Sexuality Education as Part of a Comprehensive Health Education Program in K to 12 Schools

Abstract
The American Public Health Association has asserted that all young people need the knowledge, attitudes, and skills necessary to avoid HIV, other sexually transmitted infections (STIs), and unintended pregnancy so that they can become sexually healthy adults. Rates of teenage pregnancy and STIs in the United States remain alarmingly high, and disparities persist by gender and race/ethnicity. A large body of evidence supports the implementation of comprehensive sexuality education as one solution to this problem. Evidence suggests that abstinence-only approaches do not lead to behavioral changes and result in critical health information being inappropriately withheld. Parents/guardians and families are the first and most influential sexuality educators of their children; yet, many young people report that they need additional guidance, and parents, public health professionals, and medical and social service providers support the implementation of comprehensive programs in schools. APHA calls on federal, state, and local governments and the nation’s K–12 schools, in concert with families, community groups, and health care professionals, to implement effective sexuality education programs that are developmentally and culturally appropriate; foster equality and respect; support the elimination of health disparities, sexual assault, and intimate partner violence; and are based on sound science and proven principles of instruction.

Relationship to Existing APHA Policy Statements
•    APHA Policy Statement 200610: Abstinence and U.S. Abstinence Only Education Policies: Ethical and Human Rights Concerns
•    APHA Policy Statement 2005-10: Sexuality Education As Part Of A Comprehensive Health Education Program in K to 12 Schools
•    APHA Policy Statement 9207: Underscoring the Continued Need for a Sustained National HIV Prevention and Public Education Initiative
•    APHA Policy Statement 200314: Support for Sexual and Reproductive Health and Rights in the United States and Abroad
•    APHA Policy Statement 2004-09: Promoting Public Health and Education Goals through Coordinated School Health Programs

Problem Statement
Scientific issues: Young people in the United States are at persistent risk for HIV, other sexually transmitted infections (STIs), unintended pregnancy, and intimate partner violence (IPV). Young women and youth from racial and ethnic minority backgrounds are at particular risk, as indicated by the data below. Eliminating such health disparities is a priority for APHA.

In 2010, an estimated 12,200 young people 13–24 years of age were newly infected with HIV (representing 25.7% of overall new HIV infections during that year). Black and Hispanic adolescents have been disproportionately affected by the HIV/AIDS epidemic. In 2010, Blacks accounted for 57.4% of new HIV infections among 13- to 24-year-olds, and Hispanics accounted for 19.6% of such infections. Young men who have sex with men are also disproportionately affected, with 72.1% of new infections in this age group attributable to male-to-male sexual contact.[1]

Adolescents (10- to 19-year-olds) and young adults (20- to 24-year-olds) are at higher risk for acquiring STIs than members of older age groups. Half of the 20 million new cases of STIs each year are diagnosed in 15- to 24-year-olds, even though this age group represents only 25% of the sexually active population.[2] There are also differences in STI rates according to gender and race/ethnicity. For example, in 2012, the gonorrhea rate among young Black women 15–19 years of age was 2,032.2 per 100,000, 15 times greater than the rate among White women in the same age group (134.5). Young American Indian/Alaska Native women and Native Hawaiian/Pacific Islander women also experienced elevated gonorrhea rates relative to their White counterparts in 2012 (501.9 and 279.5 per 100,000, respectively). Similarly, the gonorrhea rate among young Black men 15–19 years old (1,012.3 per 100,000) was 26 times higher than the rate among young White men (38.7 per 100,000) in 2012, and American Indian/Alaska Native men (155.9) and Native Hawaiian/Pacific Islander men (139.3) exhibited higher rates as well. For women, the second highest age-specific rates of reported chlamydia in 2012 were among 15- to 19-year-olds (3,291.5 per 100,000), whereas the rate among young men in the same age group was just 774.8 per 100,000. There were also racial/ethnic variations in rates within this age group (per 100,000), from 1,458.3 among Whites and 7,719.1 among Blacks to 2,013.6 among Hispanics, 548.9 among Asians, 3,219.8 among Native Hawaiians/Pacific Islanders, and 4,235.1 among American Indians/Alaska Natives.[3]

Recent years have seen a downward trend in rates of teenage pregnancies, births, and abortions. In 2010, the pregnancy rate among young women 15–19 years of age was 57.4 per 1,000, while the birth rate was 34.4 per 1,000 and the abortion rate was 14.7 per 1,000.[4] These data represent a 51% decline in the teen pregnancy rate since the rate reached its peak in 1990; however, racial and ethnic disparities persist. Pregnancy rates were greater among Black (99.5) and Hispanic (83.5) youth than among White youth (37.8) in 2010. There were also differences in birth rates (with rates of 51.4 among Black youth, 55.6 among Hispanic youth, and 23.6 among White youth) and abortion rates (34.5 among Black youth, 15.3 among Hispanic youth, and 8.5 among White youth).[4] Furthermore, although nationally representative data are not available, a growing body of literature demonstrates that lesbian, gay, and bisexual youth are at higher risk of becoming pregnant or causing a pregnancy than their heterosexual peers, contrary to popular belief.[5]

According to the 2013 National Youth Risk Behavior Survey, 46.8% of students in grades 9–12 reported ever having sexual intercourse, with variations by race/ethnicity (60.6% among Blacks, 49.2% among Hispanics, and 43.7% among Whites). In addition, 15.0% of students reported having had four or more sexual partners in their lifetime, again with variations according to race/ethnicity (26.1% among Blacks, 13.4% among Hispanics, and 13.3% among Whites).[6]

Young people also experience intimate partner violence at alarming rates. In 2013, 10.3% of high school students reported experiencing physical violence committed by a romantic partner. Forced sex was reported by 10.5% of female high school students and 4.2% of male students.[6] Data from the 2010 National Intimate Partner and Sexual Violence Survey showed that, among women who had experienced rape, physical violence, or stalking by a romantic partner, 22.4% first experienced some form of IPV between the ages of 11 and 17 years and 47.1% between the ages of 18 and 24 years.[7]

A number of factors affect vulnerability to adverse sexual health outcomes. Some of these factors are largely individual or personal, such as knowledge, skills, and intent. Others, including class, race, and access to services, are related to social context. For example, in a literature review of research on the influence of socioeconomic status (SES) on teen births, the authors concluded that a number of factors associated with low SES, including underemployment, low income, low education levels, neighborhood disadvantage, and neighborhood-level income inequality, were associated with teen births.[8] Numerous individual studies support the observation that contextual factors related to poverty and social class contribute to disparities in STIs and HIV infection as well.[9,10] Many factors intersect with individual, relationship, and social contexts. Some studies point to the link between depression and sexual behavior among adolescents, including a greater likelihood of multiple partners.[11,12] Abundant evidence points to gender norms and power dynamics in intimate relationships as powerful determinants of sexual behaviors and health outcomes. (In addition to operating independently, gender norms intersect with other aspects of social contexts such as poverty and racial inequality.) For example, rates of condom and/or contraceptive use tend to be lower among young people of both sexes who adhere to more traditional gender norms than their peers.[13,14] Females’ low power in sexual relationships has also been independently correlated with negative sexual and reproductive health outcomes, including significant associations between less power and both STIs and unintended pregnancy.[15,16] Moreover, gender norms underlie vulnerability to intimate partner violence. Females who experience IPV are less likely to use condoms and more likely to experience STIs and pregnancy.[15–19] Males reporting perpetration of IPV are significantly more likely to report nonuse of condoms, unplanned pregnancies, and STI or HIV diagnoses.[20,21]

Political/resource issues: The majority of policies associated with teenage pregnancy and STI infection are determined at the state and local levels. Current statutes related to sexuality education represent a patchwork of policies across the country. For example, only 22 states and the District of Columbia mandate sexuality education, and 33 states and the District of Columbia mandate HIV education. Additional states have requirements related to the content and delivery of sexuality education. For example, 13 states require that curricula be medically accurate, and 26 states and the District of Columbia require that information be age appropriate. Twenty-two states and the District of Columbia require that schools notify parents before instruction begins, giving parents the opportunity to opt their children out of such instruction; in contrast, three states require parents to proactively opt their children into sexuality education instruction. Of particular importance, given the evidence base described below, only 18 states require that information on contraception be included in sexuality education, as compared with 25 states that require instructors to stress abstinence and 19 that limit discussions of sexual activity to the context of marriage.[22]

Where state policies related to sexuality education exist, the funding needed to implement and evaluate them is often inadequate. The federal government first began funding replication of evidence-based programs for teen pregnancy prevention in 2010. In addition, federal funding streams have provided vital support for the evaluation of innovative approaches to teen pregnancy prevention as a means of expanding the evidence base for programs that focus on addressing the negative health outcomes described above. However, despite the lack of evidence supporting the effectiveness of abstinence-only-until-marriage programs described below, as well as evidence demonstrating the potential harmful effects of such programs on adolescents’ sexual health, the federal government also continues to fund abstinence-only programs. In addition, federal agencies have not set any content standards related to evidence-based curricula.

Evidence-Based Strategies to Address the Problem
While sexual risk reduction for HIV, STIs, and pregnancy prevention cannot rely on a single strategy given the many contributing factors, rigorous research and evaluations have consistently demonstrated that comprehensive sexuality education (CSE) can have a positive impact on young people’s sexual behavior.[23,24] CSE programs emphasize abstinence from all sexual activity as the most reliable method of avoiding STIs and pregnancy and teach adolescents about contraceptives and barrier methods to reduce their risk of contracting an STI and/or becoming pregnant. They should provide adolescents with developmentally appropriate information regarding a broad range of topics related to sexuality, including puberty, reproductive health, interpersonal relationships, body image, harassment, stigma and discrimination, intimate partner violence, gender norms, gender identity, and sexual orientation. Furthermore, CSE programs provide opportunities for students to develop communication, decision-making, and other interpersonal skills. Ideally, these programs would start in kindergarten and continue through the 12th grade, provide age-appropriate content, and be taught by teachers who have received proper training. CSE programs generally allow parents to exercise the option of taking their children out of (opting out of) such classes if they do not wish their children to be exposed to this information. Experts in the fields of adolescent development, health, and education recommend that sexuality education programs, as part of a comprehensive health education program, provide young people with accurate information necessary to protect their sexual health; foster equality, rights, and respect; assist youth in developing a positive view of themselves and their sexuality; and help them acquire skills to communicate effectively, make informed decisions, and stay safe.[25–27]

The evidence base for the effectiveness of comprehensive sexuality education continues to grow. In the past decade, numerous narrative reviews, meta-analyses, and systematic reviews of adolescent behavior change interventions broadly, or sex and HIV education specifically, have concluded that such programs are generally effective.[23,24,28–30] A recent meta-analysis showed that group-based, comprehensive risk reduction programs (including those conducted in schools, communities, and clinics) have significant, positive effects on a number of key sexual health outcomes, including reducing or delaying sexual activity, increasing use of condoms, and reducing STIs.[24] Consistent findings from these reviews point to the types of programs that are more likely to demonstrate significant, positive effects, and the reviews show that both content and teaching approaches matter.

Evidence indicates that teaching methods and connections to parents and schools may contribute to program impact. Specifically, the conclusion from a number of reviews is that skill building and interactive activities that help students personalize information are prevalent among effective programs.[23,28,31,32] Similarly, studies of programs that foster parent-child communication about sex demonstrate positive outcomes.[33]

The role of school connectedness in achieving positive effects is well documented. Sexuality education, by engaging students in topics that are meaningful to them and by substantively contributing to school-wide efforts to create safe and welcoming environments, can foster school connectedness. School connectedness, in turn, leads to improved sexual and reproductive health; for instance, according to the Centers for Disease Control and Prevention, “Research has shown that young people who feel connected to their school are less likely to engage in many risk behaviors, including early sexual initiation, alcohol, tobacco, and other drug use, and violence and gang involvement. Students who feel connected to their school are also more likely to have better academic achievement, including higher grades and test scores, have better school attendance, and stay in school longer.”[34]

Emerging evidence suggests that comprehensive programs that pay meaningful attention to issues related to gender and power are more likely than programs that do not address these topics to demonstrate significant, positive outcomes. For example, Sales and colleagues concluded that “broader based content, such as problem solving, capacity building, social skill building, and enhanced gender and ethnic pride, [has] the greatest impact on behavior.”[31] Another review revealed that, strikingly, 80% of curriculum-based programs that addressed gender or power, as compared with only 17% of gender-blind programs, demonstrated significantly lower rates of STIs or pregnancy.[35] This is consistent with findings in related reviews; for instance, the importance of gender and power was highlighted in a meta-analysis focusing on HIV/STI behavioral interventions for African American women, with the authors concluding that interventions should include an emphasis on empowerment issues.[36]

Research has demonstrated that parents strongly and consistently favor school-based sexuality education programs that incorporate a variety of topics as part of a comprehensive health education program, including abstinence, birth control, STIs, healthy relationships, and sexual orientation.[37–41] Parents also support sexuality instruction about topics such as anatomy and physiology, physical changes associated with puberty, and body image beginning earlier in school, preferably during the elementary grades.[42] In addition, more than 140 national organizations are committed to medically accurate, age-appropriate comprehensive sexuality education for young people in the United States. These organizations represent a broad constituency of education advocates and professionals, health care professionals, religious leaders, child and health advocates, and policy organizations.[43–47]

Opposing Arguments/Evidence
Some advocates assert that comprehensive sexuality education programs are “based on the presumption that sexual behavior after puberty is inevitable” and that such programs are consequently “non-directive in helping teens to make the most age-appropriate and healthy choice.”[48] However, CSE curricula include information on abstinence, as well as lessons on communication and refusal skills designed to prepare young people to resist pressure to have sex and to effectively say “no” to unwanted sexual activity. Indeed, evaluations consistently show that comprehensive sexuality education does not lead to earlier sexual initiation or greater frequency of sexual activity.[23,24,30]

In addition, although several reviews have shown that comprehensive programs can have a positive impact, the authors have noted that the effects are small, indicating that there is room for improvement in the design, implementation, or other aspects of such programs in schools.[31,32,49–51] Oft-cited reviews by Kirby, as well as a Cochrane review, reveal that while most sexuality education programs demonstrate increased knowledge and positive results with respect to sexual behaviors, most programs tracking STI or pregnancy rates unfortunately fail to produce positive results.[23,30] There are several potential reasons for this limitation, one being that not all CSE programs address the full range of topics outlined above. Another is that only a limited amount of time is devoted to these interventions in the school environment. A third is that a number of factors affect sexual behavior, pregnancy, and STI infection, and only a subset of these determinants are amenable to change through behavioral interventions.[23]

Finally, some have raised concerns about the feasibility of implementing comprehensive sexuality education in school settings given the limited resources and competing priorities of school districts and a perceived lack of support from parents. However, a large body of research links sexual and reproductive health outcomes to academic achievement, and pregnancy is a leading cause of school dropout among teenage girls.[52,53] These outcomes have led public health and education researchers to deem CSE an intervention with the “potential to improve school achievement and reduce school dropout rates.”[54] In fact, numerous large school districts have effectively integrated CSE into their curricula.[55–57] In addition, fears of parental disapproval of CSE are unfounded. As discussed previously, parents overwhelmingly support school-based sexuality education programs that cover a broad range of topics.

Alternative Strategies
The predominant alternative strategy to comprehensive sexuality education is abstinence-only education. Abstinence-only programs—that is, programs that conform to the criteria listed in Section 510(b) of Title V of the Social Security Act—focus exclusively on promoting abstinence until marriage. These programs are required to teach that abstinence from all sexual behavior outside of marriage is the expected standard of human sexual activity and that sexual activity outside of marriage is likely to have harmful psychological and physical effects.[58] Abstinence-only programs either do not include information about contraceptives and disease prevention methods or provide data only on the failure rates of these methods.

Reviews of the evidence from evaluations of these programs show that their overall results are inconclusive or that abstinence-only programs lack efficacy. Specifically, evaluations have revealed that such programs demonstrate little evidence of sustained, long-term impact on adolescents’ attitudes favoring abstinence, on their intentions to abstain, or on their actual delay of sexual initiation.[24,28,50,59,60]

A report prepared by the House of Representatives Committee on Government Reform in December 2004 documented that the 11 abstinence-only-until-marriage programs most widely used by grantees of the largest federal abstinence initiative contained false, misleading, or distorted information about reproductive health.[61] In particular, these programs included misrepresentations about the effectiveness of condoms in preventing STIs and pregnancy as well as gender stereotypes, moral judgments, and factual errors.[62] Additional studies have confirmed the inclusion of inaccurate or incomplete information about condoms in abstinence-only curricula.[63] Indeed, the ethical and human rights concerns caused by these programs prompted APHA in 2006 to issue a policy statement calling for the repeal of federal funding for such programs, for all sexuality education programs supported by the federal government to be medically and scientifically accurate, and for rigorous evaluations of programs promoting abstinence and reductions in sexual risk behaviors. As asserted in that statement, APHA holds that federal abstinence-only program requirements “have little to do with public health priorities; instead, they [reflect] the moral and ideological viewpoint of the majority of members of Congress at the time of the program’s authorization”; also, the programs “are inherently coercive by withholding information needed to make informed choices.”[64]

That said, abstinence is an important option in the range of strategies to decrease STIs, HIV, and pregnancy. When strictly adhered to, abstaining from intercourse is, in fact, fully protective against pregnancy and most STIs. Given the low rates of sexual activity among younger teens, emphasizing abstinence is an age-appropriate strategy for this age group.[65] Absent the moralistic tone and inaccurate and incomplete information on contraception and condoms that characterize abstinence-only-until-marriage programs, sexuality education programs at earlier ages should focus on delaying sexual initiation. Indeed, one study showed that a theory-based abstinence-only intervention implemented among 12-year-olds significantly reduced sexual initiation among program participants at the 24-month follow-up point. The authors noted, however, that their program did not conform to federal criteria for abstinence-only programs and that it “did not contain inaccurate information, portray sex in a negative light, or use a moralistic tone.” It should thus be considered an age-appropriate approach rather than an abstinence-only-until-marriage program.[66]

Action Steps
To ensure that young Americans have the evidence-based information, skills, and attitudes necessary to make responsible decisions about sexual behavior during their school years and into their adult lives, the American Public Health Association:

1.    Encourages the US Congress to continue to fund programs that promote the implementation of comprehensive sexuality education programs that have demonstrated, through rigorous evaluations, that they have a positive impact on young people’s sexual behavior. Additional resources should be devoted to the implementation and evaluation of promising approaches that address current challenges facing young people. Also, such programs should be required to include information about both abstinence and contraception; address issues related to gender, power, rights, and respect; include parent-child communication components; and teach goal-setting, decision-making, negotiation, and communication skills.
2.    Urges all states to require and adequately fund local school districts and schools to plan and implement comprehensive sexuality education as an integral part of comprehensive K–12 school health education. This education must be scientifically and medically accurate and based on theories and strategies with demonstrated evidence of effectiveness; be consistent with community standards and efforts to foster safe and welcoming schools; be implemented in a nonjudgmental manner that does not impose specific religious viewpoints on students; support positive parent-child communication and guidance; be age, developmentally, and culturally appropriate; and be taught by well-prepared teachers who have received specialized training in the subject matter. Districts should use multiple sources of data regarding students’ needs, knowledge, and behaviors so that they can plan programs that meet the prevention needs of all students, with due attention to those who might be at greater risk for HIV, other STIs, and pregnancy, such as young men who have sex with men and members of populations with high prevalence rates. Schools should be required to provide this instruction to all students unless a parent or legal guardian has specifically requested that his or her child be excused from the entirety of the instruction before it begins.
3.    Urges the US Congress to cease funding abstinence-only programs that lack efficacy and inappropriately withhold critical health information.
4.    Encourages higher education institutions to prepare prospective teachers in the content and pedagogy of effective comprehensive sexuality education.
5.    Supports the efforts of advocates of comprehensive sexuality education programs to bring this policy to the attention of national, state, and local policymakers so as to ensure that these recommendations are implemented in policies, research, and programs.

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