research on sex education indicates abstinence only programs are

What the Research Shows: Government-Funded Abstinence-Only Programs Don’t Make the Grade

What the Research Shows: Abstinence-Only-Until-Marriage Sex Education Does Not Protect Teenagers’ Health

Evidence shows that sexuality education that stresses the importance of waiting to have sex while providing accurate, age-appropriate, and complete information about how to use contraceptives effectively to prevent pregnancy and sexually transmitted diseases (STDs) can help teens make healthy and responsible life decisions. Yet there is currently no federal program dedicated to supporting this approach. Instead, since 1996, the federal government has funneled more than a billion dollars into abstinence-only-until-marriage programming, even in the face of clear evidence that these programs do not work.

Below is a review of recent research on the issue of sexuality education:

Giving teens the information they need to make responsible life decisions about sex helps teens delay sex and protects their health.

• A nationwide study of 15-19 year olds found that teens who participated in sexuality education programs that discuss the importance of delaying sex and provide information about contraceptive use were significantly less likely to report teen pregnancies than were those who received either no sex education or attended abstinence-only-until-marriage programs.

Pamela K. Kohler, RN. et al., Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy , Journal of Adolescent Health, Spring 2008.

· A review of 115 sex education programs found that curricula that stress waiting to have sex and provide information about using contraception effectively can significantly delay the initiation of sex, reduce the frequency of sex, reduce the number of sexual partners, and increase condom or contraceptive use among teens.

Douglas Kirby, Ph.D. et al., Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases , The National Campaign to Prevent Teen and Unplanned Pregnancy, November 2007.

• The Centers for Disease Control & Prevention note that “research has clearly shown that the most effective programs [to prevent the spread of HIV/AIDS] are comprehensive ones that include a focus on delaying sexual behavior and provide information on how sexually active young people can protect themselves.”

Centers for Disease Control & Prevention, Fact Sheet: Young People at Risk: HIV/AIDS Among America’s Youth , National Center for HIV, STD and TB Prevention, March 2002.

Parents want schools to teach comprehensive sexuality education and do not think taxpayer dollars should be spent on abstinence-only-until-marriage programs.

• More than 85 percent of Americans believe that it is appropriate for school-based sex education programs to teach students how to use and where to get contraceptives.

National Public Radio, Kaiser Family Foundation, and Harvard University’s Kennedy School of Government, Sex Education in America , January 2004.

• Seventy percent of Americans oppose the use of federal funds for abstinence-only-until-marriage programs that prohibit teaching about the use of condoms and contraception for the prevention of unintended pregnancies and STDs.

Advocates for Youth and SIECUS, “Americans Oppose Abstinence- Only Education Censoring Information on Contraception,” 1999.

Studies show that most abstinence-only-until-marriage programs are ineffective, and some show that these programs deter teens who become sexually active from protecting themselves from unintended pregnancy or STDs.

• A rigorous, multi-year, scientific evaluation authorized by Congress presents clear evidence that abstinence-only-until-marriage programs don’t work. The study, which looked at four federally funded programs and studied more than 2000 students, found that abstinence-only program participants were just as likely to have sex before marriage as teens who did not participate. Furthermore, program participants had first intercourse at the same mean age and the same number of sexual partners as teens who did not participate in the federally funded programs.

Christopher Trenholm et al., Impacts of Four Title V, Section 510 Abstinence Education Programs , Princeton: Mathematica Policy Research, Inc., April 2007.

Debra Hauser, Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact , Advocates for Youth, September 2004.

Hannah Brückner and Peter Bearman, “ After the promise: the STD consequences of adolescent virginity pledges ,” Journal of Adolescent Health , 36 (2005) 271-278.

A recent congressional report found that widely used federally funded abstinence-only-until-marriage curricula distort information, misrepresent the facts, and promote gender stereotypes.

· More than 80 percent of the abstinence-only-until-marriage curricula reviewed contain false, misleading, or distorted information about reproductive health.

· The curricula reviewed misrepresent the effectiveness of contraceptives in preventing STDs and unintended pregnancy. They also contain false information about the risks of abortion, blur religion and science, promote gender stereotypes, and contain basic scientific errors.

“The Content of Federally Funded Abstinence-Only Education Programs,” Prepared for Rep. Henry A. Waxman, United States House of Representatives, Committee on Government Reform – Minority Staff, Special Investigations Division, December 2004.

Related Issues

• Reproductive Freedom

Stay Informed

Every month, you'll receive regular roundups of the most important civil rights and civil liberties developments. Remember: a well-informed citizenry is the best defense against tyranny.

By completing this form, I agree to receive occasional emails per the terms of the ACLU’s privacy statement.

The independent source for health policy research, polling, and news.

Abstinence Education Programs: Definition, Funding, and Impact on Teen Sexual Behavior

Published: Jun 01, 2018

Teen sexual health outcomes over the past decade have been mixed.  On one hand, teen pregnancy and birth rates have fallen dramatically, reaching record lows. On the other hand, rates of sexually transmitted infections (STIs) among teens and young adults have been on the rise.  Many schools and community groups have adopted programming that incorporates abstinence from sexual activity as an approach to reduce teen pregnancy and STI rates.  The content of these programs, however, can vary considerably, from those that stress abstinence as the only option for youth, to those that address abstinence along with medically accurate information about safer sexual practices including the use of contraceptives and condoms. Early action from the Trump administration has signaled renewed support for abstinence-only programming. This fact sheet reviews the types of sex education models and state policies surrounding them, the major sources of federal funding for both abstinence and safer sex education, and summarizes the research on impact of these programs on teen sexual behavior.

Sex Education Models and State Policies

Fact sheet examines abstinence education programs, funding and impact on teen sexual behavior

There are two main approaches towards sex education: abstinence-only and comprehensive sex education ( Table 1 ). These categories are broad, and the content, methods, and targeted populations can vary widely between programs within each model. In general, abstinence-only programs, also known as “sexual risk avoidance programs,” teach that abstinence from sex is the only morally acceptable option for youth, and the only safe and effective way to prevent unintended pregnancy and STIs. They generally do not discuss contraceptive methods or condoms unless to emphasize their failure rates. Comprehensive sex education is more diversely defined. Most generally, these programs include medically accurate, evidence-based information about both contraception and abstinence, as well as condoms to prevent STI transmission. Some programs, known as “abstinence-plus,” stress abstinence as the best way to prevent pregnancy and STIs, but also include information on contraception and condoms. Other programs emphasize safe-sex practices and often include information about healthy relationships and lifestyles.

The type of sex education model used can vary by school district, and even by school. Some states have enacted laws that offer broad guidelines around sex education, though most have no requirement that sex education be taught at all. Only 24 states and DC require that sex education be taught in schools ( Text Box 1 ). More often, states enact laws that dictate the type of information included in sex education if it is taught, leaving up to school districts, and sometimes the individual school, whether to require sex education and which curriculum to use.

Funding Streams for Abstinence Education

Although decisions regarding if and how sex education is taught are ultimately left to individual states and school districts, abstinence-only funding offered by the federal government since the early 1980s’ has served as a strong incentive to adopt this type of programming. Since then, abstinence education curricula have evolved and federal financial support has fluctuated with each administration, peaking in 2008 at the end of the Bush Administration and then dropping significantly under the Obama administration.

Background (1981 – 2010)

Until 2010, there were three major federal programs dedicated to abstinence education: the Adolescent Family Life Act (AFLA), the Community-Based Abstinence Education program (CBAE), and the Title V Abstinence-Only-Until-Marriage program (AOUM). The AFLA and CBAE programs both provided grants to states and community organizations to promote “chastity and self-discipline,” and teach abstinence as the only acceptable practice for youth.  While these programs have since been eliminated and replaced by other sex education funding streams, the Title V AOUM program remains the largest source of federal funding for abstinence education today.

The Title V AOUM program was enacted under the Clinton Administration’s Welfare Reform Act in 1996 ( Table 2 ). Title V funds are tied to an 8-point definition of abstinence education, also referred to as the “A-H definition” ( Table 3 ). While not all eight points must be emphasized equally, AOUM programs cannot violate the intent of the A-H definition and may not discuss safer-sex practices or contraception except to emphasize their failure rates.  States that accept Title V grant money must match every four federal dollars with three state dollars, and they distribute these funds through health departments to schools and community organizations. Every state, except California, has received funding from this program at some point, and currently half of states do. 2

Current Abstinence Programs

Under the Obama Administration, there was a notable shift in abstinence education funding toward more evidence-based sex education initiatives.  The current landscape of federal sex education programs is detailed in Table 2 and includes newer programs such as Personal Responsibility Education Program (PREP), the first federal funding stream to provide grants to states in support of evidence-based sex education that teach about both abstinence and contraception. In addition, the Teen Pregnancy Prevention Program (TPPP) was established to more narrowly focus on teen pregnancy prevention, providing grants to replicate evidence-based program models, as well as funding for implementation and rigorous evaluation of new and innovative models.

Nonetheless, support for abstinence education programs continues. Although Congress allowed the Title V AOUM program to expire in 2009, it was resurrected in the Affordable Care Act legislation signed by President Obama. In 2012, Congress also established the Competitive Abstinence Education grant program, now known as the Sexual Risk Avoidance Education program (SRAE). Initially tied to the A-H definition, it no longer has this requirement; however, the program still teaches youth to “voluntarily refrain from non-marital sexual activity and prevent other youth risk behaviors.” Federal funding for this program bypasses state authority by granting funds directly to community organizations. In 2017, federal funding for the Title V and SRAE programs totaled $90 million ( Figure 1 ).

Figure 1: In 2017, One-Third of Federal Funding for Teen Sexual Health Education Programs Was For Abstinence Education

The Trump Administration’s early actions signal changes in sex education programming. The 2017 TPPP grant recipients received notice from Health and Human Services that their funding was ending on June 30, 2018, two years early, citing a lack of evidence of the program’s impact despite the fact that many of the grantees’ projects had not yet concluded. Nine organizations sued in Washington, Maryland, and the District of Columbia, arguing that their grants were wrongfully terminated. Federal judges in each of the four lawsuits ruled in favor of the organizations, allowing the programs to continue until the end of their grant cycle in 2020. At the same time, the Trump Administration announced the availability of new funding for the TPP program with updated guidelines. These new rules require grantees to replicate one of two abstinence programs—one that follows a sexual risk avoidance model, and one that follows a sexual risk reduction model– in order to receive funding. This marks a sharp departure from the rules under the Obama administration, which allowed grantees to choose from a list of 44 evidence-supported programs that vary by approach, target population, setting, length, and intended outcomes. 3 Applications for the new grants are due at the end of June 2018.

In addition, Congress passed the 2018 Consolidated Appropriations Act, which included a $10 million funding increase for abstinence-only SRAE grant program, bringing the total to $25 million – a 67% increase. 4 In November 2017, HHS also announced a new $10 million research initiative in partnership with Mathematica Policy Research and RTI International to improve teen pregnancy prevention and sexual risk avoidance programs. 5

Impact on Sexual Behavior and Outcomes Among Youth

Proponents of abstinence education argue that teaching abstinence to youth will delay teens’ first sexual encounter and will reduce the number of partners they have, leading to a reduction in rates of teen pregnancy and STIs. 6 However, there is currently no strong body of evidence to support that abstinence-only programs have these effects on the sexual behavior of youth and some have documented negative impacts on pregnancy and birth rates.

In 2007, a nine-year congressionally mandated study that followed four of the programs during the implementation of the Title V AOUM program found that abstinence-only education had no effect on the sexual behavior of youth. 7 Teens in abstinence-only education programs were no more likely to abstain from sex than teens that were not enrolled in these programs. Among those who did have sex, there was no difference in the mean age at first sexual encounter or the number of sexual partners between the two groups. The study also found that youth that participated in the programs were no more likely to engage in unprotected sex than youth who did not participate. While teens who participated in these programs could identify types of STIs at slightly higher rates than those who did not, program youth were less likely to correctly report that condoms are effective at preventing STIs. A more recent review also suggests that these programs are ineffective in delaying sexual initiation and influencing other sexual activity. 8 Studies conducted in individual states found similar results. 9 , 10 One study found that states with policies that require sex education to stress abstinence, have higher rates of teenage pregnancy and births, even after accounting for other factors such as socioeconomic status, education, and race. 11

A study that found an abstinence-only intervention to be effective in delaying sexual activity within a two-year period received significant attention as the first major study to do so. 12 While advocates of comprehensive sex education recognize the study as rigorous and credible, they argue that the programs in these studies are not representative of most abstinence-only programs. Instead, the evaluated programs differed from traditional abstinence-only programs in three major ways: they did not discuss the morality of a decision to have sex; they encouraged youth to wait until they were ready to have sex, rather than until marriage; and they did not criticize the use of condoms. 13

There is, however, considerable evidence that comprehensive sex education programs can be effective in delaying sexual initiation among teens, and increasing use of contraceptives, including condoms. One study found that youth who received information about contraceptives in their sex education programs were at 50% lower risk of teen pregnancy than those in abstinence-only programs. 14 It also found that teens in these more comprehensive programs were no more likely than those receiving abstinence-only education to engage in sexual intercourse, as some critics argue.  Another study found that over 40% of programs that addressed both abstinence and contraception delayed the initiation of sex and reduced the number of sexual partners, and more than 60% of the programs reduced the incidence of unprotected sex. 15 , 16 , 17 Despite this growing evidence, in 2014, roughly three-fourths of high schools and half of middle schools taught abstinence as the most effective method to avoid pregnancy, HIV, and other STDs, just under two-thirds of high schools taught about the efficacy of contraceptives, and about one-third of high schools taught students how to correctly use a condom ( Figure 2 ).

Figure 2: Percent of Schools in Which Teachers Taught Specific Topics as Part of Required Instruction

The Trump administration continues to shift the focus towards abstinence-only education, revamping the Teen Pregnancy Prevention Program and increasing federal funding for sexual risk avoidance programs.  Despite the large body of evidence suggesting that abstinence-only programs are ineffective at delaying sexual activity and reducing the number of sexual partners of teens, many states continue to seek funding for abstinence-only-until-marriage programs and mandate an emphasis on abstinence when sex education is taught in school. There will likely be continued debate about the effectiveness of these programs and ongoing attention to the level of federal investment in sex education programs that prioritize abstinence-only approaches over those that are more comprehensive and based on medical information.

Health and Human Services Administration (HHS). 2017 Personal Responsibility Education Program (PREP) Awards .

← Return to text

SIECUS. A History of Federal Funding for Abstinence-Only Until Marriage Programs .

Office of Adolescent Health, HHS. Evidence-Based Teen Pregnancy Prevention Programs at a Glance .

The Consolidated Appropriation Act, 2018

HHS, Administration for Children and Families. HHS Announces New Efforts to Improve Teen Pregnancy Prevention & Sexual Risk Avoidance Programs . November 3, 2017.

Heritage Foundation (2010). Evidence on the Effectiveness of Abstinence Education: An Update .

Mathematica Policy Research (2007). Impacts of Four Title V, Section 510 Abstinence Education Programs .

Santelli JS, et al. Guttmacher Institute. Abstinence-Only-Until-Marriage: An Updated Review of U.S. Policies and Programs and Their Impact. Journal of Adolescent Health, 61 (2017) 273e280.

SIECUS. Abstinence-Only-Until-Marriage Programs fact sheet .

Hauser, D. Advocates for Youth. Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact .

Stanger-Hall, K. F., & Hall, D. W. (2011). Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S . PLoS ONE, 6(10), e24658.

Jemmott JB, Jemmott LS, Fong GT. Efficacy of a Theory-Based Abstinence-Only Intervention Over 24 Months: A Randomized Controlled Trial With Young Adolescents . Arch Pediatr Adolesc Med. 2010;164(2):152–159.

Stein R. (2010, February 2). Abstinence-only programs might work, study says . Washington Post

Kohler, Pamela & Manhart, Lisa & E Lafferty, William. (2008). Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy . The Journal of adolescent health. 42. 344-51.

Kirby, D.B. The impact of abstinence and comprehensive sex and STD/HIV education programs on adolescent sexual behavior . Sex Res Soc Policy (2008) 5: 18.

S Denford et al. A Comprehensive Review of Reviews of School-Based Interventions to Improve Sexual-Health . Health Psychol Rev 11 (1), 33-52. 2016 Nov 07.

Chin, Helen B. et al. The Effectiveness of Group-Based Comprehensive Risk-Reduction and Abstinence Education Interventions to Prevent or Reduce the Risk of Adolescent Pregnancy, Human Immunodeficiency Virus, and Sexually Transmitted Infections . American Journal of Preventive Medicine, Volume 42, Issue 3, 272 – 294.

• Women's Health Policy
• Reproductive Health
• Family Planning

Also of Interest

• The U.S. Government and International Family Planning & Reproductive Health Efforts
• The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies
• Recent Trends in Mental Health and Substance Use Concerns Among Adolescents

• Search Menu
• Advance Articles
• Editor's Choice
• Author Guidelines
• Submission Site
• Open Access
• About Health Education Research
• Editorial Board
• Advertising and Corporate Services
• Journals Career Network
• Self-Archiving Policy
• Dispatch Dates
• Journals on Oxford Academic
• Books on Oxford Academic

Article Contents

Introduction, purpose of the study, literature search and selection criteria, coding of the studies for exploration of moderators, decisions related to the computation of effect sizes.

• < Previous

The effectiveness of school-based sex education programs in the promotion of abstinent behavior: a meta-analysis

• Article contents
• Figures & tables
• Supplementary Data

Mónica Silva, The effectiveness of school-based sex education programs in the promotion of abstinent behavior: a meta-analysis, Health Education Research , Volume 17, Issue 4, August 2002, Pages 471–481, https://doi.org/10.1093/her/17.4.471

• Permissions Icon Permissions

This review presents the findings from controlled school-based sex education interventions published in the last 15 years in the US. The effects of the interventions in promoting abstinent behavior reported in 12 controlled studies were included in the meta-analysis. The results of the analysis indicated a very small overall effect of the interventions in abstinent behavior. Moderator analysis could only be pursued partially because of limited information in primary research studies. Parental participation in the program, age of the participants, virgin-status of the sample, grade level, percentage of females, scope of the implementation and year of publication of the study were associated with variations in effect sizes for abstinent behavior in univariate tests. However, only parental participation and percentage of females were significant in the weighted least-squares regression analysis. The richness of a meta-analytic approach appears limited by the quality of the primary research. Unfortunately, most of the research does not employ designs to provide conclusive evidence of program effects. Suggestions to address this limitation are provided.

Sexually active teenagers are a matter of serious concern. In the past decades many school-based programs have been designed for the sole purpose of delaying the initiation of sexual activity. There seems to be a growing consensus that schools can play an important role in providing youth with a knowledge base which may allow them to make informed decisions and help them shape a healthy lifestyle ( St Leger, 1999 ). The school is the only institution in regular contact with a sizable proportion of the teenage population ( Zabin and Hirsch, 1988 ), with virtually all youth attending it before they initiate sexual risk-taking behavior ( Kirby and Coyle, 1997 ).

Programs that promote abstinence have become particularly popular with school systems in the US ( Gilbert and Sawyer, 1994 ) and even with the federal government ( Sexual abstinence program has a $250 million price tag, 1997 ). These are referred to in the literature as abstinence-only or value-based programs ( Repucci and Herman, 1991 ). Other programs—designated in the literature as safer-sex, comprehensive, secular or abstinence-plus programs—additionally espouse the goal of increasing usage of effective contraception. Although abstinence-only and safer-sex programs differ in their underlying values and assumptions regarding the aims of sex education, both types of programs strive to foster decision-making and problem-solving skills in the belief that through adequate instruction adolescents will be better equipped to act responsibly in the heat of the moment ( Repucci and Herman, 1991 ). Nowadays most safer-sex programs encourage abstinence as a healthy lifestyle and many abstinence only programs have evolved into `abstinence-oriented' curricula that also include some information on contraception. For most programs currently implemented in the US, a delay in the initiation of sexual activity constitutes a positive and desirable outcome, since the likelihood of responsible sexual behavior increases with age ( Howard and Mitchell, 1993 ).

Even though abstinence is a valued outcome of school-based sex education programs, the effectiveness of such interventions in promoting abstinent behavior is still far from settled. Most of the articles published on the effectiveness of sex education programs follow the literary format of traditional narrative reviews ( Quinn, 1986 ; Kirby, 1989 , 1992 ; Visser and van Bilsen, 1994 ; Jacobs and Wolf, 1995 ; Kirby and Coyle, 1997 ). Two exceptions are the quantitative overviews by Frost and Forrest ( Frost and Forrest, 1995 ) and Franklin et al . ( Franklin et al ., 1997 ).

In the first review ( Frost and Forrest, 1995 ), the authors selected only five rigorously evaluated sex education programs and estimated their impact on delaying sexual initiation. They used non-standardized measures of effect sizes, calculated descriptive statistics to represent the overall effect of these programs and concluded that those selected programs delayed the initiation of sexual activity. In the second review, Franklin et al . conducted a meta-analysis of the published research of community-based and school-based adolescent pregnancy prevention programs and contrary to the conclusions forwarded by Frost and Forrest, these authors reported a non-significant effect of the programs on sexual activity ( Franklin et al ., 1997 ).

The discrepancy between these two quantitative reviews may result from the decision by Franklin et al . to include weak designs, which do not allow for reasonable causal inferences. However, given that recent evidence indicates that weaker designs yield higher estimates of intervention effects ( Guyatt et al ., 2000 ), the inclusion of weak designs should have translated into higher effects for the Franklin et al . review and not smaller. Given the discrepant results forwarded in these two recent quantitative reviews, there is a need to clarify the extent of the impact of school-based sex education in abstinent behavior and explore the specific features of the interventions that are associated to variability in effect sizes.

The present study consisted of a meta-analytic review of the research literature on the effectiveness of school-based sex education programs in the promotion of abstinent behavior implemented in the past 15 years in the US in the wake of the AIDS epidemic. The goals were to: (1) synthesize the effects of controlled school-based sex education interventions on abstinent behavior, (2) examine the variability in effects among studies and (3) explain the variability in effects between studies in terms of selected moderator variables.

The first step was to locate as many studies conducted in the US as possible that dealt with the evaluation of sex education programs and which measured abstinent behavior subsequent to an intervention.

The primary sources for locating studies were four reference database systems: ERIC, PsychLIT, MEDLINE and the Social Science Citation Index. Branching from the bibliographies and reference lists in articles located through the original search provided another source for locating studies.

The process for the selection of studies was guided by four criteria, some of which have been employed by other authors as a way to orient and confine the search to the relevant literature ( Kirby et al ., 1994 ). The criteria to define eligibility of studies were the following.

Interventions had to be geared to normal adolescent populations attending public or private schools in the US and report on some measure of abstinent behavior: delay in the onset of intercourse, reduction in the frequency of intercourse or reduction in the number of sexual partners. Studies that reported on interventions designed for cognitively handicapped, delinquent, school dropouts, emotionally disturbed or institutionalized adolescents were excluded from the present review since they address a different population with different needs and characteristics. Community interventions which recruited participants from clinical or out-of-school populations were also eliminated for the same reasons.

Studies had to be either experimental or quasi-experimental in nature, excluding three designs that do not permit strong tests of causal hypothesis: the one group post-test-only design, the post-test-only design with non-equivalent groups and the one group pre-test–post-test design ( Cook and Campbell, 1979 ). The presence of an independent and comparable `no intervention' control group—in demographic variables and measures of sexual activity in the baseline—was required for a study to be included in this review.

Studies had to be published between January 1985 and July 2000. A time period restriction was imposed because of cultural changes that occur in society—such as the AIDS epidemic—which might significantly impact the adolescent cohort and alter patterns of behavior and consequently the effects of sex education interventions.

Five pairs of publications were detected which may have used the same database (or two databases which were likely to contain non-independent cases) ( Levy et al ., 1995 / Weeks et al ., 1995 ; Barth et al ., 1992 / Kirby et al ., 1991 /Christoper and Roosa, 1990/ Roosa and Christopher, 1990 and Jorgensen, 1991 / Jorgensen et al ., 1993 ). Only one effect size from each pair of articles was included to avoid the possibility of data dependence.

The exploration of study characteristics or features that may be related to variations in the magnitude of effect sizes across studies is referred to as moderator analysis. A moderator variable is one that informs about the circumstances under which the magnitude of effect sizes vary ( Miller and Pollock, 1994 ). The information retrieved from the articles for its potential inclusion as moderators in the data analysis was categorized in two domains: demographic characteristics of the participants in the sex education interventions and characteristics of the program.

Demographic characteristics included the following variables: the percentages of females, the percentage of whites, the virginity status of participants, mean (or median) age and a categorization of the predominant socioeconomic status of participating subjects (low or middle class) as reported by the authors of the primary study.

In terms of the characteristics of the programs, the features coded were: the type of program (whether the intervention was comprehensive/safer-sex or abstinence-oriented), the type of monitor who delivered the intervention (teacher/adult monitor or peer), the length of the program in hours, the scope of the implementation (large-scale versus small-scale trial), the time elapsed between the intervention and the post-intervention outcome measure (expressed as number of days), and whether parental participation (beyond consent) was a component of the intervention.

The type of sex education intervention was defined as abstinence-oriented if the explicit aim was to encourage abstinence as the primary method of protection against sexually transmitted diseases and pregnancy, either totally excluding units on contraceptive methods or, if including contraception, portraying it as a less effective method than abstinence. An intervention was defined as comprehensive or safer-sex if it included a strong component on the benefits of use of contraceptives as a legitimate alternative method to abstinence for avoiding pregnancy and sexually transmitted diseases.

A study was considered to be a large-scale trial if the intervention group consisted of more than 500 students.

Finally, year of publication was also analyzed to assess whether changes in the effectiveness of programs across time had occurred.

The decision to record information on all the above-mentioned variables for their potential role as moderators of effect sizes was based in part on theoretical considerations and in part on the empirical evidence of the relevance of such variables in explaining the effectiveness of educational interventions. A limitation to the coding of these and of other potentially relevant and interesting moderator variables was the scantiness of information provided by the authors of primary research. Not all studies described the features of interest for this meta-analysis. For parental participation, no missing values were present because a decision was made to code all interventions which did not specifically report that parents had participated—either through parent–youth sessions or homework assignments—as non-participation. However, for the rest of the variables, no similar assumptions seemed appropriate, and therefore if no pertinent data were reported for a given variable, it was coded as missing (see Table I ).

Once the pool of studies which met the inclusion criteria was located, studies were examined in an attempt to retrieve the size of the effect associated with each intervention. Since most of the studies did not report any effect size, it had to be estimated based on the significance level and inferential statistics with formulae provided by Rosenthal ( Rosenthal, 1991 ) and Holmes ( Holmes; 1984 ). When provided, the exact value for the test statistic or the exact probability was used in the calculation of the effect size.

Alternative methods to deal with non-independent effect sizes were not employed since these are more complex and require estimates of the covariance structure among the correlated effect sizes. According to Matt and Cook such estimates may be difficult—if not impossible—to obtain due to missing information in primary studies ( Matt and Cook, 1994 ).

Analyses of the effect sizes were conducted utilizing the D-STAT software ( Johnson, 1989 ). The sample sizes used for the overall effect size analysis corresponded to the actual number used to estimate the effects of interest, which was often less than the total sample of the study. Occasionally the actual sample sizes were not provided by the authors of primary research, but could be estimated from the degrees of freedom reported for the statistical tests.

The effect sizes were calculated from means and pooled standard deviations, t -tests, χ 2 , significance levels or from proportions, depending on the nature of the information reported by the authors of primary research. As recommended by Rosenthal, if results were reported simply as being `non-significant' a conservative estimate of the effect size was included, assuming P = 0.50, which corresponds to an effect size of zero ( Rosenthal, 1991 ). The overall measure of effect size reported was the corrected d statistic ( Hedges and Olkin, 1985 ). These authors recommend this measure since it does not overestimate the population effect size, especially in the case when sample sizes are small.

The homogeneity of effect sizes was examined to determine whether the studies shared a common effect size. Testing for homogeneity required the calculation of a homogeneity statistic, Q . If all studies share the same population effect size, Q follows an asymptotic χ 2 distribution with k – 1 degrees of freedom, where k is the number of effect sizes. For the purposes of this review the probability level chosen for significance testing was 0.10, due to the fact that the relatively small number of effect sizes available for the analysis limits the power to detect actual departures from homogeneity. Rejection of the hypothesis of homogeneity signals that the group of effect sizes is more variable than one would expect based on sampling variation and that one or more moderator variables may be present ( Hall et al ., 1994 ).

To examine the relationship between the study characteristics included as potential moderators and the magnitude of effect sizes, both categorical and continuous univariate tests were run. Categorical tests assess differences in effect sizes between subgroups established by dividing studies into classes based on study characteristics. Hedges and Olkin presented an extension of the Q statistic to test for homogeneity of effect sizes between classes ( Q B ) and within classes ( Q W ) ( Hedges and Olkin, 1985 ). The relationship between the effect sizes and continuous predictors was assessed using a procedure described by Rosenthal and Rubin which tests for linearity between effect sizes and predictors ( Rosenthal and Rubin, 1982 ).

Q E provides the test for model specification, when the number of studies is larger than the number of predictors. Under those conditions, Q E follows an approximate χ 2 distribution with k – p – 1 degrees of freedom, where k is the number of effect sizes and p is the number of regressors ( Hedges and Olkin, 1985 ).

The search for school-based sex education interventions resulted in 12 research studies that complied with the criteria to be included in the review and for which effect sizes could be estimated.

The overall effect size ( d +) estimated from these studies was 0.05 and the 95% confidence interval about the mean included a lower bound of 0.01 to a high bound of 0.09, indicating a very minimal overall effect size. Table II presents the effect size of each study ( d i ) along with its 95% confidence interval and the overall estimate of the effect size. Homogeneity testing indicated the presence of variability among effect sizes ( Q (11) = 35.56; P = 0.000).

An assessment of interaction effects among significant moderators could not be explored since it would have required partitioning of the studies according to a first variable and testing of the second within the partitioned categories. The limited number of effect sizes precluded such analysis.

Parental participation appeared to moderate the effects of sex education on abstinence as indicated by the significant Q test between groups ( Q B(1) = 5.06; P = 0.025), as shown in Table III . Although small in magnitude ( d = 0.24), the point estimate for the mean weighted effect size associated with programs with parental participation appears substantially larger than the mean associated with those where parents did not participate ( d = 0.04). The confidence interval for parent participation does not include zero, thus indicating a small but positive effect. Controlling for parental participation appears to translate into homogeneous classes of effect sizes for programs that include parents, but not for those where parents did not participate ( Q W(9) = 28.94; P = 0.001) meaning that the effect sizes were not homogeneous within this class.

Virginity status of the sample was also a significant predictor of the variability among effect sizes ( Q B(1) = 3.47 ; P = 0.06). The average effect size calculated for virgins-only was larger than the one calculated for virgins and non-virgins ( d = 0.09 and d = 0.01, respectively). Controlling for virginity status translated into homogeneous classes for virgins and non-virgins although not for the virgins-only class ( Q W(5) = 27.09; P = 0.000).

The scope of the implementation also appeared to moderate the effects of the interventions on abstinent behavior. The average effect size calculated for small-scale intervention was significantly higher than that for large-scale interventions ( d = 0.26 and d = 0.01, respectively). The effects corresponding to the large-scale category were homogeneous but this was not the case for the small-scale class, where heterogeneity was detected ( Q W(4) = 14.71; P = 0.01)

For all three significant categorical predictors, deletion of one outlier ( Howard and McCabe, 1990 ) resulted in homogeneity among the effect sizes within classes.

Univariate tests of continuous predictors showed significant results in the case of percentage of females in the sample ( z = 2.11; P = 0.04), age of participants ( z = –1.67; P = 0.09), grade ( z = –1.80; P = 0.07) and year of publication ( z = –2.76; P = 0.006).

All significant predictors in the univariate analysis—with the exception of grade which had a very high correlation with age ( r = 0.97; P = 0.000)—were entered into a weighted least-squares regression analysis. In general, the remaining set of predictors had a moderate degree of intercorrelation, although none of the coefficients were statistically significant.

In the weighted least-squares regression analysis, only parental participation and the percentage of females in the study were significant. The two-predictor model explained 28% of the variance in effect sizes. The test of model specification yielded a significant Q E statistic suggesting that the two-predictor model cannot be regarded as correctly specified (see Table IV ).

This review synthesized the findings from controlled sex education interventions reporting on abstinent behavior. The overall mean effect size for abstinent behavior was very small, close to zero. No significant effect was associated to the type of intervention: whether the program was abstinence-oriented or comprehensive—the source of a major controversy in sex education—was not found to be associated to abstinent behavior. Only two moderators—parental participation and percentage of females—appeared to be significant in both univariate tests and the multivariable model.

Although parental participation in interventions appeared to be associated with higher effect sizes in abstinent behavior, the link should be explored further since it is based on a very small number of studies. To date, too few studies have reported success in involving parents in sex education programs. Furthermore, the primary articles reported very limited information about the characteristics of the parents who took part in the programs. Parents who were willing to participate might differ in important demographic or lifestyle characteristics from those who did not participate. For instance, it is possible that the studies that reported success in achieving parental involvement may have been dealing with a larger percentage of intact families or with parents that espoused conservative sexual values. Therefore, at this point it is not possible to affirm that parental participation per se exerts a direct influence in the outcomes of sex education programs, although clearly this is a variable that merits further study.

Interventions appeared to be more effective when geared to groups composed of younger students, predominantly females and those who had not yet initiated sexual activity. The association between gender and effect sizes—which appeared significant both in the univariate and multivariable analyses—should be explored to understand why females seem to be more receptive to the abstinence messages of sex education interventions.

Smaller-scale interventions appeared to be more effective than large-scale programs. The larger effects associated to small-scale trials seems worth exploring. It may be the case that in large-scale studies it becomes harder to control for confounding variables that may have an adverse impact on the outcomes. For example, large-scale studies often require external agencies or contractors to deliver the program and the quality of the delivery of the contents may turn out to be less than optimal ( Cagampang et al ., 1997 ).

Interestingly there was a significant change in effect sizes across time, with effect sizes appearing to wane across the years. It is not likely that this represents a decline in the quality of sex education interventions. A possible explanation for this trend may be the expansion of mandatory sex education in the US which makes it increasingly difficult to find comparison groups that are relatively unexposed to sex education. Another possible line of explanation refers to changes in cultural mores regarding sexuality that may have occurred in the past decades—characterized by an increasing acceptance of premarital sexual intercourse, a proliferation of sexualized messages from the media and increasing opportunities for sexual contact in adolescence—which may be eroding the attainment of the goal of abstinence sought by educational interventions.

In terms of the design and implementation of sex education interventions, it is worth noting that the length of the programs was unrelated to the magnitude in effect sizes for the range of 4.5–30 h represented in these studies. Program length—which has been singled out as a potential explanation for the absence of significant behavioral effects in a large-scale evaluation of a sex education program ( Kirby et al ., 1997a )—does not appear to be consistently associated with abstinent behavior. The impact of lengthening currently existing programs should be evaluated in future studies.

As it has been stated, the exploration of moderator variables could be performed only partially due to lack of information on the primary research literature. This has been a problem too for other reviewers in the field ( Franklin et al ., 1997 ). The authors of primary research did not appear to control for nor report on the potentially confounding influence of numerous variables that have been indicated in the literature as influencing sexual decision making or being associated with the initiation of sexual activity in adolescence such as academic performance, career orientation, religious affiliation, romantic involvement, number of friends who are currently having sex, peer norms about sexual activity and drinking habits, among others ( Herold and Goodwin, 1981 ; Christopher and Cate, 1984 ; Billy and Udry, 1985 ; Roche, 1986 ; Coker et al ., 1994 ; Kinsman et al ., 1998 ; Holder et al ., 2000 ; Thomas et al ., 2000 ). Even though randomization should take care of differences in these and other potentially confounding variables, given that studies can rarely assign students to conditions and instead assign classrooms or schools to conditions, it is advisable that more information on baseline characteristics of the sample be utilized to establish and substantiate the equivalence between the intervention and control groups in relevant demographic and lifestyle characteristics.

In terms of the communication of research findings, the richness of a meta-analytic approach will always be limited by the quality of the primary research. Unfortunately, most of the research in the area of sex education do not employ experimental or quasi-experimental designs and thus fall short of providing conclusive evidence of program effects. The limitations in the quality of research in sex education have been highlighted by several authors in the past two decades ( Kirby and Baxter, 1981 ; Card and Reagan, 1989 ; Kirby, 1989 ; Peersman et al ., 1996 ). Due to these deficits in the quality of research—which resulted in a reduced number of studies that met the criteria for inclusion and the limitations that ensued for conducting a thorough analysis of moderators—the findings of the present synthesis have to be considered merely tentative. Substantial variability in effect sizes remained unexplained by the present synthesis, indicating the need to include more information on a variety of potential moderating conditions that might affect the outcomes of sex education interventions.

Finally, although it is rarely the case that a meta-analysis will constitute an endpoint or final step in the investigation of a research topic, by indicating the weaknesses as well as the strengths of the existing research a meta-analysis can be a helpful aid for channeling future primary research in a direction that might improve the quality of empirical evidence and expand the theoretical understanding in a given field ( Eagly and Wood, 1994 ). Research in sex education could be greatly improved if more efforts were directed to test interventions utilizing randomized controlled trials, measuring intervening variables and by a more careful and detailed reporting of the results. Unless efforts are made to improve on the quality of the research that is being conducted, decisions about future interventions will continue to be based on a common sense and intuitive approach as to `what might work' rather than on solid empirical evidence.

References marked with an asterisk indicate studies included in the meta-analysis.

Description of moderator variables

Effect sizes of studies

Tests of categorical moderators for abstinence

Weighted least-squares regression and test of model specification

Barth, R., Fetro, J., Leland, N. and Volkan, K. ( 1992 ) Preventing adolescent pregnancy with social and cognitive skills. Journal of Adolescent Research , 7 , 208 –232.

Billy, J. and Udry, R. ( 1985 ) Patterns of adolescent friendship and effects on sexual behavior. Social Psychology Quarterly , 48 , 27 –41.

Brown, L., Barone, V., Fritz, G., Cebollero, P. and Nassau, J. ( 1991 ) AIDS education: the Rhode Island experience. Health Education Quarterly , 18 , 195 –206.*

Cagampang, H., Barth, R., Korpi, M. and Kirby, D. ( 1997 ) Education Now And Babies Later (ENABL): life history of a campaign to postpone sexual involvement. Family Planning Perspectives , 29 , 109 –114.

Card, J. and Reagan, R. ( 1989 ) Strategies for evaluating adolescent pregnancy programs. Family Planning Perspectives , 21 , 210 –220.

Christopher, F. and Roosa, M. ( 1990 ) An evaluation of an adolescent pregnancy prevention program: is `just say no' enough? Family relations , 39 , 68 –72.

Christopher, S. and Cate, R. ( 1984 ). Factors involved in premarital sexual decision-making. Journal of Sex Research , 20 , 363 –376.

Coker, A., Richter, D., Valois, R., McKeown, R., Garrison, C. and Vincent, M. ( 1994 ) Correlates and consequences of early initiation of sexual intercourse. Journal of School Health , 64 , 372 –377.

Cook, T. and Campbell, D. (1979) Quasi-experimentation: Design and Analysis Issues for Field Settings . Houghton Mifflin, Boston.

Denny, G., Young, M. and Spear, C. ( 1999 ) An evaluation of the Sex Can Wait abstinence education curriculum series. American Journal of Health Behavior , 23 , 134 –143.*

Dunkin, M. ( 1996 ) Types of errors in synthesizing research in education. Review of Educational Research , 66 , 87 –97.

Eagly, A. and Wood, W. (1994) Using research synthesis to plan future research. In Cooper, H. and Hedges, L. (eds), The Handbook of Research Synthesis. Russell Sage Foundation, New York, pp. 485–500.

Franklin, C., Grant, D., Corcoran, J., Miller, P. and Bultman, L. ( 1997 ) Effectiveness of prevention programs for adolescent pregnancy: a meta-analysis. Journal of Marriage and the Family , 59 , 551 –567.

Frost, J. and Forrest, J. ( 1995 ) Understanding the impact of effective teenage pregnancy prevention programs. Family Planning Perspectives , 27 , 188 –195.

Gilbert, G. and Sawyer, R. (1994) Health Education: Creating Strategies for School and Community Health. Jones & Bartlett, Boston, MA.

Guyatt, G., Di Censo, A., Farewell, V., Willan, A. and Griffith, L. ( 2000 ) Randomized trials versus observational studies in adolescent pregnancy prevention. Journal of Clinical Epidemiology , 53 , 167 –174.

Hall, J., Rosenthal, R., Tickle-Deignen, L. and Mosteller, F. (1994) Hypotheses and problems in research synthesis. In Cooper, H. and Hedges, L. (eds), The Handbook of Research Synthesis. Russell Sage Foundation, New York, pp. 457–483.

Hedges, L. and Olkin, I. (1985) Statistical Methods for Meta-Analysis. Academic Press, San Diego, CA.

Herold, E. and Goodwin, S. ( 1981 ) Adamant virgins, potential non-virgins and non-virgins. Journal of Sex Research , 17 , 97 –113.

Holder, D., Durant, R., Harris, T., Daniel, J., Obeidallah, D. and Goodman, E. ( 2000 ) The association between adolescent spirituality and voluntary sexual activity. Journal of Adolescent Health , 26 , 295 –302.

Holmes, C. ( 1984 ) Effect size estimation in meta-analysis. Journal of Experimental Education , 52 , 106 –109.

Howard, M. and McCabe, J. ( 1990 ) Helping teenagers postpone sexual involvement. Family Planning Perspectives , 22 , 21 –26.*

Howard, M. and Mitchell, M. ( 1993 ) Preventing teenage pregnancy: some questions to be answered and some answers to be questioned. Pediatric Annals , 22 , 109 –118.

Hunter, J. ( 1997 ) Needed: a ban on the significance test. Psychological Science , 8 , 3 –7.

Jacobs, C. and Wolf, E. ( 1995 ) School sexuality education and adolescent risk-taking behavior. Journal of School Health , 65 , 91 –95.

Johnson, B. (1989) DSTAT: Software for the Meta-Analytic Review of Research Literatures . Lawrence Erlbaum, Hillsdale, NJ.

Jorgensen, S. ( 1991 ) Project taking-charge: An evaluation of an adolescent pregnancy prevention program. Family Relations , 40 , 373 –380.*

Jorgensen, S, Potts, V. and Camp, B. ( 1993 ) Project Taking Charge: six month follow-up of a pregnancy prevention program for early adolescents. Family Relations , 42 , 401 –406

Kinsman, S., Romer, D., Furstenberg, F. and Schwarz, D. ( 1998 ) Early sexual initiation: the role of peer norms. Pediatrics , 102 , 1185 –1192.

Kirby, D. ( 1989 ) Research on effectiveness of sex education programs. Theory and Practice , 28 , 165 –171.

Kirby, D. ( 1992 ) School-based programs to reduce sexual risk-taking behaviors. Journal of School Health , 62 , 280 –287.

Kirby, D. and Baxter, S. ( 1981 ) Evaluating sexuality education programs. Independent School , 41 , 105 –114.

Kirby, D. and Coyle, K. ( 1997 ) School-based programs to reduce sexual risk-taking behavior. Children and Youth Services Review , 19 , 415 –436.

Kirby, D., Barth, R., Leland, N. and Fetro, J. ( 1991 ) Reducing the risk: impact of a new curriculum on sexual risk-taking. Family Planning Perspectives , 23 , 253 –263.*

Kirby, D., Short, L., Collins, J., Rugg, D., Kolbe, L., Howard, M., Miller, B., Sonenstein, F. and Zabin, L. ( 1994 ) School-based programs to reduce sexual-risk behaviors: a review of effectiveness. Public Health Reports , 109 , 339 –360.

Kirby, D., Korpi, M., Barth, R. and Cagampang, H. ( 1997 ) The impact of Postponing Sexual Involvement curriculum among youths in California. Family Planning Perspectives , 29 , 100 –108.*

Kirby, D., Korpi, M., Adivi, C. and Weissman, J. ( 1997 ) An impact evaluation of Project Snapp: an AIDS and pregnancy prevention middle school program. AIDS Education and Prevention , 9 (A), 44 –61.*

Levy, S., Perhats, C., Weeks, K., Handler, S., Zhu, C. and Flay, B. ( 1995 ) Impact of a school-based AIDS prevention program on risk and protective behavior for newly sexually active students. Journal of School Health , 65 , 145 –151.

Main, D., Iverson, D., McGloin, J., Banspach, S., Collins, J., Rugg, D. and Kolbe, L. ( 1994 ) Preventing HIV infection among adolescents: evaluation of a school-based education program. Preventive Medicine , 23 , 409 –417.*

Matt, G. and Cook, T. (1994) Threats to the validity of research synthesis. In Cooper, H. and Hedges, L. (eds), The Handbook of Research Synthesis. Russell Sage Foundation, New York, pp. 503–520.

Miller, N. and Pollock, V. (1994) Meta-analytic synthesis for theory development. In Cooper, H. and Hedges, L. (eds), The Handbook of Research Synthesis. Russell Sage Foundation, New York, pp. 457–483.

O'Donnell, L., Stueve, A., Sandoval, A., Duran, R., Haber, D., Atnafou, R., Johnson, N., Grant, U., Murray, H., Juhn, G., Tang, J. and Piessens, P. ( 1999 ) The effectiveness of the Reach for Health Community Youth Service Learning Program in reducing early and unprotected sex among urban middle school students. American Journal of Public Health , 89 , 176 –181.*

Peersman, G., Oakley, A., Oliver, S. and Thomas, J. (1996) Review of Effectiveness of Sexual Health Promotion Interventions for Young People . EPI Centre Report, London.

Quinn, J. ( 1986 ) Rooted in research: effective adolescent pregnancy prevention programs. Journal of Social Work and Human Sexuality , 5 , 99 –110.

Repucci, N. and Herman, J. ( 1991 ) Sexuality education and child abuse: prevention programs in the schools. Review of Research in Education , 17 , 127 –166.

Roche, J. ( 1986 ) Premarital sex: attitudes and behavior by dating stage. Adolescence , 21 , 107 –121.

Roosa, M. and Christopher, F. ( 1990 ) Evaluation of an abstinence-only adolescent pregnancy prevention program: a replication. Family Relations , 39 , 363 –367.*

Rosenthal, R. (1991) Meta-analytic Procedures for Social Research. Sage, Newbury Park, CA.

Rosenthal, R. and Rubin, D. ( 1982 ) Comparing effect sizes of independent studies. Psychological Bulletin , 92 , 500 –504.

Sexual abstinence program has a $250 million price tag (1997) The Herald Times , Bloomington, Indiana, March 5, p. A3.

St Leger, L. ( 1999 ) The opportunities and effectiveness of the health promoting primary school in improving child health—a review of the claims and evidence. Health Education Research , 14 , 51 –69.

Thomas, G., Reifman, A., Barnes, G. and Farrell, M. ( 2000 ) Delayed onset of drunkenness as a protective factor for adolescent alcohol misuse and sexual risk taking: a longitudinal study. Deviant Behavior , 21 , 181 –210.

Visser, A. and Van Bilsen, P. ( 1994 ) Effectiveness of sex education provided to adolescents. Patient Education and Counseling , 23 , 147 –160.

Walter, H. and Vaughan, R. ( 1993 ) AIDS risk reduction among multiethnic sample of urban high school students. Journal of the American Medical Association , 270 , 725 –730.*

Weeks, K., Levy, S., Chenggang, Z., Perhats, C., Handler, A. and Flay, B. ( 1995 ) Impact of a school-based AIDS prevention program on young adolescents self-efficacy skills. Health Education Research , 10 , 329 –344.*

Zabin, L. and Hirsch, M. (1988) Evaluation of Pregnancy Prevention Programs in the School Context . Lexington Books, Lexington, MA.

• least-squares analysis
• sex education

Email alerts

Citing articles via.

• Recommend to your Library

Affiliations

• Online ISSN 1465-3648
• Print ISSN 0268-1153
• Copyright © 2024 Oxford University Press
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

< Back to my filtered results

Abstinence only vs. comprehensive sex education: What are the arguments? What is the evidence?

Abstinence Only vs. Comprehensive Sex Education: What are the arguments? What is the evidence? is a document focusing on the impact of abstinence and comprehensive sex education programs established in United States. Indeed, the United States still has the highest rates of STIs and teen pregnancy of any industrialized nation. Since President Bush, the Congress tends to promotes abstinence-only approach that will likely have serious unintended consequences by denying young people access to the information they need to protect themselves. The document demonstrates and explains why it is crucial to provide young people with comprehensive sex education, including the provision of information about contraceptive and condom use.

• UNH Library

Home > STUDENT_PUBS > PERSPECTIVES > Vol. 11 (2019)

The Impact of Abstinence-Only Sex Education Programs in the United States on Adolescent Sexual Outcomes

Publication date.

Sonja W. Heels , University of New Hampshire, Durham

Though there are many evaluations of abstinence-only sex education programs in the United States, there is a relatively small body of literature exploring the programs’ impact specifically on adolescent sexual behavior. Thus, the purpose of this literature review is to examine the impact of abstinence-only sex education programs on adolescent sexual outcomes. The phrase “sexual outcomes” refers to attitudes, behaviors, and experiences of adolescents as a result of their sex education. After an overview of sex education in the United States, I discuss three major themes found in the most recent literature: abstinence and delaying the initiation of sex, consequences of the lack of contraceptive use, and lastly, the perspectives and experiences of LGBTQ+ youth. Overall, abstinence-only sex education programs are found to have no beneficial or harmful impact on rates of abstinence, STDs, and unintended pregnancies. Additionally, strong evidence suggests that abstinence-only programs adversely impact LGBTQ+ youth, largely due to the lack of relevant information and the heteronormative framing. I conclude with a brief discussion of how these findings relate back to the current policy debate, as well as suggestions for future research.

Recommended Citation

Heels, Sonja W. (2019) "The Impact of Abstinence-Only Sex Education Programs in the United States on Adolescent Sexual Outcomes," Perspectives : Vol. 11, Article 3. Available at: https://scholars.unh.edu/perspectives/vol11/iss1/3

Since July 11, 2019

To view the content in your browser, please download Adobe Reader or, alternately, you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.

• Journal Home
• Most Popular Papers
• Receive Email Notices or RSS

Advanced Search

Home | About | FAQ | My Account | Accessibility Statement

Privacy Copyright

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Peer-reviewed

Research Article

Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S

* E-mail: [email protected]

Affiliation Department of Plant Biology, The University of Georgia, Athens, Georgia, United States of America

Affiliation Department of Genetics, The University of Georgia, Athens, Georgia, United States of America

• Kathrin F. Stanger-Hall, 
• David W. Hall

• Published: October 14, 2011
• https://doi.org/10.1371/journal.pone.0024658
• Reader Comments

The United States ranks first among developed nations in rates of both teenage pregnancy and sexually transmitted diseases. In an effort to reduce these rates, the U.S. government has funded abstinence-only sex education programs for more than a decade. However, a public controversy remains over whether this investment has been successful and whether these programs should be continued. Using the most recent national data (2005) from all U.S. states with information on sex education laws or policies (N = 48), we show that increasing emphasis on abstinence education is positively correlated with teenage pregnancy and birth rates. This trend remains significant after accounting for socioeconomic status, teen educational attainment, ethnic composition of the teen population, and availability of Medicaid waivers for family planning services in each state. These data show clearly that abstinence-only education as a state policy is ineffective in preventing teenage pregnancy and may actually be contributing to the high teenage pregnancy rates in the U.S. In alignment with the new evidence-based Teen Pregnancy Prevention Initiative and the Precaution Adoption Process Model advocated by the National Institutes of Health, we propose the integration of comprehensive sex and STD education into the biology curriculum in middle and high school science classes and a parallel social studies curriculum that addresses risk-aversion behaviors and planning for the future.

Citation: Stanger-Hall KF, Hall DW (2011) Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S. PLoS ONE 6(10): e24658. https://doi.org/10.1371/journal.pone.0024658

Editor: Virginia J. Vitzthum, Indiana University, United States of America

Received: March 8, 2011; Accepted: August 16, 2011; Published: October 14, 2011

Copyright: © 2011 Stanger-Hall, Hall. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This work was funded by the University of Georgia Research Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The appropriate type of sex education that should be taught in U.S. public schools continues to be a major topic of debate, which is motivated by the high teen pregnancy and birth rates in the U.S., compared to other developed countries [1] – [4] ( Table 1 ). Much of this debate has centered on whether abstinence-only versus comprehensive sex education should be taught in public schools. Some argue that sex education that covers safe sexual practices, such as condom use, sends a mixed message to students and promotes sexual activity. This view has been supported by the US government, which promotes abstinence-only initiatives through the Adolescent Family Life Act (AFLA), Community-Based Abstinence Education (CBAE) and Title V, Section 510 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (welfare reform), among others [5] . Funding for abstinence-only programs in 2006 and 2007 was $176 million annually (before matching state funds) [5] , [6] . The central message of these programs is to delay sexual activity until marriage, and under the federal funding regulations most of these programs cannot include information about contraception or safer-sex practices [5] , [7] .

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0024658.t001

The federal funding for abstinence-only education expired on June 30, 2009, and no funds were allocated for the FY 2010 budget. Instead, a “Labor-Health and Human Services, Education and Other Agencies” appropriations bill including a total of $114 million for a new evidence-based Teen Pregnancy Prevention Initiative for FY 2010 was signed into law in December 2009. This constitutes the first large-scale federal investment dedicated to preventing teen pregnancy through research- and evidence-based efforts. However, despite accumulating evidence that abstinence-only programs are ineffective [6] , [8] , abstinence-only funding (including Title V funding) was restored on September 29, 2009 [8] for 2010 and beyond by including $250 million of mandatory abstinence-only funding over 5 years as part of an amendment to the Senate Finance Committee's health-reform legislation (HR 3590, Amendment #2786, section 2954). This was authorized by the legislature on March 23, 2010 [9] .

With two types of federal funding programs available, legislators of individual states now have the opportunity to decide which type of sex education (and which funding option) to choose for their state, while pursuing the ultimate goal of reducing teen pregnancy rates. This large-scale analysis aims to provide scientific evidence for this decision by evaluating the most recent data on the effectiveness of different sex education programs with regard to preventing teen pregnancy for the U.S. as a whole. We used the most recent teenage pregnancy, abortion and birth data from all U.S. states along with information on each state's prescribed sex education approach to ask “what is the quantitative evidence that abstinence-only education is effective in reducing U.S. teen pregnancy rates?” If abstinence education results in teenagers being abstinent, teenage pregnancy and birth rates should be lower in those states that emphasize abstinence more. Other factors may also influence teenage pregnancy and birth rates, including socio-economic status, education, cultural influences [10] – [12] , and access to contraception through Medicaid waivers [13] – [15] and such effects must be parsed out statistically to examine the relationship between sex education and teen pregnancy and birth rates. It was the goal of this study to evaluate the current sex-education approach in the U.S., and to identify the most effective educational approach to reduce the high U.S. teen pregnancy rates. Based on a national analysis of all available state data, our results clearly show that abstinence-only education does not reduce and likely increases teen pregnancy rates. Comprehensive sex and/or STD education that includes abstinence as a desired behavior was correlated with the lowest teen pregnancy rates across states. In alignment with the Precaution Adoption Process Model advocated by the National Institutes of Health we suggest that comprehensive sex and HIV/STD education should be taught as part of the biology curriculum in middle and high school science classes, along with a social studies curriculum that addresses risk-aversion behaviors and planning for the future.

Materials and Methods

Level of emphasis on abstinence in state laws.

Data on abstinence education were retrieved from the Education Commission of the States [16] . Of the 50 U.S. states, only 38 states had sex education laws (as of 2007; Table 2 ). Thirty of the 38 state laws contained abstinence education provisions, 8 states did not. Following the analysis of the Editorial Projects in Education Research Center [17] , which categorizes the data on abstinence education into four levels (from least to most emphasis on abstinence: no provision, abstinence covered, abstinence promoted, abstinence stressed), we assigned ordinal values from 0 through 3 to each of these four categories respectively. A higher category value indicates more emphasis on abstinence with level 3 stressing abstinence only until marriage as the fundamental teaching standard (similar to the federal definition of abstinence-only education), if sex or HIV/STD education is taught (sex education is not required in most states) [16] – [18] . The primary emphasis of a level 2 provision is to promote abstinence in school-aged teens if sex education or HIV/STD education is taught, but discussion of contraception is not prohibited. Level 1 covers abstinence for school-aged teens as part of a comprehensive sex or HIV/STD education curriculum, which should include medically accurate information on contraception and protection from HIV/STDs [16] – [18] . Level 0 laws on sex education and/or HIV education do not specifically mention abstinence.

https://doi.org/10.1371/journal.pone.0024658.t002

Level of emphasis on abstinence in state laws & policies

States without sex education laws may nevertheless have policies regarding sex and/or HIV/STD education. These policies may be published as Health Education standards or Public Education codes [19] . These policies can also provide information on how existing sex education laws may be interpreted by local school boards. Information on the sex education laws and policies for all 50 US states was retrieved from the website of the Sexuality Information and Education Council of the US (SIECUS). We analyzed the 2005 state profiles on sex education laws and policy data for all 50 states [19] following the criteria of the Editorial Projects in Education Research Center [17] to identify the level of abstinence education ( Table 2 ). The coding for the state laws (N = 38) and the coding for both laws and policies (N = 48) was more or less the same for the states represented in both data sets with 6 exceptions ( Table 2 ): the additional information on policies moved two states from a level 0 (abstinence not mentioned) to level 1 (abstinence covered), and four states from a level 2 abstinence provision (abstinence emphasized) to a level 3 (abstinence stressed). Only two states had neither a state law nor a policy regarding sex or STD/HIV education (as of 2005): North Dakota and Wyoming. Analyses of the two data sets gave essentially identical results. In this paper we present the analyses of the more extensive (48 states) law and policy data set.

Teen pregnancy, abortion and birth data

Data on teen pregnancy, birth and abortion rates were retrieved for the 48 states from the most recent national reports, which cover data through 2005 [11] , [12] . The data are reported as number of teen pregnancies, teen births or teen abortions per one thousand female teens between 15 and 19 years of age. In general, teen pregnancy rates are calculated based on reported teen birth and abortion rates, along with an estimated miscarriage rate [12] . We used these data to determine whether there is a significant correlation between level of prescribed abstinence education and teen pregnancy and birth rates across states. The expectation is that higher levels of abstinence education will be correlated with higher levels of abstinence behavior and thus lower levels of teen pregnancy.

Other factors

Data on four possibly confounding factors were included in our analyses.

Socio-economics.

To account for cost-of-living differences across the US, we used the adjusted median household income for 2006 for each state from the Council for Community and Economic Research: C2ER [20] . These data are based on median household income from the Current Population Survey for 2006 from the U.S. Census Bureau [21] and the 2006 cost of living index (COLI).

Educational attainment.

As an estimate of statewide education levels among teens, we used the percentage of high school graduates that took the SAT in 2005/2006 in each state [22] .

Ethnic composition.

We determined the proportion of the three major ethnic groups (white, black, Hispanic) in the teen population (15–19 years old) for each state [12] , and assessed whether the teen pregnancy, abortion and birth rates across states were correlated with the ethnic composition of the teen population. To account for the ethnic diversity among the teen populations in the different states in a multivariate analysis of teen pregnancy and birth rates, we included only the proportion of white and black teens in the state populations as covariates, because the Hispanic teen population numbers were not normally distributed (see below).

Medicaid waivers for family planning.

Medicaid-funded access to contraceptives and family planning services has been shown to decrease the incidence of unplanned pregnancies, especially among low-income women and teens [13] . According to the Guttmacher Institute, the national family planning program prevents 1.94 million unintended pregnancies, including almost 400,000 teen pregnancies each year by providing millions of young and low-income women access to voluntary contraceptive services [13] , Medicaid covered 71% of expenditures for these programs in 2006, and it is estimated that states saved $4 (associated with unintended births) for each $1 spend on contraceptive services [13] . Since the increasing role of Medicaid in funding family planning was mainly due to the efforts of 21 states to expand eligibility for family planning for low-income women who otherwise would not qualify for Medicaid, we analyzed whether these Medicaid waivers for family planning services (available in some states but not in others) could bias our results. We determined which states had received permission (as of 2005) from the Federal Medicaid program to extend Medicaid eligibility for family planning services to large numbers of individuals whose incomes are above the state-set levels for Medicaid enrollment [15] . We assessed whether the waivers (access to family planning services) had an effect on our analysis of teen pregnancy and birth rates across states, specifically whether they could bias our analysis with respect to the effects of the different levels of abstinence education.

Statistical Analyses

Sample statistics..

Using JMP 8 software [23] , we tested all variables for normality (Goodness of Fit: Shapiro Wilkes Test; JMP 8.0). Except for teen abortion rates and Hispanic teen population data, all variables were normally distributed. The distribution of the Hispanic teen population across states was not normal: most states had relatively small Hispanic teen populations, and a few states had a relatively large population of Hispanic teens. Teen pregnancy and birth rate distributions included outliers, but these outliers did not cause the distributions within abstinence education levels to differ significantly from normal, thus all outliers were included in subsequent analyses. For all further statistical analyses we used SPSS [24] .

Correlations.

We used non-parametric (Spearman) correlations to assess relationships between variables, and for normally distributed variables we also used parametric (Pearson) correlations, but these results showed the same trends and significance levels as the non-parametric correlations. As a result, we only report the results for the non-parametric correlations here.

Multivariate analyses.

Only the two normally distributed dependent variables were included in the multivariate analysis (MANOVA and MANCOVA [24] ): teen pregnancy and teen birth rates. We tested for homogeneity of error variances (Levene's Test) and for equality of covariance matrices (Box test) between groups. For MANCOVA we report the estimated marginal means of teen pregnancy and birth rates (i.e. means after the influence of covariates was removed). For pairwise comparison between abstinence levels, we used the Bonferroni adjustment for multiple comparisons.

Among the 48 states in this analysis (all U.S. states except North Dakota and Wyoming), 21 states stressed abstinence-only education in their 2005 state laws and/or policies (level 3), 7 states emphasized abstinence education (level 2), 11 states covered abstinence in the context of comprehensive sex education (level 1), and 9 states did not mention abstinence (level 0) in their state laws or policies ( Figure 1 ). In 2005, level 0 states had an average (± standard error) teen pregnancy rate of 58.78 (±4.96), level 1 states averaged 56.36 (±3.94), level 2 states averaged 61.86 (±3.93), and level 3 states averaged 73.24 (±2.58) teen pregnancies per 1000 girls aged 14–19 ( Table 3 ). The level of abstinence education (no provision, covered, promoted, stressed) was positively correlated with both teen pregnancy (Spearman's rho  = 0.510, p = 0.001) and teen birth ( rho  = 0.605, p<0.001) rates ( Table 4 ), indicating that abstinence education in the U.S. does not cause abstinence behavior. To the contrary, teens in states that prescribe more abstinence education are actually more likely to become pregnant ( Figure 2 ). Abortion rates were not correlated with abstinence education level ( rho  = −0.136, p = 0.415). A multivariate analysis of teen pregnancy and birth rates identified the level of abstinence education as a significant influence on teen pregnancy and birth rates across states (pregnancies F = 5.620, p = 0.002; births F = 11.814, p<0.001). The significant pregnancy effect was caused by significantly lower pregnancy rates in level 0 (no abstinence provision) states compared to level 3 (abstinence stressed) states (p = 0.036), and level 1 (abstinence covered) states compared to level 3 states (p = 0.005); the significant birth effect was caused by significantly lower teen birth rates in level 0 states compared to level 3 (p = 0.006) states, and significantly lower teen birth rates in level 1 states compared to level 3 states (p<0.001).

All 48 states with state laws or policies on sex and/or HIV education are shown (North Dakota and Wyoming are not represented).

https://doi.org/10.1371/journal.pone.0024658.g001

[Rates = numbers per 1000 girls 15–19 years old: shown are means ±2 SE]. Top panel: Teen pregnancies [outliers: #28 Nevada and #29 New Hampshire]; Middle panel: Teen abortions [outlier: #32 New York]; Bottom panel: Teen births. All outliers were included in the statistical analyses. A multivariate analysis of teen pregnancy and birth rates identified the level of abstinence education as a significant influence on teen pregnancy and birth rates across states.

https://doi.org/10.1371/journal.pone.0024658.g002

https://doi.org/10.1371/journal.pone.0024658.t003

https://doi.org/10.1371/journal.pone.0024658.t004

Socio-economic status, educational attainment, and ethnic differences across states exhibited significant correlations with some variables in our model ( Table 4 ). We examined the influence of each possible confounding factor on our analysis by including them as covariates in several multivariate analyses. However, after accounting for the effects of these covariates, the effect of abstinence education on teenage pregnancy and birth rates remained significant ( Figure 3 ).

(A) The adjusted median household income significantly influenced teen pregnancy and birth rates, but the level of abstinence education still had a significant influence on teen pregnancy and birth rates after accounting for socioeconomic status. (B) Education had a significant influence on teen birth, but not on teen pregnancy rates. After accounting for the influence of teen education, the level of abstinence education still had a significant influence on both teen pregnancy and teen birth rates. (C) The proportion of white teens (but not black teens) in the population had a significant influence on teen pregnancy and teen birth rates. After accounting for this influence, the level of abstinence education still had a significant influence on teen pregnancy and birth rates.

https://doi.org/10.1371/journal.pone.0024658.g003

Socio-economic status

There was a significant negative correlation between median household income (adjusted for cost of living) and level of abstinence education ( rho  = −0.349, p = 0.015; Table 4 ), indicating a socio-economic bias at the state level on state laws and regulations with regard to sex education. The adjusted median household income was negatively correlated with teen pregnancy ( rho  = −0.383, p = 0.007) and birth ( rho  = −0.296, p = 0.041) rates across states: pregnancy and birth rates tended to be higher in lower-income states. There was no correlation between household income and abortion rates ( rho  = −0.116, p = 0.432). When including the adjusted median household income as a covariate in a multivariate analysis (evaluated at $45,892), income significantly influenced teen pregnancy (F = 5.427, p = 0.025) but not birth (F = 2.216, p = 0.144) rates. After accounting for socioeconomic status, the level of abstinence education still had a significant effect on teen pregnancy (F = 4.103, p = 0.012) and birth rates (F = 10.480, p<0.001).

Educational attainment

There was no significant correlation between statewide teen education (percentage of high school graduates that took the SAT in 2005/2006) and level of abstinence education ( rho  = −0.156, p = 0.291). Education was not correlated with teen pregnancy rates ( rho  = −0.014, p = 0.925), but it was positively correlated with teen abortion rates ( rho  = 0.662, p<0.001), and as a consequence, negatively correlated with teen birth rates ( rho  = −0.412, p = 0.004). There was no correlation between socio-economic status and teen educational attainment across states ( rho  = −0.048, p = 0.748), suggesting that these trends apply to both rich and poor states. When including education (% graduates taking the SAT) as a covariate in a multivariate analysis, education had a significant influence on teen birth (F = 8.308, p = 0.006), but not on teen pregnancy (F = 0.161, p = 0.690) rates, and after accounting for the influence of teen education (evaluated at 39.7% of graduates taking the SAT), the level of abstinence education still had a significant effect on both teen pregnancy (F = 5.527, p = 0.003) and teen birth rates (F = 10.772, p<0.001).

Ethnic composition

For this analysis we focused on the three largest ethnic groups for which data are available: white, black, and Hispanic [12] . Teen pregnancy rates differ across these three ethnic groups. For the 48 states in this analysis, an ethnic breakdown (for all three ethnic groups) of teen pregnancy and abortion rates was available for 26 states, and of teen birth rates for 43 states. Across this reduced sample of states, 2005 teen pregnancy rates averaged 48.1 (±1.95) pregnancies per 1000 white teens, 103.7 (±5.38) pregnancies per 1000 black teens, and 141.6 (±8.55) pregnancies per 1000 Hispanic teens. Teen birth rates averaged 27.6 (±1.5) births per 1000 white teens, 59.2 (±2.58) births per 1000 black teens, and 96.1 (±5.39) births per 1000 Hispanic teens. Abstinence education levels were positively correlated with teen birth rates in all three ethnic groups (white: rho  = 0.439, p = 0.002; black: rho  = 0.328, p = 0.028; Hispanic: rho  = 0.461, p = 0.001; Table 5 ).

https://doi.org/10.1371/journal.pone.0024658.t005

Across all 48 states, abstinence education levels were significantly correlated with the proportions of white and black teens in the state populations ( Table 4 ). In general, states with higher proportions of white teens tended to emphasize abstinence less ( rho  = −0.382, p = 0.007), and states with higher proportions of black teens tended to emphasize abstinence more ( rho  = 0.419, p = 0.003). When we included the proportion of white and black teens in the state populations as covariates in a multivariate analysis (evaluated at proportion white: 0.704 and proportion black: 0.138), only the proportion of white teens had a significant effect on teen pregnancy (F = 42.206, p<0.001) and teen birth rates (F = 5.894, p = 0.020). After accounting for this influence, the level of abstinence education still had a significant effect on teen pregnancy (F = 2.839, p = 0.049) and teen birth rates (N = 43 states: F = 7.782, p<0.001; Figure 3 ).

Medicaid waivers

If Medicaid waivers contribute to the positive correlation between abstinence education and teen pregnancy at the state level, then states with waivers should have different teen pregnancy and birth rates than states without waivers. This was not the case. States with waivers (N = 17) were represented across all four abstinence education levels ( Figure 4 ) and did not differ significantly in teen pregnancy rates from states without waivers (N = 21, Mann Whitney U = 237, p = 0.086), suggesting no significant effect of waivers (at the state level) on the correlation between abstinence levels and teen pregnancy rates. A recent study [14] found the same level of (non-)significance (0.05<p<0.1) for the effect of waivers on teen birth rates, but reported it as significant.

Access to waivers does not explain the difference in teen pregnancy rates (shown are means and ±2 SE) in states with a different emphasis on abstinence.

https://doi.org/10.1371/journal.pone.0024658.g004

This study used a correlational approach to assess whether abstinence-only education is effective in reducing U.S. teen pregnancy rates. Correlation can be due to causation, but it can also be due to other underlying factors, which need to be examined. Several factors besides abstinence education are correlated with teen pregnancy rates. In agreement with previous studies, our analysis showed that adjusted median household income and proportion of white teens in the teen population both had a significant influence on teen pregnancy rates. Richer states tend to have a higher proportion of white teens in their teen populations, tend to emphasize abstinence less, and tend to have lower teen pregnancy and birth rates than poorer states. A recent study [25] found that higher teen birth rates in poorer states were also correlated with a higher degree of religiosity (and a lower abortion rate) at the state level. Medicaid waivers have previously been shown to reduce teen pregnancy rates [13] , but our analysis shows that they do not explain our main result, the positive correlation between abstinence education level and teen pregnancy rates.

After accounting for other factors, the national data show that the incidence of teenage pregnancies and births remain positively correlated with the degree of abstinence education across states: The more strongly abstinence is emphasized in state laws and policies, the higher the average teenage pregnancy and birth rate. States that taught comprehensive sex and/or HIV education and covered abstinence along with contraception and condom use (level 1 sex education; also referred to as “abstinence-plus” [26] , tended to have the lowest teen pregnancy rates, while states with abstinence-only sex education laws that stress abstinence until marriage (level 3) were significantly less successful in preventing teen pregnancies. Level 0 states present an interesting sample with a wide range of education policies and variable teen pregnancy and birth data [17] – [19] . For example, several of the level 0 states (as of 2007) did not mandate sex education, but required HIV education only (e.g. CT, WV) [19] . Only three of the level 0 states (IA, NH and NV) mandated both sex education and HIV education, but one of them (NV) did not require that teens learn about condoms and contraception. This state (NV) has the highest teen pregnancy and birth rates in that group ( Figure 1 ). Nevada is also one of only five states (with MD in level 0, CO in level 2, and AZ and UT in level 3) that required parental consent for sex education in public schools instead of an opt-out requirement that is present in all the other states [16] , [19] .

The effectiveness of Level 1 (comprehensive) sex education in our nation-wide analysis is supported by Kirby's meta-analysis of individual sex education programs [8] , Underwood et al. 's analysis of HIV prevention programs [27] , and a recent review by the CDC taskforce on community preventive services [28] . All these studies suggest that comprehensive sex or HIV education that includes the discussion of abstinence as a recommended behavior, and also discusses contraception and protection methods, works best in reducing teen pregnancy and sexually transmitted diseases.

Individual research studies

Despite large differences between individual research studies that evaluate specific sex education programs (e.g. sample size, approaches to sex education studied, selection of participants, choice of control groups, types of data, control for cross-talk between students outside of class, etc.), several case studies show that abstinence-only education rarely has a positive effect on teen sexual behavior [6] , [8] , [29] . One of the few exceptions is the recent study by Jemmott et al. [30] on black middle school students in low-income urban schools: after receiving 8 hours of abstinence education as 12 year olds, significantly more students (64/95) reported to be abstinent after 24 months when compared to (control) students who received 8 hours of health education (without any form of sex education: 47/88; Fishers exact test, p = 0.037), or students who received 8 hours of safe-sex education (without an abstinence component: 41/85, Fishers exact test, p = 0.007). However, there was no significant difference in abstinence behavior between students who had received abstinence education (64/95) and students who received 8 hours of comprehensive sex education (combining sex education with abstinence education: 57/97; Fishers exact test, p = 0.138). These two groups also did not differ in rates of reported unprotected sex (8/122 versus 8/115) or use of condoms (25/33 versus 29/37) in the previous 3 months. The abstinence-only intervention in that study was unique in that it increased knowledge about HIV/STD, emphasized the delay of sexual activity, but not necessarily until marriage, did not put sex into a negative light or use a moralistic tone, included no inaccurate information, corrected incorrect views, and did not disparage the use of condoms [30] . As a result, as pointed out by the authors, this successful version of abstinence education would not have met the criteria for federal abstinence-only funding [30] . While promoting an alternative and more effective form of abstinence education, these results also support Kirby's findings [8] and the data in the present study that comprehensive sex education that includes an abstinence (delay) component (level 1), is the most effective form of sex education, especially when using teen pregnancy rates as a measurable outcome.

Individual research studies also show that teaching about contraception is generally not associated with increased risk of adolescent sexual activity or sexually transmitted diseases (STDs) [8] as suggested by abstinence-only advocates, and adolescents who received comprehensive sex or HIV education had a lower risk of pregnancy and HIV/STD infection than adolescents who received strict abstinence-only or no sex education at all in the U.S. and in other high-income countries [27] , [31] .

Abstinence-only education: public opinion and associated costs

Despite the data showing that abstinence-only education is ineffective, it may be argued that the prescribed form of sex education represents the underlying social values of families and communities in each state, and changing to a more comprehensive sex education curriculum will meet with strong opposition. However, there is strong public support for comprehensive sex education [32] . Approximately 82% of a randomly selected nationally representative sample of U.S. adults aged 18 to 83 years (N = 1096) supported comprehensive programs that teach students about both abstinence and other methods of preventing pregnancy and sexually transmitted diseases. In contrast, abstinence-only education programs, received the lowest levels of support (36%) and the highest level of opposition (about 50%).

In addition to the federal and state funds spent on abstinence-only (level 3) education, there are other costs associated with the outcomes of failed sex education and family planning. When deciding state policies on sex education, State legislators should consider these additional costs. For example, based on estimates by the National Campaign To Prevent Teen and Unplanned Pregnancy [33] , teen child bearing (compared to first birth at 20 years or older) in the U.S. cost taxpayers (in direct and indirect costs) more than $9.1 billion in 2004.

Our data show that education (% of high school graduates taking the SAT) was not correlated with teen pregnancy rates, but it was positively correlated with teen abortion rates and negatively correlated with teen birth rates. These data can be interpreted in two ways: (1) pregnant teens who give birth are less likely to finish high school and go on to college (i.e. pregnancy affects education). This is supported by a recent report [34] that showed that teen mothers are more likely to drop out of school: 51% of teen mothers earned their high school diploma by age 22, compared to 89% of women who had not given birth as teens. (2) teens who are motivated to go to college are not necessarily less likely to get pregnant, but more likely to abort their pregnancies (i.e. educational goal affects the decision of whether to carry a pregnancy to term).

As pointed out by the Society for Adolescent Medicine, the abstinence-only approach (as stressed by level 3 state laws and policies and funded by the federal abstinence-only programs) is characterized by the withholding of information and is ethically flawed [7] . Abstinence-only programs tend to promote abstinence behavior through emotion, such as romantic notions of marriage, moralizing, fear of STDs, and by spreading scientifically incorrect information [7] , [20] , [35] . For example a Congressional committee report found evidence of major errors and distortions of public health information in common abstinence-only curricula [36] . As a result, these programs may actually be promoting irresponsible, high-risk teenage behavior by keeping teens uneducated with regard to reproductive knowledge and sound decision-making instead of giving them the tools to make educated decisions regarding their reproductive health [37] . The effect of presenting inadequate or incorrect information to teenagers regarding sex and pregnancy and STD protection is long-lasting as uneducated teens grow into uneducated adults: almost half of all pregnancies in the U.S. were unplanned in 2001 [38] . Of these three million unplanned pregnancies, ∼1.4 million resulted in live births, ∼1.3 million ended in abortion, and over 400,000 ended in a miscarriage [36] , [37] at a financial cost (direct medical costs only) of ∼$5 billion in 2002 [39] .

The U.S. teen pregnancy rate is substantially higher than seen in other developed countries ( Table 1 ) despite similar cultural and socioeconomic patterns in teen pregnancy rates [40] . The difference is not due to the onset of sexual activity [1] . Instead, the main factor seems to be sex education, especially with regard to contraception and prevention of STDs [41] . Sex education in Europe is based on the WHO definition of sexuality as a lifelong process, aiming to create self-determined and responsible attitudes and behavior with regard to sexuality, contraception, relationships and life strategies and planning [42] . In general, there is greater and easier access to sexual health information and services for all people (including teens) in Europe, which is facilitated by a societal openness and comfort in dealing with sexuality [40] , by pragmatic governmental policies [43] , [44] and less influence by special interest groups.

Future Directions

While states with comprehensive sex education have lower teen pregnancy rates, even in these states rates are much higher than seen in Europe [1] . This is likely influenced by the fact that U.S. state laws and policies generally do not require that sex and STD education is taught in all schools, but only provide guidelines if local school boards decide to teach it [19] . For example, as of August 1, 2011, only 20 states mandated sex education, and 32 states mandated HIV education in their schools [45] . In addition, even states with comprehensive sex education laws or policies (level 1) received federal funding for individual abstinence-only education programs in 2005: total federal funds [19] averaged ∼$14 per teen in level 1 states compared to ∼$21 per teen in level 2 and 3 states [12] . An important first step towards lowering the high teen pregnancy rates would be states requiring that comprehensive sex education (with abstinence as a desired behavior) is taught in all public schools. Another important step would involve specialized teacher training. Presently the sex education and STD/HIV curricula are often taught by faculty with little training in this area [46] . As a further modification, “sex education” could be split into a coordinated social studies component (ethics, behavior and decision-making, including planning for the future) and a science component (human reproductive biology and biology of STDs, including pregnancy and STD prevention), each taught by trained teachers in their respective field.

As parents, educators or policy makers it should be our goals that (1) teens can make educated reproductive and sexual health decisions, that (2) teen pregnancy and STD rates are reduced to the rates of other developed nations, and that (3) these trends are maintained through the teenage years into adulthood. One possibility for achieving these goals is a close alignment and integration of sex education with the National Science Standards for U.S. middle and high schools [47] . In addition, the Precaution Adoption Process Model ( Figure 5 ) advocated by the National Institutes of Health [48] offers a good basis for communication and discussions between scientists, educators, and sex education researchers, and could serve as a reference for measuring progress in sex education (in alignment with the new evidence-based Teen Pregnancy Prevention Initiative). In addition, it could be used as a communication tool between sex education teachers and their students. It should be our specific goal to move American teens from Stages 1 or 2 (unaware or unengaged in the issues of pregnancy and STD prevention) to Stages 3–7 (informed decision-making) by providing them with knowledge, understanding, and sound decision-making skills ( Figure 5 ). For example, a recent study [49] attributes 52% of all unintended pregnancies (teenagers and adults) in the U.S. to non-use of contraception, 43% to inconsistent or incorrect use, and only 5% to method failure.

This model offers a basis for communication and discussions between educators, scientists, sex education researchers, and health professionals, and could serve as a reference for measuring progress in sex education. In addition, it could be used as a communication tool between sex education teachers and their students [48] .

https://doi.org/10.1371/journal.pone.0024658.g005

Our analysis adds to the overwhelming evidence indicating that abstinence-only education does not reduce teen pregnancy rates. Advocates for continued abstinence-only education need to ask themselves: If teens don't learn about human reproduction, including safe sexual health practices to prevent unintended pregnancies and STDs, and how to plan their reproductive adult life in school, then when should they learn it, and from whom?

Acknowledgments

We thank C2ER, the Council for Community and Economic Research, for providing additional adjusted median household income data for those states that were not included in their online data set, and two anonymous reviewers for helpful comments.

Author Contributions

Conceived and designed the experiments: DWH KSH. Performed the experiments: DWH KSH. Analyzed the data: DWH KSH. Wrote the paper: DWH KSH.

• View Article
• Google Scholar
• 2. The National Campaign to prevent teen and unplanned pregnancy. Teen birth rates: International Comparison 2006. Available: www.thenationalcampaign.org//TBR_InternationalComparison2006.pdf . Accessed 2011, Jan 10.
• 3. Canada: Statistics Canada (2005) Pregnancy outcomes by age group. Available: http://www40.statcan.gc.ca/l01/cst01/hlth65a-eng.htm . Accessed 2010, Nov 20.
• 4. UK Department of Education 2011 Under 18 and under 16 conception statistics (2011) Available: http://www.education.gov.uk/childrenandyoungpeople/healthandwellbeing/teenagepregnancy/a0064898/under-18-and-under-16-conception-statistics . Accessed 2011, Aug 3.
• 5. Advocates for Youth (2007) The History of Federal Abstinence-Only Funding. Available: http://www.advocatesforyouth.org/publications/429?task=view . Accessed 2011, Jun 19.
• 6. Trenholm C, Devaney B, Fortson K, Quay L, Wheeler J, et al. (2007) “Impacts of four Title V, Section 510 abstinence education programs” (Mathematica Policy Research). Available: http://aspe.hhs.gov/hsp/abstinence07/ . Accessed 2010, May 8.
• 8. Kirby D (2007) Emerging Answers, Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases (National Campaign to Prevent Teen and Unplanned Pregnancy, Washington, DC). www.thenational campaign.org/EA2007/EA2007_full.pdf . Accessed 2010, Jun 18.
• 9. SIECUS: Senate Finance Committee Votes to Fund Comprehensive Sex Education; Restore Failed Title V Abstinence-Only-Until-Marriage Funding. Available: http://www.siecus.org/index.cfm?fuseaction=Feature.showFeature&featureid=1816&pageid=525&parentid=523 . Accessed 2011, Jan 10.
• 12. Kost K, Henshaw S, Carlin L (2010) U.S. Teenage Pregnancies, Births and Abortions: National and State Trends and Trends by Race and Ethnicity (Guttmacher Institute). Available: http://www.guttmacher.org/pubs/USTPtrends.pdf . Accessed 2010, Jan 30.
• 13. Benson Gold R, Sonfield A, Richards CL, Frost JJ (2009) Next Steps for America's Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System, New York: Guttmacher Institute. Available: www.guttmacher.org/pubs/NextSteps.pdf . Accessed 2011, Jan 10.
• 15. Benson Gold R, Richards CL, Ranji UR, Salganicoff A (2005) Medicaid: A critical source of support for family planning in the United States. Kaiser Family Foundation and Guttmacher Institute. Available: http://www.kff.org/womenshealth/7064.cfm . Accessed 2011, Jan 10.
• 16. Zinth K (2007) Sex education laws in the states. State Note (Education Commission of the States, Denver CO). Available: http://www.ecs.org/html/educationIssues/ECSStateNotes_2007.asp . Accessed 2011, Aug 1.
• 17. Callahan J (2007) Abstinence education in state laws. Editorial Projects in Education Research Center. Available: http://www.edweek.org/rc/articles/2007/06/08/sow0608.h26.html . Accessed 2009, Jan 10.
• 18. Advocates for Youth. Sex Education Resource Center. State profiles. Washington, D.C.: Advocates for Youth. Available: http://www.advocatesforyouth.org/index.php?option=com_content&task=view&id=766&Itemid=123 ). Accessed 2010, Sep 20.
• 19. SIECUS State Profiles Fiscal Year 2005. Available: http://www.siecus.org/index.cfm?fuseaction=page.viewPage&pageID=1061&nodeID=1 . Accessed 2011, Feb 10.
• 20. The Council for Community and Economic Research. ACCRA Cost of living index (COLI). The Council for Community and Economic Research, C2ER. Available: http://www.coli.org/COLIAdjustedMHI.asp . Accessed 2010, May 10.
• 21. Census Bureau US (2006) R1901: Median Household Income for 2006. Available: http://www.census.gov/compendia/statab/2008/ranks/rank33.html . Accessed 2010, May 10.
• 22. National Center of Education Statistics (2007) SAT data. Tables and Figures: Table 137. US Department of Education. Available: http://nces.ed.gov/programs/digest/d07/tables/dt07_137.asp . Accessed 2010, Jun 10.
• 23. JMP Statistical Discovery software, version 8.0. Cary, , NC: SAS Institute Inc..
• 24. SPSS for MacInstosh, version 17.0. Chicago, , IL: SPSS Inc.
• 26. Collins C, Alagiri P, Summers T (2002) “Abstinence Only versus Comprehensive Sex education. What are the arguments? What is the Evidence?” Policy Monograph Series. San Francisco, CA: AIDS Policy Research Center & Center for AIDS Prevention Studies, AIDS Research Institute, UC San Francisco.
• 29. Goodson P, Pruitt BE, Buhi E, Wilson KL, Rasberry CN, et al. (2004) “Abstinence education evaluation phase 5 technical report”. College Station, , TX: Texas A&M University, Department of Health and Kinesiology.
• 33. Hoffmann SD (2006) By the Numbers — The Public Costs of Teen Childbearing. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy. Available: www.thenationalcampaign.org/resources/pdf/pubs/btn_full.pdf . Accessed 2010, May 10.
• 34. Perper K, Peterson K, Manlove J (2010) Diploma Attainment Among Teen Mothers (Child Trends, Publication #2010-01). Available: http://www.childtrends.org/Files/Child_Trends-2010_01_22_FS_DiplomaAttainment.pdf . Accessed 2010, Jun 10.
• 35. Kreinin T, Waggoner J (2001) Towards a sexually healthy America. Washington, D.C.: Advocates for Youth, Sexuality Information and Education Council of the United States. (SIECUS. Available: www.naccho.org/topics/HPDP/infectious/hiv//abstinenceonly.pdf . Accessed 2010, Jan 10.
• 36. US House of Representatives Committee on Government Reform — Minority Staff Special Investigations Division. The Content of Federally Funded Abstinence-Only Education Programs. Available: http://oversight.house.gov/index.php?option=com_content&view=article&id=2487&catid=44:legislation . Accessed 2010, Nov 1.
• 37. Kaye K, Suellentrop K, Sloup C (2009) The Fog Zone: How Misperceptions, Magical Thinking, and Ambivalence Put Young Adults at Risk for Unplanned Pregnancy. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy. Available: www.thenationalcampaign.org/fogzone/pdf/fogzone.pdf . Accessed 2010, Jun 10.
• 42. Advocates for Youth (2009) Adolescent Sexual Health in Europe and the U.S.— Why the Difference? 3rd edition: Sue Alford and Debra Hauser. Available: www.advocatesforyouth.org/storage/advfy/documents/fsest.pdf . Accessed 2011, Jan 30.
• 43. Bundeszentrale fuer gesundheitliche Aufklaerung (BZgA) (2006) BZgA/WHO Conference on Youth Sex Education in a Multicultural Europe, Cologne, Germany, 2006. Available: http://www.sexualaufklaerung.de/index.php?docid=1111 . Accessed 2010, Jun 10.
• 44. Bundeszentrale fuer gesundheitliche Aufklaerung (BZgA) (2006) Country papers on youth sex education in Europe. BZgA/WHO Conference, Cologne, Germany, 2006. Available: http://www.sexualaufklaerung.de/index.php?docid=1039 . Accessed 2010, Jun 10.
• 45. Guttmacher Institute (2011) State Policies in Brief: Sex and STI/HIV Education. Available: www.guttmacher.org/pubs/spib_SE.pdf . Accessed 2011, Aug 3.
• 47. National Research Council (1996) “National Science Education Standards” (National Academy Press, Washington, DC). Available: http://www.nap.edu/openbook.php?record_id=4962 . Accessed 2010, Oct 8.
• 48. National Institutes of Health (2005) Theory at a Glance, Application to Health Promotion and Health Behavior (Second Edition). U.S. Department of Health and Human Services, National Institutes of Health. Available: Available: http://www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf . Accessed 2009, Jan 10.
• 49. Frost JJ, Darroch E, Remez L (2008) Improving contraceptive use in the United States New York: Guttmacher Institute, No. 1. Available: www.guttmacher.org/pubs/2008/05//ImprovingContraceptiveUse.pdf . Accessed 2010, Oct 1.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.81(4); November, 2014

Abstinence education *

The American College of Pediatricians strongly endorses abstinence-until-marriage sex education and recommends adoption by all school systems in lieu of “comprehensive sex education.” This position is based on “the public health principle of primary prevention—risk avoidance in lieu of risk reduction,” upholding the “human right to the highest attainable standard of health” ( Freedman 1995 ).

By every measure, adolescent sexual activity is detrimental to the well-being of all involved, especially young women, and society at large. Children and adolescents from 10 to 19 years of age are more at risk for contracting a sexually transmitted infection (STI) than adults ( Centers for Disease Control and Prevention (CDC) 2007 ). This is due to the general practice of having multiple and higher risk sexual partners, and to the immaturity of the cervical tissue of girls and young women. The CDC recently stated that of the 19 million new cases of STIs annually reported in the United States, 50 percent occur in teens and young adults under 25 years of age ( CDC 2007 ). Twenty-five percent of newly diagnosed cases of HIV occur in those under 22 years of age ( Sulak and Herbelin 2005 , 30). This translates into one in four sexually active female adolescents being infected with at least one STI ( Department of Health and Human Services (HHS) 2008 ).

Bacterial STIs may cause life-threatening cases of pelvic inflammatory disease and infertility. Viral STIs which include herpes, the human papilloma virus (HPV), and HIV are generally incurable. Herpes afflicts its victims with life-long painful recurrences, may be passed on to sexual partners even when asymptomatic, and may be life threatening to infants if passed on at birth during vaginal delivery. HPV is found among 90 percent of sexually active young adults and teens ( Sulak and Herbelin 2005 , 31). While often self-limited, HPV has high-risk strains that may persist for life and cause cancer of the cervix. HIV not only causes premature demise, but also significant suffering with life-long dependence on multiple toxic and costly medications. The CDC estimates that STIs cost the U.S. Health Care System as much as $15.3 billion dollars annually ( CDC 2009 ).

Adolescent pregnancy is similarly associated with adverse socioeconomics that have an impact on the family, community, and society at large. One in thirteen high school girls becomes pregnant each year ( Sulak and Herbelin 2005 , 31). Adolescent pregnancy results in decreased educational and vocational opportunities for the mothers, an increased likelihood of the family living in poverty, and significant risk for negative long-term outcomes for the children. For example, children of adolescent mothers are more likely to be born prematurely and at a low birth weight; suffer from poor health; perform poorly in school; run away from home; be abused or neglected; and grow up without a father ( Guttmacher Institute 2006 ).

Even if sexually active teens escape acquiring STIs and becoming pregnant, few remain emotionally unscathed. Overall, one in eight teens suffers from depression ( Meeker 2007 , 68), and suicide has risen to become the third leading cause of death for adolescents, paralleling the rise in STIs within this population ( Meeker 2007 , 68). Infection with an STI has long been recognized as a cause for depression among teens. More recently, however, adolescent sexual activity alone has been acknowledged as an independent risk factor for developing low self-esteem, major depression, and attempting suicide ( Hallfors et al. 2004 ). In studies that controlled for confounding factors, sexually active girls were found to be three times as likely to report being depressed and three times as likely to have attempted suicide when compared with sexually abstinent girls ( McIlhaney and Bush 2008 , 78). Sexually active boys were more than twice as likely to suffer from depression and seven times as likely to have attempted suicide when compared with sexually abstinent boys ( McIlhaney and Bush 2008 , 78). This is not mere coincidence. Scientists now know that sexual activity releases chemicals in the brain that create emotional bonds between partners. Breaking these bonds can cause depression, and make it harder to bond with someone else in the future ( McIlhaney and Bush 2008 , 77–78).

Sexual activity is defined as genital contact. This includes mutual masturbation, as well as oral, vaginal, and anal intercourse. While only vaginal intercourse may result in pregnancy, all of these practices may spread STIs, and lead to emotional trauma. Abstaining from all sexual activity is the only 100 percent safe and effective way to avoid teen pregnancies, STIs, and the emotional fallout of adolescent sexual activity. Almost 40 years of emphasis on “safer sex” with “values-neutral sex education,” condoms and contraception has clearly failed our young people. Abstinence education does not occur in a vacuum, making it especially difficult to separate its influence from the opposing influence of the media and cultural milieu. Nevertheless, effectiveness of abstinence sex education in delaying the onset of sexual debut has been demonstrated in rigorous scientific studies. For example, five out of seven programs recently reviewed showed a significant reduction in sexual initiation rates (two programs showed rates decreased by half) ( Weed 2008 ). Evaluation of community-based abstinence programs in peer-reviewed journals showed that they are effective in significantly reducing pregnancy. According to an April 2008 report by the Heritage Foundation “fifteen studies examined abstinence programs and eleven reported positive findings of delayed sexual initiation” ( Kim and Rector 2008 ). Reviews by the Institute for Research and Evaluation state that “several well designed evaluations of abstinence programs have found significant long- term reductions in adolescent sexual activity” ( Institute for Research and Evaluation 2007 ). These do not begin to thoroughly evaluate the hundreds of ongoing programs.

In its endorsement of abstinence-based sex education, the College calls attention to the scientific controversies surrounding alternative educational platforms. Most sex education curricula fall into two categories, abstinence-until-marriage or comprehensive sex education programs (occasionally also referred to as “abstinence plus” programs). Recently, abstinence education has been criticized for not providing critical health information about condom use. Abstinence education curricula, however, do not discourage the use of condoms; rather they note that chastity obviates the need for condoms. Abstinence education programs do not claim that condoms have no place in preventing STIs. Comprehensive programs, on the other hand, are misleading in the emphasis they place on condom use. These programs give teens the impression that condoms make sexual activity safe. In reality, there has been much conflicting medical literature on the effectiveness of condoms in preventing STIs since the 2000 NIH (National Institutes of Health) report on the subject and much of the controversy remains unresolved ( National Institute of Allergy and Infectious Diseases, NIH, HHS 2000 ). Teens must be informed that condoms do not offer complete protection from either pregnancy or STIs.

The College position supporting abstinence-until-marriage education, unlike alternative education platforms, also recognizes the unique neurobiology of adolescent brains. The frontal cortex of the adolescent brain is still in development and unable to make the consistently wise executive decisions necessary to control action based on emotional input. Researcher Jay Giedd and others have found that young people do not have the physical brain capacity to make fully mature decisions until their mid-twenties ( Strauch 2003 , 16).

Consequently, when it comes to sex education, adolescents need to be given clear direction repeatedly, as is done with programs that address smoking, drugs, and alcohol use. Emphasis on contraceptive methods undermines the authority of parents and the strength of the abstinence message. This approach reinforces the ubiquitous (yet erroneous) message presented by the media that engaging in sexual activity is not only expected of teens, but also the norm. Adolescent brains are not equipped to handle these mixed messages. Parents and teachers need to “function as a surrogate set of frontal lobes, an auxiliary problem solver” for their teens, setting firm and immutable expectations ( Medical Institute for Sexual Health 2005 ). Adolescents need repetitive, clear, and consistent guidance.

As families address this issue of sex education, the American College of Pediatricians recommends that parents be fully aware of the content of the curriculum to which their children are being exposed. The national “Guidelines for Comprehensive Sex Education” that were drafted by the Sexuality Information and Education Council of the United States (SIECUS) place strong emphasis on “values neutral” sex education beginning in kindergarten . According to these guidelines, children between the ages of 5 to 8 years should be taught not only the anatomically correct names of all body parts, but also the definitions of sexual intercourse, and masturbation ( SIECUS 2004 ).

Overall, these comprehensive programs only emphasize “safer sex.” Many comprehensive programs also provide sexually erotic material to teens with explicit condom demonstrations. Other programs suggest alternative types of sexually stimulating contact (referred to as “outercourse”) that would not result in pregnancy but still could result in STIs. Some of these activities, depending on the ages of those involved and the state in which they occur, could actually be illegal. These education programs can break down the natural barriers of those not yet involved in sexual activity and encourage experimentation. Additionally, many programs emphasize that teens do not need parental consent to obtain birth control and that teens therefore need not even discuss the issue with them ( HHS 2007 , 6–7).

Discouraging parental involvement eliminates one of the most powerful deterrents to sexual activity, namely, communication of parental expectations ( McNeely et al. 2002 ; Sieving et al. 2000 ). Firm statements from parents that sex should be reserved for marriage have been found to be very effective in delaying sexual debut. Parental example and “religiosity” have also been found to be similarly protective. Adolescents reared by parents who live according to their professed faith ( Manlove et al. 2006 ) and are actively involved in their worship community ( Sinha, Cnaan, and Gelles 2007 ), are more likely to abstain from sexual activity as teens. Successful sex education programs involve parents and promote open discussion between parents and their children.

The American College of Pediatricians also believes parents should be aware of the current state of funding, and government involvement in sex education choices. Comprehensive programs receive seven to twelve times the funding of abstinence programs ( Pardue, Rector, and Martin 2004 , 8). However, according to a recent study by the HHS, comprehensive programs do not give equal time to abstinence ( HHS 2007 , 6).

In 2004 Congressman Henry Waxman of California presented a report before Congress critical of the medical accuracy of abstinence education curricula ( Waxman 2004 ). The Mathematica Study was similarly critical of the medical accuracy of abstinence education programs ( Institute for Research and Evaluation 2007 ). However, in 2007 the HHS conducted an extensive review of nine comprehensive sex education curricula using the same methods employed by Congressman Waxman and the Mathematica Study. These comprehensive programs were found to have no better record for medical accuracy. The HHS review also found that the comprehensive programs were hardly comprehensive. The amount of discussion dedicated to “safer sex” exceeded that spent on abstinence by a factor of up to seven. Some of the programs failed to mention abstinence altogether. None of the programs carefully distinguished between reducing and eliminating the risks of sexual activity, and nearly every program failed to mention the emotional consequences of early sexual activity. Although some of the comprehensive programs showed a small effect in reducing “unprotected” sex (seven of nine programs) and to a lesser extent in delaying sexual debut (two of eight programs), the impact did not extend beyond six months ( HHS 2007 , 8).

According to a 2004 Zogby Poll, 90 percent of adults and teens agree with the American College of Pediatricians position that teens should be given a strong abstinence message ( With One Voice 2004 ). Programs that teach sexual abstinence until marriage are about much more than simply delaying sexual activity. They assist adolescents in establishing positive character traits, formulating long-term goals, and developing emotionally healthy relationships. These programs increase the likelihood of strong marriages and families—the single most essential resource for the strength and survival of our nation.

Acknowledgements

The American College of Pediatricians is a national organization of pediatricians and other healthcare professionals dedicated to the health and well-being of children. Formed in 2002, the College is committed to fulfilling its mission by producing sound policy, based upon the best available research, to assist parents and to influence society in the endeavor of child-rearing. Membership is open to qualifying healthcare professionals who share the College's Mission, Vision and Values. The home office is in Gainesville, Florida, the website is http://www.acpeds.org and the office telephone number is 888-376-1877.

For over 35 years Alean Zeiler, MD has practiced pediatrics at St. Vincent Mercy Medical Center in Toledo, Ohio. She graduated from the Medical College of Ohio (now University of Toledo Medical College) in 1974. She is on the clinical faculty there and at Ohio University teaching medical students and residents in a busy urban practice. For many years she was Medical Director of Positive Choices, an abstinence until marriage (now called sexual risk avoidance) program which served many schools and community programs in the area. She provides medical services at a local high school in a program called Access to Health. She also enjoys being involved in medical mission projects in the Dominican Republic. She has been married for 35 years and has 3 adult children and 2 granddaughters.

• Centers for Disease Control and Prevention (CDC). 2007. Trends in reportable sexually transmitted diseases in the United States . Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, January 2009. http://www.cdc.gov/std/stats07/trends.htm . [ Google Scholar ]
• Centers for Disease Control (CDC). 2009. Annual CDC Report Finds High Burden of Sexually Transmitted Diseases, Especially among Women and Racial Minorities. CDC Press Release on January 13, 2009. http://www.cdc.gov/nchhstp/Newsroom/PressRelease011309.html .
• Department of Health and Human Services. 2007. Comprehensive Sex Education Curricula Report. http://www.abstinence.net/pdf/contentmgmt/Review_of_Comprehensive_Sex_Education_Curricula-2.pdf. [ PubMed ]
• Department of Health and Human Services (Dept. HHS). 2008. Oral Abstract D4a – Prevalence of sexually transmitted infections and bacterial vaginosis among female adolescents in the United States: Data from the National Health and Nutritional Examination Survey (NHANES) 2003–2004 . Presented at the 2008 National STD Prevention Conference, March 11, 2008 http://www.cdc.gov/stdconference/2008/media/summaries-11march2008.htm#tues1 . [ Google Scholar ]
• Freedman L.P.1995. Censorship and manipulation of reproductive health information . In The right to know: Human right access to reproductive health information , ed. Coliver S., 1–37 Philadelphia, PA: University of Pennsylvania Press; Quoted by in Hendricks, K. et al. 2006. The attack on abstinence education: fact or fallacy? Medical Institute for Sexual Health. [ Google Scholar ]
• Guttmacher Institute. 2006. U.S. pregnancy statistics . New York. Quoted in ‘Abstinence’ or ‘Comprehensive’ sex education? Salt Lake City, Utah: The Institute for Research and Evaluation, 2007. [ Google Scholar ]
• Hallfors D.D., Waller M.W., Ford C.A., Halpern C.T., Brodish P.H., and Iritani B.. 2004. Adolescent depression and suicide risk: Association with sex and drug behavior . American Journal of Preventative Medicine 27 : 224–30. [ PubMed ] [ Google Scholar ]
• Institute for Research and Evaluation. 2007. ‘Abstinence’ or ‘Comprehensive’ sex education? Salt Lake City, Utah: The Institute for Research and Evaluation. [ Google Scholar ]
• Kim C., and Rector R.. 2008. Abstinence education: assessing the evidence . Backgrounder 2126 Washington, DC: The Heritage Foundation. [ Google Scholar ]
• Manlove J.S., Terry-Humen E., Ikramullah E.N., and Moore K.A.. 2006. The role of parent religiosity in teens’ transitions to sex and contraception . Journal of Adolescent Health 39 : 578–87. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• McIlhaney J., and Bush F. M.. 2008. Hooked: New science on how casual sex is affecting our children . Chicago: Northfield Publishing. [ Google Scholar ]
• McNeely C.A., Shew M., Beuhring T., Sieving R., Miller B., and Blum R.W.. 2002. Mothers' influence on adolescents' sexual debut . Journal of Adolescent Health 31 : 256–65. [ PubMed ] [ Google Scholar ]
• Medical Institute for Sexual Health. 2005. Integrated Sexual Health Today: Maturation of the Teen Brain. http://WWW.MEDinstitute.org/includes/downloads/ishspring2005.pdf .
• Meeker M.2007. Your kids at risk . Washington, DC: Regnery Publishing, Inc. [ Google Scholar ]
• National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services. 2000. Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention Herndon, Virginia: National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services. [ Google Scholar ]
• Pardue M., Rector R., and Martin S.. 2004. Abstinence and its critics . Washington, DC: The Heritage Foundation. [ Google Scholar ]
• Sieving R.E., McNeely C.A., and Blum R.W.. 2000. Maternal expectations, mother child connection, and adolescent sexual debut . Archives of Pediatric and Adolescent Medicine 154 : 809–16. [ PubMed ] [ Google Scholar ]
• SIECUS. 2004. Guidelines for comprehensive sexuality education. New York, NY and Washington, DC: Sexuality Information and Education Council of the United States.
• Sinha J.W., Cnaan R.A., and Gelles R.J.. 2007. Adolescent risk behaviors and religion: Findings from a national study . Journal of Adolescent Health 30 (2) : 231–49. [ PubMed ] [ Google Scholar ]
• Strauch B.2003. The primal teen: What the new discoveries about the teenage brain tell us about our kids . New York, NY: Doubleday. [ Google Scholar ]
• Sulak P.J., and Herbelin S.. 2005. Teenagers and sex: Delaying sexual debut . The Female Patient 30 : 29–38. [ Google Scholar ]
• Waxman H.A.2004The Content of Federally Funded Abstinence-Only Education Programs. December 2004. United States House of Representatives Committee on Government Reform: Minority Staff Special Investigations Division.
• Weed S.E.2008. Testimony Before the US House of Representatives Committee on Oversight and Government Reform. April 23, 2008. Washington, DC: US Government Printing Office.
• With One Voice. 2004. National campaign to prevent teen pregnancy . Quoted in Abstinence and Its Critics . October 2006 Washington, DC: US House of Representatives Committee on Government Reform. [ Google Scholar ]