Running Head: COMPREHENSIVE SEXUAL HEALTH EDUCATION 1

The Ohio State University

John Glenn College of Public Affairs

Comprehensive Sexual Health Education as a Means of Improving Sexual Health Outcomes

Sarah Shaw

A policy brief submitted in partial fulfillment for the Master of Public Administration
COMPREHENSIVE SEXUAL HEALTH EDUCATION 2

Executive Summary

Sexual health education in the United States is inadequate. States choose what aspects of

sexual health to include in curricula so educational standards, and therefore educational

outcomes, to vary greatly from state to state. Sexual health education is so controversial in some

states that those states encourage misinformation in education to promote a religiously-

motivated, moralistic agenda. Despite evidence that abstinence-only education is less effective

than risk-mitigation education, abstinence education is engrained in American culture.

Additionally, medical professionals recommend a comprehensive curriculum that goes more in

depth on a broader range of topics than any state currently mandates to improve sexual health

outcomes.

Starting in the early 1980s, federal legislation funded curricula created by religious

conservatives who emphasize abstinence-only-until-marriage education to uphold “moral purity”

standards. Even as direct references to religion were removed, subsequent legislation on health

and welfare reform continued to fund abstinence-only education. The Affordable Care Act tried

to support comprehensive education but maintained abstinence-based funding to garner

bipartisan support. Changing sexual health education outcomes will require federal motivation

through policy action. Those actions can include some combination of shifting the department

that administers federal funding, funding comprehensive curricula, defunding ineffective

curricula, and rewarding states with positive health outcomes. Funding for sexual health

education has existed since the 1980s and can be redirected to support better educational

standards. Overall, the goal of any policy change is to increase sexual health education standards

and outcomes nationwide.

COMPREHENSIVE SEXUAL HEALTH EDUCATION 3

Table of Contents

Executive Summary 2

Table of Contents 3

Problem Statement 5

Current Curricula Issues 5

Sexual Behavior Education 5

HIV Education 6

Sexually Transmitted Infection Education 7

Sexuality Education 7

Defining Quality Sexual Health Education 8

History of Sexual Health Education 8

Legislative Impact on Sexual Health Education 9

Adolescent Family Life Act 9

Welfare Reform Act 10

Affordable Care Act 10

Policy Actions 11

Limitations 11

Policy Alternative: Shift Funding Sources 11

Policy Alternative: Fund Effective Curricula 12

Policy Alternative: Restrict Ineffective Curricula 12

Policy Alternative: Reward Positive Outcomes 13

Evaluation Structure 13

Conclusion 14
COMPREHENSIVE SEXUAL HEALTH EDUCATION 4

Appendix – Tables 16

Table 1. Sex and HIV Mandates by State 16

Table 2. Key Components of Comprehensive Sexual Health Education 17

References 19
COMPREHENSIVE SEXUAL HEALTH EDUCATION 5

Problem Statement

In the United States, sexual health education is fragmented and inconsistent.

Fragmentation comes from dividing the curriculum into specific subjects. Sexual behavior

education largely stresses abstinence until marriage, which does not educate students on forms of

contraception. Abstinence-plus education is education that addresses contraception, but still

stresses abstinence as a morally correct behavior. Sexual behavior education typically covers

biology and reproduction accurately but does not accurately represent the consequences of sexual

behavior. Sexuality is rarely addressed in sexual health curricula. HIV education is separate from

education on sexually transmitted infections (STIs) in general. Sexual health education is

inconsistent because education standards are decided at a state level. Each state has autonomy to

choose what topics to teach within sexual health education (Table 1). Positive sexual health

outcomes are not maximized because the existing curricula do not match the comprehensive

sexual health curriculum broadly supported by medical professionals (Table 2).

Current Curricula Issues

Sexual Behavior Education

Sexual behavior education refers to health education that addresses safe sex and

relationships. Broadly, there are two types of state-dictated curricula used in schools: abstinence-

only-until-marriage and abstinence focused (or abstinence-plus) (Barth, 2005). Both curricula

heavily emphasize that the only way to avoid teen pregnancy and sexually-transmitted infections

is abstinence (Barth, 2005). Abstinence-only programs are heteronormative, patriarchal, only

discuss contraception in terms of failure rates, and do not delay onset of sexual activity (Bridges

& Hauser, 2014). These curricula may legally present misleading or false information to support

their message of abstinence (Bridges & Hauser, 2014). Additionally, states with abstinence-only
COMPREHENSIVE SEXUAL HEALTH EDUCATION 6

curricula that do not cover contraceptive options see higher teenage pregnancies and birthrates in

addition to higher rates of STIs (Stanger-Hall & Hall, 2011). Programs that focus on mitigating

risk associated with sexual activity have more favorable health outcomes pertaining to uses of

contraception, number of sexual partners, and frequency of sexual activity (Santelli, et al., 2017).

HIV Education

HIV education focuses on reducing the spread of HIV/AIDS by reducing sexual behavior

and illustrating the consequences of infection. The HIV virus is spread through exchange of

bodily fluids by an HIV positive person to another person (How Is HIV Transmitted?, n.d.). At a

national level, the content of HIV education is evaluated by whether condoms and abstinence are

included in the curriculum (Sex and HIV Education, 2019). Studies show that students who

received medically accurate and age appropriate HIV education saw fewer related health

consequences and were also less likely to engage in risky behaviors like drug injection that also

relate to spreading HIV (Ma, Fisher, & Kuller, 2014). Sexual health education is typically

ineffective because, of the 39 states that require abstinence in the HIV education curriculum, 27

stress abstinence rather than broadly cover abstinence and contraception options (Sex and HIV

Education, 2019). Given that abstinence-only-until-marriage education does not reduce

adolescent sexual behavior, and a major form of HIV transmission is through sexual contact,

abstinence-focused HIV education does not reduce the spread of HIV. HIV education can also be

legally supplemented with inaccurate information, which does not mitigate risky sexual behavior

(Sex and HIV Education, 2019). Curricula in Oklahoma mandates teaching “that among other

behaviors that ‘homosexual activity’ is considered to be ‘responsible for contact with the AIDS

virus’” (Sex and HIV Education, 2019). Oklahoma specifically attributes HIV and AIDS to

homosexuality and forbids educators from correcting the record or answering students’
COMPREHENSIVE SEXUAL HEALTH EDUCATION 7

spontaneous questions about sex and sexuality (Sex and HIV Education, 2019). Though HIV can

spread through non-sexual avenues, presenting accurate prevention information would actively

minimize the viral spread.

Sexually Transmitted Infection Education

STI education refers to infections other than HIV spread through sexual contact. STI

education varies based on regional need, but broadly covers the contraction and symptoms of

gonorrhea, chlamydia, syphilis, hepatitis, herpes, and HPV (Breuner & Mattson, 2016). Students

who receive comprehensive STI education receive the same benefits as comprehensive HIV

education: better health outcomes and reduced instances of risky sexual behavior (Ma, Fisher, &

Kuller, 2014). Like with HIV, abstinence-focused education does not reduce the rate of STIs and

STIs are used as a source of fear in abstinence-only curricula to (unsuccessfully) delay sexual

behaviors (Barth, 2005). Shame and stigma surrounding STIs also motivates adolescents to

refuse screenings (Cunningham, Kerrigan, & Jennings, 2009). Students who are unaware of STIs

or choose not to get health screenings risk contracting and further spreading infection.

Sexuality Education

Sexuality education should include non-heteronormative sexual behavior. At a state level,

established curricula address sexual behavior in terms of health and reproduction but do not

address sex as a part of relationships. Curricula have not been evaluated nationwide because

states have not set standards for incorporating sexuality into school curricula (Sexuality

Education as Part of a Comprehensive Health Education Program in K to 12 Schools, 2014).

Research shows that parents and students in schools with sexuality incorporated in to the sexual

health curriculum are more satisfied with the school overall than parents and students in schools

that do not address sexuality and that and that adverse sexual health outcomes for non-
COMPREHENSIVE SEXUAL HEALTH EDUCATION 8

heterosexual students decrease when sexuality is a part of the curriculum (Sexuality Education as

Part of a Comprehensive Health Education Program in K to 12 Schools, 2014). Normalizing

sexuality curricula will improve sexual health outcomes for all people, not just those who fit in

the existing, heteronormative structure.

Defining Quality Sexual Health Education

Quality sexual health education should have seven key components: gender, sexual and

reproductive health and HIV, sexual rights and sexual citizenship, pleasure, violence, diversity,

and relationships (A Definition of Comprehensive Sexuality Education). The topics covered in

each component of a comprehensive education (Table 2) encompass and expand on sexual

behavior, HIV and STIs, and sexuality education and promote overall physical and emotional

wellness (A Definition of Comprehensive Sexuality Education). Even if a sexual health

curriculum does not encompass the seven key components outlined, it should emphasize sexual

behavior in terms of human sexuality, develop healthy attitudes and communication skills, and

encourage responsible choices and risk mitigation in sexual relationships (History of Sex

Education in the U.S., 2016).

History of Sexual Health Education

Though there were advocates for sexual health education in public schools in the 1960s

and 1970s, “the goals of social hygiene and moral purity activists eclipsed broader sexual health

concerns in the public arena” (History of Sex Education in the U.S., 2016). Sexual health

education was nationally introduced into schools in the 1980s following a period increased

teenage pregnancy and spread of HIV/AIDS (History of Sex Education). The dominant

curriculum for early sexual health education argued that teaching adolescents about sexual risk
COMPREHENSIVE SEXUAL HEALTH EDUCATION 9

reduction would increase sexual risk-taking behavior (History of Sex Education in the U.S.,

2016). Evidence emerged that curricula focusing on risk mitigation were more effective than

abstinence-only curricula (Santelli, et al., 2017), but by the time the evidence emerged, schools

were invested in the abstinence-only program (History of Sex Education in the U.S., 2016).

Legislative Impact on Sexual Health Education

Adolescent Family Life Act

The Adolescent Family Life Act, enacted in 1981, was the cornerstone of “chastity laws,”

which gave federal funding to support sexual health education. The act was Title XX of the

Public Health Service Act and received more than $200 million dollars from the Department

Health and Human Services from its passage until 2010 when federal discretionary funding for

abstinence-only-until-marriage was eliminated (A History of Federal Funding for Abstinence-

Only-Until-Marriage Programs, n.d.). The act funded programs promoting self-discipline and

moral purity as established by churches and religious conservatives (History of Sex Education in

the U.S., 2016). The ACLU challenged the act in court calling it a Trojan horse for religious

doctrines, in violation of the separation of church and state (History of Sex Education in the U.S.,

2016). In 2003, the Supreme Court finally ruled that federally funded programs could not have

direct references to religion, but by the time the ruling passed, the largest funding recipients had

already gotten schools to adopt conservatively motivated curricula (History of Sex Education in

the U.S., 2016). The curricula did not change; text that directly referenced religion were slightly

modified to comply with the court ruling (History of Sex Education in the U.S., 2016). The

Adolescent Family Life Act ultimately gave religious institutions indirect control over sexual

health education.
COMPREHENSIVE SEXUAL HEALTH EDUCATION 10

Welfare Reform Act

In 1996, Bill Clinton signed the Welfare Reform Act, which was designed to reduce the

number of people dependent on welfare (Office, HHS Press, n.d.). The act contained a provision

in the miscellaneous title to provide $50 million per year in funding for abstinence-only

education (Haskins & Bevan, n.d.). The idea was that reducing adolescent sexual behavior would

reduce the need for federally funded health and family services. The funding for abstinence-only

education was maintained through the Bush administration and ultimately expired in June 2009

(Office, HHS Press, n.d.). The Obama administration chose not to renew services under the

Adolescent Family Life Act or the Welfare Reform Act as many items would be redundant under

the Affordable Care Act (Office, HHS Press, n.d.). By 2010 many states had rejected federal

funding because evidence showed the supported curricula were ineffective, so the previously

allocated funds had gone unused (Office, HHS Press, n.d.). Though abstinence-only education

was not the Welfare Reform Act’s focus, it supplemented the Adolescent Family Life Act

funding and inadvertently helped implement religiously motivated curricula in public schools.

Affordable Care Act

Although sexual health was not the primary public concern in passing the Affordable

Care Act, there are stipulations addressing sexual health. The Personal Responsibility Education

Program (PREP), a part of the Affordable Care Act, allocated $75 million dollars annually for

evidence-based, medically accurate, and comprehensive sexual health education (National

Partnership for Women and Families, 2014). PREP funds were used to teach adolescents about

abstinence and contraception at an age-appropriate level to prevent teen pregnancy and STIs

(National Partnership for Women and Families, 2014). In order to garner support for the

Affordable Care Act, the provision creating PREP, which is administered by the Department of
COMPREHENSIVE SEXUAL HEALTH EDUCATION 11

Health and Human Services, also renewed the $50 million of annual funding for states to spend

on abstinence-only educational programs (National Partnership for Women and Families, 2014).

While the Affordable Care Act took measures to promote comprehensive education, partisan-

politics maintained funding for ineffective, abstinence-only programs.

Policy Actions

Limitations

While federal mandate requires sexual health education in schools, the specific curricula

are established at a state level. The Constitution of the United States lays out the enumerated

powers of the federal government, including the power for the legislature to act for the general

welfare of the people (U.S. Const. Article VIII). The General Welfare Clause refers specifically

to the ability to tax and spend tax money. Mandating curricula could be considered infringing on

personal liberties rather than promoting general welfare. Further, the 10th amendment reserves all

non-expressed powers to the states (U.S. Const. Amend X). Federally motivating quality sexual

health education must happen within the scope of federally enumerated powers.

Policy Alternative: Shift Funding Sources

The federal funding to support states’ sexual health education as allocated in the

Affordable Care Act should be administered through the Department of Education. The

Affordable Care Act administers PREP through the Department of Health and Human Services

(Zief, Shapiro, & Strong, 2013). Though it may change under the Trump Administration, the

program’s goals are to provide evidence-based programs providing education on abstinence and

contraception and educate youth on adulthood preparation subjects (Zief, Shapiro, & Strong,

2013). PREP is made of educational programs funded by grants. The Department of Education

already distributes grants for other specific educational purposes (Department of Education
COMPREHENSIVE SEXUAL HEALTH EDUCATION 12

Fiscal Year 2020 President's Budget, 2019), so the funding infrastructure is already in place.

Shifting departmental administration for sexual health education can reshape the content

discussion to address educational value and diversity rather than focusing on the moral health

idea that religious institutions have maintained in upholding abstinence-only curricula.

Policy Alternative: Fund Effective Curricula

Sexual health outcomes will only improve if people have the information to minimize

sexual risk-taking. Evidence shows that adolescents who receive comprehensive sexual health

education, focusing on mitigating risks have better sexual health outcomes (Santelli, et al., 2017).

As noted, the Affordable Care Act allocates $75 million annually to support PREP education

(National Partnership for Women and Families, 2014). Maintaining this funding and supporting

comprehensive and medically accurate programs is essential. Medical professionals have

established that there is more to sexual health education than information on sexual activity (A

Definition of Comprehensive Sexuality Education). States should be made eligible for scaled

funding based on the comprehensiveness of sexual health education provided. Curricula focusing

on risk mitigation education would be able to receive funding, and larger grants would be

available for curricula that covers all seven key points of education as outlined in Table 2.

Policy Alternative: Restrict Ineffective Curricula

Improving sexual health outcomes through education does not solely rely on creating an

effective curriculum; ineffective curricula also need to be removed from circulation without

removing sexual health education from school curricula. Rather than fully renewing the

provision of the Affordable Care Act that allocated $50 million annually to abstinence-only

education (National Partnership for Women and Families, 2014), the funding could be scaled

back over several years. Schools have educational materials in place and scaling back funding
COMPREHENSIVE SEXUAL HEALTH EDUCATION 13

would decrease reliance on federal support for abstinence-only education while giving states

time to modify their curricula. Scaling back federal funding for abstinence-only curricula could

also free a source of funding for more effective education programs. States would be motivated

to seek other sources of education funding, potentially by implementing more comprehensive

curricula.

Policy Alternative: Reward Positive Outcomes

States with a significant religiously conservative population are more likely to reject

implementing a comprehensive sexual health education curriculum, so additional motivating

factors would help with implementing comprehensive curricula across the nation. The overall

goal of comprehensive sexual health education is to create improved sexual health outcomes and

states should be rewarded for achieving positive outcomes. Since sexual health is most easily

measured by adolescent pregnancy rates and spread of STIs (Stanger-Hall & Hall, 2011), states

that showed decreases in both categories would have improved health outcomes. Non-

comprehensive and abstinence-focused curricula are less effective at improving sexual health

outcomes (Stanger-Hall & Hall, 2011). Better educated people also have better health outcomes

overall (Ma, Fisher, & Kuller, 2014). To motivate implementation of a comprehensive sexual

health education, states that implement comprehensive curricula and show improved sexual

health outcomes over a time would be able to use the same pool of grant funding for general

education purposes.

Evaluation Structure

The goal of changing sexual health curricula is to improve sexual health outcomes over

time. To establish if policy changes are effective, the quantitative variables measured will be

number of states drawing federal funding for comprehensive education, rate of adolescent
COMPREHENSIVE SEXUAL HEALTH EDUCATION 14

pregnancies, and reported cases of STIs. The independent qualitative variables will be majority

religious and political affiliation in each region. The dependent qualitative variable will be type

of curricula implemented (abstinence-only, medically-accurate risk-mitigation, or

comprehensive). States drawing federal funding and religious and political affiliation are the

independent variables used to see if health outcomes and increased funding are enough to

motivate change in sexual health education. For states that implement risk-mitigation or

comprehensive curricula, pregnancy rates and STI cases reported are the measure of sexual

health outcomes. Legislators and formal evaluators would determine appropriate benchmarks for

increased federal funding as health outcomes improve.

Conclusion

As it is currently implemented, average sexual health education is ineffective. It does not

cover many critical aspects of sex and sexual behavior that impact sexual health. Furthermore, in

some cases, it is willfully inaccurate to promote a specific, moralistic message. Federal

legislation, seemingly inadvertently, gave religious institutions control of sexual health curricula

and has supported abstinence-only education well beyond the point when evidence clearly

showed the curricula were ineffective. Because abstinence-only education is so engrained in state

education systems, federal policy change would be more effective in implementing effective

education standards than maintaining state-by-state standards. Policy alternatives provided

include shifting the department that administers federal funding from the Department of Health

and Human Services to the Department of Education, further supporting comprehensive

education, minimizing ineffective education, and rewarding states that show positive sexual

health outcomes with broader funding options. These alternatives can be implemented
COMPREHENSIVE SEXUAL HEALTH EDUCATION 15

independently, concurrently, or sequentially and will still have positive implications for sexual

health outcomes.
COMPREHENSIVE SEXUAL HEALTH EDUCATION 16

Appendix – Tables

Table 1. Sex and HIV Mandates by State

Type of Sex HIV Both Neither No Data

Education
Mandated
States and Mississippi Alabama California Arizona Alaska
District of North Connecticut Delaware Colorado Arkansas
Columbia Dakota Illinois District of Florida Kansas
Indiana Columbia Idaho Nebraska
Michigan Georgia Louisiana South
Missouri Hawaii Massachusetts Dakota
New Iowa Texas Wyoming
Hampshire Kentucky Virginia
New York Maine
Oklahoma Maryland
Pennsylvania Minnesota
Washington Montana
Wisconsin Nevada
New Jersey
New Mexico
North Carolina
Ohio
Oregon
Rhode Island
South Carolina
Tennessee
Utah
Vermont
West Virginia
Total 2 12 23 8 6
(Sex and HIV Education, 2019)
COMPREHENSIVE SEXUAL HEALTH EDUCATION 17

Table 2. Key Components of Comprehensive Sexual Health Education

Key Component Relevant Topics

Gender Difference between gender and sex; exploring gender roles and
attributes; understanding perceptions of masculinity and femininity
within the family and across the life cycle; society’s changing norms
and values; manifestations and consequences of gender bias,
stereotypes and inequality
Sexual and Sexuality and the life cycle; anatomy; reproductive process; condoms
Reproductive Health and other contraceptive use; pregnancy options and information;
and HIV safety and legality of abortion; HIV and other sexually transmitted
infections; sexually transmitted infection prevention and treatment;
counseling and testing for sexually transmitted infections;
antiretroviral therapy; mother-to-child transmission prevention;
intravenous drug use; virginity; abstinence and faithfulness; sexual
response and social expectations; self-esteem and bodily respect;
myths and stereotypes
Sexual Rights and Knowledge of international human rights and national policies, laws
Sexual Citizenship and structures that relate to people’s sexuality; rights-based approach
to sexual and reproductive health; social, cultural and ethical barriers
to exercising rights related to sexual and reproductive health;
understanding that sexuality and culture are diverse and dynamic;
available services and resources and how to access them;
participation; practices and norms; diversity of sexual identities;
advocacy; choice; protection; negotiation skills; consent and the right
to have sex only when you are ready; the right to freely express and
explore one’s sexuality in a safe, healthy and pleasurable way
Pleasure Having a positive approach to young people’s sexuality;
understanding that sex should be enjoyable and consensual;
understanding that sex is much more than just sexual intercourse;
sexuality as a healthy and
normal part of everybody’s life; the biology and emotions behind the
human sexual response; gender and pleasure; sexual well-being; safer
sex practices and pleasure; masturbation; love, lust and relationships;
interpersonal communication; the diversity of sexuality; the first
sexual experience; consent; alcohol, drugs and the implications of
their use; addressing stigma associated with pleasure
Violence Exploring the various types of violence toward men and women and
how they manifest, particularly gender-based violence; nonconsensual
sex and understanding what is unacceptable; rights and laws; support
options available and seeking help; community norms and myths
regarding power and gender; prevention, including personal safety
plans; self-defense techniques; understanding the dynamics of victims
and abusers; appropriate referral mechanisms for survivors;
preventing the victim from becoming a perpetrator; men and boys as
both perpetrators and allies in violence prevention
COMPREHENSIVE SEXUAL HEALTH EDUCATION 18

Diversity Recognizing and understanding the range of diversity in our lives;

positive view of diversity; recognizing discrimination, its damaging
effects and being able to manage it; developing a belief in equality;
supporting young people to move beyond just tolerance
Relationships Different types of relationships; changing relationships; emotions;
intimacy; rights and responsibilities; power dynamics; recognizing
heathy and unhealthy or coercive relationships; communication, trust,
and honesty; peer pressure and social norms; difference between love
and sex
(A Definition of Comprehensive Sexuality Education)
COMPREHENSIVE SEXUAL HEALTH EDUCATION 19

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COMPREHENSIVE SEXUAL HEALTH EDUCATION 20

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