The Ineffectiveness of Abstinence-Only Education at Preventing HIV in Youth
By Sarah Koop
Photo by Muramasa via Wikimedia Commons
"Two young people every hour are infected with HIV" (SIECUS, "The Division").
This startling statistic raises the question: How can we educate young people so that this trend does not continue? For the past three decades, abstinence-only sexual education (AOE) has been prominent in many schools and youth organizations across America. The government has poured millions of dollars into this type of program with the goal of preventing unplanned pregnancy and the spread of sexually transmitted diseases (STDs) such as human immunodeficiency virus (HIV). Nonetheless, the infection rates of HIV and other STDs are still rising in young people (SIECUS, "The Division"). This calls into question the true efficacy of these programs and raises doubts about whether their federal funding should continue. Given the current scientific evidence and studies, it is clear that AOE is not an effective form of sexual education for preventing HIV in American youth, so the government funding of abstinence programs should be reallocated to more effective forms of education.
In this paper I will present information and startling statistics on the current trends of HIV infection in the United States, increasing the importance of considering the most effective form of sexual education for youth. I will also discuss the history of AOE programs in the United States. This history will include a description of federally funded abstinence programs as well as the egregious amounts of money they have received. I will also discuss the main goals and ideology of AOE and provide information on the key demographics of support for it. This will demonstrate why there is still a danger of even more government funding being allocated to AOE programs. After presenting this background information, I will offer the best evidence and arguments in favor of AOE. I will rebut this information with scientific evidence that AOE is undoubtedly not effective in preventing HIV in youth. This will lead me to review an alternative form of education—comprehensive sexual education. After examining the effectiveness of comprehensive programs, I will argue that the government funding of AOE programs should be allocated to comprehensive sexual education programs instead.
HIV Facts and Trends
A key reason why adolescent sexual education is such a relevant issue today is the increase in sexually transmitted diseases in youth. The spread of HIV, in particular, among young people is of critical importance. HIV is a virus that is transmitted when infected blood or other body fluids come into contact with damaged tissue or enter into the bloodstream. The most common forms of HIV transmission are sexually, from mothers to infants during birth, and through injection drug use. If HIV is untreated it can progress to cause acquired immunodeficiency syndrome, or AIDS. AIDS victims suffer from a weakened immune system and can experience many negative symptoms such as rapid weight loss, tiredness, night sweats, sores, and many more. The first case of AIDS was reported in 1981, and despite efforts from the medical community, there is currently no cure. According to the U.S. Department of Human and Health Services, currently more 1.1 million people in the United States are infected with HIV ("U.S. Statistics"). Although HIV infection rates in the U.S. have remained constant in recent years, the number of youth infected is rising. The rate of HIV diagnoses between 2006 and 2009 increased in teens and was highest in 20-24 year-olds ("June 2012"). The U.S. Department of Health and Human Services reports startling statistics: "About one in four new HIV infections is among youth ages 13-24. Most of them do not know they are infected, are not getting treated, and can unknowingly pass the virus on to others" ("U.S. Statistics"). In addition, most young people are infected with HIV through sexual contact ("The HIV/AIDS Epidemic"). The rising levels of HIV in youth are of critical importance, and they display the need for adolescents to receive the most effective sexual education for preventing HIV.
A History of Abstinence-Only Education Programs
One way in which educators, parents, and lawmakers have attempted to eliminate the risk of STDs and unplanned pregnancy is by promoting a message of abstinence to youth through abstinence-only education. AOE programs began receiving government funding in 1981 (SIECUS, "A History"). Under President Reagan the first of these programs, the Adolescent Family Life Act (AFLA), was created. According to the Sexuality Information Council of the United States (SIECUS), the goals of AFLA were to promote chastity and self-discipline, and to encourage abstinence until marriage as a means of preventing pregnancy. As the SIECUS report indicates, the AFLA received over $200 million in government funding while it was in effect, but Congress eliminated it in 2010. One of the other main government-funded AOE programs is the Community-Based Abstinence Education program (CBAE). Like AFLA, this program also received a substantial amount of federal funding throughout its existence. SIECUS reports that CBAE began in 2001 with $20 million in funding. That amount increased to $113 million in 2006, was cut down to $99 million in 2009, and was eliminated in 2010 ("A History"). Nonetheless, both the ALFA and CBAE programs received hundreds of millions of dollars worth of government funding in their duration.
Although the original AOE programs have been eliminated from government funding, there are still millions of dollars each year being funneled into AOE through the Title V Abstinence-Only-Until-Marriage Program. As Howell of Advocates for Youth explains in her history, Title V is a welfare law that was part of the Social Security Act, and it created a new channel of federal funding for AOE programs. Title V was enacted in 1996 and has received $50 million annually in federal funding since 1998 (Howell 2). States can choose whether or not to accept Title V funds. If they choose to accept funding they must match three state-raised dollars for every four federal dollars. Forty-nine of the fifty states have chosen to accept funding at some point, with California being the only exception. The states then must distribute the funds to schools, community-based organizations, health organizations, faith-based organizations, or others.Congress allowed the program to expire in 2009; however, it was reenacted by conservative lawmakers to receive $250 million between 2010 and 2014 (SIECUS, "A History"). Thus, although there have been considerable shifts in federally funded AOE programs, a substantial amount of taxpayer money is still being allocated to that form of education.
The specifics of AOE can differ between programs, but the basic idea behind them is that abstaining from sex until marriage is the best way to avoid sexually transmitted infections, such as HIV, as well as unplanned pregnancy. According to SIECUS, CBAE had a more moral approach that "viewed sexual abstinence prior to marriage as an approach that would lead to a happier life, including having a healthier marriage and children, earning more money…having integrity, attaining a better education, [and more]" ("A History"). CBAE funding also explicitly prohibited programs from providing positive information about contraception (SIECUS, "A History"). Similar general principles apply to many AOE programs; however, Title V spells out the current specific definition of AOE that must be followed in order for programs to receive government funding. In order to receive funding, a program must:
- Have as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity
- Teach that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems
- Teach that a mutually faithful, monogamous relationship in the context of marriage is the expected standard of sexual activity
- Teach that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects
- Teach that bearing children out of wedlock is likely to have harmful consequences for the child, the child's parents, and society
- Teach young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances
- Teach the importance of attaining self-sufficiency before engaging in sexual activity (Trenholm et al., "Impacts of Four" 3)
It is evident from Title V's educational standards that AOE has rigid educational guidelines that must be followed. In addition, this curriculum does not discuss the benefits of condoms and contraceptives or ways in which to prevent STDs while sexually active. In fact, federally funded AOE programs are only allowed to teach the negativities and failure rates of condoms and contraceptives (Lin and Santelli 56).
Support for Abstinence-Only Education
The question of who supports AOE is widely debated. It is generally assumed that the primary supporters of AOE are politically conservative and Christian. This assumption has some validity. AOE funding grew substantially under conservative Republican Presidents Ronald Reagan and George W. Bush. Furthermore, the programs have garnered much support from Christian organizations. This is mainly due to the fact that the abstinence message is in line with many Christian ideals of morality, chastity, and fidelity to one partner. Many people believe for religious or other reasons that sex before marriage is morally wrong, and they therefore want that message taught to youth. Although a large number of the supporters of AOE fall into these two categories, a survey conducted by Pulse Opinion Research in September 2012 found that AOE also has a substantial amount of support from Democrats, with 60 percent of those surveyed indicating that they oppose Obama's efforts to eliminate all funding for AOE (Huber 2). The survey also found that 50 percent of people asked thought that more government funding should be given to teaching abstinence (Huber 25). Therefore, although funding for AOE has decreased in recent years, it should not be considered put to rest. With strong support from many conservatives and Christians, as well considerable support across the demographics, AOE funding could very well make a comeback within the next few years. For this reason, it is even more crucial to examine the effectiveness of these programs and reassess if they should really be receiving millions of taxpayer dollars each year.
Supporters of AOE argue for continued funding and implementation of the programs by citing studies that have reported, "effects of abstinence education on student knowledge, attitudes, beliefs, and intentions towards abstinence" (Trenholm et al. "Impacts of Abstinence" 257). Many of these supporters oppose the addition of education that encourages the use of condoms and contraceptives when sexually active because they believe that it will increase sexual behavior in youth (Kirby and Rolleri 19). Although the scientific evidence supporting AOE has generally been lacking, proponents of the programs gained support in 2010 when a federally funded study conducted by John Jemmot, a University of Pennsylvania professor, found that AOE could have positive effects on middle school students. The study found that only one third of the students in the AOE program started having sex within the next two years. In comparison, about half of the students who received education about both abstinence and contraception became sexually active in the same time period (Stein). This study is an important victory for AOE supporters. According to Sarah Brown, the head of the National Campaign to Prevent Teen and Unplanned Pregnancy: "This new study is game-changing. For the first time, there is strong evidence that an abstinence-only intervention can help very young teens delay sex" (Stein). The findings of this study could help garner support for more funding of these programs.
Evidence of Abstinence-Only Education's Ineffectiveness
Determining the most effective sexual education program is no easy task, and it continues to be a topic of much debate. In recent years, many studies have been done in an attempt to determine what effect AOE programs are actually having on the sexual behaviors of teens and young adults. One key study conducted by Mathematica Policy Research evaluated four AOE programs funded by Title V and found alarming results. The programs were reviewed eight years after their implementation using a program group and control group of over 2,000 teens. The programs reviewed all began receiving funding in 1998, followed the educational guidelines listed above that had been specified under Title V, and were well implemented and intense. One could argue that these programs were the idealistic models of abstinence education. However, the study found that these programs did not reduce teen sexual activity (Trenholm et al. "Impacts of Abstinence" 272). A 2008 study of nine AOE programs conducted by scientist Douglas Kirby had similar results. The study found that the programs had "no overall impact on adolescents' delay in initiation of sex, age at initiation of sex, return to abstinence, number of sexual partners, or condom or contraceptive use" (Kirby 24). In addition, there is a lack of results showing increased knowledge of STDs and use of protection when sexually active, two things that should be the goals of any successful sexual education program. This failure of AOE programs at achieving these results should be considered reason enough to rescind their government funding. However, the most detrimental failure of these programs has yet to be addressed.
As I mentioned earlier, federally funded AOE programs are extremely restricted in the education about condoms and contraceptives that they may provide. Specifically, they can only discuss their failure rates. This particular educational aspect has consequences that could potentially affect thousands of people. Additional studies conducted by Mathematica Policy Research have found that about half of all teens are sexually active by the time they leave high school, despite the encouragement to remain abstinent (Trenholm et al. "Impacts of Four" 61), which further indicates the need for those youth to be educated on methods of preventing the transmission of STDs like HIV. Promoting condom use is one of the crucial methods of preventing the spread of HIV used by health professionals, and the National Institute of Allergy and Infectious Disease found that condoms are effective in protecting against HIV when they are used correctly (Lin and Santelli 58). A 2002 study conducted by scientists Alison Lin and John Santelli also "found an 80% reduction rate in the transmission of HIV with consistent use of condoms" (Lin and Santelli 59). Unfortunately, youth in AOE programs are not taught this potentially life-saving information. Instead, they are presented with out-of-date statistics that underestimate the ability of condoms to prevent HIV, and they are led to believe that condoms do in fact allow the spread of HIV. The curriculum of one program even stated: "Condoms do not prevent pregnancy, STDs or AIDS" (Lin and Santelli 60). This information blatantly opposes the current standards accepted by the medical community, and the fact that the government is funding this type of education is unacceptable.
The effects of this misinformation on youth have also been studied, and the results are disheartening. The aforementioned study conducted by Dr. Kirby found that the youth in the AOE programs were much less likely than youth not in AOE programs to see condoms as effective at preventing STDs. Also, according to the report, "about one in seven reported being unsure about condoms' effectiveness for preventing HIV," and 21 percent of those in the AOE programs answered that condoms never prevent HIV (Kirby 44). This obvious lack of understanding about how to effectively prevent HIV poses a significant threat to the current efforts at reducing the spread of HIV and AIDS. Although it is understandable to want youth to abstain from sex for as long as possible, we must still make sure that they are properly informed and prepared for when they do begin having sex. Yet, according to Lin and Santelli, the current abstinence "curricula do not equip youth with the information or the skills they need to use condoms to protect themselves from HIV, other STIs, or unintended pregnancies" (Lin and Santelli 62). As the rate of HIV infection in teens and young adults is on the rise, we can no longer allow for this misrepresentation and lack of education to go on, or the trends of HIV transmission will undoubtedly continue.
Comprehensive Education: A Better Approach
The prevalence of HIV among youth makes it even more crucial to determine what type of sexual education is effective. Since it is clear that AOE is not the answer, we must turn our attention to the other prominent form of sexual education—comprehensive education. Proponents of comprehensive education often agree with the benefits and safety of youth abstaining from sex, but they also "recognize that many young people do engage in sexual behavior that places them at risk of STD and pregnancy, and that therefore they should be encouraged both to abstain from sex and to use condoms and/or other contraceptives if they do have sex" (Kirby and Rolleri 19). AVERT, an international HIV and AIDS charity, explains that comprehensive programs teach the benefits of waiting to have sex until they are ready, but they also make sure that the youth who do become sexually active know how to protect themselves from STDs and pregnancy ("Abstinence Sex Education"). Opponents to comprehensive programs use the program's duality as a basis for attack, claiming that teaching both abstinence and contraceptive use sends a mixed message to youth. However, supporters of comprehensive sexual education programs rebut the attack by arguing that the programs emphasize abstinence but also encourage the youth who are sexually active to use condoms and other contraceptives (Kirby and Rolleri 19). Prior to 2010, comprehensive sexual education programs received no government funding, while AOE received millions. However, in 2010 comprehensive education gained momentum and federal financial support in the form of grants worth $375 million to be spread over the course of five years (Rabin). Nonetheless, the government funding of these programs is not necessarily permanent and could easily revert back to old ways.
The evidence supporting comprehensive education is much more abundant than the evidence supporting AOE. A review of 48 comprehensive education programs also conducted by Dr. Kirby found that two-thirds had positive effects including delayed initiation of sex and increased condom use (Kirby 18). In addition, "one fourth [of the programs] reduced the frequency of sex, and nearly half reduced the number of sexual partners" (Kirby 24). A study done in 2012 by numerous scientists in conjunction with the Community Preventative Services Task Force reviewed 66 comprehensive programs and also found positive results. The review found that youth involved in comprehensive education had a significantly decreased number of sexual partners, amount of unprotected sexual activity, prevalence of STDs, as well as a significant increase in the use of protection during sex (Chin et al. 288). The study concluded that, "Based on these findings, group-based comprehensive risk reduction was found to be an effective strategy to reduce adolescent pregnancy, HIV, and STIs" (Chin et al. 272). Although these studies don't imply that comprehensive education is the perfect solution, they do show much more promise towards the goal of reducing the spread of HIV than abstinence-only programs.
Overall, it is evident that AOE programs are not effective at preventing the spread of HIV in American youth. Numerous studies have shown that AOE programs are ineffective at delaying the age of first sexual interaction, decreasing the number of sexual partners, and increasing knowledge and awareness of the dangers STDs and how to prevent them. Furthermore, the lack of understanding in youth involved in AOE programs about condom and contraceptive use could have detrimental effects and revert the efforts of the medical community at preventing the spread of HIV. Lastly, the minimal evidence in support of AOE is hardly enough to warrant the millions of dollars of government funding that the programs are currently receiving. Teens and young adults are being infected with HIV at troubling rates, and we cannot idly sit by while this trend continues. Rather, we must ensure that government funding is channeled into the most effective form of education for youth in order to combat the problem. Although more studies need to be done in order to make sure every young person receives the most beneficial sexual education, current evidence shows that comprehensive sexual education is a much better answer. This issue is far from solved, but one thing is clear: Abstinence-only education is not the answer, and comprehensive education is a more effective solution deserving of increased government funding.
 The health and medical community has recently begun using the term sexually transmitted infection (STI) in place of STD; however, since STD is the more commonly recognized term, I will be using it in place of STI throughout this paper.