Sexuality Education

Over the past twenty years sexuality education in the United States has experienced four distinct generations of school-based programs. In the first generation the focus was on providing students with knowledge of basic sexual anatomy and the risks and consequences of pregnancy. The context An instructor teaches sex education in Mexico. Topics generally covered in sex education include value formation, decision-making, peer and social pressures, intimacy, body image, gender roles, and various sexual behaviors, among a range of other issues. KEITH DANNEMILLER/CORBIS SABA for such approaches was that information was the main objective and that students would apply it as needed. This approach was consistently criticized for not showing any linkage between increasing knowledge and reducing risky sexual behavior. The second generation of programs emphasized values, communication skills, and decision making in one's personal life. This approach was based on the assumption that such areas, if enhanced using sexuality education, would inevitably produce healthier young people. Many of these efforts were also criticized for not addressing a wider range of sexuality concepts (e.g. contraception options). Although students demonstrated enhanced communication and decision-making skills, there did not appear to be any relationship with decreased sexual risk especially with regard to actual sexual behavior. The third generation currently promotes "abstinence only" and in its most strict form omits examination of various contraceptive options. Its context is conservative and often grounded in religion. It proposes that offering students too many options about contraception—and thus "safer sex"—actually encourages risky sexual actions. Their critics argue that such a philosophy ignores the reality of adolescent sexuality: a large number of youth will engage in sex and that they need to do it safely (with effective and consistent contraception). The latest generation is referred to as comprehensive sexuality education which emphasizes abstinence as the best choice but also trains students in refusal skills, assertiveness, communication strategies, and related areas. These programs revolve around acknowledging and addressing all of the major factors seen by adolescents as both real and important. This approach incorporates information about contraceptive options and even where teens can get access to contraceptives in their schools and community. Unsurprisingly, their opponents are abstinence-only advocates who suggest that including how to purchase contraceptives in a school curriculum is not only immoral and irresponsible but illegal, since students—by law—should not be having sexual relations. Conversely, in most European countries, Australia, and Canada, there is no such debate. Instead, many countries prefer to treat contraceptive access as a normal part of adolescent social development.

Since the mid-1980s, one trend in preventive sexuality education in the United States has been peer-based programs. These curricula are jointly designed and taught by well-respected, older-age peers in collaboration with the teacher. The rationale for using peers to help conduct these programs is student desire for ownership of this instruction. Peer leaders also tend to increase the credibility by which such instruction is viewed by students. Increased credibility is linked to greater student interest and ultimately to more meaningful learning. Such curricula are helpful to teachers responsible for teaching this class but who are uncomfortable with the content. Popular students recruited to help teach these programs often lessen this uneasiness and facilitate topical discussion. Results of such peer-based strategies, particularly if followed up with "booster" programs, have been variable but generally seen as favorable (Grunseit 1997).

Peers can enhance sexuality education programs, but parents and legal guardians remain the major sexuality teachers of their children. Research published by the Henry J. Kaiser Family Foundation (1999) estimated that 59 percent of youth ten to twelve years of age reported that they personally learned the "most" about sexuality from their parents. Seventy percent of parents of youth thirteen to fifteen years of age reported that they had spoken with their children regarding relationship issues and becoming sexually active. With or without parental support most communities in the United States have institutionalized sexuality education within school-based curricula. This allows teachers an opportunity to integrate parents into the curriculum content on a regular basis. The question to parents and teachers is no longer if sexuality education should be taught but how such material should be taught. Unfortunately, a number of studies indicate that relatively few parents systematically and comprehensively educate their children in sexuality (Cross 1991; Kallen, Stephenson, and Doughty 1983). Research suggests that open communication between parents and children helps develop enhanced self-confidence, caring relationships, and the skills needed to make healthy sexuality decisions later in life (Centers for Disease Control and Prevention 2000). Experts also suggest that young people who talk with their parents about sexuality are more likely to postpone first sexual activity and to use protection if and when they do become sexually active (Pike 2000; Darroch 2000). Canada, Britain, and the United States each emphasize the inclusion of parents in the schools sexuality education curriculum. They also emphasize delay of first intercourse as a major curricular theme. Such a theme is not emphasized in various European nations such as the Netherlands, Denmark, and France. Some research suggests specific areas that should be addressed in sexuality discussions within the family. These include delivering comprehensive messages, parental communication skill and sensitivity in discussing sexuality, and the timing of communication. Comprehensive messages foster discussion on a range of topics such as decision making, menstruation, reproduction, physical and sexual development, the age when one should assess whether or not to become sexually active, birth control methods, choosing partners, masturbation, and STD/HIV prevention strategies (Whitaker et al. 1998). Parental communication ability and sensitivity to difficult topics are consistently emphasized in successful school-based programs.

A recent study conducted by the Epidemiological Branch of Center for Disease Control's (CDC) Division of HIV/AIDS Prevention examined how selected individual, familial, peer, and environmental factors influence HIV risk and risk-reduction behaviors among adolescents age fourteen to seventeen. Interview data were collected from adolescent-mother pairs recruited from various public high schools and locations. The study focused on the role of mother-child communication regarding sex. The investigators examined how the content, process, and timing of this communication related to the child's later sexual risk behaviors. They found that adolescents who talked with their mothers before their first sexual encounter were three times more likely to use a condom than adolescents who did not talk with their mothers. Such a finding is critical because condom use at first intercourse strongly predicts future use. In fact, adolescents who used condoms at first intercourse were twenty times more likely to use condoms regularly in subsequent acts.

The World Health Organization's Expert Committee on Comprehensive School Health Education and Promotion released a report with recommendations that could enable schools to promote healthy lifestyles. Some of the key recommendations emphasize implementation of community and family involvement. Such involvement could serve as reinforcement for young people to adopt healthy sexual behavior throughout their adolescence and well into marriage.

Unlike their European counterparts, however, relatively few U.S. fathers play an active role in providing their children with age-appropriate sex information. Fathers who fail to participate in such education run the risk of allowing their children to interpret what they view in the media as accurate depictions of sexuality. This neglect can and often does produce negative consequences. Even when there exists a progressive, comprehensive, and developmentally sound school curriculum, parental involvement at home is needed to reinforce and support the skills, information, and viewpoints being explored at school. How to consistently foster this parental reinforcement is a dilemma for sexuality programs in U.S. schools. With the possible exception of Poland and Ireland, both Catholic countries, this dilemma does not pervade European countries. Since sexuality education is viewed the same way as any other education area such as mathematics or history, parental support and inclusion is not the major barrier it is in the United States.

There is a growing movement to implement sexuality education within various medical settings (Mansfield, Conroy, Emans, and Woods 1993). Such education is implemented in physicians' offices or hospitals during patient visits. Normally, a nurse conducts the education although health educators, or even a physician, can be employed. Mansfield and associates (1993) studied the effects of one such physician-delivered HIV education program for high-risk adolescents. After thorough counseling and preventive education in the medical office, sexual behaviors of these adolescents were not significantly changed. Other research teams (Rickert, Gottlieb, and Jay 1990) have had similar difficulty altering sexual behavior of female adolescents in clinic-based interventions. Many health maintenance organizations (HMOs) routinely employ health educators to implement sexuality programs for youth. These interventions employ interactive videos, reading material, and counseling to motivate youth to make responsible choices in sexuality areas. The effectiveness of these education efforts is clear. While knowledge and skill levels are favorably enhanced, the degree to which they prevent later risky sexual actions is not known.

Since the mid-1980s, various religious organizations have instituted their own sexuality or family life education programs. Whereas schools and medical settings tend to emphasize personal responsibility in sexual behavior, religious programs are more likely to emphasize abstinence, a choice included in most major sexuality programs. The curricula offered in more conservative and/or religious areas usually have prohibitions against specific topics and language.

Despite the wide range of contexts, settings, and types of sexuality education in the United States, programs are implemented with the goal of providing relevant knowledge and training so that such education is internalized by students and that they will, therefore, act to avert potential sexual problems (Zabin and Hayward 1993). One specific area which received attention in the 1990s is preventive sexuality education in diverse student populations. The higher epidemiologic rates of teenage pregnancy, HIV, and SDIs in minority students continue to receive significant study and support.