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Many adults do not like to think about youth engaging in sexual activity, but the reality is that the majority of young people have had sex before they graduate from high school. Exploring one’s sexuality is a normal part of adolescent development, but risks also accompany sexual behavior. Although people in American society have strong and divergent feelings about adolescents and sex, most will agree that research can and should guide efforts to help young people to stay safe and healthy as they navigate their journeys into adulthood.
Sexually transmitted infections (also called sexually transmitted diseases) are one of the most commonly diagnosed medical conditions in the United States. More than 110 million people in the United States live with such an infection. After years of decline, sexually transmitted infections are now on the rise, with young persons aged 15 to 24 disproportionately affected. The good news is that many of these infections are curable, and all are treatable. However, if left undiagnosed, they can lead to serious conditions including infertility and cancer. In addition to their health toll, sexually transmitted infections also carry a financial burden, with $16 billion spent annually on treatment. Given such high costs, it is important for researchers to examine efforts to prevent sexually transmitted infections to ensure that they are implemented as effectively as possible. One approach questioned by research is the use of graphic pictures meant to scare young people about the suffering and disfiguration having a sexually transmitted infection might entail.
Sexually Transmitted Infections and Youth Education
The majority of young people in the United States receive school-based sexuality education, including information about sexually transmitted infections. Older adolescents may also get such instruction in collegiate settings, such as classroom-based health courses or at forums held in residence halls or fraternities. Often, instructors display graphic PowerPoint slides, initially developed for use in medical training, portraying real but atypical sexually transmitted infections that have led to visually disturbing symptoms such as severe genital warts.
Many sexuality educators have strong feelings about integrating such images into their programs. Educators who use graphic pictures feel that young people should be aware of potential consequences of unprotected sex, or of sex in general. They also want young people to be prepared to recognize sexually transmitted infection symptoms. But on the other hand, educators who do not use graphic images find them misguided, in that most sexually transmitted infections have no visible symptoms at all. What is more, these reluctant educators worry that graphic images may lead young people to think that sexually transmitted infections are rare, when instead they occur frequently in less visible forms.
Public health educators are expected to use evidence-based practices, but surprisingly, the impact of sexually transmitted infection graphic images on young people’s sexual health has been unknown until recently. While understanding the impact of these pictures may seem inconsequential, most people would never feel comfortable taking a medication if its efficacy had not been tested. The same standard should be used for public health interventions.
Pros and Cons of Instilling Fear about Health Issues
Scare tactics, also called fear appeals, are intended to make people think about the worst-case scenario that can follow from a problematic health behavior. The intention is to cause mental distress in order to prompt healthy behaviors that will minimize the health threat. Fear appeals are not new in public health; they have a longstanding place in health communication campaigns – such as the infamous, decades-old “this is your brain on drugs” public service announcements.
Research reveals mixed effects from fear-inducing strategies. A well-known large-scale study found that fear appeals can be useful at changing attitudes and behaviors when people feel susceptible to the health problem and confident in their ability to take action to prevent it. Yet for people who don’t meet these two conditions, fear appeals can backfire – indeed, such tactics can induce even more risk-taking behavior. Although this research is compelling, little attention has been paid to the ethical implications and potential unintended consequences of fear appeals.
A key issue is that many fear appeals portray possible but rare and unlikely maladies in ways that may mislead. People with sexually transmitted infections are more likely than not to exhibit no symptoms at all. Because educators are supposed to impart factual information, fear appeals pointing to atypical symptoms could be seen as deceptive. Fear appeals also put the full responsibility for decision-making on individuals without recognizing or working to change root causes, the underlying reasons why many people take health risks. This can be stigmatizing to already marginalized groups in society.
In 2016 I conducted an experiment with young people enrolled in a large public Midwestern university. Participants watched one of two randomly assigned web-based sexual health programs, one with graphic sexually transmitted infection images and the other without such images but otherwise identical. I then compared the two groups of participants to assess their knowledge, beliefs, and behavioral intentions related to sexually transmitted infections. Overall outcomes were the same, but when I asked participants to provide feedback, more than a quarter of those that saw the graphic images expressed disgust and dismay. These results suggest that presenting such images may prompt stigma – without having any health benefit.
Because sexuality education is an important tool to help prevent sexually transmitted infections among young people, it is vital for programs to be crafted with great care. Given the mixed evidence, the use of graphic sexually transmitted infection images should be reevaluated. Parents, policymakers, and community members should learn more about what kind of sexuality education is being taught in local schools, and if scare tactics are used, assess whether they may be more harmful than helpful.