Does Abstinence Education Work?

Texas Legislature Puts Abstinence Education Back in the Spotlight

Credit: Ramsey Jehm

On March 31, 2015, Texas legislators overwhelmingly voted to divert $3 million in funds from its HIV screening programs to abstinence-based education. The measure, largely split along party lines in the Republican-controlled House, incited fierce—and sometimes personal—exchanges from opposing Democrats.

Despite acknowledging that Texas has the third highest HIV infection rate in the country, as well as the fifth highest teen pregnancy rate, Republican state Representative Stuart Spitzer defended the measure by stating that the "goal is for everyone to be abstinent until they're married."

Democrat Harold Dutton countered by questioning Spitzer on his own abstinence practices, by which Spitzer declared thatt he was "a virgin when he was married at age 29."

The highly charged exchange in the Texas House highlighted the polarizing nature of the abstinence debate, which oftentimes sidelines science in favor of personal and/or moral beliefs.

It is a scenario that has been played out numerous times during the course of HIV history, both here and abroad, and one that more often than not has ended with little , if any, impact on either sexual behavior or HIV avoidance. At worse, the approach often accomplishes just the opposite.

A Short History of Abstinence Based Education in HIV/AIDS

A great deal of focus was placed on abstinence-based education in the early 2000s, with many countries embracing a so-called "ABC" (or Abstinence/Be Faithful/Condomise) approach to HIV prevention. The measure was embraced at a time when national antiretroviral programs were still in their infancy in the developing world, and only a small handful of patients—less than 3 million by 2005—were under care.

In some countries like South Africa, which resisted a national response under the denialist policies of then-President Thabo Mbeki, ABC was often seen to be the only facet of the government strategy—even as infection rates skyrocketed to a point where one out of every five South Africans was HIV-infected.

It was during this time  that the United States, under the President's Emergency Plan for AIDS Relief (PEPFAR), supported abstinence-based programs, at one stage directing as much as a third of all prevention funding to the abstinence-until-marriage directive.

Uganda was one of the African nations to fully embrace the cause. Despite great, early success in responding to the AIDS crisis in the late-1980s/early-1990s, the country, under President Yoweri Museveni, undertook to pare down ABCs by removing condoms from the dialogue.

Museveni himself condemned condoms as "inappropriate" for Ugandans, while the U.S.-based Human Rights Watch reported the widespread removal of HIV/AIDS information from primary school curricula, as well as secondary school materials that described pre-marital sex as a "deviance" and suggested that HIV was easily could penetrate latex condoms.

U.S. funding for abstinence- and faithfulness-based programs in sub-Saharan Africa peaked in 2008, costing in excess of $1.3 billion.

The Impact of Abstinence and Faithfulness Programs

In 2015, researchers from Stanford University conducted an analysis to determine the trends in sexual behavior before and after PEPFAR prevention directives were in put into place in 2004. It focused on the 14 high-priority countries in sub-Saharan Africa where congressional earmarks required that 33% of PEPFAR prevention funding be spent on ABC.  The trends were the compared to eight African nations where PEPFAR funding carried no restrictions or prevention directives.

The analysis was able to detect year-on-year changes in sexual behavior as defined by

  • The number of sexual partners in the previous year for men and women
  • The age of first intercourse for men and women
  • Female teenage pregnancy

No impact was found, leading the researchers to suggest the "importance of examining alternative funding priorities for PEPFAR to improve HIV prevention in sub-Saharan Africa."

A 2006 review of U.S. policies by the Mailman School of Public Medicine at Columbia University concluded that abstinence-only education programs, as defined by federal funding requirements, were "morally problematic, by withholding information and promoting questionable and inaccurate opinions… (and threatening) fundamental human rights to health, information, and life."

The Debate Over Abstinence Education in Schools

It was reported in May 2015 that the Crane Independent School District in East Texas (just south of Odessa) had identified 20 cases of chlamydia, a sexually transmitted bacterial infection, among its students. The outbreak, which the Centers for Disease Control and Prevention (CDC) classified as "endemic," also revealed that 6% of high school students in the district—roughly one out of every 15—had been treated for chlamydia infection.

School district superintendent Jim Rumage laid the blame squarely on its abstinence-only education program, stating that it "evidently ain't working" while adding that "it's the parents' responsibility to educate their kids on sexual education."

In the aftermath, the school board voted to instate sex education into the high school curriculum.

What was seen in the Crane Independent School District was not an unusual case. A 2011 review of abstinence-only education from the University of Georgia concluded that "the more strongly abstinence was emphasized in state law, the higher the teenage pregnancy and birth rate."

By contrast, comprehensive sex and HIV/STD education—which in many cases included abstinence as a behavioral option—correlated with the lowest teen pregnancy and abortion rates across states, said the researchers.

This suggests that abstinence as part of the dialogue is not inappropriate but that abstinence-only programs tend to, in the words of the authors, "promote abstinence behavior through emotion, such as romantic notions of marriage, moralizing, fear of STDs, and by spreading scientifically incorrect information."

Whether Representative Spitzer's assertion that abstinence until marriage is a workable framework for HIV/STD prevention is dubious at best. State Senate budget negotiations will likely decide on the fate of the measure, although some fear that the Republican-controlled Senate will likely support some, if not all, of the House proposal.

Efforts in the 84th Texas Legislative Session to blunt many of the abstinence bill's more restrictive measures were met with defeat, including:

  • House Bill 467, which would have removed language indicating that sexual activity before marriage causes psychological and physical harm (FAILED).
     
  • House Bill 78, which would have ensured that sex education be evidence-based and medically accurate and include age-appropriate information on pregnancy and disease prevention approved by the U.S. Food and Drug Administration (FAILED).
     
  • Senate Bill 88, which would have required public school health education to include information on methods of contraception and the prevention of STDs in addition to promoting abstinence (FAILED).
     
  • Senate Bill 300, which would have required school districts to inform parents if the district is teaching abstinence-only education or is including information on contraception in its sex education curriculum (FAILED).

Sources:

ABC Eyewitness News. "Texas Measure Cuts HIV Funds, Boaosts Abstinence Education." Published April 1, 2015.

Daily Times Express. "No Sex-Ed in Texas School Gives Rise to Chlamydia Outbreak?" Published May 6, 2015.

Lo, N.; Lowe, A.; and Bendavid. E. "The Impact of PEPFAR Abstinence and Faithfulness Funding Upon HIV Risk Behaviors in Sub-Saharan Africa." Conference on Retroviruses and Opportunistic Infections (CROI); February 23-26, 2015; Seattle, Washington; abstract 160.

Santelli, J.; Ott, M.; Lyon, M.; et al. "Abstinence and abstinence-only education: A review of U.S. policies and programs." Journal of Adolescent Health. January 2006; 38(1):72-81.

The Texas Campaign to Prevent Teen Pregnancy. "84th Texas Legislative Session." Accessed June 27, 2016.

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