Ineffective, but still prominent: Abstinence-only sex education

Abstinence-only education is not only ineffective, it’s a violation of adolescent rights, according to a new position statement from the Society for Adolescent Health and Medicine.

“People think that this program ended somehow and it really hasn’t,” says John S Santelli, MD, MPH, of the Heilbrunn Department of Population and Family Health and the Mailman School of Public Health at Columbia University in New York, New York, and one of the authors of the position statement. “It’s pretty apparent that the adolescent doesn’t want to deal with these issues sometimes, a parent doesn’t want to deal with it, and the pediatrician doesn’t to deal with it. However, it doesn’t go away. The pediatrician is a good moderator.”

In an overall review accompanying the position paper in the Journal of Adolescent Health titled, “Abstinence-Only-Until-Marriage: An Updated Review of U.S. Policies and Programs and Their Impact,” Santelli and his colleagues detail the history and impact of abstinence-only education, concluding that these program are ineffective, violate adolescent rights, stigmatize and exclude some teenagers and adolescents, and reinforce harmful gender stereotypes.

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The emergence of sexuality is a hallmark of the adolescent years, and while abstinence is a healthy choice, abstinence-only education has been widely rejected by medical and public health experts, the paper notes. Age at first marriage is rising, and abstinence until that point, while a noble effort, often fails to be a realistic goal. Without education on safe sexual practices, adolescents who are only given information on abstinence may be left without the vital information they need to protect their health.

The paper reveals that a 2007 review of 13 abstinence-only education programs found no impact on sexual initiation, frequency of sexual relations, number of sexual partners, condom use, or the frequency of unprotected sex. Another 2016 review referenced in the paper also concluded that abstinence-only education did not result in positive changes in sexual activity or high-risk sexual behaviors.

“Abstinence from sexual intercourse has been described as ‘the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases (STDs), and other associated health problems’ in the Section 510 Title V federal definition,” the study authors note. “This is a misleading and potentially harmful message that conflates

theoretical effectiveness of intentions to remain abstinent and the actual practice of abstinence. Abstinence is often not effective in preventing pregnancy or sexually transmitted infections as many young people who intend to practice abstinence fail to do so.”

Despite this evidence, some parts of the country still embrace abstinence-only education. The percentage of schools requiring comprehensive sexual education fell from 67% in 2000 to 48% in 2014 and instruction on human immunodeficiency virus (HIV) prevention fell from 64% to 41% in the same period. In comparison, the study notes that 50% of middle schools and 76% of high schools were teaching abstinence as the primary way to avoid pregnancy and STDs as of 2014. Just 23% of middle schools and 61% of high schools gave instruction on birth control methods, and 10% of middle schools and 35% of high schools taught students about proper condom use.

The study also references data from the National Survey of Family Growth, which tracked sexual education between 1995 and 2013. It revealed that 80% to 90% of teenagers aged 15 to 19 years reported receiving education on “how to say no to sex.” In comparison, as of 1995, 81% of males and 87% of females were educated on birth control but those numbers fell to 55% of males and 60% females by 2013. Meanwhile, the percentage of teenagers that received abstinence-only education with no instruction on other birth control methods increased from 8% to 28% among females and from 9% to 35% among males during the same period.

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This data highlight the need for the medical community to offer evidence-based education to patients, with specific principles outlined in the position statement. These include the assumption that teenagers have the right to accurate and complete information to protect their health and that abstinence can be a healthy choice but that the choice should be left to adolescents to decide for themselves. It recommends that teenagers be empowered to become partners in the development and implementation of sexual health programs, and that abstinence education be provided along with more comprehensive sexual and reproductive health education. All sexual education should be comprehensive and medically accurate without stereotypes or subjective opinions, the position paper notes. Healthcare providers, government agencies, and schools should promote the dissemination of accurate, evidence-based information without censorship and the authors assert that government programs that fund or promote abstinence-only education are unethical and should be abandoned.

Abstinence-only education is particularly prominent in the South and in more conservative states, Santelli says. While pediatricians play a vital role in helping teenagers navigate their sexual development, it is particularly important in these regions, he says, adding this is part of the reason the academy drafted such a strong statement.

“Pediatricians have important roles in a couple of areas. We need to be talking about risks from sexual activity, risk of pregnancy and HIV, and STDs. This needs to begin early. We need to give them private time and talk to them about confidentiality,” Santelli says, adding that pediatricians see what can happen in the worst-case scenarios when teenagers and young adults aren’t provided with essential education, and it’s up to them to help teenagers and parents embark on conversations about safe sexual health.

“Pediatricians are particularly good at talking to parents. We sometimes don’t do as good a job at making that transition of the adolescent to the center of communication,” he says, adding healthcare providers should start talking to teenagers individually starting around age 12 or 13 years. “Parents really are a little nervous about what we’re going to do if we close the door and talk to the adolescent alone, but once they find out we share a lot of their values in terms of protecting their children and fostering health, those become great learning opportunities for everyone in the family. Pediatricians can be that catalyst to get that conversation going in the family.”