Abstinence

Abstinence Only vs.
Comprehensive Sex Education:
What are the arguments?

What is the evidence?
Chris Collins, M.P.P.

Priya Alagiri, J.D.
Todd Summers
Progressive Health Partners
Stephen F. Morin, Ph.D.
AIDS Policy Research Center &

Center for AIDS Prevention Studies
AIDS Research Institute

University of California, San Francisco
Policy Monograph Series – March 2002

Abstinence Only vs. Comprehensive Sex Education
Table of Contents
Executive Summary .......................................................................................................ii
Introduction ..................................................................................................................... 1
Definitions of Sexuality Education............................................................................. 1
Personal and Social Costs of Unprotected Teenage Sexual Behaviors ............. 2
The Continuing Epidemic of HIV and AIDS ............................................................. 2
The Dynamics of Risk and Risk Perception............................................................. 2
What Do Parents Want for Their Children? ............................................................. 3
The Role of Federal and State Policy ....................................................................... 4

Federal Policy ............................................................................................................... 4
State Policy................................................................................................................... 7
School Policies ............................................................................................................. 7
What the Research Tells Us ........................................................................................ 8

Studies on Abstinence-Only Programs..................................................................... 8
Studies on Comprehensive Sex Education Programs ........................................... 9
Government Report on Condom Effectiveness.....................................................10
Appropriate Programming for Young People at Elevated Risk ..........................11
Arguments for Abstinence-Only Sex Education .................................................12

The Medical Institute for Sexual Health (MISH) Analysis....................................12
Arguments for Comprehensive Sex Education...................................................14
Conclusion.....................................................................................................................16
Appendix: Table of Studies.......................................................................................21
Endnotes........................................................................................................................17
Acknowledgments
This policy analysis was supported by a grant from the Until There’s A Cure
Foundation. The views expressed in this monograph are the views of the a u-
thors and do not necessarily reflect those of the funder.
i
Executive Summary The last decade has brought signs of encour-

agement. Sexual activity among young people
has fallen while use of condoms is on the in-
Over the last several years, Congress has em- crease. Yet sex, and the potential for negative
phasized funding abstinence-only programs over consequences from unprotected sex, remains a
comprehensive sexuality education. President reality in the lives of young people. In 1999, one
Bush and leaders in Congress have called for half (51%) of high school seniors said they had
“parity” in funding between abstinence-only sex been sexually active within the last three
education and family planning, safe sex pro- months. Several sub-groups of young people
grams. Congress increased funding for federal are at elevated risk of HIV and STIs, including
abstinence programs in fiscal year 2002, and lesbian, gay and bisexual youth; youth of color;
has been asked by the President to increase it homeless youth; adolescents in the penal or fos-
by another $33 million in fiscal year 2003. ter care systems; and young people who have
been sexually abused.
The abstinence-only approach to sex education
is not supported by the extensive body of scien- Responding to the continuing health threats of
tific research on what works to protect young HIV, STIs and unplanned pregnancy among
people from HIV/AIDS, sexually transmitted in- young people, the widely respected Institute of
fections (STIs), and unplanned pregnancy. An Medicine of the National Academy of Sciences
assessment of the peer-reviewed, published recently recommended eliminating congres-
research reveals no evidence that abstinence- sional, federal, state and local “requirements
only programs delay sexual initiation or reduce that public funds be used for abstinence-only
STIs or pregnancy. By contrast, credible re- education.” And surveys consistently show that
search clearly demonstrates that some compre- the public wants schools to deliver strong absti-
hensive sex education, or “abstinence-plus,” nence messages alongside information about
programs can achieve positive behavioral self-protection for young people who find them-
changes among young people and reduce STIs, selves in sexual situations. The vast majority of
and that these programs do not encourage parents support sex education in the schools,
young people to initiate sexual activity earlier or including the provision of information about con-
have more sexual partners. traceptive and condom use.
The growing prominence of the abstinence-only Unfortunately, federal policy is grossly out of
approach will likely have serious unintended step with the wishes of most parents and stu-
consequences by denying young people access dents, as well as the scientific research. Since
to the information they need to protect them- the early 1980s, Congress has devoted signifi-
selves. And abstinence-only programs risk al- cant resources to abstinence-only programming.
ienating the young people at highest risk of Partly as a result of federal policy and funding
negative health outcomes by promoting a “one changes, public schools are increasingly sup-
size fits all” vision of adolescence that matches porting abstinence-only curricula that are less
the true experiences of only a minority of youth. likely to include information about birth control,
STD prevention and sexual orientation. The
Unprotected sexual activity among young people evidence tells us that these trends represent a
can have severe personal, social and financial dangerous disservice to America’s younger
costs. Unprotected sex among youth results in generation.
nearly four million STIs each year, many with
serious long term consequences. The great ma-
jority of the 10,000 annual new HIV infections
among people under 22 occurs through sexual
activity. The United States still has the highest
rates of STIs and teen pregnancy of any indus-
trialized nation.
ii
Introduction who report having had sex also reporting current

1
abstinence. In the 1999 YRBS, among those
students who reported any sexual intercourse,
“A mutually faithful monogamous relationship in 27% said they had been abstinent during the
the context of marriage is the expected standard last three months.
1
of human sexual activity.” Different people will
disagree about the veracity of this statement, but A significant percentage of sexual encounters
we know that it does not reflect the experiences among young people are not wanted. In the
of the majority of young people. Yet sex educa- 1999 CDC survey, eight percent of 13- and 14-
tion funded by the federal government is re- year-old girls reported their first sexual encoun-
quired to be delivered in a way that is consistent ter was not voluntary.
1
with this declaration.
Abstinence-Plus Education Abstinence-Only Education

Abstinence-plus education programs explore Abstinence-only education includes discussions of
the context for and meanings involved in sex. values, character building, and, in some cases,
refusal skills.
• Promote abstinence from sex • Promote abstinence from sex

• Acknowledge that many teenagers will be- • Do not acknowledge that many teenagers will
come sexually active become sexually active
• Teach about contraception and condom use • Do not teach about contraception or condom
• Include discussions about contraception, use
abortion, sexually transmitted diseases and • Avoid discussions of abortion
HIV • Cites sexually transmitted diseases and HIV
as reasons to remain abstinent
The sex education debate in America takes on Definitions of Sexuality Education

special relevance because sex, and its related The content of sexuality education curricula in
health implications, are a reality in the lives of America varies widely by region, by school dis-
many young people. One of the best data trict, and, sometimes, by classroom. The highly
sources on sexual and self-protective behaviors charged political debate concerning sex educa-
of young people is the Youth Risk Behavioral tion could lead most people to believe there are
Surveillance System (YRBS) prepared by the hard and fast divisions between educational ap-
U.S. Centers for Disease Control and Prevention proaches. In fact, there are multiple program
(CDC). For years, the YRBS has been report- designs, many of which resist clear classifica-
ing a gradual decline in the percentage of young tion, or share components of seemingly oppos-
people reporting any sexual activity. According ing approaches.
to the CDC surveys, the percentage of high
school-aged youth (freshman through seniors) For this monograph, we use the definitions
reporting they have ever had sexual intercourse commonly found in the sex education debate:
1, 2
fell from 53% in 1993 to 50% in 1999. curricula are grouped into the two broad catego-
ries of comprehensive sex education (also often
There has been slightly less change in the per- called “abstinence-plus”) and abstinence-only-
centage of these young people who reported until-marriage (or “abstinence-only”) education.
current sexual activity, defined as sexual inter- The former generally emphasizes the benefits of
course during the preceding three months. In abstinence while also teaching about contracep-
1991, 38% reported current sexual activity. tion and disease-prevention methods, including
Eight years later, 36% reported such activity. 3
condom and contraceptive use. By contrast,
Older students are more likely to currently be abstinence-only programs generally teach absti-
2
having sex. Of students in grade 12 in 1999, nence from all sexual activity as the only appro-
1
51% said they were currently sexually active. 3
priate option for unmarried people. Abstinence-
Some students choose abstinence after initiation only programs often do not provide detailed (or
of sexual activity, with about one in four students
1
any) information on contraception for the pre- nificant economic consequences in the form of
4
vention of sexually transmitted diseases and higher welfare costs.
3
unintended pregnancies.
The Continuing Epidemic of HIV and AIDS
Sexuality education in the schools is a hot but- The HIV/AIDS epidemic remains a serious
ton issue in part because it is closely intertwined health concern for young people, and unpro-
with social and parental interpretations of right tected sexual activity is responsible for a sub-
and wrong, and with people’s feelings about re- stantial majority of these infections in youth. It is
ligion and personal autonomy. Yet sex educa- estimated that of the 40,000 new HIV infections
tion is also intended to serve a very practical in the US every year, approximately one-half (or
public health purpose – to reduce STIs, 20,000) occur in people under the age of 25 ,
8
HIV/AIDS, and unintended pregnancy among and one-quarter of new infections (10,000 annu-
the country’s young people. These are goals of ally) occur among those under 22. Several
9
sex education that virtually everyone agrees on. groups of young people are at an elevated risk
The debate centers on a question of methods for HIV infection, including young men who have
(i.e., how to prevent negative health outcomes) sex with men (MSM), bisexuals, transgendered
and the ancillary goals of advocates on all sides persons, homeless youth, runaways, injection
(e.g., teaching particular moral values, or en- drug users (IDUs), victims of sexual abuse,
couraging autonomous decision making). mentally ill youth, and young people in the penal
10
or foster care systems.
Personal and Social Costs of Unprotected
Teenage Sexual Behaviors Among young people more than any other age
Although teen pregnancy and birth rates have group, HIV is spread sexually, and sex between
4 8
declined in recent years, the U.S. still has the men remains a significant risk factor. In young
highest rates of STIs and teen pregnancy of any men 20–24 years old, MSM account for 62% of
5, 6
industrialized country in the world. Each year, cumulative AIDS cases while MSM/IDUs ac-
3.75 million teenagers will contract an STI, and count for 10%. Of cumulative cases among
one in three sexually active individuals will con- young women aged 20–24, 55% are related to
7 11
tract an STI by age 24. There are approximately heterosexual sexual contact. In total, 48% of
one million teen pregnancies and about half a cumulative reported AIDS cases among all
6
million teen births each year. In the 1970s and youth aged 13–24 involves MSMs or
11
80s, pregnancy rates increased by 23% (from MSM/IDU. Approximately 11% of all cases
1972 to 1990) but fell significantly in the 1990s among young men and women in this age group
6
(by 19% from 1991 to 1997). are categorized as “risk not reported.”
STIs can lead to significant personal, social and HIV infection rates among young MSM remain
economic consequences. Pelvic inflammatory high, particularly in urban areas. A study re-
disease, which is often the consequence of an leased in 2000 found that, among young (15–22
untreated or improperly treated STI, is responsi- year old) MSM in seven metropolitan areas, the
ble for at least 30% of cases of infertility among average HIV infection rate was 7.2%, with higher
7
American women. STIs can cause ectopic rates among African Americans, Latinos, and
12
pregnancies, reproductive cancers, spontaneous young men of mixed race. Black and Hispanic
abortions or still births, and other health prob- women aged 13 to 24 account for approximately
lems, and make women 2-5 times more vulner- 75% of all HIV infections among American
7 13
able to HIV infection. women.
There are other potential costs to unprotected The Dynamics of Risk and Risk Perception
sexual activity among teenagers. Research has Young people are concerned about AIDS, but
shown that adolescent girls who become moth- interviews with teens reveal that many do not
ers are less likely to complete high school. perceive themselves to be personally at risk.
14
“[C]hildren born to younger teens may also ex- Only one in four (25%) of 15– to 17-year-old
perience poorer health outcomes, lower educa- sexually experienced youth say they have ever
tional attainment, and higher rates of adolescent 15
been tested for HIV. One reason may be lack
childbearing themselves when compared to chil- of information. In a recent survey, only 46% of
4
dren born to older mothers.” Teenage preg- 15- to 17-year-olds say they knew where to get
nancy and childbearing also carry with them sig-
2
16
tested for HIV infection or other STDs. It also condoms” discussed; 84% think sex education
appears that many adolescents do not have a should cover “how to use and where to get other
full understanding of contraception. For exam- birth control,” and 76% want homosexuality ad-
21
ple, 21% of teens mistakenly believe that birth dressed in classroom sexuality education.
control pills are very or somewhat effective at
17
HIV prevention. A public opinion survey of 1,050 adults nation-
22
wide by Hickman-Brown Research, Inc. was
In the age of AIDS, condom use among the commissioned by SIECUS and Advocates for
young has increased markedly. Between 1991 Youth in 1999. It found that 84% of adults sup-
and 1999, reported condom use at last sexual port sex education for junior high students and
intercourse increased from 46% to 58% among 93% support this education for high school stu-
18
high school students. And the percentage of dents. When asked about what particular areas
young people reporting being taught about are appropriate to teach young people at various
th th
HIV/AIDS in school increased over the period ages, 79% felt 7 and 8 graders should be
18
from 83% to 91%. Yet condom use declines as taught about abstinence and an additional 12%
th th
young people get older and other contraceptive felt 9 and 10 graders should be taught about
methods are used at increasing rates. The abstinence. A majority of adults surveyed also
longer a sexual relationship, the less likely supported junior high and high school students
19
young people are to use condoms learning about contraception, condoms and sex-
ual orientation issues. For example, 59% of
th th
Dynamics within relationships often determine adults thought 7 and 8 graders should be
whether contraceptives are used. Fifty-two per- taught about contraception and birth control, and
th th
cent of teens say that “one of the main reasons an additional 25% thought 9 and 10 graders
that teens do not use birth control is because should learn about this subject.
their partners don’t want to.” And 53% of teens
say “the main reason teens do not use contra- Adults interviewed for the survey were then
20
ception is because of drinking or using drugs.” asked which of the following statements they
Teens report mixed emotions about requesting agreed with more: “Some people believe that
that a condom be used during sex. When asked whether or not young people are sexually active,
what they would feel if a sexual partner sug- they should be given information to protect
gested using a condom, 89% would be “glad themselves from unplanned pregnancies and
they brought it up,” but 66% would be suspicious sexually transmitted diseases. Other people be-
of their partner’s sexual history, and 49% would lieve that telling young people about birth control
feel like their partners were suspicious of their and sexually transmitted diseases only encour-
17
sexual history. ages them to have sex. Which comes closer to
the way you feel?” Eighty-four percent of re-
These facts and figures offer encouragement spondents said they agreed with the first state-
and a challenge. Rates of sexual activity are ment, and 10% agreed with the second.
falling and condom use rates are increasing.
But STIs, HIV/AIDS, and unintended pregnancy Young people and parents appear to be largely
remain serious health problems. In addition, the united on the need for more information about
complex dynamics of risk and risk perception sexual health and sexual self protection. Ac-
complicate prevention efforts. In this environ- cording to a national survey of teens, 51% say
ment, sex education has a profoundly important they need more information about how to get
role to play. tested for HIV/AIDS and other STIs and 50%
want more information on STIs other than
What Do Parents Want for Their Children? HIV/AIDS; 39% want more information about
Most parents believe their children need basic abortion; 30% want more information on how to
information about sex and sexual self protection. use condoms; and 27% say they need more in-
21
According to a survey of students, parents, formation about sexual orientation.
teachers and principals commissioned by the
Kaiser Family Foundation, “parents want a wider
range of topics taught than is often included in
21
sex education today.” Ninety-eight percent of
parents say they want HIV/AIDS discussed in
sex education classes; 85% want “how to use
3
The Role of Federal and State what should be taught in schools or the real life
challenges faced by the “average” American
Policy adolescent.
In October 2001, Congressman Ernest Istook of The abstinence-only movement is pushing

Oklahoma came to the floor of the House of against balance in sex education curricula, by
Representatives to offer an amendment. Istook promoting one set of behaviors and values.
was pleased that the appropriations bill being Comprehensive sex education typically pro-
considered by Congress that day included sub- motes abstinence as the best option for young
stantial funding increases for abstinence-only people, while providing them with information
education. But he lamented that these in- about self protection if they do have sex. Absti-
creases did not bring abstinence-only funding to nence-only turns away from the challenges
parity with “safe sex, family planning” programs. young people face as they make decisions
“Mr. Chairman,” Istook said in offering his about sexuality and self-protection.
amendment, “….This does not attack the pro-
grams that we have been funding for years, but And yet with no evidence of effectiveness be-
it does say that it is about time that the average hind it, abstinence-only education is the new
American, the typical American, the normal val- wave in federal policy on sexuality education.
ues of everyday people in this country, receive Since the early 1980s, Congress has devoted
the same emphasis from their government as large sums of federal funding toward absti-
23
we have put on other things.” However, advo- nence-only-until marriage education. Combined
cacy groups explain that the “parity” argument with state matching dollars, funding for absti-
inappropriately compares funding for classroom nence-only education increased by nearly
education with funding for family planning medi- 3
24, 25
3000% from 1996 to 2001.
cal services provided to minors in clinics.
Federal Policy
Abstinence-Only Curriculum Federal law does not require sexuality education
Welfare Reform Act of 1996
in schools. In fact, several federal statutes
Allocates $50 million annually for five years stipulate that the federal government should not
to states for abstinence-only programs. The prescribe curriculum standards.
26
However,
legislation requires that, among other things, Congress has created three programs that pro-
programs teach: vide federal funding for sexuality education: 1)
• “Abstinence from sexual activity out- the Adolescent Family Life Act (AFLA); 2) tar-
side marriage as the expected stan- geted abstinence-only funding through 1996
dard for all school-age children.” welfare reform legislation; and 3) the Special
• “A mutually faithful monogamous re- Projects of Regional and National Significance–
lationship in the context of marriage Community-Based Abstinence Education
is the expected standard of sexual (SPRANS -CBAE) grant program. All three of
activity.” these programs promote abstinence-only sexu-
• “Sexual activity outside the context of ality education.
marriage is likely to have harmful
psychological and physical effects.” In fiscal year 2002, federal appropriations for
promoting abstinence-only education reached
Congressman Istook was echoing a call Presi- $102 million: $12 million through AFLA ($10 mil-
dent George W. Bush had made during his can- lion is earmarked for abstinence-only programs
didacy that federal funding for abstinence-only while $2 million is earmarked for abstinence-
programs should equal that for family planning based programs), $50 million through the wel-
programs. This new pro-abstinence-only fare reform legislation and $40 million through
movement among leading politicians sounded SPRANS-CBAE. President Bush recently pro-
reasonable enough. It was presented as a posed a $33 million increase in abstinence-only
quest for “balance” in the messages young peo- sexuality education for the FY 2003 budget,
ple hear, as an affirmation of values that are which would bring the total federal funding level
beneficial to adolescents. And yet there is little for abstinence programs to $135 million ($12
reason to conclude that abstinence-only curricu- million through AFLA, $50 million through the
lum represents the “typical” American’s wish for
4
welfare reform legislation, and $73 million In January 1993, an out-of-court settlement was
27
through the SPRANS-CBAE program). reached between the Department of Civil Justice
and the Center for Reproductive Law and Policy
stating that AFLA-funded sexuality education:
Sources of Federal Funding for “may not include religious references; must be
Abstinence-Only Sex Ed medically accurate; must respect the `principle
Fiscal Year 2002 of self-determination’ of teenagers regarding
AFLA contraceptive referrals; and must not allow
10% grantees to use church sanctuaries for their pro-
SPRANS
-CBAE grams or to give presentations in parochial
31
40% schools during school hours.”
Despite its troubles, the federal government has

invested significantly in AFLA. From fiscal year
1982 to fiscal year 1996, AFLA funding for ab-
stinence-based programs totaled approximately
32
Welfare $52 million. In 1996, AFLA was altered to re-
Reform flect the restrictive definition of abstinence edu-
50% cation contained in the 1996 welfare reform leg-
31
islation (discussed below). Since then, AFLA
has received approximately $10 million annually
for these more restrictive abstinence education
Adolescent Family Life Act
programs.
In 1981, Congress passed the AFLA, commonly
referred to as the “Chastity Act,” which was de-
signed to “promote self discipline and other pru- Welfare Reform Legislation
dent approaches to the problem of adolescent
premarital sexual relations, including adolescent In the mid-1990s, federal investment in absti-
pregnancy” and “to promote adoption as an al- nence-only sexuality education increased sig-
28
ternative for adolescent parents.” The enact- nificantly as a result of a provision attached to
ment of AFLA represents the first time the fed- the welfare reform legislation. Signed by Presi-
eral government invested in teen pregnancy dent Clinton in 1996, the welfare reform legisla-
prevention programs focused on “chastity and tion creates an automatic annual appropriation
29
self discipline.” The AFLA program awards for abstinence education in Section 510, Title V,
grants to public and nonprofit organizations to of the Social Security Act. Starting in 1998, the
provide services “which are essential to … the law provides $50 million annually for five years
prevention of adolescent premarital sexual rela- to enable states “to provide abstinence educa-
tions and adolescent pregnancy” and which pro- tion … with a focus on those groups most likely
33
vide care for “pregnant adolescents and adoles- to bear children out of wedlock.” Funds are
cent parents.”
28 only provided to programs following the legisla-
tion’s strict eight-point definition of “abstinence
In 1983, because AFLA’s early programs largely education.” Participating states must match
benefited religious groups, the ACLU, on behalf every $4 of federal funds with $3 of state
34
of clergy members and taxpayers, filed suit funds.
claiming that how AFLA was implemented vi o-
lated the separation of church and state as For purposes of the legislation, the term “absti-
30
mandated by the U.S. Constitituion. The plain- nence education” means an educational or moti-
tiffs argued that ALFA constituted an endorse- vational program that:
ment by the federal government of a particular
31
religious point of view. A federal district court • Has as its exclusive purpose, teaching
found that the program was unconstitutional, but the social, psychological, and health
3
the Supreme Court reversed that decision. Liti- gains to be realized by abstaining from
gation continued concerning how ALFA would sexual activity;
be implemented.
31 • Teaches abstinence from sexual activity
outside marriage as the expected stan-
dard for all school-age children;
5
• Teaches that abstinence from sexual SPRANS-CBAE

activity is the only certain way to avoid In 2000, Congress approved a third abstinence-
out-of-wedlock pregnancy, sexually only education program. SPRANS-CBAE (Spe-
transmitted diseases, and other associ- cial Projects of Regional and National Signifi-
ated health problems; cance–Community-Based Abstinence Educa-
• Teaches that a mutually faithful motion) is funded through a set-aside in the mater-
nogamous relationship in the context of nal and child health block grant, receiving $20
marriage is the expected standard of million in FY 2001 and $40 million in FY 2002.
human sexual activity; Similar to abstinence-only education funded un-
• Teaches that sexual activity outside of der the welfare reform law, programs funded
the context of marriage is likely to have under SPRANS-CBAE must conform to the strict
harmful psychological and physical ef- Federal eight-point definition of abstinence put
37
fects; forth in that law.
• Teaches that bearing children out -of-
wedlock is likely to have harmful conse- But SPRANS -CBAE is even more restrictive
quences for the child, the child’s par- than the welfare bill, requiring programs to be
ents, and society; “’responsive’” to each of the eight points, rather
• Teaches young people how to reject than simply not being “inconsistent” with any of
37
sexual advances and how alcohol and the points, as in the welfare legislation. Fur-
drug use increase vulnerability to sexual ther, SPRANS-CBAE does not require programs
advances; and or states to match the funding they receive. In
• Teaches the importance of attaining addition, SPRANS-CBAE funds are competitive
self-sufficiency before engaging in sex- grants awarded directly to public or private or-
35 ganizations while the welfare reform programs
ual activity.
are funded through categorical block grants to
37
states. Recipients of the grants include Mid-
State Implementation of the Welfare Reform South Christian Ministries; Choosing the Best,
Legislation Inc.; Tri-County Right to Life Education Founda-
tion; Catholic Charities of Buffalo; and The Crisis
During 1998, the first year of the program, all 50 37
Pregnancy Centers of Greater Phoenix.
states, the District of Columbia, Guam, the Vir-
gin Islands and Puerto Rico applied for grants The SPRANS-CBAE program awards two types
for abstinence-only programming authorized of grants: 15 to 21 one-year planning grants,
3
through the welfare reform bill. (Two states – ranging from $50,000 to $75,000, and approxi-
California and New Hampshire – eventually de- mately 25 to 50 three-year implementation
3
clined the grants. ) States invested their funds grants, ranging from $250,000 to $1 million.
38
on approximately 700 abstinence-only grants to On July 6, 2001, HHS announced that over
education agencies, community-based organiza- $17.1 million in new grants will be provided for
3
tions and statewide programs. Twenty-two abstinence-only education for young people be-
states introduced new abstinence-only programs 37
tween 12 and 18 years of age.
while 21 continued existing abstinence-only pro-
3
grams.
Family Life Education Act
In the second year of the program, 49 states, To date, legislation to promote comprehensive
Puerto Rico and the Virgin Islands applied for sex education has fared less well in Congress.
and received federal funding. Although Califor- On December 12, 2001, Representative Barbara
nia applied for funds, it ultimately chose not to Lee of California introduced the bipartisan-
3
participate in the program. That year, 45 juris- supported “Family Life Education Act” in the
dictions spent a total of $69 million through the House of Representatives. The legislation
program — $33 million through public entities, would provide $100 million in grants to states “to
$28 million through private entities and $7 mil- conduct programs of family life education, in-
lion (in 22 jurisdictions) through faith-based enti- cluding education on both abstinence and con-
36
ties. In FY 2000, the third year of the program, traception for the prevention of teenage preg-
California was the only state that did not apply nancy and sexually transmitted diseases, includ-
3 39
for federal funds. ing HIV/AIDS.” The legislation would permit
states to receive federal funds for comprehen-
6
sive sexuality education that includes informa- A study comparing 1988 and 1999 national sur-
tion both on abstinence and contraception. The veys of teachers found that secondary public
legislation’s co-sponsors are Representatives schools are increasingly focused on abstinence-
Lynn Woolsey, a Democrat from California, and only education, finding “steep declines” in the
Jim Greenwood, a Republican from Pennsyl- teaching of birth control, abortion and sexual
vania. The fate of this legislation is not known. orientation in the schools between 1988 and
41
1999. According to the study, 23% of secon-
State Policy dary school sexuality education teachers in 1999
taught abstinence as the only way of preventing
According to a review of states’ laws and poli-
pregnancy and STIs as compared to 2% in
cies by the Alan Guttmacher Institute, most 41
1988. Schools in the South are most likely to
states have adopted laws governing sexuality
40 have abstinence-only policies while, in contrast,
and STI education. The review found that 39
school districts in the Northeast are least likely
states require that some sexuality education be 29
to have abstinence-only policies.
provided throughout the state, and that 21 states
require that both sexuality and STD education
40
be provided. Seventeen states require the pro-
vision of STD information specifically, but not
sexuality education. Only Maine requires sexu-
ality education but not STD education, and 11
states leave the decision to teach sexuality edu-
cation and/or STD education entirely to local
40
school districts.
School Policies
While most states require schools to teach
sexuality education, local school districts are
given wide latitude in determining the content of
40
their sexuality education programs. However,
the minimal guidance that states do provide
40
stresses abstinence. More than two out of
three public school districts have a policy man-
29
dating sexuality education. According to a na-
tionwide survey taken by the Alan Guttmacher
Institute of school superintendents:
• “86% percent of school districts with a
sexuality education policy require pro-
motion of abstinence”;
• “51% require that abstinence be taught
as the preferred option but also permit
discussion of contraception as an effec-
tive means of protecting against unin-
tended pregnancy and STIs”;
• “35% require abstinence to be taught as
the only option for unmarried people,
while either prohibiting discussion of
contraception altogether or limiting dis-
cussion to contraceptive failure rates”;
and
• “14% of school districts currently have
policies that are truly comprehensive
and teach both contraception and absti-
29
nence”.
7
ferences in the lives of young people, the nega-

What the Research Tells Us tive consequences of teen sexual activity are
complex and not easily remedied with a school
class or an after school program. Teen sexuality
Behavior research cannot make judgments is influenced by parents, schools, communities,
about social values, but it can evaluate the suc- the media, society as whole, available preven-
cess of school-based curricula at producing tan- tion technology, and individual young people
gible outcomes for young people. The weight of themselves.
the evidence from peer-reviewed scientific jour-
nals clearly shows that some comprehensive Teenagers can, in most cases, choose their
sex education programs can reduce behavior sexual behavior. But the research demonstrates
that puts young people at risk of HIV, STIs and that how those decisions are made is greatly
unintended pregnancy, and that these programs influenced by the world that surrounds young
do not promote earlier onset of sexual activity or people. And many of these social factors go
an increased number of sexual partners among beyond the “values” espoused by community
adolescents. By contrast, little if any credible leaders, involving the stubborn complexities of
research exists to substantiate the claims that economic, geographic, and historical factors. As
abstinence-only programming leads to positive Kirby notes, “A substantial proportion of all the
behavior change among youth. risk factors involve some form of disadvantage,
19
disorganization, or dysfunction….” The multi-
The credible research sends a clear message to plicity and complexity of these risk and resilience
policy makers: if the goal of school-based sex factors mean that no one intervention can fully
education is to increase positive health out- address the myriad risks faced by young people
comes for youth, comprehensive (or “absti- – there are no simple answers to the challenges
nence-plus”) sex education is the proven effec- of teen sexual risk taking.
tive choice. Abstinence-only programming runs
the serious risk of leaving young people, espe- Studies on Abstinence-Only Programs
cially those at elevated risk, uninformed and al-
ienated. While much has been written on the value or
limitations of abstinence-only programs, a sur-
prisingly few number of published, peer-
reviewed abstinence-only studies exist that
“…[T]he committee recommends that: Con- demonstrate measurable behavior change
gress, as well as other federal, state, and among young people. Abstinence-only advo-
local policymakers, eliminate requirements cates claim that there are reliable studies that
that public funds be used for abstinence-only indicate the positive effects of abstinence-only
education, and that states and local school programs. For example, a report commissioned
districts implement and continue to support by the Consortium of State Physicians Resource
age-appropriate comprehensive sex educa- Councils lists six studies that the Consortium
tion and condom availability programs in says point to positive effects of the abstinence-
43
schools.” only approach. Yet only one of these studies is
a peer-reviewed published journal article issued
42
Institute of Medicine, 2001 in the last ten years. Other references include
articles in the Portland Oregonian, a doctoral
dissertation, and a report from the Michigan De-
partment of Community Health. The one recent
By far the most comprehensive survey of re-
peer-reviewed article does not actually review
search on sex education has been conducted by
an abstinence-only program, but is instead a
Dr. Douglas Kirby and a team of research ex-
report on survey findings from the National Lon-
perts. With publication of Emerging Answers in
gitudinal Study on Adolescent Health noting that
2001, Kirby provided a lengthy and sophisticated
a pledge of abstinence was the factor most as-
review of hundreds of published studies on the
sociated with a delay in initiation of sexual acti v-
outcomes of sex education curricula for young
ity among those surveyed.
people in schools, health clinics and in commu-
19
nities. One of the most important points to
Abstinence-only advocates have also touted a
come out of Kirby’s analysis is that while some 44
study published in 2001 which found that teens
sex education programs make measurable dif-
who take a pledge to remain virgins until they
8
marry are much less likely to have sexual inter- of sexual partners. To the contrary, some sex
course than adolescents who did not take the and HIV education programs delay the onset of
pledge. However, the study also found that the sex, reduce the frequency of sex, or reduce the
19
pledges were effective only when taken as part number of sexual partners.”
of a minority, although not too small, group. It
appears that pledges of virginity have particular Several specific studies have demonstrated
power only when those making the pledge feel positive outcomes from sex education curricula,
they are part of a select group. The implication including delayed initiation of sexual activity,
is, of course, that such pledges would not be increased condom use, and decreased number
47
effective for whole populations of students in any of sexual partners. Ekstrand and colleagues
school or community. studied the effects of an intervention titled
Healthy Oakland Teens in Oakland, California.
th
Also of interest is a September 2001 survey The program involved 7 graders in five adult-
commissioned by the National Campaign to led and eight peer-led sessions. Students were
Prevent Teen Pregnancy which reports that provided with information on HIV and STIs, sub-
teens cite moral and religious beliefs as signifi- stance abuse and preventive behaviors. Issues
cant factors in not engaging in sex, and that such as perception of personal risk, costs and
“[a]dolescents who are more religious hold more benefits of preventive behaviors, refusal skills
45
conservative views regarding sex.” In addition, and condom use were all addressed. The re-
the survey found that “religious” young people searchers found that those students in the inter-
are more likely to delay having sex. The survey vention group delayed initiation of sexual activ-
results point out that for many young people, a ity.
message emphasizing particular traditional and
religious values can be powerful and positive. It One intervention, called Reducing the Risk, was
must be remembered, however, that such mes- found to be effective when independently im-
sages will not resonate with some young people plemented and examined by different research-
48
and that it would be unconstitutional to teach ers in different locations. Kirby and colleagues
religion in schools. studied this intervention in urban and rural areas
th
throughout California through15 sessions in 9
th
The most rigorous study of an abstinence-only to 12 grade health education classes. The in-
program reviewed in Emerging Answers studied tervention included extensive role playing and
the outcomes of the Postponing Sexual In- emphasized avoidance of unprotected sex
volvement (PSI) curriculum, a five-session pro- through abstinence or using protection. The
gram taught by adults or peers that was imple- control group received existing sex education
46
mented in California. Although ultimately find- programs of equal length. At 18 months post-
ing that the PSI program was unlikely the cause, intervention, the program was found to have de-
the study found that students enrolled in PSI layed the initiation of intercourse, increase fre-
who received instruction from peers were more quency of contraceptive use for females and
likely to report becoming pregnant or causing a lower-risk youth, and reduce the frequency of
pregnancy. The study concluded that the pro- unprotected intercourse among more sexually
gram had no measurable impact on the initiation inexperienced youth. Seven years later, Hub-
49
of sex, the frequency of sex, or the number of bard and his colleagues also studied the Re-
sexual partners. ducing the Risk intervention, but conducted the
study in urban and rural areas in Arkansas. This
Studies on Comprehensive Sex Education study involved 16 sessions with the same age
Programs group, and also included extensive role playing
In contrast to the limited and discouraging re- and emphasized avoidance of unprotected sex
sults for studies on abstinence-only programs, through abstinence or using protection. The
the published research on sex and HIV educa- control group received existing sex education
tion programs is far more conclusive and en- activities from state-approved texts or absti-
couraging. According to Emerging Answers, “A nence-only curricula. Similarly, the study found
large body of evaluation research clearly shows that the program delayed the initiation of inter-
that sex and HIV education programs included in course and increased condom use among sexu-
this review do not increase sexual activity – they ally inexperienced youth.
do not hasten the onset of sex, increase the fre-
quency of sex, and do not increase the number
9
50
St. Lawrence and colleagues studied the inter- Government Report on Condom Effectiveness
vention Becoming A Responsible Teen, that in- Abstinence-only adherents have seized upon a
cluded eight 1½ to 2-hour weekly meetings. The study released by the US Department of Health
intervention used small group discussions and and Human Services (HHS) in July 2001 that
included role playing and sessions with HIV was widely reported to raise questions about the
positive young people. AIDS information, sexual efficacy of condoms to prevent some STIs. In
decision making, and use of condoms were all June 2000, at the request of then-Congressman
covered in the discussions. The researchers Tom Coburn (R-OK), a panel of experts was
found that young people in the intervention convened to answer the question: “What is the
group, as compared with those in the control scientific evidence on the effectiveness of latex
group, showed delayed initiation of sexual inter- male condom-use to prevent STI transmission
course, decreased number of sexual partners, during vaginal intercourse?” The 28 experts
and increased rates of condom use. reviewed more than 138 peer-reviewed pub-
lished studies on condom use. Their report con-
One recent study compared comprehensive sex cluded there is sufficient evidence to determine
education curricula with an abstinence-based that male latex condoms can reduce HIV trans-
approach. Be Proud! Be Responsible! deliv- mission and can also prevent men from acquir-
ered the two curricula (abstinence-based and ing gonorrhea from a female partner.
th th
safer sex-based) to low-income 6 and 7 grad-
ers in Philadelphia. Eight one-hour modules The panel also determined that the current sci-
were provided over two Saturdays and included entific evidence is not sufficient to make conclu-
small group discussions, videos, games and sions about the usefulness of condoms in pre-
experiential exercises. Jemmott and colleagues venting transmission of other STIs, including
found more positive effects on frequency of sex, genital human papilloma virus (HPV) or other
condom use, and frequency of unprotected sex sexually transmitted infections that might be
over time for those young people in the safer passed through lesions not covered by con-
sex-based sessions than for those in the absti- doms. However, according to the expert review,
51
nence-based sessions. The abstinence-based condoms “might afford some protection in reduc-
curriculum delayed the initiation of intercourse at ing the risk of HPV-associated diseases.” The
3 months post-intervention and increased con- final report released by HHS noted that, “the
dom use at 12 months post-intervention. It absence of definitive conclusions reflected in-
should be noted, however, that this was not a adequacies of the evidence available and should
strict abstinence-only program. Abstinence was not be interpreted as proof of the adequacy or
strongly emphasized, but condoms were men- inadequacy of the condom to reduce the risk of
tioned as a means of contraception. STIs.”
Other studies have demonstrated long lasting Referring to a new law requiring federal agen-
positive effects on behavior from comprehensive cies to provide medically accurate information,
sex education programs. Coyle and col- former Congressman Coburn opined to the Sec-
52
leagues studied an intervention called Safer retary of HHS that, “this report means that when
Choices. Ninth graders in San Jose, California condom use is discussed, it is no longer medi-
and Houston, Texas were involved in multiple cally accurate – or legal for the CDC – to refer to
activities, including sex education curriculum. sex as ‘safe’ or ‘protected’…. As a medical doc-
There was also a parent education component. tor, the best prescription I can give to avoid in-
The program emphasized abstinence, but taught fection with a sexually transmitted disease is
that condom use makes sex safer. Students abstinence until marriage and a life-long, mutu-
also received training on skills to avoid sex or ally monogamous relationship with an uninfected
use condoms if they did have sex. Researchers 53
partner.” The CDC has not announced any
found that those in the intervention group changes in its policies, however, and continues
showed increased condom usage rates and re- to report that condoms, when used properly, are
duced frequency of sex without condoms. “highly effective in preventing HIV transmis-
These positive outcomes held up more than 31 54
sion.”
months after the intervention.
Following the release of the HHS literature re-
view on condom efficacy, the American Public
Health Association, the World Health Associa-
10
tion, and the Joint United Nations Programme 10,000 new HIV infections that occur in young
on AIDS (UNAIDS) all reaffirmed their positions people under the age of 22 each year in the
regarding the importance of continuing to pro- United States. The advent of highly active anti-
mote the use of condoms for HIV prevention. retroviral therapy for HIV disease means there
are additional reasons to counsel young people
Appropriate Programming for Young People about HIV and encourage them to be tested for
at Elevated Risk HIV and seek care. One recent study found that
If one of the primary goals of sex education in only a quarter (25%) of sexually experienced 15-
15
schools is to reduce the number of HIV infec- to 17-year-olds have ever been tested for HIV.
tions and STIs, then programming must be de-
signed to meet the needs of young people at Research has established that HIV prevention
elevated risk for acquiring these infections. and sex education programming can be benefi-
These youth include the sexually experienced, cial to young people at elevated risk of negative
sexually abused youth, homeless and runaway health outcomes. For example, researcher Mary
youth, and gay and lesbian young people. Jane Rotheram-Borus studied an intervention
with homeless and runaway youth that included
While teens in each of these groups may benefit up to 30 HIV intervention sessions addressing
from a strong abstinence message, it is also general HIV knowledge, coping skills, access to
clear they will not be well served by program- health care, and individual barriers to safer sex.
ming which claims that sexual experiences The program successfully increased consistent
should occur exclusively in the context of tradi- condom use for those receiving the interven-
61
tional marriage or which shames other kinds of tion.
sexual experiences. Young people at higher risk
need guidance on how to live lives safely out-
side of the structures of traditional married life.
Failure to provide lesbian/gay-sensitive informa-
tion would effectively shut out a significant mi-
nority of young people at elevated risk from the
benefits of sexuality education. In their as-
sessment of the HIV epidemic among young
MSM, the Centers for Disease Control and Pre-
vention warned that “Abundant evidence shows
a need to sustain prevention efforts for each
55
generation of young gay and bisexual men.”
The risk of HIV and STIs is compounded for les-

bian and gay young people. The 1995 Massa-
chusetts Youth Risk Behavior Surveillance found
that being gay, lesbian or bisexual increased a
young person’s chances of having experienced
sexual contact against his or her will and of hav-
ing had sexual intercourse with four or more
56
partners. Gay, lesbian and bisexual youth face
other special challenges. They are at increased
57
risk for harassment and violence, and suffer
high rates of suicide and other mental health-
58,59
related conditions. Young lesbians, gays and
bisexuals are more likely to have left or been
abandoned by their families and, therefore, to be
out of both the private and public health care
60
system.
Lack of access to health care among young

gays and lesbians is particularly troublesome
since, as noted above, young men who have
sex with men represent a significant share of the
11
Arguments for Abstinence-Only they believe are consistent with the abstinence-
only message, have measurable positive effects.
Sex Education Concerned Women for America states that
“study after study has shown that religion acts
There are many different groups across the 63
as a deterrent to early sexual activity.” And, as
United States advocating for abstinence-only noted above, many teens say that morals, val-
sex education in the schools. They include ues and/or religious beliefs play a significant role
Concerned Women for America, the Eagle Fo- in deciding whether or not to have sex.
rum, the Family Research Council, Focus on the
Family, the Heritage Foundation, the Medical Abstinence-only proponents point to studies
Institute for Sexual Health (MISH), the National concluding that the abstinence-only education
Coalition for Abstinence Education, and STOP message has played a central role in the decline
Planned Parenthood International. of adolescent sexual activity, and related nega-
tive health outcomes, over the last decade. One
These and other proponents of abstinence-only study reports that “…abstinence and decreased
education argue primarily that sex before mar- sexual activity among sexually active adoles-
riage is inappropriate or immoral and that absti- cents are primarily responsible for the decline
nence is the only method which is 100% effec- during the 1990s in adolescent pregnancy, birth
62, 63
tive in preventing pregnancy and STIs. Many and abortion rates. Attributing these declines to
such groups emphasize that condoms are not increased contraception is not supported by the
43
fool-proof in preventing pregnancy or STIs, and data.”
that sexual activity outside marriage can result in
The logic of this argument is as follows: statistics
“serious, debilitating, and sometimes, deadly
63 show a shift in choice of contraceptives from oral
consequences.” In addition, many abstinence-
contraception to condoms among young people
only advocates are deeply concerned that infor-
in the 1990s. “[B]ased on lower reported con-
mation about sex, contraception and HIV can
traceptive use and switch to a less effective pre-
encourage early sexual activity among young
63 vention method (condoms vs. oral contracep-
people. These advocates credit the decrease
tives), sexually active adolescent females in
in teenage pregnancy largely to the advance-
64 1995 were less protected against pregnancy
ment of the abstinence-only message. 43
than in 1988.” At the same time, the out -of-
wedlock birthrate for sexually active females,
An article on the Concerned Women for America
15–19, increased from 1988 to 1995 – despite
web site states that “[t]his is not simply an issue
an increased use of condoms. The authors
of morality, but a matter of public health. The
conclude that the overall declines in pregnancy
problems that have become so entrenched in
are likely due mostly to expanded acceptance of
our country, such as AIDS, illegitimate births,
abstinence and abstinence-only teachings, re-
poverty, increasing crime and the breakdown of
sulting in an overall decline in adolescent sexual
the nuclear family, can all be attributed to the
activity.
debilitating effects of a public policy that con-
dones sex without love or responsibility. … As
The Medical Institute for Sexual Health
research clearly indicates, America is not suffer-
(MISH) Analysis
ing from a lack of knowledge about sex, but an
63 MISH has positioned itself as a leader in defi n-
absence of values.”
ing abstinence-only curricula and rebutting “ab-
Another group, Focus on the Family, decries stinence-plus” education efforts. Like the Sexu-
what they believe is a dangerous inconsistency ality Information and Education Council of the
in health curricula. “From tobacco, alcohol and United States (SIECUS), MISH has proposed
drug use to fighting, gun use and drunk driving, education guidelines for sexuality education in
the prevailing message is ‘don’t do it’ – avoid or kindergarten through high school. MISH says
eliminate the risk,” they write. “But when it that its guidelines offer “a character-based ab-
comes to sex and all the potential dangers that stinence approach to sexuality education.” A
accompany it the message is, ‘Use condoms to MISH handbook provides a side-by-side com-
reduce your risk of unwanted pregnancies and parison of SIECUS and MISH guidelines, told
65 66
sexually transmitted diseases.’” from the perspective of MISH. According to
this comparison of curricula, the MISH guide-
In addition, abstinence-only advocates argue lines promote “moral capabilities, such as the
that traditional values and religious faith, which
12
ability to judge right from wrong,” while SIECUS

informs youth that “sexual intercourse provides
pleasure” and that “homosexual love relation-
ships can be as fulfilling as heterosexual rela-
tionships.”
MISH teaches that “there are core ethical values

that are held, more or less, universally… [I]t is
most appropriate for schools to target these core
ethical values (respect for self and others, re-
sponsibility, self-discipline, self-control, integrity,
honesty, fairness, kindness, etc.) as objectives
for curricular development.” In contrast,
SIECUS is said to believe that “values should be
freely chosen after the alternatives and their
consequences are evaluated.”
The MISH critique of the safer sex approach is

that it is “value neutral,” emphasizing individual
choices by students rather than moral absolutes.
MISH urges that “it is incumbent upon responsi-
ble adults to direct students away from physi-
cally unsafe or disadvantageous lifestyle alterna-
tives and toward those which enhance opportu-
nities for successful, healthy futures.” For MISH,
counseling young people about methods of self-
protection in sex undermines the abstinence
message. Students “must not leave the sex
education classroom thinking, ‘I’m being respon-
sible and safe if I use a condom.’” If condoms
and other contraceptives are discussed, MISH
urges an emphasis on the failure rates of these
methods.
At a fundamental level, what is at issue here is

not only content, but control – who determines
what young people hear about sexuality:
schools, teachers, young people, or parents.
The MISH booklet argues that “when parent
views differ from those of their children, ‘safer
sex’ proponents generally support student inter-
ests over parental wishes.” For MISH, parental
control over the teaching of values is paramount,
and they are opposed to the promotion of young
people making free, though educated, choices
about sexual practices.
13
Arguments for Comprehensive Americans support sexuality education,” and

cites several polls, including a 1999 national
Sex Education survey finding that 93% of all Americans support
the teaching of sexuality education in high
A wide range of national organizations support schools, and 84% support sexuality education in
comprehensive sexuality education, including 26
middle and junior high.
SIECUS, Advocates for Youth, the American
Academy of Pediatrics, the American College of Comprehensive sex education advocates also
Obstetricians and Gynecologists, the American like to cite studies that find that providing teens
Medical Association, the American Public Health with contraceptive information does not encour-
Association, the National Education Association, age early sexual activity. In July 2001, Surgeon
the National Medical Association, the National General David Satcher released a Call to Action
School Boards Association, and the Society for on promoting sexual health. Reviewing the evi-
34
Adolescent Medicine. dence on comprehensive approaches to sex
education, the Surgeon General found that the
Most proponents of comprehensive sex educa- “evidence gives strong support to the conclusion
tion argue that sexuality education should en- that providing information about contraception
courage abstinence but should also provide does not increase adolescent sexual activ-
young people with information about contracep- ity…[and that] some of these evaluated pro-
tion and STD and HIV prevention (hence the title grams increased condom use or contraceptive
“abstinence-plus” programming). According to use more generally for adolescents who were
SIECUS, comprehensive school-based sexuality 67
sexually active.” The report also notes that
education that is appropriate to students’ age, there are a limited number of studies on absti-
developmental level, and cultural background nence-only programs and that it is “too early to
should be an important part of the education draw definite conclusions about this approach.”
program at every age. SIECUS defines a com-
prehensive sexuality education program as one In the previous chapter, it was noted that absti-
that “respects the diversity of values and beliefs nence-only advocates have attributed declines
represented in the community and will comple- in teen pregnancy in the 1990s to an increased
ment and augment the sexuality education chil- practice of abstinence. Comprehensive sexual-
dren receive from their families.” ity advocates argue that, in fact, most of the de-
crease in the teen pregnancy rate was due to
Comprehensive sex education proponents argue lower pregnancy rates among sexually experi-
that “[b]y denying teens the full range of informa- 68
enced young women. An analysis of the de-
tion regarding human sexuality, abstinence-only cline in teen pregnancy in the 1990s published
education fails to provide young people with the by the Alan Guttmacher Institute shows that ap-
information they need to protect their health and proximately 25% of the decrease was due to a
34
well-being.” And surveys of young people con- lower proportion of teenagers who were sexually
ducted by the Kaiser Family Foundation found experienced, while 75% of the decrease can be
that “students who have sex education – regard- attributed to lowered pregnancy rates among
less of the curriculum – know more and feel bet- those young women who were sexually experi-
ter prepared to handle different situations and enced.
21
decisions than those who have not.”
For many sex education advocates, the absti-
Advocates point to studies finding that the public nence-plus approach acknowledges the central
supports the provision of contraceptive informa- fact that at least half of high school students re-
tion to teens by wide margins. For example, a port having had intercourse, and that this sub-
survey commissioned by the National Campaign stantial portion of the population needs informa-
to Prevent Teen Pregnancy and released in tion in order to protect themselves. According
2001 found that 95% of adults and 93% of teens to a Consensus Statement of the National
said “it is important that teens be given a strong Commission on Adolescent Sexual Health, “so-
abstinence message from society,” but 70% of ciety should encourage adolescents to delay
adults and 74% of teens said that advising ab- sexual behaviors until they are ready physically,
stinence while also giving young people informa- cognitively, and emotionally for mature sexual
tion about contraception is not a mixed mes- relationships and their consequences. … Soci-
6
sage. SIECUS reports that “the vast majority of ety must also recognize that a majority of ado-
14
lescents will become involved in sexual relation-

69
ships during their teenage years.”
In 2000 the distinguished Institute of Medicine

issued a report, No Time to Lose, that assessed
HIV prevention efforts in the country. The report
recommends eliminating congressional, federal,
state and local “requirements that public funds
be used for abstinence-only education, and that
states and local school districts implement and
continue to support age-appropriate compre-
hensive sex education and condom availability
42
programs in schools.”
15
Conclusion nence-only curricula in school will not have the

tools to protect themselves in sexual situations.
No quantity of research will settle the moral and
religious disputes that circle around the sex Ultimately, the public will need to insist that pol-
education debate. What research can do is point icy makers base funding and laws on the health
parents, educators, and policy makers towards needs of young people, particularly those youth
positive health outcomes for young people. Like who are at elevated risk. Until the public de-
it or not, sexual activity is a reality for teens in mands that health education be designed to
America, and it is hard to imagine a school- prevent disease and unwanted pregnancy, so-
based intervention which will magically undo the cial agendas will drive much of the policy being
media pressures and natural hormonal urges made in Washington and state capitols around
that young people experience. Facing up to this the country.
reality means implementing responsible pro-
gramming that truly meets the test of science
and the real world needs of the young.
Several important questions need to be ad-

dressed to support more effective federal policy
and programming on sexuality education. Are
federal funding allocations for sex education
consistent with what the current science tells us
about effectiveness? Is HHS sponsoring re-
search appropriate to inform policy on sex edu-
cation? Are federal agencies providing guid-
ance on sex education research to those at the
federal, state, and local levels who design pro-
gramming? Are the results of sex education
research disseminated widely and in a way that
is accessible to parents, teachers, and school
board members? What percentage of young
people, particularly those at elevated risk, has
access to education about sexual self-
protection? What percentage of youth has ac-
cess to condoms and HIV testing?
Despite its sometimes shrill tenor, the sex edu-

cation debate does not require anyone to make
a choice between absolutes. The central ques-
tion is whether accurate information about sex-
ual self-protection is to be made available. As
the research demonstrates, promoting absti-
nence and providing basic health promotion in-
formation is not inconsistent – it can work to re-
duce the risk of disease and unplanned preg-
nancy.
The $102 million currently being spent by the

federal government on abstinence-only pro-
gramming is designed to serve social and politi-
cal goals, rather than produce solid public health
outcomes for young people. Not only is there no
credible evidence that these millions of dollars
have any positive effect, there is reason to be
concerned that young people who receive absti-
16
Endnotes
1. US Centers for Disease Control and Prevention (CDC). Youth Risk Behavior Surveil-
lance—United States, 1999. MMWR. 2000;49(SS-5).
2. US Centers for Disease Control and Prevention (CDC). Youth Risk Behavior Surveil-
lance—United States, 1993. MMWR. 1995;44(SS-1).
3. Advocates for Youth, Sexuality Information and Education Council of the United States
(SIECUS). Toward a Sexually Healthy America: Roadblocks Imposed by the Federal
Government’s Abstinence-Only-Until-Marriage Education Program [Internet]. Available
at: www.advocatesforyouth.org/publications/abstinenceonly.pdf. Accessed October 16,
2001.
4. Feijoo AN, Advocates for Youth. Teenage Pregnancy, the Case for Prevention: An Up-
dated Analysis of Recent Trends and Federal Expenditures Associated with Teenage
Pregnancy. [Internet]. Available at: www.advocatesforyouth.org/publications/coststudy/.
Accessed Oct 16, 2001.
5. Henry J. Kaiser Family Foundation. Fact Sheet: Sexually Transmitted Diseases in the
United States [Internet]. Feb 2000. Available at:
www.kff.org/content/2000/3003/STD%20Fact%20Sheet.PDF. Accessed October 16,
2001.
6. National Campaign to Prevent Teen Pregnancy. Fact Sheet: Recent trends in teen preg-
nancy, sexual activity, and contraceptive use [Internet]. August, 2001. Available at:
www.teenpregnancy.org/rectrend.htm. Accessed Oct. 25, 2001.
7. Planned Parenthood of America. Fact Sheet, Sexually Transmitted Infections [Internet].
Available at: www.plannedparenthood.org/library/STI/sti_fact.html. Accessed Feb 3,
2002.
8. US Centers for Disease Control and Prevention (CDC). Young People at Risk: HIV/AIDS
Among America’s Youth [Internet]. Available at: www.cdc.gov/hiv/pubs/facts/youth.pdf.
Accessed October 16, 2001.
9. US Centers for Disease Control and Prevention (CDC). CDC Facts: Adolescents and
HIV/AIDS. Atlanta, GA March 1998.
10. Futterman D, Chabon B, Hoffman ND. HIV and AIDS in adolescents. Pediatr Clin North
Am. Feb 2000;47(1):171-188.
11. US Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Report.
August 10 2001;12(2).
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18
33. 42 U.S.C. section 710(b)(1).

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57. Dean L, Meyer IH, Robinson K, et al. Lesbian, Gay, Bisexual, and Transgender Health:
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haviors among runaway adolescents. Jama. Sep 4 1991;266(9):1237-1241.
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[Internet]. Undated. Available at: www.abstinence.net/ArticleDetail.cfm?ArticleID=202.
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October 16, 2001.
64. Abstinence Clearinghouse. Data confirms that the abstinence message, not condoms, is
responsible for the reduction in births to teens [Internet]. May 17, 1998. Available at:
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20
Appendix: Table of Studies

19
Excerpted from Kirby, 2001; publication available through National Campaign to Prevent Teen Pregnancy (www.teenpregnancy.org)
Study Information Sample Descrip- Study Results

tion
Program(s)/ Location/ Program Description Design Analytic Change in Outcome Additional Comments
Author(s)/ Socioeconomic Methods
Publication Date Status (SES) /
Post-Sample (N)
Abstinence Only
Postponing Sexual Dispersed through- Setting: Classrooms in Experimental t-tests be- Initiation of intercourse: 0 The evaluation was
Involvement/ENABL out CA most designs; community tween inter- very rigorous; it had
organizations in one de- Random assignment of vention and Frequency of sex in previous 3 random assignment,
Kirby, Korpi, Barth, Varied SES sign entire schools, class- comparison months: 0 large sample sizes,
Cagampang rooms, or individual groups using long-term follow -up,
N=7,753 Sessions: 5 1-hour ses- youths. In part of the Frequency of sex in previous 12
1995 change months: 0 and appropriate statis-
sions study, students were scores. tical analyses. It also
randomly assigned to Number of sexual partners: 0 examined the impact
Content: Designed both adult-taught PSI, peer-
to help youth understand of PSI implemented in
taught PSI, or a control Use of condoms: 0 community settings,
social and peer pressures group.
to have sex and to de- Use of birth control: 0 individual classrooms,
velop and apply resis - Matched questionnaire or entire schools.
tance skills; emphasis data were collected at Pregnancy:
upon postponing sexual baseline, 3 and 17 Teen led: -
involvement; based on months post- Adult led: 0
social influence theory. intervention.
Methods: Taught by Intervention post- test:
adults or teens N=3,697
Comparison post- test:
N=4,056
21

tion
Post-Sample (N)
Stay SMART Mostly in urban Setting: Boys and Girls Quasi-experimental. Repeated Virgins: For non-virgins, results
areas throughout Clubs of America measures At 3 months: were inconsistent.
St. Pierre, Mark, Kal- the U.S. Fourteen clubs were ANCOVA Recency of last intercourse: 0 Stay SMART without
treider, Aikin Sessions: 12 assigned to 3 groups: used to con- Frequency of intercourse: 0 the booster appeared
Low SES comparison group, trol for the Combined measure: 0 to reduce frequency of
1995 Content: Multi-focus: which received noth-
N=273 Designed to delay sex pre-test intercourse at 27
ing; the first interven- measure of At 15 months: months. With the
and prevent alcohol, ciga- tion group, which re- Recency of last intercourse: 0
rette, and marijuana use. the outcome booster, it did not ap-
ceived Stay SMART variable, Frequency of intercourse: 0 pear to reduce fre-
Based on personal and without the booster; Combined measure: 0
social competence model gender, age, quency. These incon-
and the second inter- and ethnicity. sistent results, coupled
of prevention (broader vention group, which At 27 months:
version of social influence Recency of last intercourse: 0 with the lack of random
received Stay SMART There were assignments, small
theory). Included 9 ses- and the boosters. few signif i- Frequency of intercourse: 0,+
sions on life skills training Combined measure: 0 sample sizes, very
cant differ- high attrition rates, and
(general coping skills and If youths did not par- ences at
skills to resists negative ticipate in most of the Non-virgins: failure to adjust for
baseline; clustering effect at the
peer influences) and 3 on sessions, they were none on be- At 3 months:
postponing sexual in- dropped from the in- club level render these
havior out- Combined measure: 0 results inconclusive.
volvement (discussed sex tervention groups. comes.
in media, lines to have At 15 months:
sex, and consequences of Marched questionnaire Separate Combined measure: 0
sex and did role playing). data were collected at analyses for
baseline, 3, 15, and 27 virgins and At 27 months:
Methods: A 5-session 1- months later. non-virgins as Combined measure: 0
year booster and a 4.5- measured at
hour 2-year booster were 3-month post-test:
Stay SMART: N=83 pre-test.
designed to reinforce the
skills and knowledge and Stay SMART +
to help older youth be booster: N=81
positive role models. Comparison: N=109
Taught by staff members.

Youth volunteered to
participate.
22

tion
Post-Sample (N)
Comprehensive Sex Education

Safer Choices Urban and subur- Setting: High schools Experimental. Linear, logis- Initiation of intercourse: 0 This was a very strong
ban areas in San tic, and nega- design with random
Coyle, Basen- Jose, CA and Sessions: 10 each in 9th Twenty schools were tive binomical Frequency of sex: 0 assignment, large
Engquist, Kirby, Par- Houston, TX and 10th grades randomly assigned to regression sample sizes, long-
cel, Banspach, Collins, treatment and control Number of sex partners: 0
Content: Five major models in a term measurement of
Baumler, Carvajal, Varied SES conditions. repeated Use of condoms at last sex: + behavior and proper
Harrist components: school
Cohort N=3,058 health protection council, Control schools re- measures statistical analysis in
ANCOVA Use of contraception at last sex: two different locations.
Forthcoming (June curriculum, peer received existing +
2001) sources and school env i- sex/HIV education framework to
ronment, parent educ a- programs that were adjust for Frequency of sex without con-
tion, and school- mostly knowledge- baseline doms: +
community linkages. based. variables.
Based on social cognitive Impact was Number of sexual partners
theory, social influence Matched questionnaire measured without condoms: +
theory, and models of data were collected fall over the 31-
school change. Empha- of 9th grade (baseline) month period.
sized abstinence as the and spring of 9th, 10th,
and 11th grades. All were
safest choice; condoms multi-level to
as safer than unprotected adjust for
sex. Curriculum topics clustering.
focused on knowledge,
norms and skills to avoid
sex or use condoms.
Skill-based and interac-
tive.
23

tion
Post-Sample (N)
Kirby, Barth, Leland, Urban and rural Setting: Health education Quasi-experimental Chi-square or Initiation of intercourse: Sample sizes for some
Fetro areas throughout classes t-tests be- At 6 months: 0 subgroups were too
California Partial random as- tween inter- At 18 months: + small for reasonable
1991 Sessions: 15 signment of class- vention and power.
Varied SES rooms to intervention comparison Frequency of intercourse: 0
Content: Cognitive be- or comparison groups
N=758 havioral theory, social groups at 6 Contraceptive use at first sex:
inoculation theory; strong Comparison group and 18 At 6 months: 0
emphasis on avoiding received existing sex months At 18 months: 0
unprotected sex, either by education programs of Initial equiva-
avoiding sex or using equal length Contraceptive use at last sex:
lence of inter- At 6 months: 0
protection vention/ com-
Matched questionnaire At 18 months: 0
Methods: Experimental; data were collected at parison es-
many role plays to build baseline, 6 and 18 tablished with Frequency of contraceptive use
skills and self -efficacy months post- t- or chi- at 18 months:
intervention square tests. Overall: 0
Females: +
Interventions post-test: Males: 0
N=429 Lower-risk youth: +
Comparison post-test: Higher-risk youth: 0
N=329
Frequency of intercourse at 18
months:
Overall: 0
Sexually inexperienced at
pre-test:+
Sexually experienced at
pre-test:0
Teen pregnancy rates: 0
24

tion
Post-Sample (N)
Reducing the Risk Urban and rural Setting: Health education Quasi-experimental. One-way z - Initiation of sex: + There were no signifi-
areas in Arkansas classes. tests between cant differences be-
Hubbard, Geise, Rai- Five intervention intervention Condom use: tween groups at bas e-
ney Varied SES Sessions: 16 school districts were and compari- Sexually inexperienced at pre- line, but there was no
matched with 5 com- son groups at test: + random assignment.
1998 N=212 Content: Cognitive be- parison districts.
havioral theory; strong 18 months.
Attrition was very high
emphasis on avoiding Comparison group Initial equiva- (58%), in part because
unprotected sex either by received existing sex lence of inter- of graduation from high
avoiding sex or using education activities vention and school.
protection. from state-approved comparison
texts or abstinence- groups de- Sub-group samples
Methods: Experiential; only curricula. sizes were small.
many role-plays to build termined.
skills and self -efficacy. Matched questionnaire
data were collected at
baseline and 18-
months later from one
class selected from
each school.
Intervention post- test:
N=106
Comparison post- test:
N=106
25

tion
Post-Sample (N)
Be Proud! Be Re - Philadelphia, PA Setting: Recruited from Experimental. Ran- Chi-squared Abstinence-based: This was a very strong
sponsible! A Sexual high schools for a Satur- dom assignment to 2 tests or f- Initiation of intercourse: study. Both the design
Abstinence Curricu- Low income day program on school treatment groups and tests. At 3 months: + was strong and the
lum Total N=659 campuses. 1 control group that results were positive.
received different in- Frequency of sex: Effects in mediating
Be Proud! Be Re - Sessions: 8 1-hour mod- tervention. At 3 months: 0 variables supported
sponsible! A Safer ules delivered over 2 Sat- At 6 months: 0 behavioral effects.
Sex Curriculum urdays. Matched questionnaire At 12 months: 0 Non-significant behav-
(“Be Proud! Be Re- data were collected at ioral effects were typi-
sponsible!” now known Content: 2 curricula, 1 baseline, 3, 6, and 12 Condom use:
abstinence-based, 1 At 3 months: 0 cally in the desired
as “Making a Differ- months. direction. The safer
ence”) safer-sex based. Based At 6 months: 0
on cognitive-behavior At 12 months: + sex curriculum had
Jemmott, Jemmott, theories and elicitation significant effects upon
Fong research. Small group Frequency of unprotected sex: frequency of unpro-
discussions, videos, At 3 months: 0 tected sex among
1998 games, brainstorming, At 6 months: 0 youths sexually ex-
experiential exercises, At 12 months: 0 perienced at baseline,
and skill-building exer- but not all youth.
Safer-sex based:
cises. The safer sex cur- Initiation of intercourse: Results did no differ by
riculum also addressed At 3 months: 0 matching participants
hedonistic beliefs about and staff on gender,
condom use. Frequency of sex: nor by adult versus per
At 3 months: 0 facilitators.
Trained adult or peer At 6 months: +
facilitators. At 12 months:+
Condom use:
At 3 months: +
At 6 months: +
At 12 months: +
Frequency of unprotected sex:
At 3 months: +
At 6 months: +
At 12 months: 0
26

tion
Post-Sample (N)
Healthy Oakland Oakland, CA Setting: Social science Quasi-experimental. The 2 groups Initiation of sex: + The validity of these
Teens classes at middle school. were com- results was reduced by
Low SES A cohort of students in pared with the lack of random
Ekstrand, Siegel, Nido, Sessions: 5 adult-led / 8 the intervention school logistic re- assignment, some
Faigeles, Cummings, N=250 peer-led was compared with gression differences between
Battle, Krasnovsky, cohorts of students in controlling for the intervention and
Chiment, Coates Content: 5 adult-led ses- similar nearby schools.
sions included basic in- baseline comparison groups,
1996 formation on anatomy, Baseline questionnaire differences. relatively small sample
substance abuse, data were collected in seizes for analyses of
HIV/STDs, and preventive the 7th grade and 8-11 initiation of sex
behaviors. Eight peer-led months later in the 8th (N=190), and failure to
sessions were more inter- grade. adjust for clustering
active and included per- effects. In addition,
ception of risk, values Intervention post- test: parent consent re-
clarification, costs and N=107 quirements changed,
benefits of preventive Control post-test: but the study was re-
behaviors, influence of N=143 stricted to those re-
alcohol and drugs, peer spondents who com-
norms, refusal skills, and pleted surveys when
condom use. passive parental con-
sent was still in effect.
27

tion
Post-Sample (N)
Becoming a Respon- Jackson, MS Setting: Conference room Experimental. Repeated Initiation of intercourse: + This was a very strong
sible Teen in a health center. measures evaluation design with
Low SES Individual youth were MANOVA Sexual intercourse during pre- random assignment,
St. Lawrence, Bras- Sessions: 8 90- to 120- randomly assigned to used to vious two months: + long-term follow -up,
field, Jefferson, A l- N=225 minute weekly meetings. receive the study inter- measure Number of sex partners: + multiple outcome
leyne, O’Bannon, vention or an alterna- impact of measures, and sophis-
Shirley Content: Based upon tive 2-hour educational
social learning theory. group and Frequency of unprotected vagi- ticated statistical
intervention. gender. nal intercourse: analysis.
1995 Designed to affect c ogni-
tive and emotional mean- Matched questionnaire Males: +
No significant Females: 0 On some outcomes,
ings attached to risky data were collected at differences reported risks fluctu-
behavior, model behav- baseline, 2, 6, and 12 pre-test. Frequency of condom-protected ated considerably from
ioral competencies, and months later. vaginal intercourse: + one time period to
provide practice, feed- another.
back, and reinforce new Frequency of unprotected oral
skills. Covered AIDS sex: +
information, sexual deci-
sions and pressures, use Frequency of unprotected anal
of condoms, “lines,” effec- sex: +
tive social skills, and Frequency of condom-protected
situations that would be anal sex: 0
difficult to handle.
Percent of acts of intercourse
Methods: Small group protected by condoms: +
discussions with 5-15
youths were led by male
and female co-facilitators.
Considerable role-playing
and practice. Sessions
with HIV+ youth.
28

tion
Post-Sample (N)
Interventions for youth at high risk

Untitled New York, NY Setting: Shelter for run- Quasi-experimental. Outcomes At 3 months: Several things reduced
away youth were re- Abstained from sex: 0 the validity of this de-
Rotheran-Borus, Low SES One shelter for run- gressed onto Consistent condom use: + sign: the lack of ran-
Koopman, Haigners, Sessions: Designed as away youth offered the the number of Avoidance of high-risk situa- dom assignment; the
Davies (runaway youths) 20, but was 3 to 30. Me- program, while a sec- sessions that tions: + use of only two groups;
N=145 dian=13 sessions ond similar shelter in runaways the relatively small
1991 the same city serving At 6 months:
Content: included general participated in sample size; and the
similar youth did not. and demo- Abstained from sex: 0 failure to adequately
knowledge about Consistent condom use: +
HIV/AIDS, training in cop- Matched interview data graphic vari- control for other differ-
ables. Avoidance of high-risk situa- ences between those
ing skills (including unreal- collected at baseline, 3 tions: +
istic expectation in high- months later, and 6 youth who remained in
There were the shelter for longer
risk situations), access to months later. no significant
health care and other periods of time and
Intervention post-test: differences those who remained
resources, and methods between the
of surmounting individual N=78. for shorter periods.
Comparison post- test: 2 groups at
barriers (covered in pri- baseline. On the other hand,
vate counseling). Activi- N=67.
there were no signif i-
ties were interactive (e.g., cant differences in
developed raps and soap demographic charac-
opera dramatizations and teristics or sexual risk
practiced behavioral cop- behaviors at baseline
ing responses). between the two
groups, and the magni-
tude of the effects
appeared large.
29

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Abstinence Only vs.

Comprehensive Sex Education:

What are the arguments?

Chris Collins, M.P.P.

Progressive Health Partners

Stephen F. Morin, Ph.D.

AIDS Policy Research Center &

AIDS Research Institute

Policy Monograph Series – March 2002

Executive Summary .......................................................................................................ii

The Role of Federal and State Policy ....................................................................... 4

What the Research Tells Us ........................................................................................ 8

Arguments for Abstinence-Only Sex Education .................................................12

Arguments for Comprehensive Sex Education...................................................14

Appendix: Table of Studies.......................................................................................21

Executive Summary The last decade has brought signs of encour-

Introduction who report having had sex also reporting current

Abstinence-Plus Education Abstinence-Only Education

• Promote abstinence from sex • Promote abstinence from sex

The sex education debate in America takes on Definitions of Sexuality Education

In October 2001, Congressman Ernest Istook of The abstinence-only movement is pushing

Despite its troubles, the federal government has

• Teaches that abstinence from sexual SPRANS-CBAE

ferences in the lives of young people, the nega-

The risk of HIV and STIs is compounded for les-

Lack of access to health care among young

ability to judge right from wrong,” while SIECUS

MISH teaches that “there are core ethical values

The MISH critique of the safer sex approach is

At a fundamental level, what is at issue here is

Arguments for Comprehensive Americans support sexuality education,” and

lescents will become involved in sexual relation-

In 2000 the distinguished Institute of Medicine

Conclusion nence-only curricula in school will not have the

Several important questions need to be ad-

Despite its sometimes shrill tenor, the sex edu-

The $102 million currently being spent by the

Available at: www.kff.org/content/2001/3113/Final%20Summary.pdf,

33. 42 U.S.C. section 710(b)(1).

Appendix: Table of Studies

Study Information Sample Descrip- Study Results

Study Information Sample Descrip- Study Results

Taught by staff members.

Study Information Sample Descrip- Study Results

Comprehensive Sex Education

Study Information Sample Descrip- Study Results

Study Information Sample Descrip- Study Results

Study Information Sample Descrip- Study Results

Study Information Sample Descrip- Study Results

Study Information Sample Descrip- Study Results

Study Information Sample Descrip- Study Results

Interventions for youth at high risk

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