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The State of Sex Education in the United States

      See Related Article p. 621
      For more than four decades, sex education has been a critically important but contentious public health and policy issue in the United States [
      Guttmacher Institute
      Sex and HIV education. State Policies in Brief.
      ,

      Guttmacher Institute. Facts on American teens' sources of information about sex. Available at: http://www.guttmacher.org/pubs/FB-Teen-Sex-Ed.html. Accessed March 1, 2016.

      ,

      Sexuality Information and Education Council of the United States (SEICUS). What’s New. Available at: http://www.siecus.org/. Accessed March 1, 2016.

      ,

      Sexuality Information and Education Council of the United States (SEICUS). 2015 Sex ed state legislative year-end report: top topics and takeaways. Available at: http://www.siecus.org. Accessed April 1, 2016.

      ,
      U.S. Department of Health and Human ServicesOffice of disease prevention and health promotion
      Healthy people 2020.
      ]. 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 [
      • Lindberg L.D.
      • Ku L.
      • Sonenstein F.
      Adolescents' reports of reproductive health education, 1988 and 1995.
      ]. 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 [
      • Boonstra H.D.
      Advocates call for a new approach after the era of ‘Abstinence-Only’ sex education.
      ,
      • Santelli J.
      • Ott M.A.
      • Lyon M.
      • et al.
      Abstinence and abstinence-only education: A review of U.S. policies and programs.
      ]. 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 [
      • Boonstra H.D.
      Advocates call for a new approach after the era of ‘Abstinence-Only’ sex education.
      ,
      • Santelli J.
      • Ott M.A.
      • Lyon M.
      • et al.
      Abstinence and abstinence-only education: A review of U.S. policies and programs.
      ]. 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 [
      • Boonstra H.D.
      Advocates call for a new approach after the era of ‘Abstinence-Only’ sex education.
      ,
      • Santelli J.
      • Ott M.A.
      • Lyon M.
      • et al.
      Abstinence and abstinence-only education: A review of U.S. policies and programs.
      ,
      • Chin H.B.
      • Sipe T.A.
      • Elder R.
      • 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: Two systematic reviews for the guide to community preventive services.
      ,
      • Lindberg L.D.
      • Maddow-Zimet I.
      Consequences of sex education on teen and young adult behaviors and outcomes.
      ,
      • Kirby D.B.
      • Laris B.A.
      • Rolleri L.A.
      Sex and HIV education programs: Their impact on sexual behaviors of young people throughout the world.
      ,
      • Schalet A.T.
      • Santelli J.S.
      • Russell S.T.
      • et al.
      Invited commentary: Broadening the evidence for adolescent sexual and reproductive health and education in the United States.
      ]. 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 [

      Sexuality Information and Education Council of the United States (SEICUS). 2015 Sex ed state legislative year-end report: top topics and takeaways. Available at: http://www.siecus.org. Accessed April 1, 2016.

      ,
      • Boonstra H.D.
      Advocates call for a new approach after the era of ‘Abstinence-Only’ sex education.
      ,
      • Santelli J.
      • Ott M.A.
      • Lyon M.
      • et al.
      Abstinence and abstinence-only education: A review of U.S. policies and programs.
      ,
      • Schalet A.T.
      • Santelli J.S.
      • Russell S.T.
      • et al.
      Invited commentary: Broadening the evidence for adolescent sexual and reproductive health and education in the United States.
      ,
      • Douglas J.M.
      • Fenton K.A.
      Understanding sexual health and its role in more effective prevention programs.
      ,
      • Strasburger V.C.
      • Brown S.S.
      Sex education in the 21st century.
      ].
      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 [

      Sexuality Information and Education Council of the United States (SEICUS). What’s New. Available at: http://www.siecus.org/. Accessed March 1, 2016.

      ]. 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 [
      • Boonstra H.D.
      Advocates call for a new approach after the era of ‘Abstinence-Only’ sex education.
      ,
      • Santelli J.
      • Ott M.A.
      • Lyon M.
      • et al.
      Abstinence and abstinence-only education: A review of U.S. policies and programs.
      ,
      • Chin H.B.
      • Sipe T.A.
      • Elder R.
      • 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: Two systematic reviews for the guide to community preventive services.
      ,
      • Kirby D.B.
      • Laris B.A.
      • Rolleri L.A.
      Sex and HIV education programs: Their impact on sexual behaviors of young people throughout the world.
      ,
      • Schalet A.T.
      • Santelli J.S.
      • Russell S.T.
      • et al.
      Invited commentary: Broadening the evidence for adolescent sexual and reproductive health and education in the United States.
      ,
      • Douglas J.M.
      • Fenton K.A.
      Understanding sexual health and its role in more effective prevention programs.
      ]. Other federal funding priorities have moved positively toward more medically accurate and evidence-based programs, including teen pregnancy prevention programs [
      Guttmacher Institute
      Sex and HIV education. State Policies in Brief.
      ,

      Sexuality Information and Education Council of the United States (SEICUS). What’s New. Available at: http://www.siecus.org/. Accessed March 1, 2016.

      ,
      • Schalet A.T.
      • Santelli J.S.
      • Russell S.T.
      • et al.
      Invited commentary: Broadening the evidence for adolescent sexual and reproductive health and education in the United States.
      ]. 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” [
      • Schalet A.T.
      • Santelli J.S.
      • Russell S.T.
      • et al.
      Invited commentary: Broadening the evidence for adolescent sexual and reproductive health and education in the United States.
      ].
      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 [

      Sexuality Information and Education Council of the United States (SEICUS). 2015 Sex ed state legislative year-end report: top topics and takeaways. Available at: http://www.siecus.org. Accessed April 1, 2016.

      ,
      • Douglas J.M.
      • Fenton K.A.
      Understanding sexual health and its role in more effective prevention programs.
      ,
      • Strasburger V.C.
      • Brown S.S.
      Sex education in the 21st century.
      ]. Without cohesive or consistent implementation processes, a highly diverse “patchwork” of sex education laws and practices exists [

      Sexuality Information and Education Council of the United States (SEICUS). 2015 Sex ed state legislative year-end report: top topics and takeaways. Available at: http://www.siecus.org. Accessed April 1, 2016.

      ]. 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 [
      Guttmacher Institute
      Sex and HIV education. State Policies in Brief.
      ]. 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 [
      Guttmacher Institute
      Sex and HIV education. State Policies in Brief.
      ]. 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 [

      Center’s for Disease Control and Prevention. School Health Policies and Practices Study: Health Education. Available at: http://www.cdc.gov/healthyyouth/data/shpps/pdf/2014factsheets/health_education_shpps2014.pdf. Accessed March 11, 2016.

      ]. Moreover, 69% of high schools notify parents/guardians before students receive such instruction; 87% allow parents/guardians to exclude their children from it [

      Center’s for Disease Control and Prevention. School Health Policies and Practices Study: Health Education. Available at: http://www.cdc.gov/healthyyouth/data/shpps/pdf/2014factsheets/health_education_shpps2014.pdf. Accessed March 11, 2016.

      ]. 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 [

      Sexuality Information and Education Council of the United States (SEICUS). 2015 Sex ed state legislative year-end report: top topics and takeaways. Available at: http://www.siecus.org. Accessed April 1, 2016.

      ].
      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 [
      • Schalet A.T.
      • Santelli J.S.
      • Russell S.T.
      • et al.
      Invited commentary: Broadening the evidence for adolescent sexual and reproductive health and education in the United States.
      ,
      • Douglas J.M.
      • Fenton K.A.
      Understanding sexual health and its role in more effective prevention programs.
      ]. 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 [

      Sexuality Information and Education Council of the United States (SEICUS). 2015 Sex ed state legislative year-end report: top topics and takeaways. Available at: http://www.siecus.org. Accessed April 1, 2016.

      ,
      • Boonstra H.D.
      Advocates call for a new approach after the era of ‘Abstinence-Only’ sex education.
      ,
      • Santelli J.
      • Ott M.A.
      • Lyon M.
      • et al.
      Abstinence and abstinence-only education: A review of U.S. policies and programs.
      ,
      • Schalet A.T.
      • Santelli J.S.
      • Russell S.T.
      • et al.
      Invited commentary: Broadening the evidence for adolescent sexual and reproductive health and education in the United States.
      ,
      • Douglas J.M.
      • Fenton K.A.
      Understanding sexual health and its role in more effective prevention programs.
      ,
      • Strasburger V.C.
      • Brown S.S.
      Sex education in the 21st century.
      ].

      Trends in Adolescents' Receipt of Sex Education

      In this month's Journal of Adolescent Health, Lindberg et al. [
      • Lindberg L.D.
      • Maddow-Zimet I.
      • Boonstra H.
      Changes in adolescents’ receipt of sex education 2006-2013.
      ] 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 [
      • Lindberg L.D.
      • Santelli J.S.
      • Singh S.
      Changes in formal sex education: 1995–2002.
      ,
      • Lindberg L.
      • Maddow-Zimet I.
      Monitoring trends in sex education and information.
      ,
      • Hall K.
      • Moreau C.
      • Trussell J.
      Patterns and correlates of parental and formal sexual and reproductive health communication for adolescent women in the United States, 2002–2008.
      ]. 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 [
      • Hamilton B.E.
      • Martin J.A.
      • Osterman M.J.K.
      • et al.
      ,
      • Santelli J.
      • Lindberg L.
      • Finer L.
      • Singh S.
      Explaining recent declines in adolescent pregnancy in the United States: The contribution of abstinence and improved contraceptive use.
      ]. 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. [
      • Lindberg L.D.
      • Maddow-Zimet I.
      • Boonstra H.
      Changes in adolescents’ receipt of sex education 2006-2013.
      ] 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. [

      Guttmacher Institute. Facts on American teens' sources of information about sex. Available at: http://www.guttmacher.org/pubs/FB-Teen-Sex-Ed.html. Accessed March 1, 2016.

      ,
      • Strasburger V.C.
      • Brown S.S.
      Sex education in the 21st century.
      ,
      • Marques S.S.
      • Lin J.S.
      • Starling M.S.
      • et al.
      Sexuality education Websites for adolescents: A framework-based content analysis.
      ,
      • Nguyen P.
      • Gold J.
      • Pedrana A.
      • et al.
      Sexual health promotion on social networking sites: A process evaluation of the FaceSpace Project.
      ,

      Future of Sex Education Initiative. National Sexuality Education Standards Tools. Available at: www.futureofsexed.org/fosestandards.html. Accessed March 1, 2016.

      ].

      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 [
      • Strasburger V.C.
      • Brown S.S.
      Sex education in the 21st century.
      ,
      • Marques S.S.
      • Lin J.S.
      • Starling M.S.
      • et al.
      Sexuality education Websites for adolescents: A framework-based content analysis.
      ,
      • Nguyen P.
      • Gold J.
      • Pedrana A.
      • et al.
      Sexual health promotion on social networking sites: A process evaluation of the FaceSpace Project.
      ,

      Future of Sex Education Initiative. National Sexuality Education Standards Tools. Available at: www.futureofsexed.org/fosestandards.html. Accessed March 1, 2016.

      ]. 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 [
      • Douglas J.M.
      • Fenton K.A.
      Understanding sexual health and its role in more effective prevention programs.
      ,
      • Strasburger V.C.
      • Brown S.S.
      Sex education in the 21st century.
      ,
      • Marques S.S.
      • Lin J.S.
      • Starling M.S.
      • et al.
      Sexuality education Websites for adolescents: A framework-based content analysis.
      ,
      • Nguyen P.
      • Gold J.
      • Pedrana A.
      • et al.
      Sexual health promotion on social networking sites: A process evaluation of the FaceSpace Project.
      ,

      Future of Sex Education Initiative. National Sexuality Education Standards Tools. Available at: www.futureofsexed.org/fosestandards.html. Accessed March 1, 2016.

      ]. 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. [

      Center’s for Disease Control and Prevention. School Health Policies and Practices Study: Health Education. Available at: http://www.cdc.gov/healthyyouth/data/shpps/pdf/2014factsheets/health_education_shpps2014.pdf. Accessed March 11, 2016.

      ,
      • Boonstra H.
      Meeting the sexual and reproductive health needs of adolescents in school-based health centers.
      ].
      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 [

      Sexuality Information and Education Council of the United States (SEICUS). What’s New. Available at: http://www.siecus.org/. Accessed March 1, 2016.

      ]. 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 [

      Guttmacher Institute. Monthly policy update. Available at: https://www.guttmacher.org/statecenter/updates/index.html. Accessed March 13, 2016.

      ].
      At the state and local program level, models of sex education that are grounded in a broader interdisciplinary body of evidence are warranted [

      Sexuality Information and Education Council of the United States (SEICUS). 2015 Sex ed state legislative year-end report: top topics and takeaways. Available at: http://www.siecus.org. Accessed April 1, 2016.

      ,
      • Kirby D.B.
      • Laris B.A.
      • Rolleri L.A.
      Sex and HIV education programs: Their impact on sexual behaviors of young people throughout the world.
      ,
      • Schalet A.T.
      • Santelli J.S.
      • Russell S.T.
      • et al.
      Invited commentary: Broadening the evidence for adolescent sexual and reproductive health and education in the United States.
      ,
      • Douglas J.M.
      • Fenton K.A.
      Understanding sexual health and its role in more effective prevention programs.
      ,
      • Strasburger V.C.
      • Brown S.S.
      Sex education in the 21st century.
      ,
      • Haberland N.
      • Rogow D.
      Sexuality education: Emerging trends in evidence and practice.
      ,
      • Berglas N.F.
      • Constantine N.A.
      • Ozer E.J.
      A rights-based approach to sexuality education: Conceptualization, clarification and challenges.
      ,
      • Haberland N.A.
      The case for addressing gender and power in sexuality and HIV education: A comprehensive review of evaluation studies.
      ]. 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 [

      Sexuality Information and Education Council of the United States (SEICUS). 2015 Sex ed state legislative year-end report: top topics and takeaways. Available at: http://www.siecus.org. Accessed April 1, 2016.

      ,
      • Kirby D.B.
      • Laris B.A.
      • Rolleri L.A.
      Sex and HIV education programs: Their impact on sexual behaviors of young people throughout the world.
      ,
      • Schalet A.T.
      • Santelli J.S.
      • Russell S.T.
      • et al.
      Invited commentary: Broadening the evidence for adolescent sexual and reproductive health and education in the United States.
      ,
      • Douglas J.M.
      • Fenton K.A.
      Understanding sexual health and its role in more effective prevention programs.
      ,
      • Strasburger V.C.
      • Brown S.S.
      Sex education in the 21st century.
      ,
      • Haberland N.
      • Rogow D.
      Sexuality education: Emerging trends in evidence and practice.
      ,
      • Berglas N.F.
      • Constantine N.A.
      • Ozer E.J.
      A rights-based approach to sexuality education: Conceptualization, clarification and challenges.
      ,
      • Haberland N.A.
      The case for addressing gender and power in sexuality and HIV education: A comprehensive review of evaluation studies.
      ]. Modern implementation strategies must use complementary modes of communication and delivery, including peers, digital and social media, and gaming, to fully engage young people [
      • Strasburger V.C.
      • Brown S.S.
      Sex education in the 21st century.
      ,
      • Marques S.S.
      • Lin J.S.
      • Starling M.S.
      • et al.
      Sexuality education Websites for adolescents: A framework-based content analysis.
      ,
      • Nguyen P.
      • Gold J.
      • Pedrana A.
      • et al.
      Sexual health promotion on social networking sites: A process evaluation of the FaceSpace Project.
      ,
      • Haberland N.
      • Rogow D.
      Sexuality education: Emerging trends in evidence and practice.
      ].
      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.

      Funding Sources

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

      References

        • Guttmacher Institute
        Sex and HIV education. State Policies in Brief.
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      2. Sexuality Information and Education Council of the United States (SEICUS). What’s New. Available at: http://www.siecus.org/. Accessed March 1, 2016.

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