What's wrong with abstinence education?

Abstract: This article addresses problems with the current federal approach to abstinence education and problems with curricula that are often supported by this funding. The federal definition of abstinence education is problematic for a number of reasons. In addition, there is no published research that demonstrates this approach is effective in reducing risky sexual behaviors. Problems with many abstinence education curricula include the provision of misinformation and the use of scare tactics to persuade young people to abstain from sexual involvement. Those interested in providing young people with accurate information and effective programs should take action.

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Over 20 years ago when the Office of Adolescent Pregnancy Program (OAPP) funded their first abstinence education grants, a proposal that I had submitted from the University of Arkansas was among those awarded funding. Of the 32 funded projects that sought second year funding we were the only project that was not funded; and we were the only project that received a national award for our work. In a sworn deposition one of the agency's project officers said that contrary to official statements made by the agency, the real reason we did not receive funding was that it would have been embarrassing to certain conservative members of Congress. A recent book that documents the history of sex education states that the project from the University of Arkansas was not funded "because of pressure from anti-abortion activists that their materials were 'Godless'" (Irvine, 2002, p.96). This was about the same time that I was ordained as a deacon in the Southern Baptist church and was a candidate for a foreign mission appointment. Several years later, when we were receiving funding from OAPP, I gave a deposition with attorneys from the U.S. Department of Justice and the ACLU. The concern now was that we were promoting religion.

I am the co-author of an abstinence education curriculum series and a collection of abstinence education teaching activities. They are both widely used. A number of evaluations of these curricula, indicating positive results, have been published in scholarly journals. Our materials have, however, been actively attacked by conservative groups at both the state and national level. A few years ago one of our state representatives running for state senate told people, as part of his stump speech, that our curricula encouraged young people to engage in homosexual behavior while teens, as a way to prevent teen pregnancy. The same legislator loudly threatened to "beat the crap" out of me at a meeting of the governor's abstinence committee. Since a reporter was there, with a tape recorder running, we made front page headlines the next day, and were in the papers almost every day for the next two weeks.

Our teacher training/curriculum project from which our abstinence education materials originated is a five time winner of the U.S. Department of Health & Human Services Award for Outstanding Work in Community Health Promotion. In spite of nominating our project for the award on five different occasions, the Arkansas Department of Health has yet to provide our abstinence education project with any funding. At the recommendation of the governor's abstinence committee, our state health department canceled an abstinence education contract with us, because a workshop a colleague and I presented at an international conference in Canada, was critical of the federal government's involvement in abstinence education. An electronic abstinence education newsletter, originating in the office of a U.S. Congressman, headlined their story with the title "Sex Society Recommends Fraud to Obtain Abstinence Education Funding."

Our governor has written legislators concerning my statements about abstinence education in the state. The first sentence of his letter read "Let me address some of the untruths told you by Dr. Michael Young of the University of Arkansas." He did not provide me with a copy of the letter. He did mail a copy to our Chancellor. When another faculty member and I surveyed abstinence education coordinators, a conservative group sent letters protesting our research to every potential respondent, the Chancellor, the governor, and the University's Board of Trustees. The IRB was pressured to "unapprove" our study, the purpose of which seemed to be to have us declared guilty of research misconduct (and subsequently fired).

These are some of the "highlights" of 20 plus years of attempts to work in abstinence education. I think they give me the background to discuss the current situation in this country relative to abstinence education.

Controversy concerning public school instruction regarding human reproduction and other topics related to sexuality is nothing new. Now the controversy concerns abstinence education (and not just abstinence education, but the "right" kind of abstinence education). What is wrong with encouraging young people to abstain from participating in sexual activity? Nothing. It is what we ought to be doing. Many other sexuality educators and public health professionals also believe that encouraging young people to delay the initiation of sexual intercourse and other behaviors that can place them at risk for sexually transmitted disease is a legitimate goal of sexuality education. What is wrong with the government's current approach to abstinence education and many of the programs supported by federal tax dollars? Plenty. The purpose of this paper is to provide readers with an increased awareness of current efforts in abstinence education and encourage them to take action.

The issue relative to abstinence education is not simply that programs are encouraging young people to postpone sexual involvement. The issue is two-fold: (1) the restrictive, problematic federal welfare reform definition of abstinence education and (2) the funding of abstinence education curricula which are ineffective and provide inaccurate information. This combination translates into abstinence education programming which often deliberately provides inaccurate information in a misguided attempt to scare young people into choosing abstinence.

THE A-H DEFINITION OF ABSTINENCE EDUCATION

Federally funded abstinence education programming must meet the federal definition of abstinence education (see Table 1). Among other requirements, the a-h definition mandates that funded programs teach abstinence only, until marriage--setting marriage as "the expected standard of human sexual activity" (Block Grant, 1997, p. 10). Those who are interested in the historical aspects of federal involvement in abstinence education may wish to read the article which Eva Goldfarb and I wrote which provides background information, including the U.S. Supreme Court decision in the Kendrick case and the subsequent settlement (Young & Goldfarb, 2000). I will at this point, however, begin with discussion of the current a-h definition.

In my view, there are several problems with the ah definition. For example, part "a" of the definition indicates that abstinence education "has as its exclusive purpose, teaching the social, psychological and health gains to be realized by abstaining from sexual activity." The first question is, how can a program meet the "a" part of the definition (exclusive purpose) and then also meet the seven other parts of the definition? The answer; it can't.

The second problem is with access to information. If the program has abstinence as its exclusive purpose, then information about contraceptives should not be a part of such programs. Several programs funded with "a-h" monies do, however, include information about condoms and other methods of birth control. The emphasis, however, is on the (overstated) failure of these methods in preventing sexually transmitted disease and/or pregnancy. I visited with a friend of mine, who is very much involved in promoting an abstinence education program that is provided on an international basis, about her approach, i.e. telling students that condoms don't work. I indicated that regardless of the effectiveness of the program she was implementing, there would be people that would choose sex over abstinence. I asked "wouldn't you rather these people have sex with a condom (even if it doesn't provide perfect protection), than to have sex without a condom"? At first she wouldn't answer my question, and then said "If people think that condoms will provide some protection, then they might have sex; whereas if they think they don't work then they won't have sex." That is a major message of many abstinence programs funded under a-h, "be abstinent, because condoms don't work." My concern is that most people will not choose abstinence, but many will believe the misinformation about condom effectiveness. Consequently, because they now believe that condoms don't work, they will not protect themselves from sexually transmitted disease.

Another problem is, what does the a-h definition mean by the term "sexual activity?" Such a question, may appear to be a bit silly, but without a specific, operational definition, this term is vague and imprecise. We know from more than one research study which has examined the meaning of the term, that people interpret this term in a myriad of different ways (Horan, Phillips, & Hagan, 1998; Sanders & Reinsich, 1999; Hawkins, et al., 2002). We know it has something to do with sex, but if we are asking people to be abstinent from sexual activity, what are the specific behaviors from which we are asking them to abstain? Does sexual activity refer only to penile-vaginal sexual intercourse, or does it also include other behaviors? Are there "intimate physical behaviors" in which a person can engage, but still be sexually abstinent? If so, what are they? When questioned at Congressional hearings concerning the definition of the term "sexual activity" the head of the federal Bureau of Maternal and Child Health, Peter Van Dyck, indicated that the establishment of such a definition had been left up to individual states (Michelle Lawler, Bureau of Maternal and Child Health, personal communication, August 22, 2000). When we surveyed state abstinence coordinators, however, (Bailey, Young, Knickerbocker, and Doan, 2002), none of the states seemed to have a definition. The most recent grant guidance for SPRANS abstinence education funding indicates that the purpose of the program is to fund "interventions designed to reduce the proportion of adolescents who have engaged in premarital sexual activity, including but not limited to sexual intercourse" (U.S. Dept., 2003, p.). This does provide some guidance for grantees of that program, but by and large we still don't know what behaviors are permissible and exactly what it is that people are not supposed to do.

The "b" part of the definition indicates that abstinence education programs are those that teach abstinence from sexual activity outside marriage as the expected standard for all school age children; the "d" part of the definition expands the marriage standard from school age children to everyone, regardless of age, teaching "that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity." This is problematic for two reasons: (1) again, we don't know the behavior, or behaviors from which we are expected to abstain and (2) the definition imposes a value or standard to which the vast majority of adult Americans have not adhered and simply do not support. It is a standard supported by some religious groups.

Keep in mind that in some states abstinence grants have gone to churches and other faith based groups and some state abstinence conferences have more closely resembled a religious revival meeting than a public health conference. While I am not a constitutional lawyer, I nevertheless believe that this legislation and the manner in which it has been implemented is a clear violation of the constitutional separation of church and state.

Another concern is accuracy of information. Part "c" of the definition indicates that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems. The fact is that (1) abstinence is not a guarantee of protection from sexually transmitted disease, since diseases, such as HIV, can also be transmitted via contaminated blood; (2) non-married people who are non-infected, who only engage in sex with people who are also non-infected, will neither transmit nor receive an STD from engaging in sex with such individuals.

Part "e" of the definition also raises concerns regarding accuracy. Part "e" indicates that one should teach that sexual activity outside of marriage is likely to have harmful psychological and physical effects. The word "likely" is defined in the dictionary as "reasonably to be expected, probably." One must acknowledge that sexual activity (however it is defined, and whether inside or outside of marriage) may have harmful psychological and physical effects. Acknowledging that something is a possibility, however, is quite different from making a blanket assertion that such outcomes have a reasonable expectation of occurrence or that they will probably occur.

Finally, part "h" of the definition teaches the importance of attaining self-sufficiency before engaging in sexual activity. According to the dictionary, self-sufficiency means "to be able to get along without help, independent". The achievement of self-sufficiency appears to be a worthwhile goal, but do we really want to make it a prerequisite for access to sexual activity? Many adults, single and married, never fully realize the goal of self-sufficiency. Are we saying that they can never engage in sexual activity? Others may achieve self-sufficiency, but because of health problems, age, or loss of a job, lose their independence. Do they also lose access to sexual activity?

Most Americans probably agree that young people would be well advised to delay the initiation of sexual behaviors that place them at risk for pregnancy and sexually transmitted disease. The a-h definition, however, does not focus on risky behavior and uses a very broad term "sexual activity" which could involve a number of behaviors which pose zero risk. At the same time, some people may believe they are abstaining from sexual activity, but engage in behaviors which pose a risk for the transmission of sexually transmitted disease (i.e. oral and anal sex). The definition does not confine the promotion of abstinence to young people, but represents abstinence from sexual activity outside of marriage as the standard for all humans. The definition promotes misinformation and restricts access to accurate information. It limits access to sexual activity to married couples who are self-sufficient. I believe that the federal definition of abstinence education is problematic and should be eliminated or radically changed.

FUNDING FOR ABSTINENCE EDUCATION PROGRAMS

Three current federal programs fund abstinence education programming. There is direct federal funding of a number of Adolescent Family Life (AFL) demonstration projects from the Office of Adolescent Pregnancy Programs (OAPP). OAPP must use the a-h definition and has indicated that programs do not have to emphasize all eight aspects of the definition, but must not be inconsistent with any aspect of the definition. Abstinence education funding is also block granted to states from the Bureau of Maternal and Child Health. Again, projects must not be inconsistent with any aspect of the a-h definition. States differ in the way these funds are controlled, the way in which the definition is applied, and the manner in which the funds are spent. Some state programs are administered by public health departments. In other states the Governor has appointed "abstinence committees" whose members often represent fundamentalist religious groups and other ultra-conservative organizations to review educational materials and grant proposals, and make funding recommendations. Some states use the abstinence money to fund media campaigns encouraging young people to postpone sexual involvement. In other states conservative groups receive grant funds to conduct programs that subject young people to sex negative misinformation.

The third program is also from the Bureau of Maternal and Child Health (SPRANS Abstinence Education Grants). This program provides direct abstinence education funding to community groups. Grant applicants must demonstrate that their proposed program will meet all eight aspects of the a-h definition. These tend to be sizable grants, as much as $800,000/year for a three year project period.

In addition to the direct funding of abstinence education programs the a-h definition has had a broader influence on the educational landscape. Some states are indicating that all school-based educational programs about sexuality must teach abstinence only and have adopted the a-h definition. Many school districts in other states have also adopted an abstinence only education policy.

Clearly there is a lot of money and influence going to fund programs based on conservative ideology. Many of the grantees are faith based organizations. I have reviewed a number of proposals that have received abstinence education funding, and a number that have not received funding. I have had a number of conversations regarding funding decisions with personnel from both state and federal funding agencies. This and my own experience tells me that for some proposals the decision to fund or not fund was probably based on the merits of the proposal. The funding decision for many proposals, however, appears to have been based purely on politics. For example, one project, with which I am familiar, received approximately 1.8 million dollars over a three year period. Their proposal probably would not have received a passing grade in the course I teach on proposal writing. It was loaded with misspelled words, grammatical errors, incomplete sentences, and did not make a strong case for the project. On the plus side, however, they did list a consultant who was extremely active in Republican politics and served as chair of the county Republican women's club.

Another example is a project that has received more state abstinence money than any other abstinence project in that state. In a conversation with the woman that headed the organization, I noted that she seemed quite close to the governor and asked about that situation. She candidly told me that she and her husband had hosted campaign fund-raisers for the governor, when he was running for the office of lieutenant governor, had gotten to know him well, and had become quite close. Soon after the governor assumed office a woman who was an educator with this abstinence organization was named to the governor's staff, and in a very short time was named director of a state agency. In another case, a staff member of a funding agency told me that they planned to release an RFP very soon and to watch their website. A few months later a notice appeared on their website that no new money would be available that year. A few months after that the agency announced several new grantees that had just received funding. All of the new grantees apparently were faith-based groups that had some conservative political connections. They seemed to have been given an opportunity to apply for funding that was not available to other organizations that would have liked to have competed. All of this clearly has the appearance of rewards based on political favoritism, rather than rewards based on merit.

EFFECTIVENESS OF ABSTINENCE EDUCATION PROGRAMMING

Another issue regarding abstinence education is its effectiveness. I am reminded of a time when I was giving testimony at a legislative hearing. A state senator, who was also serving on the governor's abstinence committee, asked me what evidence that I had that our program was effective. I replied that several positive evaluation articles had been published. For example, the first published article included pretesting and posttesting of abstinence education classes, health education classes, and classes that received neither abstinence education nor health education. Results indicated that students who had participated in our abstinence education program were less likely to report participation in sexual intercourse in the last month than students in the other two groups. The senator attacked my statement, saying that this proved that our curricula were not real abstinence until marriage curricula. He did not want programs that helped kids be abstinent for a month. He wanted programs that would be effective in helping kids be abstinent until they were married. I explained to him that to evaluate programs to determine if they did accomplish this objective would require experimental and control groups and a rather lengthy longitudinal study. I also indicated that if he was interested in funding such a study, we would be glad to conduct it for him. No funding for such an evaluation has been forthcoming.

There are problems in evaluating abstinence education programs. The first problem is that, like the senator, most program people don't have a good understanding of evaluation. Additionally many abstinence proponents simply don't want their programs evaluated. A prominent proponent of abstinence only programming is often heard to say that everyone knows abstinence works. Evaluation is a waste of time and money that could be invested in additional programming. Her approach to evaluation seems to have worked well. The program she promotes and some of the other more popular abstinence education programs have been around for more than 20 years. There are, however, no evaluation articles that have been published in scholarly/professional journals that have examined the effects of these programs on any measure of sexual behavior.

Another problem concerning program effectiveness is how to evaluate an abstinence education program. There are issues involving program goals, definitions, parent/school permissions, and appropriate control/comparison groups. Wouldn't it be nice if the programs that young people receive help them develop healthy, satisfying relationships, both as a teenager and as an adult? We don't, however, really measure whether the relationships in which students are involved are healthy, and certainly not whether they are satisfying. While the goal of many programs seems to be to encourage young people to abstain from sexual activity (how ever sexual activity might be defined), evaluations of these program, when they are evaluated at all, often fail to measure sexual behavior. How can these programs be judged to be successful in reducing sexual health risk behavior, when no questions were asked regarding actual behavior? When evaluations do address sexual behavior the focus is often on penile/vaginal intercourse, and at other times not clearly defined (i.e. are you sexually active? have you had sex?). To really examine the effects of these programs on sexual risk taking behavior, we need to ask about other behaviors, like oral and anal sex, and the context in which these behaviors occurred. Solid evaluations of the more problematic curricula that address sexual risk taking behaviors, do not seem to be occurring. In fact, after reviewing a number of RFPs and visiting with a number of staff from funding several funding agencies, it is clear that in many instances meaningful evaluations are discouraged. Here OAPP is an exception, a mandatory evaluation is required, and while legislation indicated that only 3-5% of the budget be spent on evaluation waivers on this upper limit can be secured.

Are there abstinence programs that do have evidence of effectiveness? Yes, the materials with which I have been involved have shown some such evidence. Sex Can Wait (Core-Gebhart, Hart, Young, 1994a; Core-Gebhart, Hart, Young, 1994b; Young & Young, 1994)) and Abstinence: Pick & Choose Activities (Young & Young, 1996) shown positive changes in sex health risk behavior, as has Making a Difference (Jemmott, Jemmott, & McCaffree, 2002). To date, five evaluation articles concerned with Sex Can Wait have been published in professional/scholarly journals (Young, Core-Gebhart, & Marx, 1992; Spear, Young, & Denny, 1997; Denny, Young, Spear, 1999; Goldfarb, et al., 1999; Denny, et al., 2002) and recently a paper showing positive effects at an 18 month follow-up was presented at a national conference (Denny & Young, 2003). The studies do have some weaknesses. For example, the assignment of schools to groups was not random and, in the published articles, there was no long term follow-up. Nevertheless, these are positive evaluations that are published in professional journals.

The Office of Adolescent Pregnancy Programs does indicate that Sex Can Wait, and a companion curriculum, Abstinence: Pick & Choose Activities, are "not inconsistent with the a-h definition" and have approved the curricula for use in their projects. A number of states also have approved the curricula for use in their Title V projects. In spite of its evaluation success, and approval by OAPP and a number of state agencies, Sex Can Wait is not popular among conservative groups, because: (1) the publisher, ETR Associates, has historical connections with the education department of a Planned Parenthood affiliate and also publishes some materials that focus more on abstinence from "unprotected sex" rather than abstinence from "sexual activity", (2) the series provides accurate information, is neutral on religion, and abortion, and focuses on public health and life skills rather than moral purity, (3) I am one of the co-authors of the series and have been outspoken in my criticism of the a-h definition and other abstinence curricula that are popular among conservatives.

In Arkansas, the Governor's Abstinence Committee initially ruled that Sex Can Wait was inappropriate for use in Title V Abstinence Education projects in Arkansas. Upon appeal, the Committee did decide to include Sex Can Wait and Abstinence: Pick & Choose Activities on the approved list, with one requirement. Before funds can be released to a grantee, the grantee has to demonstrate how the "marriage language" of the curricula will be strengthened. In spite of its appearance on the approved list, as of this writing, no organization that has applied for funds and indicated that Sex Can Wait will be part of the abstinence education intervention has received funding. In the fall, 2002, the University of Arkansas finally did receive notification from the Health Department that a proposal that I had submitted would be funded. However, after an earlier version of this paper was presented as a workshop at the annual meeting of the Society for the Scientific Study of Sexuality, the Health Department indicated that the workshop called into question our commitment to carry out an abstinence only project and asked us to respond to several concerns. In our letter of response we provided information about the workshop, indicated our opposition to the a-h definition, but also reiterated our commitment to "play by the rules" and to carry out our project as it had been proposed and approved. We were eventually told that the project would not be funded.

Another abstinence education curriculum, Making a Difference, has also shown positive behavior changes. Again, evaluations have been published in scholarly journals, including the Journal of the American Medical Association (Jemmot, Jemmot and Fong, 1992; Jemmot, Jemmot and Fong, 1998). Making A Difference (Jemmott, Jemmott, & McCaffree, 2002) is an abstinence program, but is definitely not what conservative groups and the developers of the a-h definition had in mind. The developers indicate that "Facilitators are encouraged to praise student's answers when HIV-STD/Pregnancy prevention efforts are raised even if they include suggestions other than abstinence. Facilitators should NOT denigrate condoms, speak of them only in terms of failure rates, or exaggerate condom failure" (p. 3).

The curriculum defines abstinence as "avoiding oral sex, anal sex, and vaginal or sexual intercourse" (p. 64). Facilitators are to "Be sure participants understand the definition of vaginal intercourse, oral sex, anal sex, and masturbation" (p. 63). The curriculum defines masturbation as "rubbing, stroking, or "playing with" one's own genitals or the genitals of another person" (p. 63). The curriculum does not direct people to masturbate, but it makes it clear that this behavior is not on the list of behaviors to avoid. The emphasis is on refusing to engage in unsafe behavior. For example, one suggested response to pressure to have intercourse is to say "Let's talk about some sexual activities that are OK for both of us" (p. 171).

While Making A Difference is an abstinence curriculum, it does not focus on abstinence until marriage. It does dearly focus on avoiding behaviors that carry the risk of pregnancy and sexually transmitted disease. It does convey a sex positive message. It does have positive behavioral evaluations. It is unlikely that you will see it used in any federally funded a-h abstinence education program.

To summarize the results of the abstinence education research, there are some published evaluations which show that certain abstinence education programs have produced positive behavioral results. For the most part, however, there is little evidence that abstinence education programs, especially some of the more popular programs for which the a-h definition was designed, help young people postpone sexual involvement or reduce sexual risk-taking behavior.

INACCURATE INFORMATION IN ABSTINENCE EDUCATION CURRICULA

A big issue related to the use of many abstinence education curricula is medical accuracy. Our young people want and need accurate information, but many abstinence curricula spread misinformation. They often include a number of other errors of fact, provide incomplete and misleading information, and promote a negative view of sex.

Information about condoms. A common area of concern is condom use. Many abstinence curricula do present information about condom use, but ignore the clear weight of the evidence that demonstrates that condoms are effective in preventing pregnancy, reducing the transmission of HIV, and reducing the risk of transmission of most other STDs. Instead they concentrate on providing information designed to discredit the use of condoms, including overly exaggerated failure rates. The message is that AIDS kills and condoms and contraceptives don't work in preventing AIDS, other sexually transmitted diseases, or pregnancy:

Several programs talk about two failure rates for condoms; a high failure rate for pregnancy typically seen among adult condom users and an even higher rate (sometimes more than twice as high), typically seen among teen users. I have yet to see, however, an abstinence curriculum that offers an explanation for these differences. It might be of value to explain the concept of method failure versus user failure. After all, it is important for those who use condoms to know that if they expect condoms to work they must use them correctly, and use them every time. Curriculum authors could explain that failure rates are typically higher among teens, because teens are less likely to use condoms consistently and correctly. Instead, the authors give condoms a high failure rate, and often indicate higher rates for teens, and offer no explanation.

When Contraceptive Technology (Hatcher et al., 1998) states that condoms have a three percent failure rate for preventing pregnancy, the authors clearly explain that by this they mean that three percent of the couples who consistently and correctly use condoms to prevent pregnancy have a pregnancy at the end of a year of use. If one conservatively figures an average coital frequency of 83 acts per year, this is a failure rate due to failure of the method on an order of 0.04 percent of the times a condom is used. When abstinence curricula indicate a failure rate, they simply indicate a percentage figure, leaving students to possibly interpret a 36 percent failure rate to mean that of every 100 acts of intercourse using a condom, 36 will result in a pregnancy.

Why do abstinence curricula even talk about condoms? This seems to be in conflict with the very first tenet of the a-h definition: (a) has as its exclusive purpose, teaching the social, psychological and health gains to be realized by abstaining from sexual activity (Block, 1997). This apparent conflict has not seemed to slow these abstinence curricula in their dissemination of misinformation.

From a public health perspective, teaching people that condoms do not work is inaccurate, irresponsible, and dangerous. Programs designed to prevent adolescent pregnancy and sexually transmitted diseases should emphasize abstinence. People need to understand that condoms are not 100 percent effective. Providing young people misinformation about condoms and other contraceptives, in the hope that this approach will scare them into abstinence, is to discourage those who do engage in sexual intercourse from trying to protect themselves. After all, condoms are often viewed as inconvenient to obtain and use, and if they don't work, then why bother?

Information About Abortion. Another topic with which abstinence curricula often deal is abortion. The settlement the government reached in the Kendrick case (that went all the way to the U.S. Supreme Court) indicated that curricula used in OAPP Projects must be neutral on religion and that they must not encourage or discourage abortion (Kendrick et al. v Sullivan, 1993). The provisions of this settlement are not binding on the Title V and SPRANS programs funded from the Bureau of Maternal and Child Health. The Bureau has, however, distributed OAPP guidance to the states who generally made individual Title V grantees aware of the provisions. In fact in our state (Arkansas) Title V Abstinence Education grantees are required to sign assurances relative to neutrality on abortion. (i.e. "I hereby agree that any funds received shall not be used to provide any form of abortion counseling, that is, either encouraging or discouraging abortion").

Many abstinence only curricula, however, (including those used in Arkansas) are not neutral on abortion and do actively discourage it. Abortion is typically said to be associated with serious risks to physical health, risk of later ectopic pregnancy, miscarriage and infertility, and severe psychological and emotional consequences, including suicide. Curricula that do present this type of information fail to inform students that for the woman, the health risks associated with a legal, first trimester abortion are less that the health risks associated with carrying a normal pregnancy to term. To provide distorted and exaggerated information about the adverse consequences of abortion, without providing information relative to the risk associated with pregnancy is not acceptable.

I understand that while abortion is a legal option in this country, not everyone considers it to be a moral option. Nevertheless, abstinence education programs that are supported with public funds should provide accurate information. If curricula used in these programs address the topic of abortion the information provided should be accurate and should be presented in a way that does not encourage or discourage abortion. A number of abstinence curricula do address the topic of abortion. Typically information is included that is not accurate. The intent of the material clearly is to discourage abortion.

Other topics. For the purpose of this article I have focused on misinformation related to condoms and abortion. In addition to misinformation regarding these topics, many of the abstinence programs that are currently on the market include a number of other errors of fact, incomplete and misleading information, promote a sex negative view point and use fear and scare tactics.

In our society we endorse as a basic given the individual's right to freedom of belief. Thus, society and sexuality education should encourage respect for differing beliefs in regard to sexuality issues. In contrast, the actual situation today in many schools is that sexuality education, and especially abstinence only until marriage education, "functions as an instrument of ideological indoctrination, rather than as an educational forum for critical deliberation and intellectual development," (McKay, 1998, p. 8). The a-h definition, used in federally funded programs of abstinence education and adopted by many organizations not receiving federal abstinence education funds, is indeed an instrument for ideological indoctrination. The conflict between proponents of the a-h definition and those who would promote a less restrictive version of sexuality education is not a simple difference of opinion as to what should be taught relative to sexuality. This conflict represents, what Alexander McKay (1998) has characterized as a "dash of opposing systems of belief about the nature of the world and human kind (p.7)."

Many of the abstinence education curricula that are used in federally funded abstinence education programs also promote ideological indoctrination and misinformation. In addition, these curricula have no published evaluations demonstrating behavioral effectiveness.

What then should we do to provide our young people with accurate information? One option is to encourage potential funding applicants to forego federal abstinence education funding and to focus on providing educational programming to youth that is accurate and does not restrict access to information. Effective curricula, that provide a more comprehensive approach than abstinence only programs, are available. A second option is to compete for the abstinence funding and use it to provide abstinence education programming that is accurate, based on health behavior theory, and neutral on religion and abortion. Few abstinence only curricula meet this criteria, but some do. Grantees choosing this option must understand that if they take the money, they have to play within the rules. They don't have to like the rules, but they do have to abide by them. This option does not allow the grantee to provide as comprehensive a program as many program staff might like. It does insure that the information young people receive is accurate. It also has the result of reducing the amount of funding available for those programs based on fear and misinformation. A third option, not mutually exclusive with option two, is working to create political change. This includes overturning the language in the federal definition of abstinence education and working to ensure that public money is not used to promote curricula that provide inaccurate and misleading information. Target members of your state's Congressional delegation. Provide them with the information presented here and let them know your concerns.

There is nothing wrong with encouraging young people to abstain from sexual activity. There is much wrong with the federal approach to abstinence education. The a-h definition and many of the curricula that are often used in programs funded with federal abstinence education money, provide misinformation and promote a conservative ideological agenda. I believe that this approach is dangerous and the use of these curricula is both irresponsible, and truly bad public health. Those of us who are interested in providing young people with accurate information and effective programs should take action.

REFERENCES

Bailey, W., Young, M., Knickerbocker, C., Doan, T. A cautionary tale about conducting research on abstinence education: Howdo state abstinence coordinators define "sexual activity?" American Journal of Health Education 33 (5), 290-296, 2002.

Block Grant Application Guidance For the Abstinence Education Provision of the 1996 Welfare Law, P.L. 104-193 (1997). Office of State and Community Health, Maternal and Child Health Bureau, Department of Health and Human Services, Rockville, MD.

Core-Gebhart, P., Hart, S., and Young, M. Sex Can Wait: A curriculum far middle school classrooms, ETR Associates, Santa Cruz, 1994a.

Core-Gebhart, P., Hart, S., and Young, M. Sex Can Wait: A curriculum fro high school classrooms, ETR Associates, Santa Cruz, 1994b.

Denny, G. and Young, M. (2003) The impact of an abstinence education program on student outcomes: Results of an 18 Month Follow-up, paper presented at the annual meeting of the American School Health Association.

Denny, G., Young, M., Rausch, S., and Spear, C. (2002). An evaluation of an abstinence education curriculum series: Sex Can Wait, American Journal of Health Behavior, 26, 366-377.

Goldfarb, E. S., Donnelly, J., Duncan, D., Young, M., Eadie, C., and Castiglia, D. (1999). Evaluation of an abstinence-based curriculum for early adolescents: First year changes in sex attitudes, knowledge and behavior. North American Journal of Psychology, 1, 243-212.

Hatcher, R. A., Trussell, J., Stewart, F., Cates, W., Stewart, G. K., Guest, F., Kowal, D. (1998). Contraceptive Technology, Ardent Media, Inc., New York.

Hawkins, M. I., Davis, M., Eadie, C., Rausch, S., Donnelly, J., and Young, M. (2002). Meanings of abstinence and sexual activity for rural youth. American Journal of Health Education, 33, 140-145.

Horan, P.F., Phillips, J., Hagan, N.E. (1998). The meaning of abstinence for college students. Journal of HIV/ AIDS Prevention & Education for Adolescents & Children, 2 (2), 51-66.

Irvine, J. M. (2002). Talk about sex: The battles over sex education in the United States, University of California Press, Berkeley.

Jemmott, J. B., Jemmott, L. S., and Fong, G. T. (1992). Reductions in HIV risk-associated sexual behaviors among black male adolescents: Effects of an AIDS prevention intervention. American Journal of Public Health, 82, 373-377.

Jemmott, J. B., Jemmott, L. S., and Fong, G. T. (1998). Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: a randomized controlled trial. Journal of the American Medical Association, 279, 1529-1536.

Jemmott, L. S., Jemmott, J. B., and McCaffree, K. A. (2002). Making a difference! An abstinence-based approach to HIV/STD and teen pregnancy prevention, Select Media, Inc., New York.

Kendrick et al. v Sullivan (1993). Settlement agreement, US District Court for the District of Columbia, Civil Action No. 83-3175.

McKay, A. (1998). Sexual Ideology and Schooling: Towards Democratic Sexuality Education, The Althouse Press, London, Ontario, Canada.

Sanders, S. A. and Reinsich, J. M. (1999). Would you say you "had sex" if ...?. Journal of the American Medical Association, 281. 275-277.

U. S. Dept. of Health and Human Services, Special Projects of Regional and National Significance (SPRANS), Community Based Abstinence Education Project Grants HRSA-04-077, Catalog of Federal and Domestic Assistance (CFDA) No. 93.110 FY 2004 Program Guidance, Competing Announcement, December, 2003.

Young, M., Core-Gebhart, P., and Marx, D. Abstinence-oriented sexuality education: initial field test results of the Living Smart curriculum, Family Life Educator, 10:4-8, Summer, 1992.

Young, M. and Goldfarb, E. The problematic a-h in abstinence education, Journal of Sex Education and Therapy 25(2&3), 156-160, 2000.

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Young, M. and Young, T. Abstinence: Pick and Choose Activities, ETR Associates, Santa Cruz, 1996.

HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED

Responsibility X: Advancing the Profession of Health Education

Competency A: Provide a critical analysis of current and future needs in health education

Sub-competency 1: Relate health education issues to larger social issues

Michael Young, Ph.D., FAAHB is a University Professor in the Program in Health Science and the Director of the Health Education Projects Office at the University of Arkansas. Address all correspondence to Michael Young, Ph.D., FAAHB, University Professor, Program in Health Science, Director, Health Education Projects Office, HP326A, University of Arkansas, Fayetteville, AR 72701, PHONE: [phone], FAX: [phone], E-MAIL: [e-mail]

Table 1. The federal a-h definition of abstinence education

Abstinence education means an educational or motivational program
which:

(a)  has as its exclusive purpose, teaching the social, psychological
     and health gains to be realized by abstaining from sexual
     activity;
(b)  teaches abstinence from sexual activity outside marriage as the
     expected standard for all school age children;
(c)  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;
(d)  teaches that a mutually faithful monogamous relationship in the
     context of marriage is the expected standard of human sexual
     activity;
(e)  teaches that sexual activity outside of marriage is likely to
     have harmful psychological and physical effects;
(f)  teaches that bearing children out-of-wedlock is likely to have
     harmful consequences for the child, the child's parents and
     society;
(g)  teaches young people how to reject sexual advances and how
     alcohol and drug use increases vulnerability to sexual advances;
     and
(h)  teaches the importance of attaining self-sufficiency before
     engaging in sexual activity (Block Grant, 1997)