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Advancing Sexual and Reproductive Health Education—Pursuing the Long Arc of Justice

      See Related Articles on p. 540, 584, 588, 598
      Since 1988, the Centers for Disease Control and Prevention's (CDC) Division of Adolescent and School Health has been instrumental in our country's efforts to promote “environments where youth can gain fundamental health knowledge and skills, establish healthy behaviors, and connect to health services to prevent HIV, sexually transmitted diseases (STDs), and unintended pregnancy.” Through its commitment to “translating science into innovative programs and tools,” CDC helps the country implement effective programs and practice standards that shape the field more broadly [
      Centers for Disease Control and Prevention (CDC)
      The Path Forward: DASH 2020-2025 strategic plan, Division of adolescent and school health. U.S. Department of Health and Human Services, CDC.
      ].
      In this issue of the Journal of Adolescent Health, a quartet of timely articles by CDC researchers provides the field of adolescent sexual and reproductive health with an opportunity to reflect on both our progress thus far and future directions needed to further reduce unintended adolescent pregnancy, while also facing challenges in preventing HIV and other STDs. These efforts must further address disparities faced by significant groups within the adolescent population, representing the intersectionality of race and ethnicity, LGBTQ youth, those in foster care and the juvenile justice system, and those in under-resourced communities, among many others. Achieving racial equity must also be addressed.
      Prominent in the Division of Adolescent and School Health's mission to improve sexual and reproductive health outcomes is its strategic effort to strengthen the scaffolding of schools, families, and communities to not only better serve adolescents, but also assure that they are healthy, successful adults. In their wholistic theory- and evidence-driven model, “Addressing HIV/STD and pregnancy prevention through schools: An approach for strengthening education, health services, and school environments that promote adolescent sexual health and well-being”, Wilkens et al. clearly articulate the need to recognize the vital role that safe and supportive environments play in shaping adolescent decision-making [
      • Wilkins N.J.
      • Rasberry C.
      • Liddon N.
      • et al.
      Addressing HIV/STD and pregnancy prevention through schools: An approach for strengthening education, health services, and school environments that promote adolescent sexual health and well-being.
      ]. Specific strategies include strengthening program staff capacity, increasing access to the types of programs and services needed by adolescents, and engaging parent and community partners who represent the safety net that is necessary for adolescents to thrive.
      One of the challenges communities face in implementing such a comprehensive model is a persistent and difficult-to-dislodge perception that the provision of sexuality health education (SHE) in schools condones adolescent sexual activity. State educational policies require classroom instruction about HIV in 39 states and the District of Columbia, but only 30 states require sex education [
      National Council of State Legislators
      State policies on sex education in schools.
      ]. Guidance on how and when sex education should be taught is available, but decisions are often left to individual school districts. As a result, fewer than half of high schools and only a fifth of middle schools teach all 16 topics recommended by the CDC as essential components of sex education, including information on contraception and communication skills. Furthermore, 43% of adolescent females and 57% of adolescent males did not receive information about birth control before they had sex for the first time [
      Centers for Disease Control and Prevention
      School health profiles 2018: Characteristics of health programs among Secondary schools. Atlanta: Centers for Disease Control and Prevention.
      ]. Thus, the article, “Overwhelming support for sexual health education in US schools: A meta-analysis of 23 surveys conducted between 2000 and 2016,” aims to assure state and local policymakers that much of the public (both adults and parents) supports SHE, although the availability of such education continues to decline in the United States [
      • Szucs L.E.
      • Harper C.R.
      • Andrzeiewski J.D.
      • et al.
      Overwhelming support for sexual health education in U.S. School: A meta-analyses of 23 surveys conducted between 2000 and 2016.
      ]. The disconnect between public support and significant gaps in the availability of SHE has long represented political controversy despite decades of research documenting that the provision does not contribute to increases in the proportion of sexually active adolescents, but rather reduces their risk by delaying sexual debut and lessening other risk behaviors, such as number of partners [
      • Pedlow C.T.
      • Carey M.P.
      Developmentally appropriate sexual risk reduction interventions for adolescents: Rationale, review of interventions, and recommendations for research and practice.
      ].
      At a time of increasing political polarization, including debates that focus on aspects of the school environment, such as critical race theory and vaccine mandates, it may not be surprising that many school administrators opt for a cautious and more timid approach. This points to the importance of supporting strong state policy and the power of mobilizing additional allies, including concerned parents and other adult stakeholders, to support such efforts. Although national data and state policy may help to provide political cover, it is likely that local school districts will need local support and information regarding acceptable content topics to advance an SHE agenda. Although silence may be politically expedient, it sacrifices adolescents' futures when they lack the information and skills that they need to successfully navigate their transition to adulthood without fears of pregnancy, STDs, and HIV.
      The power of state policy in shaping adolescents' environments is reflected in the third article, “Association between LGBTQ Student Non-Discrimination Laws in Selected States and School District Support for Gay-Straight Alliances” [
      • Harper C.R.
      • Johns M.M.
      • Orenstein D.
      • et al.
      Association between LGBTQ student non-discrimination laws in selected states and school district support for Gay-Straight Alliances.
      ]. States that abide to nondiscrimination and antibullying laws are better able to support the implementation of local action, in turn, benefitting not only LGBTQ youth, but also their allies by establishing a strong youth-development model, Gay-Straight Alliances (GSAs). Such leadership builds on the previous efforts when national concerns about HIV prodded federal and state policymakers to recognize the risk of HIV/AIDS mortality and morbidity for adolescents, leading to substantial inroads in the provision of required classroom education. State policy helped set the stage and provided political cover for local implementation action, a lesson that has implications for fortifying state-level policies that provide the same type of political cover for local action to counter the ongoing dilution of national, state, and local SHE efforts. It would be illuminating to understand what factors are critical at the state level to advance antidiscrimination laws, to evaluate the specific work conducted by different GSAs, and to assess the potential “spill-over” effect of having GSAs open doors for additional youth development and SHE efforts. Noteworthy, even without such state policies, many states proceeded with setting up networks of GSAs; thus, we need to explore what factors encourage local action without the benefit of state policy.
      In the fourth article, “Increases in student knowledge and protective behaviors following enhanced supports for sexual health education in a large, urban school district,” Rasberry et al. test the hypothesis that building strong curricula and professional development, including mentoring and instructional coaching, among those delivering SHE will increase knowledge and behavioral skill improvements among diverse adolescents [
      • Rasberry C.N.
      • Young E.
      • Szucs L.E.
      • et al.
      Increases in student knowledge and protective behaviors following enhanced supports for sexual health education in a large, urban school district.
      ]. Results document that while knowledge changes are easier to accomplish, behavioral change continues to be harder to achieve. There was progress in achieving only six of 16 behavioral outcomes in intervention schools, as compared with three of 16 outcomes achieved without the benefit of enhanced supports. Even in school settings that prioritize staff investment and where motivated teachers are selected to teach, many factors must be firmly in place to achieve success, especially across different segments of adolescents representing varying degrees of risk, such as those who are economically disadvantaged and those who are at risk for dropping out of school. It would be helpful to disentangle the consistency of the curricula implemented within each school setting and for different types of student demographic and risk profiles, the effects of different degrees of exposure to the curricula (dosage) and whether the curriculum selected (not previously evaluated) was culturally appropriate.
      The value of these interconnected articles is that they elucidate the challenges faced in the field of SHE, while also supporting the iterative nature of pursuing excellence in solving pressing public health and policy problems. As committed professionals, what are the implications for future directions in the field of SHE?
      • 1.
        Quality and capacity matters. Ongoing training, mentoring, and quality-improvement monitoring of individual educators require ongoing investments and data on the quality of program implementation.
      • 2.
        Multipronged approaches to adolescent pregnancy, STDs, and HIV prevention are needed that build on individual knowledge and skills, as well as crucial support from stakeholders such as families, teachers, administrators, and policy makers over the long haul. Such important content requires curriculum sequencing and environments that adopt a youth-development approach to adolescents and their successful transition to young adulthood. Such comprehensive models may be politically unfeasible across much of our nation. Thus, we need to better understand what actions are necessary to assure that more communities can implement such models. In addition, if such comprehensive models are beyond reach, what interventions may still help advance SHE?
      • 3.
        Implementation science is needed to better understand what content and best practices are being implemented and with what fidelity to state and local policy. It is also important to ascertain how specific content contributes to improving the health of different groups of adolescents, including youth in foster care, those unsheltered, or those in the juvenile system—all health profiles represent greater risk for poorer outcomes. Better understanding of “what is in the intervention box” is needed if we are to understand how provider concordance with students, curriculum content, and types of interventions work most effectively across diverse segments of the adolescent population.
      • 4.
        Federal and state policy and resources are crucial to assure that all adolescents have access to the information and access to health care services, including reproductive care, that they need to make critical health and interpersonal decisions. Linking policy to local action and the concrete benefits of such policies on adolescents, their families, and communities may be instrumental in supporting local leaders to act in a courageous manner. Although silence may be politically expedient, young people whose lives matter are at stake.

      References

        • Centers for Disease Control and Prevention (CDC)
        The Path Forward: DASH 2020-2025 strategic plan, Division of adolescent and school health. U.S. Department of Health and Human Services, CDC.
        (Available at:)
        • Wilkins N.J.
        • Rasberry C.
        • Liddon N.
        • et al.
        Addressing HIV/STD and pregnancy prevention through schools: An approach for strengthening education, health services, and school environments that promote adolescent sexual health and well-being.
        J Adolesc Health. 2022; 70: 542-551
        • National Council of State Legislators
        State policies on sex education in schools.
        (Available at:)
        • Centers for Disease Control and Prevention
        School health profiles 2018: Characteristics of health programs among Secondary schools. Atlanta: Centers for Disease Control and Prevention.
        (Available at:)
        • Szucs L.E.
        • Harper C.R.
        • Andrzeiewski J.D.
        • et al.
        Overwhelming support for sexual health education in U.S. School: A meta-analyses of 23 surveys conducted between 2000 and 2016.
        J Adolesc Health. 2022; 70: 600-608
        • Pedlow C.T.
        • Carey M.P.
        Developmentally appropriate sexual risk reduction interventions for adolescents: Rationale, review of interventions, and recommendations for research and practice.
        Ann Behav Med. 2004; 27: 172-184
        • Harper C.R.
        • Johns M.M.
        • Orenstein D.
        • et al.
        Association between LGBTQ student non-discrimination laws in selected states and school district support for Gay-Straight Alliances.
        J Adolesc Health. 2022; 70: 586-589
        • Rasberry C.N.
        • Young E.
        • Szucs L.E.
        • et al.
        Increases in student knowledge and protective behaviors following enhanced supports for sexual health education in a large, urban school district.
        J Adolesc Health. 2022; 70: 590-599

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