Sex Education that Really Works

by Edward F. Gehringer

Imagine that there was a public-school curriculum that could cut the teenage abortion rate by up to 50%, reduce the number of children born into single-parent families, decrease welfare costs, and help curb the spread of sexually transmitted diseases. How hard would you work to bring such a program to your local schools? What you are imagining already exists. It's called abstinence-based sex education. Parents across the country are lining up behind the "Just Say NO" approach, because the latest research shows that it really does work, even in the 1990s.

The new results are all the more impressive because earlier experience showed that non-directive, or "value neutral" sex education didn't affect students' behavior very much. In 1989, two Seattle physicians, James Stout and Frederick Rivara, published a survey of sex-education programs over the period 1970 to 1987.[1] In two databases, they found 23 evaluations of school-based sex-education programs. Most of these just evaluated how much the students learned from their courses. Only five attempted to measure the programs' effect on sexual activity. In three of these studies, sex education did not affect the number of teenagers becoming sexually active. Of the other two, one showed a decrease in sexual activity and the other showed a slight increase.

The Stout and Rivara article caused quite a stir. It was written up in major newspapers like the New York Times and Washington Post. The leading advocacy groups for sex education didn't have a convincing answer. In a letter to the Times, Judith Senderowitz, Executive Director of the Center for Population Options, admitted that the benefits of sex education could not yet be measured. But, she argued, if such programs were not continued, there would little hope of reducing teen pregnancy. Updating the '89 survey. Has the situation changed in the past few years? There is a growing awareness of the need to evaluate sex education. In going back to the databases that Stout and Rivara had used, I found five results-oriented evaluations published between 1988 and 1991--as many as in the previous 18 years. Two programs[2,3] (one of which was abstinence based) claimed a major drop in pregnancies. What they really measured was a decline in births, which could also have resulted from an increase in abortion. Besides, they failed to include a "control group"--a similar group of students who did not take the sex- education program in question. Thus it was not clear whether the program, or some other factor, had caused the change in birth rates.

Of the remaining three programs, two[4,5] registered little effect on the rate of sexual activity among all teens surveyed. The third, an abstinence-based program called Postponing Sexual Involvement[6] reported a dramatic effect: the number of students initiating sexual intercourse was 37%-80% lower, depending on age, than among students who had not participated in the program. Abstinence programs really work. Postponing Sexual Involvement was not the first abstinence-based program to show results. One year earlier, a "value oriented" program called Teen STAR had reported a decrease in the number of students becoming sexually active. Teen STAR is still the only program to show success in "secondary virginity," that is, persuading students to discontinue premarital sexual activity. During its year-long course in 1988-89, more students were sexually active at the beginning than at the end. Then in early 1991, Illinois-based Project Respect, whose Sex Respect is the largest abstinence-based program in the country, released the results of a five-year study involving 29 schools. It showed that only 5% of girls who had taken the program became pregnant one or two years later, compared to 9% of the girls in the control group! Since 10% of American teenage girls become pregnant annually, this represents a drop of 40-50%.

The Sex Respect report is significant for its methodology as well as its results. The program was independently evaluated by a Utah firm, the Institute for Research and Evaluation, headed by Stan Weed. The data on pregnancy rates came from a followup survey of 3577 students, evidently the largest such survey to date. The evaluators controlled for other factors affecting pregnancy rates, such as age, but found that the impact of the program on pregnancy was statistically significant with a very high level of confidence.

The ACLU responds. Not everyone is impressed with Sex Respect. The Wisconsin ACLU thought it promoted "sex-role stereotyping," and unsuccessfully petitioned the state Department of Public Instruction to ban it. They complained that it said that boys would "aggressively seek sexual release," while girls were motivated by a need for security. Project Respect countered by citing a federal court decision in a sexual-harrassment case, which said that women are more offended than men by aggressive sexual behavior. Project Respect's Director Kathleen Sullivan surmised that the Wisconsin action must have embarrassed the national ACLU. "Can you imagine that--the ACLU is banning books?!" she marveled, and opined that it actually helped their program: "I got on about 30 talk shows because of that," she explained. Congressional committees evidently weren't very impressed either. They cut off funding for the Adolescent Family Life Act (AFLA), which funds most abstinence-based programs. Last September 12, however, funding was restored on the Senate floor, on an amendment introduced by Sen. Jesse Helms. Until recently, the AFLA prohibited recipients from spending more than 5% of their federal funds for evaluation. That only added to the difficulty of evaluating programs where the questionnaires themselves are often seen as invasions of privacy. Then there is the difficulty of getting a control group. According to Maureen Falcon, of Project Respect, "No one wants to go through all that testing for nothing--especially to ask personal questions." "You need to get permission of the parents," she adds. In order to recruit control groups, she notes, Project Respect promises them the program the next year for free. Then, the search for a control group begins anew.

[The paragraphs between here and the paragraph on the appeal of abstinence ed. may be appropriate for a sidebar.] Other kinds of "interventions." Sex education is not the only way to attack the teen-pregnancy crisis. Another method is the "community based" approach featured in a Journal of the American Medical Association article in 1987.[7] This program enlisted the support of parents, teachers, ministers and representatives of churches, and community leaders. Its primary objective was to encourage unmarried teenagers to postpone sexual intercourse. Its secondary objective was to encourage sexually active teens to use contraceptives. It targeted half of a county in South Carolina. The pregnancy (not birth) rate fell by more than half (from 61 per 1000 females to 25 per 1000 females) in the target portion of the county, while it changed little in the rest of the county or surrounding counties.

Clearly, abstinence was an important part of the message in this South Carolina program. The involvement of churches might have been instrumental in getting this message across. Since it didn't rely solely upon schools to reach teenagers, it can't be directly compared to school-based sex-education programs. The Association of Junior Leagues designed a program to prevent teenage pregnancy and school dropout by emphasizing volunteer service, to allow teens to experience being help-givers rather than just help-receivers. Sex education constituted only about 10% of the program. It seemed to reduce pregnancy and dropout rates by 30%-50%, relative to the control group.[8]

The Baltimore Pregnancy Prevention Program[9] was a program to provide sex education, individual and group counseling, and contraceptive services. It was evaluated in four inner-city Baltimore public schools between 1981 and 1984. Students in the program lost their virginity seven months later, on average, than other students. The aggressive promotion of contraceptives convinced many students to use some "protection." Within 28 months after the program, about 50% of the girls in the control group had become pregnant, but only about 23% of the girls who participated in the program.

The Baltimore program stands out among contraceptive-based programs for bringing about a reduction in pregnancy. However, its success has never been replicated. No similar programs are underway today. This is in part due to the cost of the program, about $122 per student,[10] and partly due to the difficulty of evaluation (repeat questionnaires, control groups, etc.). Ironically, the Baltimore school system replaced it with school- based clinics, whose track record is problematical at best. School-based clinics. School-based health clinics have long been under attack by right-to-lifers for their tendency to refer students for abortions. What has been their success in reducing pregnancy, their stated objective? Research has repeatedly shown that it is very difficult to bring about any decline in pregnancy by instituting a school-based clinic. Initial experience at a St. Paul, Minnesota clinic was quite favorable, but other studies suggest it is not typical. Douglas Kirby, former research director for the Center for Population Options commented on a survey of six school-based clinics in 1988, "... basically ... there is no measurable ... impact upon the use of birth control, nor upon the pregnancy rates or birth rates ... based upon the survey data."[11] A more recent literature review by the same author concluded, "... clinics ... had relatively little impact upon sexual risk-taking behaviors such as sex without birth control."[12] "In none of the sites was the pregnancy rate lower in the clinic school than in the comparison school," he reports. Still a supporter of school-based clinics, Kirby believes that more careful experimentation is needed to establish their benefits. [End of material that may be appropriate for sidebar.]

The appeal of abstinence ed. Abstinence education holds appeal for parents, teachers, and students alike. A 1988 survey of 4,000 sex-education teachers reported that 95% thought abstinence should be taught, with 25% identifying it as their most important message. Seventy percent of America's parents want students to abstain from permarital sex, according to former Education Secretary William Bennett. In The Myths of Sex Education, Josh McDowell cites a study from Psychology Today magazine that reported that 2/3 of junior-high students said their greatest need in sex education was learning how to say no to sexual pressure. In the Postponing Sexual Involvement study, 84% of sexually active teenage girls wanted information on how to say "no" without hurting the other person's feelings. How "straight" the message? But abstinence programs are not created equal. Some abstinence advocates have charged that Postponing Sexual Involvement only teaches students to remain virgins until they are sixteen. Another "abstinence program" called Success Express failed to affect students' behavior. However, Falcon alleges that it did not really teach abstinence. A California program, Reducing the Risk, taught kids how to say no to sex, but also where to obtain contraceptives. It showed a significant drop in sexual activity but no impact on pregnancy rates.

While the importance of teaching abstinence is firmly established, the repercussions of discussing contraceptives in an abstinence- oriented curriculum have not been well documented. Weed is currently comparing two "straight abstinence" programs, Sex Respect and Teen Aid, with Values and Choices, a program more sympathetic to contraceptives. Early indications are that the straight abstinence programs are more effective in discouraging sexual activity, but the evaluation is not yet complete. Getting the message out. One factor hampering the spread of abstinence-based programs is that most "experts" in the field are unaware of their success. Hardly any abstinence studies appear in scientific journals. Instead, an interested researcher would have to rely on reports to funding agencies, which are much more difficult to locate. Few developers of abstinence curricula are associated with universities, so they reap no immediate rewards from journal publications. Independent analysts like Weed are paid by the programs they evaluate, but derive no revenue from publishing scientific articles. "That's no excuse," says Kansas State University researcher Carmel White, who surveyed AFLA programs in 1988. "They could collaborate with people in universities." Until that happens, however, parents will bear most of the burden for spreading the word.

The bottom line. Nothing in social-science research is completely black and white. On can find abstinence programs that have failed, and non-abstinence programs that have succeeded. However, the largest followup study of any program involves an abstinence program that cut the pregnancy rate by nearly one-half. Non-abstinence programs have been more intensively studied, but have not often produced the desired results. Ruling out studies that measure births, and programs that rely on community involvement, there are really only two non- abstinence "interventions" that have ever succeeded in reducing pregnancy: the original school-based clinics in St. Paul and the Baltimore Pregnancy Prevention Program. However, attempts to replicate the St. Paul success have failed, and the Baltimore program has never been tried elsewhere.

Pregnancy, of course, is not the only risk of premarital sexual activity. No studies report on how sex education affects the transmission of STDs, but can there be any doubt about which program is more successful in curtailing them? Finally, abstinence education may cut the abortion rate even more than the pregnancy rate, since several studies have shown that those who are less favorable to sex outside marriage are also less likely to consider abortion an acceptable alternative. Choosing a sex-education curriculum is inevitably controversial. Every program has its proponents, but only a few programs have data to back their claims. Almost everyone agrees on the goals: cutting pregnancy and sexually transmitted disease. The challenge is to adopt a program that has shown it can achieve them.

Ed Gehringer is an associate professor of computer engineering and computer science at North Carolina State University, and, although still single, a friend of the pro-family movement.

[1] James W. Stout and Frederick P. Rivara, "Schools and sex education: does it work?" Pediatrics, March 1989, pp. 375-379.

[2] Sandra Dycus and Gwyn M. Costner, "Healthy early adolescent development: implementing a human sexuality curriculum for seventh graders," Elementary School Guidance and Counseling, October 1990, pp. 46-53.

[3] Harold R. Rubel and Otis L. Baughman, III, "The impact of a county wide sex education effort on adolescent pregnancies in one South Carolina regional medical center," Journal of the South Carolina Medical Association, July 1988, pp. 355-358.

[4] Marvin Eisen and Gail Zellman, "Changes in incidence of sexual intercourse of unmarried teenagers following a community-based sex education program," Journal of Sex Research, November 1987, pp. 527-533.

[5] Marvin Eisen, Gail Zellman, and Alfred McAlister, "Evaluating the impact of a theory-based sexuality and contraceptive education program," Family Planning Perspectives, November- December 1990, pp. 261-271.

[6] Marion Howard and Judith B. McCabe, "Helping teenagers postpone sexual involvement," Family Planning Perspectives, February 1990, pp. 21-26.

[7] M. L. Vincent, A. Cleary and M. Schluchter, "Reducing adolescent pregnancy through school and community-based education," Journal of the American Medical Association, June 26, 1987, pp. 3382-3386.

[8] J. Allen, S. Philliber and N. Hoggson, "School-based prevention of teen-age pregnancy and school dropout: process evalution of the national replication of the Teen Outreach Program," American Jnl. of Community Psychology, 1990, pp. 505-524.

[9] L. Zabin, M. Hirsch, E. Smith, R. Streett, and J. Hardy, "Evaluation of a pregnancy prevention program for urban teenagers," Family Planning Perspectives, May-June 1986, pp. 119-126.

[10] L. Zabin, M. Hirsch, E. Smith, M. Smith, M. Emerson, T. King, R. Streett, and J. Hardy, "The Baltimore Pregnancy Prevention Program for urban teenagers: what did it cost?" Family Planning Perspectives, July-August 1988, pp. 188-92.

[11] D. Kirby, presentation at the 16th Annual Meeting of National Family Planning and Reproductive Health Association, March 2, 1988, quoted by Pat Socia, "Do sex education programs work?" Project Respect, Box 97, Golf, IL 60029.

[12] D. Kirby, "School-based clinics: research results and their implications for future research methods," Evaluation and Program Planning, 1991, pp. 35-47.