By Debra Hauser, MPH, Vice President, Advocates for Youth

Introduction

Since 1991, rates of teenage pregnancy and birth have declined significantly in the United States. These are welcome trends. Yet, teens in the United States continue to suffer from the highest birth rate and one of the highest rates of sexually transmitted infections (STIs) in the industrialized world. Debate over the best way to help teens avoid, or reduce, their sexual risk-taking behavior has polarized many youth-serving professionals. On one side are those that support comprehensive sex education—education that promotes abstinence but includes information about contraception and condoms to build young people's knowledge, attitudes and skills for when they do become sexually active. On the other side are those that favor abstinence-only-until-marriage—programs that promote "abstinence from sexual activity outside marriage as the expected standard"[1] of behavior. Proponents of abstinence-only programs believe that providing information about the health benefits of condoms or contraception contradicts their message of abstinence-only and undermines its impact. As such, abstinence-only programs provide no information about contraception beyond failure rates.

In 1996, Congress signed into law the Personal Responsibility & Work Opportunities Reconciliation Act, or "welfare reform." Attached was the provision, later set out in Section 510(b) of Title V of the Social Security Act, appropriating $250 million dollars over five years for state initiatives promoting sexual abstinence outside of marriage as the only acceptable standard of behavior for young people.

For the first five years of the initiative, every state but California participated in the program.[2] (California had experimented with its own abstinence-only initiative in the early 1990's. The program was terminated in February 1996, when evaluation results found the program to be ineffective.[3]) From 1998 to 2003, almost a half a billion dollars in state and federal funds were appropriated to support the Title V initiative. A report, detailing the results from the federally funded evaluation of select Title V programs, was due to be released more than a year ago. Last year, Congress extended "welfare reform" and, with it, the Title V abstinence-only-until-marriage funding without benefit of this, as yet unreleased, report.

As the first five-year funding cycle of Title V came to a close, a few state-funded evaluations became public. Others were completed with little or no fanfare. This document reviews the findings from the 10 evaluations that Advocates for Youth was able to identify. Advocates for Youth also includes evaluation results from California's earlier attempt at a statewide abstinence-only initiative.

Available Evaluations

Ten states made some form of evaluation results available for review. For Arizona, Florida, Iowa, Maryland, Minnesota, Oregon, Pennsylvania, and Washington, Advocates was able to locate evaluation results from state Title V programs. For Missouri and Nebraska, Advocates located evaluation findings from at least one program among those funded through the state's Title V initiative. Finally, the evaluation of California's abstinence-only program was published in a peer-reviewed journal and readily available.

Funding*

During the first five years of abstinence-only-until-marriage Title V programming, the 10 states received about $45.5 million in federal funds. To further support the initiatives and to cover their required funding match, these states appropriated about $34 million in additional funds over the five years.[4] In addition, California spent $15 million in state funds between 1991 and 1994 to support its abstinence-only initiative.[3] In sum, the program efforts discussed in this paper cost an estimated $94.5 million in federal and state dollars.

Program Components

For the most part, Title V funds were administered through states' departments of health and then sub-granted to abstinence-only contractors within each state. Program components varied from state to state and from contractor to contractor within each state. However, all programs discussed in this document included an abstinence-only curriculum, delivered to young people in schools or through community-based agencies. Popular curricula included: Education Now Babies Later (ENABL), Why Am I Tempted? (WAIT), Family Accountability Communicating Teen Sexuality (FACTS), Choosing the Best Life, Managing Pressures before Marriage, and AC Green's Game Plan, among others. Some programs included peer education, health fairs, parent outreach, and/or Baby Think it Over simulators. Some states supplemented their educational programs with media campaigns, also funded through Title V.

Evaluation Designs

The 11 evaluations summarized in this document represent those Advocates for Youth could uncover through extensive research. The quality of the evaluation designs varied greatly. Most evaluations employed a simple pretest/posttest survey design. Slightly fewer than half (five) assessed the significance of changes from pre- to posttest, using a comparison group. Additionally, seven evaluations included some form of follow-up to assess the program's impact over time, although results are not yet available for two. Three of these seven also included a comparison group. For those programs that included follow-up, surveys were administered at three to 17 months after students completed their abstinence-only-until-marriage program.

Evaluation results are summarized in Table I (pdf), which also includes studies' design elements. Because the quality of the evaluation designs varied from state to state, Advocates relied heavily on the evaluators' own analyses and words to describe each program's impact.

Summary of Results

Evaluation of these 11 programs showed few short-term benefits and no lasting, positive impact. A few programs showed mild success at improving attitudes and intentions to abstain. No program was able to demonstrate a positive impact on sexual behavior over time. A description follows of short- and long-term impacts, by indicator.

Short-Term Impacts of State Abstinence-Only Programs

In 10 programs, evaluation measured the short-term impact of the program on at least one indicator, including attitudes favoring abstinence, intentions to abstain, and/or sexual behavior. Overall, programs were most successful at improving participants' attitudes towards abstinence and were least likely to positively affect participants' sexual behaviors.

Attitudes endorsing abstinence—10 evaluations tested for short-term changes in attitudes.

• Three of 10 programs had no significant impact on attitudes (Maryland, Missouri, and Nebraska, ');
• Four of 10 showed increases in attitudes favorable to abstinence (Arizona, Florida, Oregon, and Washington, );
• Three of 10 showed mixed results (California, Iowa, and Pennsylvania).**

Intentions to Abstain—Nine evaluations measured short-term changes in intentions.

• Four of nine programs showed no significant impact on participants' intentions to abstain (California, Maryland, Nebraska, and Oregon,);
• Three of nine programs showed a favorable impact on intentions to abstain (Arizona, Florida, and Washington);
• Two of nine programs showed mixed results (Iowa and Pennsylvania).**

Sexual Behaviors—Six evaluations measured short-term changes in sexual behavior.

• Three of six programs had no impact on sexual behavior (California, Maryland, and Missouri).
• Two of six programs reported increases in sexual behavior from pre- to posttest (Florida and Iowa). It was unclear whether the increases were due to youth's maturation or to a program's effect, as none of these evaluations included a comparison group.
• One of the six programs showed mixed results (Pennsylvania).**

Long-Term Impacts of State Abstinence-Only Programs

Seven evaluations included some form of follow-up survey to assess the impact of the abstinence-only programs over time. Results from two of these are not yet available (Nebraska and Oregon). Of the remaining five, three were of statewide initiatives (Arizona, California, and Minnesota). Two were evaluations of programs within statewide initiatives (Missouri's Life Walk Program and Pennsylvania's LaSalle Program). All five evaluations included questions to assess changes in participants' attitudes and behaviors between pretest/posttest and follow-up. Four also measured changes in intentions to abstain. Three evaluations included a comparison group.

Attitudes Endorsing Abstinence—Five evaluations included assessment of changes in attitudes.

Four of five evaluations showed no long-term positive impact on participants' attitudes. That is, participants' attitudes towards abstinence either declined at follow-up or there was no evidence that participating in the abstinence-only program improved teens' attitudes about abstinence relative to the comparison groups, at three to 17 months after taking the abstinence-only program (Arizona, California, Missouri, and Pennsylvania's LaSalle Program).

Follow-up surveys in Minnesota showed mixed results.

Intentions to Abstain—Four evaluations measured long-term intentions to abstain.

Three of four evaluations showed no long-term positive impact on participants' intentions to abstain from sexual intercourse. That is, participants' intentions either declined significantly at follow-up or there was no statistically significant difference in participants' attitudes relative to controls at follow-up (Arizona, California, and Minnesota).

In one of the four (Pennsylvania's LaSalle Program), evaluation showed a positive impact at follow-up on program participants' intentions to abstain relative to comparison youth.

Sexual Behavior—Five programs measured long-term impacts on sexual behavior.

No evaluation demonstrated any impact on reducing teens' sexual behavior at follow-up, three to 17 months after the program ended (Arizona, California, Minnesota, Missouri, or Pennsylvania's LaSalle Program).

Comparisons of Abstinence-Only-Until-Marriage versus Comprehensive Sex Education

Two evaluations—Iowa's and the Pennsylvania Fulton County program—compared the impact of comprehensive sex education with that of abstinence-only-until-marriage programs.

• In Iowa, abstinence-only students were slightly more likely than comprehensive sex education participants to feel strongly about wanting to postpone sex, but less likely to feel that their goals should not include teen pregnancy. There was little to no difference between the abstinence-only students and those in the comprehensive sex education program in understanding of why they should wait to have sex. Evaluation did not include comparison of data on the sexual behavior of participants in the two types of programs.
• In Fulton County, Pennsylvania, results found few to no differences between the abstinence-only and comprehensive approaches in attitudes towards sexual behavior. Evaluators found that, regardless of which program was implemented in the seventh and eighth grades, sexual attitudes, intentions, and behaviors were similar by the end of the 10th grade.

Discussion

These evaluation results—from the first five-year cycle of funding for abstinence-only-until-marriage under Section 510(b) of Title V of the Social Security Act—reflect the results of other studies. In a 1994 review[5] of sex education programs, Kirby et al assessed all the studies available at the time of school-based, abstinence-only programs that had received peer review and that measured attitudes, intentions, and behavior. Kirby et al found that none of the three abstinence-only programs was effective in producing a statistically significant impact on sexual behaviors in program participants relative to comparisons. In a 1997 report for the National Campaign to Prevent Teen Pregnancy, Doug Kirby reviewed evaluations from six abstinence-only programs[6], again finding no program that produced a statistically significant change in sexual behavior. This was again confirmed in 2000[7], when another review by Kirby found no abstinence-only program that produced statistically significant changes in sexual behaviors among program youth relative to comparisons. This failure of abstinence-only programs to produce behavior change was among the central concerns expressed by some authors of the evaluations included in this document. [For examples of authors' remarks on behavior change, see quotations under Arizona, Florida, Missouri, and Pennsylvania in the state-by-state analyses that follow.] It is important to note that a great deal of research contradicts the belief that changes in knowledge and attitudes alone will necessarily result in behavior change.[8]

A few evaluators also noted the failure of abstinence-only programs to address the needs of sexually active youth. Survey data from many of the programs indicated that sexually experienced teens were enrolled in most of the abstinence-only programs studied. For example:

• In Erie County, Pennsylvania, researchers found that 42 percent of the female participants were sexually active by the second year of the program.
• In Clinton County, Pennsylvania, data collected from program participants in the seventh, eighth, and ninth grades showed a dramatic increase in the proportion of program females who experienced first sexual intercourse over time (six, nine, and 30 percent, respectively, by grade).
• In Minnesota, 12 percent of the eighth grade program participants were sexually active at posttest.
• In Arizona, 19 percent of program participants were sexually active at follow-up. Concurrently, Arizona's evaluators found that youth's intent to pursue abstinence declined significantly at follow-up, regardless of whether the student took another abstinence-only class. Eighty percent of teens reported that they were likely to become sexually active by the time they were 20 years old.

Abstinence-only programs provide these youth with no information, other than abstinence, regarding how to protect themselves from pregnancy, HIV, and other STIs.

A third, related concern of evaluators was abstinence-only programs' failure to provide positive information about contraception and condoms. Evaluators noted more than once that programs' emphasis on the failure rates of contraception, including condoms, left youth ambivalent, at best, about using them.

• In Clinton County, Pennsylvania, researchers noted that, of those participants that reported experiencing first sexual intercourse during ninth grade, only about half used any form of contraception.
• Arizona's evaluation team found that program participants' attitudes about birth control became less favorable from pre- to posttest. They noted that this was probably a result of the "program's focus on the failure rates of contraceptives as opposed to their availability, use and access."

Table I (pdf) includes information about the evaluation design, short-term impacts, and long-term impacts of the 11 programs summarized in this document. Individual state-by-state summaries follow, ordered alphabetically by state.

Conclusion

Abstinence-only programs show little evidence of sustained (long-term) impact on attitudes and intentions. Worse, they show some negative impacts on youth's willingness to use contraception, including condoms, to prevent negative sexual health outcomes related to sexual intercourse. Importantly, only in one state did any program demonstrate short-term success in delaying the initiation of sex; none of these programs demonstrates evidence of long-term success in delaying sexual initiation among youth exposed to the programs or any evidence of success in reducing other sexual risk-taking behaviors among participants.

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* In federal fiscal year 2003, the 10 states discussed here with evaluations of Title V programs received $8,810,281 in federal funds. Under the law, states are required to provide matching funds of three state-raised dollars for every four federal dollars received. Thus in 2003, the 10 states supplied $7,268,060 in state dollars, bringing the total of public monies to Title V funded abstinence-only-until-marriage programs to $16,078,341.

** Mixed results indicated that attitudes changed in both desired and undesired directions, either by survey questions within one initiative, or by individual programs within an initiative.