1.9 Formal Sexuality Education Through a Public Health Lens

Formal sexuality education in the U.S. exists on a spectrum. On one end are comprehensive programs and on the other end are abstinence-only-until-marriage programs. People may get one of these two types of programs, or something in-between. Since 2000, the percentage of young people who received any formal sexuality education has declined, with young people who live in non-metropolitan areas being more heavily impacted (Centers for Disease Control and Prevention, 2017b; Lindberg et al., 2016). At the same time, rates of sexuality education from parents and families have not increased (Lindberg et al., 2016). This means that youth in this country are receiving less and less formal or informal sexuality education of any kind.

Comprehensive Sexuality Education

According to the Guttmacher Institute (Panchaud & Anderson, 2016), comprehensive sexuality education:

“seeks to equip young people with the knowledge, skills, attitudes and values they need to determine and enjoy their sexuality—physically and emotionally, individually and in relationships. It views sexuality holistically, as a part of young people’s emotional and social development. It recognizes that information alone is not enough. Young people need to be given the opportunity to acquire essential life skills and develop positive attitudes and values.”

Additionally, comprehensive sexuality education (Panchaud & Anderson, 2016):

• Uses a holistic format that gives people all the information and then trusts them to make decisions that are right for themselves and that are in line with their values and beliefs.
• Doesn’t restrict or skew information to get people to think or act in a certain way.
• Acknowledges that sexuality is present in individuals from birth to death, and education should occur throughout the life course.
• Provides medically accurate and unbiased information, language, and images in an age- and developmentally-appropriate manner.
• Presents sexual activity as a natural and healthy part of life.
• Focuses on the positive aspects of sex in a realistic way to help people develop healthy sexuality.
• Follows the philosophy that individuals are the experts on their own sexualities.
• Does not elevate certain sexual orientations, gender identities, partnerships, or behaviors higher than others; rather, content is inclusive of all people.
• Acknowledges that every person comes with their own unique level of skills and knowledge on these subjects; a vast difference may exist between individuals and that’s okay. Current views on sexuality are highly influenced by past experiences and upbringing, some of which people had control over, some of which they didn’t.

When individuals are able to make informed decisions, they can focus on their goals. Sex can have potential risks that can interfere with a person’s hopes and plans, including finishing their education and starting a career. Comprehensive sexuality education is one tool which increases personal wellbeing and supports individuals in being a productive and contributing member of their community and the greater society.

Comprehensive Sexuality Education is Effective

Some people get upset about comprehensive sexuality education. Why is that? One belief is that teaching about these topics is giving young adults permission to be sexually active and with multiple partners. Another belief is that it’s not an appropriate topic to discuss, or it’s the job of parents or family to be the educators. However, comprehensive sexuality is based on supporting youth in being safe and healthy by using age-appropriate strategies supported by not only pediatricians, mental health experts, and science, but also supports parents and caregivers as being partners in educating their youth.

Regardless of political affiliation, the majority of the population supports comprehensive sexuality education and believes teaching safer sex strategies is more effective than an abstinence approach (Planned Parenthood, 2023; SIECUS, 2018; Jones et al., 2018; Kantor & Levitz, 2017). In addition, studies indicate that parents see sex education as an important topic to be taught, with approval rates on average above 90% (Planned Parenthood, 2023; Eisenberg et al., 2022; Kantor & Levitz, 2017).

Study after study shows that no correlation exists between comprehensive sexuality education and an increase in the percentage of sexually active young adults. In fact, young people who have access to comprehensive sexuality education actually delay their first sexual experience, have fewer sexual partners, reduce the frequency of sexual activity, and are more likely to use contraception, condoms, and dental dams when they are sexually active (Alford et al., 2008; Kirby, 2007; Bridges & Alford, 2015; Breuner et al., 2016; U.S. Department of Health & Human Services, n.d.). In addition, over 30 years of research demonstrates positive outcomes of comprehensive sexuality education, including (Goldfarb & Lieberman, 2021):

• increased appreciation for diverse sexual and gender identities
• decreased bullying and safer environments for LGBTQ+ students
• increased recognition of the influence of gender and gender norms
• increased understanding of how power impacts sexual rights and gender equity
• decreased intimate partner violence
• increased bystander intervention
• increased knowledge, attitudes, and skills around healthy relationships and communication
• decreased child sexual abuse and recognition of personal boundaries around touch and safety as well as skills to report abuse
• increased social-emotional learning, such as the ability manage feelings, empathy, and respect for others
• increased media literacy

The overwhelming evidence of effectiveness is the reason comprehensive sexuality education is a public health supported approach.

Community Agreement Standards in Comprehensive Sexuality Education

One of the principles of comprehensive sexuality education is to collaboratively establish community agreement standards. The purpose is to help everyone understand the boundaries and feel safe within the educational environment, while also acknowledging that participants bring their own expertise and lived experiences with them. The following are typical agreements:

• Be respectful of other people’s thoughts, feelings, and experiences. Comments that are derogatory or disrespectful are not welcome.
• It’s okay to agree or disagree with what is presented, or experience a range of emotions as a response. Concepts, information, and actions may clash with personal values and beliefs. When these situations occur, challenge yourself to stop and think about why others might feel the ways they do and to be understanding. The more we listen to other people, the more we grow. A common saying in the field that’s used to describe this practice is “Don’t yuck on other people’s yums.”
• Use inclusive language which refrains from assuming sexual orientation, gender identity, likes, or preferences. When inclusive language is used, then all people can experience sexuality education that welcomes them.

Abstinence-Only-Until-Marriage Education

Abstinence-only-until-marriage educational programs have the goal of stopping people from becoming sexually active until after they’ve gotten married. More recently, these programs have rebranded and now use the term Sexual Risk Avoidance Education. In doing so, they’ve also started to use some of the same language as comprehensive programs to describe their objectives and goals, although their techniques are very different. For these programs to receive funding from the federal government, they must address the following topics, as directly stated by Section 510 (b) of Title V of the Social Security Act (2018):

• The holistic individual and societal benefits associated with personal responsibility, self-regulation, goal setting, healthy decision-making, and a focus on the future.
• The advantage of refraining from nonmarital sexual activity in order to improve the future prospects and physical and emotional health of youth.
• The increased likelihood of avoiding poverty when youth attain self-sufficiency and emotional maturity before engaging in sexual activity.
• The foundational components of healthy relationships and their impact on the formation of healthy marriages and safe and stable families.
• How other youth risk behaviors, such as drug and alcohol usage, increase the risk for teen sex.
• How to resist and avoid, and receive help regarding, sexual coercion and dating violence, recognizing that, even with consent, teen sex remains a youth risk behavior.

Programs granted this funding must “ensure that the unambiguous and primary emphasis and context for each topic is a message to youth that normalizes the optimal health behavior of avoiding nonmarital sexual activity” (Social Security Act, 2018). Additionally, in order to receive funding, these programs can not demonstrate how to use contraception, including how to properly use a condom, and they can’t distribute condoms or other contraceptives.

Abstinence-Only-Until-Marriage Education is Ineffective and Harmful

Due to the lack of effectiveness and harmful outcomes on students, public health does not support abstinence-only-until-marriage approach to sexual health education. Unlike comprehensive sexuality education, abstinence-only-until-marriage education has shown no evidence in preventing sexual activity. The studies that have shown any positive effect are full of methodological errors that decrease their rigor and reliability (Santelli et al., 2017; Woebse, 2014). Students in these programs are no more likely to abstain than peers who don’t receive any sexuality education (Santelli et al., 2017; Waxman, 2004; Woebse, 2014). In fact, students who receive this education are less likely to use condoms or contraception when they are sexually active and have higher rates of STIs and unintended pregnancies (Santelli et al., 2017, Waxman, 2004).  Moreover, these outcomes have a disproportionate effect on people with vaginas and uteri, as their anatomy puts them at higher risk of sexually transmitted infections and are the ones who would become pregnant.

Abstinence-only-until-marriage programs reinforce harmful gender stereotypes, including that men have uncontrollable sexual desires which women must try to control, and the way women dress and act invites sexual advances from men (Kay & Jackson, 2008; Santelli et al., 2017). These programs also shame sexual activity and send victim-blaming messages (Kay & Jackson, 2008; Santelli et al., 2017). A common teaching technique is comparing a person who is sexually active to a used piece of gum; no one will want to marry them if they’ve been chewed on by other people. Consider the impact of hearing that message as a victim/survivor of sexual assault. Finally, abstinence-only-until-marriage programs communicate that the expected standard for sexual activity is between a person with a penis and a person with a vagina who are married to each other; anything outside of that type of sexual relationship is abnormal and unhealthy (GLSEN, 2018; Santelli et al., 2017). This message harms students who fall outside of these binary identities.