Monday, May 19, 2014

Negligence of Adolescent Attitudes and Social Norms in Sexual Risk Avoidance Abstinence Education – Chrysanthe Peteros

“Abstinence Works”: Sexual Risk Avoidance Abstinence Education
“Abstinence Works” is an initiative established by the National Abstinence Education Foundation (NAEF), which promotes Sexual Risk Avoidance (SRA) Abstinence Education. This abstinence-centered education aims to decrease rates of teen pregnancy and transmission of sexually transmitted infections (STIs) by discouraging pre-marital sex. The “Abstinence Works” mission statement also emphasizes that one of the goals of the program is to prevent potentially damaging emotional impacts associated with sex before marriage (1). While the program does offer information about alternative contraceptive options, abstinence is consistently framed as the best, most effective way to avoid the negative consequences of engaging in sexual activity (1). As a result, a large portion of the SRA Abstinence Education content is focused on teaching adolescents how to build healthy relationships, strategies for good decision-making, and how to effectively refuse sexual advances (2).
The “Abstinence Works” campaign provides a number of tools and resources for dissemination of SRA Abstinence Education as well as reports with research that supports it’s superior efficacy in delaying intercourse amongst teenagers.  While it distinguishes itself from Abstinence-Only programs by providing basic information about condoms, the details and information offered regarding contraceptives by SRA Abstinence Education is a very small part of the content provided. The “Abstinence Works” campaign also acts as a movement against the popularization of more comprehensive programs. Comprehensive Sex Education is framed as an approach that makes “sexually explicit material” available to young adolescents and that is actually harmful to teenagers (3). This framing is unsurprising as the argument that Comprehensive Sex Education encourages teens to engage in sexual activity has long been an argument of the proponents of abstinence-only programs, despite research that shows otherwise (4).
The true difference between SRA Abstinence Education, like the “Abstinence Works” program, and Comprehensive Sex Education – sometimes referred to as Abstinence-Plus or Sexual Risk Reduction Education – is the way the concept of abstinence is presented. Both types of programs convey the message that abstinence is the only way to eliminate risk of pregnancy and STI infection, however SRA Abstinence Education teaches that abstaining from sex until marriage is ideal, while Comprehensive programs only emphasize delaying intercourse until adolescents have reached an older, unspecified age (5) – presumably once they have reached a greater level of maturity and are involved in a committed relationship. The focus on negative effects of sex is, subsequently, stronger in SRA Abstinence Risk Avoidance than those classified as Risk Reduction programs. Regardless of the claims made by the NAEF about the effectiveness of “Abstinence Works” and other abstinence-centered programs, there are many weaknesses within the program’s framework that suggest it is an ineffective approach.
Incompleteness of education
The “Abstinence Works” campaign, though an educational program, does not provide complete information regarding safe and healthy sexual behavior. Most of the information included in SRA Abstinence Education is focused on promoting delay of sexual activity. Sex is framed as a risky behavior that can have harmful effects on both physical and emotional health (6). The limited information included about condom use is presented as a flawed preventive method that minimally reduces risks of certain behaviors (6). Further, no information is given about other forms of birth control. The lack of comprehensive education about contraception puts teenagers at risk. Since there is no clear instruction on which forms of birth control protect against STI transmission versus pregnancy, there is a greater likelihood that these contraceptive methods will be used improperly, if at all. In addition, teens are likely to recognize these gaps in information and, subsequently, seek out answers from potentially unreliable sources. Given that 86.4% of US females (ages 15-44) and 90.6% of US males (7), such an approach is not realistic or particularly helpful.
Besides such logistics, the program only offers up reasons why teenagers shouldn’t have sex and why abstinence is the choice that they should be making. According to Brehm’s and Brehm’s reactance theory, the more students are told not to have sex, the more likely they will feel compelled to rebel against this message (8). A study that examined the effects of parental behaviors upon adolescent sexual behavior points out that there is a distinct difference between trying to control versus limit choice (8). By only allowing for one option – abstinence until marriage – “Abstinence Works” seizes freedom of choice from teenagers. In turn, students are likely to feel greater desire to reclaim their freedom by acting in opposition to abstinence. Given the scientific evidence that proper and consistent condom use is effective, teenagers are likely to dismiss claims of their flawed efficacy, as presented by the “Abstinence Works” campaign.
Even students who do believe information provided about condom efficacy may disregard the risks associated with sexual activity. Humans are predisposed to have optimism bias, that is to say that they tend to believe that their actions will have positive outcomes and that they are unlikely to suffer consequences as a result of their own behavior (9). This is especially true for adolescents, who are inclined to perceive themselves as invulnerable as a result of brain development and the establishment of self-identity (9). Given these feelings of invulnerability, teenagers are unlikely to believe that they themselves will “become a statistic.” Presenting data about condom effectiveness in such a way that suggests unreliability only exacerbates this issue. Furthermore, teens are less likely to believe that these are effective in preventing STI transmission and pregnancy. Since the program does include information about other contraception methods, it is unlikely that students would opt to use another option if they believed that these methods were fundamentally flawed. In fact, abstinence-until-marriage programs have been associated with a decrease in use of contraceptives amongst teens (10).
Use of Health Behavioral Model in “Abstinence Works”
The “Abstinence Works” initiative argues that this sort of abstinence-based education is effective, the preferred method by most parents, and the offered better education on the healthiest option regarding adolescent sexual behavior (1). These claims suggest that the “Abstinence Works” program employs the Health Belief Model, which posits that health behaviors are determined by the desire be well and the belief that a certain behavior will prevent or cure illness (11). In the case of “Abstinence Works,” the program relies on the notion that presenting teenagers with the idea that abstinence is the only way to be sure to avoid pregnancy or contracting a STI will, in turn, lead them to choose to abstain from sex. This idea is inherently flawed in that it assumes humans to be rational beings that make decisions based on logical thinking, even though this has been proven time and time again to be untrue. The program does not consider, and even goes so far as to ignore, the perspective and beliefs of the very people that they are trying to convince: adolescents.
While data on their website claims that 2/3 of teenagers in the US were not sexually active in 2009 (12), a 2011 CDC survey of US high school students showed that 47.4% of teenagers had engaged in vaginal intercourse (13) and the Guttmacher Institute has reported that 70% of teens have had sex by the time they turn 19 (10). This misrepresentation may be an attempt to change the perception of the “norms” of adolescent sexual behavior, which, according to Social Norms Theory (14), could encourage adolescents to abstain were they to believe pre-marital sex to be socially unacceptable. Teenagers, however, are more likely to look for acceptance from their peers and base their own decisions off of the behaviors and beliefs of their classmates (15). Students that do not have pre-existing opinions about pre-marital sex are unlikely to find the relative advantage of abstinence versus safe sex convincing.
While the “Abstinence Works” programs certainly plays into the subjective norms – that is to say, that teen sex is generally discouraged by adults – there is little focus on perceived or real social norms. The CDC reports that the mean age of males and females between the ages of 15 and 44, surveyed from 2006 through 2010, upon initiation of sexual intercourse was 17.1 (7). Consistent with this data, a 2002 study showed that the median age of sexual debut was 17.4 and 17.7 for females and males, respectively (16). Although the program ignores this reality, teenagers highly value the social norms circulating amongst their peer group. Indeed, the majority of teens get information about sex from friends and cousins, both sources that are associated with influencing adolescents to believe that having sex will have a positive outcome for themselves and their romantic partner (17). Furthermore, teens that reported cousins as being a primary source of information were also more likely to believe that they would not contract an STI or HIV if they did engage in intercourse (17). This data strongly suggests that a significant proportion of teenagers believe that it is acceptable to have sex and that their likelihood of experiencing negative consequences are quite low. In fact, receiving information from friends and cousins has also been correlated with teens believing that their classmates were engaging in sexual activity and, on a social normative level, that having sex was an acceptable behavior among their peers (17).
Beyond beliefs and attitudes influenced by peers, adolescents are also exposed to a breadth of media, which exposes them to a certain degree of sexual content. Like information sharing between friends, sex portrayed in movies and on the Internet has been associated with leading teens to believe that having sex will have a positive impact (17). Adolescents also gain a greater sense of self-efficacy in becoming sexually active through the information received from both media and friends (17). Given these strong social and mass media influences, a program based on the Health Belief Model promoting abstinence is an insufficient and ineffective approach to changing sexual behavior among adolescents.
The disconnect between attitudes, intentions, and behavior
Sexual Risk Avoidance Abstinence Education, as promoted by “Abstinence Works,” operates under the assumption that this type of education has the ability to change the attitude of teenagers towards sexual behavior. This proves ineffective as the majority of their audience maintains values and opinions that are not aligned with the program’s message. The “Abstinence Works” program explicitly calls out that the content of SRA Abstinence Education is aligned with the preference of parents (1). This focus on parental preference is problematic and misguided for several reasons. Studies have shown that only 15% of parents support abstinence-only education and that the vast majority favor programs that offer education on a wide breadth of topics regarding sexual health (16). Furthermore, by designing their educational intervention to appeal to supposed parental attitudes, the program overlooks their target audience entirely. Even if the majority of parents did support abstinence-centered programs, the social norms of adolescents, themselves, remains neglected.
Even if teens do believe that they should wait until marriage, the “Abstinence Works” program does not account for the potential effects of cognitive dissonance among young people. Individuals are more likely to change their attitude or belief - or, at minimum, reduce the importance of this belief - when there is a clear disconnect between their behaviors and values (18). According to cognitive dissonance theory, when the desire to engage in sexual activity arises, despite beliefs in what is “right or wrong” in terms of sexual behavior, teenagers often make compromises (18). This is especially true for sexuality, as it is one of the basic, visceral needs and desires, which are most likely to result in irrational behaviors (18). Statistics show that nearly half of the US teenage population (aged 15-19) have engaged in oral sex, which may be attributed to a rationalization of oral sex as not being “real sex.” This rationalization reconciles any moral opposition to pre-marital sex and eliminates fears of unwanted pregnancy.
Another fundamental flaw of the “Abstinence Works” intervention is the assumption that a teenager’s intentions will guide their actions. Intention does not directly translate into a behavior and it has been shown that a major shift in intention only results in a relatively slight change in behavior (17). A study of the virginity pledge movement, for instance, showed that pledgers were more likely to delay sexual debut, but the 88% that do engage in pre-marital sex were less likely to use contraception upon initiation of sexual activity (16). This clearly demonstrates that even consciously setting and advertising an intention to abstain does not determine the future actions of a person. While abstinence may be the only method that will 100% guarantee avoidance of pregnancy and STI contraction, it cannot be considered a 100% effective prevention strategy since the majority of teens fail to abstain from sexual activity, which includes oral sex and other sexual behavior in addition to vaginal intercourse (16).
A new approach to “abstinence-centered care”
An alternative to the “Abstinence Works” initiative, the “16 & Intelligent” campaign is a school-based educational program aimed at helping teens make informed choices. A play off of the title of a well-known MTV reality show - “16 & Pregnant” - “16 & Intelligent” would be designed to engage teenagers and give them ownership of their decisions. Like Comprehensive Sex Education, “16 & Intelligent” would include well-rounded information about contraceptive methods and instruct proper use of the various birth control options. Emphasis upon the benefits of abstinence would remain a key component of the program and given the same level of attention and importance as the other contraceptive methods covered. Information about contraception would be presented accurately through scientifically based information and statistics, highlighting that the maximum efficacy of any given contraception can only be achieved if each method is used appropriately. That said, proper condom and birth control use would be a necessary component of the education program.
Either choice, to remain abstinent or not, should be framed as equals, eliminating the idea that one decision is more harmful or negative than the other. As stated, statistics presented to teens in the program would accurately depict effectiveness of prevention methods, including abstinence. The program will stress, however, that choosing to engage in sexual activity does come with greater responsibility, but shame will not be attached to such a decision. Students will be asked to consider the possible health outcomes of unprotected sex as well as more benign consequences such as the cost of birth control and added complexity to romantic relationships. Asking teens to delay sex, as in abstinence-plus education, rather than to wait until marriage allows room for choice and maintains a sense of freedom by permitting adolescents to set their own parameters (8).
Like SRA Abstinence Education, education about healthy relationships and strategies for combating peer pressure will also be included in the “16 & Intelligent” program. Since the goal of the program is to promote healthy sexual behaviors, it is vital that adolescents are also aware of how to recognize damaging social interactions. Upon completion of the course, teens will be deemed “16 & Intelligent” and will have the opportunity to volunteer as peer mentors for students entering the program.
Positive use of labels
The “16 & Intelligent” program is designed to empower students and to encourage them to make independent and informed decisions about their choices regarding sex. These decision-making skills do not simply include the choice to have sex or not, but also strategies for countering pressure from peers to engage in behavior with which they are uncomfortable. Adolescents are prone to changing their own behavior if they believe that peers will accept them granted that they perform they a certain action, even activities that they find undesirable (19). The education program must also stress that even if a teenager is already sexually active, they should not feel obligated to engage in sex in future relationships. A major obstacle to a teenager’s ability to assert their self is, of course, the influence of friends and classmates; how an adolescent defines them self within their peer group can also impact their attitudes and behaviors (19).
In order to overcome the external pressures from peer influences, the program employs social labeling techniques (20). By granting teens the positive, pro-social label of “16 & Intelligent,” adolescents take on the identity of a well-informed, sex-positive individual. This method of assigning a label to an individual has been shown to alter self-perception and guide behavior (20). This is most effective when the label carries a positive connotation within the context of the individual’s social group (20). Being “16 & Intelligent” means making your own decisions based on comprehensive knowledge and supporting and respecting the choices that others make as well. Since people desire their actions to correspond with their assigned label (20), teens will be more likely to feel responsible for keeping informed and sharing their knowledge with each other. Furthermore, when people relate to and identify with others, they tend to base their own behaviors off of these peers (19). So as students take on the “16 & Intelligent” label, these program graduates will act as a model for other teenagers. This becomes especially true if they believe that they too are capable of mirroring the actions of others (19).
Giving adolescents ownership and responsibility
Adolescents are in a period of rapid development in which discovery of self-identity is central (15). Instead of dictating the “correct” choice, allowing teens to feel that they play an active role in the program enforces a sense of ownership and control in their education and, subsequently, sexual behavior. As adolescents form romantic relationships, they desire to have more control and privacy over this personal sphere of their lives (15). That said, an emphasis on ownership of such relationships and their freedom to choose whether or not to engage in sexual activity is vital to effectively communicating the message of any sex education program.
Since adolescents put a premium on the approval of their peers, creating this identity of “16 & Intelligent” generates a new community in which teenagers can find belonging. By taking on the same positive label, teens are able to strengthen their own sense of self as well as identify with their peers (19). In this community of “16 & Intelligent” students, young people will have another way to relate to others and find acceptance among their peers.
Furthermore, employing program graduates as peer mentors for incoming cohorts of students not only gives a stronger sense of control to the adolescents involved, but also opens up opportunity for more honest and mature conversation between students. Given that nearly 75% of teens have reported friends as being a primary source of information about sex (17), it is highly advantageous that these peers have proper information about safe and healthy sexual behaviors. Consistent condom use, for example, could be enormously improved by this peer network. Simply providing teenagers with information about contraceptives is not enough to ensure that they will consistently use protection (21). The encouragement and support of their peers would act as the motivational component to apply their knowledge and improve self-efficacy (21). Condom use, for instance, can be improved among teens if they believe that their peers are proponents of using condoms (17). Studies have also concluded that greater sexual self-efficacy gives adolescents a stronger sense of ownership of their sexual behavior and of responsibility for safe sex practices (21). Taking these findings into consideration, it is clear that peer-to-peer learning can be an extremely effective mode of guiding attitudes and behaviors.
Resetting expectations
Perhaps the strongest aspect of the “16 & Intelligent” program is that it is based in Social Norms Theory (14). Regardless of the pre-existing culture and norms within a given school, the “16 & Intelligent” campaign resets expectations for teenagers by reconciling two opposing messages that they are presented with on a regular basis. That is to say that adolescents would no longer formulate their perception of sexual behavior around the pressure to remain abstinent, as presented by abstinence-focused education, and the expectation that they do shed their virginity during their high school years, as is often represented in media. Instead, the program encourages teens to come to their own conclusions that are based on facts and understanding of protected sex, healthy relationships, and contraception.
Becoming a knowledgeable and self-responsible individual, particularly in regards to sexual behavior, becomes the norm through this “16 & Intelligent” framework. According to social norms theory, people will alter their behaviors to match the norms of their respective social group (14,17). That said, participant and engagement in the “16 & Intelligent” community could achieve a shift in the perceived norms amongst adolescents regarding sexual behavior. Instead of drawing a divisive line between sexually active and abstinent teens, the program unifies students through sex-positive education that encourages peers to support each other in making healthy decisions. Studies have shown the programs that try to scare students with negative consequences of a behavior can actually exaggerate the perception that peers are engaging in the act in question – in this case, sex (14). Consequently, students are actually more likely to align their own behavior to whatever they believe their peers to be doing (14,19). By delivering messages in a positive manner, the “16 & Intelligent” plays into the adolescent desire to act in accordance with social norms.
            Sexual education for teenagers requires a program that works within pre-existing adolescent social norms and general attitudes about sexual behavior and presents information in a way that encourages positive beliefs about sexuality (17). By promoting abstinence-until-marriage and shrouding sexuality in negativity, the “Abstinence Works” program does a disservice to teens and fails to achieve the goals of SRA Abstinence Education. The reliance upon the Health Belief Model and negligence towards adolescent attitudes and social norms renders this program largely ineffective. The “16 & Intelligent” program, on the other hand, empowers teenagers to unite with their peers and take ownership of their sexual behavior. Focusing on developing positive attitudes about sex and offering complete education is more likely to help adolescents make informed, healthy decisions regarding sexual activity throughout their development into adulthood.

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