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State of Sex Education in USA | Health Education in Schools

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Do you know what the state of sex education in the U.S. is? Sex Education taught in the form of abstinence-only & comprehensive sex education. Learn more.

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Position Statement SUMMARY
It is the position of the National Association of School Nurses (NASN) that developmentally appropriate evidence-based sexual health education should be included as part of a comprehensive school health education program and be accessible to all students. NASN recognizes the role of parents and families as the primary source of education about sexual health. The registered professional school nurse (hereinafter referred to as school nurse) is a valuable resource to parents and educators in this area and supports the implementation of evidence-based sexual health education programs that promote healthy sexual development for all students.
BACKGROUND
The social and health risks of adolescent sexual activity are well known (Dee et al., 2017). While teen pregnancy and birth rates in the United States continue to decline, rates remain higher than in other industrialized countries; and racial, ethnic and geographic disparities persist (Centers for Disease Control and Prevention [CDC], 2016a). In addition, the rates of sexually transmitted infections (STIs) are at an unprecedented high in the United States, and more than half of newly acquired infections occur among adolescents and young adults (CDC, 2016b).

Sexual health as defined by the World Health Organization (WHO) is "... a state of physical, emotional, mental and social well-being in relation to sexuality..." (WHO, 2015, pp. 5), suggesting a whole child approach to sexual health education and not merely the absence of unplanned pregnancy or sexually transmitted infections. For decades, studies have shown that the majority of parents in the United States support sexual health education in schools. In addition, findings indicated that most parents supported abstinence-based rather than abstinence-only programs (Barr, Moore, Johnson, Forrest , Jordan , 2014). Finally, a May 2016 nationwide survey of middle and high school parents found that 70% believe sex education and pregnancy prevention should "definitely be covered" in sexual health education programs (Singer, 2016).

According to the 2014 School Health Policies and Practices Study (CDC, 2015a), 72% of high schools in the United States required students to receive education on pregnancy prevention, and 83.1% required instruction on STI prevention. Topics listed as part of required instruction by order of frequency included abstinence as the most effective method to avoid pregnancy and STIs, the relationship between alcohol or other drug use and risk for STIs and pregnancy, and resisting peer pressure to engage in sexual behavior. A worrisome trend is that the percentage of schools in which students are required to receive instruction on human sexuality, pregnancy, and STI prevention has steadily declined since 2000 (CDC, 2015a)

Healthy students are more likely to achieve academic success (CDC, 2014). Szydlowski (2015b) asserts that when teens receive accurate sexual health education information and skills, they can reduce health risk factors that may impact their success in school. Data from the 2015 Youth Risk Behavior Surveillance Survey (YRBSS) indicated that, among high school students, 41% have had sexual intercourse at least once; and 30% had sexual intercourse in the three months prior to participating in the survey, reflective of a decline from previous surveys (CDC, 2015b). Although teens may be having less sex, condom use and HIV testing are declining (CDC, 2015b). Of those who had intercourse in the past three months, 43% did not use a condom the last time they had sex; 14% did not use any method to prevent pregnancy; and 21% used substances before last sexual intercourse (CDC, 2015b).

For the first time, the CDC analysis of national data gathered from the 2015 YRBS included information on the health risks of lesbian, gay, and bisexual (LGB) high school students. These findings demonstrate that LGB youth report a higher incidence of bullying at school or online, physical and sexual dating violence, drug and alcohol use, and suicide-related behaviors than their straight peers (Kann, Olsen, & McManus, 2016). In the most recent Gay, Lesbian, and Straight Network (GLSEN) National School Climate Survey, over 31% of LGBTQ students reported missing at least one day of school during the past month due to safety concerns. Students who attended schools with LGBTQ-inclusive curriculum were less likely to miss school (18% vs. 35%) for safety reasons (Kosciw, Greytak, Giga, Villenas, & Danischewski, 2016). Although not a direct measure of school performance, absenteeism has been linked to low graduation rates, which can impact future success in life (CDC, 2014).

In addition to the disparities of risk for sexual minority youth, there are racial/ethnic differences. Black high school students are more likely to have had intercourse than white and Latino students; and more black high school students and Latino students initiated sex before the age of 13 compared to white students (Kaiser Family Foundation, 2014).

Students with disabilities defined as "... a physical or mental impairment that substantially limits one or more major life activities" (Americans with Disabilities Act of 1990 [ADA], Title II Regulations, 2016, p. 187), and those with intellectual disabilities (ID) as characterized by "...signiﬁcant limitations both in intellectual functioning and in adaptive behaviour as expressed in conceptual, social, and practical adaptive skills" (Luckasson & Schalock, 2013, pp. 96) benefit from sexual health information. Low levels of knowledge can impede the recognition of sexual abuse situations, safe sex practices, and the development of positive attitudes toward sexuality (Schaafsma, Kok, Stoffelen, & Curfs, 2015). Szydlowski (2016) compiled general guidelines for sexual health educators for those with disabilities. Sexual health education needs to be tailored to the students with disabilities based on their ability, learning style, and maturity, in addition to parent values and beliefs (Szydlowski, 2016).
RATIONALE
School nurses support sexual health education that is accessible, inclusive, and developmentally and culturally appropriate for all students. Academic achievement is linked to student health (CDC, 2014). Health risk behaviors, such as early sexual initiation, are associated with lower grades and test scores, and lower educational attainment (CDC, 2016c). Evidence-based sexual health education provides accurate, complete, and developmentally appropriate information and skill development that allow young people to make decisions that are informed, responsible, and healthy (Szydlowski, 2015b). Evidence-based sexual health education can improve academic success; prevent dating violence, and bullying; help youth develop healthier relationships; delay sexual initiation; reduce unplanned pregnancy, HIV, and other STIs; and reduce sexual health disparities among LGBTQ youth (Szydlowski, 2015b). Evidence-based sexual health education reduces sexual risk behavior by delaying sexual initiation, reducing pregnancy and STIs, and increasing contraceptive use -- thereby protecting student health (Szydlowski, 2015b).

The National Sexuality Education Standards (Future of Sex Education Initiative [FOSE],2012) support a strategic and coordinated approach that includes family and community involvement, skill development and school health services. Furthermore, the Sexuality Information and Education Council of the United States (SIECUS) (2017) supports sexual health education that is appropriate to the student's age, developmental level, cultural background, and community values. SIECUS further advocates for sexual health education to augment the sexual health education provided by the family and their healthcare professionals. SIECUS specifies that sexual health education provided in an educational setting needs to be taught by an instructor trained on the principles, content and best practices of sexual health education. On behalf of Advocates for Youth, Szydlowski (2015a) emphasizes youth friendly sexual health education to assist with the positive development of sexual health, beginning in youth and continuing throughout adulthood.>

The National Sexuality Education Standards recommend that an evidence-based sexual health education program include the following characteristics (FOSE, 2012, p.9):

Focuses on specific behavioral outcomes;

Addresses individual values and group norms that support health‐enhancing behaviors;

Focuses on increasing personal perceptions of risk and harmfulness of engaging in specific health risk behaviors, as well as reinforcing protective factors;

Addresses social pressures and influences;

Builds personal and social competence;

Provides functional knowledge that is basic, accurate and directly contributes to health‐promoting decisions and behaviors;

Uses strategies designed to personalize information and engage students;

Provides age‐ and developmentally appropriate information, learning strategies, teaching methods and materials;

Incorporates learning strategies, teaching methods, and materials that are culturally inclusive;

Provides adequate time for instruction and learning;

Provides opportunities to reinforce skills and positive health behaviors;

Provides opportunities to make connections with other influential persons; and

Includes teacher information and plan for professional development and training to enhance effectiveness of instruction and student learning.

In addition, in terms of specific content, an emerging model for sexual health education is the rights-based approach, which employs a vast, comprehensive sexual education program with a focus on human rights, gender equality, access to healthcare services, and critical thinking (Constantine et al., 2015). Preliminary findings have supported that education based on theories of human rights, gender equality, and sexual development can positively impact healthy sexual behavior among adolescents (Constantine et al.).
CONCLUSION
Health education and promotion, disease prevention, and risk reduction are essential practice components for the 21st century school nurse to help students stay healthy, safe and ready to learn (NASN, 2016). School nurse leaders advocate for and support the delivery of evidence-based sexual health education that is "...medically accurate, developmentally appropriate, and ... provides students with the skills and resources that help them make informed and responsible decisions" (FOSE, 2012, p.8). School nurses -- working in collaboration with parents, students, health educators, curriculum specialists, and other school and community stakeholders -- strive to dismantle barriers and support access to evidence-based sexual health education that allows all students to make informed, responsible, and healthy decisions.
REFERENCES
Americans With Disabilities Act of 1990, Pub. L. No. 101-336, 104 Stat. 328 (1990), Title II Regulations. (2016). Part 35 Nondiscrimination on the Basis of Disability in State and Local Government Services (as amended by the final rule published on August 11, 2016). Retrieved from https://www.ada.gov/regs2010/titleII_2010/titleII_2010_regulations.htm

Barr E., Moore M., Johnson T., Forrest J., Jordan M. (2014). New evidence: Data documenting parental support for earlier sexuality education. Journal of School Health, 84(1), 10-17. doi:http://dx.doi.org/10.1111/josh.12112

Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. (2014). Health and academic achievement. Retrieved from https://www.cdc.gov/healthyyouth/health_and_academics/pdf/health-academic-achievement.pdf

Centers for Disease Control and Prevention. (2015a). Results from the school health policies and practices study 2014. Retrieved from https://www.cdc.gov/healthyyouth/data/shpps/results.htm

Centers for Disease Control and Prevention. (2015b). Youth risk behavior surveillance system (YRBSS). Retrieved from https://www.cdc.gov/healthyyouth/data/yrbs/results.htm

Centers for Disease Control and Prevention. (2016a). About teen pregnancy: Teen pregnancy in the United States. Retrieved from http://www.cdc.gov/teenpregnancy/about/index.htm

Centers for Disease Control and Prevention. (2016b). Sexually transmitted diseases surveillance 2015. Retrieved from https://www.cdc.gov/std/stats15/default.htm

Centers for Disease Control and Prevention. (2016c). Adolescent and school health: Health and academics. http://www.cdc.gov/HealthyYouth/health_and_academics/

Constantine, N. A., Jerman, P., Berglasi, N. F., Angulo-Olaiz, F., Chou, C., & Rohrbach, L. A. (2015). Short-term effects of a rights-based sexuality education curriculum for high-school students: A cluster-randomized trial. BMC Public Health, 15(293),1-13. doi:10.1186/s12889-015-1625-5

Dee, D.L., Pazol, K., Cox, S., Smith, R.A., Bower, K., & Kapaya, M. (2017). Trends in repeat births and use of postpartum contraception among teens-United States, 2004-2015. Morbidity Mortality Weekly Report, 4/28/2017; 66(16), 422-426, 5. doi: http://dx.doi.org/10.15585/mmwr.mm6616a3

Future of Sex Education Initiative. (2012). National sexuality education standards: Core content and skills, K-12 [a special publication of the Journal of School Health]. Retrieved from http://www.futureofsexeducation.org/documents/josh-fose-standards-web.pdf

Kaiser Family Foundation. (2014). Sexual health of adolescents and young adults in the United States. Menlo Park, CA: Henry J. Kaiser Family Foundation. Retrieved from http://kff.org/womens-health-policy/fact -sheet/sexual-health-of-adolescents-and-young-adults-in-the-united-states/

Kann, L., Olsen, E.O., & McManus, T. (2016). Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9-12 - United States and selected sites, 2015. MMWR Surveillance Summary 2016,65(No. SS-9), 1-202. doi: http://dx.doi.org/10.15585/mmwr.ss6509a1

Kosciw, J. G., Greytak, E. A., Giga, N. M., Villenas, C. & Danischewski, D. J. (2016). The 2015 national school climate survey: The experiences of lesbian, gay, bisexual, transgender, and queer youth in our nation's schools. New York: GLSEN.

Luckasson, R., & Schalock, R. L. (2013). What's at stake in the lives of people with intellectual disability? Part II: Recommendations for naming, defining, diagnosing, classifying, and planning supports. Intellectual and Developmental Disabilities, 51(2), 94-101. doi: 10.1352/1934-9556-51.2.094

National Association of School Nurses. (2016). Framework for 21st century school nursing practice. NASN School Nurse, 31(1), 45-53. doi: 10.1177/1942602X15618644

Schaafsma, D., Kok, G., Stoffelen, J. M. T., & Curfs, L. M. G. (2015). Identifying effective methods for teaching sex education to individuals with intellectual disabilities: A systematic review. Journal of Sex Research, 52(4), 412-432. doi: 10.1080/00224499.2014.919373.

Sexuality Information and Education Council of the United States. (2017). Human sexuality (Position Paper). Retrieved from http://www.siecus.org/index.cfm?fuseaction=Page.ViewPage&pageId=494

Singer, D.C. (Ed.). (2016). Beyond sex ed: Parents want more health topics covered in school. Retrieved from http://mottnpch.org/reports-surveys/beyond-sex-ed-parents-want-more-health-topics-covered-school

Szydlowski, M.B. (2015a). Sexual health education; research and results. School Health Equity/Advocates for Youth. Retrieved from http://www.advocatesforyouth.org/storage/advfy/documents/school-health-equity/sexual-healthed-research-and-results.pdf

Szydlowski, M.B. (2015b). Sexual health education and academic success: Effective programs foster student achievement. School Health Equity/Advocates for Youth. Retrieved from http://www.advocatesforyouth.org/school-health-equity-resources

Szydlowski, M. B. (2016). Sexual health education for young people with disabilities - Research and resources for educators. School Health Equity/Advocates for Youth. Retrieved from http://www.advocatesforyouth.org/publications/publications-a-z/2559

World Health Organization. (2015). Sexual health, human rights and the law. Retrieved from http://apps.who.int/iris/bitstream/10665/175556/1/9789241564984_eng.pdf?ua=1

Acknowledgement of Authors:
Lisa Kern MSN, RN, NCSN
Gina Emge MSN, RN
Kathy Reiner BSN, MPH, RN
Darla Rebowe BSN, RN

Adopted: October 2002
Revised: November 2005, June 2012, June 2017

(Formerly titled "School Health Education about Human Sexuality")

Suggested Citation: National Association of School Nurses. (2016). Sexual health education in schools (Position Statement). Silver Spring, MD: Author.
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.

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Position Statement SUMMARY It is the position of the National Association of School Nurses (NASN) that developmentally appropriate evidence-based sexual health education should be included as part of a comprehensive school health education program and be accessible to all students. NASN recognizes the role of parents and families as the primary source of education about sexual health.

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Kelli Stidham Hall, Ph.D., M.S., Jessica McDermott Sales, Ph.D., M.A., Kelli A. Komro, Ph.D., M.P.H., and John Santelli, M.D., M.P.H.

For more than four decades, sex education has been a critically important but contentious public health and policy issue in the United States [ 1- 5]. Rising concern about nonmarital adolescent pregnancy beginning in the 1960s and the pandemic of HIV/AIDS after 1981 shaped the need for and acceptance of formal instruction for adolescents on life-saving topics such as contraception, condoms, and sexually transmitted infections. With widespread implementation of school and community-based programs in the late 1980s and early 1990s, adolescents' receipt of sex education improved greatly between 1988 and 1995 [ 6]. In the late 1990s, as part of the "welfare reform," abstinence only until marriage (AOUM) sex education was adopted by the U.S. government as a singular approach to adolescent sexual and reproductive health [ 7, 8]. AOUM was funded within a variety of domestic and foreign aid programs, with 49 of 50 states accepting federal funds to promote AOUM in the classroom [ 7, 8]. Since then, rigorous research has documented both the lack of efficacy of AOUM in delaying sexual initiation, reducing sexual risk behaviors, or improving reproductive health outcomes and the effectiveness of comprehensive sex education in increasing condom and contraceptive use and decreasing pregnancy rates [ 7- 12]. Today, despite great advancements in the science, implementation of a truly modern, equitable, evidence-based model of comprehensive sex education remains precluded by sociocultural, political, and systems barriers operating in profound ways across multiple levels of adolescents' environments [ 4, 7, 8, 12- 14].

At the federal level, the U.S. congress has continued to substantially fund AOUM, and in FY 2016, funding was increased to $85 million per year [ 3]. This budget was approved despite President Obama's attempts to end the program after 10 years of opposition and concern from medical and public health professionals, sexuality educators, and the human rights community that AOUM withholds information about condoms and contraception, promotes religious ideologies and gender stereotypes, and stigmatizes adolescents with nonheteronormative sexual identities [ 7- 9, 11- 13]. Other federal funding priorities have moved positively toward more medically accurate and evidence-based programs, including teen pregnancy prevention programs [ 1, 3, 12]. These programs, although an improvement from AOUM, are not without their challenges though, as they currently operate within a relatively narrow, restrictive scope of "evidence" [ 12].

At the state level, individual states, districts, and school boards determine implementation of federal policies and funds. Limited in-class time and resources leave schools to prioritize sex education in competition with academic subjects and other important health topics such as substance use, bullying, and suicide [ 4, 13, 14]. Without cohesive or consistent implementation processes, a highly diverse "patchwork" of sex education laws and practices exists [ 4]. A recent report by the Guttmacher Institute noted that although 37 states require abstinence information be provided (25 that it be stressed), only 33 and 18 require HIV and contraceptive information, respectively [ 1]. Regarding content, quality, and inclusivity, 13 states mandate instruction be medically accurate, 26 that it be age appropriate, eight that it not be race/ethnicity or gender bias, eight that it be inclusive of sexual orientation, and two that it not promote religion [ 1]. The Centers for Disease Control and Prevention's 2014 School Health Policies and Practices Study found that high school courses require, on average, 6.2 total hours of instruction on human sexuality, with 4 hours or less on HIV, other sexually transmitted infections (STIs), and pregnancy prevention [ 15]. Moreover, 69% of high schools notify parents/guardians before students receive such instruction; 87% allow parents/guardians to exclude their children from it [ 15]. Without coordinated plans for implementation, credible guidelines, standards, or curricula, appropriate resources, supportive environments, teacher training, and accountability, it is no wonder that state practices are so disparate [ 4].

At the societal level, deeply rooted cultural and religious norms around adolescent sexuality have shaped federal and state policies and practices, driving restrictions on comprehensive sexual and reproductive health information, and service delivery in schools and elsewhere [ 12, 13]. Continued public and political debates on the morality of sex outside marriage perpetuate barriers at multiple levels-by misguiding state funding decisions, molding parents' (mis)understanding of programs, facilitating adolescents' uptake of biased and inaccurate information in the classroom, and/or preventing their participation in sex education altogether [ 4, 7, 8, 12- 14].

Trends in Adolescents' Receipt of Sex Education

In this month's Journal of Adolescent Health, Lindberg et al. [ 16] provide further insight into the current state of sex education and the implications of federal and state policies for adolescents in the United States. Using population data from the National Survey of Family Growth, they find reductions in U.S. adolescents' receipt of formal sex education from schools and other community institutions between 2006-2010 and 2011-2013. These declines continue previous trends from 1995-2002 to 2006-2008, which included increases in receipt of abstinence information and decreases in receipt of birth control information [ 17- 19]. Moreover, the study highlights several additional new concerns. First, important inequities have emerged, the most significant of which are greater declines among girls than boys, rural-urban disparities, declines concentrated among white girls, and low rates among poor adolescents. Second, critical gaps exist in the types of information (practical types on "where to get birth control" and "how to use condoms" were lowest) and the mistiming of information (most adolescents received instruction after sexual debut) received. Finally, although receipt of sex education from parents appears to be stable, rates are low, such that parental-provided information cannot be adequately compensating for gaps in formal instruction.

Paradoxically, the declines in formal sex education from 2006 to 2013 have coincided with sizeable declines in adolescent birth rates and improved rates of contraceptive method use in the United States from 2007 to 2014 [ 20, 21]. These coincident trends suggest that adolescents are receiving information about birth control and condoms elsewhere. Although the National Survey of Family Growth does not provide data on Internet use, Lindberg et al. [ 16] suggest that it is likely an important new venue for sex education. Others have commented on the myriad of online sexual and reproductive resources available to adolescents and their increasing use of sites such as Bedsider.org, StayTeen.org, and Scarleteen. [ 2, 14, 22- 24].

The Future of Sex Education

Given the insufficient state of sex education in the United States in 2016, existing gaps are opportunities for more ambitious, forward-thinking strategies that cross-cut levels to translate an expanded evidence base into best practices and policies. Clearly, digital and social media are already playing critical roles at the societal level and can serve as platforms for disseminating innovative, scientifically and medically sound models of sex education to diverse groups of adolescents, including sexual minority adolescents [ 14, 22- 24]. Research, program, and policy efforts are urgently needed to identify effective ways to harness media within classroom, clinic, family household, and community contexts to reach the range of key stakeholders [ 13, 14, 22- 24]. As adolescents turn increasingly to the Internet for their sex education, perhaps school-based settings can better serve other unmet needs, such as for comprehensive sexual and reproductive health care, including the full range of contraceptive methods and STI testing and treatment services. [ 15, 25].

At the policy level, President Obama's budget for FY 2017 reflects a strong commitment to supporting youths' access to age-appropriate, medically accurate sexual health information, with proposed elimination of AOUM and increased investments in more comprehensive programs [ 3]. Whether these priorities will survive an election year and new administration is uncertain. It will also be important to monitor the impact of other health policies, particularly regarding contraception and abortion, which have direct and indirect implications for minors' rights and access to sexual and reproductive health information and care [ 26].

At the state and local program level, models of sex education that are grounded in a broader interdisciplinary body of evidence are warranted [ 4, 11- 14, 27- 29]. The most exciting studies have found programs with rights-based content, positive, youth-centered messages, and use of interactive, participatory learning and skill building are effective in empowering adolescents with the knowledge and tools required for healthy sexual decision-making and behaviors [ 4, 11- 14, 27- 29]. Modern implementation strategies must use complementary modes of communication and delivery, including peers, digital and social media, and gaming, to fully engage young people [ 14, 22, 23, 27].

Ultimately, expanded, integrated, multilevel approaches that reach beyond the classroom and capitalize on cutting-edge, youth-friendly technologies are warranted to shift cultural paradigms of sexual health, advance the state of sex education, and improve sexual and reproductive health outcomes for adolescents in the United States.

Acknowledgments
Funding Sources
K.S.H. is supported by the National Institute of Child Health and Human Development #1K01HD080722-01A1.

Contributor Information

Kelli Stidham Hall, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Jessica McDermott Sales, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Kelli A. Komro, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia.

John Santelli, Department of Population & Family Health, Mailman School of Public Health, Columbia University, New York, New York.

References

7. Boonstra HD. Advocates call for a new approach after the era of 'Abstinence-Only' sex education. Guttmacher Policy Rev. 2009;12:1-6.

14. Strasburger VC, Brown SS. Sex education in the 21 st century.

18. Lindberg L, Maddow-Zimet I. Monitoring trends in sex education and information. J Adolesc Health. 2011;48:S105-6.

25. Boonstra H. Meeting the sexual and reproductive health needs of adolescents in school-based health centers. Guttmacher Policy Rev. 2015;18:1-6.

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The State of Sex Education in the United States

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Kelli Stidham Hall, Ph.D., M.S., Jessica McDermott Sales, Ph.D., M.A., Kelli A. Komro, Ph.D., M.P.H., and John Santelli, M.D., M.P.H. For more than four decades, sex education has been a critically important but contentious public health and policy issue in the United States [ 1- 5].