ABSTINENCE-ONLY EDUCATION: PROTECTING THE PUBLIC'S HEALTH OR POOR PUBLIC POLICY?
by
Alexandra Lehtonen Penney
A paper submitted to the faculty of the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Master of Public Health in the
Department of Public Health Leadership, School of Public Health.
Chapel Hill 2002
ABSTRACT
ALEXANDRA LEHTONEN PENNEY: Abstinence-only education: Protecting the public's health or poor public policy?
(Under the direction of Lorraine Johnson.)
American adolescents are paying a heavy price for their sexual activity: contending with one million pregnancies annually, suffering from 250,000 cases of HIV, and bearing a disproportionate burden of the most commonly reported sexually transmitted infections (STis ). The grim state of adolescent sexual health makes reduction of the behaviors associated with pregnancy and STI/HIV risk a high priority. Interest in reducing the nation's adolescent pregnancy and STI/HIV bnrden is part public policy and part politics; while there exists a desire to reduce the infection and pregnancy burden for the betterment of the community, many individuals view adolescent sexual activity and its consequences, such as out-of-wedlock births, as immoral. This "difference of opinion" acts as a barrier to developing initiatives to reduce adolescent sexual risk.
does exist, however, to support comprehensive, community-tailored programs that ~--target teenagers, but the funding for such programs relative to abstinence-only
curriculums is abysmal. The issue of teen sexuality has followed the same path as abortion and physician-assisted suicide, where religious theory and political election concerns, not empirical evidence, drive policy decisions.
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LCONTENTS
Chapter Page
1 1 2 3 4 5 6 7 8
INTRODUCTION ... . THE PUBLIC HEALTH IMPLICATIONS OF ADOLESCENT SEXUAL HEALTH ... . 2.1 Sexually transmitted infections (STis) ... . 2.2 HIV/AIDS ... . 2.3 Adolescent surveys related to STI and HIV risk ... .
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2.4 Pregnancy... . . . 5 ADOLESCENT DEFINITION OF SEX ... .
ADOLESCENT PERCEPTION OF SEXUAL RISK ... . PROGRAM INITIATIVES ... . 5.1 Abstinence-only education (AOE) programs ... .
6 7 8 8 5.1.1 Funding history of AOE programs... 9 5.1.2 Federal definition of AOE programs ... .
5.1.3 AOE proponents ... .
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5.1.4 AOE opponents... 14 5.2
5.3 5.4
Comprehensive education programs ... . School-based programs ... . Youth development programs ... . REDUCING ADOLESCENT RISK: EXPERT OPINION ... .
15 15 16 18 6.1 Center for Diseases Control and Prevention (CDC)... 18 6.2 National Campaign to Prevent Teen Pregnancy (NCPTP). 18 6.3 Health professions organizations... 19 EUOROPEAN ADOLESCENT COMPARISON ... .
CONCLUSIONS ... .
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ACLU AFLA AGI AOE AMCHP CDC EC HP 2010 HRSA IOM
KFF
MPRG NARAL NCPTP PRWORA STis SPRANS-CBAE UNICEFLIST OF ABBREVIATIONS
American Civil Liberties Union
Adolescent Family Life Act
Alan Guttmacher Institute
abstinence-only education
Association of Maternal and Child Health Programs
Centers for Disease Control and Prevention
emergency contraception
Healthy People 2010
Health Resources and Services Administration
Institute of Medicine
Henry J. Kaiser Family Foundation Mathematica Policy Research Group
National Abortion and Reproductive Rights Action League
National Campaign to Prevent Teen Pregnancy
Personal Responsibility and Work Opportunity Reconciliation Act
sexually transmitted infections
Special Projects of Regional and National Significance-Community Based Abstinence Education
United Nations International Children's Fund
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~-INTRODUCTION
There is little chance that any U.S. citizen has been able to avoid the great debate about what adolescents should or should not be taught about their sexual health. Adolescent sexual health education has garnered local, state, and national media coverage. Newspapers in Michigan, Maine, Louisiana, Texas, North Carolina and the District of Columbia have all run articles addressing state and national policies on sexual health education (Manolatos, 2002; Kahrl & Hill, 2002; Ritea, 2002; Ackerman, 2002; Hennessy-Piske, 2002; Rochman, 2002; Connolly, 2002). U.S. News & World Report ran a cover story entitled "Teens & Sex" in May of this year exploring the issues surrounding teen sex practices, sex education, and parental involvement (Mulrine,
Coverage of adolescent sexuality is not limited to the media. The Office of the
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Surgeon General, the Institute of Medicine, the Henry J. Kaiser Family Foundation, the National Campaign to Prevent Teen Pregnancy, and Human Rights Watch have all recently released reports addressing adolescent sexual health education. State and national politicians have debated the issue in their respective houses of government. School systems nationwide are contending with the issue. A school district in Modesto, California received national news coverage after it banned discussions pertaining to
pregnancy and contraception, citing the need to make abstinence the key feature of sex
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education classes (Henry J. Kaiser Family Foundation, 2002, May 30).
12th grade have engaged in sexual activity. Alarmingly, 6.6% of students have engaged in sexual activity before the age of 13 (CDC, 2002). American adolescents are engaging
in sexual activity and suffering the consequences: contending with high rates of
sexually transmitted infections (STis), IITV/AIDS, and pregnancy.
The purpose of this paper is to first describe the impact of adolescent sexual
activity on the nation's public health. The literature will be explored to identifY program
initiatives aimed at reducing adolescent risk. Program initiatives will be described, with
particular attention being paid to abstinence-only education curriculums. The paper will
conclude with a commentary on current U.S. policy initiatives aimed at adolescents.
THE PUBLIC HEALTH IMPLICATIONS OF ADOLESCENT SEXUAL HEALTH
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ACTIVITY
Sexually transmitted infections (STis)
When President Bush declared STis a "hazard to the Nation's public health" in a
White House press release this year there was little debate as to the truth of this
statement (White House Press Release, 2002). There are nearly twenty-five different
pathogens that can infect the human reproductive system (Cates et al., 1999). These
pathogens, when left untreated, can cause a myriad of health dilemmas including
infertility, central nervous system damage, and even death (Cates et al.). Approximately
fifteen million STI infections are reported annually (Cates et al.); 20% of these cases
occur in teenagers (CDC, 2002).
In one study published in the Journal oflnfectious Diseases, fifty percent of the
(Bunnell, 1999). DiClemente et al. (2002) published a study wherein 26% percent of the enrolled adolescents reported prior STis. The STI rates presented in these two studies are not surprising when considering the adolescent infection rates for specific STis. Each year, 46% of reported chlamydia cases in the U.S. occur in girls between the ages of 15 and 19 (CDC, 2002). Young women between the ages of 15 and 19 represent the greatest number of U.S. gonorrhea infections; young men in the same age group
represent the third highest (CDC, 2000). The human papilloma virus (HPV) is present at the "highest levels" in young women (Institute of Medicine, 1997); an estimated 15% of all female adolescents are infected with HPV (AGI, 1999).
Adolescent STI rates may be complicated by factors different from those of adults, such as higher levels of promiscuity, increased levels of unsafe sexual behavior, and developmental differences (CDC, 2002). Additionally, adolescents may not have access to the health services necessary for the diagnosis, treatment, and follow up of STis (Institute ofMedicine, 1997; Society for Adolescent Medicine Position Paper, 1992).
The costs associated with treating STis in the U.S. are astounding; approximately seventeen billion dollars is spent annually in the United States on
STIIHIV-related health care (Institute of Medicine, 1997). While STis present a serious public health issue, preventive measures are woefully lacking; for every forty-three dollars spent on treatment, one dollar is spent on prevention (Institute of Medicine).
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-i--HIV/AIDS
There are upwards of two-hundred and fifty thousand adolescents living in the
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U.S. with HIV infection (Goodenow, 2002). Between 1990 and 1995, rates ofHIV
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infection among 13-25 year olds increased 20% in the U.S. (CDC, 2002). A UNICEFreport published this year stated that the "vast majority" of 15-24 year olds from sixty different countries do not comprehend how HIV is transmitted; in some countries the percentage is as high as 80% (UNICEF, 2002). Alarmingly, but perhaps not
surprisingly, half of all new HIV infections worldwide occur in young adults between the ages of 15 and 24 (UNICEF).
In the 1997 Institute of Medicine (I OM) report entitled No Time to Lose: Getting More From HIV Prevention, the committee concluded that strong federal leadership for HIV prevention is lacking. The committee further concluded that there are great social barriers to HIV prevention, such as social taboos, political fear and disinterest. Contained within this IOM report are four strategies aimed at reducing the overall U.S. HIV burden; one of these four strategies was devoted entirely to reducing adolescent HIV risk. The IOM committee set forth two specific goals of adolescent risk reduction: ensure that teens receive information pertaining to risk reduction prior to sexual activity initiation and have continued access to education, services, and information after sexual initiation.
Adolescent surveys related to STI and HIV risk
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percent of the college men polled did not know how to use a condom correctly. In a }--survey conducted by the Henry J. Kaiser Family Foundation and Seventeen Magazine,
less than half of all teenagers have had discussions with their parents about STis and HIV (Kaiser Family Foundation/Seventeen Magazine, 2002). According to this same survey, health care providers (HCPs) are not faring any better than parents. Thirty-four percent of teenagers polled had prior discussions with their HCP regarding STis; 25% percent had prior discussions with their HCP regarding condom use (Kaiser Family
L Foundation/ Seventeen Magazine). The results of this study run contrary to the results ;___ of one study based on physician self-report. Kelts et al. (2001) reported that 73% of
family practice providers reported asking adolescents about condom use.
An element of the risk reduction controversy is that there remains doubt as to how effective condoms are at reducing STI and HIV transmission risk. This debate was fueled by a National Institutes of Health study published in 2001 citing a lack of
evidence that condoms were always effective in preventing the transmission of HIV and
STis (Adams, 2002). According to the CDC "the correct and consistent use of latex
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condoms has been shown to be highly effective in preventing the transmission of HIV and other STDs" (CDC, 2002).
Pregnancy
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The overall U.S. teen pregnancy rate for girls 15-19 years of age has dropped annually since 1991 (CDC, 2002). Currently, the teen birth rate is estimated to be 29
births per 1,000 adolescents, down from 37 in 1990 (Annie E. Casey Foundation, 2002). L Adolescents who carry their pregnancies to term face greater challenges than do older
women. Teenage mothers are more likely to smoke during pregnancy, more likely to give birth to children oflow birth weight, and less likely to obtain prenatal care (CDC, 1998). Families of teenage parents are more likely to live in poverty (Grogger &
Bronar, 1993) and less likely to achieve academically (Klepinger, 1995).
The public costs of adolescent childrearing are vast. In Washington, DC, a city with one of the highest teen pregnancy rates in the country, approximately seven-hundred and forty-seven million dollars is spent annually on public support for teen parents and their children (Henry J. Kaiser Family Foundation, 2002, June 13). In contrast, the city spends a mere six million dollars on teen pregnancy prevention efforts annually (Henry J. Kaiser Family Foundation). The CDC estimates that between 1985 and 1990, approximately 40% of the national costs associated with teen births could have been saved had those teens waited until they were twenty years of age to bear children (CDC, 1999).
ADOLESCENT DEFINITION OF SEX
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2002). Acts of adolescent partner exchange and sexual bartering have been reported ~-(Manolatos, 2002). There is danger in such incongruent definitions of sexual activity;
while it may appear that great strides have occurred in reducing adolescent risk, increasing risk may be the reality.
ADOLESCENT PERCEPTION OF SEXUAL RISK
Research has attempted to assess why adolescents engage in high-risk sexual
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behavior. Ellen eta!. (1996) found in their study that teenagers often did not consider themselves to be at risk for contracting STis. The self-assessed risk was even lower after alcohol consumption. Richter eta!. (1993) found that high-risk sexual activity among adolescents was correlated with other types of risky behavior, such as drug and alcohol use. Locket a!. (1998) found that adolescent men and women differed in how they addressed sexual risk reduction, such as condom use, with their sexual partners; adolescent women placed greater emphasis on partner trust than did their male counterparts. Ellen eta!. (1996) found in their study sample that as familiarity with a partner increased, the likelihood of condom use decreased. Kelly & Morgan-Kidd (200 1) found in their study of 48 adolescent girls that sexual risk taking was influenced by many factors, such as gender roles, peers, and the search for love.
Beal et a!. (200 1) found in their sample of 208 seventh graders that peers wielded more influence on risk taking behaviors than did parents. In contrast, other studies have shown that parental involvement can be effective in reducing adolescent sexual risk taking. McNeely et al. (2002) found that high levels of maternal
(2000), DiClemente eta!. (2001), Crosby eta!. (2002), and Jaccard (1996) all found similar positive results with parental monitoring.
The results of these studies illustrate the intricacies of addressing high-risk teen behaviors as teenagers have different thoughts, motivations, and feelings surrounding the choices that they make. The results of these studies also suggest that a single approach may not be adequate in reducing adolescent sexual risk taking.
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PROGRAM INITIATIVES L
Programs aimed at reducing adolescent sexual risk have been developed and implemented to curb overall risk. To begin the discussion of program initiatives, a discussion of two primary types of sexual health education curriculums, abstinence-only education (AOE) and comprehensive education, will take place. Both types of
curriculums take place within school systems and within the community.
The impact of AOE programs, specifically within school systems, will be discussed in this chapter in addition to a discussion of youth development programs.
Abstinence-only education (AOE) programs
The core principle of any AOE program is that adolescents should not engage in
any kind of sexual activity prior to marriage; teens are simply encouraged to avoid any L 1 and all sexual activity. Additionally, any discussion of birth control in an AOE program
Funding history of AOE programs
There are currently three federal programs that allocate funds for AOE programs: the Adolescent Family Life Act (AFLA), the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA- aka Welfare Reform), and the Special Projects of Regional and National Significance-Community Based Abstinence Education (SPRANS-CBAE). Funding for the three programs totaled one hundred and two million dollars for the current fiscal year; an additional thirty-three million dollars
was proposed for fiscal year 2003 by President Bush (NARAL, 2002). Federal funding
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allocations are based on a state's contribution. For example, under PRWORA everythree dollars in state funding is matched with four dollars in federal funding (NARAL, 2002).
Public funding of AOE programs began in 1981 under President Reagan after the passage of the Adolescent Family Life Act (AFLA) (AGI, 2002). Initially, AFLA funds primarily went to churches to support "chastity" programs until the ACLU challenged federal fiscal support of religion-based programs (Planned Parenthood, 200 I). The AFLA remains intact today, receiving a twelve million dollar allocation in 2002 (AGI).
While federal funding for AOE curriculums began in 1981, it was the passage of
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the PRWORA in 1996 that signaled a renewed interest in the use of AOE curriculums.
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we know it"), the bill was criticized by an equal number of individuals who expressed
deep disappointment in the passage of a bill that had the potential of sending millions of
men, women, and children into worsening cycles of poverty. One critic of the new
welfare policies was a former Clinton Department of Health and Human Services
appointee, Peter Edelman. In an article published in the March 1997 issue of the
Atlantic Monthly, Mr. Edelman admonished President Clinton's decision to sign the bill
into law, entitling his article "The worst thing Bill Clinton has done."
Prior to the passage of the PRWORA in 1996, no new federal legislation had
been passed for AOE funding for 15 years. The PRWORA allocated an additional fifty
million dollars for abstinence-only education curriculums (White House Press Release,
2002) and renewed the debate over what adolescents should be taught about sexual
health. However, the impact ofPRWORA on AOE curriculums went beyond money.
Federal definition of AOE programs
In addition to providing additional AOE program funding, the PRWORA carried
with it a newly created federal definition of AOE, language generated by a small
number of conservative Congressmen (AGI, 2002). Programs that qualifY for federal
funding under PRWORA are not required to address each component of the federal
AOE definition, but programs do risk funding loss if they violate any component of the
defmition (NARAL, 2002). These restrictions decrease the amount of flexibility
programs have to tailor their message to their target audience.
According to the federal AOE definition, curriculums utilizing federal dollars must:
• "Have as its exclusive purpose teaching the social, psychological, and health gains
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t-• teach abstinence from sexual activity outside marriage as the expected standard for all school-age children;
• teach that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;
• teach that mutually faithful, monogamous relationship in the context of marriage is the expected standard of sexual activity;
• teach that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects;
• teach that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child's parents, and society;
• teach young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances;
• teach the importance of attaining self-sufficiency before engaging in sexual activity."
Excerpted from Title V of the Social Security Act, Section 510(b)(2)(A-H).
On May 16th of this year, the U. S. House of Representatives passed a revision of the 1996 PRWORA entitled the Personal Responsibility, Work, and Family
Promotion Act, legislation that secures AOE funding through the year 2007 (Henry J. Kaiser Family Foundation, 2002, June 27). The U.S. House of Representatives defeated a Democratic-led proposal that would have allowed increased state flexibility to
incorporate "medically and scientifically accurate information" into sexual health education programs (Association of Maternal and Child Health Programs, 2002). At the time that this paper is being written, the bill has moved to the Senate Finance
Committee (Association of Maternal Child Health Programs).
The third funding source for AOE programs comes through the Special Projects
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(SPRANS-CBAE), a program created in 2000 by Congressional AOE proponents (NARAL, 2002). Unlike funding under the PRWORA, the SPRANS-CBAE Act mandates that each component of the federal AOE definition be included in the funded curriculum (NARAL, 2002). Programs that qualifY for SPRANS-CBAE may under no circumstances include information on sexual risk reduction strategies (NARAL, 2002).
AOE proponents
Supporters of AOE cite what economists call the "moral hazard theory" to support the continued and increased funding of AOE programs. The "moral hazard theory" is a term originally utilized by the insurance industry (Lindsey, 2002).
According to this theory, there is an increased risk of a negative event occurring when the costs of that risk are reduced for the insured (Lindsey). When applied to adolescent sexual health, this theory infers that when adolescents are armed with risk reduction knowledge their perceived risk is reduced, thus increasing the likelihood of a negative outcome. According to this theory, providing disease and pregnancy prevention information to adolescents only serves as a catalyst for engagement in high-risk activities, resulting in increased numbers of pregnancy, STis, and
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infection. Research, however, has shown otherwise.In a report published by the National Campaign to Prevent Teen Pregnancy (N CPTP), based on a meta-analysis of nearly 100 pregnancy prevention studies, authors noted that there is no evidence to suggest that programs promoting condom use
increased sexual activity (NCPTP, 2001). Song et al. (2000) completed a meta-analysis of 67 sex education studies and concluded that comprehensive programs had a positive
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effect on "overall sexual knowledge". Jaccard (1996) completed a meta-analysis of
clinic-based programs targeting adolescents and concluded that the use of such clinics
did not lead to an increase in sexual activity. Graham eta!. (2002) noted no increase in
emergency contraception (EC) use and sexual activity after an EC educational
intervention. McNeely et al. (2002) found no increase in sexual activity after teens
received parental-led education about birth control.
Support for AOE goes beyond the moral hazard theory, however. AOE
supporters often have deeply held religious beliefs and their support of AOE programs
comes from a desire to instill individual and collective morality. In fact, the AOE
movement began with a religious perspective in 1981; AFLA funds were allocated to
churches to spread the virginity message (NARAL, 2002). AOE supporters are not shy
about their religious tone; one public AOE agency official in Louisiana affirmed his
support for AOE programs by stating they will "restore our Judea-Christian heritage in
America" (ACLU, 2002).
There is a small but growing group of AOE proponents who base their support
on medical science rather than religion. This group of AOE supporters cites condom
failures, the sheer number of potential sexually transmitted infections, and the risk
associated with high numbers of sexual partners as reasons enough for adolescents to
abstain from sexual activity (Ackerman, 2002).
President Bush's administration has made AOE programs the center of its
strategy to reduce the nations' adolescent disease and pregnancy burden. In a White
House Press statement released in February of2002, the Bush Administration made the
following statement about AOE programs, "the goal of Federal policy should be to
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;emphasize abstinence as the only certain way to avoid both unintended pregnancies and STDs" (White House Press Release, 2002). As previously stated, President Bush has proposed a thirty-three million dollar increase in federal AOE program funding for fiscal year 2003 (HRSA, 2002).
AOE opponents
While many advocates of abstinence-only education programs hail its continued
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funding, there remains little research to support its effectiveness in reducing adolescent sexual activity and sexual risk taking. According to the Mathematica Policy Research
Group (MPRG), a research group selected by the federal government to evaluate the l
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effectiveness of AOE programs, no "definitive research has linked" AOE programs to reduced teen sexual activity (MPRG, 2002). A MPRG preliminary report on AOE programs is due to be completed in 2003 with a final report following in 2005 (MPRG).
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Despite the lack of scientific evidence supporting the effectiveness of AOE curriculums, AOE curriculums continue to be funded.
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In addition to the lack of reliable research showing that they are effective, AOE programs continue to be developed and implemented despite what the general public, parents, and adolescents say about adolescent sexual health education. Eighty-one
percent of American adults support sex education (KFF, 2002). Sixty-five percent of L parents are in support of their children receiving sexual education (AGI, 2001).
Adolescents themselves want more sexual health education (AGI, 2001); in one study
~--Comprehensive education programs
A comprehensive sexual health education curriculum, sometimes referred to as
abstinence-plus, also discusses sexual abstention but includes in the curriculum
information on pregnancy and disease prevention, such as correct condom use.
Unlike AOE, there is no federal definition of comprehensive sexual health education.
The U.S. Congress approved fifty million dollars for abstinence-plus programs
in May of this year (Henry J. Kaiser Family Foundation, 2002, June 7).
School-based programs
Schools are important resources for reducing high-risk adolescent activities
(Office of the Surgeon General, 2001; Institute of Medicine, 1997; Bunnell eta!., 1999).
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Schools are able to structure adolescents' sexual health class time, enable access to peer
programs, and ensure that all adolescents receive risk reduction information (Office of
the Surgeon General). One community program objective of Healthy People 2010 was
to "increase the proportion of middle, junior high, and senior high schools that provide
school health education to prevent health problems in the following areas ... unintended
pregnancy, HIV/AIDS, and STD infection" (Department of Health and Human
Services, 2001). Schools, however, have become major battlegrounds for the sexual
education debate
As previously stated, there are two primary types of school-based sexual health
education curriculums, abstinence-only and comprehensive. While the school districts
themselves develop curricula to address adolescent sexual health, the schools receive L
schools are required by law to utilize an AOE foundation (Ackerman, 2002). Great regional differences exist between the states in how they address sexual education; fifty-five percent of the programs in the Southeast are based on an AOE curriculum, versus 20% in the Northeast (AGI, 2001).
An estimated fifty-three percent of U.S. school districts changed their
curriculums after the enactment of the PRWORA, in large part because of the federal definition contained within the legislation (Landry eta!., 1999). In 1988, two percent of schools nationwide used an abstinence-only foundation for their sexual education
programs; in 1999 that number had risen to 23% (Alan Guttmacher Institute, 2001; Ackerman, 2002).
The curriculum changes that took place in school systems across the country were the result of political and ideological pressure, they were not the result of new research or the identification of best practice. For those who work within school systems providing health education services, such as school nurses, policy changes can stifle adolescent health promotion and prevention messages. Restrictive policies infringe on professional autonomy, potentially leading to increased job-related frustration and reduced job satisfaction.
Youth development programs
While it is beyond the scope of this paper to discuss each and every adolescent risk reduction strategy available, there is one specific type of curriculum that has been proven to be effective in reducing adolescent sexual risk: youth development programs. Youth development programs utilize the socio-ecological framework to create programs
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tailored for those adolescents involved. Stokols (1992) discusses the interplay of multiple levels of human functioning in addressing health behaviors in his article "Establishing and maintaining healthy environments: Toward a social ecology of health promotion." Stokols argues that success in inducing behavioral change must include perspectives involving the population, the community, and the organization, in addition to the individual. Stokols argues that the majority of health interventions incorrectly focus upon the individual level, ignoring social and cultural structures that exert pressure upon choices made at the individual level. Youth development programs utilize the principles discussed by Stokols, aiming to create healthier environments rather than focusing upon a single risk factor. The concept is simple enough: healthier adolescents make healthier choices. The following text describes some examples of youth development programs.
The Seattle Social Development Project (Lonczak eta!., 2002) and Safer Choices (Coyle et al., 1999) both utilized randomized control trials to demonstrate reduced risk taking among those enrolled adolescents. Adolescents enrolled in both interventional groups exhibited less risk taking behaviors than their control
counterparts. Project Northland (Perry eta!., 2000) also utilized a randomized control trial to reduce alcohol use among adolescents. The Students Together Against Negative Decisions (STAND) curriculum (Smith & DiClemente, 2000), a rurally based youth development program, was successful in increasing condom use and decreasing risk among its adolescent participants.
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REDUCING ADOLESCENT RISK: EXPERT OPINION ~-Centers for Disease Control and Prevention (CDC)
The CDC clearly supports multi-dimensional, community-based projects. The ~-agency funded a select number of community-based projects aimed at reducing
adolescent HIV and STI infection and provided information pertaining to these
programs on a web page entitled "Programs That Work" (CDC, 2002). The following is a sampling of the programs proven to be effective in reducing adolescent sexual risk
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featured on the CDC's website:
• Be Proud! Be Responsible! A community-based program targeting young black men ages 13-18 in an urban setting.
• Get Real About AIDS. A multi-racial school based curriculum targeting high school aged children.
• Reducing the Risk. A multi-racial program developed to reduce teen pregnancy and STD/HIV infections in high school aged children.
National Campaign to Prevent Teen Pregnancy (NCPTP)
In May of2001 the National Campaign to Prevent Teen Pregnancy (NCPTP)
published a report entitled Emerging Answers: Research Findings on Programs to l
population; a one size fits all approach is doomed to fail. Program development must be based on the needs of the adolescents to be served, taking into consideration local culture, mores, and social norms.
Health professions organizations
The vast majority of U.S. healthcare-related professional organizations have issued statements against the use of AOE curriculums. The American Public Health Association, the American Medical Association, the American Academy of Pediatrics, and the Institute of Medicine (NARAL, 2002); the American Nurses Association (ANA,
1991); and the Gay and Lesbian Medical Association (NewsRX.com, 2002) have all issued statements opposing AOE curriculums. The Office of the Surgeon General also expressed support for comprehensive programs (Office of the Surgeon General, 2001).
EUROPEAN ADOLESCENT COMPARISON
As previously stated, the U.S.Ieads the developed world in rates of teen pregnancy and STis (AGI, 2002 ). The Alan Guttmacher Institute published a
comparative study of teen sexual risk taking in the U.S., Sweden, Great Britain, Canada and France (AGI). In this study it was found that teens in the U.S. were more likely to begin sexual intercourse before the age of 15 years, engage in sexual activity with a greater number of partners, and were found to be less likely to utilize contraception than their European counterparts (AGI). Teen girls in the U.S. were found to be five and a halftimes more likely to give birth and 3.5 times more likely to have an abortion than
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their Swedish and French peers (AGI, 2002). Teenagers in the U.S. are nine times more likely to become pregnant than teenagers in the Netherlands or Japan (AGI, 1999).
Why such startling differences exist between developed countries is partly speculative, but there are differences in how adolescent sexuality is addressed from one country to another. European teenagers suffer from less stigmatization than U.S. teens
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when they engage in sexual activity, have greater access to health care services and contraception options, and have access to sexual health education (AGI, 2002). For
example, nearly 50 years ago Sweden mandated that sexual health education be taught ¥--in every school system (AGI, 2001). Today, Sweden has one of the lowest teen
pregnancy rates in the world (AGI).
An additional difference between the U.S. and Europe lies in the presence of parental notification laws. Many European adolescents do not need to obtain parental permission prior to receiving sexuality-related health care. Swedish health practitioners require no parental notification to service teenagers and guarantee their confidentiality (AGI, 2001). Studies have demonstrated that parental notification laws have an impact on adolescent healthcare access. Reddy et al. (2002) estimated that fifty-nine percent of U.S. teenagers under the age of 18 would stop all contraception and STI screenings if parental notification was required prior to receiving those services. This study
concluded that parental notification laws would reduce the likelihood of teen girls obtaining sexual health services thus "potentially increasing teen pregnancies and the spread of STDs" (Reddy et al.).
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CONCLUSIONS
Policymakers are ignoring the interplay between the various levels of human functioning. By simply encouraging them to say "no", adolescents are forced to unfairly bear the burden to change without enough thought given to greater social, cultural, and psychological states. For example, there is evidence that adolescents with a history of sexual abuse engage in higher risk sexual activity (Goodenow et al., 2002 &
Dilorio et al., 2002). Should adolescents with complex psychological issues be subjected to the same standards as other adolescents? Where do gay and lesbian adolescents fit into the AOE debate when they are not offered the same legal
recognition as heterosexual couples? And from a practical perspective, can abstinence until marriage ever be a realistic goal when a mere seven percent of men and 20% of women are virgins when they get married (UCSF, 1997)?
Restrictive sexual education policies not only affect adolescents, they place undue pressure on those health professionals designated to work with adolescents. School nurses and health educators must abide by the policies set forth by local, state and national governing bodies, often forcing them to choose between evidence-based public health principles and politically-driven public policy. Restrictive policies, such as the ones generated in support of AOE curriculums, degrade professional autonomy.
Successful adolescent risk reduction programs are based on comprehensive, multi-tiered interventions addressing multiple aspects of adolescents' lives. Research exists that can point us in the direction of producing effective adolescent risk reduction programs. Kim et al (1997) completed a meta-analysis offorty adolescent HIV risk reduction programs to assess what effective programs had in common. Kim et al. found
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that effective programs in reducing
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risk among adolescents needed to be theory based, relative to the local community and local culture, and long in duration. Loda et al. (1997) stressed the importance of tailoring the program to meet the needs of the local community when addressing adolescent pregnancy. Whaley (1999) discusses the need to integrate risk reduction program topics, such asmv
and pregnancy, into oneprogram based on the Stages of Change model. As previously discussed, youth development programs have shown great success in reducing adolescent risk. These findings identifY best practice and should serve as a guide for developing funding priorities.
But AOE curriculums ignore these evidence-based fmdings. Instead, AOE programs create a onesizefitsall curriculum that mandates teenagers simply say no -ignoring public health principles, health behavior models, human sexuality, and
common sense. No scientific evidence exists to support the idea that AOE curriculums reduce adolescent sexual risk. Supporters of AOE instead rely on their own morals and values as rationale for AOE programs. This decision by the political elite to develop policies based on their morality and not sound scientific data is a threat to the nation's public health. Ultimately, it is the individual who must decide for himself/herself what is deemed appropriate and morally sound. Until a change in the U.S. political climate occurs, however, public policy based on conjecture, not evidence, will continue to flourish.
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