Feature: Wednesday, November 28, 2002

Like Vietnam, the war over sex education is about hearts and minds and dollars.

By Adam Pitluk

ALDWELL — The students stand in a circle in the center of their sixth-period classroom, whispering, high-fiving, rearranging themselves to stand by their friends. Cindy Cobia takes a plastic cup of clear liquid from a tray and hands a cup to each of the 18 students. Cobia is the school nurse, but in her rural central Texas district, she also functions as safety supervisor. In this case, it’s sexual safety she’s teaching.

Don’t drink the liquid or smell it, she warns, but these are eighth-graders, so every one of them takes a whiff. “It’s just water,” one girl says. “Drink up, y’all,” a boy says, raising his glass.

Cobia, carrying her own plastic cup, approaches one student — Michael — and formally introduces herself. All the students giggle when the two shake hands. “Now I’m just going to give you a little bit of my fluid,” Cobia says, pouring some of the contents of her glass into his. “Now you give me a little of yours. Thank you. Now I want each student to introduce him or herself to another student and swap fluids like Michael and I just did.”

The swapping done, Cobia goes around the circle with an eyedropper — one lone drop in each cup. Five of the kids’ mixtures turn purple. Each time this happens, Cobia looks the student directly in the eye. Her jocular tone is gone, replaced by a stern catch in her voice. “Walk to the middle of the circle,” she instructs. They walk to the center of the circle—heads down, giddiness gone.

Everyone is silent, awaiting the explanation. “I’m sorry to report that everyone in the center of the circle has an STD,” Cobia announces. The room lets out a resounding “Eeewww!”

So begins Lesson Six of a 10-session, two-week sex education course at Caldwell Middle School. “Worth the Wait” is taught to sixth-, seventh-, and eighth-graders in over 30 central Texas middle schools as a continuous three-year curriculum. Like earlier sex ed programs, Worth the Wait grosses out class after class of teens and pre-teens with graphic slides showing the effects of genital herpes and chlamydia. But, unlike their predecessors of earlier years, these kids won’t be further mortified by a teacher showing them how to fit a condom on a banana. In fact, there are lots of things these kids won’t hear.

They won’t be urged to use condoms if they do engage in sexual activity — in fact, condoms will be mentioned only to tell the children that they don’t work on most sexually transmitted diseases. They won’t be taught about any form of birth control or about homosexuality or masturbation or abortion. Worth the Wait is a full-frontal abstinence program that teaches children to abstain from sex by presenting them with medical data and a good dose of social policy.

When these young teens complete the program, they’ll know more about how sexual diseases are transmitted than most adults. They’ll know about the socioeconomic impact of unwanted teenage pregnancies on the local, state, and national economies. They’ll know how to spot peer pressure and, theoretically, how to deal with it. In effect, they’ll know more than many of their parents about the consequences of teen sex. And, almost certainly, at the end, they’ll pledge, in writing, to abstain from sex until marriage. But — except for what they learn at home, from television, or on the street — they won’t know how to protect themselves if they break that vow.

Abstinence-only curricula like Worth the Wait are now a booming business in Texas, beneficiaries of the state’s large share of $530 million in state and federal funding that, since 1996, has gone only to this kind of program. More comprehensive sex education programs, which teach about things like birth control as well as the advantages of abstinence, are not allowed to partake of that $530 million bounty, and other government funding is much harder to come by.

Developers of today’s abstinence-only programs say they are based on science, not religion or wishful thinking — and many supporters are medical professionals, who have become horrified at the problems of sexually transmitted diseases in teens. But in order to dip into that $530 million river of government funding, abstinence programs have to promise, among other things, to teach that only sex within the confines of a faithful marriage meets “the expected standard of human sexual activity” and that sex outside of marriage “is likely to have harmful psychological and physical effects” — not just for teens, but for anyone. The exclusive purpose of programs must be the teaching of abstinence and its benefits.

Proponents also say that their programs are becoming the norm across the country because more comprehensive sex ed programs have been ineffective. After several years’ experience, however, there is no proof that the abstinence-only programs work any better — even in Texas, where the abstinence-only bandwagon got rolling several years earlier, under then-Gov. George W. Bush.

Nonetheless, the administration of now-President Bush has proposed increasing abstinence-only funding by another $33 million annually. And while most Tarrant County public schools currently teach comprehensive sex education, Worth the Wait’s proponents have started knocking on North Texas doors — and are now marketing their program in other states.

Both sides in this debate clearly have the kids in mind. Both sides claim to have science on their side, and decry the other’s dogma and hypocrisy — and neither has much proof of results. For the near future in this country, however, one side has already won. Abstinence educators, secure in their federal support, view the battle as one waged not against comprehensive sex education proponents, but against teen pregnancies and disease. And they have only one weapon in their arsenal.

The religious right has been fighting sex education since the Sexuality Information and Education Council of the United States (SIECUS) first began campaigning for such programs in the 1960s. Despite such opposition, comprehensive sex education programs flourished through the mid-’90s.

The tide of teen pregnancy and sexual disease continued, however. In 1981, the Adolescent Family Life Act Demonstration Grants program was created, to attempt to prevent teen pregnancy through teaching abstinence and to promote adoption (as opposed to abortion) as the appropriate choice for teenagers who become pregnant. AFLA was often viewed as the far right’s “alternative” to comprehensive sex ed. Yet AFLA never enjoyed broad-based support: Its appropriations dwindled from 1981 to 1996.

Far-right opponents of sex education learned that they could not successfully remove sex education programs by law — but that they could restrict them through health policy and funding mechanisms. They also learned that congressional and public debate resulted in the defeat or serious modification of their proposals. They applied these lessons, and what many once viewed as the impossible happened. Abstinence-only education, emerging out of welfare reform, was about to become the national model for American children.

In late 1996, the 104th U.S. Congress, with approval from President Bill Clinton, took legislative action to install abstinence-only curricula as the sexuality education standard for unmarried people in the United States. Under the Welfare Reform Act, Congress allocated $50 million annually over a five-year period to fund abstinence-only sex education programs.

The welfare reform legislation represents the broadest attack to date on the provision of comprehensive sexuality education. By 1999, abstinence-only was the curriculum in over one-third of U.S. public schools. In essence, this marked the culmination of 20 years’ worth of work on the part of the religious right first to defeat and, when that failed, to co-opt sex education.

Proponents of comprehensive sex ed, including SIECUS, Planned Parenthood Federation of America, Advocates for Youth, and Pro-Choice Resource Center, have challenged the reauthorization of the 1996 funding for abstinence education programs. These groups and their allies have crafted legislation titled the “Family Life Education Act” that would allow for federal funding of comprehensive sex ed programs.

However, most lawmakers recognize this as a futile pursuit, at least in the near future. If the Clinton White House signed abstinence-education legislature into law, the more conservative Bush White House will not likely endorse funding for anything other than abstinence-only education.

Texas is the nation’s third most populous state, but it ranks first in the numbers of pregnant and STD-infected teens. Appropriately, it received the second-largest share of funds for abstinence-based education, ahead of New York and behind only California. Including state matching funds, the Texas Department of Health expects to distribute about $9.5 million this fiscal year to 33 abstinence education contractors, plus Texas A&M and the University of North Texas. How much each program gets is determined by a TDH team of child wellness experts. Worth the Wait, with programs in more than 30 Texas school districts, received about $163,000 in fiscal 2002 and will receive over $265,000 this fiscal year.

Will it have any effect? Who knows? According to the Centers for Disease Control, there has been a 20 percent decline in the teen birth rate since the 1990s, and sexual activity decreased 15 percent. At the same time, rates of certain sexually transmitted diseases rose among adolescents. More than a quarter of all new HIV cases are occurring in people 21 and younger, and doctors report that herpes is spreading at a rate faster than in years past.

The STD statistics are like a bugle call for abstinence educators. Many of them got into programs like Worth the Wait because they think teens have been misled into believing condoms are like the holy water of sexual health, a prevent-all for both pregnancy and disease. Proponents are determined to keep every student they teach abstinent until marriage. And that, the comprehensive educators say, is as dangerous as the STD epidemic.

When most people think of abstinence education, they think of a character like Pat Robinson and the religious right. And historically, that wouldn’t have been too far from the truth.

“A lot of the abstinence movements have gotten a black eye because people associate them with right-wing fanatics or religious groups,” said Kate Darnell. “We’re neither. We just want kids to understand and get the right message from all the people that impact their lives.” Darnell is the administrator of Worth the Wait and spokeswoman for the sex education program at Scott and White Hospital in Temple, part of the A&M system, which operates Worth the Wait in Texas.

Many of the leaders of abstinence programs in Texas, in fact, came through medical experience rather than religious belief to support the idea that abstinence is a far superior practice to advocate to teens than the use of condoms that do nothing to prevent the spread of many types of STDs.

“I’ve been involved with Worth the Wait since June,” said Dr. Anthony Busti, assistant professor of internal medicine at Texas Tech Health Sciences Center in Dallas. His primary area of expertise is working with patients infected with HIV or AIDS in the center’s infectious disease clinic.

“I’m an advocate of abstinence because of the patients I manage on a daily basis,” he said. “I’ve seen the ramifications of sexually transmitted diseases. I’ve seen what poor choices can lead to.”

In order to receive funding under the Welfare Reform Act, however, abstinence programs have to go beyond stating medical realities. They try, in effect, to enforce a broad social policy — from encouraging wise choices to teaching that society accepts only one choice. Any group seeking such funds must meet eight provisions:

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

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

• 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;

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

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

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

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

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

Comprehensive educators say those provisions not only mandate social policy but are actively dangerous in leaving teens ignorant about what to do if they do have sex. Although rates have dropped, studies show that, at a minimum, almost half of American teens say they are sexually active.

A recent study by the Texas Department of Health and Fort Worth Health Department showed that Texas, Tarrant County, and Fort Worth all ranked above the national average for children born to teen-age moms. The national average in 2000 was 26.9 births for every 1,000 women aged 15 to 17. In Texas, the rate was 41.6 births per 1,000. Tarrant County posted a 37.4 rate — 15th highest of Texas’ 254 counties. Fort Worth’s rate was more than twice the national average — 57.3.

Jeff Rodriguez, director of education for Adolescent Pregnancy Prevention, Inc., a comprehensive sex education program based in Fort Worth, said that teaching kids that premarital sex can cause harmful psychological effects is a dangerous message. If a 20-year-old who has been taught only abstinence decides to have sex in college, Rodriguez said, that student would be at risk of contracting a disease or unwanted pregnancy because of ignorance.

“We fully agree that abstinence is the safest choice, and we work hard to promote that idea,” Rodriguez said. “But we also have to accept the reality that some young people are not going to make that choice. They may be having sex now, or when they get to college, or maybe not until they’re in their 20s. Whatever the situation, we think they deserve help, too. And we’re not going to ignore them.”

Fort Worth public schools use a comprehensive sex education program called Up CLOSE (Choices and Lessons on Sexuality Education). In it, students learn about the value of sexual abstinence, but also about various forms of contraception and their effectiveness. The 13-day program covers topics such as the problems of teen pregnancy, how to keep from getting pregnant, STDs, and healthy relationships. Unlike Worth the Wait, Up CLOSE receives no federal money. Like many comprehensive sex ed programs, it depends on private funding.

In April, Dr. Buzz Pruitt, a professor at Texas A&M University, along with colleague Dr. Pat Goodson, received a two-year, $360,000 grant from the Texas Department of Heath to evaluate the state’s abstinence education contractors.

Pruitt says he agrees with the tenets of abstinence education, but has found that, despite all the money being poured into such programs, there’s no data out there saying abstinence education works. In fact, he said, there isn’t even a clear-cut definition of what abstinence education is.

“When Bush was governor, he informed the public that Texas would be switching to abstinence education — that comprehensive sex ed has failed,” Pruitt said. “I wrote a letter asking what about it has failed and what criteria were used to judge these programs he said failed. I received no response.”

Part of the problem, he said, is that, “what we’re really dealing with here is a subject that is very ideologically driven.” He and Goodson have visited half of the state’s abstinence-only programs, with plans to visit the other half in the near future. They’ve interviewed personnel and conducted focus groups with students, all the while concerned with one central question: Are kids who have been through abstinence education more prone to abstain from sexual activity than kids who have been through a comprehensive program? “If the state is going to spend all this money, do we at least have some proof that abstinence education is working?” he asked.

To date, Pruitt said, there are no results indicating that it is working — and if it is, to what degree. “To my knowledge, there is no data that suggest that these programs work,” he said. “The lines of demarcation are blurry as to whether abstinence-only or comprehensive education works. As far as anything related to the effectiveness of abstinence programs on the delay of sexual involvement by kids, I have seen no reputable study.”

He hopes he can find evidence that it’s working. “These are good people trying to do good things, and so we’d really love to find some evidence somewhere that abstinence education leads to abstinence,” he said. “We’re searching for it, but as we stand right now, there’s no proof. All we have is the eight guidelines that must be met.”

The bottom line, he said, is that “nobody really knows what abstinence means.” Educators’ definitions ranged from simple avoidance of sexual activity “to a few who said abstinence is avoiding sexual thoughts altogether.”

Question: Which of the following is one of the most common STDs today and has been proven to cause cervical cancer?

A. Human papilloma virus (HPV).


C. Chlamydia.

D. Hepatitis B.

How many of you knew the answer was human papilloma virus? How many of you have heard of human papilloma virus? In schools where Worth the Wait is taught, most sixth-graders know the answer by the end of the program.

Worth the Wait is taught to sixth-, seventh-, and eighth-graders as a 10-lesson program in each year. Students learn about STD types and symptoms, reproductive anatomy and physiology, puberty, sexual influences, and — every year — the consequences of premarital sex. In eighth grade, the dreaded slides are shown. Upon completion of the program, students are asked to sign a pledge saying they will abstain from sex until marriage.

The pledge cards are handed out to all the students. They can refuse to sign — the cards are not turned back in. “Some keep it in their wallet as a reminder. Some file it away,” Darnell said. “We’re there to encourage kids to abstain from having sex. This is another way of conveying that message.”

Worth the Wait and Up CLOSE both show pictures of disease effects. As with the test questions, Worth the Wait’s version is more draconian: They show slides rather than color pictures and spend much more time than Up CLOSE’s 10 minutes on this part of the course. The slides depicting herpes on a man’s penis and on a woman’s vagina are stomach-turning. The one of genital warts looks like Braille.

Dr. Patricia Sulak, founder of Worth the Wait, said the slides are meant to educate, not scare. But she admits there’s nothing wrong with a little twinge of caution.

Up CLOSE is a 13-lesson seminar, taught in high school health class, usually to freshmen. The main difference, though, is that Up CLOSE talks about contraception, particularly condoms, whereas the only time Worth the Wait brings up condoms is to talk about their failure.

“Of the 13 lessons in our program, 12 of them either directly or indirectly encourage teens to consider abstinence,” Rodriguez said. “Only one of them, the lesson on risk reduction, focuses on contraceptive methods. What we say to young people about condoms is the same thing the Centers for Disease Control says: When they’re used correctly, latex condoms are highly effective in preventing pregnancy and STD’s.”

Rodriguez said Worth the Wait, in essence, assumes kids are ignorant. “Most young people are well aware of the risks of pregnancy, and nobody wants to get an STD,” he said. “The bigger question is why they go ahead and have sex anyway. We try to help students think critically about those decisions.”

Sulak said she can appreciate the comprehensive mentality. After all, her training is not in abstinence education, but in contraceptive research. Before she created Worth the Wait, Sulak, an obstetrician and gynecologist, had distinguished herself as one of the nation’s foremost experts in contraceptive research, primarily the birth control pill.

“I used to think all we had to do was dump condoms in the schools and be done with it,” she said. “But after reviewing the data, I’ve had to do a 180 on kids and sex. Now, I’m not going to tell kids how to put a condom on a banana. So they learn the right way to put on a condom and then, bam! They have HPV. There’s a mixed message in telling kids how to put on a condom and then telling them abstinence until marriage.”

Like DARE, the anti-drug program that has lost funding and popularity in many quarters in recent years for its lack of success in changing children’s behavior, Worth the Wait is essentially a just-say-no movement. The difference, Darnell said, is that Worth the Wait is not designed to be the only source children have for learning about sex. “It’s not like we’re withholding information,” she said.

“Abstinence-only programs may not intend to be kids’ only source of information, Rodriguez responded, “but oftentimes it ends up that way.”

Darnell and others believe it is hypocritical to tell children, on one hand, that teen sex should be avoided, but on the other hand, what to do to make it safer. She makes an analogy to drinking — one that might bother, say, Mothers Against Drunk Driving.

“You can’t go into a school and say, ‘We want you to abstain, but here are some condoms if you don’t.’ That would be like saying ‘I don’t want you to drink, but if you do, here’s $20 to take a cab home.’ We give kids the tools to remain healthy and help them acknowledge why an abstinence lifestyle is going to help them.”

That’s a big assumption, Rodriguez said, considering many children in the Fort Worth Independent School Districts are raised by or only know one parent.

While Pruitt and his colleagues were unable to find data indicating whether the program works, Darnell said Worth the Wait tracks what happens with its students.

From 1999 to 2001, the percentage of eighth-graders who admitted being sexually active dropped from 24 to 22; among seventh-graders it dropped from 16 to 12 percent. That, of course, means plenty of Worth the Wait students were still out there having sex, protected or unprotected.

Like Worth the Wait, Up CLOSE tests kids before and after the curriculum and concludes that most of the kids learned something — although Up CLOSE’s tests are decidedly easier. (Example: A person can get infected with an STD during oral sex. Answer true or false.)

Up CLOSE also has its own favorable statistics. Rodriguez said evaluations of the program’s graduates by an independent research group found that many of those who were already sexually active reported they probably would quit having sex. And 81 percent of students who had received other sexuality education said that Up CLOSE was the better program.

All of which, of course, won’t buy a single diaper for a teenage mom’s new baby.

At 7:30 one September morning, an upstairs room in the old Salado Civic Center was packed. Forty-two doctors and nurses from across the state gathered in the brick building in Central Texas to learn everything they’d ever wanted to know about sexually transmitted diseases and the perils of underage sex. Their credentials were varied, but their goal was shared: Teach the kids not to have sex until they’re married.

This was a Worth the Wait seminar, and by day’s end, the attendees would not only be certified to go out into their communities and teach middle school students about various STD’s, but would be prepared to answer questions that only an adolescent mind could conjure.

They were there to learn from other professionals, all under the watchful eye of Sulak, the keynote speaker.

In Sulak’s first seminar, on herpes and human papilloma virus, she delivered her medical message with a comedian’s touch. A small woman, she spoke as much with her hands and facial expressions as she did with her booming voice — and she came out cracking jokes.

“Herpes is kinda sneaky,” she told the room. She showed slides of what the various viruses look like, accompanied by flippant comments. One showed a man whose penis was overwhelmed with herpes. The entire shaft and head were covered with pus-filled sores, looking tremendously painful. “Hey, I probably got this from Clorox or something,” she said, imitating what the guy in the slide might have said. “You’ll find that men don’t come in for treatment unless they’re dying.” Her voice inflections were perfect. The entire room, seemingly forgetting what they were looking at for a moment, let their guard down and laughed. Sulak followed with another icebreaker. “Having just sent my oldest son to college, I sat him down and gave him the facts,” she said. “Of course, our talk was probably very different than [that of] most parents.”

That, in essence, is Sulak’s philosophy: Just the facts. However, “the facts” about topics like homosexuality, alternative lifestyles, abortion, birth control, and masturbation aren’t covered in the program’s curriculum — because federal guidelines won’t permit. Yet the facts about what could happen to you if you don’t abstain, she said, will educate the children to make the “right choice.”

“Historically, people thought abstinence programs pushed morals and religion on the kids,” she said. “That may or may not have been true. On the other side was this comprehensive sex ed. Worth the Wait gives kids reasons not to have sex for their health and well being, and we do it by using medical statistics and facts. We tell the kids that if they are going to be sexually active, recognize the concerns. But most importantly, consult a healthcare professional.”

Darnell reiterated this sentiment. And why doesn’t the program teach other preventative measures? Because that should be done in the home. “Worth the Wait is there to provide medical, legal, and socioeconomic reasons which teach that waiting is the healthy choice for kids,” she said. “The moral and ethical and value judgments need to come from the parents.”

Dr. Busti of the Texas Tech Center in Dallas is one of Worth the Wait’s local promoters, preaching the program’s merits to Fort Worth and Dallas school officials. Before long, he predicted, Worth the Wait will have a North Texas presence. Too many children, he believes, are under the assumption that protected sex is safe sex.

“I can foresee Fort Worth and Dallas Independent Schools adopting this program because, if given the facts, they’ll realize that children have been misled for too long,” he said. “I’m not doing this for financial gain. I’m doing this because I believe in the message.”

Lisa Phillips taught Up CLOSE classes in Fort Worth schools during the last school year and this year’s fall semester. She’s a cultural anthropologist, not a doctor, but she trained for the program for over a month, shadowing experienced Up CLOSE educators, co-teaching and studying the curriculum.

Phillips said that the students she taught exceeded her expectations. They were not only eager to learn, but they absorbed the information and asked intelligent questions. “Students wrote reflections at the end — letters to themselves — and the letters always showed how much these kids really think about these issues. It seemed to me that the kids almost get attached to this program because they’ve never had anyone raise these issues with them before. They were very mature about it.”

For Phillips, the choice to get into comprehensive education rather than abstinence education was clear. “I understand that teenagers do have sex,” she said. “As a program, Up CLOSE stresses making healthy choices, and not that abstinence is the only option, although abstinence is stressed. I firmly believe in the choice of abstinence, but having knowledge of how to protect yourself is empowering as well. If somebody has left high school and they have no idea about the resources that exist in the community — if they don’t know about condoms or if they have concerns about their own sexuality — if they’ve never been exposed to all this, they’ll have a harder time in life and be at a greater risk. All these risks are out there, and the students need to be aware of them.”

Phillips said she could never in good faith subscribe to the notion of abstinence-only education. “Abstinence has merit, but I don’t think it’s realistic for what’s going on in the schools,” she said. “I couldn’t go to abstinence because I understand where these teens are coming from.”

Norma Cooney teaches Worth the Wait in Central Texas. Her enthusiasm for the program echoes that of Phillips for hers. “This program is really incredible,” said the fourth-year medical student. “It’s all about the facts, and that’s what I tell the kids. If they want to act like grownups, they’ve got to think like grownups. If they’re not ready to discuss with their partner the consequences of their actions, then they’re not mature enough yet.”

“I tell the kids that Pretty Woman is one of my favorite movies, but Hollywood won’t show you Julia Roberts going to the doctor to get her genital warts burned off. Or Richard Gere for that matter. My goal is to get them to wait. In order to have no regrets, you have to make the right decisions, and teen sex won’t help them achieve their goals.”

Cooney says she does discuss condoms and other forms of contraception with her students, she just doesn’t promote them. “I understand that some of them are still going to have sex,” she said. “So they should know what’s out there.”

“Because I’m younger, they relate to me,” she said. “I spent 45 minutes in Caldwell, Texas, with four girls after class one time. We talked about STD’s and peer pressure. Some of them had questions about how to respond to guys trying to encourage them to have sex, and we had a nice dialogue.”

Like so much of the discussion of competing sex education philosophies, Cooney’s enthusiasm seems fraught with irony. In a program that hammers home only one choice, Cooney said she encourages her students to think for themselves. “You can’t walk in the middle of the road,” she said. “You’ve got to take a stand.”

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