Ignorance is not bliss: the need for real sex education at home and abroad
Rebecca Bartlein writes about her concerns with the reauthorization bill for PEPFAR in relation to its ability to prevent the transmission of HIV/AIDS.
Federally funded reproductive health education curriculum in the United States has changed dramatically in the past decade with the passage of Title V, Section 510 of the Personal Responsibility and Work Opportunity Reconciliation Act in 1998 (1). Title V, Section 510 authorized $50 million annually from the federal government for abstinence-only sex education programs in public schools across the country (2). Currently the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, commonly known as the reauthorization bill for PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief (3)) is making its way through congress. However I am personally angered to see that not only has the Bush Administration let ideological considerations supersede public health and ethical concerns in our own health education system but is continuing to export this ideology as one of the strings attached to PEPFAR aid money. Currently, PEPFAR allocates a third of its funds for abstinence-only sex education as a means to prevent HIV, and encourages youth education about condoms only when emphasizing the failure rate of these prophylaxes. Although the language in the current reauthorization act is not as specific, little change in programming will occur unless PEPFAR has specific stipulations for including comprehensive reproductive health education for young people.
The evidence that the abstinence-only educational model is not appropriate has been presented in many studies in the U.S. (4). Studies have been done to evaluate how closely the sexuality education curriculum in Title V programs follows what parents/taxpayers want and expect in terms of sexuality education for their children. One such study by researchers at the University of North Carolina - Chapel Hill showed that 89% of parents across North Carolina supported comprehensive sexuality education and more than 90% of respondents felt that parents and public health professionals should determine sexuality education content, not politicians (5). This study surveyed 1306 parents across the state of North Carolina, where there are mandated abstinence-only sex education programs. Additionally, multiple studies have shown that abstinence-only sexuality education is not effective at lowering rates of teenage pregnancy or STI/HIV infection (6)(7). In fact, the official evaluation commissioned by U.S. Congress showed no difference in sexual behaviors between youth who had access to the abstinence-only program and a control group that had no access to any sexuality education program (8). These findings do not bode well for the reputation of abstinence-only education, and yet, the administration refuses to acknowledge its failed policy and continues to push its ideological product in the face of solid facts.
So now, countries that are faced with the HIV pandemic and who are looking to the international community for support and funding are forced to accept the strict ABC (A - Abstinence, B - Be Faithful, C - Correct and Consistent use of Condoms where appropriate) approach to HIV prevention in order to receive PEPFAR aid. Unfortunately, twice the amount of emphasis is put on the A and B of the program, which reach over 41 million, than on the C goal, which is only directed to reach 16 million (9). In PEPFAR programs, condoms are only promoted to those considered “high risk” such as sex workers, truck drivers, discordant couples, etc. despite the fact that in most PEPFAR countries the epidemic is generalized throughout the population (10). PEPFAR funds may not be used to promote or distribute condoms to youth or in school settings, and abstinence and faithfulness are the only methods discussed with youth in order to prevent disease and unwanted pregnancies. In fact, PEPFAR implementing agencies are discouraged to educate youth about condoms at all unless it is to emphasize their failure rates and often this manifests in messages that condoms are not reliable enough to make them worth using or that they often have holes in them (10). The result is that people have less accurate information about condoms, which would lead them to use them less, but results in no change in sexual behaviors.
Despite strong scientific evidence that an abstinence-only approach to sexuality education does not lead to the desired results of lower STI/HIV infection rates and fewer early unplanned pregnancies, the U.S. continues to export this intervention through its PEPFAR requirements. While programs should be tailored to fit the cultural and epidemiological specificities of the populations that they aim to reach, in no situation should ideology supersede scientific findings. If the United States wants to protect its reputation as a leader in the fight against the HIV epidemic, it needs to start basing policy decisions on clear and rigorous bodies of medical and scientific evidence. All young people, no matter where they are, “need accurate, positive and comprehensive information about safer sex and condoms because they are already sexually active or will be in the future.”(10). With its dissemination of billions of dollars, the federal government must begin to support comprehensive programs and education that will actively lower the risk of youth developing STIs, HIV and unwanted pregnancies - by taking into account the realities of youth’s behaviors and culture both at home and abroad.
Rebecca Bartlein is a MPH Candidate studying within the Department of Global Health at the University of Washington
(1) “Title V, Section 510 Abstinence Education Program has allocated $50 million annually for programs that teach abstinence from sexual activity outside of marriage as the expected standard for school-age children.” C. Trenholm, B. Devaney, K. Fortson, L. Quay, J. Wheeler, M. Clark. Impacts of Four Title V, Section 510 Abstinence Education Programs Final Report April 2007. Mathematica Policy Research, Inc.
(2) Abstinence-only education for youth is defined as a program that: 1) Has as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity; 2) Teaches abstinence from sexual activity outside marriage as the expected standard for all school-age children; 3) Teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems; 4) Teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of sexual activity; 5) Teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects; 6) Teaches that bearing children out of wedlock is likely to have harmful consequences for the child, the child’s parents, and society; 7) Teaches young people how to reject sexual advances and how alcohol and drug use increase vulnerability to sexual advances, and 8 ) Teaches the importance of attaining self-sufficiency before engaging in sexual activity. C. Trenholm et al.
(3) Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008.
(4) Ethics, Ideology, and Reproductive Health Policy in the United States. Andrzej Kulczycki. Studies in Family Planning Vol. 38 Number 4 p. 333-351. December 2007.
(5) “We defined comprehensive sexuality education as education that includes a discussion of how to use and talk about contraception with partners.” K. Ito, Z. Gizlice, J. Owen-O’Dowd, E. Foust, P. Leone, W. Miller. Parent Opinion of Sexuality Education in a State with Mandated Abstinence Education: Does Policy Match Parental Preference? Journal of Adolescent Health. 2006 Apr 28; 39(5): 634-641
(6) The Content of Federally Funded Abstinence-Only Education Programs. Prepared for Rep. Henry A. Waxman. United States Committee on Government Reform - Minority Staff Special Investigation Unit, December 2004. Permanent URL: http://oversight.house.gov/documents/20041201102153-50247.pdf
(7) Pamela K. Kohler, R.N., M.P.H., Lisa E. Manhart, Ph.D., and William E. Lafferty, M.D. Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy. Journal of Adolescent Health. 2008 Aug; 42: 344-351.
(8) C. Trenholm et al.
(9) Accountability: Report on PEPFAR Partnerships for Prevention, Treatment and Care. Permanent URL: http://www.pepfar.gov/press/fourth_annual_report/99832.htm.
(10) G. Gordon, V. Mwale. Preventing HIV with Young People: A Case Study from Zambia. Reproductive Health Matters. 2006; 14 (28): 68-79.