Comprehensive sex education

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Comprehensive sex education (CSE) is a sex education instruction method based on-curriculum that aims to give students the knowledge, attitudes, skills and values to make appropriate and healthy choices in their sexual lives. The intention is that this understanding will prevent students from contracting sexually transmitted infections in the future, including HIV and HPV. CSE is also designed with the intention of reducing unplanned and unwanted pregnancies, as well as lowering rates of domestic and sexual violence, thus contributing to a healthier society, both physically and mentally.

Comprehensive sex education ultimately promotes sexual abstinence as the safest sexual choice for young people. However, CSE curriculums and teachers are still committed to teaching students about topics connected to future sexual activity, such as age of consent, safe sex, contraception such as: birth control, abortion, and use of condoms. This also includes discussions which promote safe behaviors, such as communicating with partners and seeking testing for sexually transmitted infections. Additionally, comprehensive sex education curricula may include discussions surrounding pregnancy outcomes such as parenting, adoption, and abortion. The most widely agreed benefit of using comprehensive sex education over abstinence-only sex education is that CSE acknowledges the student population will be sexually active in their future. By acknowledging this, CSE can encourage students to plan ahead to make the healthiest possible sexual decisions. This ideology of arming students to most successfully survive their future sexual experiences underlies the majority of topics within CSE, including condoms, contraception, and refusal skills.

History

As of the year 2019, sex education in the United States is mandated on a state level. It is up to the different states, districts, and school boards to determine the implementation of federal policy and funds for sex education. 24 out of the 50 U.S. states and the District of Columbia mandate sex education and 34 states mandate HIV education. Where sex education is mandated, there is no federal policy requiring the instruction of comprehensive sex education.

In prior years under the Bush administration, there was strong support in congress by conservative republicans for the sanction of abstinence-only-until-marriage sex education. Under President Obama's administration, abstinence-only-until-marriage sex education was opposed and suggested to be eliminated. Now under President Trump's administration, federal agenda has reverted back to supporting an abstinence approach. The Centers for Disease Control and Prevention’s 2014 School Health Policies and Practices Study found that on average high school courses require 6.2 hours of taught class time on human sexuality, but only 4 hours or less on HIV, other sexually transmitted infections and pregnancy prevention.

Benefits

Studies have found that comprehensive sex education is more effective than receiving no instruction and/or those who receive abstinence-only instruction. Acknowledging that people may engage in premarital sex rather than ignoring it (which abstinence-only is often criticized for) allows educators to give the students the necessary information to safely navigate their future sexual lives.

CSE advocates argue that promoting abstinence without accompanied information regarding safe sex practices is a disregard of reality, and is ultimately putting the student at risk. For example, programs funded under AEGP are reviewed for compliance with the 8 standards (listed below in "Abstinence Education Grant Program (AGEP) Requirements), but are not screened for medical accuracy. Therefore, critics believe that students under these educational programs are put at a disadvantage because it prevents them from making informed choices about their sexual health. Additionally, under these AEGP programs, health educators have referred to those that engage in sex, especially females, as "dirty" and "used." They have also used phrases such as "stay like a new toothbrush, wrapped up and unused" and "chewed-up gum" to teach abstinence. Under a CSE model, language would be more sensitive. 

There is clear evidence that CSE has a positive impact on sexual and reproductive health (SRH), notably in contributing to reducing STIs, HIV and unintended pregnancy. Sexuality education does not hasten sexual activity but has a positive impact on safer sexual behaviours and can delay sexual debut. A 2014 review of school-based sexuality education programmes has demonstrated increased HIV knowledge, increased self-efficacy related to condom use and refusing sex, increased contraception and condom use, a reduced number of sexual partners and later initiation of first sexual intercourse. A Cochrane review of 41 randomized controlled trials in Europe, the United States, Nigeria and Mexico also confirmed that CSE prevents unintended adolescent pregnancies. CSE is very beneficial in regards to teen pregnancy because studies show that, teen pregnancy and childbearing have a significant negative impact on high school success and completion, as well as future job prospects. A study in Kenya, involving more than 6,000 students who had received sexuality education led to delayed sexual initiation, and increased condom use among those who were sexually active once these students reached secondary school compared to more than 6,000 students who did not receive sexuality education. CSE also reduces the frequency of sex and the number of partners which in turn also reduces the rates of sexually transmitted infections.

UNAIDS and the African Union have recognized CSE’s impact on increasing condom use, voluntary HIV testing and reducing pregnancy among adolescent girls and have included comprehensive, age-appropriate sexuality education as one of the key recommendations to fast track the HIV response and end the AIDS epidemic among young women and girls in Africa.

As the field of sexuality education develops, there is increasing focus on addressing gender, power relations and human rights in order to improve the impact on SRH outcomes. Integrating content on gender and rights makes sexuality education even more effective. A review of 22 curriculum- based sexuality education programmes found that 80 per cent of programmes that addressed gender or power relations were associated with a significant decrease in pregnancy, childbearing or STIs. These programmes were five times as effective as those programmes that did not address gender or power. CSE empowers young people to reflect critically on their environment and behaviours, and promotes gender equality and equitable social norms, which are important contributing factors for improving health outcomes, including HIV infection rates. The impact of CSE also increases when delivered together with efforts to expand access to a full range of high- quality, youth-friendly services and commodities, particularly in relation to contraceptive choice.

A global review of evidence in the education sector also found that teaching sexuality education builds confidence, a necessary skill for delaying the age that young people first engage in sexual intercourse, and for using contraception, including condoms. CSE has a demonstrated impact on improving knowledge, self-esteem, changing attitudes, gender and social norms, and building self-efficacy.

Criticism

Comprehensiveness

While CSE implementation is on the rise in the United States, it remains difficult for state officials to regulate what is and is not taught in the classroom. This is due in large part to the undefinability of CSE; CSE has the potential to comprise such a wide range of sexual information, and over-all focus varies widely between curriculums. Educators have also accused CSE as fundamentally operating as a form of "abstinence-plus," due to the reality that CSE often involves minimal body related information and excessive promotions of abstinence. "So-called Comprehensive Sex Ed" says Sharon Lamb, a professor at the University of Massachusetts Boston, "has been made less comprehensive as curricula are revised to meet current federal, state, and local requirements."

Inclusion of LGBT community

The LGBT population experiences health disparities associated with stigma, discrimination, negative connotations as well as stereotypes. This population is subject to systemic barriers to adequate healthcare services ultimately impacting their wellbeing and welfare negatively. The care that they are provided with often is from clinicians who are not trained well in addressing the concerns of this population. This lack of training from the provider hinders the experience and ultimately influences the quality of care and adequate delivery of healthcare. Due to discrimination and lack of cultural sensitivity that perpetuate prejudice, this population experiences limited health-seeking behaviors. Thus, making preventative services unattainable, furthermore, increasing and prolonging illnesses and ailments. Research shows higher risk of contracting HIV and other STDs; the number is increased when assessing the intersecting population of gay men of color. Lesbian and bisexual females are less likely to obtain routine care like: breast and cervical cancer screenings. Gay men are at an increased risk of prostate, testicular, anal, and colon cancers, while lesbian and bisexual women have an increased risk of ovarian, breast, and endometrial cancers. As a result stigma, discrimination, victimization, and sexual abuse LGBT youth is more likely to be involved in high-risk sexual behaviors at an earlier age.

While comprehensive sex education exists in schooling, many programs do not address the needs of the LGBT community. This population faces different health disparities ultimately driven by discrimination, shortfalls of peers, the lack of parental support, community services, and school based sex education. The implementation of LGBT comprehensive sex education utilized as an intervention seeks to combat these health disparities, by informing the population of the importance of developing sexual health. Sexual health involves not only preventing disease, but also a respectful approach to sexual relationships, sexuality, and accepting an individual's gender iedntity and sexual orientation.

The term "comprehensive" is also often misleading because some comprehensive programs do not show the holistic picture of human sexuality. LGBT advocates have long been critical of the ways in which comprehensive sex education generally promotes marriage as the end goal for students. LGBT advocates want to express other forms of relationships other than marriage. Students should have sex education that encompasses the different forms and should be allowed to exercise those forms in which they are most comfortable with. Even when curriculums claim to be inclusive of LGBT experiences, they often promote heteronormative lifestyles as "normal."  Inclusion of LGBT identities and health topics is necessary for LGBT students to feel safe and seen in their sex ed classrooms. When sex education fails to include LGBT identities and experiences, LGBT youth can be vulnerable to risky sexual behaviors and encourage negative sexual health outcomes. Due to the lack of LGBT sex education provided in schools, LGBT youth will look to peers and the internet which can lead to misinformation. When these students do not have access to or an interest in marriage they are practically erased from the CSE narrative.

In a Canada, a federal report showed that LGBT community has less access to health services and faces more comprehensive health challenges compared to the general population. As a result of lack of support for the LGBT population, the Comprehensive Health Education Workers (CHEW) Project emerged in October 2014. Their goal is to educate the LGBT community about topics such sexual and gender identity, sexually transmitted infections (STIs), healthy social relationships, and depression. They do this though workshops, arts‐based projects, and one‐on‐one meetings. The CHEW project is set exclusively to the LGBT community in order to establish a safe environment in which LGBT youth can gain resources for sex education.

A cross sectional study done in New York City analyzed the sexual behaviors of high school girls. Studies found that, "high school girls who identified as LGBT were more likely to report substance use such as: alcohol, marijuana, cocaine, heroin, meth, ecstasy and prescription drugs. They also had higher rates of contemplating and/or attempting suicide." Another study found that "the LGBT youth accesses health information online five times more than the heterosexual population, and these rates are even higher for LGBT youth that identify as a person of color which stems from the fact that they lack health resources. Rights, Respect, Responsibility includes an inclusive LGBT curriculum for grades K-12. By having a curriculum, such as the Right, Respect, Responsibility suggests, students will be have accurate information to all identities as well as establish a safe classroom for LGBT students.

As of May 2018, only 12 states require discussion of sexual orientation and of these, only 9 states require that discussion of sexual orientation be inclusive (California, Colorado, Delaware, Iowa, New Jersey, New Mexico, Oregon, Rhode Island, and Washington). Additionally, several states have passed legislation that bans teachers from discussing gay and transgender issues, such as sexual health and HIV/AIDS awareness, in a positive light. Furthermore, three states require that teachers only portray LGBT people in a negative light (Alabama, South Carolina, and Texas).

School context

"Before the late 1800s, delivering sex education in the United States and Canada was primarily seen as a parent’s responsibility. Today, programs under the Sexuality Information and Education Council of the United States (SIECUS) begin comprehensive sex education in pre-kindergarten, drawing criticism related to the age at which it is appropriate to address sexual matters with children.

Federal funding for sexual education

Although there is no federal mandate that requires states to teach sexual education, there is federal funding available to assist with sexual education programs.

Abstinence Education Grant Program (AGEP)

Historically, funding for abstinence education has always been favored over CSE. In 1996, during Bill Clinton's presidency, legislation was passed to promote abstinence in education programs. Under Title V Section 510 of the Social Security Act, the Abstinence Education Grant Program (AGEP), was passed. AEGP has always been renewed before its expiration date, and each time funds gradually increase from fifty million dollars per year to seventy-five and as high as $6.75 million per state grant in 2015. The way the funds are disbursed are based on the proportion of low-income children in each state. So far, thirty-six states have been given AEGP funds.

Abstinence Education Grant Program (AGEP) Requirements

Part of Section 510(b) of Title V of the Social Security Act, contains the "A-H guidelines," which are the eight criteria that programs must abide by order to be eligible to receive federal funding. They are as follows:

A. Has as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity;

B. Teaches abstinence from sexual activity outside marriage as the expected standard for all school-age children;

C. Teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;

D. Teaches that a mutually faithful, monogamous relationship in the context of marriage is the expected standard of sexual activity;

E. Teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects;

F. Teaches that bearing children out of wedlock is likely to have harmful consequences for the child, the child's parents, and society;

G. Teaches young people how to reject sexual advances and how alcohol and drug use increase vulnerability to sexual advances; and

H. Teaches the importance of attaining self-sufficiency before engaging in sexual activity;

In addition to abiding by these 8 conditions, AGEP compliant programs cannot discuss contraception, STIs, or methods for protecting against STIs, except when describing failure rates.

Teen Pregnancy Prevention Program (TPP)

More recently legislation has pushed for funding that goes beyond abstinence only education. In 2010, President Obama introduced the Teen Pregnancy Prevention Program (TPP), which provides a total of $114.5 million annually to sex education programs that are "medically accurate and age-appropriate." TPP falls under a subsection of United States Department of Health and Human Services ("HHS") which is overseen by the Office of Adolescent Health. Funding for TPP is dispersed if "they emulate specific evidence-based programs promulgated under TPP."

California Comprehensive Sexual Health and HIV/AIDS Prevention Education Act

In January 2016, the California Healthy Youth Act, amended the California Comprehensive Sexual Health and HIV/AIDS Prevention Education Act to include minority groups and expand health education. Before it authorized schools to provide comprehensive sex education and required that all materials are made accessible to students with a variety of needs. It also focused solely on marital relationships. It now mandates that schools provide comprehensive sex education and states that "materials cannot be biased and must be appropriate for students of all races, genders, sexual orientations, and ethnic and cultural backgrounds, as well as those with disabilities and English language learners." Additionally, education must now include "instruction about forming healthy and respectful committed relationships," regardless if marital status. Furthermore, it is now required to have discussions about all FDA-approved contraceptive methods in preventing pregnancy, including the morning after pill.

In conclusion now requires that all sex education programs promulgated in the state should

• normalize sexuality as part of human development;
• ensure people receive integrated, comprehensive, accurate, and unbiased sexual health and HIV prevention and instruction; and
• provide pupils with the knowledge and skills to have healthy, positive, and safe relationships.

As a human right

Some critics state that young people’s access to CSE is grounded in internationally recognized human rights, which require governments to guarantee the overall protection of health, well-being and dignity, as per the Universal Declaration on Human Rights, and specifically to guarantee the provision of unbiased, scientifically accurate sexuality education.

These rights are protected by internationally ratified treaties, and lack of access to sexual and reproductive health (SRH) education remains a barrier to complying with the obligations to ensure the rights to life, health, non-discrimination and information, a view that has been supported by the Statements of the Committee on the Rights of the Child, the Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) Committee, and the Committee on Economic, Social and Cultural Rights.

The commitment of individual states to realizing these rights has been reaffirmed by the international community, in particular the Commission on Population and Development (CPD), which – in its resolutions 2009/12 and 2012/13 – called on governments to provide young people with comprehensive education on human sexuality, SRH and gender equality.

Other analysis show that comprehensive sex education is not an international right nor a human right because it not clearly stated in either a treaty nor custom. By international law, states are required to provide access to information and education about reproductive health, but this does not require a sex education curriculum. It may take different forms such as mandating that local school districts create a system for providing information to students, or mandating that health clinics and practitioners dispense information to patients.

In curricula

Teaching methods

As CSE gains momentum and interest at international, regional and national levels, governments are increasingly putting in place measures to scale-up their delivery of some form of life skills-based sexuality education, as well as seeking guidance on best practice, particularly regarding placement within the school curriculum. Sexuality education may be delivered as a stand-alone subject or integrated across relevant subjects within the school curricula. These options have direct implications for implementation, including teacher training, the ease of evaluating and revising curricula, the likelihood of curricula being delivered, and the methods through which it is delivered.

Within countries, choices about implementing integrated or stand-alone sexuality education are typically linked to national policies and overall organization of the curricula. The evidence base on the effectiveness of stand-alone vs. integrated sexuality education programming is still limited. However, there are discernible differences for policy-makers to consider when deciding the position of CSE within the curriculum.

As a stand-alone subject, sexuality education is set apart from the rest of the curriculum, whether on its own or within a broader stand-alone health and life skills curriculum. This makes it more vulnerable to potentially being sacrificed due to time and budget constraints, since school curricula are typically overcrowded.

However, a stand-alone curriculum also presents opportunities for specialized teacher training pathways, and the use of non-formal teaching methodologies that aim to build learners’ critical thinking skills. The pedagogical approaches promoted through sexuality education – such as learner-centred methodologies, development of skills and values, group learning and peer engagement – are increasingly being recognized as transformative approaches that impact on learning and education more widely. As a standalone subject, it is also significantly easier to monitor, which is crucial in terms of evaluating the effectiveness of programming, and revising curricula where it is not delivering the desired learning outcomes.

When sexuality education is integrated or infused, it is mainstreamed across a number of subject areas, such as biology, social studies, home economics or religious studies. While this model may reduce pressure on an overcrowded curriculum, it is difficult to monitor or evaluate, and may limit teaching methodologies to traditional approaches.

Terminology

Apart from the different teaching methods, termiology also differs. Abortion, homosexuality, abstinence have connotations and definitions that vary state. For example, the word "abstinence" may refer to disengaging from all forms of sexual activities until marriage or may refer to only disengaging from sexual intercourse. Furthermore, the degree of sexual activity that "abstinence" connotates is often unclear, because sexual behavior that is not sexual intercourse may or may not be included in its definition. As a result, students are left confused about what activities are risky and teachers do not know what they can and cannot teach.

The term "comprehensive," is also falls on spectrum, therefore can be considered an umbrella term. CSE means something radical for some institutions while it can mean something moderate and even conservative for others.

According to the Sexuality Information and Education Council of the United States (SIECUS), the guidelines for comprehensive sexuality education are as follows:

• appropriate to the age, developmental level, and cultural background of students;
• respects the diversity of values and beliefs represented in the community;
• complements and augments the sexuality education children receive from their families, religious and community groups, and healthcare professionals;
• teaches not only about abstinence, but also contraception, including emergency contraception and reproductive choice;
• teaches about lesbian, gay, bisexual, transgender (LGBT) issues and questions issues;
• teaches anatomy, development, puberty, and relationships;
• teaches all of the other issues one would expect to be covered in a traditional sexuality education class; and
• should be science-based and medically accurate

Sexual education exemption

Just as teaching methods and curricula vary by state, excusal from sex education also varies by state. States may have with an opt out or opt in produce. In some states, students can opt out of receiving sexual education without specifying a particular reason. In other states, students can only opt out for religious or moral reasons. In an opt-in provision, parents must actively agree to allow their children to receive sex education prior to the start of the sexual education.

Sexual content in the media

Since 1997, the amount of sexual content on TV has nearly doubled in the United States. Additionally, a study done in 2008 showed that nearly 40% of popular music lyrics contained sexual references which were often sexually degrading. These lyrics were also often accompanied with mentions of other risk behaviors, such as substance use and violence.

Teens (ages 13–15) in the United States, use entertainment media as their top source for education in regards to sexuality and sexual health. Additionally, a study found that 15-19 year olds in the U.S use media far more than parents or schools to obtain information about birth control. Some studies have found that, "very few teen television shows mention any of the responsibilities or risks (e.g., using contraception, pregnancy, STIs) associated with sex and almost none of the shows with sexual content include precaution, prevention, or negative outcomes as the primary theme."  Television shows 16 and Pregnant and its spin-off, Teen Mom, which first aired on MTV in 2009 received major disapproval from some parents as they thought the shows glamorized teen pregnancy and motherhood. However, 16 and Pregnant actually led to a 4.3 percent reduction in teen pregnancy, mostly as a result of increased contraceptive use. In contrast, other data shows that exposure to high levels of sexual content on the television causes adolescents to have twice the risk of becoming pregnant in the following 3 years, compared to those who were exposed to low levels.

The film Mean Girls, directed by Mark Waters shed light on the state sex education in some parts of the United States. In the film the health instructor states, "At your age, you're going to have a lot of urges. You're going to want to take off your clothes and touch each other. But if you do touch each other, you will get chlamydia and die." This line is meant to be satirical, but it illustrates common flaws within sex education in the U.S. It depicts simplistic descriptions of sexual activity and implementation of fear without any legitimate basis.

Comprehensive sex education is the main topic in the documentary The Education of Shelby Knox released in 2005 about Lubbock, Texas, which has one of the highest teen pregnancy and STD rates in the nation. The "solution" to which is a strict abstinence-only sex education curriculum in the public schools and a conservative preacher who urges kids to pledge abstinence until marriage.

In 2013, How to Lose Your Virginity was released, a documentary that questioned the effectiveness of the abstinence-only sex education movement and observed how sexuality continues to define a young woman's morality and self-worth. The meaning and necessity of virginity as a social construct is also examined through narration and interviews with notable sexuality experts, such as former Surgeon General Dr. Joycelyn Elders, "Scarleteen" creator and editor Heather Corinna, historian Hanne Blank, author Jessica Valenti, and comprehensive sex education advocate Shelby Knox.

Not only have films portrayed sex education, but so has social media. Platforms such as YouTube, Facebook, Vine, and others are used as a tool to uplift the narratives of marginalized communities such as persons of color and LGBT persons in hopes to "strengthen sexual health equity for all."

As a result of the mass amount of sex content in media, media literacy education (MLE) has emerged. It was created to address the influence of unhealthy media messages on risky health decisions, such as intention to use substances, body image issues, and eating disorders. A study analyzed the effectiveness of a teacher-led MLE program, called Media Aware Sexual Health (MASH), which provides students with accurate health information and teaches them how to apply that information to critical analysis of media messages. This comprehensive sex education resulted in increased intentions to talk to a parent, partner and medical professional prior to sexual activity, and intentions for condom use.

Due to knowledge gaps in most sex education curricula for teens, free online resources like Sex, Etc., Scarleteen.com, and teensource.org have been created to promote comprehensive, inclusive, and shame-free sex education for teenagers.