Adolescents’ REPORTS OF FORMAL SEXUAL HEALTH EDUCATION
• “Formal” sexual health education is instruction that generally takes place in a structured setting, such as a school, youth center, church or other community-based location. This type of instruction is a central source of information for adolescents.
• In 2011–2013, more than 80% of adolescents aged 15–19 had received formal instruction about STDs, HIV and AIDS or how to say no to sex. In contrast, only 55% of young men and 60% of young women had received formal instruction about methods of birth control.1
• Between 2006–2010 and 2011–2013, there were significant declines in adolescent females’ reports of having received formal instruction about birth control, STDs, HIV and AIDs, and saying no to sex. There was also a significant decline in adolescent males’ reports of having received formal instruction about birth control.1
• The share of adolescents aged 15–19 who had received formal instruction about how to say no to sex but had received no instruction about birth control methods increased between 2006–2010 and 2011–2013, from 22% to 28% among females and from 29% to 35% among males.1
• Declines in formal sex education were concentrated among young people residing in rural areas. For example, the share of rural adolescents who had received instruction about birth control declined from 71% to 48% among females, and from 59% to 45% among males.1
• Formal instruction may not be skills-based; in 2011–2013, only 50% of females and 58% of males aged 15–19 reported having received formal instruction about how to use a condom.1
• Only about half of adolescents (57% of females and 43% of males) received formal instruction about contraception before they first had sex; about four in ten (46% of females and 31% of males) received instruction about where to get birth control.1
• As of 2015, fewer than six percent of lesbian, gay, bisexual and transgender (LGBT) students aged 13–21 reported that their health classes had included positive representations of LGBT-related topics.2
EFFECTIVENESS OF FORMAL SEX EDUCATION PROGRAMS
• Leading public health and medical professional organizations—including the American Medical Association; the American Academy of Pediatrics; the American College of Obstetricians and Gynecologists; the American Public Health Association; the Health and Medicine Division of the National Academies of Science, Engineering, and Medicine (formerly the Institute of Medicine); the American School Health Association and the Society for Adolescent Health and Medicine—support comprehensive sex education.3–9
• There has been a shift toward evidence-based interventions in the United States over the last few decades. The first dedicated federal funding stream for evaluation of adolescent sexual health programs was established in 2010 and has contributed to improvement in the quality and quantity of evaluation research.10
• Strong evidence suggests that approaches to sex education that include information about both contraception and abstinence help young people to delay sex, and also to have healthy relationships and avoid STDs and unintended pregnancies when they do become sexually active. Many of these programs have resulted in delayed sexual debut, reduced frequency of sex and number of sexual partners, increased condom or contraceptive use, or reduced sexual risk-taking.11,12
• The federal government currently provides funding to evaluate new and innovative adolescent pregnancy prevention approaches, both in and out of school, as well as to replicate existing programs.13 Evaluations of programs funded under this initiative have shown that roughly one in three had a positive impact—a larger proportion than typically found in evaluation efforts of this nature.14
• “Abstinence education” programs that promote abstinence-only-until-marriage—now termed “sexual risk avoidance” by proponents—have been described as “scientifically and ethically problematic.” They systematically ignore or stigmatize many young people and do not meet their health needs.15
• Proponents of “sexual risk avoidance” programs have appropriated the terms “medically accurate” and “evidence-based,” though experts in the field agree that such programs are neither complete in their medical accuracy nor based on the widely accepted body of scientific evidence.16
• Abstinence-only-until-marriage programs threaten fundamental human rights by withholding information about human sexuality and potentially providing medically inaccurate and stigmatizing information.15
• Research finds that programs that promote abstinence until marriage while withholding information about contraceptive methods do not stop or even delay sex.17,18 Moreover, abstinence-only-until-marriage programs can actually place young people at increased risk of pregnancy and STIs.19,20
• A large body of research has found no evidence that providing young people with sexual and reproductive health information and education results in increased sexual risk-taking.12
• Most evaluations of sexual health programs focus on reducing levels of adolescent pregnancy, STIs and the behaviors that lead to them. But the broader goal of comprehensive sex education is to support young people’s development into sexually healthy adults.5,15
SCHOOL HEALTH POLICIES AND PROGRAMS
• According to the Centers for Disease Control and Prevention (CDC), instruction on sexual health topics (including human sexuality and prevention of STDs and pregnancy) is more commonly required in high school than in middle or elementary school.21
• In 2014, fewer than half of high schools and only 20% of middle schools provided instruction on all 16 topics that the CDC considers essential to sexual health education.21
• In 2014, 72% of U.S. public and private high schools taught pregnancy prevention as part of required instruction; 76% taught that abstinence is the most effective method to avoid pregnancy, HIV and STDs; 61% taught about contraceptive efficacy; and 35% taught students how to correctly use a condom.21
• At the middle-school level, 38% of schools taught pregnancy prevention as part of required instruction; 50% taught that abstinence is the most effective method to avoid pregnancy, HIV and STDs; 26% taught about contraceptive efficacy; and 10% taught students how to correctly use a condom.21
• Among schools requiring instruction about pregnancy prevention in 2014, the average class time spent on this topic annually was 4.2 hours in high schools and 2.7 hours in middle schools.21
• In 2014, 88% of schools allowed parents to exempt their children from sexual health education.21
• The share of schools providing sexual health education declined between 2000 and 2014, across topics ranging from puberty and abstinence to how to use a condom.21,22
• Within each state, relatively few high schools offered instruction on HIV, STDs or pregnancy prevention specifically relevant to lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ) youth in 2014; the proportion ranged from 11% in South Dakota to 56% in Vermont.23
Other SOURCES OF SEXUAL HEALTH information
Adolescents may receive information about sexual health topics from a range of sources beyond formal instruction. Here we consider the role of parents, health care providers and digital media as potential sources of sexual health information for adolescents.
• In 2011–2013, 70% of males and 78% of females aged 15–19 reported having talked with a parent about at least one of six sex education topics: how to say no to sex, methods of birth control, STDs, where to get birth control, how to prevent HIV infection and how to use a condom.1
• Young women were more likely than young men to talk with their parents about each of these sexual health topics except how to use a condom, which was more commonly discussed among males (45%) than among females (36%).1
• Despite declines in adolescents’ receipt of formal sex education between 2006–2010 and 2011–2013, the share of adolescents who had talked with parents about most sex education topics did not change.1
• Although most parents provide information about contraception or other sexual health topics, their knowledge of these topics may be inaccurate or incomplete.24
• More than 93% of parents say that sex education in middle and high school is important, and most think that sex education should include instruction about birth control.25
Health care providers
• Both the American Medical Association and the American Academy of Pediatrics recommend that adolescents’ primary care visits include time alone with health care providers to discuss sexuality and receive counseling about sexual behavior.26,27 The American College of Obstetricians and Gynecologists advises that contraceptive counseling be included in every visit with adolescents, including those who are not yet sexually active.28
• Despite these recommendations, only 45% of young people aged 15–17 reported in 2013–2015 that they spent time alone with a doctor or other health care provider during their most recent visit in the previous year.29
• Many health care providers do not talk with their adolescent patients about sexual health issues during primary care visits. When these conversations do occur, they are usually brief; in one study, conversations with patients aged 12–17 lasted an average of 36 seconds.30
• Many adolescents feel uncomfortable talking with their health care provider about sexual health issues, and many providers also have concerns about discussing these issues.31
• Concerns about confidentiality limit access to sexual and reproductive health care, especially when young people rely on their parents’ health insurance. In 2013–2015, 18% of all adolescents aged 15–17 and 12% of young adults aged 18–19 covered by their parents’ insurance reported that they would not seek sexual or reproductive health care because of concerns that their parents might find out.29
• Among females aged 15–17 who had ever had sex, those who reported concerns about confidentiality were one-third as likely to have received a contraceptive service in the previous year than those who did not have these concerns.29
• Many young people fall through the information cracks. Among adolescents aged 15–19 who had ever had sex and who did not get birth control instruction from either formal sources or a parent, only 7% of females and 13% of males talked with a health care provider about birth control in 2006–2010.32
• Access to the Internet is nearly universal among adolescents in the United States. Digital media offer opportunities for youth to confidentially search for information on sensitive topics, and thus are a likely source of sexual health information for young people.33,34
• Online sources may be particularly important for LGBTQ adolescents, whose needs may be left out of traditional sex education.35 The confidentiality of the Internet may also be particularly attractive for these adolescents, who may not be comfortable discussing sexual health topics with parents or friends.36
• In 2010, 19% of heterosexual youth, 40% of questioning youth, 65% of bisexual youth and 78% of lesbian/gay/queer youth aged 13–18 reported that they had used the Internet to look up sexual health information in the past year.37
• Seventy-three percent of adolescents aged 13–17 own a smartphone.38 More up-to-date research is needed to document how and to what extent adolescents access and utilize sexual health information online with smartphones and other new mobile technologies.
• Digital media, including social networking sites, apps and text messaging services, are increasingly being used to reach adolescents with sexual health interventions, and studies have demonstrated efficacy in improving knowledge and behavior across a range of sexual health outcomes.39
• The websites adolescents may turn to for sexual health information often have inaccurate information. For example, of 177 sexual health websites examined in a recent study, 46% of those addressing contraception and 35% of those addressing abortion contained inaccurate information.40
SEX EDUCATION POLICY AND FUNDING
• Currently, 22 states and the District of Columbia mandate education about both sex and HIV; two states mandate sex education alone, and another 12 mandate only HIV education.41
• A total of 37 states require that sex education programs include information about abstinence; 25 require abstinence to be stressed, while 12 simply require the topic to be included as part of the instruction.41
• Eighteen states and the District of Columbia require that sex education programs include information about contraception; no state requires that it be stressed.41
• Thirteen states require that the information presented in sex and HIV education classes be medically accurate.41
• Twenty-four states and the District of Columbia require any sex education that is provided to be age appropriate and three states require HIV education to be age appropriate.41
• Twelve states require discussion of sexual orientation in sex education classes. Nine of these states require inclusive discussion of sexual orientation, while the remaining three require that classes provide only negative information about sexual orientation.41
• In fiscal year 2017, Congress provided $176 million for evidence-based or evidence-informed, medically accurate and age-appropriate adolescent pregnancy prevention programs, the same amount provided in the previous fiscal year. This funding included $101 million for the Teen Pregnancy Prevention Program (TPPP), a competitive grant program geared toward community-based groups to support the implementation and evaluation of evidence-based and innovative adolescent pregnancy prevention approaches. It also included $75 million for the Personal Responsibility Education Program (PREP), which primarily funds state programs that inform adolescents about both abstinence and contraception for the prevention of pregnancy and STIs, including HIV, as well as adulthood preparation topics such as healthy relationships.
• Congress also provided $90 million for abstinence-only-until-marriage programs in fiscal year 2017, an increase of $5 million over the previous year’s funding. This funding included $15 million to community- and faith-based groups for “sexual risk avoidance,” to be used exclusively for the implementation of programs that promote “voluntarily abstaining from non-marital sexual activity,” and $75 million for the Title V state-grant “abstinence education” program, whose extremely narrow eight-point definition sets forth specific messages to be taught, including that sex outside of marriage—for people of any age—is likely to have harmful physical and psychological effects.
1. Lindberg LD, Maddow-Zimet I and Boonstra H, Changes in adolescents’ receipt of sex education, 2006–2013, Journal of Adolescent Health, 2016, 58(6):621–627, doi:10.1016/j.jadohealth.2016.02.004.
2. Kosciw JG et al., The 2013 National School Climate Survey: The Experiences of Lesbian, Gay, Bisexual and Transgender Youth in Our Nation’s Schools, New York: Gay, Lesbian & Straight Education Network (GLSEN), 2014, https://www.glsen.org/sites/default/files/2013%20National%20School%20Climate%20Survey%20Full%20Report_0.pdf.
3. Council on Science and Public Health (CSAPH), American Medical Association, An Updated Review of Sex Education Programs in the United States, CSAPH Report 7-A-09, 2009, https://www.ama-assn.org/sites/default/files/media-browser/public/about-ama/councils/Council%20Reports/council-on-science-public-health/a09-csaph-sex-education.pdf.
4. Breuner CC et al., Sexuality education for children and adolescents, Pediatrics, 2016, 138(2):e20161348, doi:10.1542/peds.2016-1348.
5. American College of Obstetricians and Gynecologists (ACOG), Comprehensive sexuality education, Committee Opinion No. 678, 2016, https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Comprehensive-Sexuality-Education.
6. American Public Health Association, Sexuality education as part of a comprehensive health education program in K to 12 schools, Policy Statement 20143, 2014, https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/01/23/09/37/sexuality-education-as-part-of-a-comprehensive-health-education-program-in-k-to-12-schools.
7. American School Health Association (ASHA), ASHA sign-ons & statements of support, 2016, http://www.ashaweb.org/asha-sign-ons-statements-of-support/.
8. Committee on HIV Prevention Strategies in the United States, Institute of Medicine, Ruiz MS et al., eds., No Time to Lose: Getting More from HIV Prevention, Washington, DC: National Academies Press, 2001.
9. Society for Adolescent Health and Medicine, Abstinence-only-until-marriage policies and programs: an updated position paper of the Society for Adolescent Health and Medicine, Journal of Adolescent Health, 2017, 61:400–403, doi:10.1016/j.jadohealth.2017.06.001.
10. Goesling B et al., Programs to reduce teen pregnancy, sexually transmitted infections, and associated sexual risk behaviors: a systematic review, Journal of Adolescent Health, 2014, 54(5):499–507, doi:10.1016/j.jadohealth.2013.12.004.
11. Chin HB et al., The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections, American Journal of Preventive Medicine, 2012, 42(3):272–294, doi:10.1016/j.amepre.2011.11.006.
12. United Nations Population Fund (UNFPA), Emerging Evidence, Lessons and Practice in Comprehensive Sexuality Education: A Global Review, Paris: United Nations Educational, Scientific and Cultural Organization, 2015, http://www.unfpa.org/publications/emerging-evidence-lessons-and-practice-comprehensive-sexuality-education-global-review.
13. Office of Adolescent Health, U.S. Department of Health and Human Services (HHS), Evaluation and research, 2017, https://www.hhs.gov/ash/oah/evaluation-and-research/index.html.
14. Feldman Farb A and Margolis AL, The Teen Pregnancy Prevention Program (2010–2015): synthesis of impact findings, American Journal of Public Health, 2016, 106(S1):S9–S15, doi:10.2105/AJPH.2016.303367.
15. Santelli JS et al., Abstinence-only-until-marriage: an updated review of U.S. policies and programs and their impact, Journal of Adolescent Health, 2017, 61:273–280, doi:10.1016/j.jadohealth.2017.05.031.
16. Santelli JS, Medical accuracy in sexuality education: ideology and the scientific process, American Journal of Public Health, 2008, 98(10):1786–1792, doi:10.2105/AJPH.2007.119602.
17. Kirby DB, The impact of abstinence and comprehensive sex and STD/HIV education programs on adolescent sexual behavior, Sexuality Research and Social Policy, 2008, 5(3):18–27, doi:10.1525/srsp.2008.5.3.18.
18. Underhill K, Montgomery P and Operario D, Sexual abstinence only programmes to prevent HIV infection in high income countries: systematic review, BMJ, 2007, 335(7613):248, doi:10.1136/bmj.39245.446586.BE.
19. Denford S et al., A comprehensive review of reviews of school-based interventions to improve sexual-health, Health Psychology Review, 2017, 11(1):33–52, doi:10.1080/17437199.2016.1240625.
20. Paik A, Sanchagrin KJ and Heimer K, Broken promises: abstinence pledging and sexual and reproductive health, Journal of Marriage and Family, 2016, 78(2):546–561, doi:10.1111/jomf.12279.
21. HHS and Centers for Disease Control and Prevention (CDC), Results from the School Health Policies and Practices Study 2014, 2015, https://www.cdc.gov/healthyyouth/data/shpps/pdf/shpps-508-final_101315.pdf.
22. Kann L, Brener ND and Allensworth DD, Health education: results from the School Health Policies and Programs Study 2000, Journal of School Health, 2001, 71(7):266–278, doi:10.1111/j.1746-1561.2001.tb03504.x.
23. Demissie Z et al., School Health Profiles 2014: Characteristics of Health Programs Among Secondary Schools, HHS and CDC, 2015, https://www.cdc.gov/healthyyouth/data/profiles/pdf/2014/2014_profiles_report.pdf.
24. Eisenberg ME et al., Parents’ beliefs about condoms and oral contraceptives: Are they medically accurate?, Perspectives on Sexual and Reproductive Health, 2004, 36(2):50–57, doi:10.1111/j.1931-2393.2004.tb00008.x.
25. Kantor L and Levitz N, Parents’ views on sex education in schools: How much do Democrats and Republicans agree?, PLoS ONE, 2017, 12(7), doi:10.1371/journal.pone.0180250.
26. Retford D, Mullen M and Winkler R, eds., AMA Guidelines for Adolescent Preventive Services (GAPS), Baltimore: Williams & Wilkins, 1994.
27. Hagan JF, Shaw JS and Duncan PM, eds., Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, third ed., Elk Grove Village, IL: American Academy of Pediatrics, 2008.
28. ACOG, Counseling adolescents about contraception, Committee Opinion No. 710, 2017, https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Counseling-Adolescents-About-Contraception.
29. Fuentes L et al., Adolescents’ and young adults’ reports of barriers to confidential health care and receipt of contraceptive services, Journal of Adolescent Health, 2017, 0(0), doi:10.1016/j.jadohealth.2017.10.011.
30. Alexander SC et al., Sexuality talk during adolescent health maintenance visits, JAMA Pediatrics, 2014, 168(2):163–169, doi:10.1001/jamapediatrics.2013.4338.
31. Boekeloo BO, Will you ask? Will they tell you? Are you ready to hear and respond?, JAMA Pediatrics, 2014, 168(2):111–113, doi:10.1001/jamapediatrics.2013.4605.
32. Donaldson AA et al., Receipt of sexual health information from parents, teachers, and healthcare providers by sexually experienced U.S. adolescents, Journal of Adolescent Health, 2013, 53(2):235–240, doi:10.1016/j.jadohealth.2013.03.017.
33. Simon L and Daneback K, Adolescents’ use of the Internet for sex education: a thematic and critical review of the literature, International Journal of Sexual Health, 2013, 25(4):305–319, doi:10.1080/19317611.2013.823899.
34. Lenhart A, Teens, Social Media and Technology Overview 2015, Washington, DC: Pew Research Center, 2015, http://www.pewinternet.org/2015/04/09/teens-social-media-technology-2015/.
35. Advocates for Youth, Answer, GLSEN, Human Rights Campaign, Planned Parenthood Federation of America and SIECUS, A Call to Action: LGBTQ Youth Need Inclusive Sex Education, 2015, http://www.hrc.org/resources/a-call-to-action-lgbtq-youth-need-inclusive-sex-education/.
36. Friedman CK and Morgan EM, Comparing sexual-minority and heterosexual young women’s friends and parents as sources of support for sexual issues, Journal of Youth and Adolescence, 2009, 38(7):920–936, doi:10.1007/s10964-008-9361-0.
37. Mitchell KJ et al., Accessing sexual health information online: use, motivations and consequences for youth with different sexual orientations, Health Education Research, 2014, 29(1):147–157, doi:10.1093/her/cyt071.
38. Anderson M, How having smartphones (or not) shapes the way teens communicate, Pew Research Center, 2015, http://www.pewresearch.org/fact-tank/2015/08/20/how-having-smartphones-or-not-shapes-the-way-teens-communicate/.
39. Guse K et al., Interventions using new digital media to improve adolescent sexual health: a systematic review, Journal of Adolescent Health, 2012, 51(6):535–543, doi:10.1016/j.jadohealth.2012.03.014.
40. Buhi ER et al., Quality and accuracy of sexual health information web sites visited by young people, Journal of Adolescent Health, 2010, 47(2):206–208, doi:10.1016/j.jadohealth.2010.01.002.
41. Guttmacher Institute, Sex and HIV education, State Laws and Policies (as of December 2017), 2017, https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education.
Figure 1: Declines in Birth Control Education
Source: Reference 1.
Figure 2: Sex Education in Schools
Sources: References 21, 22 and Kann L, Telljohann SK and Wooley SF, Health education: results from the School Health Policies and Programs Study 2006, Journal of School Health, 2007, 77(8):408–434, doi:10.1111/j.1746-1561.2007.00228.x.
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