Sexuality Education

1. Sexuality Education

2. Objectives • By the end of this presentation, participants will be able to: • Explain three factors that contribute to the need for sexuality education • Cite existing data with regards to the efficacy of sexuality education programs • Describe providers’ roles in sexuality education

3. Outline • The Need for Sexuality Education: Adolescent Reproductive Health Data • Determinants of the Decrease in Adolescent Pregnancy Rates • Sexuality Education to Reduce Pregnancy and STIs • The Provider’s Role in Sexuality Education

4. The Need For Sexuality Education

5. Sexuality: A Healthy Part of Adolescence • Young people develop sexually during adolescence • This is a healthy, normal part of this stage • Youth need information and guidance from trained adults

6. What Is the Purpose of Sex Ed? • Sex ed answers questions about: • The way their bodies are changing • Their feelings for members of the same or different gender • Ways to safely explore the spectrum of sexual behaviors

7. What Are the Sexual Behaviors of U.S. Teens?

8. Sexual Activity and US High School Students 2007 Youth Risk Behavior Survey

9. Ever Had Sexual Intercourse, 2007 YRBS By 12th Grade, Most Students Have Had Sexual Intercourse Total Male Female 9th 10th 11th 12th Grade

10. Condom Use at Last Intercourse 2007 Youth Risk Behavior Survey

11. Contraception Use at Last Intercourse Other 7% NSFG 2002 No Method 9% Hormonal Only 13% Condom Only 47% Dual Use 30% Female Male

12. Adolescent Sexuality is Normal • But it carries risk… • STIs • Pregnancy

13. Epidemiology of STIs and Young People • 19 million new cases/ year • ½ occur in people ages15–24 • Most asymptomatic and undiagnosed • New research: 1 in 4 teen has an STI • 2006: 1/3 of new infections were among people age 13-29 (may be as high as 50%) • Economic costs ~ $6.5 billion/year

14. Teen Pregnancy Rates Worldwide, 2000 Per 1000

15. Adolescent Sexuality is Normal • But it carries risk… • STIs • Pregnancy • How much of that risk is a function of: • Public health systems? • Societal attitudes? • Socio-demographic forces?

16. Preventing Teen Pregnancy and STIs

17. Good News: Teen Pregnancy Rates Declining

18. But Disparities Persist Pregnancies per 1,000 women aged 15-19, 2002

19. Determinants of Decline in Teenage Pregnancy Rates • Decreases in Sexual Activity Rates • Increases in Contraception Use

20. Causes of Recent Decline in Teen Pregnancy Rates • 2006 analysis concluded that for 15–19 year olds: • 14% of decline attributed to decrease in sexual activity • 86% to increase in use of contraception

21. Preventing Pregnancy and STIs Through Sexuality Education

22. Types of Programs • Programs That Focus on the Sexual Antecedents of Teen Pregnancy • Programs That Focus on Non-Sexual Antecedents

23. Focus: Sexual Antecedents of Teen Pregnancy • Curricula-Based Programs • Sex and HIV Education Programs for Parents and Families • Clinic/School-Based Programs to Provide Reproductive Healthcare or to Improve Access to Condoms or Other Contraceptives

24. Curricula Based-Programs: Abstinence-Only & Comprehensive

25. Abstinence-Only-Until-Marriage (AOUM) Programs • Teach: • Abstinence from sexual activity until marriage is the only way to avoid pregnancy, STIs, and associated health problems • Do not teach about: • Contraception, sexual identity, or positive sexuality

26. 8-Point Definition of AOUM Education • Has as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity • Teaches abstinence from sexual activity outside of marriage as the expected standard for all school-age children • Teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted infections, and other associated health problems • Teaches that a mutually faithful monogamous relationship in the context of marriage is the expected standard of sexual activity Section 510(b) of Title V of the Social Security Act, P.L. 104-193

27. 8-Point Definition of AOUM Education • Teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical side effects • Teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child's parents, and society • Teaches young people how to reject sexual advances and how alcohol and drug use increase vulnerability to sexual advances • Teaches the importance of attaining self-sufficiency before engaging in sexual activity Section 510(b) of Title V of the Social Security Act, P.L. 104-193

28. Federal Support for AOUM Programs • Major expansions in federal support since 1996 • Section 510 of the Social Security Act • Part of welfare reform in 1996 • Support to states • Community-Based Abstinence Education projects (SPRANS) program in 2000

29. Federal Support for Abstinence-Only Programs Section 510 • Prohibits information on contraceptive services, sexual identity, human sexuality • May not in any way advocate contraceptive use or discuss contraceptive methods except to emphasize their failure rates

30. Content of Abstinence-Only Programs • 80% of curricula contain false, misleading, or distorted information, including: • False information about effectiveness of contraception • False information about the risks of abortion • Blur religion and science • Treat gender stereotypes as scientific facts • Contain other scientific errors

31. AOE Programs Evaluated • Few studies on abstinence-only programs • Evaluation of 4 federally funded programs found: • Slight improvements in attitudes regarding abstinence • Ineffective at improving communication with parents or intentions to remain abstinent • Majority of other studies had methodological limitations • Measuring short-term behaviors • Small sample sizes

32. Virginity Pledge Data • Pledgers: • Delayed onset of intercourse for up to 18 months (not until marriage) • 1/3 less likely to use contraception at eventual intercourse • Had same STI rates as non-pledgers • 88% had intercourse before marriage • Pledge neither significantly decreased nor increased the chances of pregnancy

33. Follow-Up Virginity Pledge Data • Pledgers vs. Non-pledgers: Sexual Debut • Pledgers had sexual intercourse later • 61% of pledgers and 79% of inconsistent pledgers had sex before marriage • Pledgers vs. Non-pledgers: Condom Use • Pledgers: less likely to use condoms at most recent intercourse • Pledgers vs. Non-pledgers: STI Rates • STI rates did not differ from non-pledgers • Pledgers: less aware of STI status • Pledgers vs. Non-pledgers: Oral and Anal Sex • Pledgers: likely to have oral/anal but no vaginal sex

34. Government-Funded Evaluation Reports • Mathematica Policy Inc. was authorized by Congress in 1997 to conduct an evaluation of abstinence-only education programs • First Report • Released in 2005 • An implementation and process analysis • Second Report • Released in April 2006 • Rigorous, experimentally based impact evaluation to estimate effects of program

35. 2007 Evaluation Report • Evaluated the behavioral impact of 4 abstinence-only programs • My Choice, My Future! in Powhatan County, Virginia; • Recapturing the Vision in Miami, Florida; • Teens in Control in Clarksdale, Mississippi; and • Families United to Prevent Teen Pregnancy in Milwaukee, Wisconsin

36. Methodology and Results • Followed 2,000 children from elementary or middle school into high school randomized to either a program or control group • Self-reported results indicated that programs: • Had no impact on sexual initiation rates, age at first intercourse (14.9 years for both groups), or numbers of partners • Had no impact on pregnancies, births, or STDs • Same rates of condom and birth control use as control group

37. Logic Model Used in Evaluation Trenholm C, Devaney B, Forston K, Quay L, Wheeler J, Clark M. “Impacts of Four Title V, Section 510 Abstinence Education Programs,”Mathematica Research Group, 2007.

38. Estimated Impacts on Sexual Initiation Rate

39. Estimated Impacts on Number of Partners

40. Impacts on Unprotected Sex and 1st Intercourse Trenholm C, Devaney B, Forston K, Quay L, Wheeler J, Clark M. “Impacts of Four Title V, Section 510 Abstinence Education Programs,”Mathematica Research Group, 2007.

41. Impacts on Unprotected Sex, Last 12 Months

42. Impacts on Birth Control Use, Last 12 Months

43. Impacts on Pregnancy and STIs

44. Mathematica Report: Lessons Learned • Teens have important gaps in knowledge of STIs • Targeting youth at young ages may not be sufficient • Peer support for abstinence erodes as youth progress through adolescence

45. Comprehensive Sex Education • Successful programs vary in approach • Present abstinence as most effective method of preventing pregnancy and STIs • Educate teens regarding condoms and contraception • Discuss: • Sexual identity • Resisting peer pressure • Negotiating contraceptive use with a partner

46. Comprehensive Sex-Education • Review of 28 well-designed experimental studies found most programs do not adversely affect • Initiation or frequency of sexual activity • Number of partners • Many programs shown to: • Significantly improve condom use and other contraceptive methods

47. Successful Comprehensive Sex Education Curricula • Program Components • Sex education curriculum including information on abstinence and contraception • 16 sessions lasting 45 minutes (expandable to 90 minutes) • Includes experiential activities to build skills in refusal, negotiation, and communication, including parent-child communication Reducing the Risk

48. Reducing the Risk, Continued • Evaluation Methodology • Quasi-experimental design, including treatment and comparison conditions, in 13 California high schools • Urban and rural high school students (n=1,033 at baseline; n=758 after 18 months); mean age at baseline 15.3 years • Pre-test and post-test, with 6- and 18-month follow-up • Evaluation Findings • Increased parent-child communication about abstinence and contraception • Delayed initiation of sexual intercourse • Reduced incidence of unprotected sex in lower-risk youth

49. Erosion of Comprehensive Sexuality Education • Sharp declines in percent of teachers who support teaching and who actually taught about • Birth control, abortion, and sexual orientation • 21% of MS and 55% of HS taught correct use of condoms • Decline in receipt of formal education about contraception from 1995 to 2002 (87% to 70%)

50. Americans’ Opinions on Sexuality Education Public opinion Guttmacher Institute, 2004