Monday, December 24, 2012

Just Say No to Abstinence-Only Sex Education - Hasti Mehta

Teen sexual activity continues to remain a prevalent problem for the United States (U.S). Although the proportion of high school students who reported ever having sexual intercourse has remained steady since 2001, it is still nearly half population (47%) (1). Approximately 47% of adolescents aged 14-18 are sexually active, defined as having sex in the past three months (1). Early sexual activity is associated with teen pregnancy, increased risk of sexually transmitted infections (STIs) and a multitude of other physical and mental problems. The U.S. still has the highest teen birth rate amongst comparable countries even though teen pregnancy rates are at the lowest levels since the National Center for Health Statistics (NCHS) began tracking them in the 1940s (2,3). Despite these unnerving statistics, the majority of states continue to implement abstinence-only education and the U.S. continues to predominantly fund abstinence-only education.

Abstinence-Only Education
    For a program to be considered an abstinence-only education program, it must accomplish specific goals as put forth by section 510 (b) of Title V of the Social Security Act (4). The goal of abstinence-only education is to create a social environment in which abstinence from sexual activity before marriage is the norm. Abstinence-only sex education also aims to teach students the importance of healthy, monogamous relationships (namely marriage), the negative psychological impacts of sexual activity prior to marriage, and the importance of being self-sufficient before engaging in sexual activity. Overall, the program is designed as a way for youths to learn how to make sound decisions regarding sexual activity and long-term relationships. This paper seeks to address what are believed to be the primary flaws of the dominant, abstinence-only education program approach to sexual health education; namely, 1) the lack of proper communication between educators and students; 2) the role of individual level health belief models to account for context; 3) the perceived lack of control caused by abstinence-only education programs. Additionally, this paper will offer suggestions for how to improve upon current public health practices, specifically addressing each of the three criticisms outlined above.

Critique 1: Lack of Relatable Educators
            A significant obstacle in the success of the abstinence-only education programs is the difficulty that students have in connecting with the individuals conveying the message. In 2005, 42 percent of teachers in the United States were aged 50 or older compared to 11 percent of teachers who were under the age of thirty (5). In 2011, 31 percent of teachers were aged 50 or older compared to 22 percent of teachers who were under the age of thirty (5). Although the average age of teachers has been on the decline, the problem on connecting with the educator still remains. A message being delivered by someone who is liked, similar, and familiar greatly increases the chance that the message will be taken more positively (6).  Research has shown that a liked source can be more persuasive at times when the message is difficult to process (7). This concept of “liking” is an easy way for individuals to get others to comply with their requests (6). When the person delivering the message is a friend or a known person, it induces feelings of warmth and security and there is a smaller likelihood that the individual will reject the request (8). Liking the person who delivers a message increases the chances that those receiving the message will also agree with the message (9).
            Similarity is another important factor that influences an individual’s decisions. The effects of similarity, however superficial, can create an instant bond between two people (10). When presenters are similar to the audience, their credibility is increased and they have an easier time connecting with the audience. Experiments conducted by Paul J. Silvia about the effect of similarity and likeability on compliance and reducing resistance found that when the presenter’s level of similarity was low or unknown, there was a boomerang effect (9). However, when the presenter was highly similar to the audience the audience agreed with the presenter regardless of the message being delivered (9). The strength of similarity and its effects on persuasion can easily be seen in an experiment conducted at a fundraiser on a college campus where the contributions more than doubled when the phrase “I’m a student” was added to the request (11).
            The last characteristic, familiarity, is also a large influence on whether a message will be well accepted. Normally, individuals are fond of things that are familiar to them (12). Prior experiments have found that merely being exposed to the image of an individual in the past can increase the likelihood that a person will remember the individual and be more likely to be influenced by their statements (8). Although the abstinence-only message being delivered in schools is targeted towards teens, it can be difficult for them to be persuaded because they feel no connection with the teachers delivering the message.
Critique 2: Individual Level Health Models Failure to Account for Context
            The second significant obstacle in the success of abstinence-only education programs is that they do not consider context. The health belief model was developed to explain behavior at the individual level (13). According to the health belief model, individual behavior is influenced by four factors: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (13). Based on this model, an individual weighs the perceived benefits and the perceived costs of an action and makes a rational decision based on the given facts. The health belief model fails to factor in social or environmental influences. It also assumes that all individuals are rational and nothing will influence their decision once they have made it. This model treats individuals as though they are living in a vacuum, not in the real world. While the health belief model would work for one time quick decisions where the behavior will follow the reasoned thought process, it is unlikely to work in situations where the action must be sustained (14). Since the health belief model does not consider context, it is unable to effectively influence behavior. Sexual activity among adolescents has frequently been characterized as unplanned and impulsive (15), but these models are still used to insufficiently influence change amongst them.
            Recent research has shown that there is a definite difference in how individuals, specifically students, make decisions when they are aroused and when they are not. Ariely and colleagues conducted an experiment where they asked male undergraduate students to answer questions in a “cold state” (where they were not aroused) and a “hot state” (where they were aroused) (16). The research found that while in the “cold state” the students were very rational, always took the moral high ground, and predicted that they would use a condom during sexual activity (16). However, when the students were in the “hot state”, they themselves did not know what they would actually do and completely underestimated their actions (16). All thoughts of prevention, rationality, and morality disappeared and they were 25 percent more likely in the aroused state than in the cold state to predict that they would not use condoms (16). The research by Ariely et al. showed that the students who could recite all the risks and negative consequences of sexual activity in the cold state were simply irrational and unpredictable in the face of passion. Teens know the risks that sexual activity can lead to while they are in school or at home, but when it comes to an intimate setting, their perceived benefits and risks can drastically change, thus leading to the very behavior the programs are trying to prevent.

Critique 3: Perceived Threat to Personal Freedom
            The third significant obstacle in the success of abstinence-only education programs is that it specifically urges students to abstain from sex entirely rather than teach them safe-sex alternatives (4). It is common knowledge that freedom of behavior is an important part of human life. In order to make decisions, people normally weigh their wants and needs with the dangers and benefits and decide on ways to get what they want (17). When a person’s behavioral freedom is reduced or threatened, the person will begin to get agitated and look for ways to rebel (17). This need to recover their lost freedom and ensure loss of further freedom is known as psychological reactance (17). This is the problem plaguing the abstinence-only education programs. Research conducted by Sharon Brehm has indicated that children as young as two understand that their freedom is being threatened and will try to restore that freedom (18). Brehm’s study concluded that this behavior demonstrates psychological reactance because the children could not accept that they were not in control and they had to assert their control even though it was not physically possible (18).
            Another example of psychological reactance and its effects can be seen in the experiment conducted on the effect on couples relationships based on negative parental interference (19). The study found that the more the parents had a negative impact, the more the couple stayed together (19). This experiment proves that the more individuals are told not to do something, the more they crave the opposite in order to assert their control. People are very intuitive and can figure out when individuals who approach them do not agree with their point of view. Kevin Hogan, author of “Covert Persuasion” states in his book that “People are quickly receptive to information and attitudes that agree with their point of view. People will formulate arguments on the spot against any point of view that disagrees with their currently held belief” (20). The concepts taught in abstinence-only education programs are stated in a way that causes students to feel as though their personal freedom of choice is being threatened.
Proposed Intervention
            As public health professionals continue to devise different interventions to combat high teen pregnancy birth rates, it is critical they realize the importance of implementing a program to which students can relate. The proposed intervention will consist of three major changes to the current model.
The first major change will be a shift from teachers to peer educators as the main individuals who will convey the message of abstinence-only education programs. Many studies have proven the importance of having someone who is relatable when intending to convey a message. In order to increase the chances of getting the message of abstinence-only being the best way to prevent teen pregnancy across, peer educators will be likeable, similar, and familiar (6,7). It will be important to find students who are familiar with the student body and are well known.
The second change will include implementing group level health models to introduce new behavior and encourage change. Current individual level health models do not address societal factors and the notion that individuals are inherently irrational when making decisions (13,16). In order to reach the student body more widely, it is important to implement alternative models that have the ability to affect change in large groups of people and account for factors such as irrationality and social norms (21). By implementing a group level health model it will be easier to change the social norms and get a greater group of students to practice abstinence.
The third change consists of changing the way the abstinence-only model is currently framed and turning it into a comprehensive sex education model to reach more students and create a more effective program. With the current model threatening the students’ control, it is important to develop a model that allows students to understand that they have choices and it is up to them how they choose to be safe when it comes to sexual activity. By creating a comprehensive sexual health education program, the goal is to frame abstinence in a way that it shows the students that they have more control when they abstain than when they have safe sex.

Solution 1: Shift from Teachers to Peer Educators
            To be able to create an effective campaign that will be able to spread the message of abstinence-only education programs it is imperative to have likeable, similar, and familiar individuals presenting the information to their peers. By placing peers who are well liked and familiar in the role of educators, the students will be more likely to listen and accept the message the students are putting forth. This concept of liking and its positive effects in terms of influencing people was documented in Cialdini’s book, in reference to the Tupperware party. He believes the Tupperware party is the “quintessential American compliance setting” because it uses the idea of liking to sell products (8). Simply because the request to buy the Tupperware does not come from a stranger, the attendees are more likely to actually buy the products (8). This proves that if the student educating his or her peers is well liked, they will have the power to influence the thoughts of their peers.
            Another characteristic that must be present in the peer educators is that they must be similar to the group they are trying to teach. Similarities do not have to be glaringly obvious, but something as trivial as having the same style of clothing as their peers can place a positive spin on the message being delivered (8). This theory was tested out at an antiwar campaign in the 1970s where one female volunteer was dressed as a “hippie” and the other was dressed “straight” and it was found that each of the women attracted more signatures for their petitions from similarly dressed individuals (22). This example proves that dressing the same way and being able to blend in with the crowd that you are trying to persuade can play a huge role in how the message you deliver is perceived. Peer educators would be at much higher advantage than teachers when informing students about abstinence-only education because they are very similar to their peers.
            The final characteristic that is beneficial in efficiently persuading the students to understand the importance of abstinence is to ensure the peer educator’s familiarity. From the first two requirements we understand that the peer educator should be well-liked and similar to the target audience. Guaranteeing that the peer educators are also familiar to a majority of the study body is the last step. It would be beneficial to choose an individual who is involved with student government or an accomplished athlete that is well-known and liked by the students. An experiment conducted during an Ohio election in which a man with little chance of winning changed his last name to “Brown”, a family name of much of Ohio’s political tradition, ended up victorious (8). From the previous examples it is evident that choosing a well-liked, similar, and familiar student to educate his or her peers, the acceptance of abstinence-only message amongst teens can go up significantly.  

Solution 2: Institute Group Level Alternative Models
            In order to combat the flaws the individual model, which include not accounting for social norms, context, and irrational behavior, it is recommended that an alternative model be used. The alternative model will account for the group dynamic, unplanned behavior, visceral drives, and irrational behavior (21). The idea of the “tipping point” as outlined by Malcolm Gladwell would be effective in creating the intended effects. The implementation of the group-level changes in a “hot state” rather than a “cold state” would be another change that would bring about the intended effects of abstinence-only education.
             By creating situations in which students are placed in a “hot state” of mind as mentioned before, the message of abstinence may translate better when the students are in a situation where they must make a sound decision (16). In order to make sure that students are in a “hot state” of mind which can consist of fear, jealousy, anger, or arousal, if would be important to invoke those feelings when the message of abstinence-only education is being presented (16). In order to invoke these feelings, several strategies can be used, including giving the students reading exercises, having them watch videos, or having conversations that invoke the feelings associated to the “hot state”. By giving the message to the student when they are in the “hot state”, it is more likely that they will remember the message when they are engaging in sexual activity.
Gladwell has written about “tipping point”, which is the moment of critical mass, the inflection point, the boiling point at which widespread change occurs (22) and this tipping point is applicable to the diffusion of innovations theory. His book uses the example of Hush Puppies, the well-known American shoe, which were dying out in early 1994 (22). The process by which they became a popular accessory again emphasizes the approach to be taken in order to make abstinence-only more socially accepted. In early 1994, Hush Puppies were dying out and the manufacturers were planning on discontinuing the shoes, but they found that Hush Puppies were beginning to become a fashion statement again in the clubs and bars in downtown Manhattan (22). Soon fashion designers were asking the company to use the Hush Puppies in fashion shoots and other high profile individuals were asking for a pair as well (22). Soon after there was a huge increase in sales and the Hush Puppies once again became a hot trend (22). This example demonstrates that there was a time when only a few people wore the Hush Puppies, precisely because no one else was wearing them, but after the shoe was picked up by two fashion designers, there came a certain point where the shoes became a fashion statement unintentionally (22). By applying the concept of the tipping point to abstinence-only education, a few early adopters can fuel the trend, which will eventually be adopted by the rest of their peers. In this way, abstinence will become the norm rather than something students are resistant to.
Solution 3: Emphasizes Freedom of Choice  
Abstinence-only programs are very difficult to frame in a way that does not intrude on the students’ personal freedom of choice, thus the proposed intervention should include resources for students who choose to engage in sexual activity to do so safely.
Applying advertising theory to the abstinence program is another way to enact change in teens and frame the idea in a way that is appealing to the intended audience. The three main components of advertising theory are the promise, the support, and the core value (23). The idea of advertising theory is to speak to the deepest aspirations that people possess and deliver a message that addresses those aspirations. The promise will be adequately supported by images, sounds, and stories that invoke certain core values that the intended audience holds dear to them (23). Advertising theory emphasizes the desired behavioral change rather than the individual’s current action (23). Advertising theory touches on the idea that people are irrational and can be easily persuaded to change their opinion if the right techniques are employed. In order to induce change by using advertising theory, it is important to create a promise that the teen population can relate to and may actually want. Once the promise is created, it would be important to support the promise with related music and images that speak to teens. It is imperative to ensure that the advertisement speaks to the core values that teens hold dear, one of the main ones being freedom. By emphasizing the promise of freedom of choice or freedom from burden at such a young age, advertising theory can be effectively used to convey the message of abstinence-only to a larger audience.
The next piece would be to market and brand the idea in a way that would be appealing to teens. Appropriate use of marketing theory includes researching what people want and applying those findings to create and package the message in a way that fulfills the needs and wants of the target population (24). From the Florida “truth” campaign it was found that students wanted “the facts” and then they wanted to be left alone to make their own decisions (25). The “truth” campaign found that if they wanted to be successful they would have to give alternate options instead of just “don’t” (25). By defining freedom as one of the most prevalent core values in teens, the abstinence-only education programs need to be replaced by comprehensive safe-sex education programs that give teens the freedom of choice and the chance to make an educated decision if they choose to engage in sexual activity. In order to reach teens effectively, they need to receive honest, effective sex education which helps them understand the options available to them should they choose to engage in sexual activity, thus the intervention should be amended to include a comprehensive sex education component.

In summary, although there are good intentions behind the abstinence-only education programs, research has shown that they are not effective at producing favorable results when it comes to delaying early sexual activity and decreasing teen pregnancy rates. The most obvious flaws include the lack of familiarity and similarity between the educators and teens learning about abstinence, the lack of a group level intervention that accounts for irrational behavior, and the threat to teens’ freedom of choice at such a rebellious age. Through this intervention, the flaws of the abstinence-only program can be seen and the proposed solutions of adding a group-level, peer educated abstinence program with a comprehensive sex education component can gain support.


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