Correspondence to: Mary A. Ott, MD Assistant Professor of Pediatrics Section of Adolescent Medicine Department of Pediatrics Indiana University School of Medicine 410 West 10th Street, HS1001, IN 46202, USA Tel: +317 274 0133 ude.ui@ttoam
The publisher's final edited version of this article is available at Curr Opin Obstet GynecolTo review recent literature on medical accuracy, program effectiveness, and ethical concerns related to abstinence-only policies for adolescent sexuality education.
The federal government invests over 175 million dollars annually in ‘abstinence-only-until-marriage’ programs. These programs are required to withhold information on contraception and condom use, except for information on failure rates. Abstinence-only curricula have been found to contain scientifically inaccurate information, distorting data on topics such as condom efficacy, and promote gender stereotypes. An independent evaluation of the federal program, several systematic reviews, and cohort data from population-based surveys find little evidence of efficacy and evidence of possible harm. In contrast, comprehensive sexuality education programs have been found to help teens delay initiation of intercourse and reduce sexual risk behaviors. Abstinence-only polices violate the human rights of adolescents because they withhold potentially life-saving information on HIV and other STIs.
Federal support of abstinence-only as an approach to adolescent sexuality education is of much concern due to medical inaccuracies, lack of effectiveness, and the withholding and distorting of health information.
Keywords: abstinence, human rights, medical accuracy, policy, sex educationTo review the key issues related to abstinence-only or abstinence-until-marriage education (AOE), we use the term AOE to describe those programs and policies that adhere to federal requirements for abstinence education funding (see Table 1 ) [1,2].
Federal 8 Point Definition of Abstinence Education
has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity;
teaches abstinence from sexual activity outside marriage as the expected standard for all school age children;
teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;
teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity;
teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects;
teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society;
teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and
teaches the importance of attaining self-sufficiency before engaging in sexual activity.Adolescence is a time of transition to adulthood. To understand adolescent sexual behavior, one must first understand adult sexual practices. There is an 8–10 year gap between median age at first intercourse (17 years) and first marriage (25 years for women and 27 years for men) [3,4]. Few American adults abstain from sexual intercourse until marriage, and most initiate sexual intercourse during their adolescent years. A recent analysis of four cycles of the National Survey of Family Growth by Finer [5**] found that, over the past 50 years, almost all Americans of both sexes have premarital sex. By age 20, 77% of respondents reported vaginal intercourse and nearly all had sex before marriage. By age 44, 99% of respondents had sex; 95% had premarital sex; and 85% had married.
Initiation of sexual intercourse puts a teenager at risk for unintended pregnancy and sexually transmitted infection. After declining between 1991 and 2001 (54% to 46%), sexual experience among U.S. high school students has remained at 46–47% from 2001 to 2005 [6]. Over 750 000 U.S. adolescents (aged 15–19) become pregnant each year, and over 28% of these pregnancies end in abortion [7]. Most adolescent pregnancies (82%) are unintended [8]. A recent analysis of the decline in U.S. adolescent pregnancy rates between the 1995 and 2002 National Surveys of Family Growth demonstrated that 86% of the decline was due to improved contraceptive use (less nonuse, increased use of condoms and highly effective hormonal methods, and increased use of dual methods), and only 14% due to declines in sexual behavior [9**]. Although pregnancy rates have declined, the United States still leads the developed world in adolescent (aged 15–19) birth rates, with 42 births per 1000 women in 2004. By comparison, adolescents in the United Kingdom had 27 births per 1000 women; in Italy, seven births per 1000 women; and in the Netherlands, five births per 1000 women [10].
One argument for presenting abstinence to adolescents as their sole option for pregnancy and sexually transmitted infection (STI) prevention is that adolescent sexual behavior is itself harmful. This assertion is supported by data showing that adolescents who initiate sexual behavior earlier are more likely to suffer from depression and engage in other risk-taking behaviors [11]. Early adolescent sexual behavior, however, is confounded by high rates of coercive sex, older partners, and the co-occurrence of other risk behaviors such as substance use. Additionally, the same social deprivation (e.g. poverty, single-parent families, parental drug use, childhood abuse, lack of social support) that leads to early sexual initiation, also contributes to depression and other risk-taking behaviors [12]. Several analyses document the role of preexisting depression in subsequent adolescent sexual risk behavior [13,14]. A recent analysis of Add Health casts doubts on whether early sex causes depression. Sabia [15*] demonstrated that, while the association existed in cross-sectional data, it was not likely due to early initiation itself.
Adolescents demonstrate a complex and sometimes nuanced view of abstinence and sex. While refraining from vaginal intercourse is generally considered ‘abstinence,’ other sexual behaviors may be or may not be included, such as touching, kissing, mutual masturbation, oral sex, and anal sex [16,17]. Adolescents frequently frame abstinence from a values or religious perspective, using descriptors such as, ‘making a commitment’ or ‘my religion says…’ [18*,19]. Unlike adults, recent data suggest that adolescents do not view abstinence as a binary state (having sex/ not having sex), and demonstrate more developmental perspectives. For example, in a small qualitative study of abstinence among high risk 11–17 year olds, adolescents described abstinence as a natural phase of development, and when ‘ready,’ people would transition to sexual activity [18*].
Broad public support exists for comprehensive sexuality education, with abstinence as a key component of that education. Using the nationally representative Annenberg National Health Communication Survey, Bleakley [20*] found that 81% of adults believed that sex education teaching both abstinence and other methods to prevent pregnancy to be effective, while only 39% believed abstinence-only to be effective. The same survey found that 51% of adults opposed abstinence-only, whereas only 10% opposed teaching contraception and condom use. A telephone survey of parents of public school students in grades K-12 in North Carolina found similar results: 91% believed that sex education should be taught in school, with 98% rating transmission and prevention of STIs/HIV important, 91%rating abstinence as important, 93% how to talk with a partner about birth control as important, and 89% effectiveness and failure rates of birth control important [21*]. Most parents and adolescents do not perceive education that stresses abstinence while also providing information about contraception as presenting a mixed message, and the clear majority of adults (73%) and adolescents (56%) wish adolescents were getting more information about both abstinence and contraception rather than either alone [22*].
For fiscal year 2006, the federal government provided $178 million for abstinence-only education through Title V, Section 510 of the Social Security Act in 1996 (Section 510), Community-Based Abstinence Education (CBAE) projects, and the Adolescent Family Life Act program. The CBAE program bypasses the state government approval processes and makes grants directly to community- based organizations, including faith-based organizations. Federal guidance requires all programs to adhere to an eight-point definition of abstinence-only education (see Table 1 ), and prohibits programs from disseminating information on contraceptive services, sexual orientation and gender identity, and other aspects of human sexuality [2,23]. Section 510 specifies that programs must have as their ‘exclusive purpose’ the promotion of abstinence outside of marriage and may not in any way advocate contraceptive use or discuss contraceptive methods or condoms except to emphasize their failure rates. No designated federal funding stream exists for comprehensive sexuality education.
Lindberg et al. [24**] documents the erosion of comprehensive sexuality education, coincident with the rising emphasis on abstinence as the sole option for adolescents. Her analyses of 2002 NSFG data reaffirm findings from older and complementary data sets (see, for example, [25]). Adolescent and pediatric gynecology Table 1 Federal 8 Point Definition of Abstinence Education Under Section 510 of Title V of the Social Security Act, abstinence education is defined as an educational or motivational program which: (A) has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity; (B) teaches abstinence from sexual activity outside marriage as the expected standard for all school age children; (C) teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems; (D) teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity; (E) teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects; (F) teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society; (G) teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and (H) teaches the importance of attaining self-sufficiency before engaging in sexual activity. Lindberg [24**] found that a declining percentage of adolescents reported receiving education about contraception, while larger percentages reported receiving abstinence education. Between 1995 and 2002, instruction about birth control methods declined from 81% to 66% for males, and from 87% to 70% for females. Receipt of any abstinence education increased among males (74% to 83%) and receipt of only abstinence education increased among males (9% to 24%) and females (8% to 21%). In consequence, fewer adolescents reported receiving formal instruction about both abstinence and birth control methods (in males, from 65% to 59%; in females, from 84% to 65%). Among sexually experienced adolescents, 62% of females and 54% of males in 2002 reported receiving instruction about birth control methods prior to first sex.
Abstinence-only approaches have also influenced family planning and HIV prevention programs nationally and internationally. In fiscal year 2004, the Office of Population Affairs announced that program priorities for Title X grantees would include a focus on extramarital abstinence education and counseling, increasing parental involvement in the decisions of minors to seek family planning services, reporting of statutory rape, and working with faith-based organizations [26]. U.S. emphasis on abstinence may have reduced condom availability and access to accurate information on HIV/AIDS in some countries [27]. The Government Accountability Office, which is the investigative arm of U.S. Congress, issued a critique of U.S. foreign policy support for abstinence-only education in April 2006. In-country prevention teams for the President’s Emergency Plan for AIDS Relief reported that spending requirements ‘limit their efforts to design prevention programs that are integrated and responsive to local prevention needs’ [28*].
Mainstream medical professional organizations, including the American College of Obstetricians and Gynecologists (ACOG), the Society for Adolescent Medicine (SAM), the American Academy of Pediatrics (AAP), the American Medicine Association (AMA), and the American Public Health Association (APHA), oppose abstinence-only education and endorse comprehensive sexuality education that includes both abstinence and accurate information about contraception, human sexuality and STIs [29**,30– 36]. The most comprehensive of these position papers is the Society for Adolescent Medicine position paper and accompanying review article [29**,37**] which describe the importance of scientific rigor as the cornerstone for policy and programmatic decisions, as well as the troublesome ethical issues raised by deliberately withholding or distorting potentially life-saving information about contraception and STI prevention.
A federally funded evaluation of Title V programs conducted by an independent research organization [38**], a new systematic review [39**], and analyses of nationally representative longitudinal surveys of health behavior [40] demonstrate that abstinence-only programs are ineffective and may cause harm. The most important single report is Mathematica Policy Research, Inc.’s final report on the impact of four Title V, Section 510 abstinence education programs [38**]. Authorized by the U.S. Congress, and using a rigorous randomized controlled trial study design, investigators examined the impact on sexual behaviors among 2057 adolescents four years after participation in one of four carefully chosen and implemented Title V abstinence-only programs or a community-standard control. The report describes no differences in sexual abstinence or condom use between abstinence-only program group and control group. One significant finding was concerning: youth in the program group were significantly less likely to report that condoms were effective in preventing HIV and other STIs. This finding is consistent with the emphasis in AOE curricula on teaching about the failure rates for condoms, as required by federal program guidance [2].
A recent peer-reviewed systematic review examined the evidence supporting both abstinence-only programs and comprehensive sexuality education programs designed to promote abstinence from sexual intercourse [39**]. This review employed similar scientific criteria to prior systematic reviews of sexuality education programs [41,42] in selecting program evaluations, including use of experimental or quasi-experimental design and sexual behavior outcomes to demonstrate efficacy. Also similar to prior systematic reviews, this review concluded that many comprehensive sexuality education programs demonstrate efficacy in delaying initiation of intercourse, in addition to promoting other protective behaviors such as condom use. In contrast, this review found no evidence that abstinence-only programs demonstrate efficacy in delaying initiation of sexual intercourse.
The findings in the above randomized trial and systematic review are supported by a longitudinal analysis of adolescents taking virginity pledges in Add Health [40,43]. A follow-up, six years later showed 88% of young adults who reported taking virginity pledges as adolescents had initiated vaginal intercourse before marriage, and the prevalence of STIs (chlamydia, gonorrhea, and trichomoniasis) was similar among those who pledged and non-pledgers [40]. Moreover, when pledgers did initiate intercourse, many failed to protect themselves by using condoms, and were less likely to be tested for STIs. This data suggests that, while abstinence is theoretically 100% effective, in typical use, the effectiveness of abstinence may approach zero [37**].
Fueled by recent congressional and GAO reports, concerns about medical accuracy of AOE have come to the forefront. From a scientific and public health standpoint, the accuracy of the information provided through sexual and reproductive health education should be essential. Calls for medical accuracy represent one response to concerns about misinformation provided by abstinence only education. Medical accuracy can be defined as:
Information relevant to informed decision-making based on the weight of scientific evidence, consistent with generally recognized scientific theory, conducted under accepted scientific methods, published in peer-reviewed journals, and recognized as accurate, objective, and complete by mainstream professional organizations such as AMA, ACOG, APHA and AAP, government agencies such as the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA) and the National Institutes of Health (NIH), and scientific advisory groups such as the Institute of Medicine and the Advisory Committee on Immunization Practices. The deliberate withholding of information that is needed to protect life and health (and therefore relevant to informed decision-making) should be considered medically inaccurate [44].
Many AOE curricula and even the federal guidelines for AOE have been identified as containing serious inaccuracies. A content review of abstinence-only curricula conducted by the minority staff of the Committee on Government Reform of the U.S. House of Representatives found that 11 of the 13 commonly-used curricula contained false, misleading or distorted information about reproductive health including inaccurate information about condom and other contraceptive effectiveness, the risks of sexual activity and the risks of abortion, as well as other scientific errors [45]. In the fall of 2006, the Government Accountability Office (GAO) issued two reports on the federal programs that promote abstinence, both of which faulted the programs on the issue of medical accuracy [46*,47*]. In the first report, the GAO found that ACF does not review abstinence grantees’ educational materials for scientific accuracy and does not require either CBAE or Title V programs to review their own materials for scientific accuracy [47*]. The second report concluded that the federal statutory requirement (section 317P(c)(2) of the Public Health Service Act) to include medically accurate information on condom effectiveness would apply to abstinence education materials prepared and used by federal grant recipients, and that guidelines for AOE requiring programs to emphasize failure rates were potentially out of compliance [46*]. The American Civil Liberties Union and other advocacy groups have recently publicly questioned the federal government’s support for abstinence education, on the grounds that such studies are contrary to federal regulations requiring medically accurate information about condoms [48]. A review of condom and STI information in three curricula commonly used by federal abstinence funding grantees demonstrated that these curricula did not represent complete, current, and accurate medical knowledge about condom effectiveness [49]. Instead, these curricula both explicitly and implicitly conveyed the message that condoms fail to provide protection against STIs. Misrepresentations included the use of data from poorly designed studies and the exclusion or distortion of data from better-designed studies; routinely presenting information out of context; selectively reporting data; and drawing unsupported conclusions that go beyond the scope of the medical literature.
The current U.S. government approach focusing on AOE raises serious ethical and human rights concerns. While abstinence is often presented as the moral choice for adolescents, many have questioned AOE which withholds life-saving information from adolescents [27,29**,30]. Access to complete and accurate HIV/AIDS and sexual health information has been recognized as a basic human right, as complete and accurate health information is essential to realizing the highest attainable standard of health [50,51]. Such human rights thinking suggests that governments have an obligation to provide accurate information to their citizens and avoid the provision of misinformation. Such obligations extend to government funded health education and healthcare services.
A variety of international treaties and human rights statements support the rights of all people to seek and receive accurate sexual health information, including the 1994 International Conference on Population and Development Program of Action, Cairo, 1994 [52] and the 2003 report of the U.N. Committee on the Rights of the Child [53]. The latter emphasized that ‘children should have the right to access adequate information related to HIV/ AIDS prevention and care, through formal channels (e.g. through educational opportunities and child-targeted media) as well as informal channels,’ and that, ‘effective HIV/AIDS prevention requires States to refrain from censoring, withholding, or intentionally misrepresenting health-related information, including sexual education and information … State parties must ensure that children have the ability to acquire the knowledge and skills to protect themselves and others as they begin to express their sexuality’ [54].
Likewise, health educators and healthcare professionals have an ethical obligation to provide accurate and complete health information in their work. As defined by U.S. government funding regulations, abstinence-only programs are required to withhold information on contraception and other aspects of human sexuality except to emphasize their failure rates [55], and to promote scientifically questionable positions [29**,37**]. The current U.S. approach emphasizing abstinence challenges a key ethical principle of medical research and practice known as ‘respect for persons’ [56]. Healthcare providers may not withhold information from a patient in order to influence their healthcare choices. We believe that it is unethical to provide misinformation or withhold information from adolescents about sexual health, including ways for sexually active teens to protect themselves from STIs and pregnancy. Withholding information on contraception to induce adolescents to be abstinent is inherently coercive (and ineffective, as documented above). It violates the principle of beneficence (to do good and avoid harm) as it may cause an adolescent to use ineffective (or no) protection against pregnancy and STIs. Thus, current U.S. policies that promote abstinence-only education are ethically problematic, as they exclude accurate information about contraception, misinform by overemphasizing or misstating the risks of contraception, and fail to require the use of scientifically accurate information while promoting approaches of questionable value.
Related to the above concerns about a lack of efficacy, medical inaccuracy and the ethically untenable position of withholding potentially life-saving information, a number of states have refused or are planning to refuse federal Title V, Section 510 abstinence-only funding. These include California, Maine, New Jersey, Pennsylvania, Wisconsin, Ohio, Montana, and Massachusetts [57]. At the time we were preparing this manuscript (June 2007), Congressional leaders were debating reauthorization of Title V and funding levels of the CBAE programs.
Federal support of AOE as an approach to improve adolescent sexual health is deeply troubling because of medical inaccuracies, programs that are not efficacious and may harm adolescents, and the unethical practice of withholding and distorting health information. We encourage all healthcare providers involved in reproductive health to advocate for medically accurate comprehensive sexuality education for adolescents in their professional organizations, local healthcare system, schools, and communities. Professionals in the field of obstetrics and gynecology are well positioned to reframe the ‘moral’ debate so that providing comprehensive, effective and accurate reproductive health information to adolescents is the right choice.
Papers of particular interest, published within the annual period of review, have been highlighted as: * of special interest ** of outstanding interest.
1. Separate Program for Abstinence Education, SEC. 510 [42 U.S.C. 710] [Accessed 12 May 2004]; Compilation of the Social Security Laws 2004. Available from: http://www.ssa.gov/OP*Home/ssact/title05/0510.htm.
3. Abma JC, Martinez GM, Mosher WD, Dawson BS. Teenagers in the United States: sexual activity, contraceptive use, and childbearing 2002. Vital Health Stat. 2004; 23 :1–48. [PubMed] [Google Scholar]
4. Fields J. America’s families and living arrangements: 2003. Washington, DC: U. S. Census Bureau; 2004. [Google Scholar]
5** Finer LB. Trends in premarital sex in the United States, 1954–2003. Public Health Rep. 2007; 122 :73–78. Using sophisticated life-table models, this paper demonstrates that sex before and outside of marriage is ubiquitous across the life-span among Americans. It calls into question whether it is realistic and ethical to hold anyone to a premarital abstinence ideal. [PMC free article] [PubMed] [Google Scholar]
6. Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance–United States, 2005. MMWR Surveill Summ. 2006; 55 :1–108. [PubMed] [Google Scholar]
7. Guttmacher Institute. U.S. Teenage Pregnancy Statistics: National and State Trends and Trends by Race and Ethnicity. New York, NY: Guttmacher Institute; 2006. [Google Scholar]
8. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006; 38 :90–96. [PubMed] [Google Scholar]
9** Santelli JS, Lindberg LD, Finer LB, Singh S. Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. Am J Public Health. 2007; 97 :150–156. This paper demonstrates the critical role of improved contraceptive use to the declines in adolescent pregnancy between 1995 and 2002. Decreased nonuse, increased use of highly effective hormonal contraceptives, and increased dual use accounted for 86% of the decline in pregnancy rates among 15–19 year olds. This paper drives home the importance of providing comprehensive sexuality information to all adolescents, including medically accurate information on contraceptive efficacy and condom use, if we are to experience further declines in adolescent pregnancy. [PMC free article] [PubMed] [Google Scholar]
10. United Nations Statistics Division. Demographic Yearbook 2004. New York, NY: United Nations Statistics Division; 2007. Live-birth rates by age of mother and urban/ rural residence: latest available year, 1995–2004. [Google Scholar]
11. Hallfors DD, Waller MW, Bauer D, et al. Which comes first in adolescence– sex and drugs or depression? American Journal of Preventive Medicine. 2005; 29 :163–170. [PubMed] [Google Scholar]
12. Else-Quest NM, Hyde JS, Delamater JD. Context counts: long-term sequelae of premarital intercourse or abstinence. J Sex Re. 2005; 42 :102–112. [PubMed] [Google Scholar]
13. DiClemente RJ, Wingood GM, Crosby RA, et al. A prospective study of psychological distress and sexual risk behavior among black adolescent females. Pediatrics. 2001; 108 :E85. [PubMed] [Google Scholar]
14. Brown LK, Tolou-Shams M, Lescano C, et al. AT Depressive symptoms as a predictor of sexual risk among African American adolescents and young adults. J Adolesc Health. 2006; 39 (3):444 e1–8. [Epub 2006 Jul 10] [PubMed] [Google Scholar]
15* Sabia JJ. Does early adolescent sex cause depressive symptoms? J Policy Anal Manage. 2006; 25 :803–825. Longitudinal analysis of Add Health data suggesting that early teen sex is not a cause of depressive symptoms, but rather an early indicator of these symptoms. [PubMed] [Google Scholar]
16. Schuster MA, Bell RM, Kanouse DE. The sexual practices of adolescent virgins: genital sexual activities of high school students who have never had vaginal intercourse. Am J Public Health. 1996; 86 :1570–1576. [PMC free article] [PubMed] [Google Scholar]
17. Sanders SA, Reinisch JM. Would you say you ‘had sex’ if…? Jama. 1999; 281 :275–277. [PubMed] [Google Scholar]
18* Ott MA, Pfeiffer EJ, Fortenberry JD. Perceptions of sexual abstinence among high-risk early and middle adolescents. J Adolesc Health. 2006; 39 :192–198. This qualitative study shows that high risk adolescents hold a nuanced and developmental perspective on abstinence and the transition to sexual activity. [PubMed] [Google Scholar]
19. Goodson P, Suther S, Pruitt BE, Wilson K. Defining abstinence: views of directors, instructors, and participants in abstinence-only-until-marriage programs in Texas. J Sch Health. 2003; 73 :91–96. [PubMed] [Google Scholar]
20* Bleakley A, Hennessy M, Fishbein M. Public opinion on sex education in US schools. Arch Pediatr Adolesc Med. 2006; 160 :1151–1156. This survey documents overwhelming support for comprehensive sexuality information that includes information on both abstinence and contraceptives among a nationally representative adult population. [PubMed] [Google Scholar]
21* Ito KE, Gizlice Z, Owen-O’Dowd J, et al. Parent opinion of sexuality education in a state with mandated abstinence education: does policy match parental preference? J Adolesc Health. 2006; 39 :634–641. A second survey documenting overwhelming public support for comprehensive sexuality information that includes information on both abstinence and contraceptives in an ‘abstinence-only’ state. [PubMed] [Google Scholar]
22* Albert B. With One Voice 2007: America’s Adults and Teens Sound Off About Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy; 2007. This survey by the National Campaign documents showing parent and adolescent support for comprehensive sexuality information that includes information on both abstinence and contraceptives. [Google Scholar]
23. Dailard C. Legislating Against Arousal: The Growing Divide Between Federal Policy and Teenage Sexual Behavior. Guttmacher Policy Review. 2006; 9 :12–16. [Google Scholar]
24** Lindberg LD, Santelli JS, Singh S. Changes in formal sex education: 1995– 2002. Perspect Sex Reprod Health. 2006; 38 :182–189. This paper documents the erosion of comprehensive sexuality education during a time of escalating spending on abstinence-only education. It demonstrates that massive federal funding can markedly change the health education landscape across a short time period. [PubMed] [Google Scholar]
25. Darroch JE, Landry DJ, Singh S. Changing emphases in sexuality education in U.S. public secondary schools, 1988–1999. Fam Plann Perspect. 2000; 32 :204–211. 65. [PubMed] [Google Scholar]
26. Dailard C. Title X Program Announcement Articulates New Priorities for Nation’s Family Planning Program. Washington, DC: The Guttmacher Report on Public Policy; 2003. Report No. 6(5) [Google Scholar]
27. Human Rights Watch. The Philippines: Unprotected sex, condoms, and the human right to health. New York: Human Rights Watch; May, 2004. Report No. 16 (6C) [Google Scholar]
28* U.S. Government Accountability Office. Global Health: Spending Requirement Presents Challenges for Allocating Prevention Funding under the President’s Emergency Plan for AIDS Relief. Washington, DC: Government Accountability Office; Apr, 2006. Report No. GAO-06-395. One of a trio of GAO reports raising issues of medical accuracy. [Google Scholar]
29** Santelli J, Ott MA, Lyon M, et al. Abstinence-only education policies and programs: a position paper of the Society for Adolescent Medicine. J Adolesc Health. 2006; 38 :83–87. The Society for Adolescent Medicine strongly rejects presenting abstinence as the sole option for STI and pregnancy prevention to adolescents. This position paper and its companion review paper lay out how these policies do not reflect the realities of sexuality among Americans, lack effectiveness, potentially cause harm, and violate principles of medical ethics and human rights. [PubMed] [Google Scholar]
30. American Public Health Association. Abstinence and U.S. Abstinence- Only Education Policies: Ethical and Human Rights Concerns. Washington, DC: American Public Health Association; Nov, 2006. Report No. 200610. [Google Scholar]
31. American Academy of Pediatrics: Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence. Sexuality education for children and adolescents. Pediatrics. 2001; 108 (2):498–502. [PubMed] [Google Scholar]
32. American Social Health Association. [Accessed 14 September 2004]; Position on Comprehensive Sexual Health Education. Available from: http://www.ashastd.org/aboutasha/ positionstatements/Comprehensive*Sexual*Health.html.
33. American Medical Association. Sexuality Education, Abstinence, and Distribution of Condoms in Schools. Chicago, IL: American Medical Association; 2004. Report No.H-170.968. [Google Scholar]
34. Kittredge D. Abstinence and abstinence-only education. J Adolesc Health. 2006; 39 :150–151. disucssion 2; author reply 2–4. [PubMed] [Google Scholar]
35. American Psychological Association Ad Hoc Committee on Psychology and AIDS. Resolution In Favor of Empirically Supported Sex Education and HIV Prevention Programs for Adolescents: Resolution. 2005 Feb; Available from http://www.apa.org/releases/sexed*resolution.pdf.
36. Elster A, Fleming M. Abstinence and abstinence-only education. J Adolesc Health. 2006; 39 :150–152. [PubMed] [Google Scholar]
37** Santelli J, Ott MA, Lyon M, et al. Abstinence and abstinence-only education: a review of U.S. policies and programs. J Adolesc Health. 2006; 38 :72–81. This review article is a companion to the Society for Adolescent Medicine position paper. It lays out methodology for the review, and provides clear arguments against programs presenting abstinence as the sole option for pregnancy and STI prevention for adolescents. Data support conclusion that AOE is troubling from practical, program effectiveness, ethical, and human rights perspectives. [PubMed] [Google Scholar]
38** Trenholm C, Devaney B, Fortson K, et al. Impacts of Four Title V, Section 510 Abstinence Education Programs, Final Report. Princeton, NJ: Mathematica Policy Research; 2007. Commissioned by the U.S. Congress and conducted by an independent policy research firm, this prospective, randomized, controlled trial evaluated four large abstinence-only education programs, and included nearly 2500 adolescents. The final report demonstrated no effect on behavior at 4 year follow-up, and raised the possibility of future harm, in that abstinence-only program participants were more likely to believe that condoms never work to prevent STIs. If abstinence only approaches cannot be shown to be effective in model programs with careful implementation and meticulous follow-up, they are unlikely to be effective elsewhere. [Google Scholar]
39** Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs: their impact on sexual behaviors of young people throughout the world. J Adolesc Health. 2007; 40 :206–217. The most recent in a series of systematic reviews of both comprehensive and abstinence-only sex education programs examining the effectiveness of the curricula in changing specific health behaviors such as delaying the onset of sex and condom use. The authors use clear scientific criteria for inclusion, including experimental or quasi-experimental design, peer review, and behavioral outcomes. Results showed that, compared to controls, many comprehensive programs were effective, but no abstinence-only programs showed differences in behavior. [PubMed] [Google Scholar]
40. Bruckner H, Bearman P. After the promise: the STD consequences of adolescent virginity pledges. J Adolesc Health. 2005; 36 :271–278. [PubMed] [Google Scholar]
41. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy; 2001. [Google Scholar]
42. Manlove J, Romano-Papillo A, Ikramullah E. Not Yet: Programs to Delay First Sex Among Teens. Washington, DC: National Campaign to Prevent Teen Pregnancy; 2004. [Google Scholar]
43. Bearman PS, Brueckner H. Promising the Future: Virginity Pledges and First Intercourse. American Journal of Sociology. 2001; 106 :859–912. [Google Scholar]
44. Santelli JS. Medical Accuracy in Sexuality Education: Ideology and the Scientific Process. New England Journal of Medicine. (under review) [PMC free article] [PubMed] [Google Scholar]
45. U.S. House of Representatives Committee on Government Reform - Minority Staff. The Content of Federally Funded Abstinence-Only Education Programs, Prepared for Rep. Henry A. Waxman. 2004 Dec; [Google Scholar]
46* U.S. Government Accountability Office. Abstinence Education: Applicability of Section 317P of the Public Health Service Act. Washington, DC: U.S. Government Accountability Office; Oct, 2006. Report No. B-308128. One of a trio of GAO reports raising issues of medical accuracy. [Google Scholar]
47* U.S. Government Accountability Office. Abstinence Education: Efforts to Assess the Accuracy and Effectiveness of Federally Funded Programs. Washington, DC: U.S. Government Accountability Office; Oct, 2006. Report No. GAO-07-87. One of a trio of GAO reports raising issues of medical accuracy. [Google Scholar]
48. Kaiser Family Foundation. Daily HIV/AIDS Report. Politics and Policy: HHS Should Enforce Federal Law That Abstinence Education Programs Teach ‘Medically Accurate’ Information, ACLU Letter Says. Menlo Park, CA: Kaiser Family Foundation; 2007. Report No. Daily Reports 2007. [Google Scholar]
49. Santelli JS. Declaration of John S. Santelli, M.D., M.P.H. New York, New York: American Civil Liberties Union; Apr 26, 2007. [Google Scholar]
50. Freedman LP. Censorship and manipulation of reproductive health information. In: Coliver S, editor. The Right to Know: Human Rights and Access to Reproductive Health Information. Philadelphia, PA: University of Pennsylvania Press; 1995. pp. 1–37. [Google Scholar]
51. Coliver S. The right to information necessary for reproductive health and choice under international law. In: Coliver S, editor. The Right to Know: Human Rights and Access to Reproductive Health Information. Philadelphia, PA: University of Pennsylvania Press; 1995. pp. 38–82. [Google Scholar]
52. United Nations. Report of the International Conference on Population and Development. New York, NY: United Nations; Cairo; 1994. [September 1994]. Report No. A/Conf.171/13. 6 Adolescent and pediatric gynecology GCO/200201; Total nos of Pages: 7. [Google Scholar]
53. Committee on the Rights of the Child. General Comment No. 3 (2003a) HIV/ AIDS and the rights of the child. 2003 [Google Scholar]
54. Convention on the Rights of the Child. General Assembly resolution 44/25; Office of the High Commissioner for Human Rights. United Nations; [Adopted 20 November, 1989]. 1990. [Google Scholar]
55. U.S. Department of Health & Human Services. Grants Notice: Community- Based Abstinence Education Program. Administration for Children and Families. 2007 [Google Scholar]
56. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Washington, DC: Department of Health, Education, and Welfare Government Printing Office; 1978. Report No. (OS) 78-0012. [PubMed] [Google Scholar]