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Sexuality Education As Part Of A Comprehensive Health Education Program in K-12 Schools

Policy Date: 12/14/2005
Policy Number: 2005-10

The American Public Health Association has asserted that all young people must be prepared to become sexually healthy adults and provided with the knowledge and skills necessary to avoid HIV, other sexually-transmitted infections, and unintended pregnancy.1 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.2 APHA believes that the nation's K-12 schools, in concert with families, religious and community groups, and health care professionals, should implement effective sexuality education programs that are age, gender and culturally-appropriate, support the elimination of health disparities, and are based on sound science and proven principles of instruction..

Young people in the United States are at persistent risk for HIV infection, STDs, and unintended pregnancy. In addition, youth of racial and ethnic minorities are at particular risk, as indicated by the following data. Eliminating such health disparities is a priority for APHA.

According to the 2003 National Youth Risk Behavior Survey, 46.7 percent of students in grades 9-12 reported ever having sexual intercourse. The prevalence of having had sexual intercourse varied by race/ethnicity (e.g., black students  67.3 percent; Hispanic students  51.4 percent, and white students  41.8 percent). In addition, 14.4 percent of students reported having four or more sex partners in their lifetime. The prevalence of four or more partners among black students (28.8 percent) was greater than that among Hispanic students (15.7 percent) and white students (10.8 percent). Among those students who reported being sexually active, 25.4 percent had drunk alcohol or used drugs before last sexual intercourse. The prevalence of having drunk alcohol or used drugs before last sexual intercourse was greater among white students (26.8 percent) and Hispanic students (24.1 percent) than among black students (19.5 percent).3

In 2003, an estimated 2,050 young people, ages 13-24, received a diagnosis of AIDS (4.6 percent of the 43,171 estimated total of persons diagnosed with AIDS in 2003). HIV diagnosed in young adults was acquired during adolescence. Black and Hispanic adolescents have been disproportionately affected by the HIV/AIDS epidemic. In 2003, 66 percent of reported AIDS cases in 13- to 19-year-olds were in blacks, and 21 percent of AIDS cases in adolescents were in Hispanics.4

Compared to older adults, adolescents (10- to 19-year-olds) and young adults (20- to 24-year-olds) are at higher risk for acquiring STDs for a number of reasons. There are also differences in STD rates among racial/ethnic groups. For example, in 2003, black women aged 15-19 years had a gonorrhea rate of 2,947.8 cases per 100,000 females. This rate is 14 times greater than the 2003 rate among white females of similar age (204.8). The rate among black men aged 15-19 (1,464.1 cases per 100,000 males) was 39 times higher than the rate among white males of the same age (37.7 per 100,000). For women, the highest age-specific rates of reported chlamydia in 2003 were among 15- to 19-year-olds (2,687.3 per 100,000 females). Rates within this age group varied among racial/ethnic groups (whites  748.1; blacks  5,071.3; Hispanics  1,611.0, Asians/Pacific Islanders  503.9; and American Indians/Alaskan Natives  2,485.5 [all rates per 100,000]).5

The downward trend in the rates of teen pregnancies, births, and abortions has continued. In 2000, among women aged 15-19, the pregnancy rate was 83.6 (all rates per 1,000); birthrate 47.7, and the abortion rate 24.0. Pregnancy rates were greater among black youth (153.3) and Hispanic youth (137.9) than among white youth (71.4). There were also differences in birthrates (black youth  77.4; Hispanic youth  87.1; and white youth  43.2) as well as abortion rates (black youth  54.9; Hispanic youth  30.3; and white youth  17.9).6

Experts in the fields of adolescent development, health, and education recommend that sexuality education programs as part of a comprehensive health education program assist young people in developing a positive view of their sexuality, provide them with information necessary to protect their sexual health, and help them acquire skills to make informed decisions, both now and in the future.7 Currently, there are two contrasting approaches to teaching adolescents about sexuality: 1) comprehensive sexuality education (CSE) programs, which includes abstinence-based instruction; and 2) abstinence-only-until-marriage (AOUM) programs.

CSE programs emphasize abstinence from all sexual activity as the most reliable method of avoiding sexually transmitted infections and pregnancy. In addition, CSE programs teach adolescents about contraceptives and barrier methods to reduce their risk of contracting an STI and/or becoming pregnant. Ideally, CSE programs start in kindergarten and continue through the twelfth grade, are taught by teachers who have completed CSE-related instruction, and provide adolescents with developmentally appropriate information regarding a broad range of topics related to sexuality, including sexual development, reproductive health, interpersonal relationships, body image, and gender roles. Furthermore, CSE programs provide opportunities for students to develop communication, decision-making, and other interpersonal skills.7 CSE programs also allow parents to exercise the option of taking their children out of such classes if they do not wish their children to be exposed to this information.

Research has demonstrated that parents strongly and consistently favor age-appropriate and culturally sensitive school-based sexuality education programs that stress abstinence and include information about contraception as part of a comprehensive health education program2, 4-14Moreover, both parents and teens report that such programs do not send teens a mixed or confusing message.2 Parents also support sexuality instruction about topics such as reproductive anatomy and physiology, physical changes associated with puberty, and body image beginning earlier in school, preferably during the elementary grades. 8-10,12,13 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. 15 Due to the epidemic of overweight and obesity among school-aged children in the United States, such sexuality instruction is particularly warranted, as overweight and obese girls are nearly twice as likely as healthy weight girls to reach sexual maturity at an earlier age and to report greater body dissatisfaction, lower self-esteem, and to engage in a variety of health and sexual risk behaviors at an earlier age than healthy weight girls.16-24

Several comprehensive sexuality education programs have demonstrated, through rigorous evaluation, to delay the onset of sexual intercourse, reduce the frequency of sexual intercourse, reduce the number of sex partners, and/or increase the use of condoms and/or other forms of contraception among teens; some have demonstrated sustained positive effects on behavior for as long as three years25 Between 1991 and 2001, pregnancy rates declined 33 percent among youth aged 15-17 years. The Centers for Disease Control and Prevention (CDC) attributes 53 percent of this decline to decreased sexual experience and 47 percent to improved contraceptive use.26

Abstinence-only-until-marriage (AOUM) programs are required to teach abstinence from all sexual behavior outside of marriage as the expected standard of human sexual activity and that sexual activity outside of marriage is likely to have harmful psychological and physical effects.27 Moreover, AOUM programs either do not include information about contraceptives and disease-prevention methods, or only present young people with the failure rates of these methods.

A report prepared for Rep. Henry A. Waxman by the minority staff of the House Committee on Government Reform in December 2004 documented that 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.28 In particular, these programs included misrepresentations about the effectiveness of condoms in preventing STIs and pregnancy, as well as gender stereotypes, moral judgments, religious concepts, and factual errors.28

To date, no AOUM program that conforms to the eight point criteria listed in Section 510(b) of Title V of the Social Security Act and focuses exclusively on promoting abstinence until marriage has shown credible evidence of delaying sexual initiation or reducing the frequency of sexual intercourse.29-31 In addition, recent evaluations from Arizona, Florida, Iowa, Maryland, Minnesota, Missouri, Nebraska, Oregon, Pennsylvania, Texas, and Washington state found such programs demonstrated little evidence of sustained, long-term impact on adolescents' attitudes favoring abstinence or on teens' intentions to abstain.31-44

In a nationally representative study of adolescents aged 12-17 years, adolescents who took virginity pledges delayed onset of intercourse of average of 18 months longer than those who did not take a virginity pledge. The effect of pledging virginity is variable. It is effective only in the context of, and in interaction with, other youth similar to those pledging. It provides a means for young people to differentiate themselves from other people (who are non-pledgers). The effect of pledging is dependent on the number of other pledgers in the community. If there are a very few, there is no real effect on initiation of intercourse because there is no real community of like-minded young people to interact with and support the pledge. Likewise, if there are too many pledgers (more than 40 percent), there is also no effect because there is no real differentiation of identity. In addition, pledging is more effective for younger teens than older teens. However, 88 percent of adolescents who took virginity pledges within abstinence-only-until-marriage programs reported engaging in sexual intercourse before marriage.45 Even more disturbing, the study reported that adolescents who took virginity pledges were less likely to use condoms when they became sexually active, more likely to engage in oral-genital and anogenital sexual behaviors, and less likely to seek and obtain care for STIs than non-pledgers, even though they were as likely to contract an STI as non-pledgers.46

Despite the lack of evidence supporting the effectiveness of abstinence-only-until-marriage programs, as well as evidence demonstrating the potential harm such programs have on adolescents' sexual health, the federal government continues to increase funding for abstinence-only-until-marriage programs. As an example of this trend, during the fiscal year 2005, the federal government planned to spend approximately $170 million on abstinence-only-until marriage programs and in his fiscal year 2006 budget request to Congress, the president requested an appropriation increase of $38 million.47 National organizations that address medical, HIV prevention, and sexual health related issues have expressed a concern that a shift in U.S. government policy stressing lack of condom efficacy within educational materials, including within a new Department of Health and Human Services' Web site for parents, has caused confusion in the general public about whether condoms should be used and promoted for the prevention of HIV infection.48-50 However, numerous studies have demonstrated that latex condoms, when used consistently and correctly, are highly effective in preventing transmission of HIV, the virus that causes AIDS. In addition, correct and consistent use of latex condoms can reduce the risk of other sexually transmitted diseases, including gonorrhea, chlamydia, and trichomoniasis.. While the effect of condoms in preventing human papillomavirus (HPV) infection is unknown, condom use has been associated with a lower rate of cervical cancer, an HPV-associated disease51.

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

1. All states should require that local school districts and schools plan and implement comprehensive sexuality education as an integral part of comprehensive K-12 school health education. The education must: be scientifically and medically accurate and based on theories and strategies with demonstrated evidence of effectiveness; be consistent with community standards, yet be implemented in a nonjudgmental manner that does not impose religious viewpoints on students; support positive parent/child communication and guidance; be age, developmentally, linguistically, 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 student needs, knowledge, and behavior to 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 or members of populations with high prevalence rates.52 Schools should be required to provide this instruction to all students unless a parent or legal guardian has specifically requested that their child be excused from (opt-out of) the entirety of the instruction before it begins. To initiate this process, the U.S. Department of Health and Human Services should convene special advisory groups of respected experts in the fields of adolescent health and sexuality education and parents to determine how best to implement this strategy, and APHA, with its state affiliates and other state-based advocacy groups, should work together to bring this about.

2. The U.S. Department of Health and Human Services should develop a technical assistance training program between established trainers in comprehensive sexuality education and teachers in need of this training. In addition, the Centers for Disease Control and Prevention's Division of Adolescent and School Health and/or the National Institute for Child Health and Human Development should provide funding for scientific research into the effectiveness of sexuality education programs.

3. Schools of higher education should prepare prospective teachers in the content and pedagogy of effective comprehensive sexuality education.

4. The U.S. Congress should immediately require that all sexuality education programs supported by the federal government, and sexual health information disseminated by federal agencies, be medically and scientifically accurate and based on theories and strategies with demonstrated evidence of effectiveness.

5. The Department of Health and Human Services should restore to its Web site recently censored information related to the efficacy and importance of condom use. Government funded or sponsored sexual health programs should also emphasize using condoms as prevention methods for those teens who are already sexually active or who may become sexually active. A large body of scientific literature demonstrates that condoms can be effective in preventing HIV transmission, gonorrhea, chlamydia, herpes simplex virus, and syphilis.53 This information should be reflected in sexual health information disseminated by the federal government and in all federally funded sexual health education programs.

6. The U.S. Department of Health and Human Services should remedy the errors uncovered in the December 2004 report The Content of Federally Funded Abstinence-Only Education Programs 28 by directing grantees whose work was highlighted in the report to provide sufficient evidence that every program using their materials has been provided with medically and scientifically accurate information.

7. The U.S. Congress should authorize and fully fund legislation that promotes comprehensive sexuality education programs which include information about both abstinence and contraception, include parent-child communications components; and teach goal-setting, decision-making, negotiation, and communication skills.

8. Advocates of comprehensive sexuality education programs bring this policy to the attention of governors, chief state school officers, and chairs of state boards of education.

References

1. APHA Resolutions 6917Sex Education in School Systems; 9207Underscoring the Continued Need for a Sustained National HIV Prevention and Public Education Initiative; 9309Sexuality Education; 200314Support for Sexual and Reproductive Health and Rights in the United States and Abroad: and 200409  Promoting Public Health and Education Goals through Coordinated School Health Programs. Resolutions 6917 and 9309 are hereby archived and replaced by this resolution.
2. Albert, B. With One Voice 2004: America's Adults and Teens Sound Off About Teen Pregnancy: An Annual National Survey, Washington, D.C.: National Campaign to Prevent Teen Pregnancy, December 2004.
3. Centers for Disease Control and Prevention. Surveillance Summaries, May 21, 2004. MMWR 2004:53(No.SS-2).
4. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2003 MMWR 2004:15.
5. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2003. Atlanta, GA: U.S. Department of Health and Human Services, September 2004.
6. Alan Guttmacher Institute. U.S. Teenage Pregnancy Statistics: Overall Trends, Trends by Race and Ethnicity and State-by-State Information. New York, NY:Author. February 19, 2004.
7. National Guidelines Task Force, Guidelines for Comprehensive Sexuality Education: Kindergarten-12th Grade, Third Edition. New York City, NY: Sexuality Information and Education Council of the United States. 2004.
8. American Social Health Association. N.C. poll: Most voters favor condom education in schools. News Release: May 28, 1996.
9. American Social Health Association. Florida poll: Three-fourths favor condom education in the schools. News Release: January 20, 1997.
10. Lindley, L., Reininger, B., Vincent M. et al. Support for school-based sexuality education among South Carolina voters. Journal of School Health. 1998; 68(5): 205-212.
11. Rose, Lowell C. & Alec Gallup. "The 30th Annual Phi Delta Kappa/Gallup Poll of the Public's Attitudes Toward the Public Schools." Phi Delta Kappan. 1998; 80(1): 41-56.
12. Haffner D and Wagoner J. Vast majority of Americans support sexuality education. SIECUS Report. 1999; 27(6):2223.
13. Hoff T, Greene L, McIntosh M, Rawlings N, D'Amico J (Princeton Survey Research Associates). Sex Education in America: A Series of National Surveys of Students, Parents, Teachers, and Principals. Summary of Findings. Pub.#3048. September 2000.
14. NPR/Kaiser Family Foundation/Kennedy School of Government. Sex Education in America. January 29, 2004. http://www.kff.org/newsmedia/7015.cfm
15. National Coalition to Support Sexuality Education. Washington, D.C.: http://www.ncsse.org.
16. Herman-Giddens, M., Slora, E., Wasserman, R. et al. Secondary sexual characteristics and menses in young girls seen in office practice: A study from the pediatric research in office settings network. Pediatrics. 1997; 99(4): 505.
17. Adair, L. and Gordon-Larsen, P. Maturational timing and overweight prevalence in US adolescent girls. American Journal of Public Health. 2001; 91(4): 642-644.
18. Kaplowitz, P., Slora, E., Wasserman, R. et al. Earlier onset of puberty in girls: Relation to increased body mass index and race. Pediatrics. 2001; 108(2): 347-353.
19. Wingood, G., DiClemente, R., Harrington, K., Davies, S. Body image and African-American females' sexual health. Journal of Women's Health & Gender-Based Medicine. 2002; 11(5): 433.
20. Wang, Y. Is obesity associated with early sexual maturation? A comparison of the association in American boys versus girls. Pediatrics. 2002; 110(5): 903-910.
21. Krahnstoever Davison, K., Susman, E., Lipps Birch, L. Percent body fat at age 5 predicts earlier pubertal development among girls age 9. Pediatrics. 2003; 111(4): 815-821.
22. McCabe, M. and Ricciardelli, L. A longitudinal study of pubertal timing and extreme body change behaviors among adolescent boys and girls. Adolescence. 2004; 39,153.
23. Patton, G., McMorris, B., Toumbourou, J. et al. Puberty and the onset of substance use and abuse. Pediatrics. 2004; 114(3): 300-306.
24. Styne, D. Puberty, obesity and ethnicity. Trends in Endocrinology and Metabolism. 2004; 15,10.
25. Kirby, D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, D.C.: National Campaign to Prevent Teen Pregnancy, 2001.
26. Santelli, J., Abma, J., Ventura, S., Lindberg, L., Morrow, B., Anderson, J. Lyss, S., and Hamilton, B., Can Changes in Sexual Behaviors Among High School Students Explain the Decline in Teen Pregnancy Rates in the 1990s? Journal of Adolescent Health 2004;35:8090.
27. Section 510, Title V of the Social Security Act. Public Law 104-193.
28. Special Investigations Division, The Content of Federally Funded Abstinence-Only Education Programs, U.S. House of Representatives Committee on Government ReformMinority Staff, December 2004.
29. Dailard, C. Understanding Abstinence': Implications for Individuals, Programs and Policies, Guttmacher Report on Public Policy, December 2003.
30. Kirby, D. Do Abstinence-Only Programs Delay the Initiation of Sex Among Young People and Reduce Teen Pregnancy? Washington, D.C.: National Campaign to Prevent Teen Pregnancy.
31. Goodson, P., Pruitt, B., Buhi, E., et al. Abstinence Education Evaluation Phase 5: Technical Report. Texas A&M University, September 2004.
32. LeCroy & Milligan Associates. Final Report, Arizona Abstinence Only Education Program Evaluation, 1998-2003. Phoenix: Arizona Dept. of Health Services, Office of Women's and Children's Health, June 2003. This report is available at http://www.azdhs.gov/phs/owch/pdf/abstinence_final_report2003.pdf
33. Kirby D, Korpi M, Barth RP, Cagampang HH. The impact of the Postponing Sexual Involvement curriculum among youths in California. Family Planning Perspectives 1997; 29: 100-108.
34. Florida State University School of Social Work. Florida DOH Abstinence Education Providers Pretest/Posttest Analysis. Tallahassee, FL: Florida State University and Florida Department of Health, 2002-2003.
35. Saunders EJ, Landsman MJ, Graf NM, Richardson B. Evaluation of Abstinence Only Education in Iowa: Year Five Report. [Iowa City, IA]: Iowa Department of Public Health, Oct. 2003. This report is available at http://www.uiowa.edu/~nrcfcp/publications/documents/abedfin03.pdf
36. Olsen LK and Agley D. Analysis of Four Years of Abstinence-Only Human Sexuality Programs in Maryland. [Abstract of paper presented at 130th Annual Meeting of the American Public Health Association, November 13, 2002.] This abstract is available at http://apha.confex.com/apha/129am/techprogram/paper_31389.htm
37. Professional Data Analysts and Professional Evaluation Services. Minnesota Education Now and Babies Later: Evaluation Report 1998-2002. St. Paul, MN: Minnesota Dept. of Health, Division of Family Health, Maternal and Child Health Section, [2003]. This report is available at http://www.saynotyet.com/report.htm 38. Barnett JE and Hurst CS. Abstinence education for rural youth: an evaluation of the Life's Walk program. Journal of School Health 2003; 73: 264-268.
39. Barnett, Jerrold E. An Evaluation of an Abstinence-only Sex Education Program in Rural Communities. [Submitted proposal, paper and other format sessions, Presentation at the 2002 annual meeting of American Educational Research Association.] Information on this paper is available at http://edtech.connect.msu.edu/searchaera2002/viewproposaltext.asp?propID=5292
40. Sather L and Zinn K. Effects of abstinence-only education on adolescent attitudes and values concerning premarital sexual intercourse. Family & Community Health 2002; 25:1-15.
41. Dowler D. Short-Term Impact of STARS (Students Today Aren't Ready for Sex). Portland: Oregon Health Division, Program Design and Evaluation Services, 2000. This report is available at http://www.dhs.state.or.us/children/publications/tpp/stars.pdf
42. Smith E, Dariotis J, Potter S. Evaluation of the Pennsylvania Abstinence Education and Related Services Initiative: 1998-2002. Philadelphia, PA: Maternal and Child Health Bureau of Family Health, Pennsylvania Department of Health, January 2003. This report is available at http://www.dsf.health.state.pa.us/health/lib/health/familyhealth/evaluationpaabstinence1998-20021.pdf
43. McBride D, Noyes P, Wear M, Malloy C. Abstinence Education Program Evaluation: Final Report, October 2003. Prepared for the Office of Maternal and Child Health Washington State Department of Health.
44. McBride D, Noyes P, Wear M, Villanueva T et al. Washington State's Teen Aware Program Evaluation: Final Report, December 2003. Prepared for the Office of Maternal and Child Health Washington State Department of Health, 2003.
45. Bearman P. and Bruckner H. Promising the Future: Virginity Pledges and First Intercourse. American Journal of Sociology. 2001; 106(4): 859-912.
46. Bruckner H. and Bearman P. After the promise: The STD consequences of adolescent virginity pledges. Journal of Adolescent Health. 2005; 36: 271-278.
47. Federal FY 2006 funding is for three separate abstinence programs - $13 million through the Adolescent Family Life Act administered through the Office of Population Affairs, $50 million to states administered by the Agency for Children and Families (ACF) that is authorized through the welfare bill, and $143 million for SPRANS (Special Programs of Regional and National Significance: Community-Based Abstinence Education), now administered by ACF as well. The entire proposed $38 million increase over FY 2005 is for community-based programs.
48. Sexuality Information and Education Council of the United States. SIECUS joins 145 organizations to protest new HHS website for parents. Policy Alert: March 31, 2005.
49. American College of Preventive Medicine. Response to report from meeting on condom effectiveness and STDs..Resolution 2001-05(H), September 6,2001.
50. American Foundation for AIDS Research. Issue Brief No. 1: The Effectiveness of Condoms in Preventing HIV Transmission Washington, D.C.: January 2005.
51. Centers for Disease Control and Prevention: Fact Sheet: Male Latex Condoms and Sexually Transmitted Diseases Atlanta, GA: August 4, 2004. This fact sheet and reference list are available at http://www.cdc.gov/nchstp/od/latex.htm.
52. This needs assessment and planning language was used by the Michigan State Board of Education in its Policy to Promote Health and Prevent Disease and Pregnancy, September 2003, available at http://www.michigan.gov/documents/Sex_Ed_Policy_77377_7.pdf.
53. HIV Medicine Association and Infectious Diseases Society of America. Preventing HIV and other Sexually Transmitted Infections: A Call for Science-Based Government Policies. Alexandria, VA: March 17, 2005.