Amy T. Schalet

Invited Commentary: Broadening the Evidence for Adolescent Sexual and Reproductive Health and Education in the United States

Scientific research has made major contributions to adolescent health by providing insights into factors that influence it and by defining ways to improve it. However, US adolescent sexual and reproductive health policies—particularly sexuality health education policies and programs—have not benefited from the full scope of scientific understanding. From 1998 to 2009, federal funding for sexuality education focused almost exclusively on ineffective and scientifically inaccurate abstinence-only-until-marriage (AOUM) programs. Since 2010, the largest source of federal funding for sexual health education has been the “tier 1” funding of the Office of Adolescent Health’s Teen Pregnancy Prevention Initiative. To be eligible for such funds, public and private entities must choose from a list of 35 programs that have been designated as “evidence-based” interventions (EBIs), determined based on their effectiveness at preventing teen pregnancies, reducing sexually transmitted infections, or reducing rates of sexual risk behaviors (i.e., sexual activity, contraceptive use, or number of partners). Although the transition from primarily AOUM to EBI is important progress, this definition of evidence is narrow and ignores factors known to play key roles in adolescent sexual and reproductive health. Important bodies of evidence are not treated as part of the essential evidence base, including research on lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth; gender; and economic inequalities and health. These bodies of evidence underscore the need for sexual health education to approach adolescent sexuality holistically, to be inclusive of all youth, and to address and mitigate the impact of structural inequities. We provide recommendations to improve US sexual health education and to strengthen the translation of science into programs and policy.

Sexual Subjectivity Revisited: The Significance of Relationships in Dutch and American Girls’ Experiences of Sexuality

In-depth interviews with white middle-class Dutch and American girls demonstrate two important differences in the cultural beliefs and processes that shape their negotiation of heterosexuality. First, Dutch girls are able to integrate their sexual selves into their relationships with their parents, while reconciling sexuality with daughterhood is difficult for the American girls. Second, American girls face adult and peer cultures skeptical about whether teenagers can sustain the feelings and relationships that legitimate sexual activity, while Dutch girls are assumed to be able to fall in love and form steady sexual relationships. This research suggests important differences in institutionalized forms of heterosexuality. It also suggests the significance of girls’ relationships, and the cultural perceptions and processes that shape those relationships, for their sexual subjectivity.

“I Wouldn’t Be this Firm if I Didn’t Care”: Preventive Clinical Counseling for Reproductive Health

OBJECTIVE This qualitative study of health care clinicians serving women at heightened risk of sexually transmitted infections and unintended pregnancy was undertaken to explore concepts underlying reproductive health counseling messages in clinical encounters. METHODS In-depth interviews were conducted with 31 clinicians, including physicians and advanced practice nurses serving primarily low-income patients in high-risk communities throughout the U.S. RESULTS Most of the clinicians describe their influence on patients and protective behaviors as derived from medical authority and the presentation of information. The use of a parental style of authority, particularly for young or vulnerable patients, and emotional appeals to evoke negative emotions, such as fear, were also used to motivate protective behaviors. Many clinicians highlighted the importance of empathy, and understanding the cultural and social context of health behaviors. A few clinicians described innovative efforts to empower women to protect themselves and exert more control in relationships. CONCLUSION Some of the reproductive health counseling approaches described by clinicians are not consistent with leading health behavior change theories or patient-centered counseling. PRACTICAL IMPLICATIONS To improve counseling, these messages and concepts need to be evaluated for effectiveness, and possibly used to inform the development of novel theories for use in reproductive health counseling.

Sex for Life: From Virginity to Viagra, How Sexuality Changes Throughout Our Lives

These results are not groundbreaking, but innovation comes in the design and scope of the analysis. Burstein’s discussion of public preferences toward specific policies is highly relevant to contemporary public-opinion research. Here, the book intersects with theoretical quandaries in the burgeoning area of cognitive sociology: 1) evidence that people do not have opinions about specific policies, because they are rarely interested in most of the policy proposals being considered in the national government; and 2) evidence that people’s belief systems and political identities do not consistently map onto their preferences on specific issues. Nonetheless, many scholars assume that democracy requires a correspondence between government action and citizens’ preferences, including critical scholars who point to the deleterious influence of powerful interests when this ideal is not realized. Burstein posits that this assumption has led to erroneous zero-sum logic in political sociology in which absence of a strong correspondence between government policy and public opinion is evidence that advocacy/interest groups hold the actual power. Yet, his analysis finds that advocacy has little to no influence on policy formation. Again, the approach is innovative, because it links data on various types of advocacy and the random sample of 60 policy proposals. The two main findings—that advocacy events tied to specific policies 1) are relatively rare and 2) have little to no influence on policy—are surprising and interesting. Burstein then analyzes congressional hearings to examine the types of information presented to policymakers and the influence information has on the policyformation process. Here, the influence of information is substantial but is uneven across the numerous types. For example, information about the effectiveness of proposed policies is an especially strong predictor of enactment, while the presentation of empirical evidence actually produces negative results. Burstein’s approach is innovative and exciting, offering new ways to empirically examine policy change, advocacy, and information flows to policymakers. Despite these contributions to future research, Burstein’s study overlooks the influences of symbolic and material resources in the policy formation process. The argument among many class-dominance or power elite scholars rests on the insidious influence of money and social capital on policymakers. The ‘‘political dark matter’’ of power does not necessarily translate into visible advocacy and information flows to policymakers, exactly because access and resources can circumvent these legitimate channels. For example, the structural power of the financial sector in the United States makes public advocacy unnecessary and even damaging. Yet its interests are protected, because the financial sector connects to large segments of the national economy. Future research must creatively search for echoes of power resources in observable data. Equally important, social scientists cannot evoke the weak association between public opinion and government policy as evidence of elite influence.