The American Public Health Association recognizes that youth face considerable risk to their reproductive health. Adolescents have the highest age-specific risk for many sexually-transmitted infections (STIs)1 and the United States continues to lead the developed world in the rate of adolescent pregnancy.2 APHA further recognizes that abstinence from sexual intercourse is an important behavioral strategy for preventing HIV, STIs, and unintended pregnancy. Many adolescents have not initiated sexual intercourse, and many sexually experienced adolescents and young adults are abstinent for varying periods of time. We note that there is broad public support in the United States for abstinence as a necessary and appropriate part of sexuality education.3 APHA also notes that few Americans remain abstinent until marriage, and most initiate sexual intercourse as adolescents. Together, data from the 2002 National Survey of Family Growth and the 2000 U.S. Census indicate a considerable gap between the median age at first intercourse of 17 years, and the median age at first marriage of 25 in women and 27 in men.2,4 Such demographic realities raise serious questions about the feasibility of programs that promote abstinence until marriage as a universal strategy. Moreover, APHA notes that significant ethical and human rights concerns arise when abstinence is presented to adolescents as the sole choice, or when health information regarding other choices is limited or misrepresented. In previous policy statements, APHA has strongly supported sexual and reproductive rights, comprehensive health and sexuality education in schools extending from kindergarten through high school, and adolescent access to confidential reproductive health care.5-7 Since 1996 there have been major expansions in federal support for abstinence-only education (AOE) programming including Section 510 of the Social Security Act in 1996, and Community-Based Abstinence Education (CBAE) projects in 2000.8 Both Section 510 and CBAE programs prohibit disseminating information on contraceptive services, sexual orientation and gender identity, and other aspects of human sexuality.9 Programs must have as their "exclusive purpose" the promotion of abstinence outside of marriage and may not in any way advocate contraceptive use or discuss contraceptive methods except to emphasize their failure rates.9 AOE programs must teach that "a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity." These program requirements have little to do with public health priorities; instead, they reflected the moral and ideological viewpoint of the majority of members of Congress at the time of the program's authorization.8 While abstinence from sexual intercourse is theoretically fully protective against pregnancy and disease, in actual practice abstinence often fails.8,10 Longitudinal studies find that although abstinence pledgers, when compared to non-pledgers, were more likely to delay initiation of intercourse, they were less likely to use condoms and other contraception after initiation; at six-year follow-up, pledgers experienced similar rates of STIs when compared to non-pledgers.10 In addition, abstinence pledges were associated with delayed initiation primarily in younger adolescents and only in certain contexts (where there were neither too many nor too few pledgers in the community).11 Moreover, rigorous evaluations of AOE programs find little evidence of program efficacy.8,12,13 A congressional report on the AOE programs commonly supported by the U.S. federal programs found that 11 of the 13 most frequently used curricula contained false, misleading or distorted information about reproductive health- including inaccurate information about contraceptive effectiveness, risks of abortion and other scientific errors.14 Moreover, these curricula treat gender stereotypes as scientific fact, and blur religious with scientific viewpoints. In 2003, APHA called for "ensuring that government-supported sexuality education programs include comprehensive, medically-accurate information."7 Recent emphasis on abstinence-only programs and policies appears to be undermining critical public health programs in the United States and abroad including comprehensive sexuality education.8 Data from the CDC in 2000 found that 92 percent of middle schools and 96 percent of high schools taught abstinence as the best way to avoid pregnancy, HIV, and STDs, but only 21 percent of middle school and 55 percent of high school teachers taught the correct use of condoms.15 Between 1988 and 1999, sharp declines occurred in the percentage of teachers who taught about birth control, abortion, and sexual orientation,16 and in 1999, one quarter of sex education teachers said they were prohibited from teaching about contraception. Between 1995 and 2002, the proportion of adolescents who reported receiving any formal instruction about birth control declined from 87 percent to 70 percent.17 Language promoting abstinence has also appeared in federal funding announcements for the Title X program and for HIV prevention.8 AOE programs are often insensitive to sexually active and sexually abused teenagers, as well as to gay, lesbian, bisexual, transgender, questioning, and intersexed (GLBTQI) youth. Sexually experienced teens need access to complete and medically accurate information about condoms and contraception, their legal rights to health care, and ways to access reproductive health services. AOE programs do not address these needs. Abstinence-only sex education classes are unlikely to meet the health needs of GLBTQI youth, as they largely ignore issues surrounding homosexuality, and may contribute to stigmatization of homosexuality as deviant and unnatural behavior.21 Homophobia and stigmatization contribute to health problems such as suicide, feelings of isolation and loneliness, HIV infection, alcohol, tobacco and other drug use, and violence among GLBTQI youth.22 In addition, abstinence-only policies by the U.S. government have influenced global HIV prevention efforts such as the Presidents Emergency Plan for AIDS Relief (PEPFAR), which was enacted in 2003. Beginning in fiscal year 2006, PEPFAR requires grantees to devote not less than 33 percent of prevention spending to abstinence-until-marriage programs.18 In April 2006, the U.S. Government Accountability Office (GAO) issued a report titled "Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Emergency Plan for AIDS Relief" that concluded, in part, the "...requirement that country teams spend at least 33 percent of prevention funding appropriated pursuant to the act on abstinence-until-marriage programs has presented challenges to country teams' ability to adhere to the PEPFAR sexual transmission strategy...it has challenged their ability to integrate the components of the 'Abstinence, Be Faithful, Condoms' (ABC) model and respond to local needs, local epidemiology, and distinctive social and cultural patterns."19 Also, according to a report from Human Rights Watch (Dec. 2004), "Since the announcement of PEPFAR in 2003, pressure by the U.S. to make abstinence a more central part of HIV prevention strategies in donor countries appears to have reduced condom availability and access to accurate HIV/AIDS information in some countries."20 While abstinence is often presented as the only moral choice for adolescents, APHA recognizes that the current U.S. government approach focusing on AOE or abstinence-until-marriage raises serious ethical and human rights concerns. Access to complete and accurate HIV/AIDS and sexual health information has been recognized internationally as a basic human right and essential to realizing the human right to the highest attainable standard of health.23,24 In the context of sexual and reproductive health and rights, APHA has called for "affirming and upholding U.S. commitments under international human rights agreements."7 International treaties and human rights statements support the rights of all people to seek and receive information vital to their health. The U.N. Committee on the Rights of the Child has emphasized that "Consistent with the obligations of States parties in relation to health and information &, children should have the right to access adequate information related to HIV/AIDS prevention and care, through formal channels (e.g., through educational opportunities and child-targeted media) as well as informal channels..." The following is also stated in the same section of the document: "The Committee wishes to emphasize that effective HIV/AIDS prevention requires States to refrain from censoring, withholding, or intentionally misrepresenting health-related information, including sexual education and information... State parties must ensure that children have the ability to acquire the knowledge and skills to protect themselves and others as they begin to express their sexuality."25 Access to accurate health information as a basic human right has also been described in the Programme of Action of the International Conference on Population and Development- Cairo, 1994. One of its principles includes the following statements: "...States should take all appropriate measures to ensure, on a basis of equality of men and women, universal access to health-care services, including those related to reproductive health care, which includes family planning and sexual health. Reproductive health-care programmes should provide the widest range of services without any form of coercion. All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, education and means to do so."26 These treaties and human rights statements strongly suggest that governments have an obligation to provide accurate information to their citizens and to eschew the provision of misinformation in government-funded health education and health care services. Likewise, APHA holds that individuals have rights to accurate and complete information from their health care professionals, and that health care providers and health educators have ethical obligations to provide accurate health information. While good patient care is built upon notions of informed consent and free choice, APHA holds that AOE programs are inherently coercive by withholding information needed to make informed choices. As defined by the U.S. government's own funding requirements, these programs are required to withhold information on contraception and other aspects of human sexuality, and to promote scientifically questionable positions. These requirements, which limit topics for discussion in the classroom, place health educators and other public health professionals in an ethical quandary, forcing them to choose either to withhold potentially life-saving information, or to breach federal government guidelines by disclosure of such. Given these serious concerns about the efficacy and ethics of current U.S. support for abstinence-only education, the American Public Health Association urges the following: 1. Efforts to promote abstinence should be provided within public healthprograms that provide adolescents with complete and accurate information about sexual health. Such programs should be medically accurate and developmentally appropriate, sensitive to cultural diversity and social context, and based on theories and strategies with demonstrated evidence of effectiveness. APHA has strongly supported comprehensive sexuality education that includes information about concepts of healthy sexuality, sexual orientation and tolerance, personal responsibility, risks of HIV and other STIs and unwanted pregnancy, access to reproductive health care, and benefits and risks of condoms and other contraceptive methods.5 Sexuality education should be non-judgmental and support parent-child communication and should not impose religious or ideological viewpoints upon students. 2. States should support school districts and local schools to implement abstinence education as a part of comprehensive sexuality education and as an integral part of comprehensive K-12 school health education. 3. Current federal funding for abstinence-only programs under Section 510 and CBAE should be repealed and replaced with funding for a new federal program to promote comprehensive sexuality education. 4. The U.S. Congress should require that all sexuality education programs supported by the federal government, and all sexual health information disseminated by federal agencies, be medically and scientifically accurate, age and context appropriate, and based on theories and strategies with demonstrated evidence of effectiveness5 and consistent with international human rights declarations. 5. Governments and school districts should not tolerate censorship of information related to human sexual health within the public schools. 6. Federally supported public health programs should promote social and cultural sensitivity to sexually active youth and gay, lesbian, bisexual, transgendered, questioning, and intersexed youth. 7. The federal government should require evaluation of programs to promote abstinence and reduce sexual risk taking. Such evaluations should utilize rigorous scientific research methods and should assess the behavioral impact as well as outcomes such as STIs and pregnancy. The results of such evaluations should be made available to the public in an expeditious manner. References 1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2004. Atlanta, GA: U.S. Department of Health and Human Services, September 2005. 2. Abma J, Martinez GM, Mosher W, Dawson BS. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002. National Center for Health Statistics. Vital Health Stat 2004;23:1-48. 3. Albert B. With one voice 2004: America's adults and teens sound off about teen pregnancy, an annual national survey. Washington, D.C.: The National Campaign to Prevent Teen Pregnancy; 2004. 4. Fields J. Americas Families and Living Arrangements: 2003. Washington, D.C.: US Census Bureau; 2004. 5. Sexuality Education As Part of a Comprehensive Health Education Program in K-12 Schools. APHA Resolution #2005-10, 2005. 6. Adolescent Access to Comprehensive, Confidential Reproductive Health Care. APHA Resolution #9001, 1990. 7. Support for Sexual and Reproductive Health and Rights in the United States and Abroad. APHA Resolution #2003-14, 2003. 8. Santelli JS, Ott MA, Lyon M, et al. Abstinence and abstinence-only education: A review of US policies and programs. J Adolesc Health 2006;38:72-81. 9. Dailard C. Abstinence promotion and teen family planning: the misguided drive for equal funding. The Guttmacher Report on Public Policy. 2002;5(1):1-3. 10. Bruckner H, Bearman PS. After the Promise: the STD consequences of adolescent virginity pledges. J Adolesc Health 2005;36:271- 278. 11. Bearman PS, Bruckner H. Promising the Future: Virginity Pledges and First Intercourse. Am J Sociol 2001;106(4):859-912. 12. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, D.C.: National Campaign to Prevent Teen Pregnancy, 2001. 13. Manlove J, Romano-Papillo A, Ikramullah E. Not Yet: Programs to Delay First Sex among Teens. Washington, D.C.: National Campaign to Prevent Teen Pregnancy, 2004. 14. United States House of Representatives, Committee on Government Reform- Minority Staff. Prepared for Rep. Henry A. Waxman. The Content of Federally Funded Abstinence-Only Education Programs. 2004. 15. Centers for Disease Control and Prevention. School Health Policies and Programs Study 2000. Atlanta, GA: U.S. Department of Health and Human Services. Available from: www.cdc.gov/shpps 16. Darroch JE, Landry DJ, Singh S. Changing emphases in sexuality education in U.S. public secondary schools, 1988 1999. Fam Plann Perspect 2000;32(5):204 211. 17. Lindberg LD, Santelli JS, Singh S. Changes in Formal Sex Education: 1995-2002. Perspect Sex Reprod Health forthcoming. (we expect this to be published in December 2006.) 18. H.R. 1298: United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (108th Congress of the United States of America, January 7, 2003). Available at: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=108_cong_bills&docid=f:h1298enr.txt.pdf. Accessed: July 6, 2006. 19. United States Government Accountability Office: Report to Congressional Committees. Global Health: Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Emergency Plan for AIDS Relief. GAO-06-395, April 2006. 20. Human Rights Watch. Access to Condoms and HIV/AIDS Information: A Global Health and Human Rights Concern. New York, NY: Human Rights Watch, 2004. 21. Kempner ME. Toward a Sexually Healthy America: Abstinence-Only-Until-Marriage Programs that Try to Keep Our Youth "Scared Chaste". New York, NY: Sexuality Information & Education Council of the United States, 2001. 22. Garofalo R, Katz E. Health care issues of gay and lesbian youth. Curr Opin Pediatr 2001;13:298- 302. 23. Freedman LP. Censorship and manipulation of reproductive health information. In: Sandra Coliver, ed. The Right to Know: Human Rights and Access to Reproductive Health Information. Philadelphia, PA: University of Pennsylvania Press, 1995:1- 37. 24. Sandra Coliver, ed. The Right to Know: Human Rights and Access to Reproductive Health Information. Philadelphia, PA: University of Pennsylvania Press, 1995. 25. Committee on the Rights of the Child. General Comment No. 3 (2003a) HIV/AIDS and the rights of the child, 32nd Sess. (2003), para. 13. 2003. 26. United Nations. Report of the International Conference on Population and Development (Cairo, 5-13 September 1994). New York; 1994. Report No.: A/Conf.171/13.