How should sex education programs be taught?

The fight over abstinence-only sex education broke out in a recent House of Representatives hearing. On April 23, the Committee on Oversight and Government Reform heard from a line-up of medical authorities who said such programs don't work. On the other hand, some members of Congress said some of the programs do work, and that sex education should set high expectations for children.

Margaret Blythe, MD, professor of pediatrics at Indiana University School of Medicine, represented AAP. "Abstinence-only programs have not been proven to change or impact adolescence sexual behavior in an effective way, as documented by five reviews which include a federally funded evaluation," she said. "Yet, vast sums of federal monies continue to be directed towards these programs. And in fact there is evidence to suggest that some of these programs are even harmful, and have negative consequences by not providing adequate information for those teens who do become sexually active."

But Stan Weed, PhD, director of the Institute for Research and Evaluation, criticized the research that indicates comprehensive sex education programs work. Saying that he started studying abstinence education as a skeptic, Weed asserted, "Since that time, I have learned that it can work. Not all of them do. But many of them do. And we have learned which ones do and why. In the 100 programs that I have evaluated, I would not classify any of them as 'abstinence-only.' They are much broader, they are much richer, and they are much deeper."

The law for abstinence education, passed 12 years ago, funds programs that have as their "exclusive purpose teaching the social, psychological and health gains to be realized by abstaining from sexual activity." Education providers, currently funded at about $163 million per year, include schools, human service agencies, faith-based groups, youth groups, and family planning centers.

A 2006 Government Accountability Office (GAO) report notes: "Instructors can incorporate a variety of educational materials into their abstinence-until-marriage education programs, including textbooks, student manuals, brochures, slide presentations, and videos."

That GAO report was one focus of the recent hearing. It said the Administration for Children and Families (ACF), which is responsible for the two programs with the largest portion of federal spending on abstinence education, "does not review its grantees' education materials for scientific accuracy and does not require grantees of either program to review their own materials for scientific accuracy." GAO pointed, in particular, to one curriculum that stated that condoms don't work because they are porous. Over 15 states have stopped-or never started-applying for the funds.

The abstinence education programs were on the defensive at the recent hearing, but continuing support for them is apparent. At the beginning of the year Congress funded them for this fiscal year at about their previous level.

That was a compromise. The House had passed legislation that would have increased the program. But the Senate would have slashed it, with its appropriations committee saying the program must encourage further innovation in abstinence education for evidence-based interventions to show sizeable and lasting impacts.

The conference report on the final funding bill stated that the appropriations committees were directing that each program applicant certify that all materials to be used are medically accurate, and that a panel of medical experts review the applications and materials to assess whether they are so.

In the meantime, the hearing illustrated perhaps nothing so well as the continuing confusion and argument on what abstinence programs and comprehensive education programs actually teach. In written testimony, Charles Keckler, acting deputy assistant secretary in ACF, said, "Comprehensive sex education curricula may include information about abstinence, although to varying degrees, these approaches in practice exist along a continuum of approaches rather than as two completely distinct approaches."

The main difference, he said, is that comprehensive sex education programs also teach about the use of various contraceptive devices, in addition to abstinence. Abstinence education programs do not provide such instructions.

KATHRYN FOXHALL is a contributing editor to Contemporary Pediatrics.