Commentary Sexuality

In Teen Pregnancy Prevention, the Ends Don’t Justify the Means

Martha Kempner

A new document designed to settle debates over how to approach teen pregnancy prevention implies that evidence should trump content. As a sexuality educator and a mother, I have to disagree. What you say is important, as is how you say it and, frankly, equally important is what you deliberately leave out (e.g. no mention of same-sex relationships).

In December, the National Campaign to Prevent Teen and Unplanned Pregnancy released a new policy brief designed to settle ongoing arguments in the debate over how best to approach teen pregnancy. The document, Key Points About Teen Pregnancy Prevention, provides an overview of the data, research, and funding on teen pregnancy and prevention, and throws its support whole-heartedly behind funding programs that have been found to be effective. There’s nothing immediately controversial about that idea and most people undoubtedly agree, but more than once the brief implies that it doesn’t matter what we teach kids as long it works.

Beyond agreeing with the requirements that programs be medically accurate and age-appropriate—concepts which the brief suggest are debatable in-and-of-themselves—
the National Campaign repeatedly implies that what programs say is relatively unimportant. In fact, in a section called “So What’s the Problem?” the brief suggests that one of the reasons we’re still debating this issue is that we are: “Focusing on the content of intervention rather than the results.” 

I would agree that results are vital—and the downward trend in teen pregnancy rates over recent years is fantastic—but I can’t get behind the idea that content just doesn’t matter. What you say is important, as is how you say it and, frankly, what you deliberately don’t say (such as not mentioning same-sex relationships). There is a debate in this country about how best to prevent teen pregnancy and educate our young people about sex and while the answer to that debate may be rooted in efficacy it does not and cannot end there.   

The Background

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For years it seemed like the debate over teaching young people about sex was boiled down to two distinctly different sides: either you believed that young people should be given comprehensive sexuality education which taught them about everything from gender and relationships to contraception and disease prevention or you believed that programs should take a hardline abstinence approach and tell kids to wait on sex (usually until marriage). In truth, as with all things, the arguments have always been more nuanced than that but most of the distinctions were lost outside of those of us working on this issue. To the public and the media in particular, either you wanted to throw a condom at every kid over 15 because you knew just how horny they were or you wanted to slap a chastity belt on them until their wedding day. 

Under the Bush Administration this latter approach got quite a bit of attention and a lot of money. Between 1996 and 2010, abstinence-only-until-marriage programs received over one-and-a-half billion government dollars. Though these programs claimed to be about preventing pregnancy and STDs, I often argued that they were simply a conservative social agenda masquerading as prevention. Rather than teaching teens about contraception and decision-making, they taught them about the importance of heterosexual marriage and posited that the only way to achieve a happy marriage was to remain a virgin until your wedding night. Some programs went as far as to spend class time having eighth graders plan their weddings. 

I frequently argued that these programs had no education value (and were potentially harmful), while my colleagues on the policy side argued that the government was wasting its money. Researchers, including some hired by the government, proved this part to be true by conducting numerous studies that found that abstinence-until-marriage-programs did not change teens’ behavior at all. We then began to argue that government funding should only be used to promote programs that have been proven to work. Though this argument was only part of the reason that educators and advocates opposed abstinence-only programs it was certainly the one with the most political teeth and it is likely the reason that most of the funding for these program gradually dried up. (Currently, the federal government offers $50 million per year to the states under the Title V abstinence education grant and an additional $5 million to state- and community-based programs under the Community-Based Abstinence Education or CBAE grant.)

The Obama Administration then introduced some funding to support evidenced-based teen pregnancy prevention programs. The President’s Teen Pregnancy Prevention Initiative (TPPI), first funded in 2010, provides $105 million in competitive contracts and grants to public and private entities. TPPI funds medically-accurate and age-appropriate programs that have been proven to reduce teen pregnancy and associated risk behaviors. For the most part, grant recipients are funded to replicate one of two dozen or so programs that have been vetted and given the “evidence-based” seal of approval. There is also some money to fund innovative programs that have the potential to prevent teen pregnancy. A second funding stream, authorized as part of the Affordable Care Act, is called the Personal Responsibility Education Program (PREP) and receives $75 million a year from the federal government most of which is given out to states in the form of block grants. PREP recipients are required to conduct evidence-based programs that provide information on both abstinence and contraception in order to prevent unintended pregnancy and STIs, including HIV. They must also “address at least three adult preparation topics: healthy relationships, adolescent development, financial literacy, parent-child communication, educational and career success, and healthy life skills.”

Many saw these two funding streams as the opposite of, or antidote to, the billion dollar investment in abstinence-only-until-marriage programs perhaps because one was coming up as the other was waning. In truth, though, while most evidence-based programs do not take an abstinence-only-until-marriage approach, they are certainly not comprehensive sexuality education. They are limited in both scope and content and seek to change certain behaviors rather than wholly educate individuals or create a generation of sexually healthy young people (the Holy Grail for proponents of comprehensive sex education). In fact, as the National Campaign points out in its brief, one of the most often replicated packages is a youth development program “that spends little time discussing sex at all.” And anyone who thought this funding was just available to folks on the comprehensive side of the debate was proven wrong when Heritage Keepers, a very strict abstinence-only-until-marriage program, was added to the list of approved programs last year. 

The Debate

The National Campaign’s new brief seems aimed at folks who feel that these new funding streams lean too far toward comprehensive programs or are not abstinent enough. The brief appears to be saying that when it comes to this new funding neither “side” won because it’s really all about the evidence. The document continually argues that “results should trump ideology” and suggests that critics of the grant program are “mischaracterizing a funding stream dedicated to effective programs as one that supports a particular approach rather than one that focuses on results.”     

The following two bullets are included in the upfront summary:

  • “Evidence-based teen pregnancy prevention programs are not limited to or synonymous with a particular ideology—the roster of effective programs becomes more diverse each year.”
  • “Current federal funding for evidence-based programs also supports a broad array of programs giving communities flexibility to choose the program that best suits their needs.”

As I read it, one of the unstated purposes of this document is to reassure supporters of abstinence-only programs that there is room under this umbrella of evidence-based funding for them as well. The document points out that the “list of effective interventions now includes several abstinence programs.”  It goes on to say:

“While there are still relatively few abstinence-only programs that have been rigorously evaluated and shown to delay sex, the number has grown and may continue to do so.” 

And, though it explains quite clearly that researchers attribute most of the recent declines in teen pregnancy to improvement in contraceptive use, it throws the abstinence-only industry this little bone:

“Furthermore, while most of the programs supported with federal abstinence funding do not have strong evidence of changing teens behavior, it is entirely possible that the broader focus on abstinence helped some young people understand that many teens were not having sex and that delaying sex was a serious option for young people.” 

This seems like a bit of a stretch for a document that is arguing that non-biased scientific evidence is the be all and end all for decision making, no?    

I would argue that the fact that—despite decades of funding for such programs—there are so few abstinence-only-until-marriage programs that have been proven to be effective shows that this approach of prescribing behavior and denying information just doesn’t work. I would not give the abstinence movement any credit in changing the overall environment around sexual behavior as the trend toward delaying sex and the downward turn in teen pregnancy began before the movement’s big moment in the sun and continues after. But mostly, I would also argue that the brief’s conclusion that the ultimate decision about what type of program to provide should be based on results not content is short-sighted at best (especially when you take into account the fact that many of these results are only proven to last for as little as six months after the program ends).

The Messages

Last year, the Heritage Keeper’s program was added to the list of evidence-based curricula that are eligible for funding. It is a perfect example of why results cannot be the only criteria. This curriculum promotes heterosexual marriage as the only acceptable family form, suggests that sex outside of marriage is inevitably dangerous and morally wrong, and states unequivocally that life begins at conception. 

  • “But did you know that sexual activity outside of the commitment of marriage could put YOUR FUTURE at risk?” (Heritage Keepers, Teacher Manual, unnumbered page)
  • “Sex is like fire. Inside the appropriate boundary of marriage, sex is a great thing! Outside of marriage, sex can be dangerous!” (Heritage Keeper, Student Manual, p. 22)
  • “You are going to watch a video that explains, and actually shows you, how a new life develops after the sperm fertilized the egg.” (Heritage Keepers, Student Manual, p. 17)
  • “When you have sexual intercourse with someone there is a good chance that you could create an entirely new person—a living human being; a son or daughter.” (Heritage Keepers, Student Manual, p. 17)

I’m the mother of two girls who will one day be teenagers and possibly attend a pregnancy-prevention program. It’s not okay with me to give my daughters any of these messages even if doing so leads to delayed sex or increased contraception use (though I’m not sure how you can get the latter out of this program that doesn’t ever mention contraception and reads much more like a marriage promotion brochure than an educational  intervention.)

Moreover, Heritage Keeper’s include so many gender stereotypes that I fear it would undo the years I’ve spent trying to tell my girls that they can do anything they want regardless of their gender and that men and women should be equal both in the world and in relationships. 

  • Men, the curriculum says, are strong, respectful, and courageous. “A man protects.” (Heritage Keepers, Student Manual, p. 52) In contrast, a “real woman” knows herself, is confident, sends a clear message, and is caring. (Heritage Keepers, Student Manual, p. 55)
  • “Males and females are aroused at different levels of intimacy. Males are more sight orientated whereas females are more touch orientated. This is why girls need to be careful with what they wear, because males are looking! The girl might be thinking fashion, while the boy is thinking sex. For this reason, girls have a responsibility to wear modest clothing that doesn’t invite lustful thoughts.” (Heritage Keepers, Student Manual, p. 46)

Yes, it actually includes the age-old double standard that women don’t really want sex and are therefore responsible for keeping their legs shut (and better yet covered) because boys just can’t help themselves. Yes, this is the very same argument that was used for too many years to blame rape survivors for what happened to them. And no, this is not okay to tell my daughters—even if it works.    

Content Matters

I’m not sure why the National Campaign to Prevent Teen and Unplanned Pregnancy released this policy brief at this moment. Perhaps it feels that funding for the TPPI program is in danger (in this climate of spending cuts it is reasonable to believe that no federal program is completely secure). Perhaps it feels (or staff knows) that abstinence-only-until-marriage proponents are gearing up to attack the federal funding as ideological and partisan. Or perhaps it thinks (or again knows) that another abstinence-only curriculum is about to be added to the “approved” list of funded programs and it is hoping to assuage the folks (like me) who will be outraged by that move.   

I imagine that this document could be useful in those scenarios. It does lay out the history and facts of teen pregnancy prevention quite clearly and it makes an impassioned argument for sticking to evidence as the most important determinant of support for programs. The problem is that in doing so, it says one too many times, that content is not important. 

I completely disagree. Just as I would never teach my children to eat healthily by telling them that they’re fat or that chocolate has microscopic bugs in it, I refuse to get my kids to delay intercourse by telling them sex outside of marriage is morally wrong or to prevent pregnancy by telling my daughters to dress modestly and keep their legs closed tight even if I would have absolute reassurance that I would not be a grandmother before I turn 60 (my oldest will be 27 that year) and neither girl will ever get an STD. The ends simply don’t justify the means.

More importantly, though, I believe there’s a much better way to help my girls achieve these goals and grow up to have happy and healthy sex lives—complete information about sexuality coupled with good critical thinking and decision making skills and access to prevention methods when they need them.  

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.

Roundups Law and Policy

Gavel Drop: Republicans Can’t Help But Play Politics With the Judiciary

Jessica Mason Pieklo & Imani Gandy

Republicans have a good grip on the courts and are fighting hard to keep it that way.

Welcome to Gavel Drop, our roundup of legal news, headlines, and head-shaking moments in the courts.

Linda Greenhouse has another don’t-miss column in the New York Times on how the GOP outsourced the judicial nomination process to the National Rifle Association.

Meanwhile, Dahlia Lithwick has this smart piece on how we know the U.S. Supreme Court is the biggest election issue this year: The Republicans refuse to talk about it.

The American Academy of Pediatrics is urging doctors to fill in the blanks left by “abstinence-centric” sex education and talk to their young patients about issues including sexual consent and gender identity.

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Good news from Alaska, where the state’s supreme court struck down its parental notification law.

Bad news from Virginia, though, where the supreme court struck down Democratic Gov. Terry McAuliffe’s executive order restoring voting rights to more than 200,000 felons.

Wisconsin Gov. Scott Walker (R) will leave behind one of the most politicized state supreme courts in modern history.

Turns out all those health gadgets and apps leave their users vulnerable to inadvertently disclosing private health data.

Julie Rovner breaks down the strategies anti-choice advocates are considering after their Supreme Court loss in Whole Woman’s Health v. Hellerstedt.   

Finally, Becca Andrews at Mother Jones writes that Texas intends to keep passing abortion restrictions based on junk science, despite its loss in Whole Woman’s Health.