Sexuality education in the United States is as American as apple pie—most adults support sexuality education in schools, especially middle and high schools. This support may stem from the broad recognition that teenage pregnancy and sexually transmitted diseases (STDs), including HIV, are major problems in this country and that schools can help reduce them.
If polls consistently document that adults overwhelmingly favor sexuality education, why is there so much controversy about sexuality education in schools? Although most adults agree that schools should teach sexuality education, the same adults disagree about which topics sexuality education should cover and which it should not.
A small but vocal number of adults insist that such programs should teach only abstinence, and sometimes abstinence until marriage. Proponents of abstinence-only sexuality education believe that any discussion of condoms or contraceptives should be brief and emphasize only the possibilities of their failure. Among school districts with a districtwide policy on sex education, about 35 percent only allow abstinence-only sexuality education (Landry, Kaeser, & Richards, 1999).
Most adults believe that schools should teach abstinence as the only completely effective method of protection against pregnancy and STDs, including HIV, but that schools should also discuss condoms and other contraceptives in a balanced and medically accurate manner. Such programs are often called abstinence-plus programs. In terms of policy, about two-thirds of the school districts that have districtwide policies allow abstinence-plus sexuality education, but a significant percentage has no districtwide policy at all. Therefore, it is difficult to know exactly how many schools implement abstinence-plus or HIV sexuality education (Landry, Kaeser, & Richards, 1999).
- Do abstinence-only programs effectively delay the onset of intercourse or cause youth to stop having sex?
- By emphasizing the ineffectiveness of condoms and contraception, do abstinence-only programs discourage condom or contraceptive use and thereby increase adolescent sexual risk-taking behavior?
- Do abstinence-plus programs decrease sexual activity because they emphasize abstinence, or do they increase sexual activity because they describe how to have sex more safely by using condoms and contraception?
- Do abstinence-plus programs actually increase the use of condoms and contraception and thereby reduce sexual risk-taking behavior?
These are reasonable and important questions. Fortunately, two decades of research can answer some, although not all, of these questions.
The Effects of Abstinence-Only Programs
Before examining studies that have measured the impact of abstinence-only programs, I must emphasize that abstinence-only programs are very diverse and defined by just one common quality—their emphasis on abstinence as the only appropriate choice for young people. Thus, some abstinence-only programs are curriculum-based courses, whereas others are components of much broader youth-development programs. Some last for 15 to 20 sessions, and others last only 1 or 2 sessions. Some emphasize that it is immoral to have sex before marriage, and others encourage youth to postpone sex until a later age. Some are religious and begin with a prayer for God's guidance, and others are far more secular. Some rely primarily on didactic instruction, whereas others engage the participants in group activities and use role playing and other active-learning strategies to change group norms and to teach assertiveness skills. In other words, abstinence-only programs are a heterogenous group of programs.
Measuring the short-term impact of some abstinence-only programs on knowledge, attitudes, and values is relatively easy. Several studies (Olsen, Weed, Daly, & Jensen, 1992) have documented that abstinence-only programs can increase knowledge and change attitudes and values to favor abstinence. Some of these studies measure short-term effects, whereas others measure effects up to 18 months or longer (Kirby, 1997, 1999).
However, these results should be viewed somewhat cautiously for several reasons. First, response biases may have substantially inflated the findings and reduced their validity. For example, when a teacher emphasizes that it is wrong to have sex before marriage and then promptly asks students to complete a questionnaire that asks them whether premarital sex is wrong, some students may select the "correct" answer even though their own attitudes may not have changed. Second, although attitudes and values are somewhat related to the actual initiation of sex, small changes in attitudes and values may not translate into a significant delay in the initiation of sex. Finally, some studies (Kirby, Korpi, Barth, & Cagampang, 1997) indicate that the impact of abstinence programs on attitudes and values does diminish with time.
Measuring the effect of abstinence-only programs on behavior—specifically, on delaying the onset of sexual intercourse—is much more challenging, for a variety of methodological and statistical reasons. To date, only five studies have measured the impact of abstinence-only programs on the initiation of sex. None of them has found a consistent or significant impact of such programs on delaying the onset of intercourse, and at least one study provided strong evidence that the program did not delay the onset of intercourse.
Although discouraging, these studies are misleading because all but one of these evaluations had significant methodological limitations that could have obscured the actual impact of the program. For example, two of the studies measured the impact of the program for only six weeks after the end of the program, which was too short to assess whether the abstinence lesson had any impact on sexual behavior. Another study included only 91 study participants. Only one study has successfully measured the impact of abstinence-only programs on contraceptive use, and it found that the program neither decreased nor increased condom or other contraceptive use (Kirby, Korpi, Barth, & Cagampang, 1997). Thus, at the present time, we do not know whether abstinence-only programs delay sexual activity, nor do we know which particular programs are effective.
We can't be certain about the behavioral impact of abstinence-only programs until researchers conduct rigorous studies with sufficiently large sample sizes, long-term measurements of behavior, and the random assignment of youth to intervention and control groups. Such studies are currently underway.
The Effects of Abstinence-Plus Programs
Abstinence-plus programs also include a wide variety of programs, including sexuality education or AIDS education taught during regular school classes, on school campuses after school, or in homeless shelters and detention centers for high-risk youth. Abstinence-plus programs reflect the considerable creativity and diversity of the agencies implementing them.
In contrast to the studies of abstinence-only programs, a large number of studies during the past two decades have focused on abstinence-plus programs for sexuality and HIV education. Some of these studies have been very rigorous and provide solid evidence for the success of their respective programs.
Evaluations of almost 30 programs strongly support the conclusion that abstinence-plus programs for sexuality and HIV education do not increase adolescent sexual intercourse. They do not hasten the onset of intercourse, increase the frequency of intercourse, or increase the number of sexual partners (Kirby, forthcoming). These results are consistent with reviews of programs evaluated in other countries as well (Grunseit, Kippax, Aggleton, Baldo, & Slutkin, 1997).
In fact, several studies found that some abstinence-plus sexuality education or HIV education programs decreased one or more measures of sexual activity; they either significantly delayed the onset of intercourse, reduced the frequency of intercourse, or decreased the number of sexual partners. In addition, studies have demonstrated that some programs have increased condom or other contraceptive use and thereby reduced sexual risk-taking behavior for lengthy periods of time (Kirby, forthcoming).
Four abstinence-plus programs present particularly strong evidence that they positively changed behavior.
Reducing the Risk (Barth, 1996) is a 16-session curriculum for preventing pregnancy and STDs/HIV. Its central message is that youth should avoid unprotected sex—abstinence is the safest approach, but if young people have sex, they should always use condoms or other forms of contraception. The curriculum has been taught and evaluated independently in different parts of the country and found to either delay the onset of intercourse, increase the use of condoms or other contraception, or reduce the frequency of unprotected sex for 18 months (Hubbard, Geise, & Rainey, 1998; Kirby, Barth, Leland, & Fetro, 1991).
Safer Choices is a 20-session curriculum designed for two successive years (Coyle & Fetro, 1998; Fetro, Barth, & Coyle, 1998). It emphasizes that abstinence is the safest method for avoiding pregnancy and STDs/HIV and that the use of condoms is safer than unprotected sex. Research data from the schools in two states where the curriculum was implemented show that the program both increased condom use and reduced unprotected sex over a 31-month period (Coyle et al., forthcoming).
Finally, both Be Proud! Be Responsible! (Jemmott, Jemmott, & McCaffree, 1994) and Becoming a Responsible Teen (St. Lawrence, 1994) are HIV-prevention curriculums designed for higher-risk youth. Both emphasize abstinence and condom use, and studies show that both have succeeded in delaying the onset of intercourse, decreasing the frequency of sex, increasing condom use, or decreasing the frequency of unprotected sex over 12-month periods (Jemmott, Jemmott, & Fong, 1998; St. Lawrence, Jefferson, Alleyne, & Brasfield, 1995).
The data from several studies suggest that abstinence-plus sexuality and AIDS-education programs may be more effective with high-risk youth than with low-risk youth. This success stems in part from the program and in part from the statistical characteristics of the groups studied. When large percentages of the youth studied usually initiate sex within short periods of time or fail to use condoms consistently, the intervention group (the group in the program) is more likely to undergo statistically significant improvement over the control group.
Common Characteristics of Effective Curriculums
- Effective programs focus narrowly on reducing one or more sexual behaviors that lead to unintended pregnancy or STDs/HIV infection. They are not broad, comprehensive programs.
- Effective programs are based on theoretical approaches that have been successful in influencing other health-related risky behaviors.
- Effective programs give a clear message by continually reinforcing a clear stance on particular behaviors. They do not simply lay out the pros and cons of different sexual choices and implicitly let the students decide which is right for them; rather, most of the curriculum activities are directed at convincing the students that abstaining from sex or using condoms or other forms of contraception is the right choice.
- Effective programs provide basic, accurate information about the risks of unprotected intercourse and methods for avoiding unprotected intercourse. Although increasing knowledge is not the primary goal of these programs, they provide basic information that students need to assess risks and to avoid unprotected sex.
- Effective programs include activities that address social pressures associated with sexual behavior. For example, several curriculums discuss situations that might lead to sex and "lines" that are typically used to get someone to have sex.
- Effective programs provide modeling and the practice of communication, negotiation, and refusal skills. Some curriculums teach different ways to say no to sex or unprotected sex and how to insist on the use of condoms.
- Effective programs involve the participants and have them personalize the information. Instructors reach students through active learning, not through didactic instruction.
- Effective programs incorporate behavioral goals, teaching methods, and materials that are appropriate to the age, sexual experience, and culture of the students. For example, programs for younger youth, few of whom have engaged in intercourse, focus on delaying the onset of intercourse. Programs designed for high school students, some of whom have engaged in intercourse, emphasize that students should avoid unprotected intercourse, either by not having sex or by using contraception if they do have sex.
- Effective programs last a sufficient length of time to complete important activities adequately. Considerable time and multiple activities are necessary. Thus, short programs that last only a couple of hours do not appear to be effective, whereas longer programs that implement multiple activities have a greater effect.
- Effective programs select teachers or peers who believe in the program they are implementing and then provide training for those individuals. The training ranges from approximately six hours to three days.
Choose Abstinence-Plus
Given both the great diversity of abstinence-only programs and the many limitations of previous studies, there is currently too little evidence to determine whether different types of abstinence-only programs actually delay the onset of intercourse or have other positive effects on sexual and contraceptive behavior.
Until such studies are completed, the educators and policymakers who want to implement programs with strong evidence for delaying sex or reducing unprotected sex should implement effective abstinence-plus programs that emphasize both abstinence and condoms or other contraceptives. Fortunately, a large number of studies demonstrate that abstinence-plus programs do not increase sexual activity as some people fear, but, to the contrary, can delay the onset of sex, reduce its frequency, reduce the number of sexual partners, increase condom use, and increase contraceptive use—thereby reducing sexual behavior that places youth at risk of pregnancy and STDs.
To reduce the tragic rates of unintended pregnancy and STDs, including HIV, U.S. schools should implement these effective programs more widely and with fidelity.
