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Sexuality Education. 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

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Sexuality Education

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  • 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
  • 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
sexuality a healthy part of adolescence
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
what is the purpose of sex ed
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
sexual activity and us high school students
Sexual Activity and US High School Students

2007 Youth Risk Behavior Survey

ever had sexual intercourse 2007 yrbs
Ever Had Sexual Intercourse, 2007 YRBS

By 12th Grade, Most Students Have Had Sexual Intercourse

Total Male Female 9th 10th 11th 12th



Condom Use at Last Intercourse

2007 Youth Risk Behavior Survey

contraception use at last intercourse
Contraception Use at Last Intercourse



NSFG 2002

No Method





Condom Only


Dual Use




adolescent sexuality is normal
Adolescent Sexuality is Normal
  • But it carries risk…
    • STIs
    • Pregnancy
epidemiology of stis and young people
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
adolescent sexuality is normal15
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?
but disparities persist
But Disparities Persist

Pregnancies per 1,000 women aged 15-19, 2002

determinants of decline in teenage pregnancy rates
Determinants of Decline in Teenage Pregnancy Rates
  • Decreases in Sexual Activity Rates
  • Increases in Contraception Use
causes of recent decline in teen pregnancy rates
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
types of programs
Types of Programs
  • Programs That Focus on the Sexual Antecedents of Teen Pregnancy
  • Programs That Focus on Non-Sexual Antecedents
focus sexual antecedents of teen pregnancy
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
abstinence only until marriage aoum programs
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
8 point definition of aoum education
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

8 point definition of aoum education27
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

federal support for aoum programs
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
federal support for abstinence only programs
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
content of abstinence only programs
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
aoe programs evaluated
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
virginity pledge data
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
follow up virginity pledge data
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
government funded evaluation reports
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
2007 evaluation report
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
methodology and results
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
logic model used in evaluation
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.

impacts on unprotected sex and 1st intercourse
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.

mathematica report lessons learned
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
comprehensive sex education
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
comprehensive sex education46
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
successful comprehensive sex education curricula
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

reducing the risk continued
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
erosion of comprehensive sexuality education
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%)
americans opinions on sexuality education
Americans’ Opinions on Sexuality Education

Public opinion

Guttmacher Institute, 2004

sex hiv education programs for parents and families
Sex/HIV Education Programs for Parents and Families
  • Developed to improve parent/child communication
  • Studies have demonstrated:
    • Short-term increases in parent/child communication
    • Increases in parental comfort with communication
      • Increases dissipate with time
    • No statistically significant effect on the onset of sexual intercourse
programs to improve condom and contraceptive use
Programs to Improve Condom and Contraceptive Use
  • Health/Family Planning Clinic Based
  • School Based
programs within health or family planning clinics
Programs Within Health or Family Planning Clinics
  • Programs that:
    • Provided information about abstinence, condoms, and/or contraception
    • Engaged in 1-on-1 discussions about their behavior
    • Gave clear messages about sex, condoms, or contraceptive use
    • Provided condoms or contraceptives
  • Consistently increased the use of condoms and contraception without increasing sexual activity
school based programs
School-Based Programs
  • Studies show that programs providing condoms or other contraceptives through schools:
    • Do not increase sexual activity
    • Provide a substantial portion of sexually experienced students with contraceptives
    • Most cause no marked increase in school-wide use of contraceptives (substitution effect)
    • 2 studies found an increase in contraceptive use when programs focused much more on contraception
focus on non sexual antecedents
Focus on Non-Sexual Antecedents
  • Early Childhood Programs
  • Youth Development Programs
programs that focus on non sexual antecedents
Programs That Focus on Non-Sexual Antecedents
  • Focus on broader reasons why teens get pregnant
    • Being from disadvantaged families or communities
    • Detachment from school, work, or other important institutions
    • Lack of close relationships with parents and other caring adults
  • Create reasons to make responsible decisions about sex
early childhood programs
Early Childhood Programs
  • 1 study met criteria for evaluation
  • Infants from low-income families randomly assigned to:
    • A full-time day care program focused on improving intellectual and cognitive development or
    • A regular day care
  • Followed until age 21
  • Kids in the preschool program:
    • Delayed childbearing by more than a year
    • Performed higher on academic measures
youth development programs
Youth Development Programs
  • Service Learning Programs
    • 2 Components
      • Voluntary service by teens in the community
      • Structured time for preparation and reflection
    • Strongest evidence of reduction in pregnancy
  • Vocational Education Programs
    • Provide remedial, academic, and vocational education
    • Four studies found no impact on sexual activity or use of contraception
programs with sexuality and youth development
Programs with Sexuality and Youth Development

Children’s Aid Society—Carrera Program

  • Random assignment to an after-school program or
  • Program with comprehensive youth development curriculum, including
    • Family life and sex ed
    • Individual academic assessment (tutoring, etc.)
    • Work-related activities
    • Self-expression through the arts
    • Sports activities
    • Comprehensive healthcare
children s aid society carrera program evaluation
Children’s Aid Society–Carrera Program: Evaluation
  • Results at 3 years:
    • Girls in intervention group showed a positive impact on sexual and contraceptive behavior, pregnancy, and births
    • No impact on boys’ sexual and reproductive behavior
10 characteristics of effective programs
10 Characteristics of Effective Programs
  • Focus on reducing high-risk sexual behaviors
  • Based on theoretical approaches that have been:
    • Demonstrated to influence other health-related behavior
    • Identify specific important sexual antecedents to be targeted
  • Develop and reinforce a clear message about:
    • Abstaining from sexual activity
    • Using condoms or other forms of contraception
10 characteristics of effective programs63
10 Characteristics of Effective Programs
  • Provide basic, accurate information about:
    • Risks of teen sexual activity
    • Ways to avoid intercourse or use methods of protection against pregnancy and STIs
  • Include activities that address social pressures that influence sexual behavior
  • Provide examples of and practice communication, negotiation, and refusal skills
  • Employ teaching methods designed to involve participants and have them personalize the information
10 characteristics of effective programs64
10 Characteristics of Effective Programs
  • Incorporate behavioral goals, teaching methods, and materials that are appropriate to the age, sexual experience, and culture of the students
  • Last a sufficient length of time (more than a few hours)
  • Select teachers or peer leaders who believe in the program, and provide them with adequate training
discussing sexuality with adolescents
Discussing Sexuality with Adolescents
  • 2 in 3 adolescents want information regarding STIs and pregnancy from physicians
  • > ½ of physicians ask adolescents about their sexual activity
    • Fewer take a full sexual history that includes:
      • Sexual orientation
      • Number of partners
      • Sexual abuse
sex and contraceptive counseling
Sex and Contraceptive Counseling
  • AAP, AMA, AAFP, ACOG, and SAM advise:
    • Providing all adolescents with guidance on sexuality and sexual decision-making
    • Engaging all young people in open, non- judgmental, and confidential discussions within context of a comprehensive clinical encounter
    • Encouraging family involvement
    • Discussing abstinence and safe sex methods
facilitating communication
Facilitating Communication
  • Initiate conversations with parents and teens about confidential healthcare
  • Discuss whether and how a minor’s parent or legal guardian will be involved
  • Ask questions regarding the range of adolescent health, from diet and drugs to sexuality and safety
  • Withhold judgment and do not assume anything
the provider s role in sex education
The Provider’s Role in Sex Education
  • Assess adolescent’s knowledge of reproductive physiology, e.g.
    • Puberty
    • Menses
  • Assess knowledge base regarding sex, pregnancy, and STI transmission
  • Discuss myths/rumors and provide factual information
  • Nocturnal ejaculation
  • Masturbation
the provider s role in sex education70
The Provider’s Role in Sex Education
  • Discuss patient’s attitudes toward and experiences with sex and sexuality
  • Discuss abstinence andsafe-sex practices including:
    • Contraception and condoms
    • Self-esteem
    • Communication skills
  • Answer questions honestly and in accordance with published data
counseling patients and facilitating condom use
Counseling Patients and Facilitating Condom Use
  • Ask patient:
    • “What do you know about how to use a condom?” instead of“Do you know how to use a condom?”
  • Remind teens:
    • Use a new condom every time
    • Put the condom on before any genital contact
    • Hold the condom at base of penis when withdrawing
    • When and how to remove a condom
  • Ask questions to assist the teen in negotiating condom use with partners
advocating for sexuality education
Advocating for Sexuality Education
  • Be knowledgeable about community services that provide appropriate high-quality sexuality education and additional services that children, adolescents, or families need
  • Participate in development and implementation of sexuality education curricula for schools
advocating for sexuality education73
Advocating for Sexuality Education
  • Write letters to the editors of local papers in support of scientifically sound, comprehensive sexuality education
  • Present data regarding the efficacy of sexuality education programs and the risk of misinformation on adolescent health to local school boards or legislators
case 1
Case 1:

A 16-year-old male enters your office. He is first-generation Dominican. When you ask him if he is sexually active, he responds that he “kind of is.” When asked to elaborate, he tells you that his partner, another 16 year old, does not want to lose her virginity so they have been having anal sex. He tells you that he has heard that this is a way to prevent pregnancy and STIs.

  • How do you proceed with the counseling?
case 2
Case 2:

A 15-year-old woman enters your office. After you begin your clinical interview, you discover that she is not sexually active but has a serious boyfriend. She said that she and her boyfriend have discussed beginning a sexual relationship. She is interested in the pill but has heard that it will make her sterile.

  • How do you respond to her concerns?
  • How do you proceed with the interview?