Heterosexual-only sex education: next generation abstinence-only?

Rolling Stone tells of a rash of suicides among lesbian/gay/bisexual/questioning teens in a conservative town in Minnesota. They mention a next generation sex education program in public schools sponsored by evangelical organizations that questions same sex attraction. This heterosexual-only sex education program appears to be just another guise of abstinence-only sex education, and it seems to follow from the same motivation.

Both programs come from an assumption that both same sex attraction and premarital sex are brand new phenomena, and that it's possible to go back to the way things used to be. (Of course, plenty of evidence indicates that they're not new, and even if they were new, it's neither possible nor desirable to go back to a time when women's suffrage was unthinkable. None of the strong women evangelical leaders would agree to reverse feminist gains.)

Both programs attempt security via obscurity, and treat education as dangerous. Teaching a subject (contraception or same-sex attraction) is thought to encourage and legitimize the subject, and to advance an imagined liberal agenda.

Instead, the programs just delegitimize normal behavior and endanger teenagers. Abstinence-only sex education increased unsafe sex probably because it taught that pregnancy and STDs were unavoidable, so there was no point to avoiding them. Alternatively, it made teens so worried about the spiritual effects of sex that they never worried about the physical effects. That's dangerous and bad for public health, but probably no one would die from it. Hetero-only sex education is more insidious because it further marginalizes a population that is already marginalized, at high risk for educational and health disadvantages, and at high risk of suicide.

Right now these hetero-only sex education programs are coming into public schools using private funds. That's how abstinence-only sex education started in the early/mid 1990s. The next stage would be to slip funding for these programs into another bill, as abstinence-only began in 1996 with the welfare reform bill. I hope it doesn't get that far.

Is parents' aversion to teens' sexuality an extension of incest norms?

Amy Schalet has an op-ed today about parents allowing a teen to have their boyfriend/girlfriend sleep over. I think she's right that it's partially related to sex education, but I think that answer is too facile.

Another issue that she doesn't mention in her op-ed: parents' aversion to thinking about teens' sexuality may also be about incest norms. I have known Dutch young adults who had their opposite sex parent sleep with them when the parent came to visit, and that would never be done in the US as well. Many Americans would find this unusual, at minimum.

Even the most liberal parents are comfortable with their teens' having premarital sex but hope that won't be until after the teens go away to college, and they are uncomfortable teaching their teens about condoms because they're afraid that sends the wrong message that sex now is okay. One question is whether the key ingredient there is the developmental stage represented by being 18 and at college, or whether the key is being AWAY at college. Are parents of boarding school teens relatively accepting with their teens having sex at age 16 since they're out of the house?

Conversely, what many Americans find strange about virginity pledges is how they violate incest norms by drawing the wrong kind of parental attention to teens' sexuality, such as this piece also this week in the NYT. (As an aside, the author also exhibits an all/nothing view about her "purity ring", saying that for awhile she felt that she had to take it off once she had sex, thus making her sexuality even less private than it would have been in a more liberal setting.)

Certainly in some cases, there's a prudery element, but I think it's a broader cultural phenomenon about whom Americans are comfortable talking about sex with, possibly relating to incest norms, which seem to differ between here and the Netherlands.

Cognitive dissonance in faculty recruiting

The University of South Carolina has what I understand to be a very high quality School of Public Health. They are looking for a tenure-track faculty member with a description that matches my own research fairly well, studying "sexualities, sexual behavior, sexually transmitted infections, HIV/AIDS, teenage pregnancy, LGBT disparities or other sexuality and health issues." Particularly, they want someone who advocates and engages with community, state, national, and global organizations.

I checked their sex ed laws, and according to this profile, they are one of 7 states in the US to prohibit positive depictions of homosexuality in public schools, not a favorable start for any researcher who studies LGBT issues to advocate or engage with the community and local institutions. They also prohibit contraception information other than in the context of future family planning, which is better than nothing. SC is also one of the minority of states to apply for the federal abstinence-only sex education funding, meaning that the programs funded by that funding cannot even mention contraception in any positive way at all.

On the bright side, they also applied for the federal evidence-based sex education and pregnancy prevention funds, which they could certainly use since SC has the third highest gonorrhea rate in the country, and 8% of women ages 15-19 get pregnant each year, and 5% give birth. Looking at the gap between pregnancy and birth rates, it's particularly remarkable because 72% of SC women live in a county without an abortion provider (93% of counties lack an abortion provider), Medicaid does not fund abortions, they mandate a 24 hour waiting period and all procedures 12 weeks and after are a felony with mandatory minimum of 5 years in jail and/or $5000 fine.

Thanks to NARAL and Kaiser for the facts. The SC ACLU also has a long access guide listing all the sexuality, family planning, and related resources (e.g., PFLAG) in the state and neighboring states. So the state fortunately has some resources, even if they get an F by NARAL.

Vaginismus: Blame the victim

I've been eagerly reading this blog on vaginismus. The writer has been married over a year without sex. She has visited a sex therapy clinic, and seems to be making progress.

Many of the commenters blame the writer's religion for her problems. When bystanders are confronted with a really difficult situation, some will go to extreme lengths to convince themselves that it could never happen to them. They may think that being in an unconsummated marriage for over a year seems so extremely difficult, there must be some reason that it happened to her and not to other people they know. Presumably it could happen to anyone.

Some criticisms relate to ignorance, but there are so many issues that people never need to think about. How many women know what the hymen looks like? I study sexual initiation, but the anatomical details have never been relevant to me professionally, and I didn't know what the hymen looked like until I saw the above pictures.

How frivolous is sexuality?

On the Society for Adolescent Medicine mailing list, there's a discussion about a pediatrician's 14 year old male patient who has frequent bilateral testicular pain relieved by masturbation. An instantly familiar diagnosis and remarkably not attested in the medical literature. A correspondent forwarded a 11 year old paper from the journal Pediatrics, "Blue Balls": A Diagnostic Consideration in Testiculoscrotal Pain in Young Adults: A Case Report and Discussion (106:4, October 2000, page 843), with accompanying letters. Featured prominently is the fact that masturbation is a good answer, and that Dr. Jocelyn Elders lost her job for advocating teaching masturbation. The upshot of both the paper and the mailing list discussion is that no one knows anything: the only way available for doctors to address the issue was to suggest ruling out serious medical conditions.

When discussing sexuality issues without severe medical consequences, there's a real uncertainty or self-consciousness: some may see sexuality as existing outside the realm of health and medicine, and dealing with sexuality risks being seen as frivolous. Sexuality is certainly part of health, but when will sexuality be treated as part of health?

New sex ed game

This sex ed game Privates is supposed to be fun. I don't use a PC, so I will never know, but it definitely looks better than the web game that they gave as an example of a terrible sex ed game: parts were funny and parts just strange, like their character names: Captain Condom, Power Pap, Willy the Kid (phallic-shaped but short), and Wonder Vag. Really, Wonder Vag. I played for 30 seconds before I had 4th grade flashbacks. Looking forward to hearing how Privates works out.

Parent sex education

A recent XKCD notes that parents may need to teach their parents a lot more about sex now that there are internet popup ads. While it's a funny exaggeration of the situation and it seems to be a new situation, it does illustrate the age-old truth that kids always know more than adults think, making it clear that all the time discussing whether to teach contraception in schools is a waste. A study that I did found that most Southern Baptists surveyed in church Sunday School learn about birth control and STD prevention from their schools and from their peers. Take away the schools, and you are left with peers. And internet pop-up ads.

Fantastic WW2 sex ed film for soldiers

This film shown to World War II soldiers is already better than any official abstinence-only (a-h criteria compliant) education curriculum. The message is do not have sex, but if you do, use a condom, and it shows a condom and then tells how to put it on, and do not drink so much that you are careless. And then it closes with the typewritten message on the screen, "Do not be so weak as to let some ignorant individual persuade you that you must seek sex relations to be a good sport. If you follow his advice, you are only being a fool."

Short and to the point, and an easy substitute for weeks-long curricula. And this was before there was even effective treatment for either syphilis or gonorrhea. (And before we were aware of chlamydia, herpes, and HPV.) Interestingly, the film was made in 1941, or either in the 24 days after the US declared WW2 or prior to entering WW2. Either way, it's clear that the army clearly anticipated that STIs can be a major problem, and it knew that it had to prevent STIs as much as possible, rather than waiting for them to come up. Unfortunately, there is no such common unifying impetus to prevent STIs today.

Policy proposal: given that some idealize the times before the sexual revolution, states that are reluctant about giving modern comprehensive sex education should limit themselves to material produced by state and federal government bodies prior to the sexual revolution. The vintage government films that I've seen are more practical and factual than the abstinence-only curricula that I've seen.

Sweden has had sex education since 1918

While doing a literature review for a paper about syphilis, I learned that Sweden has had what we would now call comprehensive sex education since 1918 ("Venereal Diseases and Sex Education", Report by a Swedish Government Committee, British Medical Journal, vol 1, no. 3204, May 27, 1922, p.842), as part of their "venereal disease" prevention law.

A 1943 discussion of sex education shows that current discussions are almost identical to past dicussions. The Archbishop of Canterbury noted that "if men and women would abstain from fornication the problem would be reduced greatly and become a purely medical matter. The bulk of the evil is primarily a moral problem." and he suggested that by distributing condoms to the troops "the implication is that many are expected to practice fornication" and thus it increases. One person cited one example in which moral suasion worked to prevent sex among soldiers --- the Black Sea Army in World War I --- and that the forces would respond if chastity were portrayed "in the right way".

On the other side, a medical officer from St. Pancras argued that the Church's teaching was unhelpful and that creating a taboo against premarital sex causes those who break the taboo to become rebels and outcasts. An alderman calls for sex education for those age 13 and up since otherwise they will learn about sex from "street talk", while a doctor calls for sex ed starting at age 11. Meanwhile, a minister in the Church said that he has discussed venereal diseases openly for years, and in a separate report, a psychiatrist noted that "The clergy were more broad-minded than schoolmasters."

Three months without federal abstinence-only funding

The US had 3 months without abstinence-only funding on the books before the health reform law reinstated it: $50 million a year for 5 years for the states, the exact same level of state-level abstinence funding as in the previous administration, even though fewer states are applying for the funds. Even Alaska under Sarah Palin "missed the deadline" for abstinence grants in the last round. (No Sarah Palin jokes. Missing the deadline just seems to be the politically expedient method of not participating in abstinence funding.)

The difference between current funding and the previous administration seems to be $154 million: community organizations are no longer given abstinence grants ($141 million in 2009) and the Adolescent Family Life abstinence program is no longer listed in the budget ($13 million in 2009). Not funding AFL is surprising, and I wonder if I've missed something since that program has been funded consistently since the early 1980s, but I don't see in the 2011 HHS budget; this program generally flies under the radar and is usually not mentioned in media reports about abstinence education, even though organizations like Advocates for Youth track it.

The decrease in abstinence-only education funding from $204 million to $50 million represents additional good news: the $50 million is going to states who are scrutinized more heavily. For instance, some states have laws requiring that all sex education be medically accurate. On the other hand, increasing numbers of states require contraception to be taught in sex education, which may mean that even if the states wanted to apply for the abstinence funds, their state law mandates a curriculum that is incompatible with the abstinence education requirements. The a-h definition of abstinence education in the Title V is so restrictive that the only abstinence-only program that has ever been shown effective (Jemmott and Jemmott's research) could not be funded under Title V.

Another difference between the pre-2009 and current HHS budgets is that abstinence was featured prominently in the budget in 2009 and before. Many pages of the pre-2009 budgets mentioned abstinence, and there was a whole subsection describing all the sources of abstinence funding and their histories. The 2011 budget doesn't have any text about abstinence and only includes abstinence in the itemized totals, mostly for past years, and has "--" where future years of abstinence funding are supposed to be listed. (The new 50 million a year isn't yet listed in the 2011 budget.)

While the country had only the 3 month period between the zero-ing out of abstinence education at the end of December 2009 and the passage of the health reform bill at the end of March 2010, there's certainly a big shift.

The really interesting question is how many states will apply for abstinence funds, since more states now have comprehensive sex education laws that are incompatible with applying for the funds, and whether it would be possible for the a-h definition to be changed. Or if the $50 million will go only to the states with strong abstinence-only constituencies such as Louisiana and Texas.

Political compromises on sex ed

I'm an ardent moderate, but I find the administration's compromises counterproductive. Obviously the stimulus compromise didn't work: the bill was watered down, and virtually no Republicans voted for it anyhow.

If the health bill passes, the sex education situation will go to $50 million for abstinence-only education, $50 million for evidence-based comprehensive sex education, and $25 million for experimental comprehensive sex education. That's not compromise. That's going also against popular opinion: 52% of even politically "very conservative" parents favor teaching birth control in schools, and 89% of the general population of parents. Just as most of the public and most physicians favor the public option, but that doesn't make it into policy either.

More importantly, it's going agsinst the findings of the Congressionally-mandated study finding that abstinence-only sex education doesn't work.

They're not listening to either the public or the researchers they hired.

An open letter to Senator Orrin Hatch

Dear Senator Hatch,

I am the author of two of the approximately ten published papers about the sexual behavior of virginity pledgers. I found that virginity pledgers may lie about their sexual pasts and that they are less likely to use condoms when they do have sex.

Thank you for thinking of my research when you added an amendment for $50 million of Abstinence-Only Sex Education funds to the health reform bill. If the federal government does not fund abstinence education, my research into the sexual behavior of virginity pledgers and evangelical adolescents would lack policy relevance, so I'm truly grateful for this opportunity.

Nonetheless, I have to turn down this generous offer. I have a surfeit of other research topics, and I've moved on with my research. Even most abstinence proponents have moved on with their efforts. Every abstinence proponent I've spoken with, including leading Southern Baptists, seem to accept that their approach to sex education needs to be reworked. The evangelical media's reaction to my most recent paper finding virginity pledges do not work was mild (in the case of Focus on the Family Radio and the Baptist Press) and even favorable (in the case of Christianity Today).

More importantly, as you know, the case against Abstinence-Only Sex Education was definitively made by the Congressionally-mandated evaluation of the program published in 2007 by Mathematica Policy Research.

I consider that perhaps you made this amendment for ironic effect: if your amendment stays in the bill, the Democrats who favor health reform will have to vote for your abstinence funding. If so, your point was made, and I have laughed heartily at the irony. Now you can remove it.

Best of luck in your continued efforts.

Love,

Janet Rosenbaum, PhD

Review of You're Teaching My Child WHAT?

Dr. Miriam Grossman, formerly Anonymous MD, has written another book, entitled You're Teaching My Child WHAT? A Physician Exposes the Lies of Sex Education and How They Harm Your Child. My thoughts about this book are almost identical to my review of her earlier book, perhaps because the books have nearly identical tone and content. As I stated in that review, "This evident alarmism --- PC is so insidious that the author must remain anonymous or risk Birkenstocks being thrown through her front windows --- that pervades the book may cause parents and aggrieved social conservatives to pick up the book, but it does no good for Dr. Anonymous's arguments and alienates people who might otherwise agree with her." As in her previous book, Dr. Grossman makes valid points in the most invalid ways, alleging cover-ups and duplicity and a single radical academic agenda when none exists.

I have three responses specific to this book.

First, Dr. Grossman refers multiple times to a controversy between parents and experts, for instance saying "The `experts' are wrong, and parents are right." presuming parents are opposed to the allegedly radical agenda of comprehensive sex education. In fact, nearly all parents, even very conservative parents, favor school sex education that teaches birth control: 89% of all parents, more than 80% of Born Again Christian parents, and 51% of parents who call themselves politically very conservative.

Second, Dr. Grossman identifies herself in this book as an Orthodox Jew. I find it strange that she spends an entire chapter lambasting the sex education advocacy group SIECUS for encouraging sexual experimentation rather than abstinence when the only sex education curriculum developed by Orthodox Jewish institutions is based on SIECUS guidelines (Life Values and Intimacy Education sponsored by Yeshiva University's Center for the Jewish Future, published by KTAV, all institutions considered arbiters of "Authentic Judaism"). She does not try to reconcile this discrepancy, I suspect because that would blur the simple dichotomy she is trying to create between religion/parents/tradition (=good) and academia/sex education advocates/SIECUS (=bad).

Third, her chapters on homosexuality and gender identity, the latter entitled "Genderland", are problematic in ways beyond the scope of this review. She cites some legitimate research such as Lisa Diamond's fantastic 10 year longitudinal qualitative study of lesbian and bisexual women published in the 2008 book Sexual Fluidity: Understanding Women's Love and Desire. Diamond found that nearly all of her women subjects' sexual orientations seemed to change spontaneously. Grossman uses spontaneous sexual orientation change among women to bolster the case for attempting to induce changes in sexual orientation among both men and women. Besides the spontaneous vs. attempted induced changes difference, Diamond looked only at women. Grossman lists many differences between men and women in the realm of sexuality earlier in her book, all of which would imply that a study of women's sexual orientations has no relevance to men's sexual orientations. Of course mentioning NARTH is a total non-starter.

This book does make some valid points and could be readable if all the alarmist bits were pulled out and the rest toned down. As I stated in my review of her previous book, I don't think that her points are repressed at the level of academic research, but as in many areas perhaps research simply is not adequately disseminated: this certainly wouldn't be the first area where quality of health care suffered because practitioners followed their intuitions instead of evidence-based guidelines or the evidence was never disseminated in the first place.


Cutting out the alarmism would make the book about 20% shorter but would give it a chance of being looked at by those she critiques. It seems like she's not interested in dialogue, just in fomenting alarm among the alarmed. Too bad. It could have been otherwise. She wrote this book while a recipient of a Clara Booth Luce fellowship, a fund that has funded moderate research by journalist Laura Sessions Stepp, also an affiliate of the moderate group National Campaign Against Teen and Unplanned Pregnancy.

What a wasted opportunity for dialogue.

Teen-written sex ed site: sexetc.

Teen-written sex ed site includes an article "Kissing: are you missing out on life's simple pleasures" imploring readers to slow down and smell the roses; another article covers what abstinent teens do. One quoted teen says, “Now that I’ve been in a relationship for over a year and we’re considering becoming sexually active, I realize that my sex ed experiences made me terrified of sex. My teachers made it seem like everyone had an STD, and that contraceptives are expected to fail. If it weren’t for my own reading, I wouldn’t know what kinds of contraceptives are available.”

It's neat to read a quote by a real teenager illustrating what the GAO talked about in how inaccurate and negatively slanted abstinence education is.

Sweden's mandatory sex ed: a social conservative's nightmare

This is what the Evangelicals are afraid of US sex education becoming: mandatory with strawberry-flavored condoms handed out by teachers. The article also notes that tax money subsidizes sex toys sold in state-owned pharmacies.

According to the article, before the legal change "Twenty-seven percent of immigrants’ daughters are kept from participating in some school subjects." That's a large number. Does that mean boys were allowed to go?

Needless to say, the US isn't even close to being like Sweden and would never remove the option for students to opt out. Given the high rates of chlamydia and other STDs among high school students, it would be great to hand out condoms in sex ed classes, but that would never happen and if it did they would be the most boring condoms possible.

Congratulations to North Carolina

North Carolina passed a bill mandating that 7-9th graders be taught both abstinence methods of contraception and STD prevention, and the governor is expected to sign it. This bill is different than the original proposed, which had required that all schools offer two sex ed classes that parents would choose between. This bill just allows parents to pull their children from the STD/pregnancy prevention portion of the class.

The current policy for the past 15 years has been that school districts that wish to teach birth control in school must go through a separate approval process to be able to teach birth control.

It is sad that no Republicans voted for the bill. I wonder whether there is any compromise legislation or any research that would convince Republicans to allow teaching birth control in schools.

The evidence from RAND's intervention to teach parents how to teach sex education to their adolescents finds that even with an 8 week program for these parents who volunteered to participate, the majority of parents STILL didn't teach their kids how to use condoms. And this is a group of parents cherry-picked for their motivation. Other parents would likely do worse. No matter what your ideals are about parents' duties towards their adolescents, the reality seems to be that if you want condom use to be taught, you have to put it in the schools. Or let them learn on youtube or in an STD clinic waiting room. Watching instructional videos in the waiting room of an STD clinic reduces the risk of repeat visits, after all.

Reformulating or rebranding abstinence

There's a vivid and interesting piece in the Nation about the abstinence movement's attempt to rebrand/reformulate itself. At times, I laughed: Jessica Valenti writes dynamically and compellingly. She raises some important points, though I don't agree with everything she says. (E.g., I think that the trend of traditional religions using feminism to promote traditionalism is complex and subtle. Her take is that "the virginity movement is ... a targeted and well-funded backlash hellbent on rolling back women's rights using modernized notions of purity, morality and sexuality.")

The central point of her article is crucial: the abstinence movement recognizes that it needs to give accurate information about contraception, which I see as a terrific coup for the cause of scientific accuracy. Perhaps the reformulation is being done with good will: they see problems with current version and honestly they want to make it better for the sake of teens' health. Or perhaps Valenti is right and this recognition is just lip service and won't change what they are actually doing, though even lip service is good.

Whether reformulation or rebranding, this change calls for vigilance. The abstinence-only movement is taking the "only" out of their label: now it's "abstinence centered" which is confusingly similar to "abstinence-plus" or "abstinence-based" which mean comprehensive sex education, so it will take an extra moment to even determine whether a curriculum intends to be comprehensive or not.

If there are inaccuracies in the new curricula, they may be more subtle. The most productive thing reproductive health community can do is make sure that what is taught in schools is accurate. Some states mandate that all sex education gets reviewed by clinicians for accuracy, but others don't. If all states established such requirements of review by medical experts, that would make it a moot point whether the abstinence movement is doing a cynical rebranding or a good will reformulation of its movement.

Utah's sex education

Utah is considering new sex education approaches. They recently changed their sex education laws to allow teaching of contraception in school sex education classes, but teachers are still apparently afraid of saying the wrong thing and getting fired, so the new sex education law is aimed at mandating teaching contraception. The Salt Lake Tribune editorial board endorsed the bill.

I spoke with a group that is helping out the legislature about ways to bridge the ever-present gap between conservative and liberal views of sex education: conservatives are afraid that teaching contraception encourages kids to have sex, and they were confused that some programs that teach birth control actually cause kids to DELAY sex. The most obvious explanation, of course, is that teens are terrific detectors of propaganda. They want to make their own decision, but they need to be given the autonomy to do so, not just told what to do. As everyone knows, to order a teen to do something without giving them alternatives risks losing the chance to influence them at all.

I also suggested that they include parents in the sex education curriculum somehow, such as through take-home assignments that adolescents complete with their parents. It's a good idea to get parents and adolescents talking about sex, and it may reassure conservatives that the role of schools and parents in sex education is complementary.

I'm excited to see what happens. Utah!

Meanwhile, Oregon just passed a new sex education bill that requires that all abstinence sex education must also include "other material and instruction on contraceptive and disease reduction measures."

Is there any federal funding for comprehensive sex education?

When I use federal budget figures, I get all of them from the federal budget: I download the HHS budget and search the PDF for the programs I'm interested in, and I add up the numbers that come up in the search for "abstinence." That's how I got $204 million as the figure for abstinence-only sex education, for instance. Other media cite $176 million, but that excludes some of the funding mechanisms that go to abstinence.

I have never seen any indication that there was any federal funding at all for comprehensive sex education, so I have been continually confused by claims of the abstinence-only folks that comprehensive sex education has some big money pot dedicated to it. I figured that they were counting some portion of Title X funding as "comprehensive sex education" --- Title X is family planning, used primarily for teen pregnancy prevention. (Of course in the past several years they were required to follow the shutting the barn door after the horse escaped approach by teaching abstinence to their patients coming for pregnancy and STD tests.) But because I saw it repeated so often I thought maybe there was a grain of truth in their claims that there was federal funding for comprehensive sex education.

It turns out that as I had originally suspected the claims about federal funding for comprehensive sex education seem to be out of context, counting Title X as sex education funds even though they don't go to schools and are intended primarily to pay for reproductive health care for millions of women. (About 5 million, if I recall correctly.)

I'm disappointed by this distortion. Like many others, I agree with the goal of the abstinence movement to encourage delayed sex and fewer partners, (though it's much more complicated than just that!), and there are plenty of real balanced reasons for those goals, making it all the more disappointing that some in the movement distort budget figures and scientific research (e.g., the famous condom effectiveness.)

Oped in today's Baltimore Sun

Here's my oped from today's Baltimore Sun about the need for effective evidence-based sex education.

The editorial staff was really impressive in how much more easily they made the piece flow.