Abstinence or Abstinence-Only?

Naina Dhingra

Naina Dhingra is the Director of International Policy at Advocates for Youth and serves on the Developed Country NGO Board Delegation of the Global Fund.

At Wednesday's government reform hearing convened by Congressman Chris Shays on the abstinence-until-marriage earmark, Ambassador Mark Dybul, U.S. Global AIDS Coordinator, testified that the U.S. government does not fund "abstinence-only" programs. Repeatedly, U.S. government officials have stated that PEPFAR prevention programs are not abstinence-only and follow an evidence-based ABC approach.

Sorry, Ambassador Dybul, but we're not buying it.

Naina Dhingra is the Director of International Policy at Advocates for Youth and serves on the Developed Country NGO Board Delegation of the Global Fund.

At Wednesday's government reform hearing convened by Congressman Chris Shays on the abstinence-until-marriage earmark, Ambassador Mark Dybul, U.S. Global AIDS Coordinator, testified that the U.S. government does not fund "abstinence-only" programs. Repeatedly, U.S. government officials have stated that PEPFAR prevention programs are not abstinence-only and follow an evidence-based ABC approach.

Sorry, Ambassador Dybul, but we're not buying it.

After reviewing the policy directive designed to clarify the ABC approach within PEPFAR, "ABC Guidance #1: For United States Government In-Country Staff and Implementing Partners Applying the ABC Approach to Preventing Sexually-Transmitted HIV Infections Within The President's Emergency Plan for AIDS Relief," we found that the U.S. government is definitely not following an evidence-based approach.

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Advocates for Youth has published a policy brief titled, "Improving U.S. Global HIV Prevention for Youth," critiquing this guidance. The OGAC (Office of the U.S. Global AIDS Coordinator) Guidance states that the ABC approach to HIV prevention need only be comprehensive at the country level and that sub-populations within a country should be targeted with specific components of the approach (A, B, or C) based upon OGAC's perception of their needs. Young people are identified as a sub-population that need not be provided with all three components of the ABC approach. Segmenting the ABC approach by population is fundamentally flawed and defeats its effectiveness. A sole "AB" strategy for preventing HIV infection for young people is effectively an abstinence-only approach.

Underlying the OGAC guidance regarding programs for youth are the following scientific inaccuracies:

  • Youth easily fall into two categories-those that have had sex and those who have not and neither needs information about condoms.
  • Promoting abstinence-until-marriage will increase abstinence and secondary abstinence for those who already have had sex.
  • Marriage is an effective HIV prevention tool because young people in PEPFAR countries have the power to choose when to have sex
  • Providing young people with information about condoms will confuse youth and encourage them to have sex.

While abstinence is the best option for protection for youth not yet sexually active and should be included in all comprehensive youth HIV prevention programs, these programs must also take into account the fact that a large share of unmarried adolescents in PEPFAR countries are already sexually active and require information that will enable them to make informed choices and to protect themselves if they choose to remain sexually active.

Research clearly indicates that all young adults-abstinent or not-benefit from full disclosure of medically accurate, age appropriate information about both abstinence and condoms. Providing comprehensive information about HIV that is linked with sexual and reproductive health that includes honest, accurate information about condoms is a proven strategy for reducing HIV infection in young people.

Advocates for Youth is urging OGAC to revise the ABC guidance to more accurately reflect evidence-based best practices. Revising the guidance will enhance PEPFAR's efficacy and will encourage PEPFAR implementing partners to replicate effective strategies for HIV prevention among youth.

Editor's note: Read the report to see AFY's suggested changes to OGAC's ABC Guidance.

Commentary Sexual Health

Parents, Educators Can Support Pediatricians in Providing Comprehensive Sexuality Education

Nicole Cushman

While medical systems will need to evolve to address the challenges preventing pediatricians from sharing medically accurate and age-appropriate information about sexuality with their patients, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Last week, the American Academy of Pediatrics (AAP) released a clinical report outlining guidance for pediatricians on providing sexuality education to the children and adolescents in their care. As one of the most influential medical associations in the country, AAP brings, with this report, added weight to longstanding calls for comprehensive sex education.

The report offers guidance for clinicians on incorporating conversations about sexual and reproductive health into routine medical visits and summarizes the research supporting comprehensive sexuality education. It acknowledges the crucial role pediatricians play in supporting their patients’ healthy development, making them key stakeholders in the promotion of young people’s sexual health. Ultimately, the report could bolster efforts by parents and educators to increase access to comprehensive sexuality education and better equip young people to grow into sexually healthy adults.

But, while the guidance provides persuasive, evidence-backed encouragement for pediatricians to speak with parents and children and normalize sexual development, the report does not acknowledge some of the practical challenges to implementing such recommendations—for pediatricians as well as parents and school staff. Articulating these real-world challenges (and strategies for overcoming them) is essential to ensuring the report does not wind up yet another publication collecting proverbial dust on bookshelves.

The AAP report does lay the groundwork for pediatricians to initiate conversations including medically accurate and age-appropriate information about sexuality, and there is plenty in the guidelines to be enthusiastic about. Specifically, the report acknowledges something sexuality educators have long known—that a simple anatomy lesson is not sufficient. According to the AAP, sexuality education should address interpersonal relationships, body image, sexual orientation, gender identity, and reproductive rights as part of a comprehensive conversation about sexual health.

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The report further acknowledges that young people with disabilities, chronic health conditions, and other special needs also need age- and developmentally appropriate sex education, and it suggests resources for providing care to LGBTQ young people. Importantly, the AAP rejects abstinence-only approaches as ineffective and endorses comprehensive sexuality education.

It is clear that such guidance is sorely needed. Previous studies have shown that pediatricians have not been successful at having conversations with their patients about sexuality. One study found that one in three adolescents did not receive any information about sexuality from their pediatrician during health maintenance visits, and those conversations that did occur lasted less than 40 seconds, on average. Another analysis showed that, among sexually experienced adolescents, only a quarter of girls and one-fifth of boys had received information from a health-care provider about sexually transmitted infections or HIV in the last year. 

There are a number of factors at play preventing pediatricians from having these conversations. Beyond parental pushback and anti-choice resistance to comprehensive sex education, which Martha Kempner has covered in depth for Rewire, doctor visits are often limited in time and are not usually scheduled to allow for the kind of discussion needed to build a doctor-patient relationship that would be conducive to providing sexuality education. Doctors also may not get needed in-depth training to initiate and sustain these important, ongoing conversations with patients and their families.

The report notes that children and adolescents prefer a pediatrician who is nonjudgmental and comfortable discussing sexuality, answering questions and addressing concerns, but these interpersonal skills must be developed and honed through clinical training and practice. In order to fully implement the AAP’s recommendations, medical school curricula and residency training programs would need to devote time to building new doctors’ comfort with issues surrounding sexuality, interpersonal skills for navigating tough conversations, and knowledge and skills necessary for providing LGBTQ-friendly care.

As AAP explains in the report, sex education should come from many sources—schools, communities, medical offices, and homes. It lays out what can be a powerful partnership between parents, doctors, and educators in providing the age-appropriate and truly comprehensive sexuality education that young people need and deserve. While medical systems will need to evolve to address the challenges outlined above, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Parents and Caregivers: 

  • When selecting a pediatrician for your child, ask potential doctors about their approach to sexuality education. Make sure your doctor knows that you want your child to receive comprehensive, medically accurate information about a range of issues pertaining to sexuality and sexual health.
  • Talk with your child at home about sex and sexuality. Before a doctor’s visit, help your child prepare by encouraging them to think about any questions they may have for the doctor about their body, sexual feelings, or personal safety. After the visit, check in with your child to make sure their questions were answered.
  • Find out how your child’s school approaches sexuality education. Make sure school administrators, teachers, and school board members know that you support age-appropriate, comprehensive sex education that will complement the information provided by you and your child’s pediatrician.

School Staff and Educators: 

  • Maintain a referral list of pediatricians for parents to consult. When screening doctors for inclusion on the list, ask them how they approach sexuality education with patients and their families.
  • Involve supportive pediatricians in sex education curriculum review committees. Medical professionals can provide important perspective on what constitutes medically accurate, age- and developmentally-appropriate content when selecting or adapting curriculum materials for sex education classes.
  • Adopt sex-education policies and curricula that are comprehensive and inclusive of all young people, regardless of sexual orientation or gender identity. Ensure that teachers receive the training and support they need to provide high-quality sex education to their students.

The AAP clinical report provides an important step toward ensuring that young people receive sexuality education that supports their healthy sexual development. If adopted widely by pediatricians—in partnership with parents and schools—the report’s recommendations could contribute to a sea change in providing young people with the care and support they need.

Commentary Sexual Health

Fewer Young People Are Getting Formal Sex Education, But Can a New Federal Bill Change That?

Martha Kempner

Though the Real Education for Healthy Youth Act has little chance of passing Congress, its inclusive and evidence-based approach is a much-needed antidote to years of publicly funded abstinence-only-until-marriage programs, which may have contributed to troubling declines in youth knowledge about sexual and reproductive health.

Recent research from the Guttmacher Institute finds there have been significant changes in sexuality education during the last decade—and not for the better.

Fewer young people are receiving “formal sex education,” meaning classes that take place in schools, youth centers, churches, or community settings. And parents are not necessarily picking up the slack. This does not surprise sexuality education advocates, who say shrinking resources and restrictive public policies have pushed comprehensive programs—ones that address sexual health and contraception, among other topics—out of the classroom, while continued funding for abstinence-only-until-marriage programs has allowed uninformative ones to remain.

But just a week before this research was released in April, Sen. Cory Booker (D-NJ) introduced the Real Education for Healthy Youth Act (REHYA). If passed, REHYA would allocate federal funding for accurate, unbiased sexuality education programs that meet strict content requirements. More importantly, it would lay out a vision of what sexuality education could and should be.

Can this act ensure that more young people get high-quality sexuality education?

In the short term: No. Based on the track record of our current Congress, it has little chance of passing. But in the long run, absolutely.

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Less Sexuality Education Today

The Guttmacher Institute’s new study compared data from two rounds of a national survey in the years 2006-2010 and 2011-2013. It found that even the least controversial topics in sex education—sexually transmitted diseases (STDs) and HIV and AIDS—are taught less today than a few years ago. The proportion of young women taught about STDs declined from 94 percent to 90 percent between the two time periods, and young women taught about HIV and AIDS declined from 89 percent to 86 percent during the same period.

While it may seem like a lot of young people are still learning about these potential consequences of unprotected sex, few are learning how to prevent them. In the 2011-2013 survey, only 50 percent of teen girls and 58 percent of teen boys had received formal instruction about how to use a condom before they turned 18. And the percentage of teens who reported receiving formal education about birth control in general decreased from 70 percent to 60 percent among girls and from 61 percent to 55 percent among boys.

One of the only things that did increase was the percentage of teen girls (from 22 percent to 28 percent) and boys (from 29 to 35 percent) who said they got instruction on “how to say no to sex”—but no corresponding instruction on birth control.

Unfortunately, many parents do not appear to be stepping in to fill the gap left by formal education. The study found that while there’s been a decline in formal education, there has been little change in the number of kids who say they’ve spoken to their parents about birth control.

Debra Hauser, president of Advocates for Youth, told Rewire that this can lead to a dangerous situation: “In the face of declining formal education and little discussion from their parents, young people are left to fend for themselves, often turning to their friends or the internet-either of which can be fraught with trouble.”

The study makes it very clear that we are leaving young people unprepared to make responsible decisions about sex. When they do receive education, it isn’t always timely: It found that in 2011-2013, 43 percent of teen females and 57 percent of teen males did not receive information about birth control before they had sex for the first time.

It could be tempting to argue that the situation is not actually dire because teen pregnancy rates are at a historic low, potentially suggesting that young people can make do without formal sex education or even parental advice. Such an argument would be a mistake. Teen pregnancy rates are dropping for a variety of reasons, but mostly because because teens are using contraception more frequently and more effectively. And while that is great news, it is insufficient.

Our goals in providing sex education have to go farther than getting young people to their 18th or 21st birthday without a pregnancy. We should be working to ensure that young people grow up to be sexually healthy adults who have safe and satisfying relationships for their whole lives.

But for anyone who needs an alarming statistic to prove that comprehensive sex education is still necessary, here’s one: Adolescents make up just one quarter of the population, but the Centers for Disease Control and Prevention estimate they account for more than half of the 20 million new sexually transmitted infections (STIs) that occur each year in this country.

The Real Education for Healthy Youth Act

The best news about the REHYA is that it takes a very broad approach to sexuality education, provides a noble vision of what young people should learn, and seems to understand that changes should take place not just in K-12 education but through professional development opportunities as well.

As Advocates for Youth explains, if passed, REHYA would be the first federal legislation to ever recognize young people’s right to sexual health information. It would allocate funding for education that includes a wide range of topics, including communication and decision-making skills; safe and healthy relationships; and preventing unintended pregnancy, HIV, other STIs, dating violence, sexual assault, bullying, and harassment.

In addition, it would require all funded programs to be inclusive of lesbian, gay, bisexual, and transgender students and to meet the needs of young people who are sexually active as well as those who are not. The grants could also be used for adolescents and young adults in institutes of higher education. Finally, the bill recognizes the importance of teacher training and provides resources to prepare sex education instructors.

If we look at the federal government’s role as leading by example, then REHYA is a great start. It sets forth a plan, starts a conversation, and moves us away from decades of focusing on disproven abstinence-only-until-marriage programs. In fact, one of the fun parts of this new bill is that it diverts funding from the Title V program, which received $75 million dollars in Fiscal Year 2016. That funding has supported programs that stick to a strict eight-point definition of “abstinence education” (often called the “A-H definition”) that, among other things, tells young people that sex outside of marriage is against societal norms and likely to have harmful physical and psychological effects.

The federal government does not make rules on what can and cannot be taught in classrooms outside of those programs it funds. Broad decisions about topics are made by each state, while more granular decisions—such as what curriculum to use or videos to show—are made by local school districts. But the growth of the abstinence-only-until-marriage approach and the industry that spread it, researchers say, was partially due to federal funding and the government’s “stamp of approval.”

Heather Boonstra, director of public policy at the Guttmacher Institute and a co-author of its study, told Rewire: “My sense is that [government endorsement] really spurred the proliferation of a whole industry and gave legitimacy—and still does—to this very narrow approach.”

The money—$1.5 billion total between 1996 and 2010—was, of course, at the heart of a lot of that growth. School districts, community-based organizations, and faith-based institutions created programs using federal and state money. And a network of abstinence-only-until-marriage organizations grew up to provide the curricula and materials these programs needed. But the reach was broader than that: A number of states changed the rules governing sex education to insist that schools stress abstinence. Some even quoted all or part of the A-H definition in their state laws.

REHYA would provide less money to comprehensive education than the abstinence-only-until-marriage funding streams did to their respective programs, but most advocates agree that it is important nonetheless. As Jesseca Boyer, vice president at the Sexuality Information and Education Council of the United States (SIECUS), told Rewire, “It establishes a vision of what the government could do in terms of supporting sex education.”

Boonstra noted that by providing the model for good programs and some money that would help organizations develop materials for those programs, REHYA could have a broader reach than just the programs it would directly fund.

The advocates Rewire spoke with agree on something else, as well: REHYA has very little chance of passing in this Congress. But they’re not deterred. Even if it doesn’t become law this year, or next, it is moving the pendulum back toward the comprehensive approach to sex education that our young people need.

CORRECTION: This article has been updated to clarify Jesseca Boyer’s position at the Sexuality Information and Education Council of the United States.

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