Talk:Abstinence

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 * Condoms will break, but I can assure you that vows of abstinence will break more easily than condoms.
 * Former Surgeon General Joycelyn Elders


 * The few bad poems which occasionally are created during abstinence are of no great interest.
 * Wilhelm Reich


 * Abstinence education gives young people the support they need in making the decision to postpone sexual activity until they are mature enough to handle the emotional, moral and financial responsibilities of parenthood. This is more than teaching kids to say no – it will help them preserve self-esteem and build character.
 * Massachusetts governor Mitt Romney

Surplus

 * Abstinence-only programs have not demonstrated successful outcomes with regard to delayed initiation of sexual activity or use of safer sex practices.
 * American Academy of Pediatrics, "Sexuality Education for Children and Adolescents", Pediatrics, Vol 108, No. 2, 2001


 * Programs that encourage abstinence as the best option for adolescents, but offer a discussion of HIV prevention and contraception as the best approach for adolescents who are sexually active, have been shown to delay the initiation of sexual activity and increase the proportion of sexually active adolescents who reported using birth control.
 * American Academy of Pediatrics, "Sexuality Education for Children and Adolescents", Pediatrics, Vol 108, No. 2, 2001


 * Programs that have linked educational curricula with access to reproductive health services and comprehensive community-based interventions have also documented reductions in pregnancy rates. Despite these findings, among the 69% of public schools that provide district-wide sexuality education, 14% treat abstinence as an option for adolescents, 51% teach abstinence as the preferred option for adolescents but permit discussion about contraception as an effective means of protection against unintended pregnancy and STDs (an abstinence-plus policy), and more than1 in 3 (35%) teach abstinence only, with discussion of contraception prohibited or limited to discussion of its lack of effectiveness.
 * American Academy of Pediatrics, "Sexuality Education for Children and Adolescents", Pediatrics, Vol 108, No. 2, 2001


 * From a policy perspective, encouraging young people to interpret virginity as a gift – a stance consistent with many abstinence-only sex education programs – is a double-edged sword, protecting against one potential negative consequence of sexual activity (pregnancy and/or STD transmission) but increasing the likelihood of another deleterious consequence (emotional distress due to partner's nonreciprocation). In contrast, even adherents to the stigma frame whose partners ridiculed them experienced virginity loss as positive on balance, inasmuch as they lost their stigma. Participants who saw virginity loss as a process achieved the goal of gaining knowledge merely through losing their virginity, thus their partners could in practice wield little power over them.
 * Laura M. Carpenter, "The Ambiguity of 'Having Sex': The Subjective Experience of Virginity Loss in the United States", reprinted from The Journal of Sexual Research 38 (2): 127-139 (2001) in Sexualities: Identities, Behaviors, and Society (2004), 2nd ed. (2015) by Michael Kimmel and The Stony Book Sexualities Research Group (eds.), p. 104-105


 * We know that abstinence is 100% effective at preventing pregnancy and STIs; however, research has conclusively demonstrated that programs promoting abstinence-only until heterosexual marriage occurs are ineffective. A recent systematic review examined the evidence supporting both abstinence-only programs and comprehensive sexuality education programs designed to promote abstinence from sexual intercourse. In that review, most comprehensive sexuality education programs showed efficacy in delaying initiation of intercourse in addition to promoting other protective behaviors, such as condom use. There was no evidence that abstinence-only programs effectively delayed initiation of sexual intercourse.  In another review of sexuality education, Cavazos-Rehg et al found that the literature examining the efficacy of current school-based sexuality education programs had insufficient evidence to support the intervention of abstinence on the basis of inconsistent results across studies. The federal government has historically provided $178 million for abstinence-only education through Title V, Section 510 of the Social Security Act in 1996, Community-Based Abstinence Education projects through the Patient Protection and Affordable Care Act, and the Adolescent Family Life Act program. The Community-Based Abstinence Education program received the most federal funds and made direct grants to community-based organizations, including faith-based organizations. Federal guidance required all programs to adhere to an 8-point definition of abstinence-only education and prohibited programs from disseminating information on contraceptive services, sexual orientation and gender identity, and other aspects of human sexuality. Programs promoted exclusive abstinence outside of heterosexual marriage and required that contraceptive use, contraceptive methods, and specifically condoms must not be discussed except to demonstrate failure rates.
 * Cora C. Breuner, Gerri Mattson, “Sexuality Education for Children and Adolescents”, “COMMITTEE ON ADOLESCENCE and COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH”, Pediatrics, (August 2016)


 * Let’s start at the beginning: In 2001, Julian Carter of Stanford University published Birds, Bees, and Veneral Disease: Toward an Intellectual History of Sex Education, which explains why public schools began teaching sex-ed in the first place. According to Carter, demand for sex-ed courses began in the second decade of the 20th century when people started believing education was the answer to “many social ills” which consisted of the declining birth rate among the middle-class, native-born Anglo-Americans who “claimed the right to represent the core of national identity and well-being,” New Immigrants and their offspring, a growing divorce rate, and most importantly, venereal diseases on the rise. During this time period, conversations surrounding the American family were of utmost importance and seeing the “disintegration” of this ideal, viewed as the “political and spiritual foundation of the Republic”, citizens put their faith in sex education to fix it. They believed that, once given the knowledge, people would act “morally,” which would protect them from diseases and protect the American family. Protecting the family, however, translates into being married in a monogamous, heterosexual relationship–thus, abstinence-only-until-marriage programs. Under the Reagan administration, the federal government has consistently funded AOUM programs, despite massive amounts of research proving they are ineffective. Funding for these programs grew exponentially under the George W. Bush administration; between 1996 and 2010, Congress spent over one-and-a-half billion tax-payer dollars into AOUM programs.
 * Sara Lone, “Why Are We Still Fighting Against Abstinence-Only Education?”, The Humanist, (30 July 2014)


 * The findings in the above randomized trial and systematic review are supported by a longitudinal analysis of adolescents taking virginity pledges in Add Health. A follow-up, six years later showed 88% of young adults who reported taking virginity pledges as adolescents had initiated vaginal intercourse before marriage, and the prevalence of STIs (chlamydia, gonorrhea, and trichomoniasis) was similar among those who pledged and non-pledgers. Moreover, when pledgers did initiate intercourse, many failed to protect themselves by using condoms, and were less likely to be tested for STIs. This data suggests that, while abstinence is theoretically 100% effective, in typical use, the effectiveness of abstinence may approach zero.
 * Mary A. Ott and John S. Santelli, “Abstinence and abstinence-only education”, Curr Opin Obstet Gynecol. 2007 Oct; 19(5): 446–452, (2018 Apr 24)


 * This paper examines the history of abstinence education in the United States and the empirical evidence of its effectiveness in preventing teenage pregnancy. It concludes that abstinence education has not yet been proven effective, and therefore recommends that federal policy and funding should be directed towards teen pregnancy prevention programs that have demonstrated success.
 * Karen (Kay) Perrin and Sharon Bernecki DeJoy, “Abstinence-Only Education: How We Got Here and Where We're Going”, Journal of Public Health Policy, Vol. 24, No. 3/4 (2003), p. 445


 * The United States has experienced a decrease in the incidence of teen pregnancy over the past decade. From 1991 to 2001, the teenage birth rate declined significantly across the country, with all States, the District of Columbia, and the territory of Virgin Islands reporting annual declines in the birth rate for teens 15-19 years of age. During that same decade, 1991-2001, vital statistics data show the percentage of U.S. high school students who ever had sexual intercourse and the percentage who had multiple sex partners also decreased. It is tempting to think that these trends reflect an increase in responsible sexual behavior among adolescents. However, a broader perspective reveals that the United States still has much work to do. The United States continues to have the highest teen pregnancy rate has declined less steeply than in other developed countries during the past 30 years. Among currently sexually active high school students, the prevalence of condom use has reached a plateau since 1999. The percentage of students who used alcohol or drugs before last sexual intercourse has also increased . Such behaviors place these teens at increased risk for unintended pregnancy and STIs. One limitation of this information about teen sexual intercourse and pregnancy rates is the absence of data regarding other aspects of teen sexuality.
 * Karen (Kay) Perrin and Sharon Bernecki DeJoy, “Abstinence-Only Education: How We Got Here and Where We're Going”, Journal of Public Health Policy, Vol. 24, No. 3/4 (2003), p. 445


 * Many Stone-Age people had no idea where babies came from. Some thought that the spirits of children lived in certain fruits, and that pregnancy was caused by eating the fruit. Others held the sun, wind, rain, moon, or stars responsible for causing pregnancy ⎯many considered sea foam particularly potent (Jensen, 1982). Pregnancy was a magical event. Abstinence as a method of family planning never occurred to those who believed that reproduction was magic. But abstinence, for women in particular, was very important for ancient people who understood the connection between vaginal intercourse and reproduction. After menarche the time of their first menstrual periods —women in many cultures were expected to be abstinent (Sherfley, 1966). In this way, their future husbands could be sure of the paternity of their children. Throughout history, assuring men of their paternity has been the driving force behind the need for virgin brides and for keeping women out of public life (Fisher, 1992). Ironically, these same forces are the foundations of the sexual double standard and the proliferation of prostitution in most cultures (Bullough & Bullough, 1987).
 * “A History of Birth Control Methods “, ‘’Planned Parenthood’’, p.2


 * Until 2010, about $100 million in federal funds was spent annually for abstinence-only sexuality education designed to discourage unmarried young people, regardless of sexual orientation, from having sex. None of this money was allowed to be used for any program that talked about the effectiveness of condoms to reduce the chances of infection or unintended pregnancy among those young people who are already sexually active. Meanwhile, 50 percent of all HIV infections occur among people under the age of 25, and 63 percent of infections among those between the ages of 13 and 19 are among women (NIAIAD 2001).
 * “A History of Birth Control Methods “, Planned Parenthood, p.6


 * Just twelve years ago, America had the highest teen birth rate in the developed world, no doubt due to AOUM programs. Although the overall U.S. teen pregnancy rate is declining rapidly, a survey conducted in 2008 showed the states with the highest teen pregnancies were New Mexico, Mississippi, Texas, Arkansas, Louisiana, and Oklahoma. Comparatively, the states with the lowest teen pregnancy were New Hampshire, Vermont, Minnesota, Massachusetts, and Maine.
 * Sara Lone, “Why Are We Still Fighting Against Abstinence-Only Education?”, The Humanist, (30 July 2014)


 * We found, as have others, that sexual debut after marriage is not the norm.
 * Theo G.M. Sandfort, Mark Orr,  Jennifer S. Hirsch, and John Santelli; “Long-Term Health Correlates of Timing of Sexual Debut: Results From a National US Study”, Am J Public Health. 2008 January; 98(1): 155–161.


 * Contrary to the suggestions of proponents of sexual functioning than those who initiate sexual activity at a normative age. Such a finding in regard to late initiation lends credence to research showing that abstinence-only education may actually increase health risks and that strategies designed to promote relevant sexual health information, motivation, and skills are likely to be more effective than abstinence-only messages in helping young people avoid short- as well as long-term health consequences. In-depth knowledge of sexual initiation patterns and health outcomes and how they are affected by individual, social, and structural factors, including exposure to sexual education programs, is urgently needed to inform adolescent health policies and programs.
 * Theo G.M. Sandfort, Mark Orr,  Jennifer S. Hirsch, and John Santelli; “Long-Term Health Correlates of Timing of Sexual Debut: Results From a National US Study”, Am J Public Health. 2008 January; 98(1): 155–161.


 * The Grady Hospital program offers more than a "Just say no" message. It reinforces the message by having young people practice the desired behavior. The classes are led by popular older teenagers who teach middle-schoolers how to reject sexual advances and refuse sexual intercourse. The eighth-graders perform skits in which they practice refusals. Some of them take the part of "angel on my shoulder," intervening with advice and support if the sexually beleaguered student runs out of ideas. Boys practice resisting pressure from other boys. According to the program evaluator, Marion Howard, a professor of gynecology and obstetrics at Emory University, the skits are not like conventional "role plays," in which students are allowed to come up with their own endings. All skits must end with a successful rebuff. The program is short: five class periods. It is not comprehensive but is focused on a single goal. It is not therapeutic but normative. It establishes and reinforces a socially desirable behavior. And it has had encouraging results. By the end of ninth grade only 24 percent in the program group had had sexual intercourse, as compared with 39 percent in the nonprogram group. Studies of similar programs show similar results: abstinence messages can help students put off sex. It is noteworthy that although the purpose of the Grady Hospital program was to help students postpone sex, it also had an impact on the behavior of students who later engaged in sexual intercourse. Among those who had sex, half used contraception, whereas only a third did in a control group that had not taken the course.
 * Barbara Dafoe Whitehead “The Failure of Sex Education”, The Atlantic, (October 1994)


 * Postponing Sexual Involvement and similarly designed sex-education programs offer this useful insight: formal sex education is perhaps most successful when it reinforces the behavior of abstinence among young adolescents who are practicing that behavior. Its effectiveness diminishes significantly when the goal is to influence the behavior of teenagers who are already engaging in sex. Thus teaching sexually active middle school students to engage in protected intercourse is likely to be more difficult and less successful than teaching abstinent students to continue refraining from sex. This seems to hold for older teens as well. In a 1991 study Kirby points to one curriculum for tenth-graders, Reducing the Risk, which has been successful in increasing the likelihood that abstinent students will continue to postpone sex over the eighteen months following the course. However, although the program emphasizes contraception as well as sexual postponement, it does not increase the likelihood that already sexually active tenth-graders will engage in protected sex. "Once patterns of sexual intercourse and contraceptive use are established," Kirby writes, "they may be difficult to change." For that reason the Grady Hospital researchers have developed a program for sixth-graders, since 44 percent of the boys taking their course in the eighth grade were already sexually experienced (this was true of just nine percent of the girls).
 * Barbara Dafoe Whitehead “The Failure of Sex Education”, The Atlantic, (October 1994)

“Sex Education and Rape” (2010)
Michelle Anderson, “Sex Education and Rape”, Publications and Research CUNY School of Law, (2010)
 * The Department of Health and Human Services has strict guide-lines about the content of abstinence-only sex education. Section 5 10 of the Social Security Act covers the requirements of abstinence-only education:(2) For purposes of this section, the term "(abstinence education"' means an educational or motivational program which-(A) has as its exclusive purpose, teaching the social, psycho-logical, and health gains to be realized by abstaining from sexual activity;(B3) teaches abstinence from sexual activity outside marriage as the expected standard for all school age children;(C) teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;(D) teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity;(E) teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects; (F) teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child's parents, and society;(G) teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and(H) teaches the importance of attaining self-sufficiency before engaging in sexual activity?
 * pp.98-99


 * Abstinence-only and abstinence-plus sex educations have similar core messages. The core message of abstinence-only sex education is: You should wait until marriage before engaging in sex (heterosexual, vaginal penetration), and sexual abstinence is the only sure way to protect yourself from pregnancy and STDs. The core message of abstinence-plus sex education is: You should wait until marriage before engaging in sex (heterosexual, vaginal penetration), but if you do not wait, you should use condoms to protect yourself from pregnancy and STDs.
 * p.99


 * About one-third of public secondary schools report that they offer abstinence-only sex education, with the other two-thirds reporting that they offer "comprehensive" or abstinence-plus sex education. Despite different nomenclature, however, the Kaiser Family Foundation reports that abstinence-only and abstinence-plus sex educations may offer students similar experiences: Despite the apparent differences between the two approaches, the study finds that in reality the boundaries are often hazy in terms of what is actually covered in abstinence-only and more comprehensive sex education classes. At least some students and teachers in courses that they describe as having a main message of abstinence-only report that information was still included about how to use and where to get birth control or how to get tested for HIV/AIDS. Likewise, many sex education courses described as comprehensive appear to provide only surface-level information about birth control and HIV/AIDS and other STIs while not addressing more practical aspects of how to use birth control or talk with a partner about sexual health issues, or where to go to get tested for HIV or other STDs.
 * INSIDE THE NATION'S CLASSROOMS, supra note 75, at 3; as qtd. on p.100


 * Because sex education courses can be squeamish about discussions of oral sex, as well as other forms of intimacy, there is little frank talk about the relative safety of a range of sexual practices. In an abstinence-only course, "[i]t may not be clear to an adolescent whether a recommendation of abstinence means abstinence from vaginal intercourse, from anal and oral intercourse, or from all types of sexual activity."8 The result of not discussing the risks of a range of behaviors is ignorance and the health risks associated with it. For example, about 20 percent of teens are unaware that oral sex can transmit STDs.
 * RAND CORP., UNDERSTANDING THE SEXUAL. BEHAVIOR OF ADOLESCENTS (2002),http://www.rand.org/pubs/research-briefs/RB4543/indexl.html; NAT'L SURVEY OF ADOLESCENTS & YOUNG ADULTS, supra note 10, at 3; as qtd. on p.101


 * Sex education does not grapple thoroughly with the emotional aspects of sexuality." Even in later grades, sex education does not discuss how to express one's sexual desires in an ethical manner or how to find out about a partner's desires. It does not address how to assert one's own sexual boundaries or how to find out about a partner's sexual boundaries. (The only boundary sex education consistently discusses is abstinence from heterosexual, vaginal penetration.) In abstinence-only sex education, the content is not just limited; it can reinforce the very negative stereotypes about gender and sexuality that teens receive from the popular culture. Abstinence-only curricula include "persistent, official promulgations of retrogressive, anti-egalitarian sexual ideologies-of male pleasure and female shame, male recreation and female responsibility, male agency and female passivity, and male personhood and female parenthood.)
 * Cornelia T. L. Pillard, Our Other Reproductive Choices: Equality in Sex Education,Contraceptive Access, and Work-Family Policy, 56 EMORY L. J. 941, 942 (2007); p.103

“The State of Sex Education in the United States” (June 2016)
Kelli Stidham Hall, Ph.D., M.S., Jessica McDermott Sales, Ph.D., M.A., Kelli A. Komro, Ph.D., M.P.H., and John Santelli, M.D., M.P.H.; “The State of Sex Education in the United States”, J Adolesc Health. 2016 Jun; 58(6): 595–597.
 * For more than four decades, sex education has been a critically important but contentious public health and policy issue in the United States. 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. 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. 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. 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. 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.
 * 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. 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. Other federal funding priorities have moved positively toward more medically accurate and evidence-based programs, including teen pregnancy prevention programs. 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”. 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. Without cohesive or consistent implementation processes, a highly diverse “patchwork” of sex education laws and practices exists. 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 . 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. 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. Moreover, 69% of high schools notify parents/guardians before students receive such instruction; 87% allow parents/guardians to exclude their children from it. 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.


 * There's really no hard evidence in support of the notion that abstaining from sexual activity or from ejaculation has any demonstrative benefits. On the other hand, there's evidence that having fairly frequent ejaculations has health benefits in terms of lower levels of prostate cancer.
 * Nan Wise, quoted in Hanson O'Haver, "What Swearing Off Sex Does to Your Brain", Vice, Feb 13 2017


 * For years, the public has spent over $2 billion on abstinence-only programs, which not only fail to reduce teen birth rates but also reinforce gender stereotypes and are rife with misinformation. Low-income minority teens are particularly subject to these programs. Teens without knowledge about their sexual health are more likely to get pregnant and less likely to work, spiraling them to the bottom of the economic ladder.
 * Michele Gilman, “How limiting women’s access to birth control and abortions hurts the economy”, The Conversation, (April 27, 2016)


 * The reason that abstinence, whether temporary or perpetual, is not in itself sinful, while being contraceptive, is that nothing is interposed between the couple--they remain open to conception, while recognizing their freedom not to have intercourse (by mutual agreement). There are purely natural ways in which conception could still result: irregular periods, periodic changes in menstrual cycle, exceptionally long-lived spermatozoa, etc.  NFP used as a long-term or permanent means of avoiding conception involves a sinful disposition. The use of continence as a means of contraception, though, is not in itself sinful. As the late Fr. John Meyendorff noted, "both the New Testament and Church tradition consider continence as an acceptable form of family planning."--J. Meyendorff, ‘’Marriage: An Orthodox Perspective’’ (3d rev. ed., St. Vlad. Sem. Pr., 1984), p. 62. Orthodox observe approximately 180 fast days in the year, in which sexual intercourse is prohibited. At other times it is also not allowed for other reasons. Thus one Orthodox priest wrote that Orthodox do not need contraception -- they only need to keep the fasts! This is certainly analogous, in principle, to NFP.
 * William Klimon, “Contraception: Early Church Teaching”, ( March 15, 2007); September 5, 2008, at the Wayback Machine


 * Promoting abstinence until marriage as the only legitimate option for young people "violates medical ethics and harms young people," Lindberg says, because such programs generally withhold information about pregnancy and STD prevention and overstate the risk of contraceptive failure.
 * Laura Lindberg as quoted by Sarah McCammon, “Abstinence-Only Education Is Ineffective And Unethical, Report Argues”, NPR, (August 23, 2017)

“Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S” (2011)
Kathrin F. Stanger-Hall and David W. Hall; “Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S”, PLoS One. 2011; 6(10): e24658
 * 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.
 * 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. 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. Funding for abstinence-only programs in 2006 and 2007 was $176 million annually (before matching state funds). 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.
 * 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. 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. 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, 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. 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).
 * 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), 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).
 * Across all 48 states, abstinence education levels were significantly correlated with the proportions of white and black teens in the state populations. 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.
 * 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”, 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. 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). 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. 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.
 * 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. 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, 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.
 * 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. 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. For example a Congressional committee report found evidence of major errors and distortions of public health information in common abstinence-only curricula. 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. 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. 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 at a financial cost (direct medical costs only) of ∼$5 billion in 2002 . The U.S. teen pregnancy rate is substantially higher than seen in other developed countries despite similar cultural and socioeconomic patterns in teen pregnancy rates. The difference is not due to the onset of sexual activity. Instead, the main factor seems to be sex education, especially with regard to contraception and prevention of STDs. 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. 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, by pragmatic governmental policies and less influence by special interest groups.
 * 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?

“Abstinence and abstinence-only education” (2018 Apr 24)
Mary A. Ott and John S. Santelli, “Abstinence and abstinence-only education”, Curr Opin Obstet Gynecol. 2007 Oct; 19(5): 446–452, (2018 Apr 24)
 * The federal government invests over 175 million dollars annually in ‘abstinence-only-until-marriage’ programs. These programs are required to withhold information on contraception and condom use, except for information on failure rates. Abstinence-only curricula have been found to contain scientifically inaccurate information, distorting data on topics such as condom efficacy, and promote gender stereotypes. An independent evaluation of the federal program, several systematic reviews, and cohort data from population-based surveys find little evidence of efficacy and evidence of possible harm. In contrast, comprehensive sexuality education programs have been found to help teens delay initiation of intercourse and reduce sexual risk behaviors. Abstinence-only polices violate the human rights of adolescents because they withhold potentially life-saving information on HIV and other STIs.
 * Broad public support exists for comprehensive sexuality education, with abstinence as a key component of that education. Using the nationally representative Annenberg National Health Communication Survey, Bleakley found that 81% of adults believed that sex education teaching both abstinence and other methods to prevent pregnancy to be effective, while only 39% believed abstinence-only to be effective. The same survey found that 51% of adults opposed abstinence-only, whereas only 10% opposed teaching contraception and condom use. A telephone survey of parents of public school students in grades K-12 in North Carolina found similar results: 91% believed that sex education should be taught in school, with 98% rating transmission and prevention of STIs/HIV important, 91%rating abstinence as important, 93% how to talk with a partner about birth control as important, and 89% effectiveness and failure rates of birth control important. Most parents and adolescents do not perceive education that stresses abstinence while also providing information about contraception as presenting a mixed message, and the clear majority of adults (73%) and adolescents (56%) wish adolescents were getting more information about both abstinence and contraception rather than either alone.
 * Federal guidance requires all programs to adhere to an eight-point definition of abstinence-only education (see Table 1), and prohibits programs from disseminating information on contraceptive services, sexual orientation and gender identity, and other aspects of human sexuality. Section 510 specifies that programs must have as their ‘exclusive purpose’ the promotion of abstinence outside of marriage and may not in any way advocate contraceptive use or discuss contraceptive methods or condoms except to emphasize their failure rates. No designated federal funding stream exists for comprehensive sexuality education.
 * Lindberg et al. documents the erosion of comprehensive sexuality education, coincident with the rising emphasis on abstinence as the sole option for adolescents. Her analyses of 2002 NSFG data reaffirm findings from older and complementary data sets. Adolescent and pediatric gynecology Table 1 Federal 8 Point Definition of Abstinence Education Under Section 510 of Title V of the Social Security Act, abstinence education is defined as an educational or motivational program which: (A) has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity; (B) teaches abstinence from sexual activity outside marriage as the expected standard for all school age children; (C) teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems; (D) teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity; (E) teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects; (F) teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child’s parents, and society; (G) teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and (H) teaches the importance of attaining self-sufficiency before engaging in sexual activity. Lindberg found that a declining percentage of adolescents reported receiving education about contraception, while larger percentages reported receiving abstinence education. Between 1995 and 2002, instruction about birth control methods declined from 81% to 66% for males, and from 87% to 70% for females. Receipt of any abstinence education increased among males (74% to 83%) and receipt of only abstinence education increased among males (9% to 24%) and females (8% to 21%). In consequence, fewer adolescents reported receiving formal instruction about both abstinence and birth control methods (in males, from 65% to 59%; in females, from 84% to 65%). Among sexually experienced adolescents, 62% of females and 54% of males in 2002 reported receiving instruction about birth control methods prior to first sex.
 * Mainstream medical professional organizations, including the American College of Obstetricians and Gynecologists (ACOG), the Society for Adolescent Medicine (SAM), the American Academy of Pediatrics (AAP), the American Medicine Association (AMA), and the American Public Health Association (APHA), oppose abstinence-only education and endorse comprehensive sexuality education that includes both abstinence and accurate information about contraception, human sexuality and STIs. The most comprehensive of these position papers is the Society for Adolescent Medicine position paper and accompanying review article which describe the importance of scientific rigor as the cornerstone for policy and programmatic decisions, as well as the troublesome ethical issues raised by deliberately withholding or distorting potentially life-saving information about contraception and STI prevention.
 * A federally funded evaluation of Title V programs conducted by an independent research organization, a new systematic review, and analyses of nationally representative longitudinal surveys of health behavior demonstrate that abstinence-only programs are ineffective and may cause harm. The most important single report is Mathematica Policy Research, Inc.’s final report on the impact of four Title V, Section 510 abstinence education programs. Authorized by the U.S. Congress, and using a rigorous randomized controlled trial study design, investigators examined the impact on sexual behaviors among 2057 adolescents four years after participation in one of four carefully chosen and implemented Title V abstinence-only programs or a community-standard control. The report describes no differences in sexual abstinence or condom use between abstinence-only program group and control group. One significant finding was concerning: youth in the program group were significantly less likely to report that condoms were effective in preventing HIV and other STIs. This finding is consistent with the emphasis in AOE curricula on teaching about the failure rates for condoms, as required by federal program guidance.
 * The current U.S. government approach focusing on AOE raises serious ethical and human rights concerns. While abstinence is often presented as the moral choice for adolescents, many have questioned AOE which withholds life-saving information from adolescents. Access to complete and accurate HIV/AIDS and sexual health information has been recognized as a basic human right, as complete and accurate health information is essential to realizing the highest attainable standard of health. Such human rights thinking suggests that governments have an obligation to provide accurate information to their citizens and avoid the provision of misinformation. Such obligations extend to government funded health education and healthcare services.
 * Health educators and healthcare professionals have an ethical obligation to provide accurate and complete health information in their work. As defined by U.S. government funding regulations, abstinence-only programs are required to withhold information on contraception and other aspects of human sexuality except to emphasize their failure rates, and to promote scientifically questionable positions. The current U.S. approach emphasizing abstinence challenges a key ethical principle of medical research and practice known as ‘respect for persons’. Healthcare providers may not withhold information from a patient in order to influence their healthcare choices. We believe that it is unethical to provide misinformation or withhold information from adolescents about sexual health, including ways for sexually active teens to protect themselves from STIs and pregnancy. Withholding information on contraception to induce adolescents to be abstinent is inherently coercive (and ineffective, as documented above). It violates the principle of beneficence (to do good and avoid harm) as it may cause an adolescent to use ineffective (or no) protection against pregnancy and STIs. Thus, current U.S. policies that promote abstinence-only education are ethically problematic, as they exclude accurate information about contraception, misinform by overemphasizing or misstating the risks of contraception, and fail to require the use of scientifically accurate information while promoting approaches of questionable value.
 * Federal support of AOE as an approach to improve adolescent sexual health is deeply troubling because of medical inaccuracies, programs that are not efficacious and may harm adolescents, and the unethical practice of withholding and distorting health information. We encourage all healthcare providers involved in reproductive health to advocate for medically accurate comprehensive sexuality education for adolescents in their professional organizations, local healthcare system, schools, and communities. Professionals in the field of obstetrics and gynecology are well positioned to reframe the ‘moral’ debate so that providing comprehensive, effective and accurate reproductive health information to adolescents is the right choice.

“Abstinence-only education policies and programs: A position paper of the Society for Adolescent Medicine“ (January 1, 2006)
John Santelli, Mary A. Ott, Maureen Lyon, Jennifer Rogers, Daniel Summers; “Abstinence-only education policies and programs: A position paper of the Society for Adolescent Medicine“, Volume 38, ISSUE 1, p.83-87, (January 01, 2006)
 * Abstinence from sexual intercourse represents a healthy choice for teenagers, as teenagers face considerable risk to their reproductive health from unintended pregnancy and sexually transmitted infections (STIs) including infection with the human immunodeficiency virus (HIV). Remaining abstinent, at least through high school, is strongly supported by parents and even by adolescents themselves. However, few Americans remain abstinent until marriage, many do not or cannot marry, and most initiate sexual intercourse and other sexual behaviors as adolescents. Abstinence as a behavioral goal is not the same as abstinence-only education programs. Abstinence from sexual intercourse, while theoretically fully protective, often fails to protect against pregnancy and disease in actual practice because abstinence is not maintained.
 * Providing “abstinence only” or “abstinence until marriage” messages as a sole option for teenagers is flawed from scientific and medical ethics viewpoints. Efforts to promote abstinence should be based on sound science. Although federal support of abstinence-only programs has grown rapidly since 1996, the evaluations of such programs find little evidence of efficacy in delaying initiation of sexual intercourse. Conversely, efforts to promote abstinence, when offered as part of comprehensive reproductive health promotion programs that provide information about contraceptive options and protection from STIs have successfully delayed initiation of sexual intercourse. Moreover, abstinence-only programs are ethically problematic, being inherently coercive and often providing misinformation and withholding information needed to make informed choices. In many communities, abstinence-only education (AOE) has been replacing comprehensive sexuality education. In some communities, AOE has become the basis for suppression of free speech in schools. Abstinence-only education programs provide incomplete and/or misleading information about contraceptives, or none at all, and are often insensitive to sexually active teenagers. Federally funded abstinence-until-marriage programs discriminate against gay, lesbian, bisexual, transgender and questioning youth, as federal law limits the definition of marriage to heterosexual couples.
 * Although advocates of abstinence-only government policy have suggested that psychological harm is a consequence of sexual behavior during adolescence, there are no scientific data suggesting that consensual sex between adolescents is harmful. Mental health problems are associated with early sexual activity, but these studies suggest that sexual activity is a consequence not a cause of these mental health problems. We know little about how the decision to remain abstinent until marriage may promote personal resilience or sexual function/dysfunction in adulthood.
 * To demonstrate efficacy, evaluations of specific abstinence promotion programs must address a variety of methodological issues including clear definitions of abstinence, appropriate research design, measurement issues including social desirability bias, the use of behavioral changes and not just attitudes as outcomes, and biological outcomes such as STIs. Two recent reviews have evaluated the evidence supporting abstinence-only programs and comprehensive sexuality education programs designed to promote abstinence. Neither review found scientific evidence that abstinence-only programs demonstrate efficacy in delaying initiation of sexual intercourse. Likewise, research on adolescents taking virginity pledges suggest that failure rates for the pledge are very high, especially when biological outcomes such as STIs are considered. Although it has been suggested that abstinence-only education is 100% effective, these studies suggest that, in actual practice, efficacy may approach zero.
 * Likewise, federally funded abstinence-until-marriage programs discriminate against gay, lesbian, bisexual, transgender and questioning (GLBTQ) youth because federal law limits the definition of marriage to heterosexual couples. Approximately 2.5% of high school youth self-identify as gay, lesbian or bisexual and as many as one in 10 teenagers struggle with issues regarding sexual orientation. GLBTQ adolescents often are fearful of rejection or discrimination due to their orientation; they are frequently subjected to harassment, discrimination, and violence. Homophobia may contribute to health problems such as suicide, feelings of isolation and loneliness, HIV infection, substance abuse and violence among GLBTQ youth. Abstinence-only sex education classes are unlikely to meet the health needs of GLBTQ youth, as they largely ignore issues surrounding homosexuality (except when discussing transmission of HIV/AIDS), and often stigmatize homosexuality as deviant and unnatural behavior.
 * Although abstinence is often presented as the moral choice for teenagers, the current federal approach to abstinence-only funding raises serious ethical and human rights concerns. Abstinence-only education policies have implications at a public and individual level. Access to complete and accurate HIV/AIDS and sexual health information is a basic human right and is essential to realizing the human right to the highest attainable standard of health. Governments have an obligation to provide accurate information to their citizens and eschew the provision of misinformation; such obligations extend to state-supported health education and health care services. These legal guarantees are found in a number of international treaties, which provide that all people have the right to “seek, receive and impart information and ideas of all kinds,” including information about their health. Access to accurate health information is a basic human right that has also been described in international statements on reproductive rights such as the Programme of Action of the International Conference on Population and Development—Cairo, 1994. These international treaties and statements clearly define the important responsibility of governments to provide accurate and complete information on sexual health to their citizens.
 * Health care providers and health educators have ethical obligations to provide accurate health information. Patients and students have rights to accurate and complete information from health professionals. Health care providers may not withhold information from a patient in order to influence their health care choices. It is unethical to provide misinformation or withhold information about sexual health that teens need in order to protect themselves from STIs and unintended pregnancy. Withholding information on contraception to influence adolescents to become abstinent is inherently coercive and may cause teenagers to use ineffective (or no) protection against pregnancy and STIs. Current federal abstinence-only legislation is ethically problematic, as it excludes accurate information about contraception, misinforms by overemphasizing or misstating the risks of contraception, and fails to require the use of scientifically accurate information while promoting approaches of questionable value. Additionally, “abstinence until marriage” curricula are commonly provided to those teens who are already sexually experienced and to GLBTQ youth, ignoring their pressing needs for accurate information to protect their health. These ethical obligations to provide complete and accurate information also are the basis for the strong support among medical professionals for comprehensive sexuality education in schools and recent state legislative attempts to require that these sexuality education programs provide medically accurate information {e.g., Cal. Education Code § 51933}.

“Abstinence-Only-Until-Marriage: An Updated Review of U.S. Policies and Programs and Their Impact” (September 01, 2017)
John S. Santelli, Leslie M. Kantor, Stephanie A. Grilo, Craig J. Heck, Jennifer Rogers, Mary A. Ott; “Abstinence-Only-Until-Marriage: An Updated Review of U.S. Policies and Programs and Their Impact”, Volume 61, ISSUE 3, P273-280, (September 01, 2017)
 * Adolescence is marked by the emergence of human sexuality, sexual identity, and the initiation of intimate relations; within this context, abstinence from sexual intercourse can be a healthy choice. However, programs that promote abstinence-only-until-marriage (AOUM) or sexual risk avoidance are scientifically and ethically problematic and—as such—have been widely rejected by medical and public health professionals. Although abstinence is theoretically effective, in actual practice, intentions to abstain from sexual activity often fail. Given a rising age at first marriage around the world, a rapidly declining percentage of young people remain abstinent until marriage. Promotion of AOUM policies by the U.S. government has undermined sexuality education in the United States and in U.S. foreign aid programs; funding for AOUM continues in the United States. The weight of scientific evidence finds that AOUM programs are not effective in delaying initiation of sexual intercourse or changing other sexual risk behaviors. AOUM programs, as defined by U.S. federal funding requirements, inherently withhold information about human sexuality and may provide medically inaccurate and stigmatizing information. Thus, AOUM programs threaten fundamental human rights to health, information, and life. Young people need access to accurate and comprehensive sexual health information to protect their health and lives.
 * Abstinence, as the term is used by program planners and policymakers, is often not clearly defined. A variety of terms have been used to describe programs that focus exclusively on promoting abstinence, including “abstinence-only,” “AOUM,” and “sexual risk avoidance;” the latter term is increasingly used by proponents. Health professionals generally view abstinence as a behavioral or health issue, using terms such as “postponing sex,” “never had vaginal sex,” or refraining from further sexual intercourse if sexually experienced. In contrast, AOUM proponents generally define abstinence in moral terms, using language such as “chaste” or “virgin” and framing abstinence as a “commitment to chastity.” This terminology reflects the religious origins of AOUM programs. U.S. federal funding policy adopted such a moralistic definition of “abstinence education” in 1996, for example, requiring it “teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity”.
 * [I]t is important to recognize that many advocates of AOUM programs are primarily concerned with issues such as character and morality, while health professionals are generally concerned with health behaviors and health outcomes. This helps to explain the disconnect between the two groups.
 * The federal government began supporting abstinence promotion programs in 1981 via the Adolescent Family Life Act, which provided funding to community- and faith-based organizations and was established to promote “chastity” and “self-discipline.” Beginning in 1996, there was a major expansion in federal support to states for AOUM programming through the Title V AOUM program (as part of “welfare reform”) and a shift to funding programs that promoted only abstinence and restricted other information. The Community-Based Abstinence Education (CBAE) program was created in 2000, which made grants directly to community-based organizations, including faith-based organizations. Federal funding for these programs grew rapidly from fiscal year (FY) 1996 until FY 2006. The funding leveled out between FYs 2006 and 2009 and then was significantly reduced in FY 2010. Funding increased in FY 2012, and again in FY 2016. Between FYs 1982 and 2017, Congress has spent over $2 billion on domestic AOUM programs. Funding for AOUM continues today at both the federal and state levels.
 * With passage of welfare reform in 1996 came the creation of the Title V AOUM program and eight-point A–H federal statutory definition of “abstinence education,” which specifies, in part, that programs must have as their “exclusive purpose” the promotion of abstinence outside of marriage (see Table 1 for the complete definition). Programs funded through this funding stream to the states did not have to address all the eight points of the A–H definition; however, they could “not be inconsistent with any aspect of the abstinence education definition and, therefore, could not in any way advocate contraceptive use or discuss contraceptive methods except to emphasize their failure rates.
 * In 2004, the House Committee on Government Reform released a report that 11 of the 13 AOUM programs most widely used by CBAE grantees contained false, misleading, or distorted information about reproductive health, misrepresentations about the effectiveness of condoms in preventing sexually transmitted infections (STIs) and pregnancy, as well as gender and sexual minority stereotypes, moral judgments, religious concepts, and factual errors. A report released in November 2006 by the nonpartisan Government Accountability Office found the Administration for Children and Families, which oversaw the majority of federal AOUM funding, was providing very little oversight of funded AOUM programs and noted that the federal agency did not review its grantees' materials for scientific accuracy or even require grantees to review their own materials for scientific accuracy.
 * In the United States, median age at first sex among women fell from the 1960s (at age 19 years) until the early 1990s (at age 17 years); age at first sex then rose to 17.8 years in 2005 and has since plateaued. However, given secular trends towards rising age at marriage over the past 60 years, the interval of time between first intercourse and first marriage has increased over time for both women and men in the United States. While the median age at first intercourse for women is currently 17.8 years, the median age at first marriage is 26.5 years (a gap of 8.7 years); for men, the gap between the median age at first sex (18.1 years) and first marriage (29.8 years) is 11.7 years. Only a small percentage of young people wait until marriage to have their first intercourse. In contrast, among women born in the 1940s (and turning age 15 years between 1955 and 1964), the interval between first intercourse and first marriage was between 1 and 1.5 years.
 * Advocates for AOUM programs and the language of the U.S. government policy suggest that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects. We find little evidence suggesting that consensual sex between adolescents is psychologically harmful. Rather, psychological harm—when it occurs—appears to be the result of sexual coercion and nonconsensual experiences, including adverse childhood experiences and sexual abuse. Recent large studies of representative adolescent populations suggest early sexual intercourse is not associated with physical or emotional symptoms, except to the extent that cultural norms and social sanctions create disparities for girls compared to boys with respect to early sexual behavior. Rigid cultural norms and social sanctions likely account for this gender disparity; these gender stereotypes undermine adolescents' sexual health.
 * While advocates of AOUM policies and programs have asserted their effectiveness, scientific evidence suggests otherwise. A 2007 systematic review by Douglas Kirby found no scientific evidence that AOUM programs demonstrate efficacy in delaying initiation of sexual intercourse, reducing the number of sexual partners, or facilitating secondary abstinence. Moreover, a rigorous national evaluation was completed in 2007 by Mathematica Policy Research, Inc., with support from the Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation; among four-model AOUM programs, no impact was found on initiation of sexual intercourse, numbers of sexual partners, or other behaviors. A 2007 Cochrane meta-analysis of 13 AOUM programs found that evaluated programs consistently showed no impact on sexual initiation, frequency of vaginal sex, number of partners, condom use, or the incidence of unprotected vaginal sex. More recently, a 2012 meta-analysis by the U.S. Centers for Disease Control and Prevention examined 66 comprehensive risk reduction (CRR) sexual health programs and 23 abstinence programs. CRR programs had favorable effects on current sexual activity (i.e., abstinence), number of sex partners, frequency of sexual activity, use of protection (condoms and/or hormonal contraception), frequency of unprotected sexual activity, STIs and pregnancy. In contrast, the meta-analysis of risk avoidance (AOUM) programs found effects on sexual activity, but not on other behaviors. (Equivocal changes were found for a decrease in frequency of sexual activity and an increase in pregnancy.) Importantly, the effect on sexual activity was only significant in the nonrandomized control trial subgroup and not significant in the stronger randomized control trial subgroup. Thus, the Centers for Disease Control and Prevention concluded that while CRR programs were an effective strategy for reducing adolescent pregnancy and STI/HIV among adolescents, “no conclusions could be drawn on the effectiveness of group-based abstinence education.” More recently, a 2016 review of 37 systematic reviews, summarizing 224 randomized controlled trials of school-based sex education programs concluded that abstinence-only interventions did not promote positive changes in sexual initiation or other sexual behaviors.
 * Abstinence from sexual intercourse has been described as “the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases (STDs), and other associated health problems” in the Section 510 Title V federal definition. This is a misleading and potentially harmful message that conflates theoretical effectiveness of intentions to remain abstinent and the actual practice of abstinence. Abstinence is often not effective in preventing pregnancy or STIs as many young people who intend to practice abstinence fail to do so.
 * While the federal AOUM program assumes that abstinence and AOUM programs are universally valued, public opinion polls in the United States suggest strong support for comprehensive approaches to sex education—including abstinence as a behavioral goal—but also including education about condoms, contraception, and access to condoms and contraception for sexually active adolescents. In a 2014 nationally representative survey, 74% of adults support federal money going to programs proven to delay sex, improve contraceptive use and/or prevent teen pregnancy. Likewise, health professionals have overwhelmingly supported comprehensive sexuality education. The major associations of physicians and public health workers have endorsed comprehensive approaches to sexuality education; many have specifically taken positions against AOUM programs that limit sexual and reproductive health information for young people. National public health goals, established by the U.S. Department of Health and Human Services, call for increasing the share of adolescents receiving formal instruction about birth control methods, prevention of HIV/AIDS and STIs, and abstinence.
 * The percentage of schools requiring instruction about human sexuality fell from 67% in 2000 to 48% in 2014, while the share requiring instruction about HIV prevention declined from 64% to 41%. By 2014, 50% of middle schools and junior high schools and 76% of high schools taught abstinence as the best way to avoid pregnancy, HIV, and STDs. Only 23% of junior high schools and 61% of high schools taught about methods of birth control generally, while 10% of middle school and junior high school teachers and 35% of high school teachers taught specifically about the correct use of condoms. Likewise, nationally representative data from the National Survey of Family Growth tracks adolescents' reports of receipt of formal sex education from 1995 to 2013. During this period, most adolescents aged 15–19 years (80%–90%) report formal instruction about “how to say no to sex.” In 1995, 81% of adolescent males and 87% of adolescent females reported receiving formal instruction about birth control methods; by 2011–2013, this had fallen to 55% of males and 60% of females. The share of adolescents who received instruction on abstinence but no instruction about birth control methods, increased from 8% to 28% of females and from 9% to 35% of males from 1995 to 2011–2013.
 * The lack of clear federal policy guidelines or resources for adolescent comprehensive sexuality education has resulted in a wide array of sex education policies at the state and school district level, and marked disparities by state and district in access to comprehensive sex education and sexual health outcomes. For example, in Indiana, in a single school district, AOUM is taught in general health classes while comprehensive sex education is provided to pregnant and parenting teens. State laws vary considerably. When sex education is taught, 37 require abstinence to be taught, 26 require abstinence to be stressed, and 11 that abstinence only be covered. Nineteen states require teaching that sexual activity should only occur in marriage. Eight states either require negative information on sexual orientation or do not allow information to be provided on sexual orientation.
 * The U.S. federal approach to abstinence promotion raises serious ethical and human rights concerns. Access to complete and accurate STI, HIV/AIDS, and reproductive and sexual health information has been recognized as a basic human right and essential to realizing the human right to the highest attainable standard of health. Governments have an obligation to provide accurate information to their citizens and eschew the provision of misinformation; such obligations extend to government-funded health education and health care services.
 * U.N. Committee on the Rights of the Child—the U.N. body responsible for monitoring implementation of the Convention on the Rights of the Child, and which provides authoritative guidance on its provisions—has emphasized that children's right to access adequate HIV/AIDS and sexual health information is essential to securing their rights to health and information. Article 12 of the International Covenant on Economic, Social and Cultural Rights specifically obliges governments to take all necessary steps for the “prevention, treatment, and control of epidemic… diseases,” such as HIV/AIDS. The Committee on Economic, Social and Cultural Rights, the U.N. body responsible for monitoring implementation of the International Covenant on Economic, Social and Cultural Rights, and which provides authoritative guidance on its provisions, has interpreted Article 12 to require the “the establishment of prevention and education programs for behavior-related health concerns such as STDs, in particular HIV/AIDS, and those adversely affecting sexual and reproductive health”. The United Nations Guidelines on HIV/AIDS and Human Rights provide guidance in interpreting international legal norms as they relate to HIV and AIDS. These guidelines similarly call on states to “ensure that children and adolescents have adequate access to confidential sexual and reproductive health services, including HIV/AIDS information, counseling, testing and prevention measures such as condoms,”.
 * The U.S. AOUM program is also at odds with commonly accepted notions of medical ethics. Just as adolescents have the right to accurate and complete information from teachers and health educators, health care providers have ethical obligations to provide accurate health information in caring for patients. Health care providers may not withhold information from a patient to influence health care choices. Informed consent requires provision of all pertinent information to the patient. Similar ethical obligations apply to health educators. The withholding of information on contraception or barrier protection to induce the adolescent to become abstinent is inherently coercive. It violates the principle of beneficence (i.e., do good and avoid harm) as it may cause an adolescent to use ineffective (or no) protection against pregnancy and STIs. Similarly, government programs providing abstinence as a sole option are ethically problematic, as they exclude accurate information about contraception and misinform by overemphasizing or misstating the risks of contraception.
 * AOUM programming has often included different lessons for and about girls and boys and reinforces gender stereotypes about female passivity and male aggressiveness. The 2004 Waxman report found that AOUM programs included gender stereotypes. Rigid masculinity and femininity beliefs and gender inequities are often associated with negative sexual health behaviors including reduced likelihood of condom and contraceptive use. The programs that critique rigid gender norms and gender-based power imbalances are more likely to positively impact sexual and reproductive health knowledge, attitudes, behaviors, and health outcomes.
 * AOUM programs often portray abstinence from sexual activity as a conscious choice over which a young person has total control. In reality, some young people do not have the choice to remain abstinent due to intimate partner violence, sexual abuse, rape, and/or molestation. In addition, AOUM programs dismiss sexually active youth by suggesting that they are less worthy than their abstinent peers and should feel ashamed of their sexual behavior. Federal guidelines for AOUM programs associate all premarital sexual activity and nonmarital pregnancy, and parenthood with negative health outcomes, including later sexual dysfunction and or guilt about sex.
 * AOUM programs are unlikely to meet the health needs of sexual minority youth, as these programs are largely heteronormative and often stigmatize homosexuality as deviant and unnatural behavior. Stigma and discrimination can contribute to health problems such as suicide, feelings of isolation and loneliness, HIV infection, substance abuse, and violence among sexual minority youth. By excluding sexual minorities, AOUM programs may produce feelings of rejection and being disconnected to school. The U.S. Supreme Court legalized same-sex marriage across the country in 2015. Before this change, for many LGBTQ youth the AOUM message implied that they should never engage in sexual activity as marriage was not a legal option for them. However, the heterosexist bias of most AOUM curricula means that many LGBTQ youth will not get the critical health messages they need from these programs.
 * AOUM policies by the U.S. government have also influenced global HIV prevention efforts, primarily through requirements of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Launched in 2003, PEPFAR originally focused on 15 countries in sub-Saharan Africa, the Caribbean, and Asia that had been severely affected by AIDS. At that time, PEPFAR required grantees to devote at least 33% of prevention spending (and two thirds of funds for sexual transmission) to abstinence-until-marriage programs. After 2006, HIV prevention programs funded under PEPFAR were required to follow specific guidance on Abstinence, Be faithful, and Condom use issued by the Office of the U.S. Global AIDS Coordinator. The guidance necessitated that, “implementing partners must…not give a conflicting message with regard to abstinence by confusing abstinence messages with condom marketing campaigns that appear to encourage sexual activity or appear to present abstinence and condom use as equally viable, alternative choices.” In response to the Abstinence, Be faithful, and Condom use guidance, the U.S. Government Accountability Office noted that separate programming for abstinence within PEPFAR often undermined country-level national efforts to create integrated messages and programs for HIV prevention. Human rights groups also found that U.S. government policy was a source for misinformation and censorship in PEPFAR countries. The U.S. emphasis on AOUM may also have reduced condom availability and access to accurate information on HIV/AIDS in some countries.
 * Notably, a large, well-conducted randomized controlled trial in Kenya found that the national HIV/AIDS school curriculum—focusing on AOUM without mention of condoms, contraception, or health service provision—did not reduce pregnancy or STIs and had the unintended consequence of encouraging early marriage. Further, a 2016 analysis of nationally representative survey data from 22 countries in sub-Saharan Africa for the period 1998–2013 found no difference in trends in adolescent sexual behaviors such as age at first sex between PEPFAR and non-PEPFAR nations—suggesting PEPFAR AOUM funding had had no impact on sexual behaviors.
 * Policies or programs offering abstinence as a single option for unmarried adolescents are scientifically and ethically flawed. AOUM programs have little demonstrated efficacy in helping adolescents to delay intercourse, while prompting health-endangering gender stereotypes and marginalizing sexual minority youth. While abstinence from sexual intercourse is theoretically fully protective against pregnancy and STIs, in actual practice, AOUM programs often fail to prevent these outcomes. AOUM programs have generated considerable political support from social conservatives, despite their lack of scientific evidence of efficacy and the fact that they withhold critical health information. The vast majority of Americans strongly support comprehensive approaches to sexuality education. Despite the fact that health care was founded on ethical notions of informed consent and free choice, federal AOUM programs are inherently coercive, withholding information needed to make informed choices and promoting questionable, inaccurate, and stigmatizing opinions. Federal funding language promotes a specific moral viewpoint, not a public health approach. Federally funded AOUM programs censor lifesaving information about prevention of pregnancy, HIV, and other STIs and provide incomplete or misleading information about contraception and leave sexual minority youth particularly vulnerable. U.S. AOUM policies and programs are inconsistent with commonly accepted notions of human rights.