Access to accurate information that is needed to protect one’s health is an important human right. Medically accurate information is critical to preventing and treating health conditions, and few would dispute that people should have the knowledge they need to avoid risks and make wise decisions about their bodies and health care. Further, schools are expected to provide factual information about the topics they cover, including health education. However, providing critical health information to adolescents in the area of sex education has become a significant challenge. The policies of the United States and increasing amounts of federal funding have required “abstinence-only” education that restricts discussion of topics such as birth control and sexually transmitted disease prevention and mandates that schools and other youth service providers convey the message that abstinence until marriage is the expected standard of human sexual activity. (See the box below for the list of federal requirements for abstinence programs.)
Prohibiting the discussion of certain topics has resulted in students learning less than students in the past about topics such as pregnancy prevention and sexually transmitted disease prevention at a time when more than 750,000 adolescents experience an unintended pregnancy and one in four sexually active teens acquires a sexually transmitted disease annually. Guttmacher Institute, In Brief: Facts on American Teen’s Sexual and Reproductive Health . In addition, abstinence-only programs convey a large number of ideological messages about gender, sexual orientation, and family structure that further impinge on the rights of particular groups of students. When states censor or distort information for political purposes, “people become the instruments or tools of state policies that deprive them of the knowledge and information necessary to make and implement decisions about their reproduction and to express their sexuality safely. It thus involves state control over some of the most basic elements of what it means to be human.” L.P. Freedman, Censorship and Manipulation of Reproductive Health Information , in The Right to Know: Human Rights and Access to Reproductive Health Information 1 ( S. Coliver, ed., 1995).
Battles over the appropriate content of sex education in schools date back to the 1960s, when efforts were first made to include family life education in public school curricula. J.M. Irvine, Talk About Sex: The Battles over Sex Education in the United States (2002). Groups such as the Christian Crusade heavily resisted such efforts and created materials with titles like Is the School House the Proper Place to Teach Raw Sex? to make their case. The struggle over whether sex education belonged in public schools was a straightforward yes-or-no debate. Then, in the early 1980s, conservatives in Congress passed Title XX of the Public Health Service Act, the Adolescent Family Life Act (AFLA), 42 U.S.C. § 300z et seq ., which was framed as a counterpart to the nation’s Title X family planning program, established by the Family Planning Services & Population Research Act of 1970, 42 U.S.C. § 300 et seq. , that provides contraceptive services to poor women. AFLA appropriated $10.9 million for programs that emphasized chastity and adoption, and provided some moneys for services to pregnant and parenting teens. AFLA mandated that to qualify for funding, programs had to involve religious groups. Irvine, supra. Thus, much of this funding went to crisis pregnancy centers and other religiously affiliated groups. This led to an initial lawsuit, Kendrick v. Bowen, 657 F. Supp. 1547 (D.D.C.1987), in the D.C. federal district court charging that the program advanced religion and violated the wall between church and state. The U.S. Supreme Court overturned the district court, finding no facial unconstitutionality, but remanded the case to determine whether the methods by which it was administered made the program unconstitutional. Bowen v. Kendrick, 487 U.S. 589 (1988). Next, a civil action was filed to enjoin AFLA as a violation of the Establishment Clause of the First Amendment. The suit was settled when Bill Clinton was elected president. Later generations of programs would better conceal the explicit religious nature of the messages, but many would argue that the values espoused still have clear roots in Christian religious teachings.
Though the inclusion of religious messages or the implementation of programs in religious settings were the main legal grounds for challenging abstinence-only programs, numerous additional concerns were raised by public health professionals, parents, teachers, and other youth advocates. These included the fact that information about birth control was limited to discussing failure rates; that many programs included outright misinformation about topics such as contraception, condoms, and abortion; and that stereotypes about girls and boys were presented as fact. Many of these concerns were detailed in a report by the House Committee on Government Reform. U.S. House of Representatives, Committee on Government Reform— Minority Staff, The Content of Federally Funded Abstinence Only Education Programs (Dec. 2004). Specifically, the report notes that eleven of the thirteen programs they examined contained errors and distortions, that programs contain false and misleading information about the effectiveness of contraceptives, that abstinence-only curricula blur religion and science, and that programs treat stereotypes about girls and boys as scientific fact.
Funding for abstinence-only programs greatly expanded when welfare reform was passed in 1996. Section 510 of the Social Security Act, 42 U.S.C. § 710, established the various requirements outlined in the box below and an appropriation of $50 million from the federal government that also required a match from states receiving funds, which brought the total moneys to $88 million. In 2000, a third federal program was created for abstinence-only education: the Community-Based Abstinence Education (CBAE) program provided grants directly from the U.S. Department of Health and Human Services to community- and faith-based programs, bypassing the state health departments that had responsibility for overseeing Section 510 funds. The CBAE program was promoted by social conservatives who felt that state health departments were not rigidly adhering to the eight-point definition of abstinence education and were supporting programs that did not address every element in the statutory abstinence-only definition. C. Dailard, Administration Tightens Rules for Abstinence Education Grants, 8 Guttmacher Report on Public Policy 13 (Nov. 2005) . By 2005, more than 800 programs were funded via the three main federal funding streams for abstinence education, and numerous states have passed laws that require that abstinence be emphasized in schools and other publicly funded programs. C. Trenholm et al., Impacts of Four Title V, Section 510 Abstinence Education Programs: Final Report (Mathematica Policy Research, Inc. 2007); Government Accountability Office, Abstinence Education: Efforts to Assess the Accuracy and Effectiveness of Federally Funded Programs (GAO Report No. 07-87 2006). However, numerous states have begun to reject abstinence funding as the evidence builds that these programs do not work, as discussed in more depth below . In addition, states are beginning to pass laws that require medical accuracy in sex education programs. In 2007, Colorado, Iowa, and Washington all passed such laws. NARAL Pro-Choice America, Who Decides? The Status of Women’s Reproductive Rights in the United States (17th ed. 2007).
Human Rights and Ethical Concerns
Abstinence-only programs violate numerous human rights and ethical principles as these programs both prevent young people from receiving critical, perhaps life-saving, information and put teachers and health educators in the ethically challenging position of withholding scientific knowledge. Leslie Kantor et al., Abstinence-Only Policies and Programs: An Overview, 5 J. Sexuality Res. & Soc. Pol’y 6 (Sept. 2008); J. Santelli et al., Abstinence-Only Education Policies and Programs: A Position Paper of the Society for Adolescent Medicine , 38 J. Adolescent Health 83 (2006).
Access to accurate health information as a basic human right was described in the program of action at the 1994 International Conference on Population and Development. See United Nations, Report of the International Conference on Population and Development (1994), www.un.org/popin/icpd/conference/offeng/poa.html. This meeting and the resulting publications focused on reproductive issues and the application of human rights to the arena of sexual and reproductive health, including such issues as the rights of couples to make free choices about childbearing, access to reproductive health care, and equality between men and women. To achieve these goals, access to reproductive information is essential for women, men, and adolescents:
The response of societies to the reproductive health needs of adolescents should be based on information that helps them attain a level of maturity required to make responsible decisions. In particular, information and services should be made available to adolescents to help them understand their sexuality and protect them from unwanted pregnancies, sexually transmitted diseases and subsequent risk of infertility. This should be combined with the education of young men to respect women’s self-determination and to share responsibility with women in matters of sexuality and reproduction. Id . at ¶ 7.41.
Similar ethical notions are found in later international statements that address HIV/AIDS and children and adolescents. For example, in 2003 the UN Committee on the Rights of the Child emphasized that
[c]onsistent with the obligations of States parties in relation to health and information . . . , children should have the right to access adequate information related to HIV/AIDS prevention and care, through formal channels (e.g. through educational opportunities and child-targeted media) as well as informal channels.
United Nations, Committee on the Rights of the Child, HIV/AIDS and the Rights of the Child, General Comment No. 3, at ¶ 13.
Likewise, this UN document addressed the obligations of governments:
The Committee wishes to emphasize that effective HIV/AIDS prevention requires States to refrain from censoring, withholding, or intentionally misrepresenting health-related information, including sexual education and information. . . . State parties must ensure that children have the ability to acquire the knowledge and skills to protect themselves and others as they begin to express their sexuality. Id.
Under these international agreements, governments have an obligation to provide accurate information to adolescents in government-funded health education. U.S. government-funded abstinence-only programs violate these principles because they withhold the knowledge needed to make informed choices. Under the U.S. federal government’s funding requirements, abstinence-only programs are required to withhold or distort information on contraception by failing to include information on birth control or focusing on failure rates, which are generally exaggerated in such programs. U.S. House of Representatives, Committee on Government Reform, supra, at 8-12; J. Santelli et al., supra, at 79. In addition, federally supported abstinence-only education curricula often promote scientifically questionable information. By limiting classroom discussion on specific topics, the federal requirements place health educators and other public health professionals in an ethical dilemma, compelling them to withhold or manipulate potentially life-saving information. Government restrictions on medically accurate and important information should not be tolerated in schools. Several prominent national groups have raised both health and human rights concerns about abstinence-only education, including the Society for Adolescent Medicine, the American Public Health Association, and the American Academy of Pediatrics. (See this page for statements by these organizations made as part of the Congressional Committee on Government Reform’s hearings on domestic abstinence-only programs, held Wednesday, April 23, 2008.)
Abstinence-only programs have particular implications for certain groups of young people. For example, the programs posit marriage as the only appropriate context for sexual behavior, leaving gay and lesbian students in most states with the message that expressing their sexuality is unacceptable. Numerous gender stereotypes throughout the curricula reinforce ideas about how young women and men should act; these are ideological rather than educational and may marginalize those students that do not adhere to rigid gender stereotypes. For example, one abstinence-only program asserts that “Women gauge their happiness and judge their success by their relationships. Men’s happiness and success hinge on their accomplishments.” U.S. House of Representatives, Committee on Government Reform, supra, at 16. Another funded curriculum notes: “The father gives the bride to the groom because he is the one man who has had the responsibility for protecting her throughout her life. He is now giving his daughter to the only other man who will take over this protective role.” Students are also given messages that directly relate to sexuality and are incorrect, such as “[w]hile a man needs little or no preparation for sex, a woman often needs hours of emotional and mental preparation.” Id . at 18.
Abstinence-only programs tend to completely overlook the issue of sexual abuse and make blanket statements about any sexual behavior prior to marriage, perhaps leading to particular upset for those that have had involuntary experiences. And two-parent families are held up as far superior to any other family structures, ignoring the fact that many classrooms and community programs include young people from a broad array of family backgrounds. Julie Kay, Sex, Lies and Stereotypes: How Abstinence-Only Programs Harm Women and Girls 12-14 (Legal Momentum 2008). Schools are generally forbidden from disparaging groups of people in their official curricula and yet abstinence-only programs have been adopted in many schools and communities.
The Negative Influence of Abstinence-only Education
Abstinence-only education has restricted young people’s access to information. The number of young people reporting that they had received formal instruction about birth control in either a school or a community-based program declined substantially between 1995 and 2002. Among males, 81 percent reported in 1995 that they had learned about birth control, compared to 66 percent in 2002. Among females, 87 percent reported in 1995 that they had received instruction about contraception, compared to 70 percent in 2002. L.D. Lindberg et al., Changes in Formal Sex Education: 1995-2002. 38 Persp. on Sexual & Reprod. Health 182 (2006) . In 2002, only 62 percent of females and 54 percent of males reported that they had received any instruction about birth control before their first sexual experience. Id.
Reports by adolescents mirror reports from teachers. In 1999, 77 percent of teachers reported that information about birth control was taught in their schools, compared to 92 percent in 1988. J. E. Darroch et al., Changing Emphases in Sexuality Education in U.S. Public Secondary Schools, 1988-1999 , 32 Fam. Plan. Persps. 204, 207 (2000) . The topics of abortion and sexual orientation were also less likely to be discussed in 1999 compared to 1988. By 1999, abstinence was more likely to be taught than topics such as how to use a condom, the implications of teen parenthood, sexual abuse, and where to go for birth control. Id.
Not surprisingly, instruction about abstinence has been increasing. In 1999, 95 percent of teachers reported that their schools taught about abstinence, compared with 89 percent in 1988. Furthermore, one in four secondary teachers were telling students in 1999 that abstinence was the only way to prevent pregnancy and sexually transmitted diseases; in 1988, only one in fifty gave that message. In 1999, 26 percent of teachers reported that information their students needed was not included in their curriculum and 22 percent of teachers reported that their ability to answer students’ questions was curtailed. Id. at 210.
What Works to Protect Young People’s Health
Numerous studies have been conducted on comprehensive sex education programs that include information about abstinence as well as contraception, sexually transmitted disease prevention, and numerous other topics. These program evaluations show that many school and community-based programs help adolescents to wait until they are older to begin having sex, to use condoms and birth control when they do have sex, and to limit the number of partners or frequency of sexual activity. Douglas Kirby, Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases (National Campaign to Prevent Teen and Unintended Pregnancy 2007); Douglas Kirby, The Impact of Abstinence and Comprehensive Sex and STD/HIV Education Programs on Adolescent Sexual Behavior, 5 J. Sexuality Res. & Soc. Pol’y 18 (Sept. 2008).
In contrast, the studies that have been done on abstinence-only programs do not show that they help young people to change their behavior. The largest and most well-done study of abstinence-only programs thus far did not show that young people in the abstinence-only programs were any less likely to begin having sexual intercourse than those that did not receive abstinence education. Trenholm et al., supra. In other words, comprehensive sex education programs have actually been more effective in helping young people to abstain from sexual behavior than abstinence-only programs.
Furthermore, high-quality sex education includes both information and skills that young people need in order to experience lifelong health and wellness. Programs that make a difference utilize sound pedagogical approaches and help adolescents to develop their decision-making, negotiation, and communication skills. Indeed, programs that work to ensure that young people adopt healthy behaviors share seventeen basic characteristics that are outlined in the 2007 report by Kirby referenced above, at page 22.
Current Policy and Recommendations
Federal funding for abstinence-only programs has increased markedly since 1996, with support from both houses of Congress and the Bush administration. Between the three funding streams (AFLA, Section 510, and the CBAE), $175 million is appropriated annually by the federal government for abstinence-only programs. However, in April 2008, the House Committee on Oversight and Government Reform held hearings to examine domestic funding for abstinence-only programs, and there is some hope that a change in administrations will lead to a shift away from funding for programs that limit or distort information, place teachers in an ethical quandary, and violate basic human rights principles. In addition, only twenty-eight states are now applying for funding via the Section 510 program, and Arizona and Iowa plan to discontinue their receipt of funds beginning October 1, 2008. Kevin Freking, States Turn Down Abstinence Education Grants, AP, June 24, 2008. However, many states still have abstinence-only programs in operation as schools and community-based organizations can apply directly for the CBAE funds. Still, the trend away from applying for moneys illustrates that communities and policy makers want to move away from this restrictive and unproven approach. Many people remain unaware of the proliferation of abstinence-only programs and the federal requirements. The articulation of human rights concerns alongside health arguments could bring additional advocates to this issue and illuminate further reasons why these policies and programs are harmful and misguided.