Introduction
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, 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.
What is an abstinence based approach to sex
education?
Youth abstinence activity in the Democratic Republic of the Congo
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 Aspire and True Love
Waits
(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:
- 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.
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.
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.
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. One example of an
abstinence plus approach is the US developed
Reducing the
Risk. 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
Billboard promoting abstinence until marriage in Arkansas, USA
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.
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.
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. They argue
that without access to information about all aspects of sex and
sexuality making these decisions freely is
impossible. 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.
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.
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.
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.
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. 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.
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. 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.
In April 2007 the results were published of a Congressionally mandated
evaluation of federally funded abstinence based programmes in American
schools. 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." 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.
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. 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.
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.
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.
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.
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.
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.
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. 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.
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. Indeed, more
than 80% of the $1.5 billion spent on abstinence education since 1982
was spent under the Bush administration, with the 2007 budget granting approximately $204
million to abstinence only education
programmes.
However, the Obama administration has withdrawn Federal support for
abstinence only programmes within the United
States. 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.
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.
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.
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.
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. 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.
In the UK an even greater proportion of parents and young people
support comprehensive approaches to sex
education. 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.
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.
AIDS education for young people is a
crucial factor in determining the extent to which they are at risk of
HIV infection.
Billboard promoting abstinence for HIV preventionin Ghana
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.
