Readings on Teenagers and Sex Education

READINGS ON TEENAGERS AND SEX EDUCATION 1997–2003

Supported by a grant from the Program on Reproductive Health and Rights of the Open Society Institute

Page numbers referred to in the Table of Contents of this volume appear at the top center of each page. For journal articles, page numbers from the original publication are on the bottom of each page.)

© 2004 by the Alan Guttmacher Institute, A Not-for-Profit Corporation for Reproductive Health Research, Policy Analysis and Public Education; all rights, including translation into other languages, reserved under the Universal Copyright Convention, the Berne Convention for the Protection of Literary and Artistic Works and the International and Pan American Copyright Convention. ISBN 0–939253–63–1 The Alan Guttmacher Institute 120 Wall Street New York, New York 10005 1301 Connecticut Avenue, NW Suite 700 Washington, D.C. 20036

www.guttmacher.org

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TABLE OF CONTENTS

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Introduction

OVERVIEW

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Sexuality Education The Alan Guttmacher Institute Facts in Brief, 2002

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Sexuality education: Our Current Status, and an Agenda for 2010 Susan N. Wilson Family Planning Perspectives, 2000, 32(5):252–254

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Sex Education: Needs, Programs and Policies The Alan Guttmacher Institute Presentation Tool, 2004

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Can More Progress Be Made? Teenage Sexual and Reproductive Behavior in Developed Countries The Alan Guttmacher Institute Executive Summary, Occasional Report No. 3, 2001, 1–6

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Understanding “Abstinence”: Implications for Individuals, Programs and Policies Cynthia Dailard The Guttmacher Report on Public Policy, 2003, 6(5):4–6

PARENT-CHILD COMMUNICATION ABOUT SEX

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Effects of a Parent-Child Communications Intervention on Young Adolescents' Risk for Early Onset of Sexual Intercourse Susan M. Blake, Linda Simkin, Rebecca Ledsky, Cheryl Perkins and Joseph M. Calabrese Family Planning Perspectives, 2001, 33(2):52–61

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No Sexuality Education is Sexuality Education Stanley Snegroff Family Planning Perspectives, 2000, 32(5):257–258

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Teenage Partners' Communication About Sexual Risk and Condom Use: The Importance of Parent-Teenager Discussions Daniel J. Whitaker, Kim S. Miller, David C. May and Martin L. Levin Family Planning Perspectives, 1999, 31(3):117–121

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Family Communication About Sex: What Are Parents Saying and Are Their Adolescents Listening? Kim S. Miller, Beth A. Kotchick, Shannon Dorsey, Rex Forehand and Anissa Y. Ham Family Planning Perspectives, 1998, 30(5):218–222 & 235

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Studying Parental Involvement in School-Based Sex Education: Lessons Learned Diana P. Oliver, Frank C. Leeming and William O. Dwyer Family Planning Perspectives, 1998, 30(3):143–147

SCHOOL AND COMMUNITY-BASED SEX EDUCATION PROGRAMS

101 Factors Associated with the Content of Sexuality Education in U.S. Public Secondary Schools David J. Landry, Jacqueline E. Darroch, Susheela Singh and Jenny Higgins Perspectives on Sexual and Reproductive Health, 2003, 35(6): 261–269

110 The Young Men’s Clinic: Addressing Men’s Reproductive Health and Responsibilities Bruce Armstrong Perspectives on Sexual and Reproductive Health, 2003, 35(5):220–225

116 Man2Man: A Promising Approach to Addressing the Sexual and Reproductive Health Needs of Young Men Genevieve Sherrow, Tristan Ruby, Paula K. Braverman, Nathalie Bartle, Shawn Gibson and Linda Hock-Long Perspectives on Sexual and Reproductive Health, 2003, 35(5):215–219

121 An Evaluation of California's Adolescent Sibling Pregnancy Prevention Program Patricia East, Elizabeth Kiernan and Gilberto Chávez Perspectives on Sexual and Reproductive Health, 2003, 35(2):62–70

130 Preventing Sexual Risk Behaviors and Pregnancy Among Teenagers: Linking Research and Programs Debra Kalmuss, Andrew Davidson, Alwyn Cohall, Danielle Laraque and Carol Cassell Perspectives on Sexual and Reproductive Health, 2003, 35(2):87–93

137 Preventing Pregnancy and Improving Health Care Access Among Teenagers: An Evaluation Of the Children's Aid Society-Carrera Program Susan Philliber, Jacqueline Williams Kaye, Scott Herrling and Emily West Perspectives on Sexual and Reproductive Health, 2002, 34(5):244–251

145 Understanding What Works and What Doesn't In Reducing Adolescent Sexual Risk-Taking Douglas Kirby Family Planning Perspectives, 2001, 33(6):276–281

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TABLE OF CONTENTS

SCHOOL AND COMMUNITY-BASED SEX EDUCATION PROGRAMS (CONTINUED)

151 Long-Term Outcomes of an Abstinence-Based, SmallGroup Pregnancy Prevention Program in New York City Schools Lisa D. Lieberman, Heather Gray, Megan Wier, Renee Fiorentino and Patricia Maloney Family Planning Perspectives, 2000, 32(5):237–245

OTHER SOURCES OF SEX EDUCATION

215 Teenagers Educating Teenagers about Reproductive Health and Their Rights to Confidential Care Katy Yanda Family Planning Perspectives, 2000, 32(5):256–257

217 Can the Mass Media be Healthy Sex Educators? Jane D. Brown and Sarah N. Keller Family Planning Perspectives, 2000, 32(5):255–256

160 Adolescents' Reports of Reproductive Health Education, 1988 and 1995 Laura Duberstein Lindberg, Leighton Ku and Freya Sonenstein Family Planning Perspectives, 2000, 32(5):220–226

167 Changing Emphases in Sexuality Education in U.S. Public Secondary Schools, 1988–1999 Jacqueline E. Darroch, David J. Landry and Susheela Singh Family Planning Perspectives, 2000, 32(5):204–211 & 265

176 Sexuality Education in Fifth and Sixth Grades in U.S. Public Schools, 1999 David J. Landry, Susheela Singh and Jacqueline E. Darroch Family Planning Perspectives, 2000, 32(5):212–219

184 Using Randomized Designs to Evaluate ClientCentered Programs to Prevent Adolescent Pregnancy Dennis McBride and Anne Gienapp Family Planning Perspectives, 2000, 32(5):227–235

193 Pregnancy Prevention Among Urban Adolescents Younger than 15: Results of the 'In Your Face' Program Lorraine Tiezzi, Judy Lipshutz, Neysa Wrobleski, Roger D. Vaughan and James F. McCarthy Family Planning Perspectives, 1997, 29(4):173–176 & 197

198 Education Now and Babies Later (ENABL): Life History of a Campaign to Postpone Sexual Involvement Helen H. Cagampang, Richard P. Barth, Meg Korpi and Douglas Kirby Family Planning Perspectives, 1997, 29(3):109-114

204 The Impact of the Postponing Sexual Involvement Curriculum Among Youths in California Douglas Kirby, Meg Korpi, Richard P. Barth and Helen H. Cagampang Family Planning Perspectives, 1997, 29(3):100-108

219 Older, but Not Wiser: How Men get Information about AIDS and Sexually Transmitted Diseases after High School Carolyn H. Bradner, Leighton Ku and Laura Duberstein Lindberg Family Planning Perspectives, 2000, 32(1):33–38 FEDERAL, STATE AND LOCAL POLICY

227 States’ Implementation of the Section 510 Abstinence Education Program, FY 1999 Adam Sonfield and Rachel Benson Gold Family Planning Perspectives, 2001, 33(4):166–171

233 Abstinence Promotion and the Provision of Information about Contraception in Public School District Sexuality Education Policies David J. Landry, Lisa Kaeser and Cory L. Richards Family Planning Perspectives, 1999, 31(6):280–286

240 School-Based Sexuality Education: The Issues and Challenges Patricia Donovan Family Planning Perspectives, 1998, 30(4):188–193

246 Legislators Craft Alternative Vision of Sex Education to Counter Abstinence-Only Drive Heather Boonstra The Guttmacher Report on Public Policy, 2002, 5(2):1–3

249 Abstinence Promotion and Teen Family Planning: The Misguided Drive for Equal Funding Cynthia Dailard The Guttmacher Report on Public Policy, 2002, 5(1):1–3

252 State-Level Policies on Sexuality, STD Education Rachel Benson Gold and Elizabeth Nash The Guttmacher Report on Public Policy, 2001, 4(4):4–7

256 Sex Education: Politicians, Parents, Teachers and Teens Cynthia Dailard The Guttmacher Report on Public Policy, 2001, 4(1):9–12

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TABLE OF CONTENTS

FEDERAL, STATE AND LOCAL POLICY (CONTINUED)

260 Fueled by Campaign Promises, Drive Intensifies to Boost Abstinence-Only Education Funds Cynthia Dailard The Guttmacher Report on Public Policy, 2000, 3(2):1–2 & 12

263 Sexuality Education Advocates Lament Loss of Virginia’s Mandate…Or Do They? Rebekah Saul The Guttmacher Report on Public Policy, 1998, 1(3):3–4

265 Whatever Happened to the Adolescent Family Life Act? Rebekah Saul The Guttmacher Report on Public Policy, 1998, 1(2):5 & 10–11 APPENDICES

271 U.S. Teen Pregnancy Statistics: Overall Trends, Trends by Race and Ethnicity and State-by-State Information Stanley K. Henshaw and David J. Landry Special Report, Updated 2004, 1–22

293 U.S. Teenage Pregnancy Statistics with Comparative Statistics for Women Aged 20–24 Stanley K. Henshaw Special Report, Updated 2004, 1–14 & Notes

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INTRODUCTION

n the United States, teenagers typically have sexual intercourse for the first time around age 17, and almost two-thirds have had sex before graduating from high school. From the time they begin having sex until they marry, which typically occurs in their mid-20s, young people are at high risk for unintended pregnancies and sexually transmitted diseases (STDs). And it is during these formative teenage years that young people first develop the communications and negotiation skills that will influence whether their future sexual relationships are mutually respectful and fulfilling or exploitive and psychologically unhealthy. Thus, it is imperative that young people receive support in making decisions regarding sexual activity so that they can protect themselves from unintended pregnancies and STDs and grow to be sexually healthy adults.

States, begin having sex at similar ages and have similar levels of sexual activity. Clearly, more must be done to improve the sexual and reproductive health of U.S. teenagers.

Currently, adverse outcomes are far too common. Each year, nearly 822,000 teenage women become pregnant; 80% of these pregnancies are unintended. An estimated nine million new STDs occur among people younger than 25 each year, including 15,000 cases of sexually transmitted HIV. Harder to quantify is the annual number of teenagers who are subjected to or engage in exploitive sexual behavior.

Historically, decisions about the content of sex education were largely a state and local matter. This changed in 1996 with the enactment of the federal welfare reform law, which provided significant funding for abstinence programs that teach that sex outside of marriage is wrong and harmful for people of any age and deny young people complete and accurate information about contraception. Within less than a decade, cumulative federal and state matching funds for this particularly narrow brand of abstinence education approached the $1 billion mark. During this time, the debate over sex education continued and perhaps intensified at all levels of government. Yet far too often this rancorous debate has occurred in the absence of sound evidence-based arguments, and policymakers have time and again failed to heed “what works.”

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The good news is that progress is being made: Teenage pregnancy rates declined 28% between 1990 and 2000, reaching their lowest level in 30 years. This is attributable to both more teenagers delaying the initiation of sexual intercourse and improved contraceptive use among those teenagers who are having sex. But teenagers in this country continue to fare worse as a result of their sexual activity than their peers in other developed countries, even though teenagers across developed nations, including the United

Sex education can play a major role in helping teenagers make healthy and responsible decisions about sex, by providing them with the information and skills they need to delay sexual activity, to protect themselves and their partners when they become sexually active and to engage in mutually respectful relationships. However, the content of sex education that is provided in schools varies tremendously across the United States, and controversy persists over the relative merits of sex education that promotes abstinence as the only acceptable form of behavior outside of marriage and more comprehensive approaches that discuss contraception as well.

Nonetheless, recent research by The Alan Guttmacher Institute (AGI) and others now

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offers a clearer picture of sex education in this country, covering topics ranging from local school district policy to classroom practice to program effectiveness. With an eye toward informing policy debates and aiding researchers and program planners alike, this volume includes all the major documents about teenagers and sex education in the United States produced or published by AGI between 1997 and 2003. They represent the work of researchers within AGI and at other institutions. Thematically, these documents share a focus on sex education in the home, school or community, or address how teenagers get information about sex, contraception, or sexual and reproductive health. The collection includes articles published after 1996—a practical and symbolic starting point given that year’s enactment of the welfare reform law, which, for the first time, articulated the federal government’s approach to sex education. The volume is divided into five chapters that begin with an overview of the subject and move on to parent-child communication about sex; school and community-based sex education pro-

grams; other sources of sex education (including peer education efforts, the media and postsecondary education settings); and, finally, federal, state and local policy. It was produced with support from the Program on Reproductive Health and Rights of the Open Society Institute (OSI). This volume provides researchers, program planners, advocates and policymakers with a comprehensive body of information about sex education in this country at the start of the 21st century. A better understanding of the sex education landscape will help to meet the ongoing challenge of providing young people with the information and support they need to delay sexual activity, to protect themselves and their partners from pregnancy and disease when they become sexually active, and, as adults, to healthy sexual relationships.

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Sexuality Education The Alan Guttmacher Institute Facts in Brief, 2002

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Sexuality education: Our Current Status, and an Agenda for 2010 Susan N. Wilson Family Planning Perspectives, 2000, 32(5):252–254

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Sex Education: Needs, Programs and Policies The Alan Guttmacher Institute Presentation Tool, 2004

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Can More Progress Be Made? Teenage Sexual and Reproductive Behavior in Developed Countries The Alan Guttmacher Institute Executive Summary, Occasional Report No. 3, 2001, 1–6

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Understanding “Abstinence”: Implications for Individuals, Programs and Policies Cynthia Dailard The Guttmacher Report on Public Policy, 2003, 6(5):4–6

OVERVIEW

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OVERVIEW

Facts in Brief

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Sexuality Education Sex and Pregnancy Among Teenagers • By their 18th birthday, 6 in 10 teenage women and nearly 7 in 10 teenage men have had sexual intercourse. • A sexually active teenager who does not use contraception has a 90% chance of becoming pregnant within a year.

United States have levels of sexual activity similar to their Canadian, English, French and Swedish peers, they are more likely to have shorter and more sporadic sexual relationships and less likely to use contraception.

Local Sexuality Education Policy

• Of the approximately 950,000 teenage pregnancies that occur each year, more than 3 in 4 are unintended. Over 1/4 of these pregnancies end in abortion.

• More than 2 out of 3 public school districts have a policy to teach sexuality education. The remaining 33% of districts leave policy decisions up to individual schools or teachers.

• The pregnancy rate among U.S. women aged 15-19 has declined steadily—from 117 pregnancies per 1,000 women in 1990 to 93 per 1,000 women in 1997. Analysis of the teenage pregnancy rate decline between 1988 and 1995 found that approximately 1/4 of the decline was due to delayed onset of sexual intercourse among teenagers, while 3/4 was due to the increased use of highly effective and long-acting contraceptive methods among sexually experienced teenagers.

• 86% of the public school districts that have a policy to teach sexuality education require that abstinence be promoted. 35% require abstinence to be taught as the only option for unmarried people and either prohibit the discussion of contraception altogether or limit discussion to its ineffectiveness. The other 51% have a policy to teach abstinence as the preferred option for teens and permit discussion of contraception as an effective means of preventing pregnancy and STDs.

• Despite the decline, the United States continues to have one of the highest teenage pregnancy rates in the developed world—twice as high as those in England, Wales or Canada and nine times as high as rates in the Netherlands and Japan.

• Only 14% of public school districts with a policy to teach

• Every year, roughly 4 million new sexually transmitted disease (STD) infections occur among teenagers in the United States. Compared with rates among teens in other developed countries, rates of gonorrhea and chlamydia among U.S. teenagers are extremely high. • Though teenagers in the

sexuality education address abstinence as one option in a broader educational program to prepare adolescents to become sexually healthy adults. • Over 1/2 of the districts in the South with a policy to teach sexuality education have an abstinence-only policy, compared with 20% of such districts in the Northeast. • While most states require schools to teach sexuality education, STD education or both, many also give local policymakers wide latitude in crafting their own policies. The latest information on state-level policies is available at www.guttmacher.org/pubs/ spib_SSEP.pdf.

Sexuality Education in the Classroom • Sexuality education teachers are more likely to focus on abstinence and less likely to provide students with information on birth control, how to obtain contraceptive services, sexual orientation and abortion than they were 15 years ago. • The proportion of sexuality

chart a

Sex Education Policies Most school districts promote abstinence. Teach abstinence as only option Teach abstinence as preferred option

33%

23%

Teach abstinence as one option in a broader educational program No sexuality education policy

10%

34%

Source: Landry DJ, Kaeser L and Richards CL, Abstinence promotion and the provision of information about contraception in public school district sexuality education policies, Family Planning Perspectives, 1999, 31(6):280–286.

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education teachers who taught abstinence as the only way to prevent pregnancy and STDs increased from 1 in 50 in 1988 to 1 in 4 in 1999. • The overwhelming majority of sexuality education teachers believe that by the end of the 7th grade, students should have been taught about puberty, how HIV is transmitted, STDs, how to resist peer pressure to have sex, implications of teenage parenthood, abstinence from intercourse, dating, sexual abuse and nonsexual ways to show affection. • The majority of teachers believe that topics such as birth control methods and how to obtain them, the correct way to use a condom, sexual orientation, and factual and ethical information about abortion should also be taught by the end of the 12th grade. These topics are currently being taught less often

and later than teachers think they should be. • More than 9 in 10 teachers believe that students should be taught about contraception, but 1 in 4 are prohibited from doing so. • 1 in 5 teachers believe that restrictions imposed on sexuality education are preventing them from meeting their students’ needs. • The majority of Americans favor more comprehensive sexuality education over abstinence-only education. • At least 3/4 of parents say that in addition to abstinence, sexuality education should cover how to use condoms and other forms of birth control, abortion, sexual orientation, pressures to have sex and the emotional consequences of having sex. • At least 40% of students report that topics such as STDs and HIV, birth control,

chart b

Thinking vs. Doing There is a large gap between what teachers think should be taught and what they teach when it comes to birth control, abortion and sexual orientation. 100

Government Support of Abstinence-Only Education • There are currently 3 federal programs dedicated to funding restrictive abstinence-only education— Section 510 of the Social Security Act, the Adolescent Family Life Act’s teenage pregnancy prevention component, and the Special Projects of Regional and National Significance program (SPRANS)—with total annual funding of $102 million for FY 2002. • Federal law establishes a stringent 8-point definition of “abstinence-only education” that requires programs to teach that sexual activity outside of marriage is wrong and harmful—for people of any age—and prohibits them from advocating contraceptive use or discussing contraceptive methods except to emphasize their failure rates. • There is currently no federal program dedicated to supporting comprehensive sexuality education that teaches young people about both abstinence and contraception.

90 80 70 % of teachers

how to use and where to obtain birth control, and how to handle pressure to have sex either were not covered in their most recent sexuality education course or were not covered sufficiently.

60 50 40 30 20 10 0 HIV

STDs

Abstinence Instruction

Birth control

Condom use

Facts Sexual on orientation abortion

Opinion

Source: Darroch JE, Landry DJ and Singh S, Changing emphasis in sexuality education in U.S. public secondary schools, 1988–1999, Family Planning Perspectives, 2000, 32(5):204–211 & 265.

• Despite years of evaluation in this area, there is no evidence to date that abstinence-only education delays teenage sexual activity. Moreover, recent research shows that abstinence-only strategies may deter contraceptive use among sexually active teenagers, increasing their risk of unintended pregnancy and STDs. • Evidence shows that com-

prehensive sexuality education programs that provide information about both abstinence and contraception can help delay the onset of sexual activity in teenagers, reduce their number of sexual partners and increase contraceptive use when they become sexually active. These findings were underscored in Call to Action to Promote Sexual Health and Responsible Sexual Behavior, issued by former Surgeon General David Satcher in June 2001.

Sources of Data The data in this fact sheet are the most current available. Most of the data are from research conducted by The Alan Guttmacher Institute (AGI) and published in: Why is Teenage Pregnancy Declining? The Roles of Abstinence, Sexual Activity and Contraceptive Use; Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made?; and the peer-reviewed journal Perspectives on Sexual and Reproductive Health (formerly Family Planning Perspectives). Additional sources include the Kaiser Family Foundation and the National Campaign to Prevent Teen Pregnancy.

A Not-for-Profit Corporation for Reproductive Health Research, Policy Analysis and Public Education 120 Wall Street New York, NY 10005 Phone: 212.248.1111 Fax: 212.248.1951 [email protected] 1120 Connecticut Avenue, N.W. Suite 460 Washington, DC 20036 Phone: 202.296.4012 Fax: 202.223.5756 [email protected] Web site: www.guttmacher.org ©2002, The Alan Guttmacher Institute 8/02

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VIEWPOINT Sexuality Education: Our Current Status, and an Agenda for 2010 By Susan N. Wilson

T

hree articles in this issue of Family Planning Perspectives—on changing emphases in secondary school sexuality education (“Changing Emphases”), on sexuality education in grades 5–6 (“Grades 5–6”) and on adolescents’ views of reproductive health education (“Adolescents’ Views”)—provide valuable information for educators and advocates. They also point the way to new directions for research and for advocacy.

Retreat from Responsibility? Overall, the three studies present discouraging news for advocates of comprehensive sexuality education—i.e., those who favor teaching a balanced, medically correct program including both abstinence and protection against disease and unintended pregnancy. “Adolescents’ Views” reports major shifts in the prevalence and content of school-based reproductive health education in the United States over the period 1988–1995. While instruction became almost universal, it became more focused on the prevention of HIV and AIDS. Instruction about contraception, about how to say no to sex and about condoms was much less common than education about HIV and AIDS. Notably, the study reveals increased instruction about abstinence before the 1996 passage of the federal Welfare Reform Act, with its provision for major funding of abstinence-until-marriage education programs. In “Changing Emphases,” teachers of grades 7–12 testify to a marked shift from a more balanced treatment of abstinence and protection in 1988 to much heavier reliance on abstinence in 1999. In particular, there was a large increase in the percentage of teachers who taught abstinence as the only effective means of preventing Susan N. Wilson is executive coordinator of the Network for Family Life Education, Rutgers University, Piscataway, NJ.

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pregnancy and disease. These “abstinence only” programs may be driving other topics from the curriculum. In 1999, teachers were less likely to teach about condoms as a means of disease prevention than they were in 1988, to explain how each birth control method works or to give information about where students could go for birth control. Moreover, when asked at what grade level specific topics should be taught, the teachers in the “Changing Emphases” study reported more conservative views in 1999 than they did in 1988. “Grades 5–6” shows that sexuality education is much less common at these grade levels than in grades 7–12. Where programs exist, they mainly cover such topics as puberty, HIV and AIDS, sexually transmitted diseases, sexual abuse and abstinence; discussion of contraceptive methods is relatively rare. Yet half of teachers believe that birth control methods should be taught in or before grade seven. This discrepancy between belief and practice may result from administrative and community restraints. One in four teachers say their school administration is nervous about community reaction to sexuality education at these grade levels, one in five cite restrictions that prevent them from meeting their students’ needs and nearly two out of five say they have to be careful about what they teach because they fear adverse community reaction. Yet these studies reveal some bright spots as well. While teachers in grades 7–12 have become more restrictive in their beliefs about what topics they should teach, the vast majority still favor teaching topics relating to disease prevention and birth control. Moreover, around onethird of all teachers cover sensitive topics, such as giving students information about specific locations where they can go for birth control, showing the proper way to use condoms and showing actual birth

control devices. And many critical topics were actually taught earlier in grades 7–12 in 1999 than they were a decade before. Only one in five teachers believe that students who learn about both abstinence and contraception are more likely to become sexually active than those taught about abstinence alone. In addition, a surprising percentage of secondary school teachers who teach in abstinence-only programs go beyond abstinence to discuss prevention topics. With regard to sexuality education in grades five and six, few of those who teach this topic perceive their administration to be nervous about possible adverse community reaction or feel a lack of administrative support for their efforts. More than half of these teachers believe that information about birth control methods and abortion should be taught at or before seventh grade, and more than two in five believe that sexual orientation, where to go for birth control and how to use a condom should also be taught.

Sexuality Education in 1999 The context of these studies, according to a 1999 survey of public school district superintendents, is that two districts in three have a district-wide policy to teach sexuality education. Of these, 14% have a comprehensive policy (where abstinence is one option in a broader program), 51% have an abstinence-plus policy (where abstinence is the preferred option, but contraception is discussed as an effective means of protecting against disease and unintended pregnancy) and 35% (23% of all districts) have an abstinence-only policy (where abstinence is the only option and discussion of contraception is prohibited, unless it is to emphasize its shortcomings). Districts in the South are far more likely than those in the Northeast to have an abstinence-only policy.1 The news from “Changing Emphases” Family Planning Perspectives

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and “Grades 5–6” is disquieting for advocates of comprehensive sexuality education. The balance seems to be swinging toward the single message of abstinence, with the result that fewer teenagers are hearing classroom messages about birth control methods, the benefits of condom use, specific locations where they can go for birth control and the proper way to use condoms. Why are America’s schools providing their students with less information than they were a decade ago? Recent federal promotion of abstinence-until-marriage education programs cannot be responsible. Although funded at $50 million per year, these programs did not begin until the 1997–1998 school year, and in some states do not take place in schools at all. The changes are more likely the product of federal funding for HIV and AIDS education beginning in the mid-1980s, and to a lesser extent the result of increased funding for teenage pregnancy prevention. The result is a state- and local-level trend toward fear-based, abstinence-centered instruction. But if the federal abstinence-until-marriage funding—with its ban on discussions of contraception and safer sex practices—was not critical in the period 1988–1999, it is likely to extend and accelerate the trend toward abstinenceonly in the future. (This could be especially true if Gov. George W. Bush is elected president and fulfills a stated pledge to “elevate abstinence education from an afterthought to an urgent policy.”2) The trend toward reliance on abstinence-only education is especially disquieting in the face of recent statistics from the Centers for Disease Control and Prevention showing that 65% of students have sexual intercourse before the end of high school. These data also show that other measures of teenage sexual activity (such as the percentage of teenagers with four or more partners in their lifetime or the percentage who had intercourse in the past three months) are on the rise and that adolescents are having first intercourse at younger ages.3 The safety and health of these young people surely requires sexuality education that balances the topics of abstinence and HIV and AIDS with those of responsibility and protection. The CDC’s Youth Risk Behavior Surveys for the years 1991–1999 show that for about half of the 1990s—that is, from about 1991 to 1997—teenage sexual activity and the adolescent pregnancy rate declined substantially, although sexual activity rose again from 1997 to 1999.4 Proponents of abstinence-only curricula have already Volume 32, Number 5, September/October 2000

claimed that their programs are responsible for the decrease. (They have been silent about the subsequent increase.) But condom use also increased during the same period, and one analysis suggests that only about one-quarter of the decline in pregnancy is attributable to more teenagers choosing abstinence, while about three-quarters is attributable to better use of contraceptives, particularly long-term methods.5 One aim of comprehensive sexuality education is to teach an understanding of and a respect for sexual diversity. So it is of particular concern that teachers in 1999 were much less likely to teach about sexual orientation—or to think that it should be taught—than were teachers in 1988. Why are these changes taking place in an age of increasing tolerance and visibility? Is it, in fact, a reaction to that tolerance and visibility, or is it merely that the rise of abstinence-only education is driving other topics from the classroom? “Changing Emphases” and “Grades 5–6” show that teachers are not merely acceding to restrictive laws and district policy, but are themselves more conservative about what should be taught at various grade levels. At the same time, a substantial proportion feel that they are not meeting the needs of students for information and that many topics should be introduced earlier. Teachers’ ambivalence may be rooted in real or perceived opposition in the community, especially concerning sexuality education in the elementary grades. All in all, the timing of formal instruction seems to have more to do with the fears of adults than the needs of students.

An Agenda for 2010 The research articles in this issue record changes in sexuality education during the last decade of the 20th century. Our view of conditions a decade from now will be shaped, in part, by the actions of researchers and advocates in the years ahead. Areas for Further Research Like all good research, the three articles suggest avenues for new studies of sexuality education: •Teachers who report that they cover both abstinence and prevention might spend 98% of their time on one and 2% on the other. What is the average amount of time that teachers devote to key topics? •To what extent do community-based organizations, including Planned Parenthood and prochoice and antiabortion groups, visit and make presentations in classrooms? Do they teach topics that regular classroom teachers do not? If so, are

students learning a wider range of topics than these studies reveal? •Are school-based programs generally offered in heterogeneous or homogeneous instructional groupings? Which do students prefer? Which are more effective? •How much preservice education do elementary classroom teachers receive? Are they trained to talk about abstinence in meaningful ways, to help students develop behavioral skills through role-plays and to handle community and administrative pressures? •How much in-service training in sexuality education (as opposed to pure HIV and AIDS education) do secondary school teachers receive? Who pays for it? Are teachers aware of recent research indicating the effectiveness of comprehensive programs and the lack of similar research regarding abstinence-only programs? •Do teachers know of local or regional organizations that could help them persuade their administrations to make the curriculum more relevant to student needs? Do teachers see students as possible allies in efforts to improve school programs? •What do today’s students think should be taught, and when? Do they believe that school programs provide them with what they need? Do they find their teachers to be knowledgeable about and comfortable with important topics? •What do former students—those now in their young 20s—say about the usefulness of the sexuality education they received in high school? How do they think it has affected them in such areas as health, relationships and ability to communicate? An Advocacy Agenda Given the findings of the three studies, proponents of comprehensive sexuality education might consider these areas of action and advocacy: •Remind the public—and ourselves—that a consistent 80–90% of Americans say they favor courses that teach contraception and disease prevention in addition to abstinence; that 70% oppose federal funding for programs that prohibit teaching about condoms and contraception; that 69% say teaching abstinence until marriage is “just not realistic”; and that 58% think seventhand eighth-graders should be taught about condom use.6 •Continue to point out to politicians and to the public that “there does not currently exist any scientifically credible, published research” demonstrating that abstinenceonly programs have actually delayed the onset of sexual intercourse or reduced any 253

Current Status of Sexuality Education, and an Agenda for 2010

measure of sexual activity. Conversely, there is growing evidence that comprehensive programs reduce sexual activity, pregnancy rates and birthrates.7 •Continue to publicize Western European teenage pregnancy rates, birthrates and abortion rates, all of which are lower than—and many of which are a fraction of—U.S. rates, and have been achieved without any reliance on abstinence-only education programs.8 •Work to encourage the federal government and Congress to support and evaluate comprehensive sexuality education programs and to set aside narrow approaches that promote abstinence until marriage as the sole acceptable sexuality education strategy or only permitted adolescent behavior. •Reduce the remaining gaps in access to school-based programs. Sexuality education for young males, particularly for nonHispanic black males, should begin far earlier than it does now, in order to reach these students before they begin to have intercourse. Moreover, both genders need to hear identical messages about responsibility and share classroom discussions about abstinence and condom use. •Provide sexuality education in nonschool settings where dropouts can be reached, such as workplaces, alternative schools, GED programs, the criminal justice system, the military and federal programs such as the Job Corps. •Provide preservice training for gradeschool classroom teachers, since “Grades 5–6” reveals that it is largely regular classroom teachers, not school nurses, who teach the subject at this level. If any gradeschool teacher may be required to teach sexuality education, all teacher candidates

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need the equivalent of a one-semester course covering such topics as the sexual development of children and adolescents, how to answer children’s questions, how to teach refusal, negotiation and communication skills using role-plays and small groups, how to handle community and parental opposition, and how to lead discussions about values. •Provide in-service training for elementary and secondary teachers, covering new materials, effective teaching strategies, current research findings and ways to handle community pressure and controversy. •Create a privately funded national commission to make recommendations about implementing classroom programs and involving parents in grades K–6. (Several excellent curricula already exist.) •Finally, build a Web-based “second line of defense” to help young people whose schools fail to provide them with the information they need. Several excellent Web sites are already attracting millions of teenagers seeking balanced, medically accurate, nonideological information about birth control, condoms, emergency contraception, abortion, pleasure, relationships and other vital topics.

Conclusion The three research articles highlighted here offer valuable, if disappointing, information about the present state of sexuality education programs in American public schools and about changes in the past decade. The findings are troubling, given the needs of young people, the very high rates of pregnancy and sexually transmitted infections among U. S. adolescents and the specter of HIV and AIDS. The findings become even more prob-

lematic given today’s political climate and the possible outcomes of upcoming elections. Advocates of comprehensive sexuality education will be working to produce a more positive picture when researchers reexamine the subject in 2010. References 1. Landry DJ, Kaeser L and Richards CL, Abstinence promotion and the provision of information about contraception in public school district sexuality education policies, Family Planning Perspectives, 1999, 31(6):280–286. 2. Dailard C, Fueled by campaign promises, drive intensifies to boost abstinence-only education funds, The Guttmacher Report on Public Policy, 2000, 3(2):1–2 & 12; and Morse J, Practicing chastity in the classroom: more sexeducation classes are teaching kids only about abstinence: will they listen? Time, 1999, 154(16), Oct. 18. 3. Centers for Disease Control and Prevention (CDC), Youth Risk Behavior Surveillance—U.S., 1999, Morbidity and Mortality Weekly Report, 2000, 49(SS-5):19–21 & 75. 4. CDC, Trends in sexual risk behaviors among high school students—United States, 1991–1997, Morbidity and Mortality Weekly Report, 1998, 47(36):749–752; and CDC, 2000, op. cit. (see reference 3). 5. Darroch JE and Singh S, Why Is Teenage Pregnancy Declining? The Roles of Abstinence, Sexual Activity and Contraceptive Use, Occasional Report, New York: The Alan Guttmacher Institute, 1999, No. 1. 6. Donovan P, School-based sexuality education: the issues and challenges, Family Planning Perspectives, 1998, 30(4):188–193; and Public support for sexuality education reaches highest level, survey says, SIECUS Shop Talk, 1999, 4(7):1. 7. Kirby D, No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: The National Campaign to Prevent Teen Pregnancy, 1997; and Jemmott JB III, Jemmott LS and Fong GT, Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial, Journal of the American Medical Association, 1998, 279(19):1529–1536. 8. Singh S and Darroch JE, Adolescent pregnancy and childbearing: levels and trends in developed countries, Family Planning Perspectives, 2000, 32(1):14–23.

Family Planning Perspectives

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Sex Education: Needs, Programs and Policies The Alan Guttmacher Institute © April 2004

This presentation from The Alan Guttmacher Institute brings together the latest information about sex education in the United States as it relates to the prevention of unintended pregnancies and sexually transmitted diseases (STDs). It includes background information about sexual activity among American youth, sex education policy and practice in public schools, the effectiveness of programs designed to delay sexual activity and to prevent unintended pregnancy and STDs among teenagers, and the disconnect between public opinion and public policy in this area. Note: These slides were updated in February 2004 to reflect the FY 2004 Appropriations Bills, and in April 2004 to reflect new teenage pregnancy and STD data.

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The Need to Help Young People Make Healthy Decisions

There is a clear need to help young people make healthy decisions regarding sexual activity so that they can protect themselves from unintended pregnancy and STDs.

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Young people are at high risk of unintended pregnancy and STDs for many years

Me n

ar c

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Fi r in st te rc ou r

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Fi se

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st se Fir our c er nt

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e or ge m a i o r n h ar ir t nd n m e b t e st st In ildr Fir Fir ch

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Sex Education

The period of time during which young people are at greatest risk of unintended pregnancy and STDs spans many years. Most young people enter puberty in early adolescence— around age 13 for women and age 14 for men. They typically have sexual intercourse for the first time around age 17, but do not marry until their middle to late 20s. This means that they are at high risk of unintended pregnancy and STDs for almost a decade before marriage, at which point their risk diminishes but does not disappear.

Sources: The Alan Guttmacher Institute (AGI), In Their Own Right: Addressing the Sexual and Reproductive Health Needs of American Men, New York: AGI, 2002, p. 8; and Dailard C, Marriage is no immunity from problems with planning pregnancies, The Guttmacher Report on Public Policy, 2003, Vol. 6, No. 2, pp.10-13. 4

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Many teenagers experience pregnancy and STDs More than 800,000 women younger than 20 become pregnant each year 80% of these pregnancies are unintended Nine million teenagers and young adults acquire an STD each year Two young people every hour become infected with HIV ©The Alan Guttmacher Institute

Sex Education

Each year, more than 800,000 teenage women become pregnant, and about 80% of these pregnancies are unintended. Additionally, an estimated nine million teenagers and young adults acquire an STD each year. Half of the 30,000 new sexually transmitted cases of HIV infection in the United States each year occur among individuals younger than 25. That means that every hour of every day, an average of two young people become infected with HIV. Note: These slides were updated in April 2004 to reflect new teenage pregnancy and STD data. Sources: Henshaw SK, U.S. teenage pregnancy statistics with comparative statistics for women aged 20-24, New York: AGI, February, 2004, , accessed Apr. 8, 2004; Henshaw SK, Unintended pregnancy in the United States, Family Planning Perspectives, 1998, 30(1):24-29 & 46; and Weinstock H, et al., Sexually Transmitted Diseases Among American Youth: Incidence and Prevalence Estimates, 2000, Perspectives on Sexual and Reproductive Health, 2004, 36(1):6-10.

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The teenage pregnancy rate is going down Pregnancies per 1,000 women aged 15-19 120 100 80 60 40 20 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 ©The Alan Guttmacher Institute

Sex Education

The good news, however, is that the teenage pregnancy rate in this country is down 28% since its peak in 1990, and is at its lowest level in 30 years. Note: These slides were updated in April 2004 to reflect new teenage pregnancy and STD data. Source: Henshaw SK, U.S. teenage pregnancy statistics with comparative statistics for women aged 20-24, New York: AGI, February 2004, , accessed Apr. 8, 2004.

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Both abstinence and contraceptive use are responsible for the decline in teenage pregnancy 25%

Increased abstinence More effective contraceptive use 75%

Cause of decline ©The Alan Guttmacher Institute

Sex Education

Research suggests that both increased abstinence and changes in contraceptive practice are responsible for the decline in teenage pregnancy, but in different proportions. An analysis by researchers at The Alan Guttmacher Institute found that approximately one-quarter of the decline in teenage pregnancy between 1988 and 1995 was due to more teenagers remaining abstinent. Approximately three-quarters of the drop resulted from a decrease in pregnancy rates among sexually active teenagers. This decline was caused by more effective contraceptive use, resulting in large part from greater reliance on highly effective, long-lasting hormonal methods such as Depo Provera. Source: Darroch JE and Singh S, Why Is Teenage Pregnancy Declining? The Roles of Abstinence, Sexual Activity and Contraceptive Use, Occasional Report, New York: AGI, 1999, No. 1. 7

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The proportion of high school students who have had sex has declined % of students 100 80 60 40 20 0 Male

Female

1991 ©The Alan Guttmacher Institute

2001 Sex Education

A complementary analysis shows that between 1991 and 2001, the proportion of high school students who had ever had sex declined by 16% for both males and females.

Source: Brener N et al., Trends in sexual risk behaviors among high school students—United States, 1991-2001, Morbidity and Mortality Weekly Report, 2002, 51(38):856859.

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The proportion of sexually active high school students who use condoms has risen % of students 100 80 60 40 20 0 Male

Female 1991

©The Alan Guttmacher Institute

2001 Sex Education

The proportion of teenagers who had had sex decreased between 1991 and 2001, and condom use among sexually active teenagers increased during that period by 19% for males and 35% for females.

Source: Brener N et al., Trends in sexual risk behaviors among high school students—United States, 1991-2001, Morbidity and Mortality Weekly Report, 2002, 51(38):856859.

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U.S. teenagers have higher rates of pregnancy, birth and abortion than teenagers in most other developed countries Pregnancy rate Russian Federation United States Bulgaria England and Wales Canada Sweden France Japan

0

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©The Alan Guttmacher Institute

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Abortion Sex Education

Notes: Teenage pregnancy rate=number of births and abortions per 1,000 women aged 15-19. Pregnancies do not include miscarriages.

Nonetheless, more progress is needed. Teenagers in the United States fare worse as a result of their sexual activity than do teenagers in most other developed countries. U.S. teenagers have much higher pregnancy rates, birthrates and abortion rates. They also have higher rates of STDs.

Sources: AGI, Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Occasional Report, New York: AGI, 2001, No. 3; and AGI, Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics, New York: AGI, 2000.

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Why Do U.S. Teenagers Fare Worse Than Teenagers in Other Developed Countries?

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Levels of teenage sexual activity across developed countries are similar… % of women aged 20-24 who had sex in their teenage years

United States Great Britain Canada Sweden France 0

20

40

60

By age 15

By age 18

By age 20

©The Alan Guttmacher Institute

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Sex Education

Note: Data are for the mid-1990s. A common misperception is that teenagers in this country begin having sex at an unusually early age and have especially high rates of sexual activity. But research comparing adolescents in the United States with adolescents in similar developed nations shows that this is not true. By and large, American teenagers behave in much the same way as their counterparts in other countries in terms of their age at initiation of sex and their levels of sexual activity.

Source: AGI, Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Occasional Report, New York: AGI, 2001, No. 3.

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…but U.S. teenagers have higher rates of unintended pregnancy and STDs because they Are less likely to use contraceptives Have shorter relationships Have more sexual partners

©The Alan Guttmacher Institute

Sex Education

In comparison with their peers in other developed countries, sexually active teenagers in the United States are less likely to use contraceptives. When they do, they are less likely than teenagers in other countries to use the pill or other highly effective hormonal methods, possibly because they have shorter relationships. The fact that U.S. teenagers have shorter relationships and, consequently, more sexual partners over time also increases their risk for STDs.

Source: AGI, Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Occasional Report, New York: AGI, 2001, No. 3.

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What accounts for lower teenage pregnancy and STD rates in other countries? Clear and unambiguous prevention messages Strong condemnation of teenage parenthood Societal supports for young people ©The Alan Guttmacher Institute

Sex Education

There is evidence that in many developed countries with low levels of teenage pregnancy, childbearing and STDs, adults tend to be more accepting of sexual activity among teenagers than are adults in the United States. However, adults in these countries also give clear and unambiguous messages that sex should occur within committed relationships and that sexually active teenagers are expected to take steps to protect themselves and their partners from pregnancy and STDs. Moreover, while these societies may be more accepting of teenage sex than the United States, they are, in fact, less accepting of teenage parenthood. Strong societal messages convey that childbearing should occur only in adulthood, which is considered to be when young people have completed their education, are employed and are living in stable relationships. Societal supports exist to help young people with the transition to adulthood, through vocational training, education and job placement services, and child care. As a result, teenagers have positive incentives to delay childbearing.

Sources: AGI, Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Occasional Report, New York: AGI, 2001, No. 3; and Boonstra H, Teen pregnancy: trends and lessons learned, The Guttmacher Report on Public Policy, 2002, Vol. 5, No. 1, pp. 7-10.

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What accounts for lower teenage pregnancy and STD rates in other countries? Greater access to contraceptive and reproductive health services Comprehensive sex education

©The Alan Guttmacher Institute

Sex Education

Teenagers in other developed countries also have greater access to contraceptives and reproductive health services than teenagers in the United States, and they are provided with comprehensive education about pregnancy and STD prevention in schools and community settings. In contrast, sex education that exclusively promotes abstinence is common in U.S. public schools.

Sources: AGI, Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Occasional Report, New York: AGI, 2001, No. 3; and Boonstra H, Teen pregnancy: trends and lessons learned, The Guttmacher Report on Public Policy, 2002, Vol. 5, No. 1, pp. 7-10.

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Sex Education in U.S. Public Schools

Sex education can play a major role in helping teenagers to make healthy and responsible decisions about sex, but the content of sex education varies tremendously. Currently, 39 states mandate either sex education or education on HIV/AIDS and other STDs, but their laws tend to be very general. Policies specifying the content of sex education classes are typically set at the local level, and local school districts tend to have broad discretion in this area.

Sources: AGI, Sexuality education, State Policies in Brief, July 2003, , accessed July 28, 2003; and Gold RB and Nash E, Statelevel policies on sexuality, STD education, The Guttmacher Report on Public Policy, 2001, Vol. 4, No. 4, pp. 4-7.

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Most school district policies promote abstinence 14%

35%

Abstinence as only option

Abstinence as preferred option/ contraceptives effective Abstinence as one option in broader sex education 51%

Districts with a sex education policy ©The Alan Guttmacher Institute

Sex Education

Today, more than two out of three public school districts have a policy of teaching sex education. Most adopted their current policies during the mid-1990s. During this time, many state governments and local communities were experiencing heated debates over the content of sex education curricula. School districts with a sex education policy universally require that abstinence be taught, and 86% require that abstinence be promoted over other options for teenagers. Some 35% require that abstinence be taught as the only option for unmarried people, and either do not allow discussion of contraceptives or allow discussion only of their failure rates. The other 51% require that abstinence be taught as the preferred option for young people, but also permit discussion about contraception as an effective means of protecting against unintended pregnancy and STDs. Only 14% have a policy of teaching abstinence as part of a broader program designed to prepare adolescents to be sexually healthy adults. Source: Landry DJ, Kaeser L and Richards CL, Abstinence promotion and the provision of information about contraception in public school district sexuality education policies, Family Planning Perspectives, 1999, 31(6):280-286.

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School district sex education policies vary widely by region % of districts with a policy 100% 80% 60% 40% 20% 0% Northeast

South

Midwest

West

Abstinence as one option in broader sex education Abstinence as preferred option/contraceptives effective Abstinence as only option ©The Alan Guttmacher Institute

Sex Education

There is significant regional variation in school district sex education policies. More than half of school districts in the South have a policy of teaching that abstinence is the only option for teenagers, compared with 20% of districts in the Northeast. The trend in school district policy is toward abstinence promotion. Districts that switched their policies during the 1990s were twice as likely to adopt a more abstinencefocused policy as to move toward a more comprehensive approach.

Source: Landry DJ, Kaeser L and Richards CL, Abstinence promotion and the provision of information about contraception in public school district sexuality education policies, Family Planning Perspectives, 1999, 31(6):280286. 18

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There is a large gap between what teachers believe should be covered in sex education and what they actually teach % of sex education teachers 100 80 60 40 20 0 HIV

STDs

Abstinence

Opinion ©The Alan Guttmacher Institute

Birth control

Facts on abortion

Condom use

Sexual orientation

Instruction Sex Education

Not surprisingly, the emphasis on abstinence in sex education policies influences what is being taught in sex education classes. In certain areas of sex education, there is a large gap between what teachers believe they should cover and what they are actually teaching. The great majority of sex education teachers believe that sex education should cover factual information about birth control and abortion, the correct way to use a condom, and sexual orientation. However, far fewer actually teach these topics, either because they are prohibited from doing so or because they fear teaching these topics would create controversy. As a result, one in four teachers believe they are not meeting their students’ needs for information. Source: Darroch JE, Landry DJ and Singh S, Changing emphasis in sexuality education in U.S. public secondary schools, 1988-1999, Family Planning Perspectives, 2000, 32(5):204-211 & 265.

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Many sex education teachers do not teach about contraception One in four sex education teachers are prohibited from teaching about contraception Four in 10 either do not teach about contraceptive methods (including condoms) or teach that they are ineffective

©The Alan Guttmacher Institute

Sex Education

The gap between what sex education teachers think should be covered and what they actually teach is particularly acute when it comes to contraception. Sex education teachers almost universally believe that students should be provided with basic factual information about birth control, but school policies prohibit one in four teachers from doing so. Overall, four in 10 teachers either do not teach about contraceptive methods (including condoms) or teach that they are ineffective in preventing pregnancy and STDs.

Source: Darroch JE, Landry DJ and Singh S, Changing emphasis in sexuality education in U.S. public secondary schools, 1988-1999, Family Planning Perspectives, 2000, 32(5):204-211 & 265.

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Teachers who teach the effectiveness of contraception are more likely to cover key prevention topics % of sex education teachers 100 80 60 40 20 0 Condoms for STD/HIV prevention

How to resist peer pressure

Teach contraception is effective ©The Alan Guttmacher Institute

Correct and consistent method use

Sources of STD/HIV help

Teach contraception is ineffective Sex Education

That four in 10 sex education teachers either do not teach about contraceptives at all or teach that they are ineffective in preventing pregnancy and STDs is particularly troubling. New research shows that teachers who present contraception as effective are more likely than those who present it as ineffective to provide young people with specific information about topics key to the prevention of unintended pregnancy and STDs, including the importance of using contraceptives consistently, the use of condoms to prevent STD/HIV infection and where to obtain STD/HIV help.

Source: Landry DJ et al., Factors influencing the content of sex education in U.S. public secondary schools, Perspectives on Sexual and Reproductive Health, 2003, forthcoming.

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Public Opinion

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Americans overwhelmingly favor broader sex education 1% 18%

Abstinence, pregnancy and STD prevention should be taught Only abstinence should be taught

Don't know

81% Public opinion ©The Alan Guttmacher Institute

Sex Education

What many students are being taught in sex education classes does not reflect public opinion about what they should be learning. Americans overwhelmingly support sex education that includes information about both abstinence and contraception. Moreover, public opinion polls consistently show that parents of middle and high school students support this kind of sex education over classes that teach only abstinence. Parents also want sex education classes to cover topics that are perceived as controversial by many school administrators and teachers. At least three-quarters of parents say that sex education classes should cover how to use condoms and other forms of birth control, as well as provide information on abortion and sexual orientation. Yet these topics are the very ones that teachers often do not cover. Finally, two in three parents say that significantly more classroom time should be devoted to sex education. Source: The Henry J. Kaiser Family Foundation (KFF), Sex Education in America, Menlo Park: KFF, 2000. 23

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Students say they need more sex education in school than they currently receive % who want more information 100 80 60 40 20 0 What to do if sexually assaulted

STDs

©The Alan Guttmacher Institute

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How to talk with a partner about birth control and STDs

Birth control

How to handle pressure to have sex

Sex Education

Similarly, students report that they want more information about sexual and reproductive health issues than they are receiving in school. Some 40-50% of students in grades 712 report wanting more factual information about birth control and HIV/AIDS and other STDs, as well as what to do in the event of rape or sexual assault, how to talk with a partner about birth control and how to handle pressure to have sex.

Source: The Henry J. Kaiser Family Foundation (KFF), Sex Education in America, Menlo Park: KFF, 2000. 24

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Many teenage males do not receive sex education before first sex % who have sex before receiving sex education 100 80 60 40 20 0 How to put How to say on a no to sex condom ©The Alan Guttmacher Institute

STDs

Birth control

AIDS prevention

Any

Sex Education

In addition to receiving too little information, students are receiving sex education too late to fully protect themselves against unintended pregnancy and STDs. For example, research on teenage males suggests that 30% do not receive any sex education before they have sex for the first time. This figure climbs to 46% for black teenage males. With respect to specific topics, more than 40% of teenage males do not receive any formal education about birth control or STDs before they have sex for the first time.

Source: Lindberg LD, Ku L and Sonenstein F, Adolescents’ reports of reproductive health education, 1988-1995, Family Planning Perspectives, 2000, 32(5):220-226.

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Support for comprehensive sex education American Medical Association American Academy of Pediatrics American Nurses Association American College of Obstetricians and Gynecologists American Psychological Association American Public Health Association National Institutes of Health Institute of Medicine ©The Alan Guttmacher Institute

Sex Education

Major medical and public health organizations also support more comprehensive forms of sex education that include information about both abstinence and contraception for the prevention of teenage pregnancy and STDs. These include the American Medical Association, the American Academy of Pediatrics, the American Nurses Association, the American College of Obstetricians and Gynecologists, the American Psychological Association, the American Public Health Association, the National Institutes of Health and the Institute of Medicine.

Source: Boonstra H, Legislators craft alternative vision of sex education to counter abstinence-only drive, The Guttmacher Report on Public Policy, 2002, Vol. 5, No. 2, pp. 1-3.

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The Big Disconnect Teachers, parents, students and health organizations want young people to receive comprehensive sex education Conservative groups and politicians are promoting education in U.S. schools that emphasizes abstinence and denies young people accurate information about contraception.

©The Alan Guttmacher Institute

Sex Education

A growing body of research therefore highlights a troubling disconnect: Although teachers, parents, students and health organizations want young people to receive more comprehensive information about how to avoid unintended pregnancy and STDs and about how to become sexually healthy adults, U.S. policymakers continue to promote school-based abstinence education that fails to provide accurate information about contraception, including condoms.

Source: Dailard C, Sex education: Politicians, parents, teachers and teens, The Guttmacher Report on Public Policy, 2001, Vol. 4, No. 1, pp. 9-12; and Boonstra H, Legislators craft alternative vision of sex education to counter abstinence-only drive, The Guttmacher Report on Public Policy, 2002, Vol. 5, No. 2, pp. 1-3. 27

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U.S. Government Support for Abstinence Education

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The Federal Definition of Abstinence Education “Abstinence education…has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity”

©The Alan Guttmacher Institute

Sex Education

Beginning in 1981, the federal government provided funding on a small scale for education that promoted abstinence. Under the 1996 welfare reform law, however, it committed $50 million a year in federal funding and required another $38 million in state matching funds to support abstinence education. The 1996 law established a stringent eight-point definition of “abstinence education” that requires funded programs to teach that sexual activity outside of marriage is wrong and harmful—for people of any age. Funded programs must exclusively promote abstinence. As a result, they are prohibited from advocating contraceptive use. They must either refrain from discussing contraceptive methods altogether or limit their discussion to contraceptive failure rates. This eight-point definition represents the only articulation of sex education policy in federal law.

Source: P.L. 104-193, Aug. 22, 1996. 29

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Total Federal Funding for Abstinence Education—FY 2004 Welfare: AFLA: SPRANS: Total:

©The Alan Guttmacher Institute

$50 million $12 million $75 million $137 million

Sex Education

Since 1996, Congress has also supported abstinence education that omits accurate information about contraception through two other funding streams, both of which use the welfare law’s eight-point definition. In 2004, Congress provided $12 million for abstinence education through the Adolescent Family Life Act and $75 million for Special Projects of Regional and National Significance. Across these three programs, the federal government devoted $137 million to abstinence education in 2004. Note: Updated February 2004.

Source: Dailard C, Abstinence promotion and teen family planning: the misguided drive for equal funding, The Guttmacher Report on Public Policy, 2002, Vol. 5, No. 1, pp. 1-3.

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The Grand Total Federal and matching state funding for abstinence education that fails to include accurate and complete information about contraception has totaled almost $1 billion since 1996.

©The Alan Guttmacher Institute

Sex Education

Overall, federal and matching state funding for abstinence education that fails to include accurate and complete information about contraception has totaled almost $1 billion since 1996.

Note: Updated February 2004

Source: Dailard C, Funding history for abstinence programs, memorandum, Washington, DC: AGI, 2003.

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Effectiveness of Sex Education

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What do evaluations say about the effectiveness of sex education? No evidence that abstinence without contraceptive education effectively protects teenagers Contraceptive education does not encourage sexual activity

©The Alan Guttmacher Institute

Sex Education

Despite at least two decades of abstinence education, there have been few rigorous evaluations to date of programs focusing exclusively on abstinence. None of these, moreover, has shown evidence that these programs either delay sexual activity or reduce teenage pregnancy. Program evaluations clearly show, however, that contraceptive education does not promote sexual activity among teenagers. These results refute long-standing claims by proponents of abstinence education that providing teenagers with information about the value of both abstinence and contraceptive use sends “mixed messages” that encourage sexual activity. Sources: Kirby D, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: The National Campaign to Prevent Teen Pregnancy, 2001; and Satcher D, The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior, Rockville, MD: Office of the Surgeon General, 2001.

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What do evaluations say about the effectiveness of sex education? Considerable evidence that certain programs that include abstinence and contraceptive education help teenagers: delay sexual activity increase contraceptive use reduce number of partners

©The Alan Guttmacher Institute

Sex Education

Furthermore, there is considerable scientific evidence that certain programs that include information about both abstinence and contraception help teenagers delay sexual activity. Teenagers who have participated in these more comprehensive programs also demonstrate increased contraceptive use when they do become sexually active and have fewer sexual partners.

Sources: Kirby D, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: The National Campaign to Prevent Teen Pregnancy, 2001; and Satcher D, The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior, Rockville, MD: Office of the Surgeon General, 2001.

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The Potential for Harm Virginity pledges may deter young people from using contraceptives when they become sexually active HIV prevention messages that promote only abstinence and not condoms may result in more unprotected sex than do safer-sex messages ©The Alan Guttmacher Institute

Sex Education

Research suggests that education and strategies that promote abstinence but withhold information about contraceptives in general, and condoms in particular, can actually place young people at risk of pregnancy and STDs. For example, a study of teenagers who took a pledge promising to abstain from sex until marriage and subsequently broke their pledge were one-third less likely to use contraceptives than those who had not pledged virginity in the first place. Another study found that sexually experienced teenagers who received messages promoting only abstinence for HIV prevention were more likely to have unprotected sex than those who received safer-sex messages emphasizing abstinence, but advising condom use for teenagers who are sexually active. More research needs to be done to determine how long these negative effects last. Sources: Bearman PS and Bruckner H, Promising the future: virginity pledges and first intercourse, American Journal of Sociology, 2001, 106(4):859-912; Jemmott JB, Jemmott LS and Fong GT, Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial, Journal of the American Medical Association, 1998, 279(19):1529-1536; and Dailard C, Abstinence promotion and teen family planning: the misguided drive for equal funding, The Guttmacher Report on Public Policy, 2002, Vol. 5, No. 1, pp. 1-3.

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In Conclusion…

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A “risk reduction” approach to teenage sexual activity remains vital Fact: Sex among young people is common in the United States and worldwide Fact: Undermining confidence in contraception threatens young people’s lives and health Fact: Only a balanced approach will help young people protect themselves ©The Alan Guttmacher Institute

Sex Education

The promotion of abstinence education that questions the effectiveness of contraceptives in general, and condoms in particular, is at the heart of a socially conservative movement to undermine the validity of “risk reduction” as a public health paradigm. Proponents of this view say that only complete “risk elimination” through abstinence until marriage to an uninfected partner and mutual lifelong monogamy offers total protection from STDs. Furthermore, they say that this is the only prevention message that should be provided to young people. Yet sex among young people, and unmarried people of all ages, is common—both in this country and around the world. Thus, undermining people’s confidence in the effectiveness of contraceptives, including condoms, threatens their health and lives. Providing young people with balanced and accurate information about contraception as part of basic sex education must therefore remain a key component of public health efforts to help young people protect themselves against unintended pregnancies and STDs. Source: Boonstra H, Public health advocates say campaign to disparage condoms threatens STD prevention efforts, The Guttmacher Report on Public Policy, 2003, Vol. 6, No. 1, pp. 1-2 & 14.

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Summary Many U.S. teenagers experience unintended pregnancy and STDs Teenagers in other developed countries fare better Abstinence education that omits accurate information about contraceptives is prevalent across the country Many sex education teachers believe they are not meeting students’ needs

©The Alan Guttmacher Institute

Sex Education

In summary, too many young people in this country experience poor reproductive and sexual health outcomes, including unintended pregnancy and STDs. Individuals and organizations working to improve the health and welfare of young people can learn from the experience of other developed countries, where young people have significantly lower rates of unintended pregnancy and STDs. In contrast to schools in these other countries, where sex education includes comprehensive information about pregnancy and STD prevention, U.S. schools commonly provide abstinence education that either excludes information about or denigrates contraception. As a result, many sex education teachers believe they are not meeting their students’ needs for information.

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Summary Current federal policy ignores public opinion and research on “what works” Only a balanced and comprehensive approach will help teenagers to become sexually healthy adults

©The Alan Guttmacher Institute

Sex Education

By promoting abstinence education that omits accurate and complete information about contraception, U.S. policy ignores the experience of other countries, public opinion and research about “what works.” Preserving and continuing the gains of the last decade requires a balanced approach that emphasizes all the key means of prevention—including effective contraceptive and condom use, as well as abstinence. Ultimately, only such a comprehensive approach will provide young people with the tools they need to protect themselves and to become sexually healthy adults.

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Major Sources National Surveys Youth Risk Behavior Survey–Centers for Disease Control and Prevention National Survey of Family Growth– National Center for Health Statistics Surveys of school superintendents and sex education teachers–AGI Survey of students and public opinion– Henry J. Kaiser Foundation National Survey of Adolescent Males– Urban Institute ©The Alan Guttmacher Institute

Sex Education

This presentation uses information from a variety of nationally representative surveys from federal and private agencies. The data sources include surveys of school superintendents, teachers, students and the general public. Other data and sources include birth and international abortion statistics from a range of sources, evaluation research results on the effectiveness of sex education programs and policy analysis conducted by AGI staff.

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Major Sources Other Sources Teenage pregnancy statistics–AGI International birth and abortion statistics from various sources Evaluation research–National Campaign to Prevent Teen Pregnancy Federal law and policy Statements on sex education from national organizations Policy analysis from AGI ©The Alan Guttmacher Institute

Sex Education

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This presentation was developed with support from the Program on Reproductive Health and Rights of the Open Society Institute.

For more information, visit www.guttmacher.org

Acknowledgments: This presentation was prepared by Cynthia Dailard, with the assistance of David Landry, Jennifer Nadeau and Rebecca Wind, all with The Alan Guttmacher Institute (AGI). It was supported by a grant from the Program on Reproductive Health and Rights of the Open Society Institute. AGI is grateful to the following individuals, who reviewed earlier drafts of this presentation and provided valuable information and advice: Krista Anderson, Planned Parenthood of the Rocky Mountains; Kelson EttienneModest, Weaver High School; Marcela Howell, Advocates for Youth; Douglas Kirby, ETR Associates; Mike McGee, Planned Parenthood Federation of America; Jennifer Parker, ACCESS/Women’s Health Rights Coalition; and Susan Wilson, Rutgers University.

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References Slide 3: The Alan Guttmacher Institute (AGI), In Their Own Right: Addressing the Sexual and Reproductive Health Needs of American Men, New York: AGI, 2002, p. 8; and Dailard C, Marriage is no immunity from problems with planning pregnancies, The Guttmacher Report on Public Policy, 2003, Vol. 6, No. 2, pp.10-13. Slide 4: Henshaw SK, U.S. teenage pregnancy statistics with comparative statistics for women aged 20-24, New York: AGI, May 2003, , accessed July 28, 2003; Henshaw SK, Unintended pregnancy in the United States, Family Planning Perspectives, 1988, 30(1):24-29 & 46; and Centers for Disease Control and Prevention (CDC), Young People at Risk: HIV/AIDS Among America’s Youth, Atlanta: CDC, Mar. 2002. Slide 5: Henshaw SK, U.S. teenage pregnancy statistics with comparative statistics for women aged 20-24, New York: AGI, May 2003, , accessed July 28, 2003. Slide 6: Darroch JE and Singh S, Why Is Teenage Pregnancy Declining? The Roles of Abstinence, Sexual Activity and Contraceptive Use, Occasional Report, New York: AGI, 1999, No. 1. Slide 7: Brener N et al., Trends in sexual risk behaviors among high school students—United States, 1991-2001, Morbidity and Mortality Weekly Report, 2002, 51(38):856-859. Slide 8: Brener N et al., Trends in sexual risk behaviors among high school students—United States, 1991-2001, Morbidity and Mortality Weekly Report, 2002, 51(38):856-859. Slide 9: AGI, Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Occasional Report, New York: AGI, 2001, No. 3; and AGI, Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics, New York: AGI, 2000. Slide 11: AGI, Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Occasional Report, New York: AGI, 2001, No. 3. Slide 12: AGI, Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Occasional Report, New York: AGI, 2001, No. 3. Slide 13: AGI, Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Occasional Report, New York: AGI, 2001, No. 3; and Boonstra H, Teen pregnancy: trends and lessons learned, The Guttmacher Report on Public Policy, 2002, Vol. 5, No. 1, pp. 7-10. ©The Alan Guttmacher Institute

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References Slide 14: AGI, Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made? Occasional Report, New York: AGI, 2001, No. 3; and Boonstra H, Teen pregnancy: trends and lessons learned, The Guttmacher Report on Public Policy, 2002, Vol. 5, No. 1, pp. 7-10. Slide 15: AGI, Sexuality education, State Policies in Brief, July 2003, , accessed July 28, 2003; and Gold RB and Nash E, State-level policies on sexuality, STD education, The Guttmacher Report on Public Policy, 2001, Vol. 4, No. 4, pp. 4-7. Slide 16: Landry DJ, Kaeser L and Richards CL, Abstinence promotion and the provision of information about contraception in public school district sexuality education policies, Family Planning Perspectives, 1999, 31(6):280-286. Slide 17: Landry DJ, Kaeser L and Richards CL, Abstinence promotion and the provision of information about contraception in public school district sexuality education policies, Family Planning Perspectives, 1999, 31(6):280-286. Slide 18: Darroch JE, Landry DJ and Singh S, Changing emphasis in sexuality education in U.S. public secondary schools, 1988-1999, Family Planning Perspectives, 2000, 32(5):204-211 & 265. Slide 19: Darroch JE, Landry DJ and Singh S, Changing emphasis in sexuality education in U.S. public secondary schools, 1988-1999, Family Planning Perspectives, 2000, 32(5):204-211 & 265. Slide 20: Landry DJ et al., Factors influencing the content of sex education in U.S. public secondary schools, Perspectives on Sexual and Reproductive Health, 2003, forthcoming. Slide 22: The Henry J. Kaiser Family Foundation (KFF), Sex Education in America, Menlo Park: KFF, 2000. Slide 23: The Henry J. Kaiser Family Foundation (KFF), Sex Education in America, Menlo Park: KFF, 2000. Slide 24: Lindberg LD, Ku L and Sonenstein F, Adolescents’ reports of reproductive health education, 1988-1995, Family Planning Perspectives, 2000, 32(5):220-226.

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References Slide 25: Boonstra H, Legislators craft alternative vision of sex education to counter abstinence-only drive, The Guttmacher Report on Public Policy, 2002, Vol. 5, No. 2, pp. 1-3. Slide 26: Dailard C, Sex education: Politicians, parents, teachers and teens, The Guttmacher Report on Public Policy, 2001, Vol. 4, No. 1, pp. 9-12; and Boonstra H, Legislators craft alternative vision of sex education to counter abstinence-only drive, The Guttmacher Report on Public Policy, 2002, Vol. 5, No. 2, pp. 1-3. Slide 28: P.L. 104-193, Aug. 22, 1996. Slide 29: Dailard C, Abstinence promotion and teen family planning: the misguided drive for equal funding, The Guttmacher Report on Public Policy, 2002, Vol. 5, No. 1, pp. 1-3. Slide 30: Dailard C, Funding history for abstinence programs, memorandum, Washington, DC: AGI, 2003. Slide 32: Kirby D, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: The National Campaign to Prevent Teen Pregnancy, 2001; and Satcher D, The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior, Rockville, MD: Office of the Surgeon General, 2001. Slide 33: Kirby D, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: The National Campaign to Prevent Teen Pregnancy, 2001; and Satcher D, The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior, Rockville, MD: Office of the Surgeon General, 2001. Slide 34: Bearman PS and Bruckner H, Promising the future: virginity pledges and first intercourse, American Journal of Sociology, 2001, 106(4):859-912; Jemmott JB, Jemmott LS and Fong GT, Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial, Journal of the American Medical Association, 1998, 279(19):1529-1536; and Dailard C, Abstinence promotion and teen family planning: the misguided drive for equal funding, The Guttmacher Report on Public Policy, 2002, Vol. 5, No. 1, pp. 1-3. Slide 36: Boonstra H, Public health advocates say campaign to disparage condoms threatens STD prevention efforts, The Guttmacher Report on Public Policy, 2003, Vol. 6, No. 1, pp. 1-2 & 14. ©The Alan Guttmacher Institute

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THE ALAN GUTTMACHER INSTITUTE

Can More ProgressBeMade? Teenage Sexual and Reproductive Behavior in Developed Countries Major Conclusions

Executive Summary There is strong consensus in the United States that teenage pregnancy and birth levels are too high. Despite dramatic decreases in teenage pregnancy rates and birthrates in the United States over the past decade, this country still has substantially higher levels of adolescent pregnancy, childbearing and abortion than in other Western industrialized countries. Moreover, teenage birthrates have declined less steeply in the United States than in other developed countries over the last three decades (Chart 1, page 2). While much can be learned from the experience and insights of people in the United States who are engaged in efforts to reduce teenage pregnancy rates and birthrates, important lessons can also be learned from other countries. Cross-national comparisons can help to identify factors that may be so pervasive, they are not readily recognized within the United States; such comparisons can also suggest new approaches that might be helpful. This executive summary presents the highlights of a large-scale investigation, Teenage Sexual and Reproductive Behavior in Developed Countries, conducted in Sweden, France, Canada, Great Britain1 and the United States between 1998 and

2001 (see box, page 2). Teenage pregnancy rates and birthrates in these five countries vary widely, with the lowest rates in Sweden and France, moderate rates in Canada and Great Britain, and the highest rates in the United States. Although the focus of this executive summary is on what the United States can learn from the other countries, many of the insights gained may also be useful to them, as well as to countries not involved in this study. Beneath the generalizations necessary when making cross-national comparisons, there are often large differences across areas and groups within a country, and varying national contexts and histories. While all of the study countries have democratic governments and are highly developed, they differ in some basic respects, such as population size and density, and political, economic and social perspectives and structures. For example, the United States has long emphasized individual responsibility for one’s own welfare. As much as possible, government is expected to stay out of people’s lives, especially in the area of health and social policy, and only as a last resort, to play a remedial role as provider of assistance. The resulting deregulated, individualistic society has tended to foster more fluid social structures, greater flexibility and innovation, and more economic vibrancy than can be found in much of Europe. On the other hand, the social and political commitment to providing a social and economic safety net, including health care for all, which has been so strong in Europe since World War II, is largely missing from the United States. The large U.S. population, geographic area and economy encompass far greater diversity than is found in the other study countries, but the United States is also characterized by greater inequality and more widespread poverty, which are compounded by the country’s history of slavery and racism.

■ Continued high levels of teenage childbearing in the United States compared with levels in Sweden, France, Canada and Great Britain reflect higher pregnancy rates and smaller proportions of pregnant teenagers having abortions. Since timing and levels of sexual activity are quite similar across countries, the high U.S. rates arise primarily because of less, and possibly less-effective, contraceptive use by sexually active teenagers. ■ Growing up in conditions of social and economic disadvantage is a powerful predictor of early childbearing in all five countries. The greater proportion of teenagers from disadvantaged families in the United States contributes to the country’s high teenage pregnancy rates and birthrates. At all socioeconomic levels, however, American teenagers are less likely to use contraceptives and more likely to have a child than their peers in the other countries. ■ Stronger public support and expectations for the transition to adult economic roles, and for parenthood, in Sweden, France, Canada and Great Britain than in the United States provide young people with greater incentives and means to delay childbearing. ■ Societal acceptance of sexual activity among young people, combined with comprehensive and balanced information about sexuality and clear expectations about commitment and prevention of childbearing and STDs within teenage relationships, are hallmarks of countries with low levels of adolescent pregnancy, childbearing and STDs. ■ Easy access to contraceptives and other reproductive health services in Sweden, France, Canada and Great Britain contributes to better contraceptive use and therefore lower teenage pregnancy rates than in the United States. Easy access means that adolescents know where to obtain information and services, can reach a provider easily, are assured of receiving confidential, nonjudgmental care and can obtain services and contraceptive supplies at little or no cost.

61 Chart 1. Teenage birthrates declined less steeply in the United States than in other developed countries between 1970 and 2000.

Births per 1,000 women 15–19

100

80 United States 60

England and Wales Canada

40

France 20

Sweden

0 1970

1975

1980

1985

1990

1995

2000*

*Data are for 1997 in Canada, 1998 in France and 1999 in England, Wales and Sweden.

Pathways to High U.S. Rates Teenage pregnancy levels are higher in the United States than in the other study countries. U.S. teenagers have higher birthrates than adolescents in the other study countries because they are much more likely to become pregnant, and because those who become pregnant are less likely than pregnant adolescents in the other countries to have abortions (Chart 2). At the same time, however, U.S. teenagers also have a higher abortion rate than their peers in the other countries because they are more likely to become pregnant unintentionally. In addition to having higher rates of unplanned pregnancy, teenage women in the United States are more likely than their peers in the other countries to want to become mothers. Surveys indicate that even if only those teenagers who wanted to become mothers did so, the resulting teenage birthrate in the United States (18 per 1,000 women aged 15–19) would still be higher than the total adolescent birthrates in France and Sweden and about two-thirds as high as the total teenage birthrates in Great Britain and Canada. Differences between countries in levels of sexual activity are too small to account for the wide variation in teenage pregnancy rates. Levels of sexual activity and the age when teenagers become sexually active do not vary appreciably across the five

THE ALAN GUTTMACHER INSTITUTE

countries (Chart 3). Moreover, most measures indicate less, rather than more, exposure to sexual intercourse among teenage women and men in the United States than among those in the other four countries. However, some potentially important differences exist between countries in patterns of teenage sexual activity. Teenagers in the United States are the most likely to have sexual intercourse before age 15. They also appear, on average, to have shorter and more sporadic sexual relationships. For example, American teenagers who had intercourse in the past year are more likely to have had more than one partner than young people in the other countries, especially those in France and Canada (Chart 4). Less contraceptive use and less use of hormonal methods are the primary reasons U.S. teenagers have the highest rates of pregnancy, childbearing and abortion. U.S. teenagers are less likely to use any contraceptive method than young women in the other study countries and are also less likely to use the pill or a long-acting reversible hormonal method (the injectable or the implant), which have the highest use-effectiveness rates (Chart 5, page 4). Data on the effectiveness with which women and men use contraceptive methods are available only for the United States. However, estimates using these effectiveness rates and country method-use patterns suggest that lesssuccessful use of contraceptive methods also contributes to higher pregnancy rates among U.S. teenagers.

2

More sexual partners, a higher prevalence of infection and, probably, less condom use contribute to higher teenage sexually transmitted disease (STD) rates in the United States. STD rates are higher among U.S. teenagers than among adolescents in the other study countries. U.S. teenagers have more sexual partners than teenagers in the other study countries, especially France and Canada. This increases their risk of contracting an STD, including HIV. Moreover, while sexually active teenagers in the United States are more likely than their counterparts in the other countries to rely on condoms as their main method, available data suggest they are less likely than teenagers in Great Britain and probably Canada to use condoms in addition to a hormonal method. Thus, American teenagers who are sexually active are more likely to be exposed to the risk of STDs and may be less likely to use condoms. Higher levels of STD infection in the U.S. population as a whole than in the other study countries suggest that another factor contributing to high STD levels among teenagers is the greater prevalence of both viral and untreated bacterial STDs among their partners.

Information Sources Collaborating research teams carried out case studies for each of the five countries. The study teams used a common approach to gather information and prepare in-depth country reports. The project also included two workshops, analyses of teenage pregnancy and STD levels in all developed countries, and site visits by the U.S. study team, who were also the project leaders, that involved extensive consultation with reproductive health professionals in each of the focus countries. Study-team participants were in Canada, Eleanor Maticka-Tyndale, Alex McKay and Michael Barrett; in France, Nathalie Bajos and Sandrine Durand; in Great Britain, Kaye Wellings; in Sweden, Maria Danielsson, Christina Rogala and Kajsa Sundström; and in the United States, Jacqueline E. Darroch, Jennifer Frost, Susheela Singh, Rachel Jones and Vanessa Woog. Project funding was provided by The Ford Foundation and The Henry J. Kaiser Family Foundation.

CAN MORE PROGRESS BE MADE?

62 Chart 2: U.S. teenagers have higher pregnancy rates, birthrates and abortion rates than adolescents in other developed countries. Sweden

Birth Abortion

France

Canada Great Britain United States 0

20

40

60

80

100

Rate per 1,000 women aged 15–19

Note: Data are for mid-1990s.

Society’s Influences on Teenagers’ Behavior The behavior of young people in the study countries and the types of policies and programs developed for teenagers reflect the social, historical and governmental contexts of the individual countries. For example, the unplanned pregnancy rate among women aged 15–44 in the early to mid1980s was much higher in the United States than in Sweden, Canada and Great Britain; the U.S. rate was similar to the rate in France. The abortion rate in the mid-1990s was higher not only among teenagers but also among women in their 20s and among all women aged 15–44 in the United States than in any of the other study countries. The greatest differences in abortion rates were not among teenagers but among women in their early 20s, with the U.S. abortion rate at 50 per 1,000 women aged 20–24, compared with rates in the other study countries no higher than 31 per 1,000. Social and economic well-being and equality are linked to lower teenage pregnancy rates and birthrates.

tributes to widespread inequity in the United States. For example, one-fifth of U.S. women of reproductive age have no health insurance. The national and local governments play a remedial role, making services such as public health clinics, housing and income assistance available to poor, uninsured and other disadvantaged people. However, because public services are primarily for the disadvantaged, their use carries a stigma in many communities. Numerous nongovernmental organizations help make up for the lack of public services, but their coverage and scope vary widely. In contrast, the other study countries, especially Sweden and France, have stronger social welfare systems, and are committed to reducing economic disparity within their populations. Government provides or pays for basic services such as health care for everyone. Public services are therefore considered a right, and no stigma is attached to their use. •Compared with adolescents in the other countries, U.S. teenagers are more likely to grow up in disadvantaged circumstances and those who do are more likely to have a child during their teenage years. In all of the study countries, young people growing up in disadvantaged economic, familial and social circumstances are more likely than their better-off peers to engage in risky sexual behavior and to become parents at an early age. Although the United States has the highest median per capita income of the five countries, it also has the largest proportion of its population who are poor. The higher proportion of teenagers from disadvantaged back-

Chart 3: Differences in levels of teenage sexual activity across developed countries are small. Sweden

France

•Government commitment to social welfare and equality for all members of society provides greater support for individual well-being in other countries than in the United States. The philosophy that individuals are responsible for their own welfare and that the government should stay out of people’s lives as much as possible, especially in the areas of health and social policy, con-

Canada Great Britain United States 0

20

40

60

80

100

% of women 20–24 who had sex in their teenage years

By age 15

By age 18

By age 20

Chart 4: Among teenagers who had sex in the last year, those in the United States are more likely than those in other developed countries to have had two or more partners.

Sweden

Females Males

France Canada Great* Britain* United States 0

20

40

60

80

100

% of 18–19-year-olds who had two or more partners *Data for 16–19-year-olds. Note: Data are for mid-1990s.

grounds contributes to the high teenage pregnancy rates and birthrates in the United States. At all socioeconomic levels, however, U.S. youth have lower levels of contraceptive use and higher levels of childbearing than their peers in the other study countries. For example, the level of births among U.S. teenagers in the highest income subgroup is 14% higher than the level among similarly advantaged teenagers in Great Britain and higher than the overall levels in Sweden and France. Differences are greatest among disadvantaged youth: U.S. teenagers in the lowest income subgroup have birth levels 58% higher than similar teenagers in Great Britain. Not only do Hispanic and black teenagers in the United States, who are much more likely than whites to be from low socioeconomic circumstances, have very high pregnancy rates and birthrates, the birthrate among nonHispanic white teenagers (36 per 1,000) is higher than overall rates in the other study countries. Strong and widespread governmental support for young people’s transition to adulthood, and for parents, may contribute to low teenage birthrates in the countries other than the United States. Adolescence is viewed in all the study countries as a time of transition to adult roles, rights and responsibilities. However, while Sweden and France, and to some extent Great Britain and Canada, seek to help all youth through this transition, the United States primarily assists only those in greatest need. •Education and employment assistance help young people become estab-

Note: Data are for mid-1990s. THE ALAN GUTTMACHER INSTITUTE

3

CAN MORE PROGRESS BE MADE?

63 lished as adults. In the United States, the transition to adult roles and the process of settling on a vocation and finding employment are generally up to the individual adolescent and his or her family. Government employment training and assistance programs tend to be remedial and directed at small numbers of poor youth who are unable to find work on their own. The U.S. approach offers great freedom of choice and flexibility for many, but does little to help those who are less knowledgeable about opportunities for school and work or are less able to take advantage of them on their own. Youth in the other countries tend to receive more societal assistance and support for this transition, in the form of vocational education and training, help in finding work, and unemployment benefits. Such assistance is available to all youth through both public programs and private employers. These efforts not only smooth the transition from school to work but also convey to teenagers that they are of value to society, that their development and input are important, and that there are rewards for making the effort to fit into expected social roles. •Support for working parents and families signifies the high value of children and parenting, and gives youth the incentive to delay childbearing. In the United States, paid maternity leave is rare and child benefits are available only to some poor women and families. In the other study countries, working mothers (and sometimes fathers) are guaranteed paid parental leave and other benefits. Although the parental leave and family support policies in these countries, particularly Sweden and France, are quite generous in terms of time and money, they are not an incentive for younger women and teenagers to have children, because parental leave payments are tied to prior salary levels. These policies appear to reinforce societal norms that childbearing is best postponed until a young couple’s careers have been established. Support for working parents thus offers young people both the incentive to delay childbearing until they have completed school and become employed and the assurance that they will be able to combine work and childrearing. Positive attitudes about sexuality and clear expectations for behavior in sexual relationships contribute to THE ALAN GUTTMACHER INSTITUTE

responsible teenage behavior. •Openness and supportive attitudes about sexuality in other countries have not led to greater sexual activity or risktaking. The U.S. society is highly conflicted about sexuality in general and about expectations for adolescent behavior in particular. Adults in the other countries are less conflicted about both sexuality and teenage sexual activity, at least for older teenagers. Although a majority of adults in all five countries frown on young people’s having sex before age 16, such behavior is more likely to be accepted in Sweden and Canada (where 39% and 25%, respectively, think it is not wrong at all or only sometimes wrong) than it is in the United States and Great Britain (where 13% and 12%, respectively, hold Chart 5: U.S. teenagers are less likely to use a contraceptive method and to use a hormonal method than teenagers in other developed countries. Sweden*

France

Canada† Great Britain†† United States 0

20

40

60

80

100

% of of women 15–19 who used a method at last intercourse

Long-acting

Condom

Pill

Other

*Data are for 18–19-year-olds. †The condom category includes all methods other than the pill, but the condom is the predominant “other method.” ††Data are for 16–19-year-olds. Note: Users reporting more than one method were classified by the most effective method. Data are for early to mid-1990s.

these views).2 Adults in the other countries are also much more accepting of sex before marriage than are Americans: 84–94% in Canada, Great Britain and Sweden, compared with only 59% in the United States. Although there are no comparable data for France, initiation of intercourse before marriage or cohabitation is the norm there. In spite of these differences in attitudes, similar proportions of young people in all the study countries become sexually active during their adolescence. •There is a strong consensus in countries other than the United States that childbearing belongs in adulthood. Young people in Europe are usually con4

sidered adults only when they have finished their education, become employed and live independently from their parents. And only when they have established themselves in a stable union is it considered appropriate to begin having children. This view is most clearly established in Sweden and France, but it is also more common in Canada and Great Britain than in the United States. Few adolescents in any of the study countries meet these criteria for parenthood. For example, the proportion of adolescent women who are married or cohabiting ranges from 4% to roughly 10% in these countries. Nonetheless, of the few teenage births that occur in Sweden and France, 51% in each country are to young women who are married or cohabiting, compared with 38% in the United States (data are not available for Canada or Great Britain). Because the overall teenage birthrate in the United States is so high, the birthrate among women who are not in union—37 per 1,000—is much higher than in Sweden and France—no more than 5 per 1,000. •Countries other than the United States give clearer and more consistent messages about appropriate sexual behavior. Positive acceptance of sexuality in countries other than the United States is by no means value-free. In France and Sweden in particular, sexuality is seen as normal and positive, but there is widespread expectation that sexual intercourse will take place within committed relationships (though not necessarily formal marriages) and that those who are having sex will protect themselves and their partners from unintended pregnancy and STDs. In these countries, and also increasingly in Canada and Great Britain, sexual relationships among adolescents are accepted by others. This acceptance carries with it expectations of commitment, mutual monogamy, respect and responsibility. While adults in the other study countries focus chiefly on the quality of young people’s relationships and the exercise of personal responsibility within those relationships, adults in the United States are often more concerned about whether young people are having sex. Close relationships are often viewed as worrisome because they may lead to intercourse, and contraception may not be discussed for

CAN MORE PROGRESS BE MADE?

64 fear that such a discussion might lead to sexual activity. These generalities across countries are borne out in the behavior of young people. As was noted earlier, teenagers in the United States who have had sex appear more likely than their peers in the other countries to have short-term and sporadic relationships, and they are more likely to have many sexual partners during their teenage years. •Comprehensive sexuality education, not abstinence promotion, is emphasized in countries with lower teenage pregnancy levels. In Sweden, France, Great Britain and, usually, Canada, the focus of sexuality education is not abstinence promotion but the provision of comprehensive information about prevention of HIV and other STDs; pregnancy prevention; contraceptives and, often, where to get them; and respect and responsibility within relationships. Sexuality education is mandatory in state or public schools in England and Wales, France and Sweden and is taught in most Canadian schools, although the amount of time given to sexuality education, its content and the extent of teacher training vary among these countries and within them as well. In Sweden, the country with the lowest teenage birthrate, sexuality education has been mandated in schools for almost half a century, which reflects, and promotes, the topic’s acceptance as a legitimate and important subject for young people. Extremely vocal minority groups in the United States pressure school districts not to allow information about contraception to be provided in sexuality education classes, and substantial federal and state funds are directed to promoting abstinence for unmarried people of all ages, particularly for adolescents. Some 35% of the school districts that mandate sexuality education require that abstinence be presented as the only appropriate option outside of

marriage for teenagers and that contraception either be presented as ineffective in preventing pregnancy and HIV and other STDs or not be covered at all. •Media is used less in the United States than elsewhere to promote positive sexual behavior. Young people in all five countries are exposed through television programs, movies, music and advertisements to sexually explicit images and to casual sexual encounters with no consideration for preventing pregnancy or STDs. However, entertainment media and advertising messages about sexuality are seemingly less influential in the other countries than in the United States, because they are balanced by more pragmatic parental and societal attitudes and by nearly universal comprehensive sexuality education. Pregnancy and STD prevention campaigns undertaken in the United States generally have a punitive tone and focus on the negative aspects of teenage childbearing and STDs rather than on promotion of effective contraceptive use. The media have been used more frequently in the other countries for public campaigns to prevent STDs and HIV; the messages are generally positive about sexuality and are more likely to be humorous than judgmental. For example, the Swedish government works closely with youth to publish a frank and informative periodical magazine featuring subjects such as love, identity and sexuality that is widely read—and trusted—by young people. A government contraceptive campaign in France used television spots to air the message, “Contraception: The choice is yours.” Contraceptive use is higher, and pregnancy and STDs less common, where teenagers have easy access to sexual and reproductive health services. •Only in the United States do substantial proportions of adolescents lack health insurance and therefore have poor access to health care. Study countries

Table 1: The cost of reproductive health care for teenagers varies by country and by type of service. Service

Sweden

France

Canada

Great Britain

United States

Clinic visit

Free

Free

Free

Free

Mostly free

Private physician visit

Free

Pay full cost; insurance will reimburse 80%

Free

Free

Pay full cost; insurance may reimburse at varying levels

Initial cycles free; then $1–3 per cycle

Free at clinic; $1–7 at pharmacy

Initial cycles free; then $3–11 per cycle

Free

Free or discounted at clinics; $5–35 per cycle at pharmacy

Pill prescription

THE ALAN GUTTMACHER INSTITUTE

5

other than the United States have national systems for the financing and delivery of health care for everyone. Although the systems vary, they provide assurance that teenagers can access a clinician. In contrast, substantial proportions of U.S. teenagers and their families have no health insurance, and some who do have insurance may not be covered for contraceptive supplies or may fear that using insurance for reproductive health services will compromise their confidentiality, since their coverage usually comes through their parents’ policy. Many teens, regardless of their insurance status, turn to public health care providers for contraceptive services. •Contraceptive services and other reproductive health care are generally more integrated into regular medical care in countries other than the United States. In Sweden, France, Great Britain and Canada, contraceptive services are usually integrated into other types of primary care. This not only contributes to ease of access, but also lends support for the notion that contraceptive use is normal and important. In the United States, in contrast, contraception is still not fully accepted as basic health care. It is often not covered by private health insurance policies and, at least for teenagers, not always provided confidentially and sensitively by private physicians, who provide most people’s care. The fact that teenagers rely heavily on family planning clinics rather than the family doctor for contraceptive services simultaneously stigmatizes the clinics for providing care that is somewhat outside the mainstream and their teenage clients for doing something wrong by seeking those services in the first place. •U.S. teenagers have greater difficulty obtaining contraceptive services than do adolescents in the other study countries. Youth in the study countries obtain contraceptive services and supplies from a variety of providers, including physicians, nurse clinicians and clinics that either provide care to women and men of all ages or serve adolescents exclusively. No one type of contraceptive service provider appears necessarily the best for teenagers. What appears crucial to success is that adolescents know where they can go to obtain information and services, can get there easily and are assured of

CAN MORE PROGRESS BE MADE?

65 receiving confidential, nonjudgmental care, and that these services and contraceptive supplies are free or cost very little. In all five countries, teenagers seeking contraceptive services from clinic providers are guaranteed confidentiality, both legally and in practice. However, in the United States, numerous attempts to reverse this policy have been made at the national and state levels. While private physicians are usually legally protected from liability for serving minors on their own consent, there is little information about whether they always provide confidential care. Regulations in Great Britain state that physicians may prescribe contraceptives for an adolescent younger than 16 if it is in her best medical interest and she can give informed consent, but controversy about the standards and changes in policy guidelines have left many youth confused about whether they can obtain care confidentially from clinics or from private physicians. Contraceptive services and supplies are free or low-cost in Sweden, France, Canada and Great Britain. In the United States, the cost of care and supplies can be very high and depends on the type of provider; a young person’s income level; whether she is covered by health insurance that includes contraceptive coverage and, if so, whether she feels comfortable with the possibility her parents will know she used that coverage (Table 1, page 5). Providers’ attitudes may influence teenagers’ choice of a method. In countries other than the United States, the pill is the method usually offered to young women and most providers view oral contraceptives as the best method for adolescents and assume that young people are able to use them effectively. In the United States, almost all providers offer the pill along with a range of other methods, and many young women have turned to long-acting hormonal methods because of their own or their provider’s perception that these may be easier to use successfully. Sweden offers examples of ways to provide youth-friendly services. All Swedish providers guarantee confidentiality for young people seeking contraceptive and STD information and services; youth who seek STD testing are considered to be acting responsibly. In addition to maternal and child health

THE ALAN GUTTMACHER INSTITUTE

clinics, youth clinics throughout the country provide primary health care, including contraceptive and STD services, and psychological counseling to adolescents. These clinics are run by nurse-midwives who have direct authority to prescribe oral contraceptives. Young people often make informational visits to these clinics as part of school programs, and the clinics offer hotlines to call for information, advice and appointments. Other approaches have been used in France, where many family planning clinics offer sessions just for teenagers on Wednesday afternoons, when public schools throughout the country are closed. A recent government media campaign offered a hotline and brochures to help publicize government health clinics that provide free contraceptives to youth. •In study countries other than the United States, there is easier access to abortion. There is relatively little controversy in Sweden, France, Canada and Great Britain over the provision of abortion services, which are often provided through government health services or covered by national health insurance, and which are available confidentially to teenagers, although providers often encourage young women to involve their parents. In contrast, almost all abortion services in the United States are provided by private organizations, separate from women’s regular sources of medical care. Abortion is barred from coverage in federal and most state insurance programs, except in cases of rape, incest and danger to the woman’s life. Many American teenagers live in states that mandate parental consent or notice, or approval by a judge, before minors can obtain abortions.

other countries—most notably Sweden and France—appear to have clear social expectations that young people can and will make responsible decisions about sexual relationships, use contraceptives effectively, prevent STDs and obtain health services they need in a timely fashion, and that adults should provide them with guidance, support and assistance along the way. Where young people receive social support, full information and positive messages about sexuality and sexual relationships, and have easy access to sexual and reproductive health services, they achieve healthier outcomes and lower rates of pregnancy, birth, abortion and STDs. 1

Great Britain comprises England, Scotland and Wales. Some of the study information is available only for England and Wales. 2 Widmer ED, Treas J and Newcomb R. Attitudes toward nonmarital sex in 24 countries, Journal of Sex Research, 1998, 35(4):349–357.

©2001 The Alan Guttmacher Institute

The full report, Teenage Sexual and Reproductive Behavior in Developed Countries: Can More Progress Be Made?, and separate reports for Sweden, France, Canada, Great Britain and the United States are available for purchase. To order, call 1-800-355-0244 or 1-212-248-1111, or visit www.guttmacher.org and click “buy.”

Final Thoughts The findings suggest that improving adolescents’ prospects for successful adult lives and giving them tangible reasons to view the teenage years as a time to prepare for adult roles rather than to become parents are likely to have a greater impact on their behavior than exhortative messages that it is wrong to start childbearing early. Many in the United States give little support to young people as they establish sexual relationships. They consider adolescents to be developmentally incapable of making good judgments about their own behavior and of using contraceptives and condoms effectively. In contrast, the 6

A Not-for-Profit Corporation for Sexual and Reproductive Health Research, Policy Analysis and Public Education 120 Wall Street New York, NY 10005 Phone: 212.248.1111 Fax: 212.248.1951 [email protected] 1120 Connecticut Avenue, N.W. Suite 460 Washington, DC 20036 Phone: 202.296.4012 Fax: 202.223.5756 [email protected] Web site: www.guttmacher.org CAN MORE PROGRESS BE MADE?

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Issues & Implications

Understanding ‘Abstinence’: Implications for Individuals, Programs and Policies By Cynthia Dailard The word “sex” is commonly acknowledged to mean different things to different people. The same can be said for “abstinence.” The varied and potentially conflicting meanings of “abstinence” have significant public health implications now that its promotion has emerged as the Bush administration’s primary answer to pregnancy and sexually transmitted disease (STD) prevention for all people who are not married. For those willing to probe beneath the surface, critical questions abound. What is abstinence in the first place, and what does it mean to use abstinence as a method of pregnancy or disease prevention? What constitutes abstinence “failure,” and can abstinence failure rates be measured comparably to failure rates for other contraceptive methods? What specific behaviors are to be abstained from? And what is known about the effectiveness and potential “side effects” of programs that promote abstinence? Answering questions about what abstinence means

CONTRACEPTIVE EFFECTIVENESS RATES FOR PREGNANCY PREVENTION*

CONTRACEPTIVE M ETHOD ABSTINENCE F EMALE STERILIZATION ORAL CONTRACEPTIVES MALE CONDOM WITHDRAWAL

P ERFECT U SE

TYPICAL U SE

100 99.5 99.5–99.9** 97 96

??? 99.5 92.5 86.3 75.5

*Percentage of women who successfully avoid an unintended pregnancy during their first year of use. **Depending on formulation. Sources: Perfect use—Hatcher, RA, et al., Contraceptive Technology, 17th ed., 1998, page 216. Typical use—AGI, Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics, 2000, page 44.

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at the individual and programmatic levels, and clarifying all of this for policymakers, remains a key challenge. Meeting that challenge should be regarded as a prerequisite for the development of sound and effective programs designed to protect Americans from unintended pregnancy and STDs, including HIV. Abstinence and Individuals What does it mean to use abstinence? When used conversationally, most people probably understand abstinence to mean refraining from sexual activity—or, more specifically, vaginal intercourse—for moral or religious reasons. But when it is promoted as a public health strategy to avoid unintended pregnancy or STDs, it takes on a different connotation. Indeed, President Bush has described abstinence as “the surest way, and the only completely effective way, to prevent unwanted pregnancies and sexually transmitted disease.” So from a scientific perspective, what does it mean to abstain from sex, and how should the “use” of abstinence as a method of pregnancy or disease prevention be measured? Population and public health researchers commonly classify people as contraceptive users if they or their partner are consciously using at least one method to avoid unintended pregnancy or STDs. From a scientific standpoint, a person would be an “abstinence user” if he or she intentionally refrained from sexual activity. Thus, the subgroup of people consciously using abstinence as a method of pregnancy or disease pre-

vention is obviously much smaller than the group of people who are not having sex. The size of the population of abstinence users, however, has never been measured, as it has for other methods of contraception. When does abstinence fail? The definition of an abstinence user also has implications for determining the effectiveness of abstinence as a method of contraception. The president, in his July 2002 remarks to South Carolina high school students, said “Let me just be perfectly plain. If you’re worried about teenage pregnancy, or if you’re worried about sexually transmitted disease, abstinence works every single time.” In doing so, he suggested that abstinence is 100% effective. But scientifically, is this in fact correct? Researchers have two different ways of measuring the effectiveness of contraceptive methods. “Perfect use” measures the effectiveness when a contraceptive is used exactly according to clinical guidelines. In contrast, “typical use” measures how effective a method is for the average person who does not always use the method correctly or consistently. For example, women who use oral contraceptives perfectly will experience almost complete protection against pregnancy. However, in the real world, many women find it difficult to take a pill every single day, and pregnancies can and do occur to women who miss one or more pills during a cycle. Thus, while oral contraceptives have a perfect-use effectiveness rate of over 99%, their typical-use effectiveness is closer to 92% (see chart). As a result, eight in 100 women who use oral contraceptives will become pregnant in the first year of use. Thus, when the president suggests that abstinence is 100% effective, he is implicitly citing its perfect-use rate—and indeed, abstinence is 100% effective if “used” with perfect

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consistency. But common sense suggests that in the real world, abstinence as a contraceptive method can and does fail. People who intend to remain abstinent may “slip” and have sex unexpectedly. Research is beginning to suggest how difficult abstinence can be to use consistently over time. For example, a recent study presented at the 2003 annual meeting of the American Psychological Society (APS) found that over 60% of college students who had pledged virginity during their middle or high school years had broken their vow to remain abstinent until marriage. What is not known is how many of these broken vows represent people consciously choosing to abandon abstinence and initiate sexual activity, and how many are simply typical-use abstinence failures.

doms fail as much as 14% of the time, they should be given a comparable typical-use failure rate for abstinence. What behaviors should be abstained from? A recent nationally representative survey conducted by the Kaiser Family Foundation and seventeen magazine found that half of all 15–17year-olds believed that a person who has oral sex is still a virgin. Even more striking, the APS study found that the majority (55%) of college students pledging virginity who said they had kept their vow reported having had oral sex. While the pledgers generally were somewhat less likely to have had vaginal sex than non-

that exclusively promote “abstinence from sexual activity outside of marriage” (“Abstinence Promotion and Teen Family Planning: The Misguided Drive for Equal Funding,” TGR, February 2002, page 1). The law, however, does not define “sexual activity.” As a result, it may have the unintended effect of promoting noncoital behaviors that leave young people at risk. Currently, very little is known about the relationship between abstinence-promotion activities and the prevalence of noncoital activities. This hampers the ability of health professionals and policymakers to shape effective public health interventions designed to reduce people’s risk.

There is no question, however, that increased abstinence—meaning delayed vaginal intercourse among young people—has played a role in reducing both teen pregnancy rates in To promote abstinence, its propothe United States and HIV rates in at nents frequently cite the allegedly least one developing country. high failure rates of other contracepResearch by The Alan Guttmacher tive methods, particularly condoms. Institute (AGI) indicates that 25% of By contrasting the perfect use of the decrease in the U.S. teen pregpledgers, they were equally likely to abstinence with the typical use of nancy rate between 1988 and 1995 have had oral or anal sex. Because other contraceptive methods, howwas due to a decline in the proportion oral sex does not eliminate people’s ever, they are comparing apples to of teenagers who had ever had sex risk of HIV and other STDs, and oranges. From a public health per(while 75% was due to improved conspective, it is important both to sub- because anal sex can heighten that risk, being technically abstinent may traceptive use among sexually active ject abstinence to the same scientherefore still leave people vulnerable teens). A new AGI report also shows tific standards that apply to other contraceptive methods and to make to disease. While the press is increas- that declines in HIV-infection rates in consistent comparisons across meth- ingly reporting that noncoital behav- Uganda were due to a combination of iors are on the rise among young peo- fewer Ugandans initiating sex at ods. However, researchers have young ages, people having fewer sexple, no research data exists to never measured the typical-use ual partners and increased condom confirm this. effectiveness of abstinence. use (see related story, page 1). Therefore, it is not known how frequently abstinence fails in the real Abstinence Education Programs But abstinence proponents freworld or how effective it is compared Defining and communicating what is quently cite both U.S. teen pregwith other contraceptive methods. nancy declines and the Uganda This represents a serious knowledge meant by abstinence are not just academic exercises, but are crucial example as “proof” that abstinencegap. People deserve to have consisonly education programs, which tent and accurate information about to public health efforts to reduce the effectiveness of all contraceptive people’s risk of pregnancy and STDs. exclude accurate and complete For example, existing federal and information about contraception, are methods. For example, if they are state abstinence-promotion policies effective; they argue that these protold that abstinence is 100% effecgrams should be expanded at home tive, they should also be told that, if typically neglect to define those used correctly and consistently, con- behaviors to be abstained from. The and exported overseas. Yet neither experience, in and of itself, says anydoms are 97% effective in preventing federal government will provide thing about the effectiveness of propregnancy. If they are told that con- approximately $140 million in FY 2004 to fund education programs

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Abstinence is 100% effective if ‘used’ with perfect consistency. But common sense suggests that in the real world, it can and does fail.

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grammatic interventions. In fact, significant declines in U.S. teen pregnancy rates occurred prior to the implementation of governmentfunded programs supporting this particularly restrictive brand of abstinence-only education. Similarly, informed observers of the Ugandan experience indicate that abstinenceonly education was not a significant

most public health experts stress the importance of achieving desired behavioral outcomes such as delayed sexual activity.

To date, however, no education program in this country focusing exclusively on abstinence has shown success in delaying sexual activity. Perhaps some will in the future. In the meantime, considerable scienTo date, no education tific evidence already demonstrates program focusing exclu- that certain types of programs that sively on abstinence has include information about both abstinence and contraception help shown success in delayteens delay sexual activity, have ing sexual activity. fewer sexual partners and increase contraceptive use when they begin having sex. It is not clear what it is program intervention during the years when Uganda’s HIV prevalence about these programs that leads teens to delay—a question that rate was dropping. Thus, any researchers need to explore. What is assumptions about program effecclear, however, is that no program of tiveness, and the effectiveness of abstinence-only education programs any kind has ever shown success in convincing young people to postin particular, are misleading and pone sex from age 17, when they potentially dangerous, but they are nonetheless shaping U.S. policy both typically first have intercourse, until marriage, which typically occurs at here and abroad (see related story, age 25 for women and 27 for men. page 13). Nor is there any evidence that the “wait until marriage” message has Accordingly, key questions arise about how to measure the success of any impact on young people’s deciabstinence-promotion programs. For sions regarding sexual activity. This example, the administration is defin- suggests that scarce public dollars could be better spent on programs ing program success for its abstinence-only education grants to com- that already have been proven to munity and faith-based organizations achieve delays in sexual activity of any duration, rather than on proin terms of shaping young people’s grams that stress abstinence until intentions and attitudes with regard to future sexual activity. In contrast, marriage.

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Finally, there is the question of whether delays in sexual activity might come at an unacceptable price. This is raised by research indicating that while some teens promising to abstain from sex until marriage delayed sexual activity by an average of 18 months, they were more likely to have unprotected sex when they broke their pledge than those who never pledged virginity in the first place. Thus, might strategies to promote abstinence inadvertently heighten the risks for people when they eventually become sexually active? Difficult as it may be, answering these key questions regarding abstinence eventually will be necessary for the development of sound and effective programs and policies. At a minimum, the existing lack of common understanding hampers the ability of the public and policymakers to fully assess whether abstinence and abstinence education are viable and realistic public health and public policy approaches to reducing unintended pregnancies and HIV/STDs. This is the fourth in a series of articles examining emerging issues in sex education and related efforts to prevent unintended pregnancy and sexually transmitted diseases. The series is supported in part by a grant from the Program on Reproductive Health and Rights of the Open Society Institute. The conclusions and opinions expressed in these articles, however, are those of the author and The Alan Guttmacher Institute.

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Effects of a Parent-Child Communications Intervention on Young Adolescents’ Risk for Early Onset of Sexual Intercourse Susan M. Blake, Linda Simkin, Rebecca Ledsky, Cheryl Perkins and Joseph M. Calabrese Family Planning Perspectives, 2001, 33(2):52–61

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No Sexuality Education is Sexuality Education Stanley Snegroff Family Planning Perspectives, 2001, 32(5):257–258

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Teenage Partners' Communication About Sexual Risk and Condom Use: The Importance of Parent-Teenager Discussions Daniel J. Whitaker, Kim S. Miller, David C. May and Martin L. Levin Family Planning Perspectives, 1999, 31(3):117–121

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Family Communication About Sex: What Are Parents Saying and Are Their Adolescents Listening? Kim S. Miller, Beth A. Kotchick, Shannon Dorsey, Rex Forehand and Anissa Y. Ham Family Planning Perspectives, 1998, 30(5):218–222 & 235

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Studying Parental Involvement in School-Based Sex Education: Lessons Learned Diana P. Oliver, Frank C. Leeming and William O. Dwyer Family Planning Perspectives, 1998, 30(3):143–147

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ARTICLES Effects of a Parent-Child Communications Intervention on Young Adolescents’ Risk for Early Onset of Sexual Intercourse By Susan M. Blake, Linda Simkin, Rebecca Ledsky, Cheryl Perkins and Joseph M. Calabrese

Context: The quality of parent-child communications about sex and sexuality appears to be a strong determinant of adolescents’ sexual behavior. Evaluations of interventions aimed at improving such communications can help identify strategies for preventing early onset of sexual behavior. Methods: A school-based abstinence-only curriculum was implemented among 351 middle school students, who were randomly assigned to receive either the classroom instruction alone or the classroom instruction enhanced by five homework assignments designed to be completed by the students and their parents. An experimental design involving pretest and posttest surveys was used to assess the relative efficacy of the curriculum delivered with and without the parent-child homework assignments. Results: In analyses of covariance controlling for baseline scores, immediately after the intervention, adolescents who received the enhanced curriculum reported greater self-efficacy for refusing high-risk behaviors than did those who received the classroom instruction only (mean scores, 16.8 vs. 15.8). They also reported less intention to have sex before finishing high school (0.4 vs. 0.5), and more frequent parent-child communications about prevention (1.6 vs. 1.0) and sexual consequences (1.6 vs. 1.1). In all significant comparisons, the direction of the findings favored adolescents who received the enhanced curriculum. Dose-response relationships supported the findings. Conclusions: Parent-child homework assignments designed to reinforce and support schoolbased prevention curricula can have an immediate impact on several key determinants of sexual behavior among middle school adolescents. Family Planning Perspectives, 2001, 33(2):52–61

T

he extent to which parents are involved and the manner in which they are involved in their children’s lives are critical factors in the prevention of high-risk sexual activity. Children whose parents talk with them about sexual matters or provide sexuality education or contraceptive information at home are more likely than others to postpone sexual activity. And when these adolescents become sexually active, they have fewer sexual partners and are more likely to use contraceptives and condoms than young people who do not discuss sexual matters with their parents, and therefore are at reduced risk for pregnancy, HIV and other sexually transmitted diseases (STDs).1 The positive effects of parent-child communications appear to be mediated by several critical factors: the frequency and specificity of communications;2 the quality and nature of exchanges;3 parental 52

knowledge, beliefs and comfort with the subject matter;4 and the content and timing of communications (for example, whether they take place before the young person initiates sexual activity).5 A number of more general indices of family structure and relationship quality also play a role in adolescent sexual behavior. These include family cohesion or closeness;6 family structure;7 parenting style, including parental monitoring, supervision or coercion;8 and general parent-child communication patterns.9 Thus, while the precise mechanisms whereby parental communications influence adolescent sexual behavior have not been fully determined, the preponderance of evidence regarding communication effectiveness supports the important role that parents can play in preventing early sexual onset. Previous investigators have suggested that efforts to increase parent-child com-

munications should parallel the HIV, STD and pregnancy prevention education that is provided in schools.10 Although multiple strategies and programs to increase parent-child communication have been described in the literature,11 relatively few have been evaluated. Programs designed to increase parent-child communications about HIV, sexuality or sexual abuse have been effective in elevating parental knowledge;12 building communication confidence and skills, as well as intentions to discuss sexuality;13 and raising the frequency or quality of parent-child communications about sex and sexuality.14 The few studies that have reported an impact on the sexual attitudes, skills or behaviors of participating children have documented generally positive results.15 Yet, none of these studies clearly demonstrated a direct impact of parent-child communication on adolescent intentions, other potential mediators or sexual behavior, and few discussed how self-selection may have influenced the makeup of the groups of parents and children participating or the nature of the parent-child communication. In summary, the quality of parent-child relationships and parenting style in general, and communications about sex and sexuality more specifically, appear to be strong determinants of adolescent sexual Susan M. Blake is associate research professor, Department of Prevention and Community Health, The George Washington University Medical School, School of Public Health and Health Services, Washington, DC; Linda Simkin is senior program officer, Academy for Educational Development (AED), New York; Rebecca Ledsky is research and evaluation officer, AED, Washington, DC; Cheryl Perkins is director of youth programs, Prevention Partners, Rochester, NY; and Joseph M. Calabrese is executive director, Prevention Partners. The authors acknowledge the important contributions of Catherine M. Shisslak, Kim S. Miller, Andrew S. Doniger, Susan Rogers, Tom Lehman, Paula Hollerbach, Cookie Waller and Brenda Jagatic. The work on which this article was based was supported by contract APH 000391-01-0 from the Office of Adolescent Pregnancy Programs, U.S. Department of Health and Human Services.

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behavior. Relationships to adolescent sexual behavior have been found in both cross-sectional and prospective studies, particularly when parent-child communications were characterized as being “open and receptive.” Given the consistency of these findings, it is rather surprising that so few interventions have been developed and tested for effectiveness in improving parent-child communications related to sex and sexuality, and consequently adolescent sexual behavior. We sought to develop such an intervention targeting younger adolescents, the majority of whom were not yet sexually experienced, to prevent early onset of sexual intercourse. Five homework assignments, each involving parental participation, were developed to reinforce and support a standard abstinence-only curriculum, entitled Managing the Pressures Before Marriage (MPM), that was being used in middle schools. Social learning and social cognitive theoretical constructs were applied to involve parents in reinforcing the skills and information that children learned in class, and in clearly specifying and modeling expected behaviors.16 The purpose of this study was to assess the effectiveness of these homework assignments delivered in conjunction with the curriculum (referred to here as MPMenhanced) as compared with the effectiveness of the school-based curriculum alone (MPM only). We hypothesized that the enhanced intervention would be more effective in changing adolescent beliefs, self-efficacy and intentions to delay sexual onset than the curriculum alone. Specifically, we expected that students receiving the homework assignments would, as a result, not only communicate more often with their parents about these issues, but also express stronger beliefs supporting abstinence, greater self-efficacy and firmer intentions to remain abstinent than those who received the standard curriculum only.

Methods Intervention Description The MPM curriculum, developed by the Center for Adolescent Reproductive Health at Grady Memorial Hospital, is a modified version of Postponing Sexual Involvement (PSI), a skills-based curriculum that has been tested and found to be effective.17 Early studies demonstrated PSI’s acceptability and its contribution to adolescents’ decisions to postpone sex.18 Among lower-income, minority adolescents of middle school age, PSI reduced the proportion initiating sexual interVolume 33, Number 2, March/April 2001

course (4% in the intervention group vs. 20% in the comparison group), but it had no discernible impact on adolescents who were already sexually active. While results were less impressive after one year, group differences remained significant, particularly among females.19 MPM and PSI use basically the same content and instructional methods. Both consist of five one-hour sessions led by pairs of trained youth leaders. Both address risks of early sexual involvement, social and media pressures to become sexually active, and assertiveness and communication skills an adolescent needs to resist peer pressure. Instructional strategies include brainstorming, critical analysis, role-playing, and skill training and rehearsal. The only significant difference between these two curricula is that MPM reinforces the message that abstinence until marriage is the expected standard of behavior, whereas PSI provides a general message that students should postpone sexual intercourse without specifying for how long. The five homework assignments were developed on the basis of formative research. Focus groups were conducted with parents and adolescents, and the lessons, other available curricula and scientific literature related to parent-child communications about sexuality and sexual behavior were reviewed. The homework assignments were designed to increase parents’ understanding of the changes and pressures that their children of middle school age face; facilitate open and receptive parent-child communications about sex and sexuality; increase parents’ ability to encourage their children to avoid or resist peer pressure to become sexually active; and build parents’ and children’s skills in identifying and reducing the risks of pregnancy, HIV and other STDs. The assignments did not stress abstaining from sex until marriage. (Details of each assignment are described in the appendix, page 60). Like the school-based curriculum, the strategies and activities developed for the homework assignments were based upon principles of social learning theory. Communication exercises were aimed at facilitating new parent-child exchanges, encouraging interpersonal learning, increasing equity and exchange during parent-child communications, and shifting habitual ways of communicating and thinking about these issues. For example, both parents and children were encouraged to discuss challenges they face, to talk about their wishes for one another

and to compare their responses to similar questions (such as what kinds of qualities to look for in close friendships or dating relationships). Activities included structured communications, modeling, demonstration and rehearsal. Procedures Active parental consent procedures were used. All parents were offered the opportunity to exempt their child from participation in a class where instruction would be based on an abstinence-only pregnancy prevention curriculum. (Only one parent refused.) Along with the consent form, parents of children in the MPM-enhanced group received copies of the homework assignments. Youth leaders were recruited from local high schools by means of morning or afternoon announcements; interested students were invited to attend an informational meeting after school that described the basic program and youth leader responsibilities. Contacts at the high schools (usually health or home economics teachers) also recruited students who they thought might be interested and would do a good job. Of the 38 students who participated, 25 were female and 36 were white; 28 were in grades 10 and 11, six were in ninth grade and four were in 12th grade. Youth leaders received 30 hours of training before conducting MPM classroom sessions. In general, one pair of leaders was assigned to each classroom, but on occasion, one leader filled in for another in a different classroom. One program staff member attended and assisted with each lesson. Youth leaders were aware that some classes were receiving homework assignments and some were not. However, they were not given detailed information regarding why, nor was there any evidence that their presentation of the lessons changed as a result of differences in classroom assignment. The lessons were implemented in five weekly sessions and were identical for classes receiving MPM alone and those receiving the enhanced intervention. Additional coordination activities were required in the MPM-enhanced group. Project staff introduced the first parentchild homework assignment immediately after students completed the baseline survey, and before the classroom sessions began. The difficulties both adolescents and parents have when talking about sex or sexuality-related topics were acknowledged, and students’ concerns and questions about talking to their parents 53

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were addressed. Students who felt uncomfortable talking with their parents were encouraged to complete the assignments with a project staff member or another adult. The remaining homework assignments were completed after each of the first four classroom sessions so that the last one could be reviewed on the final day of class. After each lesson, if time permitted, program staff asked the students general questions about the homework assignment (e.g., whether they completed it and liked the activities). Staff acknowledged that the lessons generally left little time to go into specifics about the homework activities. Students were reminded at the end of each session to complete at least one activity in the next assignment before the next class. Study Design and Data Collection The relative efficacy of the MPM curriculum delivered with and without the five parent-child homework assignments was assessed by means of an experimental design in which study and comparison groups in the same schools were examined before and after the intervention. Once we had obtained administrative approval in three middle schools, we randomly assigned (by quarter marking period within schools) 19 eighth-grade health or family and consumer science classrooms to receive either the curriculum only or the curriculum plus the five parent-child homework assignments during the 1998–1999 school year. Because the number of classrooms available in each school was smaller than we would have preferred, and we wished to maximize exposure to the parent-child homework assignments, eight classrooms received the curriculum only, and 11 received the enhanced intervention. One week prior to the intervention, project staff introduced the study to students, explained that it involved two surveys, and stressed the confidential and voluntary nature of students’ responses and participation. Students completed baseline surveys at this time. Postintervention surveys were administered seven weeks later, within one week following completion of the MPM curriculum. Survey questionnaires were collected from 389 students at baseline and from 410 students immediately postintervention. The analyses presented here include only *Copies of the survey are available from Susan M. Blake, The George Washington University Medical School, School of Public Health and Health Services, 2175 K St. NW, Suite 700, Washington, DC 20037.

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the subset of 351 adolescents from whom we collected both questionnaires—190 who received the enhanced curriculum and 161 who received MPM only. The preintervention sample was equally divided by gender (males, 52%; and females, 48%); the majority of adolescents were white and non-Hispanic (85%). Students lived in predominantly middle-class suburban communities outside Rochester, New York. No additional demographic data were collected because of programmatic constraints and a desire to reduce the burden on respondents and the time required to complete the survey. Three forms in addition to the survey questionnaires were used to gather data: an attendance form, which project staff completed at each session; a homework form, which students in the MPM-enhanced group were asked to fill out with their parents after completing each assignment; and a form given to students who did not return a homework form, to document that the assignment had not been completed. Linkages among data sources, as well as participants’ confidentiality, were facilitated by unique identification numbers staff assigned to each student on the basis of classroom enrollment data. Homework forms included questions regarding which lesson activities were completed, the date of completion, and what the student and parent separately liked or disliked about the lesson. A space was provided, if an activity was not completed, to explain why not. The bottom of the form contained a line for both the parent and the child to sign, verifying completion (or not) of each assignment. Because of initial difficulties in retrieving homework forms, incentives were provided for their completion. For each form students returned, they were given one ticket for a raffle at the end of the intervention; prizes (e.g., a family pack of four tickets to the movies or a video arcade) had been voted upon by each class. Students who turned in forms could also select one item from a “goodie box” filled with candy bars, markers, key chains, pens and stickers. Those who did not turn in a signed homework form but completed a form describing whether the assignment was completed or the reason for noncompletion were given a lesser incentive. A total of 642 homework forms and noncompletion forms were returned— 68% of the possible 950 (190 students for each of five sessions). Of these, 492 indicated that some portion of the assignment

was completed, and 41 that the assignment had not been completed; 109 forms were unclear as to whether the assignment had been completed. The proportion of returned homework forms was 78% for the first session, but it declined steadily, to 58% for the last session. Similarly, the proportion of students who completed the homework assignments was 65% for the first session, but it declined for each session thereafter (to 38% for the final session). Measures The independent variable in this study was treatment condition (MPM-enhanced vs. MPM only). Dependent variables were multiple determinants of sexual onset, characteristics of parent-child communication about sex and risk-related behaviors. The survey also asked about students’ age, grade, race or ethnicity, and average grades in school.* •Knowledge. Two knowledge items that may influence when young people initiate sexual intercourse were assessed: students’ perceptions of the effectiveness of abstinence as a preventive method and of the risks of pregnancy the first time one has sexual intercourse. •Sexual beliefs and attitudes. A variety of measures assessing beliefs about sex and perceptions of norms were grouped into summary scales. Three scales are based on items for which possible responses ranged from one (indicating strong agreement) to four (strong disagreement): overall sexual beliefs (14 items; alpha=.78), personal beliefs that support delaying sexual intercourse (eight items; alpha=.77) and perceived peer beliefs supporting such delay (three items; alpha=.67). Three items independently measured perceptions that substance use increases risk taking, that adolescents who have had sexual intercourse will expect it from their next partner and that the media encourage adolescent sex; possible responses ranged from one (strongly agree) to four (strongly disagree) for the first two items and from one (strongly disagree) to four (strongly agree) for the third. Adolescents’ perceptions of the number of males and females in their school who had ever had sexual intercourse (with response options ranging from zero, indicating none, to four, indicating almost all) were combined into a summary scale (two items; alpha=.88). •Self-efficacy for refusal/avoidance. We asked adolescents to rate how sure they were that they could refuse or avoid hypothetical situations involving peer or partner Family Planning Perspectives

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pressure to drink alcohol, use drugs or engage in sexual intercourse; possible responses ranged from one (very unsure) to four (very sure). We constructed individual scales to reflect overall self-efficacy (five items; alpha=.83) and self-efficacy related to substance use (two items; alpha= .70) and sexual avoidance or refusal (three items; alpha=.77). •Behavioral intentions. We asked adolescents to rate the likelihood that they would have sex before finishing middle school and before finishing high school; possible responses ranged from one (no chance) to four (already have). Using only responses from sexually inexperienced students, we combined these measures into a summary scale (two items; alpha=.84). Two additional items, both rated on a five-point scale ranging from one (definitely not) to five (definitely would), were combined into one scale (alpha=.87) measuring the likelihood of sexual intercourse under specific circumstances—that is, “if you had sexual feelings for someone you liked” and “if someone you liked wanted to have sex with you.” •Parent-child communications. Adolescents rated their comfort in talking with their parents about sex on a scale ranging from one (very uncomfortable) to four (very comfortable). We assessed the frequency of conversations in which parents addressed nine specific topics (how they expected their child to behave when it comes to having sex; abstinence; developing positive relationships; body changes during puberty; reasons to wait to have sex; and ways to avoid sexual pressure situations, to refuse sex, to avoid HIV and other STDs, and to prevent pregnancy). Responses, ranging from zero (never) to three (six or more), were combined into five variables: a single item on communications about puberty and physiological changes, and summary scales measuring the overall frequency of communications (nine items; alpha=.90) and the frequency of communications about sexual expectations (four items; alpha=.80), prevention strategies (two items; alpha=.91) and consequences of sexual intercourse (two items; alpha=.83). Two items separately measured the extent to which students discussed with their parents what they learned in class or worked on for a homework assignment.* •Sexual opportunities. Adolescents rated how often in the previous three months they were exposed to each of two situations that we classified as “potentially sexual” (i.e., someone pressured them to drink alcohol or use drugs, and someone Volume 33, Number 2, March/April 2001

tried to get them into a Table 1. Percentage of students reporting specific knowledge or situation where sex behaviors, or mean score (and standard deviation) for dependent might occur) and three variables, at baseline and posttest surveys situations that we cateBaseline Posttest gorized as “sexual” (i.e., Variable Knowledge they kissed or touched effectiveness (%) 69.7 86.9**** someone sexually, Abstinence Pregnancy risk (%) 86.9 91.4 someone tried to have intercourse with them Sexual beliefs and attitudes beliefs supporting delay 42.3 (6.7) 43.3 (7.4) and they tried to have Overall Personally support delay 26.6 (4.6) 26.9 (4.9) intercourse with some- Friends/peers support delay 8.5 (2.3) 8.8 (2.4)* 2.1 (1.0) 2.0 (1.0) one). Scales were devel- Substance use increases risk-taking Expect sex if had sex before 2.4 (0.9) 2.3 (1.0) oped to measure expo- Media encourage adolescent sex 2.9 (1.0) 3.4 (0.9)*** sure to the “potentially Perceive fewer sexually active peers 1.1 (0.8) 1.1 (0.8) sexual situations” (two Self-efficacy for refusal/avoidance items; alpha=.77) and Overall 15.7 (4.1) 16.3 (3.9) the “sexual situations” Substance refusal/avoidance 6.4 (1.8) 6.5 (1.8) 9.4 (2.5) 9.8 (2.4)* (three items; alpha=.71), Sexual refusal/avoidance and overall exposure to Behavioral intentions 0.6 (0.6) 0.5 (0.6)** any situations (five Likely to have sex before finishing H.S. Likelihood of intercourse (if attracted to items; alpha=.84). an individual) 2.3 (2.2) 2.1 (2.3) •Avoidance or refusal in high-risk sexual situations. Parent-child communications 2.5 (1.1) 2.6 (1.0)* We also assessed how Comfort communicating with parents about sex Frequency of communication about sex† often adolescents who Overall 6.0 (5.9) 6.5 (6.3) Puberty/physiological changes 0.7 (0.9) 0.7 (0.9) were exposed to highSexual expectations 2.9 (2.8) 3.2 (3.0) risk situations refused to Prevention strategies 1.0 (1.6) 1.3 (1.7) engage in risky behavConsequences of sexual intercourse 1.4 (1.8) 1.4 (1.8) ior. Six variables indicate Frequency of discussions about class activities Class lessons na 2.2 (1.0) what proportion of Homework assignments na 2.1 (1.2) times adolescents refused risky behavior Sexual opportunities† of potentially sexual situations 1.3 (1.9) 1.3 (1.8) overall (six items, No. No. of sexual situations 1.6 (2.2) 1.5 (2.2) alpha=.89), in potentially sexual situations (two Avoided/refused high-risk or sexual situations‡ 72.4 (44.7) 77.8 (56.9) items; alpha=.69) and in Overall Refused potentially sexual situations 74.0 (55.8) 63.9 (49.7) sexual situations (four Refused sexual situations 75.1 (51.7) 86.5 (64.6) items; alpha=.87). Substance use and sexual behaviors •Substance use and sexu- Lifetime alcohol use 2.0 (1.2) 2.1 (1.5) al behaviors. Two vari- Recent alcohol use§ 0.4 (0.9) 0.5 (1.2) 1.5 (0.7) 1.6 (0.6) ables were created from Went further sexually than wanted to‡ Ever had sexual intercourse (%) 5.7 6.4 one survey item to re- Recent sexual intercourse (%)† 2.0 4.4 flect lifetime and recent **p≤.01. ***p≤.001. ****p≤.0001. †In the past three months. ‡Among those in these alcohol use. Responses *p≤.05. situations in the past three months. §In the past 30 days. Note: na=not applicable. for lifetime use were coded from one (never had alcohol) to seven (drank alcohol on Data Analysis 20–30 of the past 30 days); for recent use, Basic frequencies and means were calcuresponses were coded from zero (no use lated for each variable and summary scale in the past 30 days) to five (drank on 20–30 on the baseline and postintervention surof the past 30 days). Separate items as- veys. Interitem correlation coefficients for sessed whether adolescents had ever had each scale were calculated from pretest sexual intercourse, whether they had had data, using Cronbach’s alpha. T-tests for intercourse in the past three months, their mean differences, kappa statistics and lifetime number of partners and the reg- McNemar tests for nonindependent samularity with which they used condoms; ples were used to assess changes in knowlonly the first two of these items were used edge, attitudes, intentions and practices in this study because of the small number from baseline to postintervention. of students who reported sexual intercourse. One item assessed the number of *Although students in the MPM-only group did not receive homework assignments to complete with their partimes that adolescents “went further, sex- ents, they may have shared with their parents workbooks ually,” than they really wanted to in the or other materials that they received as part of their work past three months. in class. 55

Effects of a Parent-Child Communications Intervention

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both instances, gender was included as an independent variable to determine whether males Variable MPM-only MPMF and females were equalenhanced ly likely to benefit. These Knowledge results are not presented Abstinence effectiveness (%) 87.2 (2.6) 84.6 (2.6) ns in this article, but may be Pregnancy risk (%) 91.8 (2.0) 92.9 (2.0) ns found elsewhere.20 Sexual beliefs and attitudes We initially perOverall beliefs supporting delay 43.5 (0.40) 43.3 (0.37) ns Personally support delay 26.9 (0.28) 27.1 (0.26) ns formed standard statisFriends/peers support delay 8.8 (0.15) 9.0 (0.14) ns tical tests using SAS Substance use increases risk-taking 2.1 (0.07) 1.9 (0.07) ns (data presented in taExpect sex if had sex before 2.4 (0.07) 2.2 (0.06) 3.6* Media encourage adolescent sex 3.4 (0.06) 3.3 (0.06) ns bles), and then emPerceive fewer sexually active peers 1.1 (0.05) 1.1 (0.05) ns ployed mixed-model analyses using SAS Self-efficacy for refusal/avoidance Overall 15.8 (0.24) 16.8 (0.22) 10.3** PROC MIXED statistical Substance refusal/avoidance 6.2 (0.12) 6.8 (0.11) 10.7*** software to address poSexual refusal/avoidance 9.6 (0.15) 10.2 (0.14) 7.5** tential clustering of obBehavioral intentions servations. Because the Likely to have sex before finishing H.S. 0.5 (0.03) 0.4 (0.03) 8.3** probability of a type I Likelihood of intercourse (if attracted error increases when the to an individual) 2.2 (0.12) 1.9 (0.11) ns unit of randomization Parent-child communications and intervention delivComfort communicating with ery is the classroom but parents about sex 2.6 (0.07) 2.7 (0.06) ns Frequency of communication about sex† data analyzed are from Overall 5.8 (0.39) 7.2 (0.37) 6.9** individual students, we Puberty/physiological changes 0.7 (0.06) 0.7 (0.06) ns Sexual expectations 3.0 (0.19) 3.4 (0.19) ns used mixed-model proPrevention strategies 1.0 (0.11) 1.6 (0.11) 13.3*** cedures to confirm these Consequences of sexual intercourse 1.1 (0.11) 1.6 (0.11) 8.0** results. For significant Frequency of discussions about class activities findings, we also calcuClass lessons 1.8 (0.08) 2.5 (0.08) 29.7**** lated the amount of variHomework assignments 1.3 (0.08) 2.9 (0.07) 241.8**** ance in outcomes exSexual opportunities† plained by group No. of potentially sexual situations 1.3 (0.11) 1.3 (0.10) ns membership. Finally, No. of sexual situations 1.5 (0.13) 1.5 (0.12) ns analyses of covariance, Avoided/refused high-risk or sexual situations‡ again controlling for the Overall 71.6 (4.0) 72.6 (4.3) ns baseline value of each Refused potentially sexual situations 68.7 (5.4) 76.3 (5.6) ns variable, were used to Refused sexual situations 73.9 (4.5) 70.4 (5.4) ns determine whether adoSubstance use and sexual behaviors lescents who completed Lifetime alcohol use 2.2 (0.08) 1.9 (0.08) 5.4* more homework assignRecent alcohol use§ 0.6 (0.06) 0.4 (0.06) 4.2* Went further sexually than wanted to‡ 1.5 (0.22) 1.7 (0.26) ns ments and activities Ever had sexual intercourse (%) 7.4 (1.6) 5.1 (1.5) ns were more likely to benRecent sexual intercourse (%)† 4.5 (1.3) 3.2 (0.11) ns efit. Since students’ de*p≤.05. **p≤.01. ***p≤.001. ****p≤.0001. †In the past three months. ‡Among those in these mographic and baseline situations in the past three months. §In the past 30 days. Note: ns=not significant. characteristics may have influenced their likeliWe employed two strategies to deter- hood of completing homework assignmine whether the assignments were effec- ments, we performed post-hoc compartive. First, we used repeated-measures isons, controlling for these factors, to analyses of variance to simultaneously as- determine whether dose-response relasess the effects of time (baseline vs. postin- tionships remained significant. tervention) and treatment condition (MPM-enhanced vs. MPM only). Second, Results we conducted analyses of covariance to as- Baseline Comparisons sess differences after the intervention be- No baseline differences existed between tween the two treatment groups, and after groups in race or ethnicity, age, sex or acacontrolling for the baseline values of each demic achievement. One-way analyses of variable. Both analyses included all ado- variance indicated that the MPM-enlescents from the MPM-enhanced group, hanced group was significantly more likeirrespective of whether they completed the ly than the MPM-only group to believe parent-child homework assignments. In that substance use increases sexual risk Table 2. Percentage of students reporting specific knowledge or behaviors, or adjusted mean score (and standard error) for dependent variables, by intervention group, posttest survey

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(2.2 vs. 2.0; p≤.05) and that the media influence adolescent sexual behavior (3.0 vs. 2.8; p≤.01); they also were more likely to say that they had gone further than they had wanted to sexually within the previous three months (1.6 vs. 1.1; p≤.01). Students in the MPM-only group were more likely than others to have been in high-risk sexual situations in the past three months (1.7 vs. 1.4; p≤.05), to report lifetime alcohol use (2.1 vs. 1.8; p≤.05) and to say that they had used alcohol recently (0.5 vs. 0.3; p≤.05). No other differences were found between groups at baseline. Overall Change We compared values of the dependent variables at baseline and postintervention for both treatment groups combined (Table 1, page 55). Adolescents were significantly more likely to know of the effectiveness of abstinence as a prevention strategy after the intervention (87%) than before (70%), but their level of knowledge about the risk of pregnancy at first sex did not change; nevertheless, the proportion who answered both knowledge items correctly rose from 63% to 80% (not shown). The belief that peers and friends support abstinence increased from baseline to the second survey (8.5 vs. 8.8), as did the perception that the media influence adolescent sexual behavior (2.9 vs. 3.4). The average score reflecting self-efficacy for sexual refusal or avoidance rose significantly from the baseline to the postintervention survey (9.4 vs. 9.8), and the score for intentions to have sex before finishing high school declined (0.6 vs. 0.5). Perceived comfort communicating with parents about sex improved (2.5 vs. 2.6), but the frequency of parent-child communications about sex did not change significantly. All other measures were similar at baseline and postintervention. These results remained significant in the mixedmodel analyses. Impact of the Enhanced Curriculum In analyses controlling for baseline values, adolescents in the MPM-enhanced group did not differ from those in the MPM-only group with respect to knowledge or most attitudinal values immediately after the intervention (Table 2). The one exception is that those in the MPM-only group were more likely than those who received the enhanced curriculum to agree that adolescents who have had sexual intercourse will always expect to have sex in their next relationship (mean scores, 2.4 and 2.2, respectively). Students in the MPM-enhanced group expressed signifFamily Planning Perspectives

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icantly greater self-efficacy with regard to refusing or avoiding substance use and sexual behavior (16.8 vs. 15.8 overall), and were less likely to intend to have sex before completing high school (0.4 vs. 0.5). In the postintervention survey, the two groups reported similar levels of comfort in talking to their parents about sex. As we expected, however, students in the MPMenhanced group reported more frequent communication with their parents than did adolescents who did not receive the parent-child homework assignments (overall means, 7.2 and 5.8, respectively). This difference reflects more frequent communications about prevention strategies (1.6 vs. 1.0) and consequences of sexual intercourse (1.6 vs. 1.1). In addition to having completed the homework assignments together, adolescents in the MPMenhanced group talked more often with parents about the class lessons (2.5 vs. 1.8). Although the MPM-only group was more likely to have been exposed to potentially sexual or sexual situations at baseline (not shown), the analyses controlling for baseline differences revealed no group differences after the intervention in exposure to high-risk situations, refusal when exposed to high-risk sexual situations, or lifetime or recent sexual intercourse. However, students in the MPMenhanced group had significantly lower scores than those in the MPM-only group on lifetime alcohol use (1.9 vs. 2.2) and on alcohol use in the previous three months (0.4 vs. 0.6). In the analyses controlling for the cluster sampling design, all but two of the significant findings reported above remained significant: The belief that sexually experienced adolescents will expect sex in future relationships and recent alcohol use became marginally significant (p=.08). Although the amount of variance explained in the overall models was relatively high in both the repeated-measures analyses and the analyses of covariance (e.g., for self-efficacy, at least 40%), the variance attributable to differences between groups was small (e.g., less than 5% for self-efficacy, intentions and parent-child communications), except with regard to having talked to parents about class lessons (9%) and completing homework assignments together (45%). Selection Biases and Dose Response The majority of students in the MPMenhanced group completed at least one parent-child homework assignment: Thirty percent completed one or two assignVolume 33, Number 2, March/April 2001

Table 3. Percentage of students reporting specific knowledge or behaviors, or mean score for dependent variables, by whether any homework activities were completed Variable

All students MPM-only (N=351) (N=161)

Parent-child communications Overall frequency† Puberty/physiological changes† Sexual expectations† Prevention strategies† Consequences of sexual intercourse† Frequency of discussions about class activities Class lessons Homework assignments

Pairwise comparison

Overall significance

a*** a*** a**

.05 .001 .05

None (N=36)

Any (N=154)

15.8 6.2 9.6

16.5 6.4 10.1

17.0 6.9 10.2

0.5

0.5

0.3

0.4

a,** b*

.01

6.5 0.7 3.2 1.3

5.8 0.7 3.0 1.0

5.2 0.6 2.0 1.1

7.4 0.7 3.6 1.6

a**, c* a*, c** a***

.01 ns .01 .001

1.4

1.1

1.4

1.6

a**

.05

2.2 2.1

1.8 1.3

1.4 1.5

2.6 3.2

a***, c*** a***, c***

.0001 .0001

2.2 0.6

2.1 0.6

1.8 0.4

a** a**

.01 .05

1.5 7.0 4.4

3.1 14.3 14.3

1.3 4.0 2.0

b**, c***

.01 ns .001

Self-efficacy for refusal/avoidance Overall 16.3 Substance refusal/avoidance 6.5 Sexual refusal/avoidance 9.9 Behavioral intentions Likely to have sex before finishing high school

Homework completed

Substance use and sexual behaviors Lifetime alcohol use 2.0 Recent alcohol use‡ 0.5 Went further sexually than wanted to go§ 1.6 Ever had sexual intercourse (%) 6.4 Recent sexual intercourse (%)† 4.4

b*, c**

* p≤.05. ** p≤.01. *** p≤.001. **** p≤.0001. †In the past three months. ‡In the past 30 days. §Among adolescents in this situation in the past three months. Notes: The “overall significance” column refers to general tests of differences between groups, whereas the “pairwise comparison” column provides the precise location of differences between groups. a=MPM-only vs. any homework; b=MPM-only vs. did no homework; c=did no homework vs. did any homework. ns=nonsignificant.

ments, and 51% completed three or more; 19% completed no assignments. Each assignment included 3–5 activities (for a total of 18 activities), but students and their parents could choose which activities to complete; therefore, not all of the activities were completed. Fifty-four percent of students completed a total of three or fewer activities, 41% completed 4–8 and 5% completed nine or more. Using demographic information from the survey questionnaires in conjunction with information from the homework completion forms, we found several selection biases influencing the completion of homework assignments. The proportion of students who had completed no assignments was higher among black and Hispanic adolescents than among nonHispanic whites (43% vs. 18%; p