The US abstinence-only-until-marriage programme

Ironically, these are exactly the kind of sentiments attributed to young people involved in American programmes that have actively campaigned against the provision of comprehensive sex education to young people. These programmes have also pursued a policy of teaching that the only safe sex is sex within marriage - advice which, if followed literally, would imply no choice but celibacy for entire populations.

Such ‘abstinence-only-until-marriage’ (AOUM) sex education programmes became an important factor and focal point of debate within global HIV prevention from 1996 onwards, because the largest single programme funder, the USA, pursued a policy of reserving HIV prevention funding (or a proportion of funding) solely to programmes that taught this philosophy. This policy applied not only to domestic HIV budgets but to PEPFAR, the US President's Emergency Plan for AIDS Relief, the largest single funder of international HIV care and prevention.

From 1996 onwards, the only money directed by the federal government towards sex education for young people in the United States was directed towards programmes specifically teaching teenagers that the only sure way to avoid pregnancy, STIs and HIV was to abstain from sex altogether until marriage.

Note that this policy change happened around the start of Bill Clinton’s second term, as the policy is usually and erroneously associated exclusively with the George W Bush administration (though Bush greatly increased funding for this programme). The Clinton administration was the first to set aside $50 million a year specifically for abstinence education, though the Christian Education Centre had first mooted abstinence education as a way of reducing HIV and STIs in 1987, and programmes such as ‘True Love Waits’ had been running since 1992.

Comprehensive sex education packages, often financed by states or local authorities, included abstinence as one of the strategies teenagers could use. However they also included unbiased information on methods teenagers could use if they were sexually active, including condoms and oral contraceptives.

Abstinence-only-until-marriage programmes were quite explicit about ruling out such a comprehensive approach. Two of the three federal funding streams that financed these programmes (AFLA and Title V) required that states signed up to an eight-point definition of abstinence education, which stated that, to be eligible for funding, a programme must:

A Have as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity;

B Teach abstinence from sexual activity outside marriage as the expected standard for all school-age children;

C Teach 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 Teach that a mutually faithful, monogamous relationship in the context of marriage is the expected standard of sexual activity;

E Teach that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects;

F Teach that bearing children out of wedlock is likely to have harmful consequences for the child, the child’s parents, and society;

G Teach young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances;

H Teach the importance of attaining self-sufficiency before engaging in sexual activity.

By 2000, three separate programmes financed AOUM programmes:

1. Section 510 of the Social Security Act (Title V), federal funding

2. The Adolescent Family Life Act (AFLA)

3. The Community-Based Abstinence Education Program (CBAE).

Total funding in 2007 for these programmes was $204 million, and in total the George W Bush administration is calculated to have spent 80% of the $1.5 billion directed towards AOUM programmes.¹ There was no comparative federal funding set aside directly for comprehensive, non abstinence-based sex education in schools. Conservative think-tank The Heritage Foundation² argued that this was still only one-twelfth the money spent on all condom provision and comprehensive sex education, and that a large proportion of the federal money was in fact being spent by ‘abstinence-plus’ programmes which taught abstinence as the preferred option in a comprehensive sex education package.

Abstinence-only programmes and their public funding attracted criticism from the start, however, and opposition to them grew as the scientific evidence pointed towards their ineffectiveness (see below). In June 2006, more than 200 organisations, coming from all 50 US states and the District of Columbia, launched a nationwide No More Money campaign (see  www.nomoremoney.org) in an effort to stop federal funding for AOUM programmes, co-ordinated by the Sexuality Information and Education Council of the US (SIECUS). California had always refused Title V funding, and a growing list of states joined in this refusal.

From the late 1990s, scientific studies, including randomised controlled trials, were conducted on abstinence programmes, and also on non-exclusive comprehensive sex education. This research found that AOUM programmes did not achieve their aims. Over long-term follow-up, most AOUM programmes had no effect whatsoever on any measure of subsequent sexual risk taking (see below). In contrast, similar studies showed that comprehensive sex education programmes that mentioned abstinence as one of a menu of choices, alongside monogamy, condoms, contraception and so on, were in the main effective using the same measures.

In the face of this convincing scientific evidence, the administration of President Barack Obama made a major policy change. It abolished the Adolescent Family Life Act (AFLA) and Community-Based Abstinence Education Program (CBAE) streams in 2009, and in 2010 it proposed the replacement of the largest funding stream, Title V, with a new stream called the Personal Responsibility Education Program (PREP), which would teach comprehensive sex education to children and young people between the ages of ten and 20. This was allocated $500 million over the next five years. The background documents to PREP explicitly encourage states to devise curricula that are based on “the needs of lesbian, gay, bisexual, transgender (LGBT) and questioning youth” and rates against “how their programs will be inclusive of and non-stigmatizing towards such participants”.

In August 2010, however, Obama lost a vote in congress to abolish Title V altogether. Instead, the money was split equally between Title V and the new PREP scheme, allocating $250m over the next five years to each. However, while the PREP programme offers 100% grants towards states applying for it, states applying for Title V funding only get 25% of the cost and must match-fund it with the other 75%. Under these circumstances, state governors who opt exclusively for Title V are open to the accusation of wasting public money.