Virginity Pledges as a Preventative Measures for Preventing Unwanted Sexual, Behavioral, and Biological Outcomes: A Systematic Review of Adolescents and Young Adults in the U.S. Thesis Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the College of Public Health of The Ohio State University By Nicole J. Murphy College of Public Health The Ohio State University Thesis Committee Maria Gallo, PhD, M.S., Advisor Abigail Norris Turner, PhD Copyrighted by Nicole Murphy 2018 Abstract A common approach of abstinence promotion is the virginity pledge, a promise to abstain from sexual intercourse. A systematic review was performed in order to assess existing literature pertaining to virginity pledges and their effectiveness among the American adolescent and young adult population. Twelve publications of cohort and cross-sectional designs met the criteria and were included in the qualitative analysis. While most studies support a statistically significant difference in sexual initiation or age of sexual debut between pledgers and non-pledgers, the pledgers that did participate in sexual relations had similar risk-taking behaviors to those that did not pledge. Religious commitment, high levels of morality, and highly supportive environments were often highly correlated to making a virginity pledge. Keywords: Virginity pledge, abstinence pledge, abstinence-only, sexual initiation, oral sex, teenage sex, contraceptive use iii Acknowledgments I would like to sincerely thank Dr. Maria Gallo and Dr. Abigail Norris-Turner for their ultimate patience and guidance. iv Vita 2010……………………….……..….. Winnacunnet High School, Hampton, NH 2014 …………………………………. B.S. Public Health, University of Massachusetts, Amherst, MA Fall 2014–Fall 2017…......................... Student Research Assistant, The Ohio State University, Columbus, OH Presentations Murphy, N., Gouin, S., Desai, D. (April 2014). Improving the Treatment of Malaria in Sub-Saharan African Children by Increasing Education of Patent Medicine Vendors. University of Massachusetts, Amherst Undergraduate Research Conference, Amherst, MA. Fields of Study: Public Health, Epidemiology, and Psychology v Table of Contents ............................................................................................................................................... Abstract .............................................................................................................................. iii Acknowledgments .............................................................................................................. iv Vita ...................................................................................................................................... v List of Tables .................................................................................................................... vii List of Figures .................................................................................................................. viii Chapter 1. Introduction ....................................................................................................... 1 Chapter 2. Methods ............................................................................................................ 4 Chapter 3. Results .............................................................................................................. 7 Chapter 4. Discussion ...................................................................................................... 40 Bibliography ..................................................................................................................... 46 Appendix A. Search Strategy ............................................................................................ 50 Appendix B. Risk of Bias Assessment ............................................................................. 51 Appendix C. Evidence Table of included studies ............................................................. 54 vi List of Tables Table 1 Study Summary……………...…………………….......………………………...11 Table 2 Virginity Pledge and Sexual Intercourse ............................................................. 25 Table 3 Virginity Pledge and Sexual Partners…………………………………………...28 Table 4 Virginity Pledge and Non-Coital Sexual Behavior ...........……………………...32 Table 5 Virginity Pledge and Out-of-Wedlock Pregnancy ……………………………...39 vii List of Figures Figure 1 PRISMA Flow Diagram ....................................................................................... 8 viii Chapter 1. Introduction The United States is unique in that a virginity pledge is a common approach to delay sexual debut (Landor & Simons, 2014). The idea of the virginity pledge program was formally introduced in 1993 in a Southern Baptist Church (Bearman & Bruckner, 2001; Rosenbaum, 2006). This idea of a declaration of one’s abstinence from sexual intercourse until marriage spread across the country, and similar programs were created across America. Many pledge programs have been created since; True Love Waits and The Silver Ring Thing being two of the most popular. In fact, True Love Waits claims to have had around 2.5 million pledgers since its inception in 1993 (“Baptist Press”, 2005). These programs became increasingly popular in religious Christian settings, particularly Southern Baptist or Evangelical denominations (Rosenbaum, 2006). Support for virginity pledges was often tangled with support for abstinence-only education, and religion and sexual education became seemingly intertwined. These virginity pledge programs were designed to highlight the importance of purity and dedication to abstinence. Various organizations utilize information regarding virginity pledges to assess how effective an abstinence only sex-education program is. If many of the participants take a pledge of virginity, the program would be considered successful (Rosenbaum, 2009). Success and effectiveness of pledge programs as a deterrent to intercourse can be evaluated by assessing sexual behavior and health outcomes among pledgers versus non-pledgers. In the United States, adolescents and young adults 15 to 24 years of age contribute about 9.7 million new cases of reportable STIs every year, nearly 1 half of the total infections reported annually (HHS, CDC, & NCHHSTP, 2016). This is especially concerning, as this age group only comprises a quarter of the sexually active population (Boonstra, 2014; Wind, 2016). While teenage pregnancy rates have declined over the past decade, the United States still has one of the highest incidences of teen pregnancy among all developed countries (Sedgh, Finer, Bankole, Eilers, & Singh, 2015). Around 6% of U.S. teenage females become pregnant every year (Boonstra, 2014). 1.1. The Virginity Pledge The virginity pledge, also commonly known as an abstinence pledge or a purity pledge, is a promise to abstain from sexual intercourse (Bersamin, Walker, Waiters, Fisher, & Grube, 2005). When someone traditionally thinks of a virginity pledge, they often imagine a public declaration of no sex until marriage, such as in a church group (Rostosky, Regnerus, & Wright, 2003). The idea expands far beyond that. This particular public declaration is considered a “formal pledge of abstinence”; an individual can pledge until marriage or until he or she reaches an older age when they feel more mature. A private pledge differs, as the individual does not necessarily have to explicitly express their abstinence on a public level, but instead makes a personal, private commitment to remain a virgin (Bersamin et al., 2005). A person taking a pledge can consider themselves a private pledger, a public pledger, or both. Often, those who pledge publicly have also made an internal commitment to vow their abstinence from sexual intercourse. In addition, a pledger can be considered an inconsistent pledger if they reported different pledge status, or more specifically retracted their pledge, at different points in 2 longitudinal data collection (Hannah Brückner & Bearman, 2005a; Rosenbaum, 2006). Studies found that this is common, as many pledgers retract their pledge status in later Waves of data collection (Rosenbaum, 2006). By distinguishing inconsistent pledgers from consistent pledgers, this study aimed to capture how likely it is for pledgers to adhere to their word and abstain from sex (Hannah Brückner & Bearman, 2005a). Adding to the complexity of understanding the different levels of commitment, a new Wave of virginity pledgers consider themselves “born again virgins.” These were those who have already had sexual intercourse, but decide to further abstain from sexual intercourse until they were older or in a committed, long-term relationship (Rosenbaum, 2006, 2009). 1.3. Objective The primary objective of this systematic review was to get a better understanding of the virginity pledge, especially its association with sexual behavior and health. This review also seeks to uncover bias and gaps in the literature. By collectively evaluating existing research, a more thorough understanding can be had of the effectiveness of the virginity pledge in delaying or preventing sexual intercourse, negative biological, and behavioral sexual health outcomes. 3 Chapter 2. Methods 2.1. Search and Data Collection A systematic review of literature pertaining to virginity pledges was performed according to the widely accepted guidelines from PRISMA (Moher et al., 2015). The search strategy was created according to Cochrane in consultation