Defining Harm Reduction and Abstinence
The Pros and Cons of Two Public Health Approaches
Many public health concerns (think: drug and alcohol use, smoking, sexual activity) use either a harm reduction or an abstinence strategy to improve health outcomes. In the U.S., there is often a partisan divide on which strategy is preferred. Progressives tend to prefer harm reduction, while conservatives often favor abstinence. This impacts what kids get taught in school, what programs get government funding, and how people seeking services are treated.
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Many people engage in some form of risky behavior
People engage in all sorts of activities that can be dangerous to their health and well-being, especially when done in excess versus moderation. Some people drink. Others may smoke. Some people have unprotected sex (sometimes with multiple partners). Still, others use drugs. People can also engage in more than one risky behavior at the same time (such as excessive drinking prior to unprotected sex, etc.).
Harm reduction strategies acknowledge that some may not be ready or able to completely stop engaging in the risky behavior. Therefore, harm reduction tries to minimize the risk and keep people as safe as possible. Alternatively, abstinence strategies are based on the premise that the only way to keep people safe is to stop engaging in the risky behavior completely. Or never engage in the activity in the first place. Both approaches have the same goal: to prevent people from experiencing harm. And there is no one-size-fits-all answer, especially when it comes to addiction. On an individual level, there are many people addicted to certain behaviors/activities for whom abstinence is the only solution. However, the evidence suggests that harm reduction is a more effective overall approach and is less stigmatizing.
What is abstinence?
Abstinence is about stopping people from engaging in potentially harmful activities and behaviors entirely. Prohibition, zero-tolerance, and “just say no” programs are forms of abstinence strategies. They take an all-or-nothing approach. Most abstinence programs are not neutral about the behavior or activity. Instead, they often pass moral judgment against the behavior. For example, abstinence programs may think people who use drugs are weak or that pre-marital sex is a sin.
Examples of abstinence
Alcoholics Anonymous (AA) is a good example of an abstinence approach. People who go through AA’s 12-step program must fully abstain from alcohol and commit to total sobriety. Other examples include Narcotics Anonymous, virginity pledges in lieu of sex education, quitting smoking cold turkey without the aid of nicotine patches or e-cigarettes, or lockdowns and isolating at home to prevent the spread of disease during a global pandemic.
Critiques of abstinence
Critics of abstinence believe that it can be hard for some people to completely abstain from addictive and/or risky behaviors. Therefore, they believe that abstinence fails to reach those who are not ready or can’t completely abstain from the behavior. These people need to be taught moderation and be provided with the tools and information to be as safe as possible.
Further, treatment programs that require people to completely abstain from an activity or behavior to receive services are unachievable for many people. But if they relapse, they may be kicked out of the program. This means that many people in need of support don’t get the services they need. And, this doesn’t just occur with addiction treatment. Consider street-involved youth who sell sex in exchange for food or housing. What are they supposed to do if they enter a program that requires abstinence from sex work, but that doesn’t help them gain other forms of income?
All-or-nothing approaches that moralize and shame people who engage in the activity don’t work either. In fact, these approaches can push people to hide their behavior and make them less likely to adhere to risk mitigation advice, making it even more dangerous.
What is harm reduction?
Harm reduction strategies guide people to be as safe as possible when engaging in potentially risky behavior. The idea is to mitigate the risk of harm. A harm reduction approach doesn’t mean you condone the behavior or activity. But by being neutral about it, not passing judgment, and not stigmatizing people, harm reduction can limit or prevent negative consequences resulting from the behavior or activity.
Examples of harm reduction
Syringe Services Programs (SSPs) (previously known as needle exchange programs) for people who use drugs are a good example of a harm reduction approach. These programs allow people who inject drugs to obtain clean syringes. Studies show that this reduces the spread of blood-borne infectious diseases like HIV and hepatitis C. And because people don’t feel stigmatized, they may be more open to receiving information about addiction treatment services.
Other examples of harm reduction include distributing condoms to sex workers, teaching sex education in schools, using nicotine aids to gradually stop smoking, encouraging sugar moderation for diabetics, and wearing masks and social distancing to prevent the spread of Covid.
Critiques of harm reduction
Critics of harm reduction believe that it increases undesirable behavior because people feel they can do it safely and limit the risk. Others feel that even talking about how to safely engage in a potentially harmful activity promotes that activity. For example, that providing clean needles leads people to use drugs, or providing condoms to adolescents encourages them to have sex.
There can also be unintended consequences to insufficiently funded harm reduction programs. For instance, a syringe services program that doesn’t include spaces where people can use safely in the presence of a medical professional who can respond in the event of an overdose and dispose of syringes (aka safe consumption spaces) can put an undue burden on the community to support people who use drugs, particularly those who are unhoused. The community often becomes responsible for things like overdose prevention and syringe clean-up. We need fully-funded harm reduction programs and legalized safe consumption spaces that support people who use drugs and reduce the burden on communities.
Abstinence versus harm reduction when applied to adolescents
Adolescence is a period of immense growth, learning, and exploration. Risk-taking and experimentation are key elements of adolescent development. As part of this, young people often engage in behaviors that could have harmful consequences. For example, what do you do about the fact that many young people experiment with drinking? Some people decide to give young people the tools and knowledge to be as safe as possible, even while discouraging the behavior. Others have a zero-tolerance policy which could have unintended consequences, such as pushing young people to drink and drive because they are afraid to call for help.
Sex education vs abstinence-only education
One area of heated debate on this question relates to sex education in schools. Comprehensive sexuality education (CSE) is a form of harm reduction. CSE teaches people to make well-informed and healthy choices in relationships and their sexual lives using medically accurate and age-appropriate information that addresses gender norms, sexuality, human rights, and public health. Learn more at the Pop Council.
Abstinence-only education includes virginity pledges demanding that young people avoid pre-marital sex and refrains from providing students with medically accurate information. This approach can reinforce harmful gender stereotypes and undermine public health programs. And the evidence shows it does not delay first sexual experience, avoid unintended pregnancies, or prevent sexually transmitted infections. In fact, in places where abstinence-only education is taught, it has been found to increase teen pregnancy rates.
Abstinence and harm reduction as a political issue
Like many things in our increasingly polarized society, how to approach public health concerns has become more and more partisan. From drug use to sex education, people on the left tend to promote harm reduction strategies while people on the right are more likely to promote abstinence. The media and politicians often pit moral arguments for abstinence against rigorous scientific evidence on the efficacy of harm reduction approaches.
This has real-world applications when, for the first time ever, the U.S. is on a path to top 100,000 overdose deaths in a single 12-month period, and there were over 93,000 preventable overdose deaths in 2020. Because of politics, states like West Virginia, which consistently ranks number one in annual drug overdose rates, have seen harm reduction programs scaled back or even banned. Even as the federal government seeks a historic 435% funding increase for drug use harm reduction services.
Similarly, we are experiencing increasing threats to abortion access, and restrictions on the right to terminate an unwanted pregnancy are being implemented in many states across the country. As a result, young people need access to comprehensive sexuality education that teaches them how to avoid getting pregnant more than ever. Yet, conservative states in the U.S. spend millions of dollars on abstinence-only programs and actively pressure school boards to limit sex education.
In most cases, Everyday Activism Network supports harm reduction approaches. Harm reduction is rooted in social justice by ensuring that nobody is excluded from social services or treatment programs and that all people have access to non-judgmental, accurate, and age-appropriate information to help them make safer decisions.
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Originally published November 9, 2021.
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