

MMWR

(2003)

L.T. Strauss et al.

Abortion surveillance—United States, 2001

MMWR

(2004)

B. Albert

American Opinion on Teen Pregnancy and Related Issues 2003

(2004)

C. Dailard

Sex educationpoliticians, parents, teachers and teens

Issues Brief (Alan Guttmacher Inst)

(2001)

Solomon-Fears C. Reducing teen pregnancy: adolescent family life and abstinence education programs. Congressional...

C. Dailard

Abstinence promotion and teen family planningthe misguided drive for equal funding

The Guttmacher Report on Public Policy

(2002)

Carrier P. Maine turns down sex-ed funds. Portland Herald Press. September 20, 2005 [cited 2005 Sep 28]. Available...

The content of federally funded abstinence-only education programs

(2004)

Republican Study Committee. Federal abstinence programs: policy brief 2003 [cited 2005 Jul 29]. Available from:...

Administration for Children of Families. Fiscal Year 2005 Abstinence Education Formula Grant Program (Section 510) to...

T.E. Smith et al.

Measurement in abstinence education. Critique and recommendations

Eval Health Prof

(2003)

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Review articleAbstinence and abstinence-only education: A review of U.S. policies and programs

Abstract

Section snippets

Methodology

Definitions of abstinence

Initiation of sexual intercourse and marriage

Physical and psychological health outcomes for adolescent sexual behaviors

Public support for abstinence and comprehensive sexuality education

Current federal policy and local programs

Evaluations of abstinence-only education and comprehensive sexuality education programs in promoting abstinence

Concepts of efficacy for abstinence in preventing pregnancy and STIs

Impact of abstinence-only policies on comprehensive sexuality education

Impact of federal abstinence policies on pregnancy and HIV prevention programs

Abstinence-only education and sexually active youth

Abstinence-only education and GLBTQ youth

The human right to sexual health information

Ethical obligations of health care providers and health educators

Summary and authors’ commentary

Acknowledgments

Obstet Gynecol

Am J Obstet Gynecol

Child Youth Serv Rev

J Adolesc Health

J Adolesc Health

The sexual practices of adolescent virginsgenital sexual activities of high school students who have never had vaginal intercourse

Am J Public Health

Defining abstinenceviews of directors, instructors, and participants in abstinence-only-until-marriage programs in Texas

J Sch Health

Social Security Act: Title V: Maternal and Child Health Services Block Grant. Separate Program for Abstinence Education

Teenagers in the United Statessexual activity, contraceptive use, and childbearing, 2002

Vital Health Stat 23

America’s Families and Living Arrangements2003

Sexually Transmitted Disease Surveillance, 2003

The Best IntentionsUnintended Pregnancy and the Well-Being of Children and Families

U.S. Teenager Pregnancy Statistics with Comparative Statistics for Women Aged 20–24

Sexually transmitted diseases among American youthincidence and prevalence estimates, 2000

Perspect Sex Reprod Health

Testing PositiveSexually Transmitted Disease and the Public Health Response

Epidemiology of HIV infection and AIDS in the United States

Science

Scope of the AIDS epidemic in the United States

Science

Youth & HIV/AIDSAn American Agenda

HIV prevalence and associated risks in young men who have sex with men

JAMA

Heterosexual Transmission of HIV—29 states, 1999–2002

MMWR

Sex and America’s Teenagers

Coerced first intercourse and reproductive health among adolescent women in Rakai, Uganda

Int Fam Plan Perspect

Mental health, social environment, and sexual risk behaviors of adolescent service usersa gender comparison

J Child Fam Stud

Early conduct problems and later risk of teenage pregnancy in girls

Dev Psychol

Psychological factors in abortiona review

Am Psychol

Abortion among adolescents

Am Psychol

When urban adolescents choose abortioneffects on education, psychological status, and subsequent pregnancy

Fam Plann Perspect

Adolescents and abortionare minors at greater risk?

Psychol Public Policy Law

Pregnancy-related mortality surveillance—United States, 1991–1999

MMWR

Abortion surveillance—United States, 2001

MMWR

American Opinion on Teen Pregnancy and Related Issues 2003

Sex educationpoliticians, parents, teachers and teens

Issues Brief (Alan Guttmacher Inst)

Abstinence promotion and teen family planningthe misguided drive for equal funding

The Guttmacher Report on Public Policy

The content of federally funded abstinence-only education programs

Measurement in abstinence education. Critique and recommendations

Eval Health Prof

Review article
Abstinence and abstinence-only education: A review of U.S. policies and programs