Most teens are Abstinent (pdf)Teen Abortion Trends Lower in States Accepting Abstinence Education Funding vs States that Reject Abstinence Education Funding (pdf)Related LinksAnother Look at the Evidence:Abstinence and Comprehensive Sex Education in Our SchoolsThere is a common perception that school-based comprehensive sex education programs are effective at protecting teens from the problems related to sexual activity while abstinence education programs are not. In fact, some have called for the complete abandonment of abstinence education. With 1 in 4 teen girls in the U.S. now infected with an STD,1 there is clearly a need for more effective programs to protect adolescents. However, before a program can be called effective it is necessary to clarify what “effective” means. This document offers basic criteria for effective programs and presents evidence about the effectiveness of both comprehensive and abstinence-based sex education in our schools. A. What is an Effective Program? After more than 15 years of evaluating school-based sex education programs, the Institute for Research & Evaluation suggests that effective programs should produce:
B. Evidence of Effectiveness for School-based Comprehensive Sex Education. “Comprehensive sex education” (CSE) is a term applied to programs that purport to teach both abstinence and condom use as a central part of the curriculum. The Institute has reviewed the large body of research on the effectiveness of these programs in school classroom settings (excluding other settings such as clinics or community programs—see notation5). In this document we refer to these as “school-based” programs. Although the perception may be that CSE programs in the schools are successful, when they are evaluated against the above criteria, there is a surprising lack of evidence to support that assumption.6 For example:
C. Evidence of Effectiveness for School-based Abstinence Education. Scientific evaluation is relatively new to abstinence education, and the number of good studies is limited. However, a pattern of evidence is emerging that indicates well-designed abstinence programs can be effective:
D. Summary. Using the criteria outlined above to examine the body of research on the effectiveness of school-based sex education, we find the following:
Notes 1. Centers for Disease Control and Prevention. (2008). Nationally Representative CDC Study Finds 1 in 4 Teenage Girls Has a Sexually Transmitted Disease. Press Release 11 March – 2008 National STD Prevention Conference. Available at www.cdc.gov/stdconference/2008/media/release-11march2008.htm. 2. See Crosby RA, DiClemente RJ, Wingood GM, Lang D, Harrington KF. (2003). Value of consistent condom use: A study of sexually transmitted disease prevention among African American adolescent females. American Journal of Public Health; 93: 901–2.; Shlay JC, McCung MW, Patnaik JL et al. (2004). Comparison of sexually transmitted disease prevalence by reported level of condom use among patients attending an urban sexually transmitted disease clinic. Sex Transm Dis; 31(3):154–60.; Ahmed S, Lutalo T, Wawer M et al. (2001). HIV incidence and sexually transmitted disease prevalence associated with condom use: a population study in Rakai, Uganda. AIDS; 15(16):2171–9.; Grinsztejn B, Veloso V, Levi J, Velasque L, Luz P et al. (2009). Factors associated with increased prevalence of human papillomavirus infection in a cohort of HIV-infected Brazilian women. International Journal of Infectious Diseases, 13, 72–80.; Centers for Disease Control and Prevention. (2003). Fact Sheet for Public Health Personnel—Male Latex Condoms and Sexually Transmitted Diseases. National Center for HIV, STD, and TB Prevention. Atlanta, GA: U.S. Department of Health and Human Services (paragraph 4). Retrieved October 31, 2003 from www.cdc.gov/nchstp/od/latex.htm. According to the CDC, “inconsistent use, e.g., failure to use condoms with every act of intercourse, can lead to STD transmission because transmission can occur with a single act of intercourse” (CDC, 2003). A study in the journal AIDS (Ahmed et al., 2001) found, “Irregular condom use was not protective against HIV or STD and was associated with increased gonorrhea/Chlamydia risk.” A Denver study (Shlay et al., 2004) reported that “when all condom users were compared with non-users (N=126,220), there was limited evidence of protection against specific STD.” But when consistent vs. inconsistent users were compared, the consistent users had significantly lower infection rates. 3. See Weller S & Davis K. (2002). Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev, 1. [Abstract].; Sanchez J, Campos P, Courtois B, Gutierrez L, Carrillo C, Alarcon J et al. (2003). Prevention of sexually transmitted diseases (STDs) in female sex workers: Prospective evaluation of condom promotion and strengthened STD services. Sexually Transmitted Diseases, 30:273–9.; Holmes KK, Levine R, Weaver M. (2004). Effectiveness of condoms in preventing sexually transmitted infections. Bull World Health Organ, 82(6):454–461. 4. See Hallfors DD, Waller MW, Ford CA et al. (2004). Adolescent depression and suicide risk: association with sex and drug behaviors. Am J Prev Med. 27:224–230.; Sabia JJ & Rees DI. (2008). The effect of adolescent virginity status on psychological well-being. Journal of Health Economics, 27:1368–1381.; Silverman JG, Raj A, Clements K. (2004). Dating violence and associated risk and pregnancy among adolescent girls in the United States. Pediatrics,114(2), e220–225. 5. The school classroom is the setting in which many CSE interventions and most abstinence programs occur. It is the setting most people think of when they hear the term “sex education.” It is probably the most cost-effective venue through which to deliver prevention programs to the greatest number of youth. And for the purpose of comparing the abstinence and CSE strategies, limiting our review to programs in this setting provides the most comparability, i.e., allows us to compare “apples to apples.” We define this category as programs that go through the school system to reach the students, and that are held in the school in a classroom or curriculum setting, including after school or Saturday classes. It does not include such programs as school-based clinics, school condom-distribution programs, or school-based service learning programs—many of which target high-risk populations, or school classroom-based character education or social development programs that do not address sexual health or abstinence. 6. Weed S. Testimony before the U.S. House of Representatives Committee on Oversight and Government Reform. April 23, 2008. 7. Kirby D. (2007). Emerging Answers 2007. Washington DC: National Campaign to Prevent Teen and Unplanned Pregnancy, p.15. 8. Only 3 non-school-based programs in Emerging Answers 2007 reported significant program impact on consistent condom use that lasted more than 3 months; all were 12-month effects. One was a community-based parent training program for fathers of teens (Dilorio et al., 2007), one was a clinic-based program for high-risk girls (DiClemente et al., 2004), and the third was a school-based program that did not increase consistent condom use for the participants, but achieved a significant effect because the comparison group declined substantially on this outcome (Villarruel et al., 2006). Two programs increased consistent condom use for 3 months (Jemmott et al, 1998 & Walter & Vaughn, 1993). 9. Seven non-school-based prevention programs in Emerging Answers 2007 reported reduction in pregnancy rates for the full program group at least 9 months after the program. One was an abstinence program (Doniger et al., 2001), two were service learning programs (Allen et al., 1997 & Philliber et al., 1992), one was a social development program for elementary school children and their parents that included no sex education or discussions of sex (Lonczak et al., 2002), one was a multi-component youth development program, including clinic services (Philliber et al., 2002), one was an in-home parent training program (Stanton et al., 2004) and the last was a clinic-based program (Winter et al., 1991). Only 3 prevention programs in Emerging Answers 2007 reported reducing STD rates for more than 6 months after the program. Two were clinic-based programs for high-risk teens (DiClemente et al., 2004 & Jemmott et al., 2005, both 12-month effects) and the third was a time-intensive parent training program that had a 24-month effect on reducing teen STDs (Prado et al., 2007). 10. Four different evaluations of Reducing the Risk (Hubbard et al., 1998, Kirby et al., 1991, Zimmerman et al., in press, and Zimmerman et al., in press) found reductions in teen sexual initiation after at least one year, as reported in Emerging Answers 2007. The Hubbard study also reported increased condom use, but only for the subgroup of students not sexually experienced at the pretest. Four studies of non-school-based CSE programs in Emerging Answers 2007 reported reduced rates of sexual initiation for the full program group for at least 12 months: one was clinic-based CSE, one was CSE at a drug treatment center (St. Lawrence, 1995 & 2002, respectively), one was a community-based CSE program within public housing (Sikkema et al., 2005), and one was a social skills program that did not teach about sexuality at all (Lonczak et al., 2002). 11. See Coyle et al., 2004, Fisher et al., 2002, and Jemmott et al., 1998, in Emerging Answers 2007. Six other school-based programs are reported in that review which increased condom use (but not consistent use) for 3 or 6 months or for a subgroup of the program participants. 12. National Campaign to Prevent Teen and Unplanned Pregnancy. (2008). What Works 2008: Curriculum-Based Programs That Prevent Teen Pregnancy. Washington DC: author. 13. See Philliber, S., Kaye, J.W., Herrling, S., & West, E. (2002). Preventing pregnancy and improving health care access among teenagers: An evaluation of the Children’s Aid Society-Carrera Program. Perspectives on Sexual and Reproductive Health, 34(5), 244-251. (This was a multi-component youth development program, including clinic services.); Lonczak HS, Abbott RD, Hawkins JD, Kosterman R, Catalano RF. (2002). Effects of the Seattle Social Development Project on sexual behavior, pregnancy, birth, and sexually transmitted disease outcomes by age 21 years. Archives of Pediatric Adolescent Medicine, 156:439-447. (This was a social development program for elementary school children and their parents—it included no sex education or discussions of sex.); Stanton B, Cole M, Galbraith J, Li X, Pendleton S et al. (2004). Randomized trial of a parent intervention: Parents can make a difference in long-term adolescent risk behaviors, perceptions, and knowledge. Archives of Pediatric Adolescent Medicine,158: 947-955. (This program trained parents in their homes.) There were 3 other programs that reported reductions in pregnancy for a shorter follow-up time (less than 12 months after the program). Two were “service learning” programs in which students left their schools to provide service in the community, and the other was based at a medical clinic. 14. Weed SE, Ericksen IH, Birch PJ. (2005). An evaluation of the Heritage Keepers Abstinence Education program. In Golden A (ed.) Evaluating Abstinence Education Programs: Improving Implementation and Assessing Impact. Washington DC: Office of Population Affairs and the Administration for Children and Families, Department of Health & Human Services 2005:88–103. 15. Weed SE, Ericksen IE, Lewis A et al. (2008). An Abstinence Program’s Impact on Cognitive Mediators and Sexual Initiation. Am J Health Behav; 32(1):60–73. 16. Jemmott III JB, Jemmott LS, Fong GT. (2006). Efficacy of an abstinence-only intervention over 24 months: a randomized controlled trial with young adolescents. Oral abstract session: AIDS 2006 - XVI International AIDS Conference: Abstract no. MOAX0504. 17. Howard M. & McCabe JB. (1990). Helping teenagers postpone sexual involvement. Family Planning Perspectives, 22: 21–26. This program was taught by peer leaders and was developed as a separate 5-day abstinence intervention that was presented following an existing human sexuality program that included birth control information, which had been evaluated previously and found to be ineffective. 18. See Jemmott et al., 2006, above, and Trenholm C, Devaney B, Fortson K, Quay L, Wheeler J, Clark M. (2007). Impacts of Four Title V, Section 510 Abstinence Education Programs. Princeton, NJ: Mathematica Policy Research, Inc. April 2007. 19. One study has reported that teens who took a virginity pledge were less likely to use condoms the first time they had intercourse. However, there was no indication as to whether these teens had received an abstinence education program, and they were not less likely to use condoms at last intercourse or over a 12-month period than non-pledging teens. See Bruckner H & Bearman P. (2005). After the promise: The STD consequences of adolescent virginity pledges. The Journal of Adolescent Health, 36(4):271–278. Published by The Institute for Research & Evaluation, Salt Lake City, UT. Revised March 6, 2009.
Physical Health BenefitsDelaying sexual debut has a considerable impact on the physical health outcomes of adolescents. Youth who abstain from sexual activity avoid the consequences that directly result from a non-marital pregnancy, as well as the potential lifelong implications of STDs. The indirect complications of early sexual debut include other negative health outcomes, such as increased vulnerability to partner violence, elevated risks of HIV/AIDS, and a higher probability for other risk behaviors. Teen Pregnancy Data from the National Survey of Family Growth (a five wave longitudinal study of roughly 10,000 women between the ages of 15-44), shows that beginning sexual activity at a later age reduces the risk that a teenager will experience a non-marital pregnancy and non-marital birth; both events that pose a significant physical health challenge for adolescent girls, not to mention the physical demands that are required to raise a child once it is born. Sexually Transmitted Diseases In 2008, the Centers for Disease Control and Prevention (CDC) estimated that one in four (approximately 26 percent or 3.2 million) girls in the U.S. between the ages of 14 and 19 are infected with at least one of the most common STDs (human papillomavirus, chlamydia, herpes simplex virus, and trichomoniasis). 39 This data adds to what we already know, that about 19 million new STD cases occur annually, almost half among young people ages 15-24.40 The age at first intercourse has a strong association with a persons number of lifetime sexual partners, and the more sexual partnerships one has, the greater the risk of contracting an STD.47 Research shows that adolescents who experience early sexual debut have poorer overall health and more STDs,48 while an increased number of sexual partners places them at risk for HIV/AIDS.49 Considering that new sexual partnerships among adolescents increase the incidence of STD infection,50 initiating sex at a later age decreases the probability of acquiring an STD. Adolescent Condom Use Adolescent condom use further exacerbates their vulnerability to STDs, mainly because of the inconsistent and incorrect use during teen sex. Ranking contraceptives by effectiveness over the first 12 months of use, one study found that the typical method failure rate for male condoms was 15 percent.52 However, the problem with adolescent condom use does not primarily lie in the method failure rate, but rather, the user failure rate. Research indicates that females report less consistent condom use than males;53 for example, one study found that young women reported consistent use only 50 percent of the time.54 Adolescent males fare a little better, as recent data suggests that two-thirds use condoms consistently.55 However, other studies demonstrate that due to incorrect use, the user failure rate of condoms can be as high as 70 percent.56 Similarly, a 2007 survey at Kent State University reveals that only 30 percent of sexually active college students regularly use condoms during sexual intercourse.57 Interconnectedness Research indicates that sexual risk behaviors among adolescents, including having multiple sex partners, correlates with illicit drug use.68 For example, among sexually active high school students in the U.S., one-fourth reported using alcohol or drugs at last intercourse.69 Another study found that adolescents with an increased number of sexual partners are at greater risk for alcohol, tobacco, and marijuana use, as well as dating violence, fighting, and carrying weapons.70 Moreover, research shows that sexually active adolescents are much more likely to engage in a variety of risk behaviors than their virgin peers.71 Mental Health BenefitsAdolescent Brain Development Dr. Jay Giedd of the National Institute of Mental Health used Magnetic Resonance Imaging (MRI) to determine the amount of cortical gray matter and increases in white matter among 145 child and adolescent brains, ages 4 to 20 years old. Dr. Giedd found that the prefrontal cortex, the part of the brain most associated with reasoning, making judgments, controlling impulses, and foreseeing consequences, is still quite immature during adolescence. The immaturity of the prefrontal cortex, which is very common at this age, is the neurobiological explanation for why adolescents exhibit poor judgment.75 Psychological/Emotional Damage and Depression Medical and psychiatric professionals have long pointed out the dangers associated with early sexual debut and the psychological damage it causes. In Epidemic: How Teen Sex is Killing Our Kids, Dr. Meg Meeker argues that adolescents who engage in sex at young ages routinely experience emotional turmoil. Teens may attempt to fill unmet needs through sexual escape, and they often fall into a trap of seeking love through sex, even if that sexual experience is not positive. This in turn can result in a vicious cycle, and perhaps a psychological condition called repetition/compulsion. This condition causes adolescents to seek the illusion of satisfaction in sex or substance abuse, with the idea that temporary relief will satisfy their needs. As a result, many adolescents sink further into depression.80 Adolescents who experience early sexual debut are more likely to engage in intercourse with casual partners,85 and the resulting encounters are often superficial, based on desire or physical attraction; spontaneous, and impulsive.86 Casual sex is more likely to harm the female psyche than the male, as it may alter a girls social context and induce stress by changing her self-perception.87 It may further damage females, especially considering the importance they place on the emotional investment and intimacy that results from sexual intercourse.88 These brief sexual encounters often fail to meet the needs of the female, leaving a deep emotional void. Suicide Suicide is the third leading cause of death among adolescents ages 15-19.94 Research indicates that youth who engage in early sexual activity are more likely to contemplate and attempt to take their own lives than abstainers and sexually active girls ages 12-16 were over 4 times more likely, and sexually active boys were nearly 2 times more likely, to attempt suicide, compared to their abstaining peers. Another study analyzing Wave II of the Add Health data found that sexually active girls were nearly three times and sexually active boys were eight times more likely to attempt suicide than abstainers. Financial BenefitsOne of the best predictors of financial success in the U.S. is an individuals level of lifetime academic achievement. Generally, those who enroll and succeed in higher education enjoy high rates of return to their investment.99 Teen Sexual Activity and Academic Performance Studies suggest that early sexual activity may conflict with academic achievement, and at the very least, lead youth to become involved in a problem behavior syndrome that stands in the way of their education.106 A recent study using data from the National Survey of Children (a three-wave multistage stratified probability sample of over 2,000 U.S. children) found that adolescents who were virgins were more likely to have higher educational goals and academic achievement when compared to those who initiated sex. Personality and Self-Control as an Indicator of Academic Success Impulsiveness and self-control represent two traits within an adolescents personality that may determine the potential to succeed in academic endeavors, as well as their likeliness to engage in problem behavior. For those who regulate their behavior, self-control has the ability to increase in capacity, improving gradually and strengthening over time. If adolescents learn to control their sexual impulses and focus their attention on areas such as education, their ability to delay gratification may result in higher academic performance. Research shows that students with self-discipline achieve better grades, and high levels of self-control in children can predict future success. Teenage Sex, High School Dropout and Delinquency Research shows that early parenthood among adolescent girls decreases their educational attainment.129 and is a major obstacle to financial stability for female adolescents. According to the National Campaign to Prevent Teen and Unplanned Pregnancy, mothers who delay childbearing until the ages of 20-21, compared to teenage mothers ages 17 or younger, earn an average of $84,000 more over the first 15 years of motherhood, or $5,600 annually.134 One study found that early and persistent sex, especially among boys, was associated with alcohol use, delinquent behavior, and poorer academic achievement.139 Studies based on the Add Health data have also found associations between early sex and delinquency. One study found that early sex was associated with a higher probability for suspension, unexcused absences, lower school-connectedness, and reduced aspirations to attend college.140 Social Benefits/Healthy RelationshipsForming healthy relationships is an integral part of adolescent sexual development. Dating has historically been recognized as one of the means by which adolescents gain experience in romantic relationships and learn to become fully sexual beings. When adolescents choose to wait to avoid premarital sexual bonds with other partners they are less likely to get involved in cohabitations, which is a major risk factor for future marital infidelity and divorce. Influences and Outcomes of Early and Steady Dating Dating relationships, while socially acceptable, afford adolescents opportunities to engage in sexual activity, and may even motivate them to become sexually active.164 Early dating (specifically steady dating) is associated with sexual activity among young people, as it provides the social structure for such activity to take place. In one study, nearly one in three teens had sex in the same month or before their dating relationship began, and another thirty-five percent experienced sexual debut within the first three months of their relationship. Adolescents who begin dating at an early age are likely to date more frequently and have early steady relationships, develop permissive attitudes concerning premarital sex, and have multiple sexual partners in the future.172 One study found that early adolescents involved in steady dating relationships were five times more likely to be sexually experienced than those who were not steady daters.173 Dating Violence and Abuse Dating violence and abuse are another risk factor for early daters, and are quite common among adolescent relationships that involve sex in fact, recent data indicates that about one in five sexually active girls have a history of dating violence.174 Results of this study also indicate that engaging in sex increases the risk of partner violence for male and female victims, and that a majority of violence, including verbal abuse, came after, rather than before the sex.176 Girls are often pressured, coerced, and even forced to engage in sex before they desire, usually because their partners are substantially older. For example, one study found that compared to girls who dated boys their own age, the odds of a 13 year-old girl having sexual intercourse was six times higher if her partner was six or more years older than her.179 Stable Marriage and Family The formation of a stable marriage and family is in many ways the product of a healthy relationship. A study following 14,000 American adults over a period of 10 years found that marital status was one of the most important predictors of happiness.182 Additionally, children in families whose parents are married have better emotional and physical health, have more opportunities to achieve academically, and enjoy improved life outcomes.183Thus, due to their ability to shape happiness and well-being, marriage and family are two of the most important institutions in society, and the existence of healthy relationships within these institutions is a key factor that determines its vitality. Cohabitation, Marital Disruption and Infidelity In a study using data from the National Survey of Families and Households, which includes over 13,000 individuals involved in cohabiting and marital relationships, cohabitation was associated with greater marital conflict, lower quality of marriage, poorer communication, less commitment to marriage, and more individualistic views of marriage among wives. Additionally, cohabiters perceived a greater likelihood of divorce when compared to couples that did not cohabit before marriage, and longer cohabitation was associated with a higher probability of divorce.191 Indeed, studies have found cohabitation to be a causal influence for divorce.192 Research shows that women incur a greater chance of marital disruption when they cohabitate or have their first sexual experience with a man whom they do not marry.193
Marital Bonding The process of pair bonding assists in cementing the marital bond between husband and wife, and is universal in all humans.196 Also defined as amorousness (or sexual love), pair bonding is a powerful biological impulse that is intensified by a surge of the chemical oxytocin during sexual orgasm in both sexes.19 Because pair bonding intensifies and grows with duration, especially in women,201 it is important that sexual activity occur in the confines of a monogamous marriage; otherwise, the amorous attachment could be misplaced with a partner other then ones spouse (e.g., cohabitation and multiple premarital sexual partners). Therefore, adolescent sexual activity outside of the proper biological context of marriage not only results in the disruption of the pair bonding process, but also indicates a major problem within the society in which it takes place. Research shows that a woman is likely to have her most intense love with her first sexual partner.205 In a longitudinal study of post-adolescent college students, women reported more love for a man if he was her first sexual partner. Similarly, men reported greater love for a woman who lost her virginity with him than with a previous partner.206 Correlation between Virginity and Adult Marital Stability In 2001, the National Center for Health Statistics estimated that 43 percent of all first marriages in the U.S. ended in divorce within the first 15 years.207 One explanation for this trend is the destructive effects that premarital sex and cohabitation have on adolescents prior to marriage. In a study analyzing the National Survey of Family Growth, non-virgin women faced a much higher risk of divorce than women who were virgins when they first marrried.209 In a similar study, among women who divorced, dissolution rates were higher for those who initiated sexual activity before marriage.210 Additionally, data from the National Longitudinal Survey of Youth indicate that among 18 year-old men and women, those who were virgins were twice as likely to stay married as those who were sexually active.211 Marriage and Well-Being Healthy relationships in marriage not only benefit society by providing a safe and nurturing atmosphere for children, but they also provide considerable benefits to each spouse. These benefits are found, in most part, in the life-long partnership of marriage; they are attributed to a better overall quality of life, or what is also known as an individuals well-being. Research demonstrates that married men and women, on average, have better health outcomes than single or divorced individuals. A recent study analyzing data from the Health and Retirement Survey of Americans, which includes persons between the ages of 51 and 61, found that married persons, compared to cohabiting, divorced, and widowed, had the lowest rates of incidence and morbidity for each of the major diseases surveyed, as well as the lowest rates of functional disability.219 One longitudinal study found that becoming and staying married is associated with lower levels of depression (especially among men) and lower levels of alcohol consumption among women.220 Individuals who are married, especially men, rely heavily on the emotional and psychological support that a spouse provides for their well-being. In fact, one study found that divorced men and women are more than twice as likely to take their own lives.222 Married couples are also more likely to be financially well off; compared to cohabiting couples and divorced/single individuals, married persons save more, build more wealth, and receive more financial transfers from their older family members.225 39 Centers for Disease Control and Prevention (CDC) Press Release. (March 11, 2008). Nationally Representative CDC Study Finds 1 in 4 Teenage Girls Has a Sexually Transmitted Disease. Retrieved 3/19/08 from:http://www.cdc.gov/stdconference/2008/media/release-11march2008.htm. 40 Weinstock, H., Berman, S., & Cates, W. (2000) Sexually transmitted diseases among american youth: Incidence and prevalence estimates. Perspectives on Sexual and Reproductive Health, 36(1), 6-10. 47 U.S. Department of Health and Human Services. (2001). Trends in the Well-Being of Americas Children and Youth, 2000. 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