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Abstinence Education Programs: Definition, Funding, and Impact on Teen Sexual Behavior

Published: Jun 01, 2018

Teen sexual health outcomes over the past decade have been mixed.  On one hand, teen pregnancy and birth rates have fallen dramatically, reaching record lows. On the other hand, rates of sexually transmitted infections (STIs) among teens and young adults have been on the rise.  Many schools and community groups have adopted programming that incorporates abstinence from sexual activity as an approach to reduce teen pregnancy and STI rates.  The content of these programs, however, can vary considerably, from those that stress abstinence as the only option for youth, to those that address abstinence along with medically accurate information about safer sexual practices including the use of contraceptives and condoms. Early action from the Trump administration has signaled renewed support for abstinence-only programming. This fact sheet reviews the types of sex education models and state policies surrounding them, the major sources of federal funding for both abstinence and safer sex education, and summarizes the research on impact of these programs on teen sexual behavior.

Sex Education Models and State Policies

Fact sheet examines abstinence education programs, funding and impact on teen sexual behavior

There are two main approaches towards sex education: abstinence-only and comprehensive sex education ( Table 1 ). These categories are broad, and the content, methods, and targeted populations can vary widely between programs within each model. In general, abstinence-only programs, also known as “sexual risk avoidance programs,” teach that abstinence from sex is the only morally acceptable option for youth, and the only safe and effective way to prevent unintended pregnancy and STIs. They generally do not discuss contraceptive methods or condoms unless to emphasize their failure rates. Comprehensive sex education is more diversely defined. Most generally, these programs include medically accurate, evidence-based information about both contraception and abstinence, as well as condoms to prevent STI transmission. Some programs, known as “abstinence-plus,” stress abstinence as the best way to prevent pregnancy and STIs, but also include information on contraception and condoms. Other programs emphasize safe-sex practices and often include information about healthy relationships and lifestyles.

The type of sex education model used can vary by school district, and even by school. Some states have enacted laws that offer broad guidelines around sex education, though most have no requirement that sex education be taught at all. Only 24 states and DC require that sex education be taught in schools ( Text Box 1 ). More often, states enact laws that dictate the type of information included in sex education if it is taught, leaving up to school districts, and sometimes the individual school, whether to require sex education and which curriculum to use.

Funding Streams for Abstinence Education

Although decisions regarding if and how sex education is taught are ultimately left to individual states and school districts, abstinence-only funding offered by the federal government since the early 1980s’ has served as a strong incentive to adopt this type of programming. Since then, abstinence education curricula have evolved and federal financial support has fluctuated with each administration, peaking in 2008 at the end of the Bush Administration and then dropping significantly under the Obama administration.

Background (1981 – 2010)

Until 2010, there were three major federal programs dedicated to abstinence education: the Adolescent Family Life Act (AFLA), the Community-Based Abstinence Education program (CBAE), and the Title V Abstinence-Only-Until-Marriage program (AOUM). The AFLA and CBAE programs both provided grants to states and community organizations to promote “chastity and self-discipline,” and teach abstinence as the only acceptable practice for youth.  While these programs have since been eliminated and replaced by other sex education funding streams, the Title V AOUM program remains the largest source of federal funding for abstinence education today.

The Title V AOUM program was enacted under the Clinton Administration’s Welfare Reform Act in 1996 ( Table 2 ). Title V funds are tied to an 8-point definition of abstinence education, also referred to as the “A-H definition” ( Table 3 ). While not all eight points must be emphasized equally, AOUM programs cannot violate the intent of the A-H definition and may not discuss safer-sex practices or contraception except to emphasize their failure rates.  States that accept Title V grant money must match every four federal dollars with three state dollars, and they distribute these funds through health departments to schools and community organizations. Every state, except California, has received funding from this program at some point, and currently half of states do. 2

Current Abstinence Programs

Under the Obama Administration, there was a notable shift in abstinence education funding toward more evidence-based sex education initiatives.  The current landscape of federal sex education programs is detailed in Table 2 and includes newer programs such as Personal Responsibility Education Program (PREP), the first federal funding stream to provide grants to states in support of evidence-based sex education that teach about both abstinence and contraception. In addition, the Teen Pregnancy Prevention Program (TPPP) was established to more narrowly focus on teen pregnancy prevention, providing grants to replicate evidence-based program models, as well as funding for implementation and rigorous evaluation of new and innovative models.

Nonetheless, support for abstinence education programs continues. Although Congress allowed the Title V AOUM program to expire in 2009, it was resurrected in the Affordable Care Act legislation signed by President Obama. In 2012, Congress also established the Competitive Abstinence Education grant program, now known as the Sexual Risk Avoidance Education program (SRAE). Initially tied to the A-H definition, it no longer has this requirement; however, the program still teaches youth to “voluntarily refrain from non-marital sexual activity and prevent other youth risk behaviors.” Federal funding for this program bypasses state authority by granting funds directly to community organizations. In 2017, federal funding for the Title V and SRAE programs totaled $90 million ( Figure 1 ).

Figure 1: In 2017, One-Third of Federal Funding for Teen Sexual Health Education Programs Was For Abstinence Education

The Trump Administration’s early actions signal changes in sex education programming. The 2017 TPPP grant recipients received notice from Health and Human Services that their funding was ending on June 30, 2018, two years early, citing a lack of evidence of the program’s impact despite the fact that many of the grantees’ projects had not yet concluded. Nine organizations sued in Washington, Maryland, and the District of Columbia, arguing that their grants were wrongfully terminated. Federal judges in each of the four lawsuits ruled in favor of the organizations, allowing the programs to continue until the end of their grant cycle in 2020. At the same time, the Trump Administration announced the availability of new funding for the TPP program with updated guidelines. These new rules require grantees to replicate one of two abstinence programs—one that follows a sexual risk avoidance model, and one that follows a sexual risk reduction model– in order to receive funding. This marks a sharp departure from the rules under the Obama administration, which allowed grantees to choose from a list of 44 evidence-supported programs that vary by approach, target population, setting, length, and intended outcomes. 3 Applications for the new grants are due at the end of June 2018.

In addition, Congress passed the 2018 Consolidated Appropriations Act, which included a $10 million funding increase for abstinence-only SRAE grant program, bringing the total to $25 million – a 67% increase. 4 In November 2017, HHS also announced a new $10 million research initiative in partnership with Mathematica Policy Research and RTI International to improve teen pregnancy prevention and sexual risk avoidance programs. 5

Impact on Sexual Behavior and Outcomes Among Youth

Proponents of abstinence education argue that teaching abstinence to youth will delay teens’ first sexual encounter and will reduce the number of partners they have, leading to a reduction in rates of teen pregnancy and STIs. 6 However, there is currently no strong body of evidence to support that abstinence-only programs have these effects on the sexual behavior of youth and some have documented negative impacts on pregnancy and birth rates.

In 2007, a nine-year congressionally mandated study that followed four of the programs during the implementation of the Title V AOUM program found that abstinence-only education had no effect on the sexual behavior of youth. 7 Teens in abstinence-only education programs were no more likely to abstain from sex than teens that were not enrolled in these programs. Among those who did have sex, there was no difference in the mean age at first sexual encounter or the number of sexual partners between the two groups. The study also found that youth that participated in the programs were no more likely to engage in unprotected sex than youth who did not participate. While teens who participated in these programs could identify types of STIs at slightly higher rates than those who did not, program youth were less likely to correctly report that condoms are effective at preventing STIs. A more recent review also suggests that these programs are ineffective in delaying sexual initiation and influencing other sexual activity. 8 Studies conducted in individual states found similar results. 9 , 10 One study found that states with policies that require sex education to stress abstinence, have higher rates of teenage pregnancy and births, even after accounting for other factors such as socioeconomic status, education, and race. 11

A study that found an abstinence-only intervention to be effective in delaying sexual activity within a two-year period received significant attention as the first major study to do so. 12 While advocates of comprehensive sex education recognize the study as rigorous and credible, they argue that the programs in these studies are not representative of most abstinence-only programs. Instead, the evaluated programs differed from traditional abstinence-only programs in three major ways: they did not discuss the morality of a decision to have sex; they encouraged youth to wait until they were ready to have sex, rather than until marriage; and they did not criticize the use of condoms. 13

There is, however, considerable evidence that comprehensive sex education programs can be effective in delaying sexual initiation among teens, and increasing use of contraceptives, including condoms. One study found that youth who received information about contraceptives in their sex education programs were at 50% lower risk of teen pregnancy than those in abstinence-only programs. 14 It also found that teens in these more comprehensive programs were no more likely than those receiving abstinence-only education to engage in sexual intercourse, as some critics argue.  Another study found that over 40% of programs that addressed both abstinence and contraception delayed the initiation of sex and reduced the number of sexual partners, and more than 60% of the programs reduced the incidence of unprotected sex. 15 , 16 , 17 Despite this growing evidence, in 2014, roughly three-fourths of high schools and half of middle schools taught abstinence as the most effective method to avoid pregnancy, HIV, and other STDs, just under two-thirds of high schools taught about the efficacy of contraceptives, and about one-third of high schools taught students how to correctly use a condom ( Figure 2 ).

Figure 2: Percent of Schools in Which Teachers Taught Specific Topics as Part of Required Instruction

The Trump administration continues to shift the focus towards abstinence-only education, revamping the Teen Pregnancy Prevention Program and increasing federal funding for sexual risk avoidance programs.  Despite the large body of evidence suggesting that abstinence-only programs are ineffective at delaying sexual activity and reducing the number of sexual partners of teens, many states continue to seek funding for abstinence-only-until-marriage programs and mandate an emphasis on abstinence when sex education is taught in school. There will likely be continued debate about the effectiveness of these programs and ongoing attention to the level of federal investment in sex education programs that prioritize abstinence-only approaches over those that are more comprehensive and based on medical information.

Health and Human Services Administration (HHS). 2017 Personal Responsibility Education Program (PREP) Awards .

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SIECUS. A History of Federal Funding for Abstinence-Only Until Marriage Programs .

Office of Adolescent Health, HHS. Evidence-Based Teen Pregnancy Prevention Programs at a Glance .

The Consolidated Appropriation Act, 2018

HHS, Administration for Children and Families. HHS Announces New Efforts to Improve Teen Pregnancy Prevention & Sexual Risk Avoidance Programs . November 3, 2017.

Heritage Foundation (2010). Evidence on the Effectiveness of Abstinence Education: An Update .

Mathematica Policy Research (2007). Impacts of Four Title V, Section 510 Abstinence Education Programs .

Santelli JS, et al. Guttmacher Institute. Abstinence-Only-Until-Marriage: An Updated Review of U.S. Policies and Programs and Their Impact. Journal of Adolescent Health, 61 (2017) 273e280.

SIECUS. Abstinence-Only-Until-Marriage Programs fact sheet .

Hauser, D. Advocates for Youth. Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact .

Stanger-Hall, K. F., & Hall, D. W. (2011). Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S . PLoS ONE, 6(10), e24658.

Jemmott JB, Jemmott LS, Fong GT. Efficacy of a Theory-Based Abstinence-Only Intervention Over 24 Months: A Randomized Controlled Trial With Young Adolescents . Arch Pediatr Adolesc Med. 2010;164(2):152–159.

Stein R. (2010, February 2). Abstinence-only programs might work, study says . Washington Post

Kohler, Pamela & Manhart, Lisa & E Lafferty, William. (2008). Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy . The Journal of adolescent health. 42. 344-51.

Kirby, D.B. The impact of abstinence and comprehensive sex and STD/HIV education programs on adolescent sexual behavior . Sex Res Soc Policy (2008) 5: 18.

S Denford et al. A Comprehensive Review of Reviews of School-Based Interventions to Improve Sexual-Health . Health Psychol Rev 11 (1), 33-52. 2016 Nov 07.

Chin, Helen B. et al. The Effectiveness of Group-Based Comprehensive Risk-Reduction and Abstinence Education Interventions to Prevent or Reduce the Risk of Adolescent Pregnancy, Human Immunodeficiency Virus, and Sexually Transmitted Infections . American Journal of Preventive Medicine, Volume 42, Issue 3, 272 – 294.

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Abstinence only vs. comprehensive sex education: What are the arguments? What is the evidence?

Abstinence Only vs. Comprehensive Sex Education: What are the arguments? What is the evidence? is a document focusing on the impact of abstinence and comprehensive sex education programs established in United States. Indeed, the United States still has the highest rates of STIs and teen pregnancy of any industrialized nation. Since President Bush, the Congress tends to promotes abstinence-only approach that will likely have serious unintended consequences by denying young people access to the information they need to protect themselves. The document demonstrates and explains why it is crucial to provide young people with comprehensive sex education, including the provision of information about contraceptive and condom use.

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The Impact of Abstinence-Only Sex Education Programs in the United States on Adolescent Sexual Outcomes

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Sonja W. Heels , University of New Hampshire, Durham

Though there are many evaluations of abstinence-only sex education programs in the United States, there is a relatively small body of literature exploring the programs’ impact specifically on adolescent sexual behavior. Thus, the purpose of this literature review is to examine the impact of abstinence-only sex education programs on adolescent sexual outcomes. The phrase “sexual outcomes” refers to attitudes, behaviors, and experiences of adolescents as a result of their sex education. After an overview of sex education in the United States, I discuss three major themes found in the most recent literature: abstinence and delaying the initiation of sex, consequences of the lack of contraceptive use, and lastly, the perspectives and experiences of LGBTQ+ youth. Overall, abstinence-only sex education programs are found to have no beneficial or harmful impact on rates of abstinence, STDs, and unintended pregnancies. Additionally, strong evidence suggests that abstinence-only programs adversely impact LGBTQ+ youth, largely due to the lack of relevant information and the heteronormative framing. I conclude with a brief discussion of how these findings relate back to the current policy debate, as well as suggestions for future research.

Recommended Citation

Heels, Sonja W. (2019) "The Impact of Abstinence-Only Sex Education Programs in the United States on Adolescent Sexual Outcomes," Perspectives : Vol. 11, Article 3. Available at: https://scholars.unh.edu/perspectives/vol11/iss1/3

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Research Article

Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S

* E-mail: [email protected]

Affiliation Department of Plant Biology, The University of Georgia, Athens, Georgia, United States of America

Affiliation Department of Genetics, The University of Georgia, Athens, Georgia, United States of America

• Kathrin F. Stanger-Hall, 
• David W. Hall

• Published: October 14, 2011
• https://doi.org/10.1371/journal.pone.0024658
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The United States ranks first among developed nations in rates of both teenage pregnancy and sexually transmitted diseases. In an effort to reduce these rates, the U.S. government has funded abstinence-only sex education programs for more than a decade. However, a public controversy remains over whether this investment has been successful and whether these programs should be continued. Using the most recent national data (2005) from all U.S. states with information on sex education laws or policies (N = 48), we show that increasing emphasis on abstinence education is positively correlated with teenage pregnancy and birth rates. This trend remains significant after accounting for socioeconomic status, teen educational attainment, ethnic composition of the teen population, and availability of Medicaid waivers for family planning services in each state. These data show clearly that abstinence-only education as a state policy is ineffective in preventing teenage pregnancy and may actually be contributing to the high teenage pregnancy rates in the U.S. In alignment with the new evidence-based Teen Pregnancy Prevention Initiative and the Precaution Adoption Process Model advocated by the National Institutes of Health, we propose the integration of comprehensive sex and STD education into the biology curriculum in middle and high school science classes and a parallel social studies curriculum that addresses risk-aversion behaviors and planning for the future.

Citation: Stanger-Hall KF, Hall DW (2011) Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S. PLoS ONE 6(10): e24658. https://doi.org/10.1371/journal.pone.0024658

Editor: Virginia J. Vitzthum, Indiana University, United States of America

Received: March 8, 2011; Accepted: August 16, 2011; Published: October 14, 2011

Copyright: © 2011 Stanger-Hall, Hall. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This work was funded by the University of Georgia Research Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The appropriate type of sex education that should be taught in U.S. public schools continues to be a major topic of debate, which is motivated by the high teen pregnancy and birth rates in the U.S., compared to other developed countries [1] – [4] ( Table 1 ). Much of this debate has centered on whether abstinence-only versus comprehensive sex education should be taught in public schools. Some argue that sex education that covers safe sexual practices, such as condom use, sends a mixed message to students and promotes sexual activity. This view has been supported by the US government, which promotes abstinence-only initiatives through the Adolescent Family Life Act (AFLA), Community-Based Abstinence Education (CBAE) and Title V, Section 510 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (welfare reform), among others [5] . Funding for abstinence-only programs in 2006 and 2007 was $176 million annually (before matching state funds) [5] , [6] . The central message of these programs is to delay sexual activity until marriage, and under the federal funding regulations most of these programs cannot include information about contraception or safer-sex practices [5] , [7] .

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https://doi.org/10.1371/journal.pone.0024658.t001

The federal funding for abstinence-only education expired on June 30, 2009, and no funds were allocated for the FY 2010 budget. Instead, a “Labor-Health and Human Services, Education and Other Agencies” appropriations bill including a total of $114 million for a new evidence-based Teen Pregnancy Prevention Initiative for FY 2010 was signed into law in December 2009. This constitutes the first large-scale federal investment dedicated to preventing teen pregnancy through research- and evidence-based efforts. However, despite accumulating evidence that abstinence-only programs are ineffective [6] , [8] , abstinence-only funding (including Title V funding) was restored on September 29, 2009 [8] for 2010 and beyond by including $250 million of mandatory abstinence-only funding over 5 years as part of an amendment to the Senate Finance Committee's health-reform legislation (HR 3590, Amendment #2786, section 2954). This was authorized by the legislature on March 23, 2010 [9] .

With two types of federal funding programs available, legislators of individual states now have the opportunity to decide which type of sex education (and which funding option) to choose for their state, while pursuing the ultimate goal of reducing teen pregnancy rates. This large-scale analysis aims to provide scientific evidence for this decision by evaluating the most recent data on the effectiveness of different sex education programs with regard to preventing teen pregnancy for the U.S. as a whole. We used the most recent teenage pregnancy, abortion and birth data from all U.S. states along with information on each state's prescribed sex education approach to ask “what is the quantitative evidence that abstinence-only education is effective in reducing U.S. teen pregnancy rates?” If abstinence education results in teenagers being abstinent, teenage pregnancy and birth rates should be lower in those states that emphasize abstinence more. Other factors may also influence teenage pregnancy and birth rates, including socio-economic status, education, cultural influences [10] – [12] , and access to contraception through Medicaid waivers [13] – [15] and such effects must be parsed out statistically to examine the relationship between sex education and teen pregnancy and birth rates. It was the goal of this study to evaluate the current sex-education approach in the U.S., and to identify the most effective educational approach to reduce the high U.S. teen pregnancy rates. Based on a national analysis of all available state data, our results clearly show that abstinence-only education does not reduce and likely increases teen pregnancy rates. Comprehensive sex and/or STD education that includes abstinence as a desired behavior was correlated with the lowest teen pregnancy rates across states. In alignment with the Precaution Adoption Process Model advocated by the National Institutes of Health we suggest that comprehensive sex and HIV/STD education should be taught as part of the biology curriculum in middle and high school science classes, along with a social studies curriculum that addresses risk-aversion behaviors and planning for the future.

Materials and Methods

Level of emphasis on abstinence in state laws.

Data on abstinence education were retrieved from the Education Commission of the States [16] . Of the 50 U.S. states, only 38 states had sex education laws (as of 2007; Table 2 ). Thirty of the 38 state laws contained abstinence education provisions, 8 states did not. Following the analysis of the Editorial Projects in Education Research Center [17] , which categorizes the data on abstinence education into four levels (from least to most emphasis on abstinence: no provision, abstinence covered, abstinence promoted, abstinence stressed), we assigned ordinal values from 0 through 3 to each of these four categories respectively. A higher category value indicates more emphasis on abstinence with level 3 stressing abstinence only until marriage as the fundamental teaching standard (similar to the federal definition of abstinence-only education), if sex or HIV/STD education is taught (sex education is not required in most states) [16] – [18] . The primary emphasis of a level 2 provision is to promote abstinence in school-aged teens if sex education or HIV/STD education is taught, but discussion of contraception is not prohibited. Level 1 covers abstinence for school-aged teens as part of a comprehensive sex or HIV/STD education curriculum, which should include medically accurate information on contraception and protection from HIV/STDs [16] – [18] . Level 0 laws on sex education and/or HIV education do not specifically mention abstinence.

https://doi.org/10.1371/journal.pone.0024658.t002

Level of emphasis on abstinence in state laws & policies

States without sex education laws may nevertheless have policies regarding sex and/or HIV/STD education. These policies may be published as Health Education standards or Public Education codes [19] . These policies can also provide information on how existing sex education laws may be interpreted by local school boards. Information on the sex education laws and policies for all 50 US states was retrieved from the website of the Sexuality Information and Education Council of the US (SIECUS). We analyzed the 2005 state profiles on sex education laws and policy data for all 50 states [19] following the criteria of the Editorial Projects in Education Research Center [17] to identify the level of abstinence education ( Table 2 ). The coding for the state laws (N = 38) and the coding for both laws and policies (N = 48) was more or less the same for the states represented in both data sets with 6 exceptions ( Table 2 ): the additional information on policies moved two states from a level 0 (abstinence not mentioned) to level 1 (abstinence covered), and four states from a level 2 abstinence provision (abstinence emphasized) to a level 3 (abstinence stressed). Only two states had neither a state law nor a policy regarding sex or STD/HIV education (as of 2005): North Dakota and Wyoming. Analyses of the two data sets gave essentially identical results. In this paper we present the analyses of the more extensive (48 states) law and policy data set.

Teen pregnancy, abortion and birth data

Data on teen pregnancy, birth and abortion rates were retrieved for the 48 states from the most recent national reports, which cover data through 2005 [11] , [12] . The data are reported as number of teen pregnancies, teen births or teen abortions per one thousand female teens between 15 and 19 years of age. In general, teen pregnancy rates are calculated based on reported teen birth and abortion rates, along with an estimated miscarriage rate [12] . We used these data to determine whether there is a significant correlation between level of prescribed abstinence education and teen pregnancy and birth rates across states. The expectation is that higher levels of abstinence education will be correlated with higher levels of abstinence behavior and thus lower levels of teen pregnancy.

Other factors

Data on four possibly confounding factors were included in our analyses.

Socio-economics.

To account for cost-of-living differences across the US, we used the adjusted median household income for 2006 for each state from the Council for Community and Economic Research: C2ER [20] . These data are based on median household income from the Current Population Survey for 2006 from the U.S. Census Bureau [21] and the 2006 cost of living index (COLI).

Educational attainment.

As an estimate of statewide education levels among teens, we used the percentage of high school graduates that took the SAT in 2005/2006 in each state [22] .

Ethnic composition.

We determined the proportion of the three major ethnic groups (white, black, Hispanic) in the teen population (15–19 years old) for each state [12] , and assessed whether the teen pregnancy, abortion and birth rates across states were correlated with the ethnic composition of the teen population. To account for the ethnic diversity among the teen populations in the different states in a multivariate analysis of teen pregnancy and birth rates, we included only the proportion of white and black teens in the state populations as covariates, because the Hispanic teen population numbers were not normally distributed (see below).

Medicaid waivers for family planning.

Medicaid-funded access to contraceptives and family planning services has been shown to decrease the incidence of unplanned pregnancies, especially among low-income women and teens [13] . According to the Guttmacher Institute, the national family planning program prevents 1.94 million unintended pregnancies, including almost 400,000 teen pregnancies each year by providing millions of young and low-income women access to voluntary contraceptive services [13] , Medicaid covered 71% of expenditures for these programs in 2006, and it is estimated that states saved $4 (associated with unintended births) for each $1 spend on contraceptive services [13] . Since the increasing role of Medicaid in funding family planning was mainly due to the efforts of 21 states to expand eligibility for family planning for low-income women who otherwise would not qualify for Medicaid, we analyzed whether these Medicaid waivers for family planning services (available in some states but not in others) could bias our results. We determined which states had received permission (as of 2005) from the Federal Medicaid program to extend Medicaid eligibility for family planning services to large numbers of individuals whose incomes are above the state-set levels for Medicaid enrollment [15] . We assessed whether the waivers (access to family planning services) had an effect on our analysis of teen pregnancy and birth rates across states, specifically whether they could bias our analysis with respect to the effects of the different levels of abstinence education.

Statistical Analyses

Sample statistics..

Using JMP 8 software [23] , we tested all variables for normality (Goodness of Fit: Shapiro Wilkes Test; JMP 8.0). Except for teen abortion rates and Hispanic teen population data, all variables were normally distributed. The distribution of the Hispanic teen population across states was not normal: most states had relatively small Hispanic teen populations, and a few states had a relatively large population of Hispanic teens. Teen pregnancy and birth rate distributions included outliers, but these outliers did not cause the distributions within abstinence education levels to differ significantly from normal, thus all outliers were included in subsequent analyses. For all further statistical analyses we used SPSS [24] .

Correlations.

We used non-parametric (Spearman) correlations to assess relationships between variables, and for normally distributed variables we also used parametric (Pearson) correlations, but these results showed the same trends and significance levels as the non-parametric correlations. As a result, we only report the results for the non-parametric correlations here.

Multivariate analyses.

Only the two normally distributed dependent variables were included in the multivariate analysis (MANOVA and MANCOVA [24] ): teen pregnancy and teen birth rates. We tested for homogeneity of error variances (Levene's Test) and for equality of covariance matrices (Box test) between groups. For MANCOVA we report the estimated marginal means of teen pregnancy and birth rates (i.e. means after the influence of covariates was removed). For pairwise comparison between abstinence levels, we used the Bonferroni adjustment for multiple comparisons.

Among the 48 states in this analysis (all U.S. states except North Dakota and Wyoming), 21 states stressed abstinence-only education in their 2005 state laws and/or policies (level 3), 7 states emphasized abstinence education (level 2), 11 states covered abstinence in the context of comprehensive sex education (level 1), and 9 states did not mention abstinence (level 0) in their state laws or policies ( Figure 1 ). In 2005, level 0 states had an average (± standard error) teen pregnancy rate of 58.78 (±4.96), level 1 states averaged 56.36 (±3.94), level 2 states averaged 61.86 (±3.93), and level 3 states averaged 73.24 (±2.58) teen pregnancies per 1000 girls aged 14–19 ( Table 3 ). The level of abstinence education (no provision, covered, promoted, stressed) was positively correlated with both teen pregnancy (Spearman's rho  = 0.510, p = 0.001) and teen birth ( rho  = 0.605, p<0.001) rates ( Table 4 ), indicating that abstinence education in the U.S. does not cause abstinence behavior. To the contrary, teens in states that prescribe more abstinence education are actually more likely to become pregnant ( Figure 2 ). Abortion rates were not correlated with abstinence education level ( rho  = −0.136, p = 0.415). A multivariate analysis of teen pregnancy and birth rates identified the level of abstinence education as a significant influence on teen pregnancy and birth rates across states (pregnancies F = 5.620, p = 0.002; births F = 11.814, p<0.001). The significant pregnancy effect was caused by significantly lower pregnancy rates in level 0 (no abstinence provision) states compared to level 3 (abstinence stressed) states (p = 0.036), and level 1 (abstinence covered) states compared to level 3 states (p = 0.005); the significant birth effect was caused by significantly lower teen birth rates in level 0 states compared to level 3 (p = 0.006) states, and significantly lower teen birth rates in level 1 states compared to level 3 states (p<0.001).

All 48 states with state laws or policies on sex and/or HIV education are shown (North Dakota and Wyoming are not represented).

https://doi.org/10.1371/journal.pone.0024658.g001

[Rates = numbers per 1000 girls 15–19 years old: shown are means ±2 SE]. Top panel: Teen pregnancies [outliers: #28 Nevada and #29 New Hampshire]; Middle panel: Teen abortions [outlier: #32 New York]; Bottom panel: Teen births. All outliers were included in the statistical analyses. A multivariate analysis of teen pregnancy and birth rates identified the level of abstinence education as a significant influence on teen pregnancy and birth rates across states.

https://doi.org/10.1371/journal.pone.0024658.g002

https://doi.org/10.1371/journal.pone.0024658.t003

https://doi.org/10.1371/journal.pone.0024658.t004

Socio-economic status, educational attainment, and ethnic differences across states exhibited significant correlations with some variables in our model ( Table 4 ). We examined the influence of each possible confounding factor on our analysis by including them as covariates in several multivariate analyses. However, after accounting for the effects of these covariates, the effect of abstinence education on teenage pregnancy and birth rates remained significant ( Figure 3 ).

(A) The adjusted median household income significantly influenced teen pregnancy and birth rates, but the level of abstinence education still had a significant influence on teen pregnancy and birth rates after accounting for socioeconomic status. (B) Education had a significant influence on teen birth, but not on teen pregnancy rates. After accounting for the influence of teen education, the level of abstinence education still had a significant influence on both teen pregnancy and teen birth rates. (C) The proportion of white teens (but not black teens) in the population had a significant influence on teen pregnancy and teen birth rates. After accounting for this influence, the level of abstinence education still had a significant influence on teen pregnancy and birth rates.

https://doi.org/10.1371/journal.pone.0024658.g003

Socio-economic status

There was a significant negative correlation between median household income (adjusted for cost of living) and level of abstinence education ( rho  = −0.349, p = 0.015; Table 4 ), indicating a socio-economic bias at the state level on state laws and regulations with regard to sex education. The adjusted median household income was negatively correlated with teen pregnancy ( rho  = −0.383, p = 0.007) and birth ( rho  = −0.296, p = 0.041) rates across states: pregnancy and birth rates tended to be higher in lower-income states. There was no correlation between household income and abortion rates ( rho  = −0.116, p = 0.432). When including the adjusted median household income as a covariate in a multivariate analysis (evaluated at $45,892), income significantly influenced teen pregnancy (F = 5.427, p = 0.025) but not birth (F = 2.216, p = 0.144) rates. After accounting for socioeconomic status, the level of abstinence education still had a significant effect on teen pregnancy (F = 4.103, p = 0.012) and birth rates (F = 10.480, p<0.001).

Educational attainment

There was no significant correlation between statewide teen education (percentage of high school graduates that took the SAT in 2005/2006) and level of abstinence education ( rho  = −0.156, p = 0.291). Education was not correlated with teen pregnancy rates ( rho  = −0.014, p = 0.925), but it was positively correlated with teen abortion rates ( rho  = 0.662, p<0.001), and as a consequence, negatively correlated with teen birth rates ( rho  = −0.412, p = 0.004). There was no correlation between socio-economic status and teen educational attainment across states ( rho  = −0.048, p = 0.748), suggesting that these trends apply to both rich and poor states. When including education (% graduates taking the SAT) as a covariate in a multivariate analysis, education had a significant influence on teen birth (F = 8.308, p = 0.006), but not on teen pregnancy (F = 0.161, p = 0.690) rates, and after accounting for the influence of teen education (evaluated at 39.7% of graduates taking the SAT), the level of abstinence education still had a significant effect on both teen pregnancy (F = 5.527, p = 0.003) and teen birth rates (F = 10.772, p<0.001).

Ethnic composition

For this analysis we focused on the three largest ethnic groups for which data are available: white, black, and Hispanic [12] . Teen pregnancy rates differ across these three ethnic groups. For the 48 states in this analysis, an ethnic breakdown (for all three ethnic groups) of teen pregnancy and abortion rates was available for 26 states, and of teen birth rates for 43 states. Across this reduced sample of states, 2005 teen pregnancy rates averaged 48.1 (±1.95) pregnancies per 1000 white teens, 103.7 (±5.38) pregnancies per 1000 black teens, and 141.6 (±8.55) pregnancies per 1000 Hispanic teens. Teen birth rates averaged 27.6 (±1.5) births per 1000 white teens, 59.2 (±2.58) births per 1000 black teens, and 96.1 (±5.39) births per 1000 Hispanic teens. Abstinence education levels were positively correlated with teen birth rates in all three ethnic groups (white: rho  = 0.439, p = 0.002; black: rho  = 0.328, p = 0.028; Hispanic: rho  = 0.461, p = 0.001; Table 5 ).

https://doi.org/10.1371/journal.pone.0024658.t005

Across all 48 states, abstinence education levels were significantly correlated with the proportions of white and black teens in the state populations ( Table 4 ). In general, states with higher proportions of white teens tended to emphasize abstinence less ( rho  = −0.382, p = 0.007), and states with higher proportions of black teens tended to emphasize abstinence more ( rho  = 0.419, p = 0.003). When we included the proportion of white and black teens in the state populations as covariates in a multivariate analysis (evaluated at proportion white: 0.704 and proportion black: 0.138), only the proportion of white teens had a significant effect on teen pregnancy (F = 42.206, p<0.001) and teen birth rates (F = 5.894, p = 0.020). After accounting for this influence, the level of abstinence education still had a significant effect on teen pregnancy (F = 2.839, p = 0.049) and teen birth rates (N = 43 states: F = 7.782, p<0.001; Figure 3 ).

Medicaid waivers

If Medicaid waivers contribute to the positive correlation between abstinence education and teen pregnancy at the state level, then states with waivers should have different teen pregnancy and birth rates than states without waivers. This was not the case. States with waivers (N = 17) were represented across all four abstinence education levels ( Figure 4 ) and did not differ significantly in teen pregnancy rates from states without waivers (N = 21, Mann Whitney U = 237, p = 0.086), suggesting no significant effect of waivers (at the state level) on the correlation between abstinence levels and teen pregnancy rates. A recent study [14] found the same level of (non-)significance (0.05<p<0.1) for the effect of waivers on teen birth rates, but reported it as significant.

Access to waivers does not explain the difference in teen pregnancy rates (shown are means and ±2 SE) in states with a different emphasis on abstinence.

https://doi.org/10.1371/journal.pone.0024658.g004

This study used a correlational approach to assess whether abstinence-only education is effective in reducing U.S. teen pregnancy rates. Correlation can be due to causation, but it can also be due to other underlying factors, which need to be examined. Several factors besides abstinence education are correlated with teen pregnancy rates. In agreement with previous studies, our analysis showed that adjusted median household income and proportion of white teens in the teen population both had a significant influence on teen pregnancy rates. Richer states tend to have a higher proportion of white teens in their teen populations, tend to emphasize abstinence less, and tend to have lower teen pregnancy and birth rates than poorer states. A recent study [25] found that higher teen birth rates in poorer states were also correlated with a higher degree of religiosity (and a lower abortion rate) at the state level. Medicaid waivers have previously been shown to reduce teen pregnancy rates [13] , but our analysis shows that they do not explain our main result, the positive correlation between abstinence education level and teen pregnancy rates.

After accounting for other factors, the national data show that the incidence of teenage pregnancies and births remain positively correlated with the degree of abstinence education across states: The more strongly abstinence is emphasized in state laws and policies, the higher the average teenage pregnancy and birth rate. States that taught comprehensive sex and/or HIV education and covered abstinence along with contraception and condom use (level 1 sex education; also referred to as “abstinence-plus” [26] , tended to have the lowest teen pregnancy rates, while states with abstinence-only sex education laws that stress abstinence until marriage (level 3) were significantly less successful in preventing teen pregnancies. Level 0 states present an interesting sample with a wide range of education policies and variable teen pregnancy and birth data [17] – [19] . For example, several of the level 0 states (as of 2007) did not mandate sex education, but required HIV education only (e.g. CT, WV) [19] . Only three of the level 0 states (IA, NH and NV) mandated both sex education and HIV education, but one of them (NV) did not require that teens learn about condoms and contraception. This state (NV) has the highest teen pregnancy and birth rates in that group ( Figure 1 ). Nevada is also one of only five states (with MD in level 0, CO in level 2, and AZ and UT in level 3) that required parental consent for sex education in public schools instead of an opt-out requirement that is present in all the other states [16] , [19] .

The effectiveness of Level 1 (comprehensive) sex education in our nation-wide analysis is supported by Kirby's meta-analysis of individual sex education programs [8] , Underwood et al. 's analysis of HIV prevention programs [27] , and a recent review by the CDC taskforce on community preventive services [28] . All these studies suggest that comprehensive sex or HIV education that includes the discussion of abstinence as a recommended behavior, and also discusses contraception and protection methods, works best in reducing teen pregnancy and sexually transmitted diseases.

Individual research studies

Despite large differences between individual research studies that evaluate specific sex education programs (e.g. sample size, approaches to sex education studied, selection of participants, choice of control groups, types of data, control for cross-talk between students outside of class, etc.), several case studies show that abstinence-only education rarely has a positive effect on teen sexual behavior [6] , [8] , [29] . One of the few exceptions is the recent study by Jemmott et al. [30] on black middle school students in low-income urban schools: after receiving 8 hours of abstinence education as 12 year olds, significantly more students (64/95) reported to be abstinent after 24 months when compared to (control) students who received 8 hours of health education (without any form of sex education: 47/88; Fishers exact test, p = 0.037), or students who received 8 hours of safe-sex education (without an abstinence component: 41/85, Fishers exact test, p = 0.007). However, there was no significant difference in abstinence behavior between students who had received abstinence education (64/95) and students who received 8 hours of comprehensive sex education (combining sex education with abstinence education: 57/97; Fishers exact test, p = 0.138). These two groups also did not differ in rates of reported unprotected sex (8/122 versus 8/115) or use of condoms (25/33 versus 29/37) in the previous 3 months. The abstinence-only intervention in that study was unique in that it increased knowledge about HIV/STD, emphasized the delay of sexual activity, but not necessarily until marriage, did not put sex into a negative light or use a moralistic tone, included no inaccurate information, corrected incorrect views, and did not disparage the use of condoms [30] . As a result, as pointed out by the authors, this successful version of abstinence education would not have met the criteria for federal abstinence-only funding [30] . While promoting an alternative and more effective form of abstinence education, these results also support Kirby's findings [8] and the data in the present study that comprehensive sex education that includes an abstinence (delay) component (level 1), is the most effective form of sex education, especially when using teen pregnancy rates as a measurable outcome.

Individual research studies also show that teaching about contraception is generally not associated with increased risk of adolescent sexual activity or sexually transmitted diseases (STDs) [8] as suggested by abstinence-only advocates, and adolescents who received comprehensive sex or HIV education had a lower risk of pregnancy and HIV/STD infection than adolescents who received strict abstinence-only or no sex education at all in the U.S. and in other high-income countries [27] , [31] .

Abstinence-only education: public opinion and associated costs

Despite the data showing that abstinence-only education is ineffective, it may be argued that the prescribed form of sex education represents the underlying social values of families and communities in each state, and changing to a more comprehensive sex education curriculum will meet with strong opposition. However, there is strong public support for comprehensive sex education [32] . Approximately 82% of a randomly selected nationally representative sample of U.S. adults aged 18 to 83 years (N = 1096) supported comprehensive programs that teach students about both abstinence and other methods of preventing pregnancy and sexually transmitted diseases. In contrast, abstinence-only education programs, received the lowest levels of support (36%) and the highest level of opposition (about 50%).

In addition to the federal and state funds spent on abstinence-only (level 3) education, there are other costs associated with the outcomes of failed sex education and family planning. When deciding state policies on sex education, State legislators should consider these additional costs. For example, based on estimates by the National Campaign To Prevent Teen and Unplanned Pregnancy [33] , teen child bearing (compared to first birth at 20 years or older) in the U.S. cost taxpayers (in direct and indirect costs) more than $9.1 billion in 2004.

Our data show that education (% of high school graduates taking the SAT) was not correlated with teen pregnancy rates, but it was positively correlated with teen abortion rates and negatively correlated with teen birth rates. These data can be interpreted in two ways: (1) pregnant teens who give birth are less likely to finish high school and go on to college (i.e. pregnancy affects education). This is supported by a recent report [34] that showed that teen mothers are more likely to drop out of school: 51% of teen mothers earned their high school diploma by age 22, compared to 89% of women who had not given birth as teens. (2) teens who are motivated to go to college are not necessarily less likely to get pregnant, but more likely to abort their pregnancies (i.e. educational goal affects the decision of whether to carry a pregnancy to term).

As pointed out by the Society for Adolescent Medicine, the abstinence-only approach (as stressed by level 3 state laws and policies and funded by the federal abstinence-only programs) is characterized by the withholding of information and is ethically flawed [7] . Abstinence-only programs tend to promote abstinence behavior through emotion, such as romantic notions of marriage, moralizing, fear of STDs, and by spreading scientifically incorrect information [7] , [20] , [35] . For example a Congressional committee report found evidence of major errors and distortions of public health information in common abstinence-only curricula [36] . As a result, these programs may actually be promoting irresponsible, high-risk teenage behavior by keeping teens uneducated with regard to reproductive knowledge and sound decision-making instead of giving them the tools to make educated decisions regarding their reproductive health [37] . The effect of presenting inadequate or incorrect information to teenagers regarding sex and pregnancy and STD protection is long-lasting as uneducated teens grow into uneducated adults: almost half of all pregnancies in the U.S. were unplanned in 2001 [38] . Of these three million unplanned pregnancies, ∼1.4 million resulted in live births, ∼1.3 million ended in abortion, and over 400,000 ended in a miscarriage [36] , [37] at a financial cost (direct medical costs only) of ∼$5 billion in 2002 [39] .

The U.S. teen pregnancy rate is substantially higher than seen in other developed countries ( Table 1 ) despite similar cultural and socioeconomic patterns in teen pregnancy rates [40] . The difference is not due to the onset of sexual activity [1] . Instead, the main factor seems to be sex education, especially with regard to contraception and prevention of STDs [41] . Sex education in Europe is based on the WHO definition of sexuality as a lifelong process, aiming to create self-determined and responsible attitudes and behavior with regard to sexuality, contraception, relationships and life strategies and planning [42] . In general, there is greater and easier access to sexual health information and services for all people (including teens) in Europe, which is facilitated by a societal openness and comfort in dealing with sexuality [40] , by pragmatic governmental policies [43] , [44] and less influence by special interest groups.

Future Directions

While states with comprehensive sex education have lower teen pregnancy rates, even in these states rates are much higher than seen in Europe [1] . This is likely influenced by the fact that U.S. state laws and policies generally do not require that sex and STD education is taught in all schools, but only provide guidelines if local school boards decide to teach it [19] . For example, as of August 1, 2011, only 20 states mandated sex education, and 32 states mandated HIV education in their schools [45] . In addition, even states with comprehensive sex education laws or policies (level 1) received federal funding for individual abstinence-only education programs in 2005: total federal funds [19] averaged ∼$14 per teen in level 1 states compared to ∼$21 per teen in level 2 and 3 states [12] . An important first step towards lowering the high teen pregnancy rates would be states requiring that comprehensive sex education (with abstinence as a desired behavior) is taught in all public schools. Another important step would involve specialized teacher training. Presently the sex education and STD/HIV curricula are often taught by faculty with little training in this area [46] . As a further modification, “sex education” could be split into a coordinated social studies component (ethics, behavior and decision-making, including planning for the future) and a science component (human reproductive biology and biology of STDs, including pregnancy and STD prevention), each taught by trained teachers in their respective field.

As parents, educators or policy makers it should be our goals that (1) teens can make educated reproductive and sexual health decisions, that (2) teen pregnancy and STD rates are reduced to the rates of other developed nations, and that (3) these trends are maintained through the teenage years into adulthood. One possibility for achieving these goals is a close alignment and integration of sex education with the National Science Standards for U.S. middle and high schools [47] . In addition, the Precaution Adoption Process Model ( Figure 5 ) advocated by the National Institutes of Health [48] offers a good basis for communication and discussions between scientists, educators, and sex education researchers, and could serve as a reference for measuring progress in sex education (in alignment with the new evidence-based Teen Pregnancy Prevention Initiative). In addition, it could be used as a communication tool between sex education teachers and their students. It should be our specific goal to move American teens from Stages 1 or 2 (unaware or unengaged in the issues of pregnancy and STD prevention) to Stages 3–7 (informed decision-making) by providing them with knowledge, understanding, and sound decision-making skills ( Figure 5 ). For example, a recent study [49] attributes 52% of all unintended pregnancies (teenagers and adults) in the U.S. to non-use of contraception, 43% to inconsistent or incorrect use, and only 5% to method failure.

This model offers a basis for communication and discussions between educators, scientists, sex education researchers, and health professionals, and could serve as a reference for measuring progress in sex education. In addition, it could be used as a communication tool between sex education teachers and their students [48] .

https://doi.org/10.1371/journal.pone.0024658.g005

Our analysis adds to the overwhelming evidence indicating that abstinence-only education does not reduce teen pregnancy rates. Advocates for continued abstinence-only education need to ask themselves: If teens don't learn about human reproduction, including safe sexual health practices to prevent unintended pregnancies and STDs, and how to plan their reproductive adult life in school, then when should they learn it, and from whom?

Acknowledgments

We thank C2ER, the Council for Community and Economic Research, for providing additional adjusted median household income data for those states that were not included in their online data set, and two anonymous reviewers for helpful comments.

Author Contributions

Conceived and designed the experiments: DWH KSH. Performed the experiments: DWH KSH. Analyzed the data: DWH KSH. Wrote the paper: DWH KSH.

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Federal Policy Snapshots

Federally Funded Abstinence-Only Programs: Harmful and Ineffective

Reproductive rights are under attack. Will you help us fight back with facts?

All young people should have access to comprehensive sexual and reproductive health information that is medically accurate, LGBTQ-inclusive, and culturally and age appropriate so that they can make informed decisions about their sexual behavior, relationships and reproductive choices. Yet the federal government wastes $110 million per year on misleading and incomplete abstinence-only-until-marriage programs that harm young people and fail to achieve their stated goals. These programs disguise abstinence-only messaging as “sexual risk avoidance” and deny young people necessary and even life-saving information about their own bodies, reproductive health and sexuality. The federal government must eliminate all funding for these programs and use that money to fund sex education programs that offer informative and inclusive curricula.

How federal abstinence-only programs work

• There are two federal funding streams dedicated to abstinence-only programs : the Title V Sexual Risk Avoidance Education (SRAE) grant program, which is funded for several years at a time, and the discretionary SRAE grant program, which receives funding through annual spending bills. Both are managed by the Family and Youth Services Bureau within the Administration for Children and Families at the U.S. Department of Health and Human Services (HHS).
• The Title V SRAE program was established in 1996. Between 1998 (the first year it was implemented) and 2016, the program received $50 million annually. Since 2017, it has been funded at $75 million per year. Between state and non-state (competitive) grants, it supports grantees in 44 states and five territories.
• The discretionary SRAE program is a rebranding of the Competitive Abstinence Education grant program and was established by the 2016 appropriations bill. Funding for the program started at $5 million and has grown steadily; since 2019, it has received $35 million annually. It currently supports grantees in 15 states .
• The goal of both programs is to discourage young people from having sex before marriage. While the curricula funded through these programs must provide information that is medically accurate, they are far from comprehensive. For example, the Title V SRAE program allows grantees to discuss contraception, but they are barred from providing demonstrations of how specific methods work.
• Funds may be granted to states, territories, local governments, tribal governments, nonprofits, public and private colleges and universities, and small businesses.

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Impact of abstinence-only programs

Ineffective at their stated goals.

• Research shows that federal abstinence-only funding does not lower adolescent birth rates . In fact, the more that state policies emphasize abstinence-only programs, the higher the incidence of adolescent pregnancies and births.
• An HHS-funded analysis found that abstinence-only programs do not affect the incidence of pregnancy, HIV or other STIs in adolescents.
• Young people who express intentions to wait until marriage to have sex have the same rates of premarital sex, STIs, and anal and oral sex as their peers who do not take pledges. They are also less likely to use contraceptives , are at higher risk for HPV and have higher rates of nonmarital pregnancy compared with those who never pledged abstinence.

Harmful to young people

• By the end of high school, the majority (57%) of teenagers will have had sex , yet abstinence-only programs are not designed to equip them with the information about contraceptives, STIs, consent or healthy communication that they need to safely navigate these experiences.
• Abstinence-only programs promote judgment, fear, guilt and shame around sex. These programs frame premarital sexual activity and pregnancy as wrong or risky choices with negative health outcomes and seek to shame sexually active young people.
• Abstinence-only programs are often heteronormative and frame LGBTQ students as deviant. Stigma and discrimination against LGBTQ students increase their risk of HIV infection, substance use disorder, suicide and experiencing violence.
• Framing abstinence as a choice—and anything else as a failure—is isolating and cruel to students who have been coerced or forced into sexual experiences. For example, abstinence-only programs are completely unprepared to meet the needs of the one in nine girls and one in 53 boys who have experienced sexual abuse or assault by an adult.
• Many abstinence-only programs tout gender stereotypes as scientific fact and reinforce messages about male aggression and female passivity.
• Abstinence-only programs typically overemphasize the risks associated with contraception and downplay or overlook its benefits beyond pregnancy prevention , such as reducing pregnancy-related mortality and morbidity, reducing the risk of developing certain reproductive cancers, and being used to treat menstrual symptoms and disorders.
• Medical experts, including the American Medical Association , American College of Obstetricians and Gynecologists , and the Society for Adolescent Health and Medicine oppose abstinence-only programs.
• The majority of parents of high school students support instruction on a broad range of sex education topics, rather than teaching only about abstinence.

What policymakers can do

To end federal funding for abstinence-only programs and support programs that provide a more constructive approach to sex education, Congress and the Biden-Harris administration should take the following steps:

• Eliminate all funding for Title V SRAE and discretionary SRAE grants and redirect those funds to sex education programs that offer informative and inclusive curricula.
• Increase funding for evidence-based federal programs, including the Teen Pregnancy Prevention Program and the Personal Responsibility Education Program , that recognize young people’s sexual and reproductive health needs.

Figure: Vast majority of parents support sex education in high school

1. Kantor L and Levitz N, Parents’ views on sex education in schools: How much do Democrats and Republicans agree?,  PLOS ONE , 2017, 12(7):e0180250, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0180250 .

The Path Ahead: Restoring and Advancing Sexual and Reproductive Health and Rights

Sex and hiv education, new name, same harm: rebranding of federal abstinence-only programs, adolescents deserve better: what the biden-harris administration and congress can do to bolster young people’s sexual and reproductive health, united states.

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You are here, does abstinence-only education work.

GSE Professor Rebecca Maynard discusses abstinence-only sex education on NPR.  Click here to listen.

New research by Penn GSE Professor Rebecca Maynard has shown that abstinence-only sex education has no effect on the onset of sexual activity among children or on the likelihood that, if they do engage in sex, they will use a condom.

A foundation stone of the Bush Administration's social agenda, these programs receive $176 million a year in federal funding annually, with millions more coming from state and local matching grants.

Dr. Maynard's research was designed to gather scientifically valid evidence about whether these programs make a difference in the lives of children. Her project incorporated four studies looking at different programs at four different sites - two urban, two rural. A randomized trial, the study looked at statistically comparable groups of children, some in abstinence-only programs and others who experienced "business as usual."

While short-term findings showed some shift in attitudes about delaying sex, findings over the longer term indicated no difference between the abstinence-only groups and the control groups.

Says Dr. Maynard, "There were some indications that you would change knowledge and values that would delay onset of sexual activity. You could change what kids would tell you about their values and their expectations - that they would wait until they were older or married until they had sex."

An early analysis by his organization showed some attitude shifts toward delaying sex among students in the abstinence programs, but those differences disappeared as students got older. One thing they also learned, Trenholm said, was that kids receiving abstinence instruction did not use condoms less often than other kids, a possibility that critics occasionally raise. They also showed slightly better knowledge about the prevention of sexually transmitted disease.

But when the research team looked at the long-term findings, they found that, as students got older, these impacts disappeared - that is, students receiving abstinence-only instruction displayed the same attitudes and behaviors as those who did not.

"We can conclude that the programs did not delay sexual onset," says Dr. Maynard. "But they also didn't reduce the likelihood that kids were going to use contraception when they did engage in sex."

Penn GSE Professor Rebecca Maynard recently appeared on WHYY's Radio Times program to discuss the evidence on abstinence-only education programs. To listen to the full interview, click here .

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What the Research Shows: Government-Funded Abstinence-Only Programs Don’t Make the Grade

What the Research Shows: Abstinence-Only-Until-Marriage Sex Education Does Not Protect Teenagers' Health

Evidence shows that sexuality education that stresses the importance of waiting to have sex while providing accurate, age-appropriate, and complete information about how to use contraceptives effectively to prevent pregnancy and sexually transmitted diseases (STDs) can help teens make healthy and responsible life decisions. Yet there is currently no federal program dedicated to supporting this approach. Instead, since 1996, the federal government has funneled more than a billion dollars into abstinence-only-until-marriage programming, even in the face of clear evidence that these programs do not work.

Below is a review of recent research on the issue of sexuality education:

Giving teens the information they need to make responsible life decisions about sex helps teens delay sex and protects their health.

• A nationwide study of 15-19 year olds found that teens who participated in sexuality education programs that discuss the importance of delaying sex and provide information about contraceptive use were significantly less likely to report teen pregnancies than were those who received either no sex education or attended abstinence-only-until-marriage programs.

Pamela K. Kohler, RN. et al., Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy , Journal of Adolescent Health, Spring 2008.

· A review of 115 sex education programs found that curricula that stress waiting to have sex and provide information about using contraception effectively can significantly delay the initiation of sex, reduce the frequency of sex, reduce the number of sexual partners, and increase condom or contraceptive use among teens.

Douglas Kirby, Ph.D. et al., Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases , The National Campaign to Prevent Teen and Unplanned Pregnancy, November 2007.

• The Centers for Disease Control & Prevention note that “research has clearly shown that the most effective programs [to prevent the spread of HIV/AIDS] are comprehensive ones that include a focus on delaying sexual behavior and provide information on how sexually active young people can protect themselves.”

Centers for Disease Control & Prevention, Fact Sheet: Young People at Risk: HIV/AIDS Among America’s Youth , National Center for HIV, STD and TB Prevention, March 2002.

Parents want schools to teach comprehensive sexuality education and do not think taxpayer dollars should be spent on abstinence-only-until-marriage programs.

• More than 85 percent of Americans believe that it is appropriate for school-based sex education programs to teach students how to use and where to get contraceptives.

National Public Radio, Kaiser Family Foundation, and Harvard University’s Kennedy School of Government, Sex Education in America , January 2004.

• Seventy percent of Americans oppose the use of federal funds for abstinence-only-until-marriage programs that prohibit teaching about the use of condoms and contraception for the prevention of unintended pregnancies and STDs.

Advocates for Youth and SIECUS, “Americans Oppose Abstinence- Only Education Censoring Information on Contraception,” 1999.

Studies show that most abstinence-only-until-marriage programs are ineffective, and some show that these programs deter teens who become sexually active from protecting themselves from unintended pregnancy or STDs.

• A rigorous, multi-year, scientific evaluation authorized by Congress presents clear evidence that abstinence-only-until-marriage programs don’t work. The study, which looked at four federally funded programs and studied more than 2000 students, found that abstinence-only program participants were just as likely to have sex before marriage as teens who did not participate. Furthermore, program participants had first intercourse at the same mean age and the same number of sexual partners as teens who did not participate in the federally funded programs.

Christopher Trenholm et al., Impacts of Four Title V, Section 510 Abstinence Education Programs , Princeton: Mathematica Policy Research, Inc., April 2007.

Debra Hauser, Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact , Advocates for Youth, September 2004.

Hannah Brückner and Peter Bearman, “ After the promise: the STD consequences of adolescent virginity pledges ,” Journal of Adolescent Health , 36 (2005) 271-278.

A recent congressional report found that widely used federally funded abstinence-only-until-marriage curricula distort information, misrepresent the facts, and promote gender stereotypes.

· More than 80 percent of the abstinence-only-until-marriage curricula reviewed contain false, misleading, or distorted information about reproductive health.

· The curricula reviewed misrepresent the effectiveness of contraceptives in preventing STDs and unintended pregnancy. They also contain false information about the risks of abortion, blur religion and science, promote gender stereotypes, and contain basic scientific errors.

“The Content of Federally Funded Abstinence-Only Education Programs,” Prepared for Rep. Henry A. Waxman, United States House of Representatives, Committee on Government Reform – Minority Staff, Special Investigations Division, December 2004.

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Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen pregnancy

Affiliation.

• 1 Department of Health Services, University of Washington, Seattle, Washington 98195-7660, USA.
• PMID: 18346659
• DOI: 10.1016/j.jadohealth.2007.08.026

Purpose: The role that sex education plays in the initiation of sexual activity and risk of teen pregnancy and sexually transmitted disease (STD) is controversial in the United States. Despite several systematic reviews, few epidemiologic evaluations of the effectiveness of these programs on a population level have been conducted.

Methods: Among never-married heterosexual adolescents, aged 15-19 years, who participated in Cycle 6 (2002) of the National Survey of Family Growth and reported on formal sex education received before their first sexual intercourse (n = 1719), we compared the sexual health risks of adolescents who received abstinence-only and comprehensive sex education to those of adolescents who received no formal sex education. Weighted multivariate logistic regression generated population-based estimates.

Results: Adolescents who received comprehensive sex education were significantly less likely to report teen pregnancy (OR(adj) = .4, 95% CI = .22- .69, p = .001) than those who received no formal sex education, whereas there was no significant effect of abstinence-only education (OR(adj) = .7, 95% CI = .38-1.45, p = .38). Abstinence-only education did not reduce the likelihood of engaging in vaginal intercourse (OR(adj) = .8, 95% CI = .51-1.31, p = .40), but comprehensive sex education was marginally associated with a lower likelihood of reporting having engaged in vaginal intercourse (OR(adj) = .7, 95% CI = .49-1.02, p = .06). Neither abstinence-only nor comprehensive sex education significantly reduced the likelihood of reported STD diagnoses (OR(adj) = 1.7, 95% CI = .57-34.76, p = .36 and OR(adj) = 1.8, 95% CI = .67-5.00, p = .24 respectively).

Conclusions: Teaching about contraception was not associated with increased risk of adolescent sexual activity or STD. Adolescents who received comprehensive sex education had a lower risk of pregnancy than adolescents who received abstinence-only or no sex education.

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The State of Sex Education in the United States

Kelli stidham hall.

Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia

Jessica McDermott Sales

Kelli a. komro, john santelli.

Department of Population & Family Health, Mailman School of Public Health, Columbia University, New York, New York

For more than four decades, sex education has been a critically important but contentious public health and policy issue in the United States [ 1 – 5 ]. Rising concern about nonmarital adolescent pregnancy beginning in the 1960s and the pandemic of HIV/AIDS after 1981 shaped the need for and acceptance of formal instruction for adolescents on life-saving topics such as contraception, condoms, and sexually transmitted infections. With widespread implementation of school and community-based programs in the late 1980s and early 1990s, adolescents’ receipt of sex education improved greatly between 1988 and 1995 [ 6 ]. In the late 1990s, as part of the “welfare reform,” abstinence only until marriage (AOUM) sex education was adopted by the U.S. government as a singular approach to adolescent sexual and reproductive health [ 7 , 8 ]. AOUM was funded within a variety of domestic and foreign aid programs, with 49 of 50 states accepting federal funds to promote AOUM in the classroom [ 7 , 8 ]. Since then, rigorous research has documented both the lack of efficacy of AOUM in delaying sexual initiation, reducing sexual risk behaviors, or improving reproductive health outcomes and the effectiveness of comprehensive sex education in increasing condom and contraceptive use and decreasing pregnancy rates [ 7 – 12 ]. Today, despite great advancements in the science, implementation of a truly modern, equitable, evidence-based model of comprehensive sex education remains precluded by sociocultural, political, and systems barriers operating in profound ways across multiple levels of adolescents’ environments [ 4 , 7 , 8 , 12 – 14 ].

At the federal level, the U.S. congress has continued to substantially fund AOUM, and in FY 2016, funding was increased to $85 million per year [ 3 ]. This budget was approved despite President Obama’s attempts to end the program after 10 years of opposition and concern from medical and public health professionals, sexuality educators, and the human rights community that AOUM withholds information about condoms and contraception, promotes religious ideologies and gender stereotypes, and stigmatizes adolescents with nonheteronormative sexual identities [ 7 – 9 , 11 – 13 ]. Other federal funding priorities have moved positively toward more medically accurate and evidence-based programs, including teen pregnancy prevention programs [ 1 , 3 , 12 ]. These programs, although an improvement from AOUM, are not without their challenges though, as they currently operate within a relatively narrow, restrictive scope of “evidence” [ 12 ].

At the state level, individual states, districts, and school boards determine implementation of federal policies and funds. Limited in-class time and resources leave schools to prioritize sex education in competition with academic subjects and other important health topics such as substance use, bullying, and suicide [ 4 , 13 , 14 ]. Without cohesive or consistent implementation processes, a highly diverse “patchwork” of sex education laws and practices exists [ 4 ]. A recent report by the Guttmacher Institute noted that although 37 states require abstinence information be provided (25 that it be stressed), only 33 and 18 require HIV and contraceptive information, respectively [ 1 ]. Regarding content, quality, and inclusivity, 13 states mandate instruction be medically accurate, 26 that it be age appropriate, eight that it not be race/ethnicity or gender bias, eight that it be inclusive of sexual orientation, and two that it not promote religion [ 1 ]. The Centers for Disease Control and Prevention’s 2014 School Health Policies and Practices Study found that high school courses require, on average, 6.2 total hours of instruction on human sexuality, with 4 hours or less on HIV, other sexually transmitted infections (STIs), and pregnancy prevention [ 15 ]. Moreover, 69% of high schools notify parents/guardians before students receive such instruction; 87% allow parents/guardians to exclude their children from it [ 15 ]. Without coordinated plans for implementation, credible guidelines, standards, or curricula, appropriate resources, supportive environments, teacher training, and accountability, it is no wonder that state practices are so disparate [ 4 ].

At the societal level, deeply rooted cultural and religious norms around adolescent sexuality have shaped federal and state policies and practices, driving restrictions on comprehensive sexual and reproductive health information, and service delivery in schools and elsewhere [ 12 , 13 ]. Continued public and political debates on the morality of sex outside marriage perpetuate barriers at multiple levels—by misguiding state funding decisions, molding parents’ (mis)understanding of programs, facilitating adolescents’ uptake of biased and inaccurate information in the classroom, and/or preventing their participation in sex education altogether [ 4 , 7 , 8 , 12 – 14 ].

Trends in Adolescents’ Receipt of Sex Education

In this month’s Journal of Adolescent Health , Lindberg et al. [ 16 ] provide further insight into the current state of sex education and the implications of federal and state policies for adolescents in the United States. Using population data from the National Survey of Family Growth, they find reductions in U.S. adolescents’ receipt of formal sex education from schools and other community institutions between 2006–2010 and 2011–2013. These declines continue previous trends from 1995–2002 to 2006–2008, which included increases in receipt of abstinence information and decreases in receipt of birth control information [ 17 – 19 ]. Moreover, the study highlights several additional new concerns. First, important inequities have emerged, the most significant of which are greater declines among girls than boys, rural-urban disparities, declines concentrated among white girls, and low rates among poor adolescents. Second, critical gaps exist in the types of information (practical types on “where to get birth control” and “how to use condoms” were lowest) and the mistiming of information (most adolescents received instruction after sexual debut) received. Finally, although receipt of sex education from parents appears to be stable, rates are low, such that parental-provided information cannot be adequately compensating for gaps in formal instruction.

Paradoxically, the declines in formal sex education from 2006 to 2013 have coincided with sizeable declines in adolescent birth rates and improved rates of contraceptive method use in the United States from 2007 to 2014 [ 20 , 21 ]. These coincident trends suggest that adolescents are receiving information about birth control and condoms elsewhere. Although the National Survey of Family Growth does not provide data on Internet use, Lindberg et al. [ 16 ] suggest that it is likely an important new venue for sex education. Others have commented on the myriad of online sexual and reproductive resources available to adolescents and their increasing use of sites such as Bedsider.org, StayTeen.org, and Scarleteen. [ 2 , 14 , 22 – 24 ].

The Future of Sex Education

Given the insufficient state of sex education in the United States in 2016, existing gaps are opportunities for more ambitious, forward-thinking strategies that cross-cut levels to translate an expanded evidence base into best practices and policies. Clearly, digital and social media are already playing critical roles at the societal level and can serve as platforms for disseminating innovative, scientifically and medically sound models of sex education to diverse groups of adolescents, including sexual minority adolescents [ 14 , 22 – 24 ]. Research, program, and policy efforts are urgently needed to identify effective ways to harness media within classroom, clinic, family household, and community contexts to reach the range of key stakeholders [ 13 , 14 , 22 – 24 ]. As adolescents turn increasingly to the Internet for their sex education, perhaps school-based settings can better serve other unmet needs, such as for comprehensive sexual and reproductive health care, including the full range of contraceptive methods and STI testing and treatment services. [ 15 , 25 ].

At the policy level, President Obama’s budget for FY 2017 reflects a strong commitment to supporting youths’ access to age-appropriate, medically accurate sexual health information, with proposed elimination of AOUM and increased investments in more comprehensive programs [ 3 ]. Whether these priorities will survive an election year and new administration is uncertain. It will also be important to monitor the impact of other health policies, particularly regarding contraception and abortion, which have direct and indirect implications for minors’ rights and access to sexual and reproductive health information and care [ 26 ].

At the state and local program level, models of sex education that are grounded in a broader interdisciplinary body of evidence are warranted [ 4 , 11 – 14 , 27 – 29 ]. The most exciting studies have found programs with rights-based content, positive, youth-centered messages, and use of interactive, participatory learning and skill building are effective in empowering adolescents with the knowledge and tools required for healthy sexual decision-making and behaviors [ 4 , 11 – 14 , 27 – 29 ]. Modern implementation strategies must use complementary modes of communication and delivery, including peers, digital and social media, and gaming, to fully engage young people [ 14 , 22 , 23 , 27 ].

Ultimately, expanded, integrated, multilevel approaches that reach beyond the classroom and capitalize on cutting-edge, youth-friendly technologies are warranted to shift cultural paradigms of sexual health, advance the state of sex education, and improve sexual and reproductive health outcomes for adolescents in the United States.

Acknowledgments

Funding Sources

K.S.H. is supported by the National Institute of Child Health and Human Development #1K01HD080722-01A1.

Contributor Information

Kelli Stidham Hall, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Jessica McDermott Sales, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Kelli A. Komro, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia.

John Santelli, Department of Population & Family Health, Mailman School of Public Health, Columbia University, New York, New York.