2017 What Percentage of Schools Believe in Sexual Education

Problem

According to the 2015 Youth Risk Behavior Survey, 41.2% of teens in the United States reported ever having sexual intercourse and 30.1% had been sexually active in the 3 months prior to the survey (Center for Disease Control [CDC], 2015). Teen pregnancy and sexually transmitted infections (STIs) are leading public health problems in the United States (Office of Disease Prevention and Health Promotion, 2017). While abstinence is the only 100% effective way to prevent these potential problems, over 40% of students are not practicing abstinence. Moreover, studies show that abstinence only education (AOE) programs are not effective in reducing sexual risk-taking behaviors (Society for Adolescent Health and Medicine [SAHM], 2017). Comprehensive sex education (CSE) teaches medically accurate and age-appropriate information about abstinence and contraceptives and also addresses the psychosocial, emotional, physical, and mental aspects of sexuality (Sexuality Information and Education Council of the United States [SIECUS], 2009). CSE programs show the most promise in helping reduce risky sexual behaviors (Advocate for Youth, 2012).

Sexual health education in U.S. schools has changed significantly over the past 50 years as a direct result of federal and state legislation and funding. Beginning in the 1960s, in response to the sexual revolution, federal legislation on sexual health education became more progressive. In 1966, the U.S. Department of Education, to address the growing issue of teen pregnancy, funded 645 agencies throughout the United States to develop sexual health education programs. While there were no stipulations on the type of sexual health education required, CSE that emphasized birth control was included in many of the curricula. In 1971, President Nixon supported the implementation of CSE in all public schools, emphasizing sex as a healthy part of life, and giving students access to the information required to make informed healthy sexual decisions (Huber & Firmin, 2014).

The promotion and expansion of CSE was halted in the 1980s in response to the HIV epidemic and efforts of the religious right (Huber & Firmin, 2014). Legislation was enacted encouraging states to discard CSE and adopt AOE (Carr & Packham, 2017). In 1981, the Adolescent Family Life Act was passed with a primary goal to promote chastity and self-discipline; in 1996, the welfare reform law enacted Title V of the Social Security Act that provided grants to states that adopted AOE and its tenets (Lerner & Hawkins, 2016). In order to receive a grant, the curricula needed to cover the eight points of AOE (https://www.acf.hhs.gov/fysb/resource/aegp-fact-sheet; U.S. Department of Health and Human Services, 2017). The grants grew substantially between 1996 and 2006, with many states adopting abstinence programs to obtain federal funding. It is estimated that over US$2 billion has been spent on AOE in the United States (Donovan, 2017). This trend continued until 2010 when President Obama cut funding to AOE and increased funding to programs that supported CSE (Kaiser Foundation, 2002; Weiser & Miller, 2010). Currently, there are still more federal funding opportunities available to AOE programming than to CSE (Lerner & Hawkins, 2016).

While the U.S. government has promoted AOE in schools, leading health and educational organizations have supported CSE (WHO, 1993). The United Nations Educational, Scientific and Cultural Organization (UNESCO) and the World Health Organization (WHO) view CSE as a human right, with the objective to provide accurate, realistic information and life skills in a nonjudgmental way to help adolescents make informed decisions. Information should be free of stigma and reviewed regularly for inaccuracies (UNESCO, 2015; WHO, 2010). The CDC (2014) recommends comprehensive education delivered by trained instructors that provides information on the benefits of abstinence but also discusses 16 critical sexual health topics including communication, HIV and STI transmission risks, contraceptives, decision-making skills, and the efficacy of condoms. The SAHM (2017), released a position paper addressing the problems with AOE, recommending it be abandoned due to the lack of evidence of efficacy. Failures identified in the position paper included not meeting the needs of youth in sexual minority, being in violation of the sexual and reproductive rights of youth, and the negative impact of the programs misinformation.

The purpose of this review was to examine the role of policy on sexual health education. Further, this review provides an understanding about continued governmental support for AOE in the United States, despite the fact that leading health and educational organizations promote CSE. A systemic review of studies published between 2000 and 2017 was conducted to evaluate the role of federal policy and funding on sexual health education in U.S. public schools.

Literature Search

The review was conducted according to the Preferred Reporting Items for Systemic Review and Meta-Analysis (PRISMA) guidelines (Moher, Liberati, Tetzlaff, Altman, & the PRISMA Group, 2009). The search was conducted using four online databases: CINAHL, PubMed, Scopus, and EBSCO. The search strategy for CINAHL was as follows: Limits were set to include research articles published in English in peer-reviewed academic journals, age restriction set to "all child," and major heading of "sex education." The search date was set from January 2000 to December 2017. The reason for the 2000 start date was to give programs established and funded by the 1996 Title V Welfare Reform Act the opportunity to be implemented, evaluated, and published. Subject age was restricted to "all child" to eliminate articles that included college-age individuals. The combinations of the search terms used were "sexual health education" and "policy" and "schools"; "sexual health education" and "policy"; and "sex education policies." The same searches were conducted in each of the other databases. The process is illustrated in Figure 1 . The initial searches yielded a total of 548 articles; 497 articles could be excluded after reading the title or abstract, and 51 articles were viewed in full text. Articles reviewed addressed sexual health education policy and its influence on primary and secondary school education; articles that analyzed parents, students, and staff opinions of sexual health education policy; and articles that addressed policy recommendations by trusted health organizations. After reading the full text articles, 26 articles were excluded for the following reasons: 3 articles were editorials; 10 were not set in the United States; 2 discussed only elementary school programming; 6 addressed program implementations, not policy; and 6 addressed individual school or district policies. Hence, a total of 25 articles were included in the review (Table 1).

Figure 1. PRISMA diagram showingssss search and screening process, and selection of studies for inclusion in review. Note. PRISMA = preferred reporting items for systemic review and meta-analysis.

Table 1. Review of Studies Related to Sexual Health Education Policy in Schools.

Current State Policies

While most teens report having received some form of sexual health education in school, the content of the programming varies widely. According to the CDC (2015), fewer than 50% of high school students and only 20% of middle school students receive instruction on all 16 essential topics of CSE recommended by the CDC. One study reviewed reported a decline in the receipt of formal instruction in schools on methods of birth control, saying no to sex, STIs, and HIV (Lindberg, Maddow-Zimet, & Boonstra, 2016). Another study examined differences in content presented to students based on geographical region in the United States (Landry, Darrach, Singh, & Higgins, 2003). Teachers in the South were less likely to instruct on CSE and more likely to instruct on AOE and the ineffectiveness of contraceptives than teachers in the Northeast (Landry et al., 2003). However, the problem of curriculum content does not seem to be restricted by geography. There was no reporting by districts to the state about exactly what is taught for both AOE and CSE (Malone & Rodriguez, 2011).

The federal government does not mandate a specific type of sexual health education program. Policy adopted at the state level and implemented by individual districts in the state dictate program type (Malone & Rodriguez, 2011). The Guttmacher Institute (2017) has published a summary of state policies regarding sex education. Only 24 states mandate sex education, and just 13 states require that the information taught be medically accurate. If sex education is taught in a state, 26 states require that abstinence be the emphasis, 18 require highlighting the importance of sex only in marriage, and 12 require discussion of sexual orientation. Of note is the fact that three states require that only negative information is provided with regard to sexual orientation. Even in states that have no mandate, AOE is the number one curriculum being taught (Guttmacher, 2017).

Program Effectiveness

To evaluate the efficacy of programs, researchers have examined teen sexual health outcomes (Jozkowski & Crawford, 2016). Three studies focused on teen birth or abortion rates to determine whether there was a difference between states that offered AOE compared to states that offered CSE (Chevrette & Abenhaim, 2015; Stanger-Hall & Hall, 2011; Yang & Gaydos, 2010). One study found no difference in teen birth or abortion rates based on policy, but two found increased teen birth rate in states that had AOE (Chevrette & Abenhaim, 2015; Stanger-Hall & Hall, 2011; Yang & Gaydos, 2010). Researchers provided evidence that as AOE monies increased in a state so did the birth rate (Stanger-Hall-Hall & Hall, 2011; Yang & Gaydos, 2010). Another study examined data on teen health outcomes in five states that switched from no policy to AOE and found no difference in teen birth and abortion rates (Carr & Packham, 2017). Of note, after changing to AOE, there was a 10% increase in STI rates (Carr & Packham, 2017). Another study in this review reported that such an increase in STI rates is likely due to the negative or false information presented in AOE regarding contraceptives and their failure rate (Weiser & Miller, 2010). This misinformation was felt to lead adolescents into falsely believing that condoms do not work, leaving them at greater risk of pregnancy and STIs (Weiser & Miller, 2010). The empirical evidence does not support the notion that AOE delays sexual initiation or reduces pregnancy and abortion rates (Chevrette & Abenhaim, 2015). On the contrary, the lack of information on safe sex, or misinformation provided, inhibits adolescents from making informed responsible safe sex decisions (Weiser & Miller, 2010).

The content of AOE has come under scrutiny in the recent past. Legislators have known since 2004 that AOE could cause harm. U.S. Congressman Henry Waxman examined abstinence curricula and found that 80% contained false information, the curricula inaccurately presented the effectiveness of contraceptives and risks of abortion, contained scientific errors, blurred the lines between religion and science, and treated male and female stereotypes as scientific fact (U.S. House of Representatives Committee on Government Reform-Minority Staff Special Investigations Division, 2004). This misinformation inhibits an adolescent's ability to make an informed decision on sexual behavior and ultimately puts them at greater risk of STIs and pregnancy (Weiser & Miller, 2010).

Many parents are concerned that CSE will increase an adolescent's sexual activity and cause early sexual initiation (Kohler, Manhart, & Lafferty, 2008). To determine whether these concerns were justified, researchers surveyed 1,719 adolescents throughout the United States. Results showed that 9.4% of adolescents surveyed had never received sexual health education, 23.8% received AOE, and 66.8% received CSE (Kohler et al., 2008). Adolescents who received CSE did not have increased sexual activity or early initiation to sex and had a lower risk for pregnancy than those who received AOE or no education (Kohler et al., 2008).

It appears that AOE has a negative impact on adolescent health. Teen pregnancy and STI rates are higher in states that mandate an emphasis on AOE. In the 10 states with the highest teen birth rates, 7 stress abstinence in their sexual health education and 6 states focus on the importance of sex only within the context of marriage (CDC, 2018; Guttmacher Institute, 2017). Conversely, in the states with the 10 lowest teen birth rates, only 3 mandate abstinence be emphasized (CDC, 2018; Guttmacher Institute, 2017). With regard to STI rates, the same pattern is seen. In the 10 states with the highest reported gonorrhea rates, 9 require an emphasis on abstinence education, as opposed to the 10 lowest where only 3 require such an emphasis (CDC, 2017; Guttmacher Institute, 2017). By focusing on AOE, youth are missing critical information that can help them make better sexual health decisions.

Factors Influencing Policy

States have consistently adopted sexual education programming that is in contrast to public health officials' recommendations (CDC, 2015). The reason for such decisions that go against scientific evidence may be the availability of grant money for AOE. In the fiscal year 2008, US$177 million was allocated in the federal budget for AOE grants to states, with no funding for CSE programs. In 2010, Title V was amended to include the Personal Responsibility Education Program, a program aimed at teaching adolescents about abstinence and contraception (Donovan, 2017). Since the amendment funding to AOE has decreased and CSE has increased, many states are still not adopting CSE programming (Guttmacher, 2017).

Other factors can impact the type of sexual health education policy that a state implements, such as political affiliation, religiosity, and conservative or liberal views (Baker, Smith, & Stoss, 2015; Bleakley, Hennessy, & Fishbein, 2010; Kaiser Foundation, 2002; Kantor & Levitz, 2017). Religious and political views have been cited as two key factors in determining whether a person is in favor of CSE (Bleakley et al., 2010). Liberals are more likely than conservatives to support CSE and democrats more likely in favor of sex education that provides birth control, STIs healthy relationships, and sexual orientation information than republicans (Constantine, Jerman, & Haung, 2007; Kantor & Levitz, 2017). Previous research has demonstrated that states with self-reported high levels of theism are more likely to have sexual health programming that focuses on abstinence, and states with low levels of theism are more likely to have CSE (Baker et al., 2015).

Opinions on Policy

Despite the federal impetus for AOE, most American citizens support CSE (Constantine et al., 2007; Kantor & Levitz, 2017). Numerous studies have been conducted using random surveys and all show overwhelming support for CSE (Bleakley, Hennessy, & Fishbein, 2006; Constantine et al., 2007; Eisenberg, Bernat, Bearinger, & Resnick, 2008, 2009; Millner, Mulekar, & Turrens, 2015). One study surveyed 1,602 parents in Minnesota regarding CSE and condom instruction. The Minnesota study found that 89.3% of parents supported CSE, 86% agreed information on condoms should be taught, and 59% agreed condoms should be made available to high school students who ask for them (Eisenberg et al., 2008, 2009). Four cross-sectional studies using telephone surveys have been conducted to assess public opinions about sexual health education. Two studies were conducted in areas with AOE, one in a state with CSE (Ito et al., 2006), and one was a national survey (Millner et al., 2015). In all four studies, the majority of individuals surveyed supported CSE and opposed politicians determining sexual health education content in schools (Bleakley et al., 2006; Constantine et al., 2007; Ito et al., 2006; Millner et al., 2015). In summary, with regard to CSE and AOE, the literature shows that policy does not match public or parental opinion. All studies reviewed showed overwhelming support for CSE, even in areas where AOE is the policy of the state.

Discussion

This review focused on the state of policy influence on sexual health education in U.S. schools and based on literature published from 2000 to 2017. In general, the American public and parents support comprehensive sexual education in schools. However, the reality is that most U.S. schools provide abstinence only programs.

Parents should be aware of the type of sexual health education that their children are receiving. Parents living in a state, or if children are attending a school, with an AOE policy, then parents could work with administrators and policy makers to change to CSE. There is a need for politicians and policy makers to start listening to parents and public health organizations to improve the type and quality of sexual health programming offered in schools.

Public opinion and research, not personal opinion, needs to guide policy. For example, Texas has one of the highest teen birth rates in the country, 37.8 births per 1,000 teenage girls compared to 24.2 births per 1,000 teenage girls in the United States, yet they mandate AOE programs because the politicians choose to follow their beliefs, not the needs of their constituents (Smith, 2010). Moreover, CSE has helped decrease the teen birth rate in other states (Stanger-Hall-Hall, & Hall, 2011; U.S. Department of Health and Human Services, 2016). Better teen outcomes can be achieved if parents, schools, and policy makers realize the success of CSE and work with public health organizations to create and implement high-quality CSE (Jozkowski & Crawford, 2016). Efforts need to be made to stop allocation of Title V monies to programming that has been shown to be misleading and unsuccessful (U.S. House of Representatives Committee on Government Reform-Minority Staff Special Investigations Division, 2004). Funding should instead be invested in CSE that meets the 16 CDC (2014) critical sex education topics (https://www.cdc.gov/healthyyouth/data/profiles/pdf/16_criteria.pdf). Much literature exists to support the notion that current sex education policies should be adjusted to match public opinion and the recommendations of public health agencies (Bleakley et al., 2006; Constantine et al., 2007; Ito et al., 2006; Millner et al., 2015). Sex education needs to be holistic; contain information on abstinence as well as contraceptives and STI; and provide information to meet the mental, physical, emotional, and psychosocial needs of sexuality in an adolescent (SIECUS, 2009).

Implications for School Nursing Practice

Sex education in schools is a matter of public health, not a religious or political one (Baker et al., 2015; Bleakley et al., 2006). CSE is much more than just handing out condoms. If implemented correctly, sex education teaches students about anatomy and physiology, healthy relationships, hygiene, positive self-image, how to handle uncomfortable situations, and about health resources available to them. School nurses are in a unique position to play a critical role in policy change with regard to sex education. As public health professionals, school nurses have the responsibility to advocate for legislation that enhances the sexual health and well-being of their students. School nurses should take the lead in raising awareness among parents, teachers, administrators, and staff about the successes of CSE on teen sexual health outcomes. Strategies for raising awareness might include such activities as school presentations at parent teachers association, faculty, school board, and community meetings to draw attention to the issue and gain support. Further, school nurses can seek political sponsors to make proposals, rally cosponsors for support, and give testimony to the effectiveness of CSE programming (Maryland & Gonzalez, 2012).

Conclusion

This review indicated that U.S. government officials are endorsing AOE while leading health and educational organizations clearly support CSE. There is strong published evidence with regard to outcomes of sexual health programs. AOE programs have been shown to be detrimental to teen sexual health outcomes (Weiser & Miller, 2010; Yang & Gaydos, 2010). Conversely, CSE programs have been shown to decrease teen birth rates and meet the educational needs of teens who are already sexually active or in the sexual minority (Malone & Rodriguez, 2011; Stanger-Hall-Hall & Hall, 2011). Yet, policy makers continue to allocate funding for AOE in schools (Donovan, 2017). Factors that play a role in policy, such as conservative political and religious, must be considered. A majority of the public has voiced support for CSE, even when identifying as religious and conservative (Bleakley et al., 2010; Constantine et al., 2007; Kantor & Levitz, 2017). Policy needs to change to match parent opinion and public health recommendations. Sex education in schools should provide adolescents with medically accurate information and the skills needed to make informed decisions regarding their sexual behaviors.

Future research should focus on strategies to empower parents and voters to address mandates for AOE. While the studies in this review examined opinion versus policy and suggested making educational choice known to politicians and administrators, there was no direction provided or strategies given about how to change policy (Constantine et al., 2007; Eisenberg et al., 2008, 2009). Effective interventions are needed that can help parents and citizens work to change policy and advocate to help forge the path for CSE.

Author Contributions
MR and ME contributed to the conception and design of the work, data collection, data analysis and interpretation, critical revision of the manuscript, and final revision approval. MR drafted the manuscript.

Declaration of Conflicting Interests
The authors(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD
Maureen Rabbitte, MSN, RN, PEL-CSN http://orcid.org/0000-0003-3964-9221

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Maureen Rabbitte, MSN, RN, PEL-CSN, is a PhD student of Sinclair School of Nursing at University of Missouri, Columbia, MO, and an assistant professor at Saint Xavier University, Chicago, IL.

Maithe Enriquez, PhD, APRN, FAAN, is an associate professor of Sinclair School of Nursing at University of Missouri, Columbia, MO.

2017 What Percentage of Schools Believe in Sexual Education

Source: https://journals.sagepub.com/doi/full/10.1177/1059840518789240

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