Promoting Healthy Sexuality in an Era of Abstinence-Only Programs 

When so much public discourse about sexuality education centers on abstinence, promoting comprehensive sexuality education becomes all the more important. Discussions about managed care have often focused on the benefits of prevention and health promotion -- recognizing that maintaining people’s health is less costly than paying for treatment. Promoting sexually healthy behaviors however, is fraught with controversy. Few, if any, educators have a community mandate to help young people develop healthy and satisfying sexual lives. If the organizations that fund sexuality education programs are interested only in changing adolescent behavior to reduce the negative outcomes of intercourse, how do educators promote sexual health? If adults’ messages to young people are only about the dangers of sexual behavior, as with many of the programs funded with abstinence-only-until-marriage dollars from the federal government, where do teens learn how to have healthy relationships? There is, after all, a 12-year gap between the time adolescents are capable of reproducing and the average age of first marriage. Planned Parenthood and similar organizations are working to address the needs of youth, families and communities. In an era of abstinence-only fan fare and funding, emphasizing the need for comprehensive sexuality education is a complex task.

Planned Parenthood’s History

In 1916, Margaret Sanger opened the first birth control clinic in the United States in Brooklyn, New York, and was promptly arrested on obscenity charges under the notorious Comstock laws. Sanger was arrested two years earlier and again later, in 1921, while educating women and men about the possibility of controlling their fertility. At that time, speaking publicly about sexuality was a risky business – particularly when the speaker was a woman, and the content of the speech flew in the face of convention.

Today, the organization that Sanger began, Planned Parenthood Federation of America, provides services to five million women, men, and young people in the U.S. every year. One and a half million of those served are the participants in our community-based education and training programs. Over 850 staff educators and 900 volunteers work in our communities in education and training. Each of us is challenged to follow Margaret Sanger’s example, and speak up publicly in support of healthy sexuality. Eighty-seven years after that first clinic opened, the world is very different, and the movement for reproductive self-determination has had a profound impact. However, sexuality educators across the country are again muzzled.

During its first several decades, Planned Parenthood education programs focused on contraception for married couples. In the 1960s, however, with the introduction of the birth control pill and evolving social movements for civil rights, sexual liberation, and equal rights for women and homosexuals, our sexuality educators broadened their focus to encompass these issues. Public discourse about sexual issues flourished throughout the 1970s.

In the 1980s, with the AIDS pandemic, interest in and funding for sexuality education (about HIV in particular) significantly increased. But while the symptoms of HIV disease were just becoming a public concern in 1981, the Adolescent Family Life Act (AFLA) was introduced in Congress by Jeremiah Denton. As mandated by the law, AFLA's early grants went almost exclusively to far-right and religious groups. Much of the funding was used to develop the first generation of so-called fear-based curricula such as Sex Respect and Teen Aid, which relied on scare tactics to promote abstinence. They often distorted information related to the effectiveness of contraceptive and disease prevention methods. In 1983 the ACLU brought a lawsuit, charging that the AFLA was funding programs that, in some settings, violated the doctrine of separation of church and state. After 10 years of litigation, the Kendrick v. Sullivan settlement guarded against overtly sectarian programs. This funding stream continues today, but it has been rewritten to ensure that programs funded under it comply with stringent guidance developed for the more onerous 1996 welfare reform law.

In a 1992 local battle over abstinence curricula, the suit Planned Parenthood of Northeast Florida v. Duval County School Board was filed, with seven families and Planned Parenthood of Northeast Florida (PPNEF) in Florida state court. Florida law required all public school students, grades kindergarten through 12, to receive accurate, complete, and philosophically neutral instruction on human reproduction, pregnancy prevention, and reduction of the risk of sexually transmitted disease. Therefore, Planned Parenthood argued that Jacksonville's school board failed to provide sexuality education that met the standards of Florida's comprehensive health education laws. The Duval County School Board, however, chose to adopt for its seventh grade the fear based curriculum titled Me, My World, My Future, published by Teen Aid, Inc. of Spokane, Washington. Intervening on behalf of Teen Aid were Pat Robertson's attorneys, the American Center for Law and Justice. The plaintiff families won several pre-trial motions, but before going to trial, a political solution was forged. In September 1994, the school board member who had been the biggest proponent of Teen Aid was defeated, leaving a school board majority that supported responsible, balanced sexuality education. A community task force was appointed to develop a new, comprehensive K-12 curriculum. This task force included representatives from both sides of the controversy, who together developed a balanced curriculum that was adopted officially in 1996. The lawsuit was then dropped.

1996 was also the year that conservative members of Congress quietly inserted language into legislation designed to overhaul the nation's welfare system. This language – section 510 of the Social Security Act – guaranteed $50 million annually over five years beginning in fiscal year 1998 for abstinence-only education grants to the states. In addition to that amount, states that accept the Title V funding must provide a three dollar "match" for every four dollars of federal funding, meaning that $37.5 million more is spent each year on abstinence-only-until-marriage in the states. A program funded with this money must adhere to the federal definition of abstinence.

Special Projects of Regional and National Significance program (SPRANS), funded through the maternal and child health block grant, directly finances community-based organizations. SPRANS sponsored programs differ from section 510 in at least three significant ways: programs must target adolescents aged 12-18; they must teach all components of the eight-point definition; and, in most cases, they cannot provide young people in SPRANS programs with information about contraception or safer-sex practices -- even in settings that are not funded by SPRANS.

Does it Work?

No comprehensive scientifically valid evaluations to date have demonstrated that this approach has made any difference in the number of young people who delay intercourse until marriage. Thus far, over half a billion public dollars have been spent on these unproven programs, with the result being that there are areas of the country where young people do not get medically accurate information about condoms, contraception, or a wide range of other topics appropriate to healthy sexual development.

The environment in which Planned Parenthood and other organizations is working has become increasingly polarized around public discourse about sexuality--the discussion often centers on whether or not a program promotes abstinence, rather than whether or not it promotes sexual health. Research conducted by the Alan Guttmacher Institute (AGI) demonstrates that although more than nine in 10 public school teachers believe that students should be taught about contraception (and half believe that contraception should be taught in grade seven or earlier), one in four are instructed not to teach the subject. While the vast majority of teachers also believe that sexuality education courses should cover where to go for birth control, information about abortion, the correct way to use a condom, and sexual orientation, far fewer actually cover these topics.

As a result, Planned Parenthood clinicians in Waco, Texas, for instance, report a profound disconnect with their young clients. When teenage girls come in for pregnancy tests, they are counseled to use condoms in addition to other methods of contraception. The counselor suggests that condoms are helpful for reducing the risk of contracting a sexually transmitted infection (STI). These sexually experienced girls say, “Oh, no thanks. We learned in school that they don’t really work anyway.”

Educators report that they may be invited into the school to do “the lecture on pregnancy prevention,” but that they are asked to avoid talking about condoms. In some school districts struggling to offer students a balanced sexuality education, the contortions include inviting a (publicly-funded abstinence-only) crisis pregnancy counselor to teach about puberty, and then bringing the Planned Parenthood educator in the next day to present “the other side.”

Many of the programs that Planned Parenthood provides are often meant to prevent unintended pregnancy and STIs. Some programs do have these outcomes – notably the affiliates that have replicated Michael Carrera’s comprehensive, long-term program developed with the Children’s Aid Society. These programs have been shown to delay intercourse and increase protected intercourse at sexual debut, among other positive effects. Several Planned Parenthood affiliates have also replicated programs that the Centers for Disease Control (CDC) have identified as “programs that work” to reduce the risk of STIs; among them, “Reducing the Risk,” “Be Proud, Be Responsible,” and “Safer Choices.” However, at the direction of Congress, the CDC has recently discontinued the “programs that work” initiative and is considering a new process that is “more responsive to changing needs and concerns of state and local education and health agencies and community organizations.” Currently 48 of these proven programs are fully replicated at Planned Parenthood affiliates.

Looking toward the Future

Taking the long view, Planned Parenthood developed a vision for how we would like the world to be in the year 2025. One of our bold goals is to “ensure that sexuality is understood as an essential lifelong aspect of being human, and that it is celebrated with respect, openness, and mutuality.” Part of achieving that goal is to develop a social marketing initiative that will normalize mature public talk about sexuality. Over time, our hope is that our community-based education and training programs, coupled with advertising and public relations activities will help Americans to speak up for sexual health in ways that are mature and respectful, and lead to a healthier society. We want to normalize public talk about sexuality that is authentic rather than polarizing. This vision is entirely consistent with former Surgeon General Dr. David Satcher’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior. We are taking seriously that document, with community forums to discuss appropriate local responses to his Call to Action.

Educators in the field believe that responsible sexuality education should provide accurate information. It should provide a context for understanding personal values about sexuality. It should help people to develop the social skills they need to resist pressure to engage in unwanted sexual activity as well as the skills to create satisfying relationships. Finally, sexuality education should help individuals to behave responsibly -- protecting themselves and their sex partners from the negative outcomes of sexual behavior.

Too often, the focus is only on the last goal. What we have learned from the evaluations of existing sexuality education, teenage pregnancy prevention, and HIV prevention programs is that they can be successful. Research conducted for the National Campaign to Prevent Teen Pregnancy, for instance, has shown the benefits of a variety of programs that have had an impact on the sexual behavior of young people. The positive outcomes can include increasing knowledge, clarifying values, increasing parent-child communication, helping young people to delay intercourse, and increasing the use of contraceptives and condoms. The evidence also indicates that these programs do not increase the likelihood that young people will begin intercourse or increase the frequency of intercourse for sexually active youth.

As we develop or replicate programs, to solve a problem or to promote sexual health, we have a profound need for more and better research into the antecedents of healthy behaviors and the most effective ways to support young people’s healthy sexual development. We seek strategic alliances and partnerships with those who share our vision. We hope to engage the research community and other sexuality education providers in order to ensure that sexuality is understood as an essential lifelong aspect of being human, and that it is celebrated with respect, openness, and mutuality. We need to create a safe and public place for mature discussions about sexuality and health.

As Dr. Satcher has said, “We cannot remain complacent. Doing nothing is unacceptable. Our efforts not only will have an impact on the current health status of our citizens, but will lay a foundation for a healthier society in the future.”

* Michael McGee, C.S.T., is the Vice President of Education and Social Marketing at Planned Parenthood Federation of America.

* More information can be found at Planned Parenthood and teenwire.com.