Leslee Unruh is a happy camper. The president of the National Abstinence Clearinghouse, a network of organizations aiming "to promote the appreciation for and practice of sexual abstinence (purity) until marriage," has good reason to be happy: Her movement, which focuses heavily on promoting "abstinence-only" education in public schools, is on a roll.
"It's growing so fast, as soon as we finish collecting data we end up starting over," Unruh says. "It's growing by leaps and bounds."
And that, say medical researchers, AIDS prevention experts and even U.S. Surgeon General David Satcher, represents a potential public health disaster. Abstinence-only curricula, they argue, withhold from teens vital information about disease prevention and birth control, and often try to keep kids "scared chaste" by giving them "facts" about STDs and condom failure that are misleading, exaggerated or simply wrong. Gay and lesbian teens, whose relationships are ignored or actively disparaged in such programs, may be most at risk.
Money for chastity
Unruh -- whose Web site proclaims on its home page, "Safe Sex is a Deadly Game" -- says she doesn't know exactly how many school districts have adopted abstinence-only programs, but researchers have tracked a major shift in that direction. A study published in the journal Family Planning Perspectives compared similar surveys of secondary school teachers conducted in 1988 and 1999, finding a quantum leap in abstinence-only teaching. "In 1999, 23 percent of secondary school sexuality education teachers taught abstinence as the only way of preventing pregnancy and STDs, compared with two percent who did so in 1988," researchers reported. A 1998 survey of school officials published in the same journal found that 32 percent of U.S. students in grade six or above attended school in districts with abstinence-only policies.
The trend dates from the start of the Reagan administration. The religious right, having lost the battle to keep sexuality education out of America's public schools, pushed to change the direction of that education. In 1981 President Reagan signed the Adolescent Family Life Act (AFLA), appropriating $11 million for programs to promote "chastity and self-discipline" for adolescents. That program continues, with $20 million in funding last year.
This relatively small effort is dwarfed by a measure attached to the 1996 welfare reform bill. The provision, officially Title V of the Social Security Act, authorized $50 million per year in funding for state-run abstinence-only programs for five years, requiring receiving states to chip in their own money equal to at least 75 percent of the federal grant -- making a total of $87.5 million per year. Funding was first distributed in 1998 and will continue through 2002, when the program is up for renewal.
Unlike AFLA, Title V programs must meet a strict, eight-point definition: An acceptable program "has as its exclusive purpose teaching the social, psychological and health gains to be realized by abstaining from sexual activity ... that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases and other associated health problems ... that a mutually faithful monogamous relationship in the context of marriage is the expected standard of sexual activity," and "that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects." The definition effectively bars these programs from teaching teens anything about condoms, contraception or other methods for reducing sexual risk, except to point out their shortcomings.
Steve Morin, director of the University of California-San Francisco AIDS Research Institute's AIDS Policy Research Center, was an aide to Congresswoman Nancy Pelosi when the bill was passed. The abstinence-only provision, he says, was added at the last minute, in the House-Senate conference committee, and never got a full debate. But when Pelosi later tried to remove it, she was treated like she was condemning apple pie and ice cream. "I've never seen such a vicious attack on any legislation in my life," Morin recalls. "Even the Democrats were coming up to us and saying, 'Why are you against abstinence?'"
States quickly lined up for the new money. California is the only state that has not applied for or received Title V funds.
A third law, adopted early last year, added another $50 million in abstinence-only funds over two years, under yet another program using the same eight-point definition. On July 6 Health and Human Services Secretary Tommy Thompson announced $17.1 million in grants from this newest batch of funds.
One of the biggest problems with abstinence-only is that there is no evidence that it works. The new grants came just a week after the Surgeon General issued a report gently noting the lack of research showing that abstinence-only instruction actually causes teens to delay sex. The document, which was immediately attacked by far-right groups like the Family Research Council, added that available evidence "gives strong support to the conclusion that providing information about contraception does not increase adolescent sexual activity."
Indeed, every impartial analysis of research on abstinence-only programs suggests that they are at best unproven, with some researchers believing they actually do harm. In a 200-page analysis just published by the National Campaign to Prevent Teen Pregnancy, researcher Douglas Kirby reviewed 250 studies of programs aimed at reducing teen pregnancy and sexual risk-taking. "Very little rigorous evaluation of abstinence-only programs has been completed," he wrote. "The primary conclusion that can be drawn ... is that the evidence is not conclusive about abstinence-only programs." In contrast, he found that at least some comprehensive programs, which may promote abstinence but also teach contraception and disease prevention for those who have sex, have been shown to change teens' sexual behavior.
"There is no evidence that abstinence-only works," Morin says. "In point of fact it's likely that it's actually detrimental because people are less likely to use protection."
That conclusion is backed by a study in the May 20, 1998 Journal of the American Medical Association comparing the effect on African-American middle-school students of two different sex education programs -- one using an abstinence-only approach and another emphasizing safer sex. Though the abstinence group was less likely to have sex in the three months following the program, that effect faded by the six-month and 12-month follow-ups. Of those who did have sex, youths in the safer-sex group were over three times as likely to use condoms at three months, and continued reporting more condom use at later follow-ups.
Scientific authorities almost uniformly oppose abstinence-only. In its analysis of HIV prevention published last year, the prestigious Institute of Medicine called for "eliminating congressional, federal, state and local requirements that public funds be used for abstinence-only education, and that states and local school districts implement and continue to support age-appropriate comprehensive sex education and condom availability programs in the schools."
A 1996 editorial in the American Journal of Public Health put it even more bluntly: "The victims of this fruitless cultural ideological debate have been the children and adolescents left uninformed and untaught in how to reach responsible decisions about their intimate relationships with opposite- or same-sex partners. ... To promote sexual abstinence without comprehensive sex education (including information on contraceptives and family planning) is futile, as has been shown many times here and abroad."
Other supporters of the comprehensive approach to sex education include the American Medical Association, American Medical Women's Association, American Nursing Association, American Public Health Association, American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry.
Misinformation and homophobia
Numerous abstinence-only curricula have been developed -- often by religiously affiliated groups -- and implemented in America's schools. A common thread running through many of them is use of shame and scare tactics to frighten youths into avoiding sex.
An analysis of nine abstinence-only curricula (including several from groups just funded by Health and Human Services) published this spring by the Sexuality Information and Education Council of the U.S. (SIECUS) notes that they "rely on fear and shame, omit critical information, contain medical misinformation" and "include biases based on gender and sexual orientation."
Some of the most critical misinformation involves exaggerated or misleading statistics about condom failure (see "Condom Canards," p. 19), but there are other problems as well. Curriculum materials often "avoid discussing all sexual behaviors except penile-vaginal intercourse," SIECUS notes. "As a result, students are often left with the belief that merely abstaining from this one behavior will protect them from all STDs and unintended pregnancy."
Sometimes the information presented is flat wrong. SIECUS notes that a curriculum called Choosing the Best -- just bolstered by $593,000 from Health and Human Services -- warns kids about syphilis, stating that "over 100,000 new cases [are] reported each year, according to a CDC report." In fact, according to the Centers of Disease Control's STD Surveillance, only 6,657 cases of primary and secondary syphilis were reported in 1999.
Given research showing that gays in their teens and early 20s are at high risk for HIV, one critical issue is how abstinence-only curricula impact lesbian, gay and bisexual teens. Astonishingly, there is no published research on this subject and no one contacted by SIECUS -- including the Surgeon General's office, UCSF AID's Research Institute, SIECUS and numerous other institutions and researchers -- knew of anyone even contemplating such a study.
But there are good reasons to worry. SIECUS cites several instances of homophobia in abstinence-only materials, including an admonition in Sex Respect to "avoid homosexual behavior" in order to avoid AIDS. Some think the core idea of abstinence-only -- instructing teens that only married people can have acceptable sexual relationships -- injures the self-esteem of lesbian/gay/bisexual adolescents. Curricula that disparage condoms, as many do, could increase the damage.
"Nobody that I know of has explicitly examined the impact of this horrific heterosexism on LGB teens," says UC-Davis researcher Stephen T. Russell, author of a study in the June American Journal of Public Health documenting the dangers facing such adolescents. "However, I think the available evidence would affirm that it is bad news for LGB youth. First, we know that schools generally fail to meet their needs -- resulting in negative school climates and negative outcomes (grades, esteem) for LGB youth. Second, the recent article by Susan Blake and colleagues in the same issue of AJPH demonstrated that LGB youth in schools with 'gay-sensitive' HIV education engage in less risky behavior. This suggests what we would assume -- that messages about 'abstinence until marriage' are not only not relevant, but may be harmful to LGB youth, either because they are emotionally/psychologically damning or because they willfully omit critical health/relationship information that LGB youth need."
Asked for her group's message for gay teens, the National Abstinence Clearinghouse's Unruh responds, "We refer to organizations like Exodus," the association of "ex-gay" ministries. "A lot of current sex education is actually recruitment, making a person feel they're homosexual when they're not." NAC's Web site includes a link to the National Association for Research and Therapy of Homosexuality, which promotes "reparative therapy."
Despite the weight of scientific evidence against abstinence-only, Congress is expected to reauthorize Title V next year. SIECUS policy director Bill Smith observes, "I think the real question is not whether this program is going to be reauthorized, but how it will come out the other end." Smith and colleagues hope to at least modify the eight-point definition "to make it less harmful and less destructive for young people" and add a provision -- long opposed by abstinence-only proponents -- requiring that information given teens be medically accurate.
Unruh thinks the political climate bodes well for her effort, saying, "Now that we have a president who believes in abstinence till marriage, it's growing by leaps and bounds."
-- Bruce Mirken is a San Francisco-based writer who has been writing about the AIDS epidemic since the mid-1980s. His work has appeared in wide variety of publications, including the San Francisco Chronicle, Miami Herald and Men's Health.