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School-based sex education plays a vital role in the sexual health and well-being of young people. Little is known, however, about the effectiveness of efforts beyond pregnancy and sexually transmitted disease prevention. The authors conducted a systematic literature review of three decades of research on school-based programs to find evidence for the effectiveness of comprehensive sex education.
Methods
Researchers searched the ERIC, PsycINFO, and MEDLINE. The research team identified papers meeting the systematic literature review criteria. Of 8,058 relevant articles, 218 met specific review criteria. More than 80% focused solely on pregnancy and disease prevention and were excluded, leaving 39. In the next phase, researchers expanded criteria to studies outside the U.S. to identify evidence reflecting the full range of topic areas. Eighty articles constituted the final review.
Results
Outcomes include appreciation of sexual diversity, dating and intimate partner violence prevention, development of healthy relationships, prevention of child sex abuse, improved social/emotional learning, and increased media literacy. Substantial evidence supports sex education beginning in elementary school, that is scaffolded and of longer duration, as well as LGBTQ–inclusive education across the school curriculum and a social justice approach to healthy sexuality.
Conclusions
Review of the literature of the past three decades provides strong support for comprehensive sex education across a range of topics and grade levels. Results provide evidence for the effectiveness of approaches that address a broad definition of sexual health and take positive, affirming, inclusive approaches to human sexuality. Findings strengthen justification for the widespread adoption of the National Sex Education Standards.
Attention to the full range of sexual health topics, scaffolded across grades, embedded in supportive school environments and across subject areas, has the potential to improve sexual, social, and emotional health and academic outcomes for young people.
See Related Editorial on p.7
Public health practitioners and policy-makers have long considered school-based sex education to play a vital role in the sexual health and well-being of young people. Likewise, surveys of the public over several decades have consistently shown strong support for comprehensive sex education (CSE; also known as comprehensive sexuality education) [
]. Nevertheless, except for evaluations of sexually transmitted infection (STI) and pregnancy prevention programs, not enough is known about the effectiveness of sex education efforts, which have the potential to influence adolescent health in a variety of ways. This paper describes the results of a literature review of three decades of research on the effectiveness of school-based programs, from both the U.S. and around the world, that focus on a range of outcomes associated with CSE.
Background
Sex education has long been characterized by competing definitions, goals, and philosophies, which has muddied efforts to understand and gauge its effectiveness [
]. When it comes to measuring impact and outcomes, research has been dominated by interest in prevention programs aimed at reducing STI and pregnancy rates [
Psychosocial predictors of HIV-associated sexual behaviors and the efficacy of prevention interventions in adolescents at-risk for HIV infection: What works and what doesn’t work?.
]. What has remained largely unstudied, however, are approaches with a broader and more comprehensive focus on human sexuality, defined by SIECUS as:
“…the sexual knowledge, beliefs, attitudes, values, and behaviors of individuals. Its various dimensions involve the anatomy, physiology, and biochemistry of the sexual response system; identity, orientation, roles, and personality; and thoughts, feelings, and relationships” [
In 2012, the Future of Sex Education, a partnership among three leading national sex education organizations, Advocates for Youth, Answer, and SIECUS, released the National Sexuality Education Standards (NSES) [
]. The goal of the NSES is to provide school districts with “clear, consistent, and straightforward guidance on the essential, minimum, core content, and skills needed for sex education that is age-appropriate for students in Grades K-12 to be effective” [
]. It consists of the following seven topic areas: Consent and Healthy Relationships, Anatomy and Physiology, Puberty & Adolescent Sexual Development, Gender Identity and Expression, Sexual Orientation and Identity, Sexual Health, and Interpersonal Violence [
Since the initial publication of the NSES, school districts across the country have been relying on these standards to develop and implement CSE, with recent data suggesting that more than 40% of districts in the U.S. have adopted the NSES [
]. Along with increasing dependence on the NSES has come growing and renewed interest in the evidence that supports their use.
Methods
The authors conducted a Systematic Literature Review (SLR) dating back to 1990 to find evidence for the effectiveness of CSE. The year 1990 represents a fundamental shift in the field of sex education as evidenced by the publication in 1991 of the SIECUS Guidelines for Comprehensive Sexuality Education Kindergarten through 12th Grade [
]. The Guidelines provided the first national framework for the concepts, topics, and skills that should be taught to young people at different ages and grade levels. As such, they were the precursor to the NSES and can justifiably be seen as representing the beginning of the “modern era” of CSE.
The SLR was designed to cast a wide and inclusive net to assure that all aspects of CSE were included. The criteria for the initial search were as follows: (1) qualitative or quantitative studies evaluating outcomes of school-based, K-12 educational approaches; (2) both within sex education and across the curriculum; and (3) that were U.S. based.
In consultation with the research team, an information specialist, experienced in SLR searches, developed and tested the strategy using an iterative process. ERIC and PsycINFO were searched on the Ebsco platform, as well as MEDLINE on Web of Science. All searches were performed on December 14, 2017. Strategies used a combination of controlled vocabulary (e.g., “Sex Education,” “Schools,” and “Sexual Health”) and keywords (e.g., “curriculum,” “K-12,” and “LGBTQ”; the search terms included both common acronyms [e.g., LGBTQ and STI] as well as the individual words [e.g., LGBTQ, sexually transmitted infections, etc.]). The initial list of terms was derived from the 2012 NSES. The research team added terms they deemed important based on their expertise in the field of sex education, and then the entire list was reviewed independently by an outside group of sex education experts for accuracy and thoroughness. Vocabulary and syntax were adjusted across the selected databases. All searches were limited to the English language.
A team of four graduate research assistants and the authors reviewed the first 1,500 records to develop and refine the coding strategy. Using article title and abstract, a coding scheme was developed: (1) articles that met the specified criteria for the SLR; (2) articles that needed further review to determine eligibility (and then recoded accordingly); (3) articles that were completely unrelated to the subject and eliminated. With an eye toward potential expansion of the review, two additional categories were coded: (4) articles that were non-U.S. based, but otherwise met the inclusion criteria; and (5) articles that were related to the topic of sex education, but did not meet the specified criteria.
Next, in teams of two, research assistants coded the remaining records. After scoring them independently, partners met to compare codes. Interrater reliability for papers coded 1 or 2 was calculated after review of 25% of the records, with 96% agreement for both of the teams. The lead researchers were called on to reconcile differences.
The search results are summarized in the PRISMA diagram [
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration.
] (Figure 1). Because the search intentionally identified material that broadly met the concepts of CSE, the initial result included more than 46,000 records, deduplicated to 42,447. After eliminating articles that were completely unrelated to the topic, 8,058 papers remained. Among those, 481 met the initial criteria for the SLR, 2,094 were non-U.S. based, and 5,483 were related to sex education, but were not school-based evaluations. These 481 papers, plus 50 additional articles from review of references, were read in full text, resulting in 218 remaining in the “1” category. Among those, 179 focused solely on pregnancy and disease prevention approaches, and 39 focused on other CSE topics delineated in the NSES. Given the breadth and sheer number of studies, and in the interest of drawing conclusions about the broader impact of CSE, the researchers decided to exclude studies focused only on pregnancy and disease prevention programs. The ample literature reflecting the effectiveness of sex education in helping young people lower their risk of unplanned pregnancy, STIs, and HIV is the subject of another article.
In the next phase of the review, the team expanded the criteria to include evaluation studies that were coded as 4 (non-U.S.) or 5 (related to CSE, such as school-wide initiatives) and also met review criteria as evaluation studies of school-based programs. After completion of this process, two research assistants conducted a targeted online search of the literature, excluding pregnancy and STI prevention studies, for research published after the initial search was conducted through November 2019. A total of 80 articles constitute the final set for this review.
The researchers identified the outcomes in each study and then sorted those outcomes into several overarching categories based on commonly identified aims of CSE. These were identified as appreciation of sexual diversity, dating and intimate partner violence (IPV) prevention, development of healthy relationships, and prevention of child sex abuse. Within these overarching categories, several subtopics emerged that correspond with widely recognized goals of CSE [
The studies that form the basis of this review vary widely in their size, rigor of analysis, and generalizability of findings. They include methodologically strong studies, using quasi-experimental or experimental designs, as well as meta-analyses and SLRs. They also include a substantial number of studies with less rigorous designs, smaller samples, and/or more qualitatively based approaches that when taken together lead to strong evidence of outcomes. Table 1 provides details for the outcome studies reviewed here including methodology and alignment of outcomes with the NSES topic areas [
Outcome Subtopics:Appreciation of sexual diversity: 1 = lower homophobia; 2 = reduced homophobic bullying; 3 = expanded understanding of gender/gender norms; 4 = recognition of gender equity, rights, social justice.Dating and intimate partner violence: 5 = improved knowledge and attitudes about, and reporting of, sexual and intimate partner violence; 6 = decreased sexual and intimate partner violence perpetration and victimization; 7 = increased bystander intentions and behaviors.Healthy relationships: 8 = increased relationship knowledge, attitudes, and skills; 9 = improved communication skills and intentions.Child sex abuse: 10 = improved knowledge, attitudes, skills, and social–emotional outcomes related to personal safety and touch; 11 = improved disclosure skills and behaviors.Additional outcomes: 12 = social–emotional learning; 13 = media literacy.
Toward inclusive understandings of marriage in an early childhood classroom: Negotiating (un)readiness, community, and vulnerability through a critical reading of "King and King".
Associations of lesbian, gay, bisexual, transgender, and questioning-inclusive sex education with mental health outcomes and school-based victimization in U.S. high school students.
Tal Como Somos/Just as We Are: An educational film to reduce stigma toward gay and bisexual men, transgender individuals, and persons living with HIV/AIDS.
Assessing the long-term effects of the safe dates program and a booster in preventing and reducing adolescent dating violence victimization and perpetration.
Does an evidence-based healthy relationships program for 9th graders show similar effects for 7th and 8th graders? Results from 57 schools randomized to intervention.
Relationship education for youth in high school: Preliminary evidence from a non-controlled study on dating behavior and parent-adolescent relationships.
Utilizing a train-the-trainer model for sexual violence prevention: Findings from a pilot study with high school students of Asian and Pacific Islander descent in Hawai‘i.
Effects of PREPARE, a multi-component, school-based HIV and intimate partner violence (IPV) prevention programme on adolescent sexual risk behaviour and IPV: Cluster randomised controlled trial.
Effects of the child sexual abuse prevention education (C-SAPE) program on South Korean fifth-grade students' competence in terms of knowledge and self-protective behaviors.
Body image in primary schools: A pilot evaluation of a primary school intervention program designed by teachers to improve children's body satisfaction.
CHR = consent and healthy relationships; AP = anatomy and physiology; PD = puberty and adolescent sexual development; GI = gender identity and expression; SO = sexual orientation and identity; SH = sexual health; IV = interpersonal violence; YRBS = Youth Risk Behavior Surveillance.
a Outcome Subtopics:Appreciation of sexual diversity: 1 = lower homophobia; 2 = reduced homophobic bullying; 3 = expanded understanding of gender/gender norms; 4 = recognition of gender equity, rights, social justice.Dating and intimate partner violence: 5 = improved knowledge and attitudes about, and reporting of, sexual and intimate partner violence; 6 = decreased sexual and intimate partner violence perpetration and victimization; 7 = increased bystander intentions and behaviors.Healthy relationships: 8 = increased relationship knowledge, attitudes, and skills; 9 = improved communication skills and intentions.Child sex abuse: 10 = improved knowledge, attitudes, skills, and social–emotional outcomes related to personal safety and touch; 11 = improved disclosure skills and behaviors.Additional outcomes: 12 = social–emotional learning; 13 = media literacy.
A notable update in the NSES Second Edition is a prominent focus on social justice and equity, as well as intersectionality. Some of the findings of this SLR reflect this broader conceptual focus and are reported as such here.
Appreciation of sexual diversity
Studies discussed in this section report on outcomes that together represent appreciation of sexual diversity. Classroom approaches ranged from preschool through grade 12, were found throughout the curriculum (not just in health or sex education), and included, in many cases, the use of literature to address gender and sexual orientation issues. Research on LGBTQ–inclusive curricula across topics and grade levels are reviewed, as well as approaches aimed specifically at reducing homophobia, homophobic bullying and harassment, and other outcomes related to appreciation of sexual diversity.
Lower homophobia
Curricula designed specifically to reduce homophobia have been found to be successful across grade levels using a variety of approaches both formally within sexuality education and throughout other areas of the curriculum [
Toward inclusive understandings of marriage in an early childhood classroom: Negotiating (un)readiness, community, and vulnerability through a critical reading of "King and King".
]. A Quebec study using immediate post-tests and 3-month follow-ups, as well as participant interviews and focus groups, reported on 227 high school (HS) students who participated in a program in which a gay man and a lesbian spoke in their classrooms. Students exhibited increased normalization of lesbian and gay people, a reduction in stereotyping about gender expression and norms for lesbian and gay women and men, empathy for those who come out, an appreciation for the positive aspects of being lesbian and gay, a recognition that sexual orientation does not have to correlate with sexual behavior, and lower use of homophobic slurs [
]. Strategies that use literature featuring gay and lesbian characters have also resulted in lowered homophobia and homophobic behaviors both at the elementary school level [
In addition to reduced homophobic attitudes, research demonstrates that curricula that are inclusive of all sexual orientations, gender identities, and expressions, across areas of study, and most strongly within CSE, reduce homophobic bullying and harassment, and increase safety for LGBTQ students [
A 2015 survey of 1,232 gay and straight middle and high school students from 154 schools in California found that inclusive curricula were associated with higher reports of safety at both the individual and school levels and lower levels of bullying at the school level. LGBTQ-supportive curricula were also related to students feeling safer at school and more aware of bullying at both the school and individual levels. Although these outcomes resulted from inclusiveness throughout the curriculum, the study found that having sex education and health classes that were LGBTQ inclusive had the greatest impact on school climate [
A rigorous, three-wave longitudinal study examined an LGBTQ-inclusive curriculum in six Dutch high schools provided to 601 tenth- to twelfth-grade students. Researchers found that, along with covering a variety of topics, inclusion of sexual orientation and gender identity that was extensive in both content and frequency predicted decreased name-calling and, among girls, increased willingness to intervene when witnessing name-calling by others, leading to an improved school climate [
]. Other methodologically strong studies have found that LGBTQ-inclusive sex education is related to lower reports of adverse mental health (suicidal thoughts and suicide plans) among all youth and of experiences of bullying among sexual minority youth [
Associations of lesbian, gay, bisexual, transgender, and questioning-inclusive sex education with mental health outcomes and school-based victimization in U.S. high school students.
]. As well, they are related to better health outcomes among gay, lesbian, and bisexual students, including fewer sex partners, less use of drugs or alcohol before sex, less pregnancy, and better school attendance [
Although research suggests that narrow views of gender and the reinforcement of gender stereotypes in young children can lead to gender-based harassment [
], little evaluation research has looked at efforts to counteract these views. A few smaller studies, including qualitative/ethnographic research and studies looking at short-term or single-dose programs, taken together, suggest that focused efforts to increase acceptance of transgender and gender-nonconforming people can be effective [
Tal Como Somos/Just as We Are: An educational film to reduce stigma toward gay and bisexual men, transgender individuals, and persons living with HIV/AIDS.
]. Qualitative studies of efforts to expand understanding of gender and gender norms, all at the elementary school level (third to fifth grades), suggest that making children's literature that challenges gender stereotypes available and accessible to students may not be enough. Using that literature to engage students in discussions, relating gender-based bullying and harassment to harassment and oppression of other marginalized populations, and using a critical literacy approach [
] engaged students in different ways of thinking about and expressing the messages from these books and other media. They also helped young children to expand their views of gender, gender expression, and gender norms and created an environment that allowed students to challenge and to cross their own stereotypical gender boundaries safely [
], the author reported that “over time…both girls and boys felt safe in discussing and challenging one another's assumptions about gender's role in their reading choices” (p. 384) and concluded, “Children need safe spaces in which to experience, play with, and begin to challenge the naturalized assumptions about gender.” (p. 384). The studies noted here, as well as one of a preschool class [
Toward inclusive understandings of marriage in an early childhood classroom: Negotiating (un)readiness, community, and vulnerability through a critical reading of "King and King".
], highlight that young children are, in fact, quite capable of understanding and discussing issues related to gender diversity, including gender expectations, gender nonconformity, and gender-based oppression. They also underscore that the development of such understanding requires instructional scaffolding over a period, and not just one session.
Recognition of gender equity, rights, and social justice
The use of social justice and rights-based frameworks in designing and teaching topics related to sexuality and sexual health has increased over the past several years and has been advocated by leading sexual health organizations [
]. A social justice lens uses the concepts of human rights and equality through which to challenge power, privilege, and structural and systemic discrimination of marginalized communities. There is evidence to suggest that this approach is well-founded and can be applied across the curriculum and at all grade levels [
]. A number of studies report outcomes related to increased knowledge, awareness and appreciation of gender equity and sexual rights, and awareness of discrimination and oppression based on gender and sexual orientation [
Toward inclusive understandings of marriage in an early childhood classroom: Negotiating (un)readiness, community, and vulnerability through a critical reading of "King and King".
The programs on which the research is based span preschool through high school and range from a one-shot music-based program focused on attitudinal change related to racism, classism, homophobia, and misogyny [
], both of which reported increased understanding and awareness of these rights-based issues. One strong study using a clustered randomized trial to evaluate a 12-session, rights-based approach to sexuality education among predominantly Hispanic and African-American HS populations in Los Angeles found that, compared with students who received more traditional sex education, students who received the rights-based curriculum demonstrated more positive attitudes about sexual relationship rights [
Toward inclusive understandings of marriage in an early childhood classroom: Negotiating (un)readiness, community, and vulnerability through a critical reading of "King and King".
]. One such ethnographic study of a 10th grade literature class on oppression and diversity used field notes; audiotapes and videotapes; student surveys; writing samples; interviews with teachers, students, parents, and school personnel; and a retrospective group discussion with students 2 years post-intervention [
]. Respondents reported having myths of homosexuality dispelled, emerging empathy for gays and lesbians, and a belief in rights of gay and lesbian people to be who they are. The authors noted that establishing a safe climate in which to discuss sensitive and controversial issues was essential to the positive outcomes. Despite being an older (1996) study, it nonetheless supports the use of targeted strategies to increase acceptance and understanding of the LGBTQ community. Another study examined a high school literature class that used an “anti-oppression curriculum.” Using qualitative analysis software to analyze teacher and student interviews and questionnaires, the study reported that students moved from discomfort to confidence in discussing LGBTQ issues, gained a fuller understanding of the complexities of sexuality, and became more supportive allies and advocates of the LGBTQ community [
Two smaller studies are worth noting for their support of teaching about sexual rights in the context of social justice to younger children. In one, fourth- and fifth-grade students exposed to LGBTQ literature, history, and current events were successful in discussing and understanding issues of social justice and equity for LGBTQ people. They had the capacity to understand LGBTQ discrimination and lack of power and how they are related to oppression based on race, religion, culture, and other identities [
]. In a qualitative study of a preschool class that used literature to discuss marriage equality and LGBT rights, 4-year-olds expressed an inclusive understanding of marriage and a social justice stance on LGBTQ rights [
Toward inclusive understandings of marriage in an early childhood classroom: Negotiating (un)readiness, community, and vulnerability through a critical reading of "King and King".
Finally, there is support for programs that use a gender-transformative approach to promote more equitable relationships among genders. Such programs make discussions of gender in the context of power and the promotion of gender equality and women's empowerment, central to an intervention [
]. Finally, although the current literature review is not focused on disease and pregnancy prevention programs, it is important to note that a focus on gender and power has the potential to influence a broad array of important sexual health outcomes. A meta-analysis that reviewed 22 sexuality and HIV curricula, across multiple age groups, found that programs addressing gender and power in relationships were five times more likely to be effective in reducing STI and pregnancy rates than those that did not address these topics. Specifically, 80% of such curricula versus 12% of curricula that did not address these topics were associated with lower STI and pregnancy rates [
Strong evaluations demonstrate a range of positive outcomes for programs that focus on prevention of dating violence (DV) and intimate partner violence (IPV) among both middle school and high school youth. The terms DV and IPV are used interchangeably in some studies, while others, particularly those that are earlier, tend to use only the term DV.) School-based efforts have the potential to play an important role in reducing DV and, in many cases, have shown positive long-term outcomes [
Assessing the long-term effects of the safe dates program and a booster in preventing and reducing adolescent dating violence victimization and perpetration.
]. Outside of pregnancy and disease prevention, this has been the most extensively evaluated aspect of school-based sex education efforts. There is strong evidence that programs can increase knowledge, change attitudes, and improve skills to reduce DV and IPV and can actually reduce the incidence of both DV and IPV.
The most promising approaches to addressing DV and IPV for school-aged youth have focused on social justice [
Does an evidence-based healthy relationships program for 9th graders show similar effects for 7th and 8th graders? Results from 57 schools randomized to intervention.
Does an evidence-based healthy relationships program for 9th graders show similar effects for 7th and 8th graders? Results from 57 schools randomized to intervention.
Does an evidence-based healthy relationships program for 9th graders show similar effects for 7th and 8th graders? Results from 57 schools randomized to intervention.
Relationship education for youth in high school: Preliminary evidence from a non-controlled study on dating behavior and parent-adolescent relationships.
Does an evidence-based healthy relationships program for 9th graders show similar effects for 7th and 8th graders? Results from 57 schools randomized to intervention.
Improved knowledge and attitudes about, and reporting of, DV and IPV
There is extensive evidence that school-based programs have resulted in improved knowledge and attitudes related to DV and IPV, including reduction in rape myths, victim blaming, and sexist attitudes [
Utilizing a train-the-trainer model for sexual violence prevention: Findings from a pilot study with high school students of Asian and Pacific Islander descent in Hawai‘i.
Does an evidence-based healthy relationships program for 9th graders show similar effects for 7th and 8th graders? Results from 57 schools randomized to intervention.
] to reject sexual harassment. In one study, significant change in HS students' attitudes about DV at post-test and follow-up was greater for students who had reported higher school connectedness at pretest [
]. This finding suggests that efforts to help connect youth to school more generally may have the potential to influence longer term outcomes beyond school performance.
Decreased DV and IPV perpetration and victimization
Several large, rigorous studies are notable for strong behavioral outcomes in the area of DV and IPV prevention. These include a randomized evaluation of The Fourth R [
Does an evidence-based healthy relationships program for 9th graders show similar effects for 7th and 8th graders? Results from 57 schools randomized to intervention.
Assessing the long-term effects of the safe dates program and a booster in preventing and reducing adolescent dating violence victimization and perpetration.
Assessing the long-term effects of the safe dates program and a booster in preventing and reducing adolescent dating violence victimization and perpetration.
Effects of PREPARE, a multi-component, school-based HIV and intimate partner violence (IPV) prevention programme on adolescent sexual risk behaviour and IPV: Cluster randomised controlled trial.
Assessing the long-term effects of the safe dates program and a booster in preventing and reducing adolescent dating violence victimization and perpetration.
Notably, several programs that took place in the eighth grade or earlier showed important long-term outcomes. The Fourth R: Skills for Youth Relationships, initially developed for ninth graders, stands out for its sequential version in Grades 7 and 8, demonstrating decreases in both physical and emotional DV among boys at ninth-grade follow-up [
]. Safe Dates, in the eighth grade, with evaluation differentiating a range of violence-related outcomes, demonstrated reduction of sexual violence perpetration at immediate post-test [
], as well as reduced perpetration and victimization of physical violence at the 4-year follow-up. Compared with controls, treatment schools reported 25% less psychological abuse perpetration, 60% less sexual violence perpetration, and 60% less physical violence perpetration with a current dating partner [
Assessing the long-term effects of the safe dates program and a booster in preventing and reducing adolescent dating violence victimization and perpetration.
Utilizing a train-the-trainer model for sexual violence prevention: Findings from a pilot study with high school students of Asian and Pacific Islander descent in Hawai‘i.
]. A systematic review of 7th- to 12th-grade bystander intervention programs suggests beneficial effects on bystander behaviors up to 4 months following the programs [
]. An IPV prevention program in an alternative HS showed strong improvements in bystander skills, gender-equitable attitudes, and bystander interventions, leading to improved overall school climate and improvement in the external reputation of the school [
]. A strong randomized study of a coach-led intervention in 16 high schools increased intentions to intervene, improved gender-equitable attitudes, and improved bystander actions among male athletes, both at post-test and 1-year follow-up [
Programs specifically designed to reduce dating and interpersonal violence often had broader healthy relationship concepts among their measured outcomes. This section, however, reviews healthy relationship outcomes outside the specific context of DV or IPV prevention programs. These efforts focused on healthy relationships as a foundation for adolescent sexual health [
Relationship education for youth in high school: Preliminary evidence from a non-controlled study on dating behavior and parent-adolescent relationships.
Two important studies demonstrated improvements in knowledge and attitudes related to healthy relationships. In a one-group, repeated-measures design with 3,658 ninth graders, the Relationship Smarts curriculum demonstrated significant improvements in healthy relationship knowledge and dating skills, as well as improved relationship skills for parent–adolescent relationships, both at post-test and 1-year follow-up [
Relationship education for youth in high school: Preliminary evidence from a non-controlled study on dating behavior and parent-adolescent relationships.
]. Notably, knowledge about healthy relationships at baseline predicted improvements in parent–adolescent relationship scores at post-test, suggesting that knowledge in one relationship context has the potential to translate to other types of relationships. In addition, a peer-facilitated, five-session healthy relationship program for academically at-risk adolescents, adapted for cultural relevance in three metropolitan areas of Southeastern U.S., demonstrated strong improvements among ninth graders on knowledge and attitudes about healthy relationships [
Curricula that addressed communication within relationships resulted in improved communication skills and intentions, including increased intentions to discuss relationships and/or sex within relationships [
Relationship education for youth in high school: Preliminary evidence from a non-controlled study on dating behavior and parent-adolescent relationships.
]. A longitudinal study of 1,600 Mexican fourth graders, in the Yo Quiero Yo Puede program, which focused on the importance of talking about taboo and difficult subjects, demonstrated improved communication skills in these subjects and increased self-efficacy and intentions to discuss difficult subjects, including romance, sexuality, and threatening or unpleasant topics [
]. Rigorous evaluations found significant increases in communication skills for both the Respectful Relationships 6th to 10th grade sequential curriculum [
This review found strong evidence for the effectiveness of child sex abuse prevention efforts in elementary school. Such programs typically use behavioral practice and role-play [
] demonstrate significant effects on a wide range of outcomes, including behaviors in simulated at-risk situations. Another large systematic review concluded that, in general, parental involvement, opportunities for practice, repeated exposure, and sensitivity to developmental level were key characteristics of effective child sex abuse programs [
Improved knowledge, attitudes, skills and social–emotional outcomes related to personal safety and touch
A systematic review of 22 North American and UK curricula for K-6 children found significant increases in knowledge across programs, improved self-protective skills, particularly among older elementary students, and emotional gains in self-esteem, self-efficacy, and feelings of safety, in approximately one third of the programs. Gains in knowledge and some social–emotional outcomes remained at 3- to 5-month follow-up [
]. In a rigorous cluster randomized study of six New York City elementary schools, Safe Touches for second and third graders showed significant improvement in knowledge of safe touch [
]. Notably, intervention–control group differences were larger when “stranger danger” items were removed, suggesting that this curriculum was able to address inappropriate touch in a more nuanced way. Stay Safe primary prevention, for 7- and 10-year-olds in Ireland, demonstrated gains in knowledge, skills, and self-esteem, maintained at 3-month follow-up. Notably, gains were greatest for the younger students [
Child abuse prevention programs for second to fourth graders demonstrated significant increases in knowledge of appropriate and inappropriate touch, what to do in an inappropriate situation [
]. A strong randomized study in 21 urban U.S. schools found gains were maintained at 1 year, with no increase in anxiety, concluding that it is safe to discuss sensitive subjects with young children, and demonstrating the value of early education [
] reported positive effects on sense of control and safety felt by children, including, in one, more positive feelings about their genitals (e.g., it's okay to touch one's own private parts).
Improved disclosure skills and behaviors
Several studies have demonstrated improvements in young children's skills and behaviors specifically related to disclosure [
Effects of the child sexual abuse prevention education (C-SAPE) program on South Korean fifth-grade students' competence in terms of knowledge and self-protective behaviors.
]. Evaluation of an early elementary sexual abuse prevention program in China focused on “no, go, and tell,” using random assignment by classroom to intervention and non-intervention groups, found significant increases for important skills related to reporting [
Effects of the child sexual abuse prevention education (C-SAPE) program on South Korean fifth-grade students' competence in terms of knowledge and self-protective behaviors.
] showed significant improvement in self-protective behaviors. A systematic review of childhood sex abuse curricula in the U.S. and Canada concluded that one of the most common effects was increased knowledge of a resource person to whom children would report abuse [
]. More important, behavioral outcomes included increased parent–child communication about child sex abuse, and when implemented with a group of children known to have been abused, increased disclosure.
Additional outcomes
Social–emotional learning
Although not identified as a goal of sex education per se, the incorporation of social-emotional learning into sex education has been explored in the literature [
]. Studies identified here demonstrate a range of important social–emotional outcomes, across grade levels, resulting from sex education in the classroom, including increased empathy [
Body image in primary schools: A pilot evaluation of a primary school intervention program designed by teachers to improve children's body satisfaction.
Relationship education for youth in high school: Preliminary evidence from a non-controlled study on dating behavior and parent-adolescent relationships.
]. For example, evaluation of Respectful Relationships, a sequential, 4-year social justice program in Canada, with 1,748 6th to 10th graders, demonstrated significant growth in empathy, self-esteem, ability to speak one's opinion, belief in equal rights for all, and “seeing people for who they are on the inside.” In addition, the program demonstrated increased nonviolent conflict resolution among girls, and among boys, increased discomfort in seeing others being picked on [
Similarly, media literacy is not commonly included in discussions about sex education outcomes, although it is recognized as an important life skill for young people. Two studies reviewed here, however, suggest that media literacy may be particularly important as an outcome within sex education. Two eighth grade programs using a media literacy approach [
] demonstrated increased media deconstruction skills, understanding of how media affects both sense of self and perceptions of teen norms, and, most notably, intentions for communication with parents, partners, and medical providers about sex.
Discussion
The purpose of this review was to understand whether achieving certain CSE goals is possible. The SLR aimed to triangulate findings from a wide range of peer-reviewed studies to identify evidence that supports educational approaches to improving adolescent sexual health and provides theoretical guidance for the broad goals of CSE. As such, we did not seek to identify or recommend specific programs or educational methodologies. Different settings, cultures, and local practices will dictate what specific approaches will ultimately be most effective and appropriate.
There is ample evidence that the physical and emotional health of young people is related to their academic achievement, as healthier students are more likely to stay in school and achieve higher grades, whereas health-related problems may contribute to academic struggles including higher absenteeism and dropping out [
]. Evidence reviewed here highlights this point with respect to sexual health. That is, if students are able to avoid early pregnancy, STIs, sexual abuse, and interpersonal violence and harassment, while feeling safe and supported within their school environment, they are more likely to experience academic success, a foundation for future stability.
This systematic review of the literature on sexual health outcomes from the past 30 years, provides encouraging documentation for the field of CSE. By setting aside studies looking strictly at pregnancy and STI prevention efforts, we were able to put a spotlight on critical CSE goals that often get lost in discussions about the impact of sex education on adolescent health. The findings reported here highlight important topics and approaches that show evidence of success, as well as areas of CSE that remain understudied. What this review found is that school-based CSE can lower homophobia and homophobic-related bullying, can increase understanding of gender and gender norms, can improve knowledge and skills that support healthy relationships, can build child sex abuse prevention skills, and can reduce dating and intimate partner violence.
Support for early, scaffolded, and multigrade approaches
This review offers substantial evidence that sexuality education is most effective when begun early and before sexual activity begins [
Body image in primary schools: A pilot evaluation of a primary school intervention program designed by teachers to improve children's body satisfaction.
]. As well, several studies, including some strong systematic reviews and meta-analyses, provide ample support for teaching that builds on previous lessons and/or grades and for programs of longer duration [
Toward inclusive understandings of marriage in an early childhood classroom: Negotiating (un)readiness, community, and vulnerability through a critical reading of "King and King".
Does an evidence-based healthy relationships program for 9th graders show similar effects for 7th and 8th graders? Results from 57 schools randomized to intervention.
]. As with all other areas of the curriculum, building an early foundation and scaffolding learning with developmentally appropriate content and teaching are key to long-term development of knowledge, attitudes, and skills that support healthy sexuality.
CSE is designed to include all grade levels, K-12, and in the early grades, even in preschool, there seems to be little controversy or discomfort around discussions in the context of child sex abuse prevention. The literature on sexual abuse prevention efforts in early grades reviewed here shows strong evidence that young children can develop self-protective knowledge, skills, and intentions, including an increased likelihood of reporting sexual abuse and knowing how to respond in a dangerous situation, all without increasing anxiety. Other than in this area, though, there are only limited examples of sexuality-related content in the K-5 curriculum [
]. The data, however, strongly indicate that such topics are developmentally appropriate and produce positive outcomes, while providing a foundation for future learning. This review suggests that not only are younger children able to discuss sexuality-related issues but that the early grades may, in fact, be the best time to introduce topics related to sexual orientation, gender identity and expression, gender equality, and social justice related to the LGBTQ community before hetero- and cisnormative values and assumptions become more deeply ingrained and less mutable. Children learn gender role attitudes at an early age from observing the people in their families [
The family environment: Where gender role socialization begins.
in: Worell J. Goodheart C.D. Oxford Series in Clinical Psychology. Handbook of Girls’ and Women’s Psychological Health: Gender and Well-Being across the Lifespan. Oxford University Press,
Oxford, UK2006: 262-271
]. As they progress through school, these attitudes are further shaped by classmates and peers, as well as by the biases of teachers, the design of the curriculum, and the school environment [
]. Given the influence of this early socialization and learning, it is important to introduce concepts that would disrupt stereotypical and harmful biases related to gender and sexual orientation, during this formative time.
Tackling homophobia, transphobia, and hostile school environments
Particularly at-risk, LGBTQ students continue to face a hostile environment in school, routinely hearing anti-LGBTQ language and experiencing victimization and discrimination at school [
]. These students have “worse educational outcomes and poorer psychological well-being,” experiencing lower self-esteem and higher rates of depression [
]. Efforts to reduce homophobic bullying and harassment and to increase appreciation for sexual diversity can improve the school climate for all students, and, as this review found, create a safer environment that is more conducive to learning, and to better mental health for sexual minority students. Evidence of success was found from individual classroom efforts, as well as from inclusivity across the curriculum, in promoting a more accepting and welcoming environment for sexual minority youth.
Social justice pedagogy
The literature highlights both the efficacy and importance of addressing gender and sexual orientation within the context of human rights and equality [
Best not forget lesbian, gay, bisexual, and transgender themed children's literature: A teacher's reflections of a more inclusive multicultural education and literature program.
]. Helping young people to challenge the social structures and systems that lead to discrimination and oppression based on gender and sexual orientation is critical to their sexual, emotional, and social development. The evidence reviewed here suggests that expanding social justice pedagogy within the sex education curriculum beyond the topics of gender and sexual orientation makes sense as well, and that research on such efforts is much needed.
Importance of social-emotional learning
SEL has been found to improve academic outcomes and behaviors that confer real-life benefits among students from kindergarten through high school including improved classroom behavior, increased ability to manage challenging emotions, and better attitudes about themselves, others, and school [
]. The findings from this review suggest that CSE represents a critical component of SEL and outcomes. Given that, it is essential that core SEL competencies be proactively integrated into school-based sex education efforts [
It is worth noting that in this review, many of the positive outcomes and promising approaches that worked toward creating affirming, inclusive school environments occurred not in traditional health or sex education classes, but in social studies, English, physical education, mathematics, music, and art. In particular, the vast majority of successful approaches to LGBTQ and gender norm topics in the elementary school grades used literature with students as the entry point for learning and discussion, most with the goal of increasing appreciation and acceptance of sexual and gender diversity [
Toward inclusive understandings of marriage in an early childhood classroom: Negotiating (un)readiness, community, and vulnerability through a critical reading of "King and King".
]. The fact that topics falling within sex education can be addressed successfully across the curriculum is encouraging and offers much needed flexibility to schools, both in terms of available time and talented teachers to tackle difficult and important topics. It also provides an opportunity to explore sexuality-related issues in different contexts and by applying a variety of lenses. Given that most schools have limited time allotted to health or sex education [
], a coordinated and concerted effort to teach and reinforce important sexual health concepts throughout other areas of the curriculum is a promising strategy.
Unmet needs
Several areas of focus are notably absent from the evaluation literature. Two topics often excluded from curricula, and therefore not included in outcome evaluations, are pleasure and desire [
]; most sex education is focused on sex as a problem behavior. The literature suggests that there is a need for, but little evidence of, teaching that views teen sex as normative, rather than pathological [
]. Furthermore, a few studies have concluded that it is not sexual behavior, per se, but the lack of a relationship context when it occurs, that is predictive of poor school outcomes [
]. Yet, the focus on sexual behavior as problematic itself eliminates the opportunity for young people to explore and experience normal, healthy, safe, and pleasurable sexual activity.
It is important to note that much of the dating violence and IPV prevention literature focuses on programs that are traditionally gendered, that is, most do not address IPV specific to sexual minority youth. As schools begin to demonstrate greater acknowledgment of nonbinary gender identities, hopefully this change will be reflected in future research. Some studies have demonstrated that mixed gender interventions have stronger outcomes than interventions conducted in single-gender groups [
]. Thus, more research on programs with expansive gender paradigms is needed, given that single-gender and gender-binary interventions have the potential to further victimize gender-nonconforming, nonbinary youth.
Two studies specifically noted that children with disabilities were excluded from analyses [
], there is limited literature that has attempted to evaluate the effectiveness of such approaches. Yet, young people with intellectual or physical disabilities may be at greater risk for poor sexual health including sexual abuse and exploitation, pregnancy and STIs, and difficulty forging and maintaining healthy relationships [
] stress that sex education must be taught within the larger context of intersectionality, that is, the fact that young people cross a variety of sexual orientation, gender identity, racial, ethnic/cultural, and other groups. Sex education researchers have also raised this important point [
Best not forget lesbian, gay, bisexual, and transgender themed children's literature: A teacher's reflections of a more inclusive multicultural education and literature program.
] were those with an explicit social justice aim. To realize the full potential of CSE, considerations of race, class, culture, ability, SES, and other important characteristics need to be more deliberately woven into curricula, teaching, and evaluation. Further, this review suggests the need for a broader social justice approach within sex education – one that examines sexual orientation and gender together with race, culture, and other identities, in the context of systemic oppression and its impact on marginalized communities. This approach is consistent with the guidance offered by the updated NSES and suggests that additional research on the outcomes of such efforts is much needed.
Limitations
Despite a systematic approach, this review is not exhaustive and may not have yielded the full range of evidence. Because the search focused on keywords and databases that reflect the peer-reviewed sex education and sexual health literature, some of the research published outside of this literature may not have been fully represented. In addition, the inclusion only of English-language papers limited our ability to assess all the existing literature on this topic. Thus, it is likely that some effective approaches were not included. As well, most of the studies on sexual orientation and related outcomes focus on LGB concepts as a summary term, but reports of reduced homophobia, for example, may not have specifically measured reduction in “biphobia.” This lack of clarity may reduce the ability to generalize outcomes reported here to include bisexuality.
It is also of note that the vast majority of studies identifying positive outcomes related to puberty, and anatomy and physiology, tend to be within the context of pregnancy and disease prevention programs. Thus, they are not reviewed in this article.
Finally, the initial search was based on the language of the NSES First Edition [
]; thus some important terms may have been underrepresented in the results. For example, one of the strongest findings was related to the use of a social justice framework to teach about sexuality. Had the NSES Second Edition [
], which address this issue more thoroughly, been used in the original search, it is possible there would have been even more evidence in this area. Nevertheless, this review provides extensive support for a broad and comprehensive treatment of sex education and the effectiveness of such an approach.
Support for comprehensive sex education
A review of the literature of the past three decades offers strong support for comprehensive sex education. The findings provide evidence for the effectiveness of approaches that address a broad definition of sexual health and well-being and take positive, affirming, and inclusive approaches to human sexuality, across multiple grade levels. Notably, they reinforce the guidance to public schools provided by the National Sex Education Standards and further strengthen the justification for their widespread adoption.
The implications of this work for school communities are important. In short, attention to the full range of sexual health topics, scaffolded across grades, embedded in supportive school environments and across subject areas, has the potential to improve sexual, social, and emotional health, and academic outcomes for young people.
Acknowledgments
The authors acknowledge, with great thanks: The Grove Foundation, which funded this project; FoSE (the Future of Sex Education), for guidance and vision in the scope of this work; Alejandra Kaplan, M.P.H.; Jacqueline Bavaro, M.P.H.; Emma Opthof, M.P.H.; Natalie Strucinski, M.P.H.; Katharine Mauro, M.P.H. and Rachel Wilkins, M.P.H. candidate, for their tireless work on this project.
References
Planned Parenthood Federation of America
Sex education: A national survey on support among likely voters.
Psychosocial predictors of HIV-associated sexual behaviors and the efficacy of prevention interventions in adolescents at-risk for HIV infection: What works and what doesn’t work?.
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration.
Toward inclusive understandings of marriage in an early childhood classroom: Negotiating (un)readiness, community, and vulnerability through a critical reading of "King and King".
Associations of lesbian, gay, bisexual, transgender, and questioning-inclusive sex education with mental health outcomes and school-based victimization in U.S. high school students.
Tal Como Somos/Just as We Are: An educational film to reduce stigma toward gay and bisexual men, transgender individuals, and persons living with HIV/AIDS.
Assessing the long-term effects of the safe dates program and a booster in preventing and reducing adolescent dating violence victimization and perpetration.
Does an evidence-based healthy relationships program for 9th graders show similar effects for 7th and 8th graders? Results from 57 schools randomized to intervention.
Relationship education for youth in high school: Preliminary evidence from a non-controlled study on dating behavior and parent-adolescent relationships.
Utilizing a train-the-trainer model for sexual violence prevention: Findings from a pilot study with high school students of Asian and Pacific Islander descent in Hawai‘i.
Effects of PREPARE, a multi-component, school-based HIV and intimate partner violence (IPV) prevention programme on adolescent sexual risk behaviour and IPV: Cluster randomised controlled trial.
Effects of the child sexual abuse prevention education (C-SAPE) program on South Korean fifth-grade students' competence in terms of knowledge and self-protective behaviors.
Body image in primary schools: A pilot evaluation of a primary school intervention program designed by teachers to improve children's body satisfaction.
The family environment: Where gender role socialization begins.
in: Worell J. Goodheart C.D. Oxford Series in Clinical Psychology. Handbook of Girls’ and Women’s Psychological Health: Gender and Well-Being across the Lifespan. Oxford University Press,
Oxford, UK2006: 262-271
Best not forget lesbian, gay, bisexual, and transgender themed children's literature: A teacher's reflections of a more inclusive multicultural education and literature program.
Conflicts of interest: Funding for this project was provided by the Grove Foundation. The sponsor was not involved in the study design, collection or analysis of data, or writing of the report, but funded the project with the intention of a systematic literature review for publication. The authors worked directly with the Future of Sex Education to identify the scope of the study. Future of Sex Education reviewed an earlier draft of the article for the purpose of assuring accuracy related to discussion of the National Sex Education Standards.
Substantial evidence exists for the efficacy and effectiveness of comprehensive sex education (CSE) in positively influencing behaviors related to preventing unintended pregnancy and sexually transmitted diseases (STDs), including delaying sexual intercourse, increasing contraception and condom use, and reducing the frequency of sex and number of partners [1–3]. The scientific evidence also provides ample assurance that sex education does not have negative outcomes [1–5]. The value of systematically gathering evidence about effective sex education programs is exemplified by two pioneering reports by Dr.
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