School-based Sex Education in the U.S. at a Crossroads: Taking the Right Path
2021; Elsevier BV; Volume: 69; Issue: 6 Linguagem: Inglês
10.1016/j.jadohealth.2021.09.007
ISSN1879-1972
AutoresJohn Santelli, David L. Bell, Maria Trent, Jonathan D. Klein, Laura K. Grubb, Jesse Barondeau, Margaret Stager, Steve North,
Tópico(s)HIV/AIDS Research and Interventions
ResumoSchool-based sex education in the U.S. is at a crossroads. The United Nations defines sex education as a curriculum-based process of teaching and learning about the cognitive, emotional, physical, and social aspects of sexuality [[1]UNESCO. InternationalTechnical guidance on sexuality education, revised edition.in: Paris, fr: UNESCO, UNAIDS, UNFPA, UNICEF, UN women. WHO, 2018https://www.unfpa.org/publications/international-technical-guidance-sexuality-educationDate accessed: September 10, 2021Google Scholar]. Over many years, sex education has had strong support among both parents [[2]Kantor L. Levitz N. Holstrom A. Support for sex education and teenage pregnancy prevention programmes in the USA: Results from a national survey of likely voters.Sex Education. 2019; 20: 239-251Crossref Scopus (8) Google Scholar] and health professionals [3Breuner C.C. Mattson G. Committee on adolescence, committee on Pyschosocial aspects of child and family health. Sexuality education for children and adolescents.Pediatrics. 2016; 138e20161348Crossref PubMed Scopus (136) Google Scholar, 4The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 5American Medical AssociationSexuality education, sexual violence prevention, abstinence, and Distribution of condoms in schools H-170.968.https://policysearch.amaassn.org/policyfinder/detail/Sexuality%20Education,%20Sexual%20Violence%20Prevention,%20Abstinence,%20and%20Distribution%20of%20Condoms%20in%20Schools%20H-170.968?uri=%2FAMADoc%2FHOD.xml-0-993.xmlGoogle Scholar, 6American College of Obstetricians and GynecologistsComprehensive sexuality education. Committee Opinion No. 678. . Obstet Gynecol Web site.https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/11/comprehensive-sexuality-educationGoogle Scholar], yet the receipt of sex education among U.S. adolescents has declined or stagnated over the past 25 years (1995–2019) [7Lindberg L.D. Santelli J.S. Singh S. Changes in formal sex education: 1995–2002.Perspect Sex Reprod Health. 2006; 38: 182-189Crossref PubMed Scopus (109) Google Scholar, 8Lindberg L.D. Maddow-Zimet I. Boonstra H. Changes in adolescents' receipt of sex education, 2006-2013.J Adolesc Health. 2016; 58: 621-627Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar, 9Lindberg L.D. Kantor L. Adolescents' Receipt of Sex Education in a Nationally Representative Sample, 2011-2019.J Adolesc Health. 2021; https://doi.org/10.1016/j.jadohealth.2021.08.027Abstract Full Text Full Text PDF Scopus (11) Google Scholar]. In 2015–2019, only half of adolescents received sex education that met the minimum standards articulated in Healthy People 2020 [[9]Lindberg L.D. Kantor L. Adolescents' Receipt of Sex Education in a Nationally Representative Sample, 2011-2019.J Adolesc Health. 2021; https://doi.org/10.1016/j.jadohealth.2021.08.027Abstract Full Text Full Text PDF Scopus (11) Google Scholar]. Receipt of sex education is even worse among young men and men of color than that among young women and white men [[8]Lindberg L.D. Maddow-Zimet I. Boonstra H. Changes in adolescents' receipt of sex education, 2006-2013.J Adolesc Health. 2016; 58: 621-627Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar].Strong scientific evidence has demonstrated that sex education is effective in reducing adolescent behaviors that lead to unintended pregnancy, HIV, and sexually transmitted infections [[10]Chin H.B. Sipe T.A. Elder R. et al.The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections: Two systematic reviews for the Guide to community preventive Services.Am J Prev Med. 2012; 42: 272-294Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar]. Sex education also impacts a broader set of outcomes, including appreciation of sexual orientation and gender diversity; prevention of homophobic bullying, intimate partner violence, and child abuse; and promotion of healthy relationships, social emotional learning, and media literacy [[11]Goldfarb E.S. Lieberman L.D. Three Decades of research: The Case for comprehensive sex education.J Adolesc Health. 2021; 68: 13-27Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar]. Sex education received before college may also protect against sexual assault during college [[12]Santelli J.S. Grilo S.A. Choo T.H. et al.Does sex education before college protect students from sexual assault in college?.PLoS One. 2018; 13: e0205951Crossref PubMed Scopus (40) Google Scholar]. Despite this growing body of evidence, the content of sex education taught in U.S. public schools has often diminished over time. For example, in 1995, 87% of females and 81% of males reported sex education about birth control methods, compared with 64% and 63% in 2015–2019 [[7]Lindberg L.D. Santelli J.S. Singh S. Changes in formal sex education: 1995–2002.Perspect Sex Reprod Health. 2006; 38: 182-189Crossref PubMed Scopus (109) Google Scholar,[9]Lindberg L.D. Kantor L. Adolescents' Receipt of Sex Education in a Nationally Representative Sample, 2011-2019.J Adolesc Health. 2021; https://doi.org/10.1016/j.jadohealth.2021.08.027Abstract Full Text Full Text PDF Scopus (11) Google Scholar].Support for sex education and reproductive rights has been strong and consistent among mainstream medical and health organizations [3Breuner C.C. Mattson G. Committee on adolescence, committee on Pyschosocial aspects of child and family health. Sexuality education for children and adolescents.Pediatrics. 2016; 138e20161348Crossref PubMed Scopus (136) Google Scholar, 4The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 5American Medical AssociationSexuality education, sexual violence prevention, abstinence, and Distribution of condoms in schools H-170.968.https://policysearch.amaassn.org/policyfinder/detail/Sexuality%20Education,%20Sexual%20Violence%20Prevention,%20Abstinence,%20and%20Distribution%20of%20Condoms%20in%20Schools%20H-170.968?uri=%2FAMADoc%2FHOD.xml-0-993.xmlGoogle Scholar, 6American College of Obstetricians and GynecologistsComprehensive sexuality education. Committee Opinion No. 678. . Obstet Gynecol Web site.https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/11/comprehensive-sexuality-educationGoogle Scholar,[13]American Public Health AssociationSexuality education as Part of a comprehensive health education Program in K to 12 schools.https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/01/23/09/37/sexuality-education-as-part-of-a-comprehensive-health-education-program-in-k-to-12-schoolsGoogle Scholar]. This support should not be surprising. Health care providers know that preventing adverse sexual and reproductive health outcomes is much better than attempting to treat their consequences.As adolescent health care providers who support sex education, we were dismayed by the revised and recently released Medical Institute for Sexual Heath (MISH) K-12 Standards for Optimal Sexual Development (M-SOSD) [[14]Medical Institute for Sexual HealthK-12 standards for Optimal sexual development. MISH, Dallas, TX2021https://newsexedstandards.org/Date accessed: September 10, 2021Google Scholar]. MISH has long been a strong supporter of abstinence-only approaches (now described as sexual risk avoidance) to adolescent sexual and reproductive health—despite a lack of evidence for the efficacy for such approaches and the harm from withholding lifesaving information from young people [[4]The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar]. These new "standards" are seriously flawed from both scientific and human rights' perspectives. We strongly support sex education that is science-based, medically accurate, and developmentally appropriate. Our review of the M-SOSD finds they fail on each of these criteria.There are multiple ways to strengthen the provision of sex education in the U.S. One important mechanism has been the promulgation of standards for sex education that reflect scientific understanding and adolescent developmental needs. The National Sex Education Standards (NSES) [[15]Future of Sex EducationNational sex education standards.ed. FoSE, Washington, DC2020https://www.advocatesforyouth.org/resources/health-information/future-of-sex-education-national-sexuality-education-standards/Date accessed: September 10, 2021Google Scholar], developed in partnership between sex education organizations and health professionals, provide clear, consistent, and straightforward guidance on the essential content for students in grades K–12. The NSES have also been used in the development of Centers for Disease Control and Prevention's recently released Health Education Curriculum Analysis Tool [[16]Centers for Disease Control and PreventionHealth education curriculum Analysis Tool, 2021. CDC, Atlanta2021https://www.cdc.gov/healthyyouth/hecat/pdf/2021/full-hecat-2021.pdfDate accessed: September 14, 2021Google Scholar]. Similarly, global guidance is available in the 2018 UNESCO International Technical Guidance on Sexuality Education [[1]UNESCO. InternationalTechnical guidance on sexuality education, revised edition.in: Paris, fr: UNESCO, UNAIDS, UNFPA, UNICEF, UN women. WHO, 2018https://www.unfpa.org/publications/international-technical-guidance-sexuality-educationDate accessed: September 10, 2021Google Scholar].Key concepts within NSES include the following:•Information should be medically accurate information, and curricula should include a broad set of topics essential to human sexuality (Table 1). Medical accuracy means curricula should be based on weight of scientific evidence and scientific theory, published in peer-reviewed journals, and recognized as accurate, objective, and complete by mainstream professional organizations [[17]Santelli J.S. Medical accuracy in sexuality education: Ideology and the scientific process.Am J Public Health. 2008; 98: 1786-1792Crossref PubMed Scopus (39) Google Scholar].Table 1Comparing glossaries from Medical Institute for Sexual Heath K-12 Standards for Optimal Sexual Health (M-SOSD) and the National Sex Education Standards (NSES)Key• = Included in both glossariesX = Not included in the other glossary∗ = Included in both but with different definitions, see table footnotesM-SOSDaMedical Institute for Sexual Heath K-12 Standards for Optimal Sexual Development.NSESbThe National Sex Education Standards.Both M-SOSD and NSESGlossary XAbleism XAbstinence XAbstinence-only-until-marriage programsAdolescenceAdolescence• XAdoptionACEscAdverse childhood experiences.X XAge appropriate XAge of consent XAgender XAIDSdAcquired immune deficiency syndrome. XAll studentsAnal sex∗M-SOSD lists "incorrect/correct" usage, and NSES lists "internal/external". The M-SOSD definition heavily implies that correct condom use is rare and exaggerates ineffectiveness.Anal sex• XAndrogynous XAsexualAsymptomaticX XBiological sex XBiomedical approach XBisexual XBodily autonomy XBody image XBullying XChild sexual abuse XCisgender XClassism XClimate setting XCommunity violence XComprehensive sex education/sexuality education XConscious biasCoercionXCognitive MaturityXConnectednessXConsentConsent•Consistent and correct condom use∗M-SOSD lists "incorrect/correct" usage, and NSES lists "internal/external". The M-SOSD definition heavily implies that correct condom use is rare and exaggerates ineffectiveness.Condoms (see external condoms, internal condoms)•Consistent and correct contraceptive useContraception•CounselorsX XCultural competence XCulturally responsive XCycle of violenceDatingX XDating violenceDisciplineX XDisclosure XDisproportionate risk XDomestic violence XEmergency contraception XExperiential learning cycle XFactFamily/family membersFamily structure•FertilizationX XGay XGender XGender binary XGender expansive XGender expression XGender identity XGender nonbinary XGender nonconforming XGender pronouns XGender roles XGenderqueer XGender-based violenceGrit/resilienceX XHarassmentHealthy marriageHealthy relationships XHeterosexual XHIVeHuman immunodeficiency virus. XHomophobia XIncest XInclusiveInconsistent and incorrect condom/contraceptive useX XInduced abortionInfatuationX XInstitutional value XInterpersonal violence XIntersectionality XIntersex XIntimate partner violenceLegacyX XLesbian XLived experience XLARCfLong-acting reversible contraception.LoveX MarriageX XMasturbationMaturityXMedically accurateMedically accurate• XMiscarriageMutual masturbationXNonmarital sexual activityXObjectifyXOppressionXOptimal sexual developmentX XOral sexOutercourseX XPansexualParentX XPEPgPost-exposure prophylaxis.Personal boundariesXPornographySexually explicit materialNSES includes pornography in its definition of "sexually explicit material".• XPower XPregnancy options XPrEPhPre-exposure prophylaxis. XPrivilege XProfessional boundariesPubertyPuberty• XQueer XQuestioning XRacial justice XRacismRapeRape•Refusal skillsXReproductionX XReproductive justiceRomantic relationshipsX XSafe and affirming learning environments XSafety plan XSelf-concept XSelf-esteem XSex assigned at birth XSex positiveSex traffickingSex trafficking• XSexismSextingXSexual abuseSexual abuse•Sexual activitySexual behavior• XSexual agencySexual assaultSexual assault•Sexual consentSee "consent" above.•Sexual exploitationSexual exploitation•Sexual groomingX XSexual harassment XSexual identitySexual intercourseSexual intercourse• XSexual orientation XSexual response cycleSexual risk avoidanceSexual risk avoidance•Sexual risk reduction∗Exaggerates ineffectiveness of risk reduction compared with risk avoidance.XSexual violenceSexual violence• XSexualitySexualizeXSexually explicit contentSexually explicit material•STDsiSexually transmitted diseases./STIsjSexually transmitted infections.STDs• XSocial justice XSocioeconomic status XSpontaneous abortion XStudent centeredSTD/STI-related cancerX"Success sequence"X XTeaching strategies XTeasingTeenXTeen pregnancyXTransactions (transactional sex)X XTransgender XTransphobia XTrauma (individual) XTrauma (systemic) XTrauma informedTrusted adultTrusted adult• XTwo-spiritTypical human useX XUnconscious bias XUndetectable viral load XUniversal valuesVaginal intercourseVaginal sex•ValuesValue• XViral suppressionState of well-beingXWholenessX∗ M-SOSD lists "incorrect/correct" usage, and NSES lists "internal/external". The M-SOSD definition heavily implies that correct condom use is rare and exaggerates ineffectiveness.∗∗ NSES includes pornography in its definition of "sexually explicit material".∗∗∗ Exaggerates ineffectiveness of risk reduction compared with risk avoidance.a Medical Institute for Sexual Heath K-12 Standards for Optimal Sexual Development.b The National Sex Education Standards.c Adverse childhood experiences.d Acquired immune deficiency syndrome.e Human immunodeficiency virus.f Long-acting reversible contraception.g Post-exposure prophylaxis.h Pre-exposure prophylaxis.i Sexually transmitted diseases.j Sexually transmitted infections. Open table in a new tab •Opportunities for adolescents to explore their identity and values and the values and beliefs of their family, their religion, their culture, and their community.•Opportunities to practice the communication, negotiation, decision-making, and assertiveness skills needed to create healthy relationships.•Sex education should be developmentally appropriate information and geared to the age-appropriate interests and developmental capacity of children and adolescents. For example, while sex education for children should focus on family life, sex education for adolescents needs to focus on their expanding social world including peers, media, and culture [[15]Future of Sex EducationNational sex education standards.ed. FoSE, Washington, DC2020https://www.advocatesforyouth.org/resources/health-information/future-of-sex-education-national-sexuality-education-standards/Date accessed: September 10, 2021Google Scholar].Although the revised M-SOSD represent some progress from a previous version, they still fall short. Those prior MISH recommendations were criticized as medically inaccurate, based in faith not fact, and providing inaccurate information on condoms and contraception [[18]Mayer R. MISH publishes new framework for fear-based, abstinence-only education.SIECUS Rep. 1997; 25: 14-16PubMed Google Scholar]. In the new M-SOSD, information on contraception is factually correct, although incomplete and focused on limitations in contraceptive effectiveness. Marriage is specifically defined as a "couple" and not as a "man and a woman", and the focus on adolescent relationships and sexual consent and inclusion of adolescent developmental concepts such as resiliency, developmental assets, and adverse childhood experiences is potentially helpful. However, the application of these ideas is not well developed in the document.Our review finds that the M-SOSD miss many essential topics. We compared the extensive glossary of terms provided in both the NSES and the M-SOSD. Remarkably, the two glossaries overlap rarely (Table 1), except on a few issues like sexual violence and sexual consent. Missing from M-SOSD but included in NSES are topics such as sexual orientation and gender identity; social determinants of health such as poverty, racism, and other forms of discrimination; disabilities; reproductive justice; prevention of HIV infection using PreP therapy; and adolescent health care issues such as adolescent rights and minor consent laws. Topics included in M-SOSD but not included in NSES include discipline, marriage, and infatuation and love. Many of sex education topics missing from the M-SOSD are recommended by mainstream medical groups including the American Medical Association, the American Academy of Pediatrics, and the Society for Adolescent Health and Medicine [3Breuner C.C. Mattson G. Committee on adolescence, committee on Pyschosocial aspects of child and family health. Sexuality education for children and adolescents.Pediatrics. 2016; 138e20161348Crossref PubMed Scopus (136) Google Scholar, 4The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 5American Medical AssociationSexuality education, sexual violence prevention, abstinence, and Distribution of condoms in schools H-170.968.https://policysearch.amaassn.org/policyfinder/detail/Sexuality%20Education,%20Sexual%20Violence%20Prevention,%20Abstinence,%20and%20Distribution%20of%20Condoms%20in%20Schools%20H-170.968?uri=%2FAMADoc%2FHOD.xml-0-993.xmlGoogle Scholar]. A glaring omission from M-SOSD is any information on the authors or their process for evidence review; these are standard in scientific review and guideline development.A few topics are addressed but are woefully incomplete. M-SOSD misleadingly assert it is "inclusive of all students, irrespective of their sexual orientation or gender identity" as well as culturally inclusive; however, the M-SOSD learning objectives do not address either sexual orientation or gender identity. Remarkably, the M-SOSD say little about how adolescent health care should be addressed in sex education or about adolescents' legal rights to counseling, diagnosis, and treatment, despite coming from a self-identified medical group. M-SOSD learning objectives briefly mention vaccines and medications to prevent sexually transmitted infections but without endorsing these and instead focusing on parental permission.While many topics are missing or incomplete, other topics are misrepresented or simply inaccurate (Table 2). Marriage and abstinence until marriage are portrayed as panaceas to healthy sexuality and are described as the expected goal for adolescent relationship building. This is inconsistent with research on marriage and adolescent sexual behaviors. The revised M-SOSD retain an erroneous belief that premarital and extramarital sex is dangerous to the adolescent's physical and mental health; the Society for Adolescent Health and Medicine has reviewed the research on this topic and specifically disagrees [[4]The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar]. The M-SOSD also recycle old half-truths like "avoiding sexual activity is the only 100% effective way to avoid teen pregnancy". The M-SOSD say little about adolescent cognitive capacity, but include a wildly inaccurate statement that "cognitive maturity is not fully reached until the late 20s". Research on cognitive development suggests that cognitive capacity and young people's ability to participate in guided decision-making develop in early adolescence [[20]Hein I.M. Troost P.W. Broersma A. et al.Why is it hard to make progress in assessing children's decision-making competence?.BMC Med Ethics. 2015; 16: 1-6Crossref PubMed Scopus (0) Google Scholar,[21]Hein I.M. De Vries M.C. Troost P.W. et al.Informed consent instead of assent is appropriate in children from the age of twelve: Policy implications of new findings on children's competence to consent to clinical research.BMC Med Ethics. 2015; 16: 1-7Crossref PubMed Scopus (48) Google Scholar]. Adolescents can and do make wise choices when guided by teachers and clinicians who understand, respect, and nurture young people's decision-making capacities.Table 2Examples of medically inaccurate information in the Medical Institute for Sexual Heath (MISH) K-12 Standards for Optimal Sexual Development (M-SOSD)TopicQuote from MISH standardsEvidence disproving claimAbstinence4.B.1. Explain how avoiding sexual activity is the only 100% effective way to avoid teen pregnancy.Yes, but extensive research on adolescent sexual behavior suggests that abstinence intentions often fail. Likewise, abstinence-only-until-marriage programs are ineffective in delaying the age of sexual intercourseCognitive capacity1.B.3. Cognitive maturity is not fully reached until the late 20s; therefore, guidance from parents, family members, or other trusted adults is beneficial and should be sought for healthy decision-making.Research on cognitive capacity suggests adolescent cognitive capacity matures in early adolescence. The development of judgment takes longer. Adolescents can make wise choices when guided by teachers and clinicians who understand, respect, and nurture young people's decision-making capacities.Conception3.B.2 Define fertilization as the initiation of reproduction by the joining of a sperm and an egg, which results in the complete and distinct genetic profile of a unique individual.Approximately 30% of fertilized eggs never implant. Most medical groups believe that conception begins at implantation [[19]Benson Gold R. The implications of defining when a woman is pregnant.The Guttmacher Rep Public Policy. 2005; 8: 7-10Google Scholar].Marriage as a panacea2.D.7. Making healthy choices before marriage, including avoiding sexual activity, can strengthen fidelity in marriage.Marriage is not a panacea. Half of marriages in the U.S. end in divorce. The vast majority of Americans initiate sex before marrying.Sexual behavior3.C.9. Summarize research on the physical and emotional benefits of avoiding nonmarital sexual activity.4.A. Avoiding sexual risks: Sexual activity outside of marriage can have harmful physical and emotional consequences.Nonmarital consensual sex between adolescents does not cause emotional damage. Psychological harm related to adolescent sexual activity most likely occurs in coercive and nonconsensual experiences [[4]The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar].As the age of marriage has increased over the past several decades, marriage is no longer a realistic or relevant marker for the start of healthy sexual activity [[4]The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar].While the median age at first intercourse for women is currently 17.8 years, the median age at first marriage is 26.5 years (a gap of 8.7 years); for men, the gap between the median age at first sex (18.1 years) and first marriage (29.8 years) is 11.7 years [[4]The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar]. Only a small percentage of young people wait until marriage to have their first intercourse. In contrast, among women born in the 1940s (and turning age 15 years between 1955 and 1964), the interval between first intercourse and first marriage was between 1 and 1.5 years.Success sequence4.A.4. Describe the concept of the "success sequence" and how avoiding early sexual activity has the potential to protect against negative life outcomes, including maternal and child poverty.The success sequence ignores social determinants of health, such as racial inequity, intergenerational poverty, and geographic segregation, that influence education, employment, and relationship opportunities Open table in a new tab The new M-SOSD are incomplete and deeply flawed. Key science is ignored or misrepresented. On careful examination, the M-SOSD appear to be a justification for sex education based on abstinence-only-until-marriage beliefs, not science. Every adolescent has a right to complete and accurate information about human sexuality, as intrinsic to the right to health. School-based sexuality education is essential to that basic human right. States and local communities aiming to improve adolescent sexual and reproductive health and looking for national standards on sex education should adopt the NSES. School-based sex education in the U.S. is at a crossroads. The United Nations defines sex education as a curriculum-based process of teaching and learning about the cognitive, emotional, physical, and social aspects of sexuality [[1]UNESCO. InternationalTechnical guidance on sexuality education, revised edition.in: Paris, fr: UNESCO, UNAIDS, UNFPA, UNICEF, UN women. WHO, 2018https://www.unfpa.org/publications/international-technical-guidance-sexuality-educationDate accessed: September 10, 2021Google Scholar]. Over many years, sex education has had strong support among both parents [[2]Kantor L. Levitz N. Holstrom A. Support for sex education and teenage pregnancy prevention programmes in the USA: Results from a national survey of likely voters.Sex Education. 2019; 20: 239-251Crossref Scopus (8) Google Scholar] and health professionals [3Breuner C.C. Mattson G. Committee on adolescence, committee on Pyschosocial aspects of child and family health. Sexuality education for children and adolescents.Pediatrics. 2016; 138e20161348Crossref PubMed Scopus (136) Google Scholar, 4The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 5American Medical AssociationSexuality education, sexual violence prevention, abstinence, and Distribution of condoms in schools H-170.968.https://policysearch.amaassn.org/policyfinder/detail/Sexuality%20Education,%20Sexual%20Violence%20Prevention,%20Abstinence,%20and%20Distribution%20of%20Condoms%20in%20Schools%20H-170.968?uri=%2FAMADoc%2FHOD.xml-0-993.xmlGoogle Scholar, 6American College of Obstetricians and GynecologistsComprehensive sexuality education. Committee Opinion No. 678. . Obstet Gynecol Web site.https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/11/comprehensive-sexuality-educationGoogle Scholar], yet the receipt of sex education among U.S. adolescents has declined or stagnated over the past 25 years (1995–2019) [7Lindberg L.D. Santelli J.S. Singh S. Changes in formal sex education: 1995–2002.Perspect Sex Reprod Health. 2006; 38: 182-189Crossref PubMed Scopus (109) Google Scholar, 8Lindberg L.D. Maddow-Zimet I. Boonstra H. Changes in adolescents' receipt of sex education, 2006-2013.J Adolesc Health. 2016; 58: 621-627Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar, 9Lindberg L.D. Kantor L. Adolescents' Receipt of Sex Education in a Nationally Representative Sample, 2011-2019.J Adolesc Health. 2021; https://doi.org/10.1016/j.jadohealth.2021.08.027Abstract Full Text Full Text PDF Scopus (11) Google Scholar]. In 2015–2019, only half of adolescents received sex education that met the minimum standards articulated in Healthy People 2020 [[9]Lindberg L.D. Kantor L. Adolescents' Receipt of Sex Education in a Nationally Representative Sample, 2011-2019.J Adolesc Health. 2021; https://doi.org/10.1016/j.jadohealth.2021.08.027Abstract Full Text Full Text PDF Scopus (11) Google Scholar]. Receipt of sex education is even worse among young men and men of color than that among young women and white men [[8]Lindberg L.D. Maddow-Zimet I. Boonstra H. Changes in adolescents' receipt of sex education, 2006-2013.J Adolesc Health. 2016; 58: 621-627Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar]. Strong scientific evidence has demonstrated that sex education is effective in reducing adolescent behaviors that lead to unintended pregnancy, HIV, and sexually transmitted infections [[10]Chin H.B. Sipe T.A. Elder R. et al.The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections: Two systematic reviews for the Guide to community preventive Services.Am J Prev Med. 2012; 42: 272-294Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar]. Sex education also impacts a broader set of outcomes, including appreciation of sexual orientation and gender diversity; prevention of homophobic bullying, intimate partner violence, and child abuse; and promotion of healthy relationships, social emotional learning, and media literacy [[11]Goldfarb E.S. Lieberman L.D. Three Decades of research: The Case for comprehensive sex education.J Adolesc Health. 2021; 68: 13-27Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar]. Sex education received before college may also protect against sexual assault during college [[12]Santelli J.S. Grilo S.A. Choo T.H. et al.Does sex education before college protect students from sexual assault in college?.PLoS One. 2018; 13: e0205951Crossref PubMed Scopus (40) Google Scholar]. Despite this growing body of evidence, the content of sex education taught in U.S. public schools has often diminished over time. For example, in 1995, 87% of females and 81% of males reported sex education about birth control methods, compared with 64% and 63% in 2015–2019 [[7]Lindberg L.D. Santelli J.S. Singh S. Changes in formal sex education: 1995–2002.Perspect Sex Reprod Health. 2006; 38: 182-189Crossref PubMed Scopus (109) Google Scholar,[9]Lindberg L.D. Kantor L. Adolescents' Receipt of Sex Education in a Nationally Representative Sample, 2011-2019.J Adolesc Health. 2021; https://doi.org/10.1016/j.jadohealth.2021.08.027Abstract Full Text Full Text PDF Scopus (11) Google Scholar]. Support for sex education and reproductive rights has been strong and consistent among mainstream medical and health organizations [3Breuner C.C. Mattson G. Committee on adolescence, committee on Pyschosocial aspects of child and family health. Sexuality education for children and adolescents.Pediatrics. 2016; 138e20161348Crossref PubMed Scopus (136) Google Scholar, 4The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 5American Medical AssociationSexuality education, sexual violence prevention, abstinence, and Distribution of condoms in schools H-170.968.https://policysearch.amaassn.org/policyfinder/detail/Sexuality%20Education,%20Sexual%20Violence%20Prevention,%20Abstinence,%20and%20Distribution%20of%20Condoms%20in%20Schools%20H-170.968?uri=%2FAMADoc%2FHOD.xml-0-993.xmlGoogle Scholar, 6American College of Obstetricians and GynecologistsComprehensive sexuality education. Committee Opinion No. 678. . Obstet Gynecol Web site.https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/11/comprehensive-sexuality-educationGoogle Scholar,[13]American Public Health AssociationSexuality education as Part of a comprehensive health education Program in K to 12 schools.https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/01/23/09/37/sexuality-education-as-part-of-a-comprehensive-health-education-program-in-k-to-12-schoolsGoogle Scholar]. This support should not be surprising. Health care providers know that preventing adverse sexual and reproductive health outcomes is much better than attempting to treat their consequences. As adolescent health care providers who support sex education, we were dismayed by the revised and recently released Medical Institute for Sexual Heath (MISH) K-12 Standards for Optimal Sexual Development (M-SOSD) [[14]Medical Institute for Sexual HealthK-12 standards for Optimal sexual development. MISH, Dallas, TX2021https://newsexedstandards.org/Date accessed: September 10, 2021Google Scholar]. MISH has long been a strong supporter of abstinence-only approaches (now described as sexual risk avoidance) to adolescent sexual and reproductive health—despite a lack of evidence for the efficacy for such approaches and the harm from withholding lifesaving information from young people [[4]The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar]. These new "standards" are seriously flawed from both scientific and human rights' perspectives. We strongly support sex education that is science-based, medically accurate, and developmentally appropriate. Our review of the M-SOSD finds they fail on each of these criteria. There are multiple ways to strengthen the provision of sex education in the U.S. One important mechanism has been the promulgation of standards for sex education that reflect scientific understanding and adolescent developmental needs. The National Sex Education Standards (NSES) [[15]Future of Sex EducationNational sex education standards.ed. FoSE, Washington, DC2020https://www.advocatesforyouth.org/resources/health-information/future-of-sex-education-national-sexuality-education-standards/Date accessed: September 10, 2021Google Scholar], developed in partnership between sex education organizations and health professionals, provide clear, consistent, and straightforward guidance on the essential content for students in grades K–12. The NSES have also been used in the development of Centers for Disease Control and Prevention's recently released Health Education Curriculum Analysis Tool [[16]Centers for Disease Control and PreventionHealth education curriculum Analysis Tool, 2021. CDC, Atlanta2021https://www.cdc.gov/healthyyouth/hecat/pdf/2021/full-hecat-2021.pdfDate accessed: September 14, 2021Google Scholar]. Similarly, global guidance is available in the 2018 UNESCO International Technical Guidance on Sexuality Education [[1]UNESCO. InternationalTechnical guidance on sexuality education, revised edition.in: Paris, fr: UNESCO, UNAIDS, UNFPA, UNICEF, UN women. WHO, 2018https://www.unfpa.org/publications/international-technical-guidance-sexuality-educationDate accessed: September 10, 2021Google Scholar]. Key concepts within NSES include the following:•Information should be medically accurate information, and curricula should include a broad set of topics essential to human sexuality (Table 1). Medical accuracy means curricula should be based on weight of scientific evidence and scientific theory, published in peer-reviewed journals, and recognized as accurate, objective, and complete by mainstream professional organizations [[17]Santelli J.S. Medical accuracy in sexuality education: Ideology and the scientific process.Am J Public Health. 2008; 98: 1786-1792Crossref PubMed Scopus (39) Google Scholar].Table 1Comparing glossaries from Medical Institute for Sexual Heath K-12 Standards for Optimal Sexual Health (M-SOSD) and the National Sex Education Standards (NSES)Key• = Included in both glossariesX = Not included in the other glossary∗ = Included in both but with different definitions, see table footnotesM-SOSDaMedical Institute for Sexual Heath K-12 Standards for Optimal Sexual Development.NSESbThe National Sex Education Standards.Both M-SOSD and NSESGlossary XAbleism XAbstinence XAbstinence-only-until-marriage programsAdolescenceAdolescence• XAdoptionACEscAdverse childhood experiences.X XAge appropriate XAge of consent XAgender XAIDSdAcquired immune deficiency syndrome. XAll studentsAnal sex∗M-SOSD lists "incorrect/correct" usage, and NSES lists "internal/external". The M-SOSD definition heavily implies that correct condom use is rare and exaggerates ineffectiveness.Anal sex• XAndrogynous XAsexualAsymptomaticX XBiological sex XBiomedical approach XBisexual XBodily autonomy XBody image XBullying XChild sexual abuse XCisgender XClassism XClimate setting XCommunity violence XComprehensive sex education/sexuality education XConscious biasCoercionXCognitive MaturityXConnectednessXConsentConsent•Consistent and correct condom use∗M-SOSD lists "incorrect/correct" usage, and NSES lists "internal/external". The M-SOSD definition heavily implies that correct condom use is rare and exaggerates ineffectiveness.Condoms (see external condoms, internal condoms)•Consistent and correct contraceptive useContraception•CounselorsX XCultural competence XCulturally responsive XCycle of violenceDatingX XDating violenceDisciplineX XDisclosure XDisproportionate risk XDomestic violence XEmergency contraception XExperiential learning cycle XFactFamily/family membersFamily structure•FertilizationX XGay XGender XGender binary XGender expansive XGender expression XGender identity XGender nonbinary XGender nonconforming XGender pronouns XGender roles XGenderqueer XGender-based violenceGrit/resilienceX XHarassmentHealthy marriageHealthy relationships XHeterosexual XHIVeHuman immunodeficiency virus. XHomophobia XIncest XInclusiveInconsistent and incorrect condom/contraceptive useX XInduced abortionInfatuationX XInstitutional value XInterpersonal violence XIntersectionality XIntersex XIntimate partner violenceLegacyX XLesbian XLived experience XLARCfLong-acting reversible contraception.LoveX MarriageX XMasturbationMaturityXMedically accurateMedically accurate• XMiscarriageMutual masturbationXNonmarital sexual activityXObjectifyXOppressionXOptimal sexual developmentX XOral sexOutercourseX XPansexualParentX XPEPgPost-exposure prophylaxis.Personal boundariesXPornographySexually explicit materialNSES includes pornography in its definition of "sexually explicit material".• XPower XPregnancy options XPrEPhPre-exposure prophylaxis. XPrivilege XProfessional boundariesPubertyPuberty• XQueer XQuestioning XRacial justice XRacismRapeRape•Refusal skillsXReproductionX XReproductive justiceRomantic relationshipsX XSafe and affirming learning environments XSafety plan XSelf-concept XSelf-esteem XSex assigned at birth XSex positiveSex traffickingSex trafficking• XSexismSextingXSexual abuseSexual abuse•Sexual activitySexual behavior• XSexual agencySexual assaultSexual assault•Sexual consentSee "consent" above.•Sexual exploitationSexual exploitation•Sexual groomingX XSexual harassment XSexual identitySexual intercourseSexual intercourse• XSexual orientation XSexual response cycleSexual risk avoidanceSexual risk avoidance•Sexual risk reduction∗Exaggerates ineffectiveness of risk reduction compared with risk avoidance.XSexual violenceSexual violence• XSexualitySexualizeXSexually explicit contentSexually explicit material•STDsiSexually transmitted diseases./STIsjSexually transmitted infections.STDs• XSocial justice XSocioeconomic status XSpontaneous abortion XStudent centeredSTD/STI-related cancerX"Success sequence"X XTeaching strategies XTeasingTeenXTeen pregnancyXTransactions (transactional sex)X XTransgender XTransphobia XTrauma (individual) XTrauma (systemic) XTrauma informedTrusted adultTrusted adult• XTwo-spiritTypical human useX XUnconscious bias XUndetectable viral load XUniversal valuesVaginal intercourseVaginal sex•ValuesValue• XViral suppressionState of well-beingXWholenessX∗ M-SOSD lists "incorrect/correct" usage, and NSES lists "internal/external". The M-SOSD definition heavily implies that correct condom use is rare and exaggerates ineffectiveness.∗∗ NSES includes pornography in its definition of "sexually explicit material".∗∗∗ Exaggerates ineffectiveness of risk reduction compared with risk avoidance.a Medical Institute for Sexual Heath K-12 Standards for Optimal Sexual Development.b The National Sex Education Standards.c Adverse childhood experiences.d Acquired immune deficiency syndrome.e Human immunodeficiency virus.f Long-acting reversible contraception.g Post-exposure prophylaxis.h Pre-exposure prophylaxis.i Sexually transmitted diseases.j Sexually transmitted infections. Open table in a new tab •Opportunities for adolescents to explore their identity and values and the values and beliefs of their family, their religion, their culture, and their community.•Opportunities to practice the communication, negotiation, decision-making, and assertiveness skills needed to create healthy relationships.•Sex education should be developmentally appropriate information and geared to the age-appropriate interests and developmental capacity of children and adolescents. For example, while sex education for children should focus on family life, sex education for adolescents needs to focus on their expanding social world including peers, media, and culture [[15]Future of Sex EducationNational sex education standards.ed. FoSE, Washington, DC2020https://www.advocatesforyouth.org/resources/health-information/future-of-sex-education-national-sexuality-education-standards/Date accessed: September 10, 2021Google Scholar]. Although the revised M-SOSD represent some progress from a previous version, they still fall short. Those prior MISH recommendations were criticized as medically inaccurate, based in faith not fact, and providing inaccurate information on condoms and contraception [[18]Mayer R. MISH publishes new framework for fear-based, abstinence-only education.SIECUS Rep. 1997; 25: 14-16PubMed Google Scholar]. In the new M-SOSD, information on contraception is factually correct, although incomplete and focused on limitations in contraceptive effectiveness. Marriage is specifically defined as a "couple" and not as a "man and a woman", and the focus on adolescent relationships and sexual consent and inclusion of adolescent developmental concepts such as resiliency, developmental assets, and adverse childhood experiences is potentially helpful. However, the application of these ideas is not well developed in the document. Our review finds that the M-SOSD miss many essential topics. We compared the extensive glossary of terms provided in both the NSES and the M-SOSD. Remarkably, the two glossaries overlap rarely (Table 1), except on a few issues like sexual violence and sexual consent. Missing from M-SOSD but included in NSES are topics such as sexual orientation and gender identity; social determinants of health such as poverty, racism, and other forms of discrimination; disabilities; reproductive justice; prevention of HIV infection using PreP therapy; and adolescent health care issues such as adolescent rights and minor consent laws. Topics included in M-SOSD but not included in NSES include discipline, marriage, and infatuation and love. Many of sex education topics missing from the M-SOSD are recommended by mainstream medical groups including the American Medical Association, the American Academy of Pediatrics, and the Society for Adolescent Health and Medicine [3Breuner C.C. Mattson G. Committee on adolescence, committee on Pyschosocial aspects of child and family health. Sexuality education for children and adolescents.Pediatrics. 2016; 138e20161348Crossref PubMed Scopus (136) Google Scholar, 4The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 5American Medical AssociationSexuality education, sexual violence prevention, abstinence, and Distribution of condoms in schools H-170.968.https://policysearch.amaassn.org/policyfinder/detail/Sexuality%20Education,%20Sexual%20Violence%20Prevention,%20Abstinence,%20and%20Distribution%20of%20Condoms%20in%20Schools%20H-170.968?uri=%2FAMADoc%2FHOD.xml-0-993.xmlGoogle Scholar]. A glaring omission from M-SOSD is any information on the authors or their process for evidence review; these are standard in scientific review and guideline development. A few topics are addressed but are woefully incomplete. M-SOSD misleadingly assert it is "inclusive of all students, irrespective of their sexual orientation or gender identity" as well as culturally inclusive; however, the M-SOSD learning objectives do not address either sexual orientation or gender identity. Remarkably, the M-SOSD say little about how adolescent health care should be addressed in sex education or about adolescents' legal rights to counseling, diagnosis, and treatment, despite coming from a self-identified medical group. M-SOSD learning objectives briefly mention vaccines and medications to prevent sexually transmitted infections but without endorsing these and instead focusing on parental permission. While many topics are missing or incomplete, other topics are misrepresented or simply inaccurate (Table 2). Marriage and abstinence until marriage are portrayed as panaceas to healthy sexuality and are described as the expected goal for adolescent relationship building. This is inconsistent with research on marriage and adolescent sexual behaviors. The revised M-SOSD retain an erroneous belief that premarital and extramarital sex is dangerous to the adolescent's physical and mental health; the Society for Adolescent Health and Medicine has reviewed the research on this topic and specifically disagrees [[4]The Society for Adolescent Health and MedicineAbstinence-only-until-marriage Policies and Programs: An Updated Position Paper of the Society for adolescent health and medicine.J Adolesc Health. 2017; 61: 400-403Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar]. The M-SOSD also recycle old half-truths like "avoiding sexual activity is the only 100% effective way to avoid teen pregnancy". The M-SOSD say little about adolescent cognitive capacity, but include a wildly inaccurate statement that "cognitive maturity is not fully reached until the late 20s". Research on cognitive development suggests that cognitive capacity and young people's ability to participate in guided decision-making develop in early adolescence [[20]Hein I.M. Troost P.W. Broersma A. et al.Why is it hard to make progress in assessing children's decision-making competence?.BMC Med Ethics. 2015; 16: 1-6Crossref PubMed Scopus (0) Google Scholar,[21]Hein I.M. De Vries M.C. Troost P.W. et al.Informed consent instead of assent is appropriate in children from the age of twelve: Policy implications of new findings on children's competence to consent to clinical research.BMC Med Ethics. 2015; 16: 1-7Crossref PubMed Scopus (48) Google Scholar]. Adolescents can and do make wise choices when guided by teachers and clinicians who understand, respect, and nurture young people's decision-making capacities. The new M-SOSD are incomplete and deeply flawed. Key science is ignored or misrepresented. On careful examination, the M-SOSD appear to be a justification for sex education based on abstinence-only-until-marriage beliefs, not science. Every adolescent has a right to complete and accurate information about human sexuality, as intrinsic to the right to health. School-based sexuality education is essential to that basic human right. States and local communities aiming to improve adolescent sexual and reproductive health and looking for national standards on sex education should adopt the NSES. The authors thank Gwendolyn Rosen for her excellent assistance with preparation of tables, checking references, and proof-reading of drafts. The authors received no external funding supporting this commentary.
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