Three Decades of Research: The Case for Comprehensive Sex Education

Affiliations.

  • 1 Department of Public Health, Montclair State University, Montclair, New Jersey. Electronic address: [email protected].
  • 2 Department of Public Health, Montclair State University, Montclair, New Jersey.
  • PMID: 33059958
  • DOI: 10.1016/j.jadohealth.2020.07.036

Purpose: School-based sex education plays a vital role in the sexual health and well-being of young people. Little is known, however, about the effectiveness of efforts beyond pregnancy and sexually transmitted disease prevention. The authors conducted a systematic literature review of three decades of research on school-based programs to find evidence for the effectiveness of comprehensive sex education.

Methods: Researchers searched the ERIC, PsycINFO, and MEDLINE. The research team identified papers meeting the systematic literature review criteria. Of 8,058 relevant articles, 218 met specific review criteria. More than 80% focused solely on pregnancy and disease prevention and were excluded, leaving 39. In the next phase, researchers expanded criteria to studies outside the U.S. to identify evidence reflecting the full range of topic areas. Eighty articles constituted the final review.

Results: Outcomes include appreciation of sexual diversity, dating and intimate partner violence prevention, development of healthy relationships, prevention of child sex abuse, improved social/emotional learning, and increased media literacy. Substantial evidence supports sex education beginning in elementary school, that is scaffolded and of longer duration, as well as LGBTQ-inclusive education across the school curriculum and a social justice approach to healthy sexuality.

Conclusions: Review of the literature of the past three decades provides strong support for comprehensive sex education across a range of topics and grade levels. Results provide evidence for the effectiveness of approaches that address a broad definition of sexual health and take positive, affirming, inclusive approaches to human sexuality. Findings strengthen justification for the widespread adoption of the National Sex Education Standards.

Keywords: CSE; K-12; National Sex Education Standards; National Sexuality Education Standards; Sex education; Sexuality education; Systematic Literature Review; comprehensive sex education.

Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

Publication types

  • Research Support, Non-U.S. Gov't
  • Systematic Review
  • Sex Education*
  • Sexual Behavior
  • Sexually Transmitted Diseases*

Sex Education that Goes Beyond Sex

  • Posted November 28, 2018
  • By Grace Tatter

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Historically, the measure of a good sex education program has been in the numbers: marked decreases in the rates of sexually transmitted diseases, teen pregnancies, and pregnancy-related drop-outs. But, increasingly, researchers, educators, and advocates are emphasizing that sex ed should focus on more than physical health. Sex education, they say, should also be about relationships.

Giving students a foundation in relationship-building and centering the notion of care for others can enhance wellbeing and pave the way for healthy intimacy in the future, experts say. It can prevent or counter gender stereotyping and bias. And it could minimize instances of sexual harassment and assault in middle and high school — instances that may range from cyberbullying and stalking to unwanted touching and nonconsensual sex. A recent study from Columbia University's Sexual Health Initative to Foster Transformation (SHIFT) project suggests that comprehensive sex education protects students from sexual assault even after high school.

If students become more well-practiced in thinking about caring for one another, they’ll be less likely to commit — and be less vulnerable to — sexual violence, according to this new approach to sex ed. And they’ll be better prepared to engage in and support one another in relationships, romantic and otherwise, going forward. 

Giving students a foundation in relationship-building can enhance wellbeing and pave the way for healthy intimacy in the future, experts say. It can also prevent or counter gender stereotyping, and it could minimize instances of sexual harassment and assault in middle and high school.

Introducing Ethics Into Sex Ed

Diving into a conversation even tangentially related to sex with a group of 20 or so high school students isn’t easy. Renee Randazzo helped researcher Sharon Lamb pilot the Sexual Ethics and Caring Curriculum while a graduate student at the University of Massachusetts Boston. She recalls boys snickering during discussions about pornography and objectification. At first, it was hard for students to be vulnerable.

But the idea behind the curriculum is that tough conversations are worth having. Simply teaching students how to ask for consent isn’t enough, says Lamb, a professor of counseling psychology at UMass Boston, who has been researching the intersection between caring relationships, sex, and education for decades. Students also to have understand why consent is important and think about consent in a variety of contexts. At the heart of that understanding are questions about human morality, how we relate to one another, and what we owe to one another. In other words, ethics.

“When I looked at what sex ed was doing, it wasn’t only a problem that kids weren’t getting the right facts,” Lamb says. “It was a problem that they weren’t getting the sex education that would make them treat others in a caring and just way.”

She became aware that when schools were talking about consent — if they were at all — it was in terms of self-protection. The message was: Get consent so you don’t get in trouble.

But there’s more at play, Lamb insists. Students should also understand the concept of mutuality — making decisions with a partner and understanding and addressing other people’s concerns or wishes — and spend time developing their own sense of right and wrong. 

“If a young person is not in a healthy relationship, they can’t negotiate sex in a meaningful way. Even if they’re not having sex yet, they’re grappling with the idea of what a healthy relationship is.”

The curriculum she developed invites students to engage in frank discussions about topics like objectification in the media and sexting. If a woman is shamed for being in a sexy video, but she consented to it, does she deserve the criticism? Regardless of what you think, can you justify your position?

“How do they want to treat people, what kind of partner do they want to be? That takes discussion,” Lamb says. “It’s not a skill-training thing.”

The idea behind the curriculum isn’t that anything goes, so long as students can discuss their reasoning. Instead, the goal is that students develop the critical-reasoning skills to do the right thing in tricky situations. 

After Randazzo’s students got over their cases of the giggles, the conversations were eye-opening, she says. “You give them the opportunity unpack their ideas and form their own opinions,” she says.

Healthy Relationships — and Prevention

Most sexual assault and violence in schools is committed by people who know their victims — they’re either dating, friends, or classmates. Regardless, they have a relationship of some sort, which is why a focus on relationships and empathy is crucial to reducing violence and preparing students for more meaningful lives.

And while it might seem uncomfortable to move beyond the cut-and-dried facts of contraception into the murkier waters of relationships, students are hungry for it. A survey by researchers at the Harvard Graduate School of Education's  Making Caring Common  initiative found that 65 percent of young-adult respondents wished they had talked about relationships at school.

“It’s so critical that kids are able to undertake this work of learning to love somebody else,” says developmental psychologist Richard Weissbourd , the director of Making Caring Common and lead author of a groundbreaking report called The Talk: How Adults Can Promote Young People’s Healthy Relationships and Prevent Misogyny and Sexual Harassment . “They’re not going to be able to do it unless we get them on the road and are willing to engage in thoughtful conversations.”

Nicole Daley works with OneLove , a nonprofit focused on teen violence prevention. She previously worked extensively with Boston Public Schools on violence prevention. She echoes Lamb and Weissbourd: A focus on relationships is key to keeping students safe.

“If a young person is not in a healthy relationship, they can’t negotiate sex in a meaningful way,” she says. “Really discussing healthy relationships and building that foundation is important. Even if they’re not having sex yet, they’re grappling with the idea of what healthy relationship is.”

And it’s critical to start that work before college.

Shael Norris spent the first two decades of her career focusing on college campuses, but now is focused on younger students with her work through Safe BAE . By college, many people’s ideas about how to act when it comes to sex or romance are entrenched, she says. The earlier young people can start interrogating what they know about sex and relationships, the better.

Safe BAE is led by Norris and young survivors of sexual assault. The organization works to educate students about healthy relationships, sexual violence, students’ rights under Title IX, and other related topics.

Movement to change middle and high school curricula to include a focus on healthy relationships and consent has been slow, Norris notes. In 2015, Senators Tim Kaine (D-Va.) and Claire McCaskill (D-Mo.) introduced the Teach Safe Relationships Act, which would have mandated secondary schools teach about safe relationships, including asking for consent, in health education courses. It didn’t go anywhere. And while eight states now mandate some sort of sexual consent education , there’s no consensus about what that should entail.

Instead, the momentum for a more comprehensive sexual education that considers relationships and violence prevention is coming from individual teachers, students and parents.

“We don’t have to wait for politicians to start having conversations about this,” Norris says.

A New Approach to Sex Ed

  • Develop an ethical approach to sex ed. Place emphasis on helping students learn how to care for and support one another. This will reduce the chance they’ll commit, or be vulnerable to, sexual violence.
  • Don’t just tell students how to ask for consent; prompt them to consider why concepts like consent are important. It’s not just about staying out of legal trouble — it’s also about respecting and caring for others.
  • Respect students’ intelligence and engage them in discussions about who they want to be as people. Serious dialogue about complicated topics will hone their critical-thinking skills and help them be prepared to do the right thing.
  • Even without access to a curriculum, students, parents and educators can work together to facilitate conversations around sexual violence prevention through clubs, with help from organizations like Safe BAE.

Additional Resource

  • National Sexuality Education Standards: Core Content and Skills, K–12

Part of a special series about preventing sexual harassment at school.  Read the whole series .

Illustration by Wilhelmina Peragine

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Consent education in America

The State of Sex Ed in America

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Part of the Conversation: Rachel Hanebutt, MBE'16

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The State of Sex Education

Summary State Policies on Sex Education in Schools

Why is sexual education taught in schools.

A 2017 Centers for Disease Control and Prevention (CDC)  survey  indicates that nearly 40 percent of all high school students report they have had sex, and 9.7 percent of high school students have had sex with four or more partners during their lifetime. Among students who had sex in the three months prior to the survey, 54 percent reported condom use and 30 percent reported using birth control pills, an intrauterine device (IUD), implant, shot or ring during their last sexual encounter.

The birth rate for women aged 15-19 years was  18.8 per 1,000 women  in 2017, a drop of 7 percent from 2016. According to CDC, reasons for the decline are not entirely clear, but evidence points to a higher number of teens abstaining from sexual activity and an increased use of birth control in teens who are sexually active. Though the teen birth rate has declined to its lowest levels since data collection began, the United States still has the highest teen birth rate in the industrialized world.

Certain social and economic costs can result from teen pregnancy. Teenage mothers are less likely to finish high school and are more likely than their peers to live in poverty, depend on public assistance, and be in poor health. Their children are more likely to suffer health and cognitive disadvantages, come in contact with the child welfare and correctional systems, live in poverty, drop out of high school and become teen parents themselves. These costs add up, according to The National Campaign to Prevent Teen and Unplanned Pregnancy, which estimates that teen childbearing costs taxpayers at least $9.4 billion annually. Between 1991 and 2015, the teen birth rate dropped 64%, resulting in approximately  $4.4 billion  in public savings in one year alone.

Sexually transmitted infections (STIs) disproportionately affect adolescents due to a variety of behavioral, biological and cultural reasons. Young people ages 15 to 24 represent  25 percent  of the sexually active population, but acquire half of all new STIs, or about 10 million new cases a year. Though many cases of STIs continue to go  undiagnosed and unreported , one in four sexually-active adolescent females is reported to have an STI.

Human papillomavirus  is the most common STI and some estimates find that up to 35 percent of teens ages 14 to 19 have HPV. The rate of reported cases of chlamydia, gonorrhea, and primary and secondary syphilis increased among those aged 15-24 years old between 2017-2018. Rates of reported chlamydia cases are consistently highest among women aged 15-24 years, and rates of reported gonorrhea cases are consistently highest among men aged 15-24 years. A CDC analysis reveals the annual number of new STIs is roughly equal among young women and young men. However, women are more likely to experience long-term health complications from untreated STIs and adolescent females may have increased susceptibility to infection due to biological reasons.

The estimated direct medical costs for treating people with STIs are nearly $16 billion annually, with costs associated with HIV infection accounting for more than 81% of the total cost. In 2017, approximately  21 percent  of new HIV diagnoses were among young people ages 13 to 24 years.

Sex Education and States

All states are somehow involved in sex education for public schoolchildren.

As of October 1, 2020:

  • Thirty states and the District of Columbia require public schools teach sex education, 28 of which mandate both sex education and HIV education.
  • Thirty-nine states and the District of Columbia require students receive instruction about HIV.
  • Twenty-two states require that if provided, sex and/or HIV education must be medically, factually or technically accurate. State definitions of “medically accurate" vary, from requiring that the department of health review curriculum for accuracy, to mandating that curriculum be based on information from “published authorities upon which medical professionals rely.” (See table on medically accuracy laws.)

Many states define parents’ rights concerning sexual education:

  • Twenty-five states and the District of Columbia require school districts to notify parents that sexual or HIV education will be provided.
  • Five states require parental consent before a child can receive instruction.
  • Thirty-six states and the District of Columbia allow parents to opt-out on behalf of their children.

*Medical accuracy is not specifically outlined in state statue, rather it is required by the New Jersey Department of Education, Comprehensive Health and Physical Education Student Learning Standards.

** Medical accuracy requirement is pursuant to rule R277-474 of the Utah Administrative Code.

***Medical accuracy is not outlined in state statute, rather it is included in the Virginia Department of Education Standards of Learning Document for Family Life Resources.

Source: NCSL, 2019; Guttmacher Institute, 2019; Powered by StateNet

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What Works In Schools : Sexual Health Education

CDC’s  What Works In Schools  Program improves the health and well-being of middle and high school students by:

  • Improving health education,
  • Connecting young people to the health services they need, and
  • Making school environments safer and more supportive.

What is sexual health education?

Quality provides students with the knowledge and skills to help them be healthy and avoid human immunodeficiency virus (HIV), sexually transmitted infections (STI) and unintended pregnancy.

A quality sexual health education curriculum includes medically accurate, developmentally appropriate, and culturally relevant content and skills that target key behavioral outcomes and promote healthy sexual development. 1

The curriculum is age-appropriate and planned across grade levels to provide information about health risk behaviors and experiences.

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Sexual health education should be consistent with scientific research and best practices; reflect the diversity of student experiences and identities; and align with school, family, and community priorities.

Quality sexual health education programs share many characteristics. 2-4 These programs:

  • Are taught by well-qualified and highly-trained teachers and school staff
  • Use strategies that are relevant and engaging for all students
  • Address the health needs of all students, including the students identifying as lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ)
  • Connect students to sexual health and other health services at school or in the community
  • Engage parents, families, and community partners in school programs
  • Foster positive relationships between adolescents and important adults.

How can schools deliver sexual health education?

A school health education program that includes a quality sexual health education curriculum targets the development of functional knowledge and skills needed to promote healthy behaviors and avoid risks. It is important that sexual health education explicitly incorporate and reinforce skill development.

Giving students time to practice, assess, and reflect on skills taught in the curriculum helps move them toward independence, critical thinking, and problem solving to avoid STIs, HIV, and unintended pregnancy. 5

Quality sexual health education programs teach students how to: 1

  • Analyze family, peer, and media influences that impact health
  • Access valid and reliable health information, products, and services (e.g., STI/HIV testing)
  • Communicate with family, peers, and teachers about issues that affect health
  • Make informed and thoughtful decisions about their health
  • Take responsibility for themselves and others to improve their health.

What are the benefits of delivering sexual health education to students?

Promoting and implementing well-designed sexual health education positively impacts student health in a variety of ways. Students who participate in these programs are more likely to: 6-11

  • Delay initiation of sexual intercourse
  • Have fewer sex partners
  • Have fewer experiences of unprotected sex
  • Increase their use of protection, specifically condoms
  • Improve their academic performance.

In addition to providing knowledge and skills to address sexual behavior , quality sexual health education can be tailored to include information on high-risk substance use * , suicide prevention, and how to keep students from committing or being victims of violence—behaviors and experiences that place youth at risk for poor physical and mental health and poor academic outcomes.

*High-risk substance use is any use by adolescents of substances with a high risk of adverse outcomes (i.e., injury, criminal justice involvement, school dropout, loss of life). This includes misuse of prescription drugs, use of illicit drugs (i.e., cocaine, heroin, methamphetamines, inhalants, hallucinogens, or ecstasy), and use of injection drugs (i.e., drugs that have a high risk of infection of blood-borne diseases such as HIV and hepatitis).

What does delivering sexual health education look like in action?

To successfully put quality sexual health education into practice, schools need supportive policies, appropriate content, trained staff, and engaged parents and communities.

Schools can put these four elements in place to support sex ed.

  • Implement policies that foster supportive environments for sexual health education.
  • Use health content that is medically accurate, developmentally appropriate, culturally inclusive, and grounded in science.
  • Equip staff with the knowledge and skills needed to deliver sexual health education.
  • Engage parents and community partners.

Include enough time during professional development and training for teachers to practice and reflect on what they learned (essential knowledge and skills) to support their sexual health education instruction.

By law, if your school district or school is receiving federal HIV prevention funding, you will need an HIV Materials Review Panel (HIV MRP) to review all HIV-related educational and informational materials.

This review panel can include members from your School Health Advisory Councils, as shared expertise can strengthen material review and decision making.

For More Information

Learn more about delivering quality sexual health education in the Program Guidance .

Check out CDC’s tools and resources below to develop, select, or revise SHE curricula.

  • Health Education Curriculum Analysis Tool (HECAT), Module 6: Sexual Health [PDF – 70 pages] . This module within CDC’s HECAT includes the knowledge, skills, and health behavior outcomes specifically aligned to sexual health education. School and community leaders can use this module to develop, select, or revise SHE curricula and instruction.
  • Developing a Scope and Sequence for Sexual Health Education [PDF – 17 pages] .This resource provides an 11-step process to help schools outline the key sexual health topics and concepts (scope), and the logical progression of essential health knowledge, skills, and behaviors to be addressed at each grade level (sequence) from pre-kindergarten through the 12th grade. A developmental scope and sequence is essential to developing, selecting, or revising SHE curricula.
  • Centers for Disease Control and Prevention. Health Education Curriculum Analysis Tool, 2021 , Atlanta: CDC; 2021.
  • Goldfarb, E. S., & Lieberman, L. D. (2021). Three decades of research: The case for comprehensive sex education. Journal of Adolescent Health, 68(1), 13-27.
  • Centers for Disease Control and Prevention (2016). Characteristics of an Effective Health Education Curriculum .
  • Pampati, S., Johns, M. M., Szucs, L. E., Bishop, M. D., Mallory, A. B., Barrios, L. C., & Russell, S. T. (2021). Sexual and gender minority youth and sexual health education: A systematic mapping review of the literature.  Journal of Adolescent Health ,  68 (6), 1040-1052.
  • Szucs, L. E., Demissie, Z., Steiner, R. J., Brener, N. D., Lindberg, L., Young, E., & Rasberry, C. N. (2023). Trends in the teaching of sexual and reproductive health topics and skills in required courses in secondary schools, in 38 US states between 2008 and 2018.  Health Education Research ,  38 (1), 84-94.
  • Coyle, K., Anderson, P., Laris, B. A., Barrett, M., Unti, T., & Baumler, E. (2021). A group randomized trial evaluating high school FLASH, a comprehensive sexual health curriculum.  Journal of Adolescent Health ,  68 (4), 686-695.
  • Marseille, E., Mirzazadeh, A., Biggs, M. A., Miller, A. P., Horvath, H., Lightfoot, M.,& Kahn, J. G. (2018). Effectiveness of school-based teen pregnancy prevention programs in the USA: A systematic review and meta-analysis. Prevention Science, 19(4), 468-489.
  • Denford, S., Abraham, C., Campbell, R., & Busse, H. (2017). A comprehensive review of reviews of school-based interventions to improve sexual-health. Health psychology review, 11(1), 33-52.
  • Chin HB, Sipe TA, Elder R. 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(3):272–94.
  • Mavedzenge SN, Luecke E, Ross DA. Effective approaches for programming to reduce adolescent vulnerability to HIV infection, HIV risk, and HIV-related morbidity and mortality: A systematic review of systematic reviews. J Acquir Immune Defic Syndr 2014;66:S154–69.

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Sex Education in School, are Gender and Sexual Minority Youth Included?: A Decade in Review

Comprehensive sexual health education increases sexual health knowledge and decreases adverse health outcomes and high-risk behaviors in heterosexual youth but lacks information relevant to gender and sexual minority youth. Universal access to comprehensive sexual health education that includes information relevant to gender and sexual minority individuals is lacking in the United States, leading to poor health outcomes for gender and sexual minority youth. The purpose of this review was to examine sexual health education programs in schools in the United States for the inclusion of information on gender identity and sexual orientation. The review provides information on current programs offered in schools and suggestions to make them more inclusive to gender and sexual minority youth.

Is Sex Education for Everyone?: A Review

Gender and sexual minority youth (GSMY), youth who do not identify as heterosexual or their gender identity are non-binary, have increased sexual risk behaviors and adverse health outcomes compared to their heterosexual and cisgender peers ( Kann et al., 2016 ; Rasberry et al., 2017 , 2018 ). According to the 2017 YRBS youth that identified as a sexual minority (lesbian, gay, bisexual, or another non-heterosexual identity or reporting same-sex attraction or sexual partners) reported increased sexual partners, earlier sexual debut, the use of alcohol or drugs before sex, decreased condom and contraceptive use than their heterosexual peers ( Rasberry et al., 2018 ). Comprehensive sexual health education increase sexual health knowledge and decreases adverse health outcomes, sexually transmitted infections (STIs), HIV, and pregnancy and high-risk behaviors in heterosexual youth, age of sexual initiation, the number of sex partners, sex without protection, sex while under the influence of drugs and alcohol ( Bridges & Alford, 2010 ; Mustanski, 2011 ; Sexuality Information and Education Council of the United States (SIECUS)., 2004 ; Steinke et al., 2017 ). Research conducted with heterosexual adolescents shows comprehensive sexual health education, medically accurate material that includes information on STIs, HIV, pregnancy, condoms, contraceptives as well as abstinence and sexual decision making, increases sexual health knowledge and decreases adverse health outcomes, STIs, HIV, and pregnancy and high-risk behaviors ( Bridges & Alford, 2010 ; Mustanski, 2011 ; Sexuality Information and Education Council of the United States (SIECUS)., 2004 ; Steinke et al., 2017 ). Most GSMY report receiving some form of sexual health education in school ranging from comprehensive to abstinence-only, however GSMY-inclusive sexual health education, education that includes information on all genders and sexual orientations, is out of reach for a majority of youth in the United States ( Charest et al., 2016 ; Human Rights Campaign, 2015 ; Kosciw et al., 2018 ; Steinke et al., 2017 ). Not having access to GSMY-inclusive sex education, GSMY lack the information they need to understand their sexuality and gender concerns and to make informed sexual decisions ( Charest et al., 2016 ; Steinke et al., 2017 ).

Most teens, 70%, report receiving some form of sexual health education in school; while the content varies widely, from abstinence-only to comprehensive, it is primarily penile-vaginal in nature ( Human Rights Campaign, 2015 ; Lindberg et al., 2016 ). Universal access to comprehensive and GSMY-inclusive sexual health education is lacking in the United States and can lead to poor health outcomes for GSMY ( Human Rights Campaign, 2015 ). Currently, only 27 states mandate sexual health and HIV education ( Guttmacher Institute, 2020 ). Seventeen states require discussion of sexual orientation, with only 10 requiring information to be inclusive of gender and sexuality, and seven mandating only negative information be provided on homosexuality and positive information solely be provided on heterosexuality ( Guttmacher Institute, 2020 ). These laws intended to prohibit the promotion of homosexuality, deny SGMY the sexual health information they need and serve to further stigmatize them for their gender identity and sexual orientation ( Gay, Lesbian and Straight Education Network (GLSEN), 2018 ).

Significance of the Topic

Despite the effectiveness of comprehensive sexual health education in increasing sexual health outcomes in heterosexual youth, little research has been done on its effects on GSMY ( Human Rights Campaign, 2015 ; Kosciw et al., 2018 ; Steinke et al., 2017 ). The sex education offered in schools primarily describes penile-vaginal intercourse and does not include information on oral, anal, or manual intercourse or ways to practice safe sex with these types of sexual activity. Less than 7% of GSMY in the United States report receiving sexual health education that was inclusive of both gender and sexual minorities ( Charest et al., 2016 ; Human Rights Campaign, 2015 ; Kosciw et al., 2018 ; Steinke et al., 2017 ). Many GSMY look to the internet or pornography for information on sex, leading to misinformation or an unrealistic expectation of intercourse and relationships ( Arbeit et al., 2016 ; Charest et al., 2016 ; Haley et al., 2019 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Roberts et al., 2019 ).

Teens and young adults account for 21% of all new HIV cases in the United States, with 81% of newly diagnosed cases attributed to young men who have sex with men ( Centers for Disease Control and Prevention (CDC), 2019 ). Lindley & Walsemann, (2015) conducted a study of teens in New York and found that GSMY youth had between a two to seven times higher chance of being involved in a pregnancy than their heterosexual peers. According to the Centers for Disease Control and Prevention (2018) , young men who have sex with men have a higher incidence of gonorrhea, chlamydia, and syphilis compared to women and men who have sex with women only. The 2017 YRBS report revealed that GSMY reported significantly higher incidences of forced sex, dating violence, suicidal thoughts, attempted suicide, bullying, alcohol and drug use, earlier initiation into sex, more sexual partners, and were also less likely to use condoms during sexual intercourse than their heterosexual peers ( Kann et al., 2018 ; Rasberry et al., 2018 ). To improve sexual health outcomes in GSMY, they need to receive sexual health education that is comprehensive and inclusive to all genders and sexual orientations at an early age.

The purpose of this review was to examine the sexual health education programs in public and private schools in the United States for the inclusion of information on gender identity and sexual orientation. Further, this review provides an understanding of the sexual health education needs of GSMY, how it is reflected in the programs offered to young adults, and what changes could be made. A review of studies published between 2010 and 2020 was conducted to evaluate the inclusion of gender and sexual minority information in sexual health education offered in schools.

Literature Search

The review was conducted according to the Preferred Reporting Items for Systemic Review and Meta-Analysis (PRISMA) guidelines ( Moher et al., 2009 ). The search was conducted using three online databases: CINAHL, PubMed, and Scopus. The search strategy for CINAHL was as follows: limits were set to include research articles published in English in peer-reviewed academic journals, age restriction set to “all child” major heading “sex education” and “sexual health”. The search date was set from January 2010 to March 2020. The reason for the 2010 start date was to get the latest information on sexual health education programs. The combinations of the search terms used were “sex education” and “sexual minority”; “sexual health education” and “sexual minority”; “inclusive” and “sex education” and “school”; “LGBT” and “sex education”. The same searches were conducted in each of the other databases. The process is illustrated in Figure 1 . The initial searches yielded a total of 83 articles after duplicates were removed; 56 articles could be excluded after reading the title or abstract due to location or not discussing sex education in the primary or high school setting, 27 articles were viewed in full text. After reading the full-text articles, 14 articles were excluded for the following reasons: seven did not discuss sex education programs in school, five discussed program implementations, and two were not set in the United States. A total of 13 peer reviewed articles were included in this review ( Table 1 ).

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PRISMA diagram showing search and screening process, and selection of studies for inclusion in the review.

Review of Studies Related to Inclusive Sexual Health Education

Current Education Offered

Heteronormative information.

A majority of the research reported the content of the sexual health education offered in schools was heteronormative, the belief that heterosexuality and binary gender are the norms, and the intercourse discussed was penile-vaginal intercourse ( Arbeit et al., 2016 ; Bodnar & Tornello, 2019 ; Gowen & Winges-Yanez, 2014 ; Haley et al., 2019 ; K. S. Hall et al., 2016 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Rasberry et al., 2017 ; Steinke et al., 2017 ). The lessons primarily consisted of information about puberty, the dangers of sex, penile-vaginal intercourse, STIs, and pregnancy; information the GSMY in the studies reported as irrelevant to them ( Gowen & Winges-Yanez, 2014 ; Haley et al., 2019 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Pingel et al., 2013 ; Roberts et al., 2019 ). Of the 13 studies, eight mentioned students being taught about external condoms, one mentioned internal condoms, 1 discussed students being shown a condom demonstration and none reported information being given on dental dams or finger condoms. ( Arbeit et al., 2016 ; Gowen & Winges-Yanez, 2014 ; Haley et al., 2019 ; K. S. Hall et al., 2016 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Rasberry et al., 2017 ; Roberts et al., 2019 ). In seven of the studies, participants reported their questions regarding gender identity or sexual orientation went unanswered in class. This was due to the teacher ignoring the question, the teacher lacking the information to answer, or the teacher not being allowed to answer due to school and state policy ( Arbeit et al., 2016 ; Gowen & Winges-Yanez, 2014 ; Haley et al., 2019 ; K. S. Hall et al., 2016 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Mahdi et al., 2014 ; Pingel et al., 2013 ; Steinke et al., 2017 ).

Supplying only heteronormative education contributed to poorer mental outcomes for GSMY. Non-heterosexual, non-binary, and gender-nonconforming individuals and their behavior were often pathologized in the education presented, leading to internalized homophobia, increased depression, increased anxiety, and self-loathing in GSMY ( Arbeit et al., 2016 ; Bodnar & Tornello, 2019 ; Gowen & Winges-Yanez, 2014 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Pingel et al., 2013 ; Steinke et al., 2017 ). The exclusion of information about gender and sexual minorities made GSMY feel confused about how they were feeling, made them feel something was wrong with them and made them feel like they did not exist ( Gowen & Winges-Yanez, 2014 ; Haley et al., 2019 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Rasberry et al., 2017 ; Roberts et al., 2019 ). Lack of GSMY-inclusive information also led to an increase in bullying of GSMY in schools from both students and teachers ( Arbeit et al., 2016 ; Gowen & Winges-Yanez, 2014 ; W. J. Hall et al., 2019 ; McCarty-Caplan, 2015 ; Roberts et al., 2019 ). Numerous studies described a decrease in bullying of GSMY in schools with GSMY-inclusive education, potentially due to a normalizing non-heterosexual, non-binary, and gender-nonconforming individuals, ( Gowen & Winges-Yanez, 2014 ; Haley et al., 2019 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Proulx et al., 2019 ; Roberts et al., 2019 ).

Incomplete and Inaccurate Information

The negative impact an incomplete sex education had on GSMY health was a common theme in the literature ( Bodnar & Tornello, 2019 ; Gowen & Winges-Yanez, 2014 ; Haley et al., 2019 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Pingel et al., 2013 ). Many of the lessons taught in school only covered the “mechanics” of penile-vaginal intercourse and the problems that can occur from that action, with few reporting receiving lessons about other types of sex (anal, oral, manual, masturbation), healthy relationships, consent, or the enjoyment of sex ( Gowen & Winges-Yanez, 2014 ; Haley et al., 2019 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Roberts et al., 2019 ). No studies reported information being taught on transgender identity, non-binary identity, or use of proper pronouns ( Haley et al., 2019 ; Hobaica et al., 2019 ; Roberts et al., 2019 ).

Several authors discussed inaccurate information being offered to students in schools ( Haley et al., 2019 ; K. S. Hall et al., 2016 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ). Hobaica and Kwon (2017) reported in 2016 only 20 states required sexual health information provided to students in school to be medically accurate. Inaccurate information given to youth included inflated failure rates of condoms and birth control, inaccurate information on the transmission of STIs, and inaccurate representation of gender and sexual minority individuals ( Haley et al., 2019 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Roberts et al., 2019 ; Steinke et al., 2017 ). Lack of information and inaccurate information contributed to GSMY making uninformed decisions about sex, leading to increased sexual experiences, increased number of partners, non-consensual sexual experiences, unprotected sex, sex while intoxicated, STIs, and pregnancy ( Bodnar & Tornello, 2019 ; Gowen & Winges-Yanez, 2014 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Rasberry et al., 2017 ).

Timing of Information

The timing of education being offered to students occurred in middle school and high school ( Bodnar & Tornello, 2019 ; Haley et al., 2019 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ). For some GSMY this information came too late to be helpful. Sexual minority youth report earlier initiation into sex and many received sex education after they had already become sexually active leading to early risky sexual behaviors and pregnancy ( Arbeit et al., 2016 ; Bodnar & Tornello, 2019 ; Haley et al., 2019 ; Hobaica & Kwon, 2017 ). Gender minority and non-binary individuals recommended that information about gender and puberty start as early as 1 st and 2 nd grade to help with the problems associated with gender dysphoria.

Recommendations

There were many recommendations included in the literature on how to make sexual health education more inclusive and appropriate for GSMY. To be relevant to all students sexual health education must be inclusive of all genders and sexual orientations and it is important that affirming gender and sexuality inclusive language and pronouns are used when describing different subgroups of GSMY ( Arbeit et al., 2016 ; Gowen & Winges-Yanez, 2014 ; Haley et al., 2019 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Pingel et al., 2013 ; Rasberry et al., 2017 ; Roberts et al., 2019 ; Steinke et al., 2017 ). It is important that the education provided be medically accurate and cover different types of sex acts, not just penile-vaginal intercourse, include information on the type of protection needed to have safe sex based on the sexual act being performed, and local resources where it can be obtained ( Arbeit et al., 2016 ; Bodnar & Tornello, 2019 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Pingel et al., 2013 ; Roberts et al., 2019 ). Education should also include information on medical and non-medical gender-affirming interventions, information on relationships, consent, and reputable resources for healthcare and sexual health information ( Gowen & Winges-Yanez, 2014 ; Haley et al., 2019 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Pingel et al., 2013 ; Roberts et al., 2019 ). There was a reported need for inclusion of historical gender and sexual minority individuals in the core curriculum. This would allow GSMY to have role models and would allow others could see gender and sexual minority individuals in a different light ( Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Pingel et al., 2013 ).

This paper reviewed how sexual health education has been presented in schools over the past ten years. All studies reported participants receiving some form of sexual health education in school. However, the education presented was almost exclusively heteronormative and exclusive to GSMY needs leaving them feeling left out and lacking the information they needed to better understand themselves and make informed sexual health decisions ( Bodnar & Tornello, 2019 ; Gowen & Winges-Yanez, 2014 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Rasberry et al., 2017 ).

School administrators need to be aware of the specific sexual health needs of GSMY and tailor education to meet the needs of all the students, not only cisgender, heterosexual students. Providing comprehensive GSMY-inclusive education improves the physical and mental health outcomes of all youth and decreases bullying of GSMY in school ( Hobaica et al., 2019 , 2019 ; Human Rights Campaign, 2015 ; Proulx et al., 2019 ; Roberts et al., 2019 ). GSMY-inclusive education has been shown to decrease negative mental health outcomes and bullying by normalize the LGBT experience ( Gowen & Winges-Yanez, 2014 ; Proulx et al., 2019 ; Roberts et al., 2019 ) and potentially decrease pregnancy and STI rates, and increase the use of condoms and the age of sexual debut ( Haley et al., 2019 ; Hobaica et al., 2019 ; Pingel et al., 2013 ). If school administrators are unable to provide GSMY-inclusive sex education due to policy at the local or state level, it is important to offer vetted outside resources for students and to work with politicians to change these stigmatizing laws ( W. J. Hall et al., 2019 ; Human Rights Campaign, 2015 ; Steinke et al., 2017 ).

The needs of students should take precedent when creating sexual health education programs. Administration, faculty, and staff should be educated on the needs of GSMY. Curricula presented to students in schools must be evidence-based and facilitated by trained LGBT (lesbian, gay, bisexual, and transgender) affirming educators ( Gowen & Winges-Yanez, 2014 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Human Rights Campaign, 2015 ; Steinke et al., 2017 ).

Limitations

This review is not without limitations. The search databases used were health and medical and not educational in nature due to the author examining the physical and mental health aspects of sex education on GSMY. The number of articles included was small and more may have been included had educational databases been used. MeSH terms were not used in the search as they had a limiting effect on the results. Lastly, there is very little research on the long-term benefits of GSMY-inclusive sex education in the United States. One of the reasons for this is there is no consistent sex education offered to students, with instructional content often being based on state, local, mandate or teacher preference.

This review indicated that schools are still presenting sexual health education exclusive of gender and sexual minority needs. Sex education is a public health necessity, allowing individuals to make informed decisions concerning their sexual health and wellbeing, and GSMY are being overlooked, leading to poorer mental and physical health outcomes ( Gowen & Winges-Yanez, 2014 ; Haley et al., 2019 ; Hobaica et al., 2019 ; Hobaica & Kwon, 2017 ; Rasberry et al., 2017 ; Roberts et al., 2019 ). Sex education in schools needs to be medically accurate, affirming, and reflect all genders and sexual orientations to help reduce health disparities and increase the quality of life for GSMY. Future research should focus on strategies to implement comprehensive and GSMY-inclusive sex education in schools to evaluate its impact on the health and wellness of all youth.

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Encyclopedia of Evolutionary Psychological Science pp 7208–7213 Cite as

Sex Education in Schools

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Comprehensive sexuality education ; Holistic sexuality education ; Sex Ed ; Sexuality education

The process of gathering accurate information, developing attitudes and beliefs, and gaining skills on the biological, sociological, and psychological facets of sexuality in a formal academic setting.

Introduction

Sexuality education provides individuals with information about their bodies, identities, relationships, and health-promoting skills as they relate to sexuality. International health and human rights organizations assert that access to developmentally and culturally appropriate sexuality education is a basic human right (UNESCO 2018 ). Adolescents receive sex education from formal sources, like schools or clinics, and informal sources, like family members, friends, or digital resources. While these can all be important, affirming sources of information, formal sources are more likely to provide students with accurate and age-appropriate information (UNESCO 2018 )....

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Smarr, J., Rayne, K. (2021). Sex Education in Schools. In: Shackelford, T.K., Weekes-Shackelford, V.A. (eds) Encyclopedia of Evolutionary Psychological Science. Springer, Cham. https://doi.org/10.1007/978-3-319-19650-3_2455

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Introduction, purpose of the study, literature search and selection criteria, coding of the studies for exploration of moderators, decisions related to the computation of effect sizes.

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The effectiveness of school-based sex education programs in the promotion of abstinent behavior: a meta-analysis

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Mónica Silva, The effectiveness of school-based sex education programs in the promotion of abstinent behavior: a meta-analysis, Health Education Research , Volume 17, Issue 4, August 2002, Pages 471–481, https://doi.org/10.1093/her/17.4.471

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This review presents the findings from controlled school-based sex education interventions published in the last 15 years in the US. The effects of the interventions in promoting abstinent behavior reported in 12 controlled studies were included in the meta-analysis. The results of the analysis indicated a very small overall effect of the interventions in abstinent behavior. Moderator analysis could only be pursued partially because of limited information in primary research studies. Parental participation in the program, age of the participants, virgin-status of the sample, grade level, percentage of females, scope of the implementation and year of publication of the study were associated with variations in effect sizes for abstinent behavior in univariate tests. However, only parental participation and percentage of females were significant in the weighted least-squares regression analysis. The richness of a meta-analytic approach appears limited by the quality of the primary research. Unfortunately, most of the research does not employ designs to provide conclusive evidence of program effects. Suggestions to address this limitation are provided.

Sexually active teenagers are a matter of serious concern. In the past decades many school-based programs have been designed for the sole purpose of delaying the initiation of sexual activity. There seems to be a growing consensus that schools can play an important role in providing youth with a knowledge base which may allow them to make informed decisions and help them shape a healthy lifestyle ( St Leger, 1999 ). The school is the only institution in regular contact with a sizable proportion of the teenage population ( Zabin and Hirsch, 1988 ), with virtually all youth attending it before they initiate sexual risk-taking behavior ( Kirby and Coyle, 1997 ).

Programs that promote abstinence have become particularly popular with school systems in the US ( Gilbert and Sawyer, 1994 ) and even with the federal government ( Sexual abstinence program has a $250 million price tag, 1997 ). These are referred to in the literature as abstinence-only or value-based programs ( Repucci and Herman, 1991 ). Other programs—designated in the literature as safer-sex, comprehensive, secular or abstinence-plus programs—additionally espouse the goal of increasing usage of effective contraception. Although abstinence-only and safer-sex programs differ in their underlying values and assumptions regarding the aims of sex education, both types of programs strive to foster decision-making and problem-solving skills in the belief that through adequate instruction adolescents will be better equipped to act responsibly in the heat of the moment ( Repucci and Herman, 1991 ). Nowadays most safer-sex programs encourage abstinence as a healthy lifestyle and many abstinence only programs have evolved into `abstinence-oriented' curricula that also include some information on contraception. For most programs currently implemented in the US, a delay in the initiation of sexual activity constitutes a positive and desirable outcome, since the likelihood of responsible sexual behavior increases with age ( Howard and Mitchell, 1993 ).

Even though abstinence is a valued outcome of school-based sex education programs, the effectiveness of such interventions in promoting abstinent behavior is still far from settled. Most of the articles published on the effectiveness of sex education programs follow the literary format of traditional narrative reviews ( Quinn, 1986 ; Kirby, 1989 , 1992 ; Visser and van Bilsen, 1994 ; Jacobs and Wolf, 1995 ; Kirby and Coyle, 1997 ). Two exceptions are the quantitative overviews by Frost and Forrest ( Frost and Forrest, 1995 ) and Franklin et al . ( Franklin et al ., 1997 ).

In the first review ( Frost and Forrest, 1995 ), the authors selected only five rigorously evaluated sex education programs and estimated their impact on delaying sexual initiation. They used non-standardized measures of effect sizes, calculated descriptive statistics to represent the overall effect of these programs and concluded that those selected programs delayed the initiation of sexual activity. In the second review, Franklin et al . conducted a meta-analysis of the published research of community-based and school-based adolescent pregnancy prevention programs and contrary to the conclusions forwarded by Frost and Forrest, these authors reported a non-significant effect of the programs on sexual activity ( Franklin et al ., 1997 ).

The discrepancy between these two quantitative reviews may result from the decision by Franklin et al . to include weak designs, which do not allow for reasonable causal inferences. However, given that recent evidence indicates that weaker designs yield higher estimates of intervention effects ( Guyatt et al ., 2000 ), the inclusion of weak designs should have translated into higher effects for the Franklin et al . review and not smaller. Given the discrepant results forwarded in these two recent quantitative reviews, there is a need to clarify the extent of the impact of school-based sex education in abstinent behavior and explore the specific features of the interventions that are associated to variability in effect sizes.

The present study consisted of a meta-analytic review of the research literature on the effectiveness of school-based sex education programs in the promotion of abstinent behavior implemented in the past 15 years in the US in the wake of the AIDS epidemic. The goals were to: (1) synthesize the effects of controlled school-based sex education interventions on abstinent behavior, (2) examine the variability in effects among studies and (3) explain the variability in effects between studies in terms of selected moderator variables.

The first step was to locate as many studies conducted in the US as possible that dealt with the evaluation of sex education programs and which measured abstinent behavior subsequent to an intervention.

The primary sources for locating studies were four reference database systems: ERIC, PsychLIT, MEDLINE and the Social Science Citation Index. Branching from the bibliographies and reference lists in articles located through the original search provided another source for locating studies.

The process for the selection of studies was guided by four criteria, some of which have been employed by other authors as a way to orient and confine the search to the relevant literature ( Kirby et al ., 1994 ). The criteria to define eligibility of studies were the following.

Interventions had to be geared to normal adolescent populations attending public or private schools in the US and report on some measure of abstinent behavior: delay in the onset of intercourse, reduction in the frequency of intercourse or reduction in the number of sexual partners. Studies that reported on interventions designed for cognitively handicapped, delinquent, school dropouts, emotionally disturbed or institutionalized adolescents were excluded from the present review since they address a different population with different needs and characteristics. Community interventions which recruited participants from clinical or out-of-school populations were also eliminated for the same reasons.

Studies had to be either experimental or quasi-experimental in nature, excluding three designs that do not permit strong tests of causal hypothesis: the one group post-test-only design, the post-test-only design with non-equivalent groups and the one group pre-test–post-test design ( Cook and Campbell, 1979 ). The presence of an independent and comparable `no intervention' control group—in demographic variables and measures of sexual activity in the baseline—was required for a study to be included in this review.

Studies had to be published between January 1985 and July 2000. A time period restriction was imposed because of cultural changes that occur in society—such as the AIDS epidemic—which might significantly impact the adolescent cohort and alter patterns of behavior and consequently the effects of sex education interventions.

Five pairs of publications were detected which may have used the same database (or two databases which were likely to contain non-independent cases) ( Levy et al ., 1995 / Weeks et al ., 1995 ; Barth et al ., 1992 / Kirby et al ., 1991 /Christoper and Roosa, 1990/ Roosa and Christopher, 1990 and Jorgensen, 1991 / Jorgensen et al ., 1993 ). Only one effect size from each pair of articles was included to avoid the possibility of data dependence.

The exploration of study characteristics or features that may be related to variations in the magnitude of effect sizes across studies is referred to as moderator analysis. A moderator variable is one that informs about the circumstances under which the magnitude of effect sizes vary ( Miller and Pollock, 1994 ). The information retrieved from the articles for its potential inclusion as moderators in the data analysis was categorized in two domains: demographic characteristics of the participants in the sex education interventions and characteristics of the program.

Demographic characteristics included the following variables: the percentages of females, the percentage of whites, the virginity status of participants, mean (or median) age and a categorization of the predominant socioeconomic status of participating subjects (low or middle class) as reported by the authors of the primary study.

In terms of the characteristics of the programs, the features coded were: the type of program (whether the intervention was comprehensive/safer-sex or abstinence-oriented), the type of monitor who delivered the intervention (teacher/adult monitor or peer), the length of the program in hours, the scope of the implementation (large-scale versus small-scale trial), the time elapsed between the intervention and the post-intervention outcome measure (expressed as number of days), and whether parental participation (beyond consent) was a component of the intervention.

The type of sex education intervention was defined as abstinence-oriented if the explicit aim was to encourage abstinence as the primary method of protection against sexually transmitted diseases and pregnancy, either totally excluding units on contraceptive methods or, if including contraception, portraying it as a less effective method than abstinence. An intervention was defined as comprehensive or safer-sex if it included a strong component on the benefits of use of contraceptives as a legitimate alternative method to abstinence for avoiding pregnancy and sexually transmitted diseases.

A study was considered to be a large-scale trial if the intervention group consisted of more than 500 students.

Finally, year of publication was also analyzed to assess whether changes in the effectiveness of programs across time had occurred.

The decision to record information on all the above-mentioned variables for their potential role as moderators of effect sizes was based in part on theoretical considerations and in part on the empirical evidence of the relevance of such variables in explaining the effectiveness of educational interventions. A limitation to the coding of these and of other potentially relevant and interesting moderator variables was the scantiness of information provided by the authors of primary research. Not all studies described the features of interest for this meta-analysis. For parental participation, no missing values were present because a decision was made to code all interventions which did not specifically report that parents had participated—either through parent–youth sessions or homework assignments—as non-participation. However, for the rest of the variables, no similar assumptions seemed appropriate, and therefore if no pertinent data were reported for a given variable, it was coded as missing (see Table I ).

Once the pool of studies which met the inclusion criteria was located, studies were examined in an attempt to retrieve the size of the effect associated with each intervention. Since most of the studies did not report any effect size, it had to be estimated based on the significance level and inferential statistics with formulae provided by Rosenthal ( Rosenthal, 1991 ) and Holmes ( Holmes; 1984 ). When provided, the exact value for the test statistic or the exact probability was used in the calculation of the effect size.

Alternative methods to deal with non-independent effect sizes were not employed since these are more complex and require estimates of the covariance structure among the correlated effect sizes. According to Matt and Cook such estimates may be difficult—if not impossible—to obtain due to missing information in primary studies ( Matt and Cook, 1994 ).

Analyses of the effect sizes were conducted utilizing the D-STAT software ( Johnson, 1989 ). The sample sizes used for the overall effect size analysis corresponded to the actual number used to estimate the effects of interest, which was often less than the total sample of the study. Occasionally the actual sample sizes were not provided by the authors of primary research, but could be estimated from the degrees of freedom reported for the statistical tests.

The effect sizes were calculated from means and pooled standard deviations, t -tests, χ 2 , significance levels or from proportions, depending on the nature of the information reported by the authors of primary research. As recommended by Rosenthal, if results were reported simply as being `non-significant' a conservative estimate of the effect size was included, assuming P = 0.50, which corresponds to an effect size of zero ( Rosenthal, 1991 ). The overall measure of effect size reported was the corrected d statistic ( Hedges and Olkin, 1985 ). These authors recommend this measure since it does not overestimate the population effect size, especially in the case when sample sizes are small.

The homogeneity of effect sizes was examined to determine whether the studies shared a common effect size. Testing for homogeneity required the calculation of a homogeneity statistic, Q . If all studies share the same population effect size, Q follows an asymptotic χ 2 distribution with k – 1 degrees of freedom, where k is the number of effect sizes. For the purposes of this review the probability level chosen for significance testing was 0.10, due to the fact that the relatively small number of effect sizes available for the analysis limits the power to detect actual departures from homogeneity. Rejection of the hypothesis of homogeneity signals that the group of effect sizes is more variable than one would expect based on sampling variation and that one or more moderator variables may be present ( Hall et al ., 1994 ).

To examine the relationship between the study characteristics included as potential moderators and the magnitude of effect sizes, both categorical and continuous univariate tests were run. Categorical tests assess differences in effect sizes between subgroups established by dividing studies into classes based on study characteristics. Hedges and Olkin presented an extension of the Q statistic to test for homogeneity of effect sizes between classes ( Q B ) and within classes ( Q W ) ( Hedges and Olkin, 1985 ). The relationship between the effect sizes and continuous predictors was assessed using a procedure described by Rosenthal and Rubin which tests for linearity between effect sizes and predictors ( Rosenthal and Rubin, 1982 ).

Q E provides the test for model specification, when the number of studies is larger than the number of predictors. Under those conditions, Q E follows an approximate χ 2 distribution with k – p – 1 degrees of freedom, where k is the number of effect sizes and p is the number of regressors ( Hedges and Olkin, 1985 ).

The search for school-based sex education interventions resulted in 12 research studies that complied with the criteria to be included in the review and for which effect sizes could be estimated.

The overall effect size ( d +) estimated from these studies was 0.05 and the 95% confidence interval about the mean included a lower bound of 0.01 to a high bound of 0.09, indicating a very minimal overall effect size. Table II presents the effect size of each study ( d i ) along with its 95% confidence interval and the overall estimate of the effect size. Homogeneity testing indicated the presence of variability among effect sizes ( Q (11) = 35.56; P = 0.000).

An assessment of interaction effects among significant moderators could not be explored since it would have required partitioning of the studies according to a first variable and testing of the second within the partitioned categories. The limited number of effect sizes precluded such analysis.

Parental participation appeared to moderate the effects of sex education on abstinence as indicated by the significant Q test between groups ( Q B(1) = 5.06; P = 0.025), as shown in Table III . Although small in magnitude ( d = 0.24), the point estimate for the mean weighted effect size associated with programs with parental participation appears substantially larger than the mean associated with those where parents did not participate ( d = 0.04). The confidence interval for parent participation does not include zero, thus indicating a small but positive effect. Controlling for parental participation appears to translate into homogeneous classes of effect sizes for programs that include parents, but not for those where parents did not participate ( Q W(9) = 28.94; P = 0.001) meaning that the effect sizes were not homogeneous within this class.

Virginity status of the sample was also a significant predictor of the variability among effect sizes ( Q B(1) = 3.47 ; P = 0.06). The average effect size calculated for virgins-only was larger than the one calculated for virgins and non-virgins ( d = 0.09 and d = 0.01, respectively). Controlling for virginity status translated into homogeneous classes for virgins and non-virgins although not for the virgins-only class ( Q W(5) = 27.09; P = 0.000).

The scope of the implementation also appeared to moderate the effects of the interventions on abstinent behavior. The average effect size calculated for small-scale intervention was significantly higher than that for large-scale interventions ( d = 0.26 and d = 0.01, respectively). The effects corresponding to the large-scale category were homogeneous but this was not the case for the small-scale class, where heterogeneity was detected ( Q W(4) = 14.71; P = 0.01)

For all three significant categorical predictors, deletion of one outlier ( Howard and McCabe, 1990 ) resulted in homogeneity among the effect sizes within classes.

Univariate tests of continuous predictors showed significant results in the case of percentage of females in the sample ( z = 2.11; P = 0.04), age of participants ( z = –1.67; P = 0.09), grade ( z = –1.80; P = 0.07) and year of publication ( z = –2.76; P = 0.006).

All significant predictors in the univariate analysis—with the exception of grade which had a very high correlation with age ( r = 0.97; P = 0.000)—were entered into a weighted least-squares regression analysis. In general, the remaining set of predictors had a moderate degree of intercorrelation, although none of the coefficients were statistically significant.

In the weighted least-squares regression analysis, only parental participation and the percentage of females in the study were significant. The two-predictor model explained 28% of the variance in effect sizes. The test of model specification yielded a significant Q E statistic suggesting that the two-predictor model cannot be regarded as correctly specified (see Table IV ).

This review synthesized the findings from controlled sex education interventions reporting on abstinent behavior. The overall mean effect size for abstinent behavior was very small, close to zero. No significant effect was associated to the type of intervention: whether the program was abstinence-oriented or comprehensive—the source of a major controversy in sex education—was not found to be associated to abstinent behavior. Only two moderators—parental participation and percentage of females—appeared to be significant in both univariate tests and the multivariable model.

Although parental participation in interventions appeared to be associated with higher effect sizes in abstinent behavior, the link should be explored further since it is based on a very small number of studies. To date, too few studies have reported success in involving parents in sex education programs. Furthermore, the primary articles reported very limited information about the characteristics of the parents who took part in the programs. Parents who were willing to participate might differ in important demographic or lifestyle characteristics from those who did not participate. For instance, it is possible that the studies that reported success in achieving parental involvement may have been dealing with a larger percentage of intact families or with parents that espoused conservative sexual values. Therefore, at this point it is not possible to affirm that parental participation per se exerts a direct influence in the outcomes of sex education programs, although clearly this is a variable that merits further study.

Interventions appeared to be more effective when geared to groups composed of younger students, predominantly females and those who had not yet initiated sexual activity. The association between gender and effect sizes—which appeared significant both in the univariate and multivariable analyses—should be explored to understand why females seem to be more receptive to the abstinence messages of sex education interventions.

Smaller-scale interventions appeared to be more effective than large-scale programs. The larger effects associated to small-scale trials seems worth exploring. It may be the case that in large-scale studies it becomes harder to control for confounding variables that may have an adverse impact on the outcomes. For example, large-scale studies often require external agencies or contractors to deliver the program and the quality of the delivery of the contents may turn out to be less than optimal ( Cagampang et al ., 1997 ).

Interestingly there was a significant change in effect sizes across time, with effect sizes appearing to wane across the years. It is not likely that this represents a decline in the quality of sex education interventions. A possible explanation for this trend may be the expansion of mandatory sex education in the US which makes it increasingly difficult to find comparison groups that are relatively unexposed to sex education. Another possible line of explanation refers to changes in cultural mores regarding sexuality that may have occurred in the past decades—characterized by an increasing acceptance of premarital sexual intercourse, a proliferation of sexualized messages from the media and increasing opportunities for sexual contact in adolescence—which may be eroding the attainment of the goal of abstinence sought by educational interventions.

In terms of the design and implementation of sex education interventions, it is worth noting that the length of the programs was unrelated to the magnitude in effect sizes for the range of 4.5–30 h represented in these studies. Program length—which has been singled out as a potential explanation for the absence of significant behavioral effects in a large-scale evaluation of a sex education program ( Kirby et al ., 1997a )—does not appear to be consistently associated with abstinent behavior. The impact of lengthening currently existing programs should be evaluated in future studies.

As it has been stated, the exploration of moderator variables could be performed only partially due to lack of information on the primary research literature. This has been a problem too for other reviewers in the field ( Franklin et al ., 1997 ). The authors of primary research did not appear to control for nor report on the potentially confounding influence of numerous variables that have been indicated in the literature as influencing sexual decision making or being associated with the initiation of sexual activity in adolescence such as academic performance, career orientation, religious affiliation, romantic involvement, number of friends who are currently having sex, peer norms about sexual activity and drinking habits, among others ( Herold and Goodwin, 1981 ; Christopher and Cate, 1984 ; Billy and Udry, 1985 ; Roche, 1986 ; Coker et al ., 1994 ; Kinsman et al ., 1998 ; Holder et al ., 2000 ; Thomas et al ., 2000 ). Even though randomization should take care of differences in these and other potentially confounding variables, given that studies can rarely assign students to conditions and instead assign classrooms or schools to conditions, it is advisable that more information on baseline characteristics of the sample be utilized to establish and substantiate the equivalence between the intervention and control groups in relevant demographic and lifestyle characteristics.

In terms of the communication of research findings, the richness of a meta-analytic approach will always be limited by the quality of the primary research. Unfortunately, most of the research in the area of sex education do not employ experimental or quasi-experimental designs and thus fall short of providing conclusive evidence of program effects. The limitations in the quality of research in sex education have been highlighted by several authors in the past two decades ( Kirby and Baxter, 1981 ; Card and Reagan, 1989 ; Kirby, 1989 ; Peersman et al ., 1996 ). Due to these deficits in the quality of research—which resulted in a reduced number of studies that met the criteria for inclusion and the limitations that ensued for conducting a thorough analysis of moderators—the findings of the present synthesis have to be considered merely tentative. Substantial variability in effect sizes remained unexplained by the present synthesis, indicating the need to include more information on a variety of potential moderating conditions that might affect the outcomes of sex education interventions.

Finally, although it is rarely the case that a meta-analysis will constitute an endpoint or final step in the investigation of a research topic, by indicating the weaknesses as well as the strengths of the existing research a meta-analysis can be a helpful aid for channeling future primary research in a direction that might improve the quality of empirical evidence and expand the theoretical understanding in a given field ( Eagly and Wood, 1994 ). Research in sex education could be greatly improved if more efforts were directed to test interventions utilizing randomized controlled trials, measuring intervening variables and by a more careful and detailed reporting of the results. Unless efforts are made to improve on the quality of the research that is being conducted, decisions about future interventions will continue to be based on a common sense and intuitive approach as to `what might work' rather than on solid empirical evidence.

References marked with an asterisk indicate studies included in the meta-analysis.

Description of moderator variables

Effect sizes of studies

Tests of categorical moderators for abstinence

Weighted least-squares regression and test of model specification

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  • least-squares analysis
  • sex education

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School-based comprehensive sexuality education for prevention of adolescent pregnancy: a scoping review

  • Su Mon Myat 1 , 2 ,
  • Porjai Pattanittum 2 ,
  • Jen Sothornwit 3 ,
  • Chetta Ngamjarus 2 ,
  • Siwanon Rattanakanokchai 2 ,
  • Kyaw Lwin Show 2 , 4 ,
  • Nampet Jampathong 5 &
  • Pisake Lumbiganon 3  

BMC Women's Health volume  24 , Article number:  137 ( 2024 ) Cite this article

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Adolescent pregnancy is a global public health problem. Numerous approaches for Comprehensive Sexuality Education (CSE) delivery in schools have been implemented around the world. Previous reviews on CSE did not follow the International Technical Guidance on Sexuality Education (ITGSE) because CSE is very diverse in terms of population, interventions, settings and outcomes. We conducted this scoping review to identify and map the evidence of school-based CSE for prevention of adolescent pregnancy with emphasis on adolescents’ contraceptive use, unintended pregnancy and abortion.

We searched PubMed, CENTRAL, Scopus, ISI Web of Science, CINAHL, and WHO ICTRP to identify potential eligible studies from their inception to 4 th Nov 2023.We included randomized controlled trials (RCTs) and non-RCTs of CSE implemented in public or private schools for adolescents. CSE was defined as a multi-session intervention in school that covered topics including contraception, pregnancy, abortion, and HIV/STI. School-based interventions were the main intervention that may be either stand-alone or multicomponent. There was no limitation on study’s geographical area, but only English-language studies were considered. Two reviewers selected and extracted data independently, discussed for consensus or consulted the third reviewer if there were discrepancies for final conclusion. Data were presented using figures, map and table.

Out of 5897 records, 79 studies (101 reports) were included in this review. Most studies were conducted in the United States and other high-income countries in secondary or high schools with cluster RCTs. All studies included participatory methods. Almost all studies included Sexual and Reproductive Health which is the eighth concept of CSE. Very few studies reported the prespecified primary outcomes of contraceptive use during last sex, unintended pregnancy and abortion and hence this highlighted the gaps of available evidence for these outcomes. The number of concepts, components, duration and providers of CSE varied across the included studies. However, none of the interventions identified in this scoping review adhered to the ITGSE recommended approach.

Conclusions

Our scoping review shows gaps in school-based CSE implementation in terms of completeness of concepts, components, providers, duration and outcomes recommended by ITGSE.

Peer Review reports

Adolescent girls aged 15–19 years had an estimated 21 million pregnancies each year globally [ 1 ]. Half of these pregnancies were unintended and 55% of them ended in abortions [ 2 , 3 ]. Pregnancy complications and unsafe abortions were the leading cause of death among adolescent girls [ 3 ]. About 14 million adolescents were not using contraception despite not wanting to become pregnant [ 2 ]. Only about one-third of adolescent girls in low- and middle-income countries (LMICs) used modern contraceptives, which consist of oral hormonal pills, injectables, male or female condoms, vaginal barrier methods, intrauterine devices, implants, female and male sterilization and emergency contraception [ 4 ].

Comprehensive Sexuality Education (CSE) was found to be effective in preventing and reducing unintended pregnancies in various countries [ 5 ].CSE is “a curriculum-based process of teaching and learning about the cognitive, emotional, physical, and social aspects of sexuality”. This is according to the 2018 revised edition of International Technical Guidance on Sexuality Education (ITGSE) by United Nations Educational, Scientific and Cultural Organization (UNESCO). Currently, the 2018 ITGSE (second edition) is perhaps the most comprehensive international guidance available for CSE. For delivering effective CSE, it must be integrated into existing curriculum or stand-alone subject and included multiple, sequential sessions over years [ 6 ].

CSE is one of the key interventions in adolescent-specific essential sexual and reproductive health and rights (SRHR) [ 7 ] which is recommended in several World Health Organization (WHO) guidelines [ 8 , 9 , 10 , 11 , 12 ].In addition, CSE is also one of the evidence-based health interventions for adolescents’ health described in Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) [ 13 ].

CSE can have positive effect on sexual behavior such as increase use of condom and contraception [ 14 ]. In 2016, a review on the effectiveness and implementation of CSE worldwide by UNESCO reported that CSE increased knowledge and improved attitudes related to SRH and contributed to the outcomes of increased condom and contraception use [ 6 , 15 ]. Cochrane systematic reviews concluded that education alone was not effective and needed to be combined with contraceptive services [ 16 , 17 ]. It was proven that CSE together with the policy and youth-friendly health services could increase adolescent contraceptive use to prevent pregnancy [ 18 ]. Moreover, the effect of CSE would be magnified if the laws, gender, poverty and social norms are addressed at a different level [ 7 , 19 ].

Globally, 1.3 billion adolescents represent 16% of the global population [ 20 ] and 14% of all unsafe abortions in LMICs took place in adolescent girls [ 12 ]. In recent time, the unprecedented event of the US Supreme Court’s decision to overturn safe abortion services and comprehensive SRHR may have a huge impact and negative ripple effect on SRHR information and services in LMICs [ 21 ]. Some countries such as South Africa and Spain have access to legal abortion on request but such countries as in UK, Nigeria, Tanzania or Zambia, legal condition for abortion is to save the women lives and to protect her physical or mental health [ 22 ]. With the possibility of disrupted support and services, the need to access CSE for the current and future generations of adolescents is more pressing than ever [ 23 ].

Numerous approaches for CSE delivery in schools have been implemented around the world. Schools are the cost-effective and equitable platform for education and health sectors to work together to deliver essential adolescent SRHR interventions [ 7 , 24 ]. Regarding the intervention, reviews prior to 2018 did not consider the recommended interventions according to ITGSE [ 16 , 17 , 25 , 26 ]. CSE is very diverse in terms of population, interventions, settings and outcomes, we therefore conducted this scoping review to identify and map evidence on school-based CSE interventions to prevent adolescent pregnancy with emphasis on contraceptive use, unintended pregnancy, and abortion to improve adolescent SRHR and knowledge gaps in the contents and contexts of school-based CSE.

The protocol of this scoping review was registered at the Open Science Framework (Registration DOI: https://doi.org/10.17605/OSF.IO/7CYZK ). This scoping review is reported according to Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [ 27 ]. The PRISMA-ScR checklist can be accessed in Supplementary Table S 1 .

Criteria for considering studies for the review

This review included studies conducted in public or private schools. Other types of schools (e.g. alternative, vocational) were not included in this review due to their differing nature, objectives, curricula and teaching methods in comparison to public or private schools. Moreover, interventions implemented in a college or university setting were excluded from this review because the participants within those studies were older than the target age group of this review.

Types of studies

This review included randomized controlled trials (RCTs), cluster RCTs, quasi-RCTs, interrupted time series (ITS) and controlled before and after studies. There was no limitation of geographical area. We included studies published in the English language only.

Types of participants

The participants in this review were adolescents between the ages of 10 and 19 years defined by United Nations [ 28 ]. The majority of participants in this review were 19 years or younger but students older than 19 years from the same classes were also included because school-based interventions were conducted in classes of the same grade rather than targeted to a specific age group.

Types of interventions

This review focused on school-based CSE that aimed to prevent adolescent pregnancy. The educational interventions that were implemented within a context of a multisession curriculum, which took place in schools were included. Interventions that provided information on at least one of the following topics: pregnancy, abortion, contraceptives (available methods, effectiveness, and appropriate method use), and HIV/STI prevention (including condom use) were included. The intervention sessions were either didactic or participatory, with or without the use of technology and without any restrictions on the provider of the intervention. Additionally, the intervention may have been supplemented with parenting, services, or communication, and may have been presented in either print or digital format, or via interpersonal communication. The comparison group either received routine sexuality education or no intervention.

Types of outcome measures

Primary outcomes.

Studies that reported one of the following outcomes were included.

Contraceptive use during the last sex

Unintended Pregnancy

In order to measure the impact of interventions on contraceptive use, a minimum follow up of three months after the intervention was required. For pregnancy and abortion, the minimum time required to measure these outcomes was six months after the intervention. However, if the prespecified follow up was unavailable, the follow up period defined by the authors was utilized. In case where contraceptive use was assessed in various ways, the focus was on the contraceptive use during the last sex. If none of the prespecified outcomes were reported, the outcome(s) defined by the authors were included, e.g. sex without effective pregnancy prevention.

Secondary outcomes

Knowledge of contraception or contraceptive effectiveness

Awareness of contraceptive methods

Attitude toward contraception or a specific contraceptive method

The time frame for evaluating these secondary outcomes was determined by the definitions of the outcomes, as defined by the authors.

Search methods for identification of studies

Electronic searches.

We performed a systematic literature search from the existence of each database to 4th Nov 2023 using major electronic databases, including 1) PubMed, 2) the Cochrane Central Register of Controlled Trials (CENTRAL), 3) Scopus, 4) ISI Web of Science, and 5) Cumulative Index to Nursing and Allied Health Literature (CINAHL), to identify potential eligible studies. We also searched for potential eligible ongoing studies in the clinicaltrials.gov and WHO International Clinical Trials Registry Platform (WHO ICTRP). Full search strategies are presented in Supplementary Table S 2 .

Searching other sources

We checked the reference lists of relevant systematic reviews to identify potential eligible studies. Internet searches for the websites and organizations (e.g. Guttmacher Institute, CDC, WHO, UNFPA, UNESCO, etc.) were also done to identify articles for evidence-based sexuality education programs. In addition, we conducted Google scholar searches and screened the first 50 results to identify sexuality education programs and policies led by government bodies or other agencies and organizations relevant to adolescent health.

Study selection

All the titles and abstracts of studies obtained from the electronic database searches were checked and deduplicated in Mendeley software. Following the screening of titles and abstracts, the full texts of studies that met the eligibility criteria were reviewed using the Rayyan software. All the processes were done independently by two review authors (SMM, JS, and KLS). Any discrepancies were discussed and if necessary, consultation of a third person was sought (PL, PP, or CN). PRISMA flow diagram was used to illustrate a summary of the study selection process.

Data collection

The data extraction form using Microsoft Excel was tested with ten randomly selected studies independently (SMM and JS) and checked for consistency. Two review authors (SMM and KLS) extracted data from the included studies independently into the data extraction form. We extracted the following information: participants’ characteristics (e.g. age, gender, etc.), countries and settings (e.g. types of school, etc.), interventions (e.g. concepts, duration, providers, etc.), outcomes of interest (e.g. contraceptive use, unintended pregnancy, etc.), and study designs (e.g. RCTs, quasi-RCTs, etc.). Any differences between reviewers were solved through discussion or by asking the opinion from the third reviewer (PL, PP, or CN) if necessary. If additional information or clarification was required, we contacted the first and corresponding authors of the studies.

Synthesis of results

The extracted data were summarized using frequency and percentage for categorical variables. We presented the findings in figure, map and table. The findings were categorized and reported according to the following themes:

Study characteristics: country and setting, type of studies and participants

School-based CSE: components, mode of delivery, concepts, duration and provider

Outcomes reported in the included studies: primary outcomes included contraceptive use during the last sex, unintended pregnancy, abortion and secondary outcomes included knowledge of contraception or contraceptive effectiveness, awareness of contraceptive methods and attitude toward contraception or a specific contraceptive method

Results of the search

The screening process of the study is summarized in the PRISMA flow diagram (Fig.  1 ). The searches yielded 5828 records from major electronic databases and registers and 69 additional records from citation searches and Google scholar.

figure 1

PRISMA flow chart

Among records identified from electronic databases, after removing 887 duplicates, a total of 4941 records were screened. We excluded 4828 records after screening the titles and abstracts. We reviewed 112 of 113 full texts since one full text could not be identified. Authors of three studies were contacted for more information and two provided publications of the studies. Thirty-eight reports were excluded due to ineligible study design (8 reports), ineligible intervention (18 reports), ineligible setting (7 reports), ineligible population (2 reports), and non-English language (3 reports).

We were only able to download the full texts for 61 of the reports identified from other sources. Of these, 34 reports did not meet the inclusion criteria of this review: due to ineligible study design (19 reports), ineligible interventions (9 reports), ineligible settings (2 reports), and ineligible outcomes (4 reports). Subsequently, 84 studies (101 reports) were found to be eligible for inclusion in this scoping review, five of these studies are ongoing studies (Supplementary Table S 3 ). Therefore, a total of 79 studies were included in this review (Supplementary Table S 4 ) and the characteristics of these included studies are described in Supplementary Table S 5 .

Description of included studies

In this section, we have provided an overview of the key characteristics of the included studies, based on countries and settings as well as type of studies, participants, interventions and outcomes (Supplementary Table S 5 ).

Countries and settings

The majority of the included studies were conducted in the United States (30 studies, 40%), followed by South Africa (7 studies), United Kingdom (5 studies), Nigeria (4 studies), Tanzania (3 studies), Spain (3 studies), Zambia (3 studies) and Bahamas, Ethiopia, Indonesia, Ghana, Mexico, Uganda (2 studies each) (Supplementary Figure S 1 ). According to the 2022 World Bank classification [ 29 ], 43 studies (54.4%) were from high income countries (HICs), 13 from upper-middle income countries (UMICs), 16 from lower-middle income countries (LMICs), and seven from low income countries (LICs). Twenty-seven studies (3.2%) were conducted in high schools, another 27 studies (3.2%) in secondary/middle schools and seven studies (8.9%) in elementary/primary schools. However, 18 studies (22.8%) did not specify the type of schools. The number of schools involved in the included studies ranged from one to 157 schools.

Type of studies

The majority of the included studies were cluster RCTs (57 studies, 72.2%) followed by 20 quasi-RCTs (25.3%), and two RCTs (2.5%). ITS and before and after study could not be identified. The studies were published between 1986 and 2023. Thirty studies (38.0%) were published before 2010, 13 studies (16.3–5%) between 2010 and 2015, and 36 studies (45.6%) after 2015.

Participants

Participants in most included studies (77 studies, 97.5%) were adolescents between the age of 10 and 19 years. However, two studies also included older participants (10–24 years and 15–30 years) because although interventions were implemented for adolescents, they were followed up until 24 or 30 years of age. Sixty-eight studies included both genders while eight studies were exclusively targeted towards girls, and one study focused on boys only. Sample sizes across studies ranged from 125 to over 15,000 students.

Interventions

A wide variety of interventions were evaluated among the included studies. Twenty-eight studies (35.4%) were aimed at delaying sexual initiation, promoting safe sex behavior, preventing pregnancy, while 37 studies (46.8%) aimed at preventing HIV/STI and 14 studies (17.7%) targeted the prevention of both pregnancy and HIV. One intervention focused on emergency contraception, and some interventions were designed to be combined with other topics, such as drug abuse in three studies and alcohol in two studies. Among included studies which reported primary outcomes, only a few revealed culturally sensitive interventions indirectly but none of them had ever mentioned any aspect of religion. Twenty-nine studies used standard or existing sex education and 16 studies used health promotion as the control. The interventions with more than two arms were observed in 15 studies (18.9%).

All studies included participatory activities, such as discussion, group work and self-directed learning (e.g. demonstration and role play). Sixteen studies (20.3%) used films or videos, two studies used webisodes or online content, two used computer-based intervention, two used media and three used magazine or book for teaching aids. In sixteen studies (20.3%), the multi-component interventions involving education, school committee, community and services were reported. Interventions for parents were included in eleven studies (13.9%). Health services for students were integrated in eight studies (10.1%), while three interventions offered counseling. The community component was integrated in five studies and three studies used students’ clubs.

Figure  2 provides the CSE concepts categorized by the intervention providers. The first group comprises interventions delivered solely by teachers (27 studies, 34.1%), indicating the CSE concepts and the duration of the interventions. Other groups included interventions delivered by teachers in combination with peer or other facilitators, or delivered solely by peers. The last group (30 studies, 38.0%) includes interventions delivered by others such as facilitators, researchers, health educator, school health nurses, etc. Among the eight concepts of CSE, sexual and reproductive health (SRH) was included in almost all studies (77 studies, 97.5%), followed by skills for health and well-being (36 studies, 48.0%), the human body and development (21 studies, 28.0%), gender (14 studies, 18.7%), relationship (11 studies, 14.7%), values, rights and culture (eight studies, 10.7%), violence and staying safe (nine studies, 12.0%) and sexuality and sexual behavior (three studies, 4.0%) (Fig.  2 ).

figure 2

Concepts of School-based Comprehensive Sexuality Education (CSE) categorized by the intervention providers

The evidence map presented in Fig.  3 provides a summary of school-based CSE, covering the concepts, duration (number of sessions, time of each session and the distribution of sessions) and providers of the interventions. Regarding the number of concepts covered, 35 studies (44.3%) of the intervention covered only one concept, while 18 studies (22.8%) covered two concepts, eleven studies (13.9%) covered three concepts, nine studies (11.4%) covered four concepts, and three studies, (3.7%) each covered for six and seven concepts (Fig.  3 ).

figure 3

Summary of School-based Comprehensive Sexuality Education (CSE). Each square represents the number of included studies with duration of the intervention (rows) against number of CSE concepts (columns); additionally, the provider of the intervention is provided (color). The optional intervention is highlighted by the light orange rectangular on the right side

The interventions in the included studies varied in terms of session and duration of each session and distribution of these sessions throughout the school year and are provided in Fig.  3 . Thirty-three studies (41.8%) had interventions with 12 or more sessions, each lasting for 50 min and were conducted throughout the school year which is recommended by ITGSE. Of these 33 studies, 15 studies provided only one CSE concept. Twenty-four studies (30.4%) had interventions with less than 12 sessions, each lasting 50 min, conducted only in some period of the school year (Fig.  3 ).

An optimal approach for delivering the eight concepts of CSE would involve teachers and other providers throughout the school year, with at least 12 sessions of 50 min each, to achieve the desired outcomes. This recommended approach is highlighted by the light orange rectangular on the right side of the Fig.  3 . However, none of the interventions identified in this scoping review adhered to this recommended approach (Fig.  3 ).

Seventy-seven out of 79 included studies provided our prespecified primary and secondary outcomes and other outcomes. The summary of primary and secondary outcomes reported in the included studies by study design was presented in Table  1 and other outcomes by study design in Table  2 .

Twenty-three studies (17 cluster-RCTs and six quasi-RCTs) evaluated contraceptive use during the last sex. Seventeen studies implemented CSE alone, among these, four studies found that CSE was effective in increasing contraceptive use during the last sex. Among six studies which implemented CSE combined with other interventions (parent or community or services), three studies found that CSE was effective in increasing contraceptive use during the last sex. Three cluster RCTs reported unintended pregnancy. All showed a reduction in unintended pregnancy, two studies implemented CSE alone and the remaining one had CSE combined with services. Three cluster RCTs examined abortion. Two studies implemented CSE alone, and another one study combined CSE with access to services. None of these cluster RCTs showed significant impact of CSE on abortion (Table  1 ).

Knowledge of contraception or contraceptive effectiveness was reported in 25 studies including one RCT, 20 cluster RCTs and four quasi-RCTs, awareness of contraceptive methods was reported in one cluster RCT and attitude towards contraception or a specific contraceptive method was reported in nine studies (two cluster RCTs and seven quasi-RCTs) (Table  1 ).

Other outcomes

The other non-prespecified outcomes reported in the included studies were contraceptive uptake (four items) and pregnancy (four items). Please see details in Table  2 .

This scoping review presents a summary of the available evidence regarding school-based CSE and its effect on contraceptive use, unintended pregnancy and abortion among adolescents for prevention of adolescent pregnancy. This review shows gaps in school-based CSE implementation in terms of completeness of concepts, components, providers, duration and outcomes recommended by ITGSE.

CSE is a key for sustainable development, crucial in improving health, a pillar in delivering education of good quality and contributes to gender equality [ 30 ]. However, more than half of the studies included in this review were conducted in High-Income Countries (HICs), with two-fifth of the studies being conducted in the United States. CSE studies were concentrated in the US because more resources are available for conducting research, including funding, experienced researchers and access to advanced technologies and research infrastructure. Moreover, the US has a policy focusing on adolescent pregnancy prevention and a large amount of funding are available for sexuality education research, a culture that places a high value on scientific research and evidence-based policy making. Researchers seek to understand how different populations are affected by different approaches to sexuality education because US is a large country with diverse communities and cultures [ 31 ].

About three-quarters of the included studies used cluster RCTs as their study design which were appropriate because of the feasibility, practicality, and avoidance of risk of contamination between intervention and control groups. However, the authors should use appropriate statistical methods at the sample size calculation and analysis to take account for clustering effect.

All included studies were school-based and focused on all adolescent students in general and no special consideration was given to their diverse sexual and gender identities.

Sexuality education would be more impactful when school-based program is complemented with adolescent friendly health services, parental engagement, and community involvement [ 6 , 32 , 33 ]. However, in this scoping review, only one fifth of studies used multicomponent interventions. This might be because of scarcity of resources to be multicomponent. Although school is the best platform for CSE intervention, it should be integrated with community and health services involvement. This is worth to be seriously considered in the future CSE studies.

None of the included studies covered all eight concepts of CSE per the ITGSE. Nearly half of the included studies covered only one concept. Almost all studies covered Sexual and Reproductive Health which is the eighth concept of CSE. The most common concept was “Sexual and Reproductive Health” followed by “Skill for Health and Well-being” and the least common was “Sexuality and Sexual Behavior”. Each of the eighth concept of CSE covers two to five topics, each topic has key ideas and learning objectives to improve knowledge, attitude, and skills [ 6 ]. However, we could not get detail information about the topics and the key ideas for each concept stated in ITGSE. In addition, the modification and adaptation of CSE with regards to religious and cultural context is key for effective CSE but many had failed to indicate these social contexts in the intervention.

The delivery of sexuality education is very important to be able to develop the skills of adolescents needed to support healthy choices. Planning and implementing CSE is complex [ 33 ]. The participatory teaching methods and self-directed learning ensures adolescents to actively involve and help them internalize and integrate information [ 6 , 32 ]. Almost all interventions in this review described participatory activities. The role of digital media as a delivery mechanism should be considered in the age of technology and the innovative, creative approaches by adolescents for adolescents will magnify the effect of sexuality education. Only some studies in this review incorporated webisodes or online, computer and media.

The teachers were the providers for CSE in one third of the included studies. However, for CSE, capable and motivated educators are essential [ 6 ]and there should be more investment in teacher education and support [ 33 ]. We need to consider the teachers training (preservice and in service) with accessible resources and support to deliver the best quality sexuality education in schools.

The included studies reported a heterogeneous range of outcomes which hinder reliable comparison between studies. Besides, very few studies reported the prespecified primary outcomes of contraceptive use during last sex, unintended pregnancy, and abortion and hence this highlighted the gaps of available evidence for these outcomes. Therefore, the standard outcomes are needed for measuring and comparing the CSE interventions. Two-fifths of the studies who reported primary outcomes were effective and among them, two-fifths of the studies implemented multicomponent CSE.

In conclusion, duration, concepts, teaching methods and providers varied across studies. Though, some degree of school-based CSE effectiveness on contraceptive use during the last sex and unintended pregnancy was reported, none of the included study implemented the recommended CSE approach showing the prominent gaps of the school-based CSE implementation.

Strengths and limitations

To the best of our knowledge, this is the first scoping review to identify and map the available evidence of school based CSE for prevention of adolescent pregnancy with ITGSE globally. The review included all interventions related to promoting safe sex behavior, preventing pregnancy and HIV/STI and was not restricted by publication year. The screening and data extraction were done independently by two review authors. The review team met regularly and discussed how to resolve queries and concerns and ensured every step in a systematic way. However, there are some limitations. Due to limited time and resources, only publications in English were included. Furthermore, only the references list of systematic reviews but not all included studies were searched.

Implications for future practice and research

We recommend a further systematic review to evaluate the effectiveness of school-based CSE. However, the heterogeneity of outcome measures across studies might be a challenge to performing a meta-analysis. To address this, it is important to establish standardized key outcome set, also known as CORE outcome set, for evaluating the effectiveness of school-based CSE interventions.

Our review highlights the need for well-defined school-based multicomponent programs that cover all ITGSE concepts and have an appropriate duration provided by teachers, particularly in LMICs. The study design should be cluster rather than individual RCTs using CORE outcome set.

This scoping review provides the overview of the currently available evidence on school-based CSE aimed to prevent adolescent pregnancy. This review shows gaps in school-based CSE implementation in terms of completeness of concepts, components, providers, duration and outcomes recommended by ITGSE.

Availability of data and materials

All data generated or analyzed during this study are included in this published article or the supplementary files.

Abbreviations

Centers for Disease Control and Prevention

Cochrane Central Register of Controlled Trials

Cumulative Index to Nursing and Allied Health Literature

Cluster Randomized Controlled Trials

Comprehensive Sexuality Education

High Income Countries

Human Immunodeficiency Virus

International Technical Guidance on Sexuality Education

Interrupted Time Series

Low Income Countries

Low- and Middle-Income Countries

Medical Male Circumcision

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews

Quasi-Randomized Controlled Trials

Randomized Controlled Trials

Sustainable Development Goals

Sexual and Reproductive Health

Sexual and Reproductive Health and Rights

Sexually Transmitted Infections

Upper-Middle Income Countries

United Nations Educational, Scientific and Cultural Organization

United Nations Population Fund

United States

Virtual Infant Parenting

World Health Organization

WHO International Clinical Trials Registry Platform

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Acknowledgements

I, Su Mon Myat, would like to express my sincere gratitude to the Cochrane Thailand for the technical support throughout this review.

Su Mon Myat received funding from the HRP Alliance, part of the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO), to complete her studies. This article represents the views of the named authors only and does not represent the views of the World Health Organization.

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Department of Public Health, School Health Division, Ministry of Health, Naypyidaw, Myanmar

Su Mon Myat

Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand

Su Mon Myat, Porjai Pattanittum, Chetta Ngamjarus, Siwanon Rattanakanokchai & Kyaw Lwin Show

Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

Jen Sothornwit & Pisake Lumbiganon

Department of Medical Research, Ministry of Health, Naypyidaw, Myanmar

Kyaw Lwin Show

Cochrane Thailand, Khon Kaen University, Khon Kaen, Thailand

Nampet Jampathong

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This study was conceptualized by SMM, PL, PP and JS and the protocol was developed by SMM, PL, PP and JS. In addition, SR and SMM prepared the search strategies and performed the searches. SMM, JS and KLS conducted title and abstract screening and full text screening. SMM and KLS conducted data extraction. SMM, PL, PP, CN, SR and NJ contributed to data analysis. SMM drafted the manuscript and all authors reviewed and revised the manuscript critically. All authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work.

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Correspondence to Porjai Pattanittum .

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Myat, S.M., Pattanittum, P., Sothornwit, J. et al. School-based comprehensive sexuality education for prevention of adolescent pregnancy: a scoping review. BMC Women's Health 24 , 137 (2024). https://doi.org/10.1186/s12905-024-02963-x

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Favor sex education in public schools.

Debates over sex education in schools often pit abstinence instruction against providing students information on birth control methods, but the public sees no conflict in pursuing both of these approaches — in an August 2005 Pew Forum survey, 78% favor allowing public schools to provide students with birth control information; nearly as many (76%) believe schools should teach teenagers to abstain from sex until marriage. Solid majorities in every major religious group say schools should be allowed to provide students with information on birth control methods. But a sizeable minority of white evangelical Protestants (30%) is opposed. White evangelicals also are among the most supportive of having public schools teach teenagers to abstain from sex until marriage. Seculars express the greatest reservations about schools promoting abstinence; 62% support that approach, while roughly a third (34%) are opposed. Read More

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February 18, 2024

U.S. States Tighten Restrictions On Sex Education In Classrooms

Eight states passed laws last year restricting sex education taught in classrooms, with the possibility of more states following this year.

In a shift that raises concerns about the breadth and scope of sex education in American schools, eight states passed laws last year restricting the content taught in classrooms, with the possibility of more states following suit this year, according to USA Today .

Florida led the charge by expanding its controversial “Don’t Say Gay” law, preventing discussions on sexual orientation and gender identity until the ninth grade. Arkansas, Idaho, Indiana, Iowa, Kentucky, Mississippi, and North Dakota followed right behind. The trend, documented by the Sexuality Information and Education Council of the United States, signifies an 800% increase in restrictive legislation from the previous year.

These laws primarily target LGBTQ+ content, prohibiting discussions on sexual orientation and gender identity in early elementary grades. Florida’s legislation goes further by restricting these conversations until the ninth grade, adding complexity to issues surrounding sexual orientation and gender identity. Policymakers argue that these measures protect parental rights, a sentiment echoed across states implementing similar laws.

The legislative trends have serious implications for children, especially LGBTQ+ youth . Research indicates that omitting LGBTQ+ content from sex education leaves these individuals ill-equipped to navigate relationships, setting the stage for potential mental health challenges as they mature. The new restrictions extend beyond LGBTQ+ topics, with some states limiting information about abortion.

The National Sex Education Standards, developed by groups including the Sexuality Information and Education Council, emphasize high-quality, inclusive, and age-appropriate sex education. The recent laws, however, contradict these standards. The standards advocate for teaching reproductive anatomy, puberty, and essential skills such as setting boundaries and accessing resources from trusted adults. They also stress the importance of inclusivity, covering sexual orientation and gender identity in age-appropriate ways.

Conservative groups argue that such content is inappropriate for public school classrooms, igniting a debate about the role of sex education in early childhood. Advocates stress the importance of teaching these topics from a young age, emphasizing safety, healthy relationships, and understanding concepts like bodily autonomy and consent.

A concerning trend is the increasing number of bills framed under the banner of parental rights, impacting sex education and book restrictions. Over 20 such bills were enacted across 14 states last year, reflecting a 73% increase from the previous year. According to the outlet, the push for parental rights often includes provisions restricting the use of preferred pronouns on campus and book bans, raising questions about the influence of ideological parental cohorts on school curricula.

While restrictions are on the rise, a countermovement aims to protect students’ rights to comprehensive sex education. Ten states passed laws last year that protect curriculum content related to dating, sexual violence, and healthy relationships. Additionally, some states are considering bills to increase youth access to contraception and family planning resources in the wake of the 2022 U.S. Supreme Court ruling overturning the constitutional right to an abortion.

RELATED CONTENT : Women of Power: Dr. Hilda Hutcherson Talks Healthy Sex and the Working Woman

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National divide on teaching race, LGBTQ issues in classrooms captured in new survey

The topics are facing increasing classroom restrictions in many states.

Schools nationwide have been at the center of the country's culture wars. Restrictions on education and programs relating to race, gender, and sexual orientation have been implemented in several states, while schools and libraries are facing increasing waves of book-banning attempts .

In a new survey , the Pew Research Center asked public K-12 teachers, teens, and the American public about the ongoing scrutiny placed on classroom curricula , mainly regarding race and LGBTQ identities.

Here's what teachers, teens and the American public said, according to the Pew survey.

PHOTO: A demonstrator props up a sign during a protest against critical race theory before a school board meeting for the Jefferson County Public Schools district in Louisville, Ky., July 27, 2021.

What teachers say

Pew found that 41% of teachers say these debates have had a negative impact on their ability to do their job. Only 4% say the debates have had a positive impact.

Most public K-12 teachers -- 60% -- say parents should not be able to opt their children out of learning about racism or racial inequality in school, even if the topics are taught in a way that conflicts with a parent's beliefs. A quarter of teachers surveyed say the opposite, Pew found.

Of the Americans surveyed by Pew, 34% of them said they believe parents should be able to opt their children out of learning about racism and racial inequality.

Most surveyed teachers, 64%, say students should learn that the legacy of slavery still affects the position of Black people in American society today.

Regarding slavery's legacy, 23% of teachers surveyed believe that students should learn that slavery is part of American history but no longer affects the position of Black people in American society. Only 8% say students shouldn't learn about this topic in school at all.

PHOTO: Great Oak High School students hold signs during a protest of the districts ban of critical race theory curriculum in Temecula, Calif., Dec. 16, 2022.

MORE: Permission slip controversy in Florida school highlights debate on race education

When it comes to sexual orientation or gender identity, about 33% of teachers say parents should not be able to opt their children out of learning about these topics. 48% say the opposite, Pew found. Of the Americans surveyed by Pew, 54% of them said they believe parents should be able to opt their children out of learning about sexual orientation and gender identity, while 34% said they should not be able to opt out.

Half of public school teachers say students shouldn't learn about whether a person's gender can be different from or is determined by their sex assigned at birth, according to the Pew survey. Among teachers, one-third believe students should learn that someone can be a boy or a girl even if that is different from the sex they were assigned at birth, Pew found. About 14% of teachers said they should learn that their gender is determined by their sex assigned at birth.

Pew found that a majority of teachers, 71%, say they don't have enough influence over what's taught in public schools in their area. A smaller majority of teachers, 58%, say their state government has too much influence, while 35% say it has about the right amount of influence, with the remainder saying state government doesn't have enough influence.

PHOTO: Great Oak High School students leave campus Dec. 16, 2022, in protest of the districts ban of critical race theory curriculum in Temecula, Calif.

MORE: Georgia educators sue school district over race, LGBTQ classroom restrictions

What teens say.

Students across the country have been vocal about the impact that restrictions on teaching and programs relating to race, gender, and sexual orientation restrictions have had on their education. Pew surveyed teens between the ages 13 to 17 who are not homeschooled to gauge their opinions.

Those teens who say topics concerning race and LGBTQ identities have come up in their classes, also say they are more comfortable than uncomfortable learning about racism and racial inequality.

Regarding racism or racial inequality, the Pew survey found Black teens are nearly twice as likely than white teens, 33% to 19%, to feel uncomfortable when the subjects come up in class, and about twice as likely than their Hispanic classmates, 33% to 17%.

MORE: School culture wars push students to form banned book clubs, anti-censorship groups

When teens were asked how they would prefer to learn in school about the legacy of slavery, Pew found that 48% overall say they'd rather learn that it still affects the position of Black people in American society today. Another 40% said they would rather learn that slavery is part of American history but no longer affects the position of Black people in American society today. Just 11% said slavery's legacy shouldn't be a subject in school at all.

Teens were also asked about being taught about gender identity in school. Pew found that 48% of teens surveyed say they should not learn about gender identity in school. Of those who feel otherwise, a quarter of teens say they would prefer to learn that someone can have a gender that does not align with the sex they were assigned at birth. A similar share, 26%, say they would prefer to learn that gender is determined by the that's sex assigned at birth.

On the subjects of sexual orientation or gender identity, Pew found that 29% of teens surveyed said they feel very or somewhat comfortable when the subjects come up in class, while 33% said they feel very or somewhat uncomfortable when the subjects arise. The majority, 37%, said they feel neither comfortable nor uncomfortable.

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USA TODAY

8 states restricted sex ed last year. More could join amid growing parents' rights activism

W hen Florida passed a 2022 bill prohibiting classroom discussions of sexual orientation and gender identity for children in kindergarten through third grade, it kicked off a trend.

Last year, eight states enacted laws restricting sex education, often targeting LGBTQ+-related discussions in early elementary grades and, in some cases, banning any form of sex education at those levels. Florida, meanwhile, went on to expand what critics call its "Don't Say Gay" law, making it illegal to teach kids about sexual orientation and gender identity until they're in ninth grade and restricting students' use of pronouns to those aligning with the sex they were assigned at birth.

In addition to the new laws targeting LGBTQ+ content, a few restricted information about abortion. Many were advanced by policymakers who argued that such restrictions were key to protecting parental rights.

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The new measures across the country represent an 800% jump in restrictive legislation from the year prior, according to the Sexuality Information and Education Council of the United States, an advocacy group that authored a new report documenting the legislative trends.

More states are poised to join this year with bills that find new ways to restrict what students learn about LGBTQ+ relationships. The policies, if enacted, could have serious implications for children. Research has shown that sex education that excludes such instruction can leave LGTBQ+ youth poorly equipped to safely navigate their relationships and sexual health and sets them up for potential mental health challenges as they grow older. 

Which states passed laws restricting sex education?

◾ Arkansas passed two laws limiting sex education, including a far-reaching omnibus measure that prohibits such learning before fifth grade. The second law requires educators to teach kids about adoption and why it’s better than other alternatives to continuing a pregnancy and giving birth, such as abortion. 

◾ Florida passed an expanded version of its “Don’t Say Gay” law implemented last year banning classroom discussion of sexual orientation and gender identity before third grade. The new law bans such conversations and lessons through eighth grade while also limiting them in grades nine to 12 if they aren't "age-appropriate." The law also bans using a student’s preferred pronouns if they’re different from a child’s sex assigned at birth.

◾ Idaho already had an abstinence-only policy, but last year it expanded the definition of sexual activities kids ought to abstain from to any intimate physical contact between individuals that could result in pregnancy, cause them to contract sexually transmitted diseases and infections, or present emotional risks. It also limits sex education content to studying the anatomy and physiology of human reproduction, which means, according to the Sexuality Information and Education Council, it effectively excludes non-heterosexual and nonmarital relationships whose end goal isn't reproduction.

◾ Indiana now prohibits sex education in kindergarten through third grade in a law that also, according to the council, includes a clause that pressures school employees to “out” trans students.

◾ Iowa passed a bill that prohibits teaching children in sixth grade and lower about sexual orientation or gender identity. Lawmakers also got rid of a policy requiring instruction about AIDS and human papillomavirus, or HPV. The new law also restricts access to “sexually explicit” books in libraries. 

◾ Kentucky enacted a law that bans sex education for students in kindergarten through fifth grade and prohibits the board of education from approving policies that would require teachers to use students’ desired pronouns. 

◾ Mississippi formerly had a policy requiring abstinence-only education that was set to expire . Last year, it passed a provision deleting the expiration date , which the council said means the abstinence-only is now codified in law.

◾ North Dakota added a sex education requirement mandating that schools show an ultrasound video and an animation depicting a human’s development from fertilization to birth. The council says this policy “seeks to stigmatize abortion and other pregnancy outcomes.”

'Set them up for failure': Sex education not required in many states where abortion is or will be banned

Advocates: Learning the basics of sex education early on is critical

The National Sex Education Standards , developed by a coalition of groups including the Sexuality Information and Education Council, offers essential criteria schools can use to ensure they are providing high-quality, inclusive and age-appropriate lessons on sex, identity and relationships. 

The council says policies such as those enacted last year in eight states run afoul of those standards. The standards say, for example, that elementary schoolers should learn the basics of reproductive anatomy and puberty, and skills like how to set personal boundaries and access resources from trusted adults. Schools should promote inclusivity and include some content on sexual orientation and gender identity in age-appropriate ways. 

Some conservative groups say such content is inappropriate and discussions about same-sex relationships or gender nonconformity have no place in public school classrooms.  

The council, however, stressed the importance of teaching this content, beginning at a young age. It’s in part a matter of safety, said Michelle Slaybaugh, a veteran sex educator who serves as director of social impact and strategic communications with the council. “Young people need the opportunity to practice the language, to practice being able to articulate their likes and their dislikes when people have crossed boundaries,” she said in a presentation on Tuesday. It teaches kids about healthy practices not only in romantic relationships but also in platonic friendships.

“It’s important for young people to understand … bodily autonomy and consent,” she said.

“When sex education in early childhood is prohibited, kids fail to develop the critical skills needed to have respect for themselves and their peers, which is a foundation for individual growth as well as being positive members of society.”

Comprehensive sex education: Americans are being misled. Here is what the model actually does.

‘Parental rights’ bills return, targeting sex education and books

Sex education bills and related legislation have increasingly been proposed under the mantle of parental rights. These bills are often far-reaching, comprising provisions that call for book restrictions and bans on students being allowed to use their preferred pronouns on campus. 

More than 20 such bills were enacted last year across 14 states. All in all, the 242 bills introduced last year marked a 73% increase from the year prior. 

Measures promoting parental rights were the most common of the bills pre-filed for the 2024 legislative sessions and analyzed by the council. 

The council said that having those opinions as parents is an important right but that one ideological cohort of parents shouldn't hinder schools' ability to provide basic education to students on health, safety and identity issues.

“It’s totally your right as an American citizen – you can absolutely take your child out of (a school) system and put them in a different type of education system,” said Alison Macklin, the policy and advocacy director at the council. “But those parents shouldn’t get to determine what my child learns or what your child learns. My right as a parent does not supersede any other parents’ rights.”

One trend the council anticipates will build momentum this year is parents wanting to control what content kids consume online through social media.

Protecting students' rights

Although there has been a notable uptick in restrictions, the council also documented a movement to protect students’ rights to sex education and related learning. Ten states last year passed laws that enshrine protections on this curriculum. They include laws that require teaching students about dating and sexual violence and healthy relationships.

Also in the aftermath of the 2022 U.S. Supreme Court ruling overturning the decision that made abortion legal nationwide, some states are considering bills that would increase youth access to contraception or other family planning resources.

This article originally appeared on USA TODAY: 8 states restricted sex ed last year. More could join amid growing parents' rights activism

Compared to 2019, Monroe County saw a 77% increase in gonorrhea cases in 2020, the highest rise by county in New York State.

research on sex education in schools

Texas got a sex education update two years ago. Advocates say there are still gaps

Emily Cabral, right, and Isabella Good look over a question during Sex Ed Trivia Night benefiting Wholly Informed Sex Ed on Thursday, Feb. 8, 2024, at Hello Dumpling in Dallas.

Two years ago, Texas students received updated health curriculum , including instruction on human sexuality, across all grade levels. It was the first time since the 1990s the Texas State Board of Education updated the learning goals for school districts.

But the new curriculum did not include information on consent, gender or sexuality. Lawmakers also made the instruction opt-in, meaning parents and caregivers have to sign a permission slip so students can receive this information.

According to the U.S. Centers for Disease Control and Prevention (CDC), Texas ranked in the top 20 states with high rates of chlamydia and gonorrhea in 2022. Texas is also in the top 10 states for teen birth , and had the second-highest rate of repeat teen births in the country in 2021

Advocates say one way to improve these outcomes would be prevention efforts, like sex education. But despite the update, they say things are worse than they were two years ago, and they’re concerned kids are missing crucial information.

“If we are able to provide this information in a preventative measure, we’re going to see better outcomes for all people,” said Alison Macklin, the director of policy and advocacy for national policy organization Sex Ed for Social Change (SEICUS).

Participants decide on answers during Sex Ed Trivia Night on Thursday, Feb. 8, 2024, at Hello Dumpling in Dallas. The event benefits Wholly Informed Sex Ed, a nonprofit that advocates for comprehensive, medically accurate sex education.

Sex education in Texas

Health education in Texas is required in elementary school and middle school, but sex education is not required in high school.

According to the Texas Education Agency (TEA) , elementary school students learn skills around five topic areas: physical health, mental health, and injury and violence prevention. Middle school and high school students learn about reproductive and sexual health, drug prevention and interpersonal violence.

The new curriculum standards implemented in 2022, called the Texas Essential Knowledge and Skills (TEKS) for Health Education, included information on puberty, contraceptives, sexually transmitted infections (STIs), and boundaries. These standards start in middle school and continue into high school.

Sex education in Texas is abstinence-first and does not have to be comprehensive or medically accurate. According to SEICUS, Texas “receives the highest amount of abstinence-only funding in the country” from federal programs through the U.S. Department of Health and Human Services .

“It’s very much about risk and risk avoidance,” said Sherri Cook, founder of Wholly Informed Sex Ed (WISE) , a Dallas-based organization providing whole-health sex education instruction. “It’s all about pushing away other people and not trusting. There’s very little in there about learning how to be a healthy person in relationship with other people.”

Sherri Cook with Wholly Informed Sex Ed reads out a question for Sex Ed Trivia Night on Thursday, Feb. 8, 2024, at Hello Dumpling in Dallas.

Decades of research show abstinence-only and abstinence-first programs have “little demonstrated efficacy in helping adolescents to delay intercourse,” often have “medical inaccuracies” and participate in the "unethical practice of withholding and distorting health information.”

Texas is also one of five states that has an opt-in policy for sex education, and the only state with an opt-in policy for abuse prevention education, which includes child abuse, dating violence and sex trafficking. The state previously had an opt-out policy, which allowed for parents and guardians to exempt their students from sex education.

But now, parents and guardians must sign a permission slip to allow students to participate, which advocates flagged as a barrier to access for vulnerable kids.

"The big concern with the opt-in policy is that some kids will just slip through the cracks,” Jen Biundo with Healthy Futures of Texas told KERA in 2022 . "Maybe they're not living with a parent or guardian, or maybe they don't have a parent or guardian who's closely engaged. Those might be the kids that need this information the most."

Teams of participants decide on answers during Sex Ed Trivia Night Thursday, Feb. 8, 2024, at Hello Dumpling in Dallas. The event benefits Wholly Informed Sex Ed, a nonprofit that advocates for comprehensive, medically accurate sex education.

Sex education as a health prevention tool

According to the American Academy of Pediatrics (AAP), comprehensive sex education helps “in reducing rates of sexual activity, sexual risk behaviors, STIs, and adolescent pregnancy and delaying sexual activity.”

Comprehensive sex education, said the AAP, includes evidence-based, medically accurate curriculum that provides information on human development, relationships, sexual behavior, sexual health and society and culture.

Raul Rojas, the director of community health education for Planned Parenthood of Greater Texas , said when sex education is taught in Texas, it’s “archaic.”

“It’s taught from a very heteronormative perspective of boys and girls engaging in risky behaviors, and not wanting the result of those behaviors to be a pregnancy,” he said. “It’s missing the piece that talks to you as an individual.”

That includes spaces for self-reflection, said Rojas, about people’s values, identities, and self-esteem.

“Sex education should be taught so you can be healthier, happier, and a better person to those around you,” he said, “not only your community, but your colleagues and your friends as you’re growing.”

A team of participants playfully heckles another team after they won a round at Sex Ed Trivia Night on Thursday, Feb. 8, 2024, at Hello Dumpling in Dallas. The event benefits Wholly Informed Sex Ed, a nonprofit that advocates for comprehensive, medically accurate sex education.

But Rojas said without resources and support, young people are finding information from less credible sources, like friends, TV, and pornography. He said he and other sex education instructors spend a lot of time busting myths and correcting misinformation.

“Whenever we teach an anatomy and physiology portion, what’s really funny is a lot of folks will [say], ‘Oh, I didn’t know I had that body part,’ or ‘I didn’t know that about my body,’” said Rojas. “We had one class with a bunch of grandmothers, and we had a question about menopause. We talked about perimenopause side effects. And a lot of women who were in their 60s and 70s were like, ‘Oh, I didn’t even know that.’”

Texas lawmakers have also sought to limit kids’ access to information that could be considered “sexually explicit” or “sexually relevant,” from book bans to laws that would prohibit schools from providing “instruction, guidance, activities or programming regarding sexual orientation or gender identity.”

While Rojas thinks “any sex education is better than no sex education,” he said these limitations have “increased a lot of people’s negative perceptions of what sex education is.”

“I think some of the loudest voices are also some of the most scared perspectives when it comes to sex education,” Rojas said. “That’s not the reality of young people or the adults in Texas.”

Sherri Cook with Wholly Informed Sex Ed welcomes participants to Sex Ed Trivia Night on Thursday, Feb. 8, 2024, at Hello Dumpling in Dallas.

Sex education outside of schools

Since sex education isn’t required in high school, and the state’s TEKS are limited in terms of instruction, some parents have looked for resources outside of school districts.

That’s what Sherri Cook did when she founded WISE in 2020 .

“People love to point out the statistics in Texas, which many people are aware of: high teen pregnancy rates, repeat teen pregnancy rates, high rate of STI transmission, all those things,” Cook said. “They rarely talk about positive sexual health because it seems like everyone just wants to strike fear into your heart about what could go wrong. And so, we thought this would be a very meaningful contribution to the health of the Dallas community.”

WISE uses the Whole Lives Curriculum , said Cook, which is a secular curriculum that originated in the Unitarian Universalist Church.

Cook said it helps define sex education as “how we understand our bodies, and our relationships with ourselves and others.” The curriculum helps students answer the question, “What does it mean to be a human being in a body, in relationship with other people with bodies?”

It includes information on gender, sexuality, and race, but also discusses media literacy, communication skills, and affirmative connection.

Cook understands the pressure and constraints teachers are under—she was a classroom educator for 13 years. She said it’s “too heavy a lift for schools” to provide sex education instruction on top of everything else.

Isabella Good, right, and Emily Cabral check participants in for Sex Ed Trivia Night Thursday, Feb. 8, 2024, at Hello Dumpling in Dallas. The event benefits Wholly Informed Sex Ed, a nonprofit that advocates for comprehensive, medically accurate sex education for youth.

“What we need is more sex educators,” Cook said. “But it is a difficult environment. People are not just jumping up into this space and saying, ‘Oh, I can't wait to teach sex ed in a state that doesn't want me to even be there.’ So that's hard.”

WISE has worked with community groups, summer programs and private schools to “meet students where they are,” but Cook said there’s been a “climate of fear we didn’t have in 2020.”

“A small part of the population in our state has basically hijacked the narrative around what constitutes healthy sexuality,” she said. “And in Texas, we're promoting ideology over health. And good sex ed is based in science and not politics.”

Inclusive, comprehensive instruction was important to Emily Cabral, who learned about WISE when her daughter Isabella was in middle school. Cabral was grateful there was a space that went more in-depth.

“Just teaching someone about condom use is not going to change hearts and minds,” Cabral said. “If you have an educational program that's focused on social skills, building self-awareness, building self-esteem…that is much more likely to result in behavior changes than just facts alone.”

Participants decide on answers during Sex Ed Trivia Night on Thursday, Feb. 8, 2024, at Hello Dumpling in Dallas. The event benefits Wholly Informed Sex Ed, a nonprofit that advocates for comprehensive, medically accurate sex education.

It’s helped her learn more about sex education topics, like gender identity, alongside her daughter.

“I didn't know as much about the vast array of different identities that we can inhabit,” Cabral said. “I just didn't even know all of the terminology that was available.”

Isabella, who’s now 14 and a freshman in high school, said most kids just want to know, “Is this OK? Is this normal? Is this healthy? Am I normal?”

She said she feels “more equipped to make smart choices” with what she’s learned from WISE, along with what her parents have taught her. But she also just wants to be a teenager along with the rest of her friends.

“What we talk about during lunch is our teachers that are irritating us, or the math homework that we didn’t do last night,” Isabella said. “We’re not talking about sex and pregnancy. We do think about those issues, but it’s not our main focus in life, unless it has to be.”

Amanda De Anda and Triniti Stone talk about putting on the health fair through the Community Health Worker certificate program Wednesday, Jan. 17, 2024, at Evolution Academy Charter School in Richardson.

Holistic health education as part of career training

Comprehensive health education is also helpful for students thinking of going into health professions, like Amanda De Anda, 17, and Triniti Stone, 16. They are both in the community health worker program at Evolution Academy Charter School in Richardson . Their cohort coordinated a community health fair last semester for students and adults.

The health fair included mental health and sexual health resources, like STI and HIV testing, in addition to blood pressure screenings and vaccinations.

“I think it is very good to learn about these resources, and just learn how to deal with these situations,” Stone said. “I think it’s very good for kids, especially our age, to learn more about their body and the mental side, why you should or should not be doing this right now, and why you should protect yourself and others.”

De Anda said the health fair was “only the beginning” of learning about how to connect people to support.

“When it comes to sex education, you want to know what to do to be protected,” she said.

Stone said learning more about health through the community health worker program has helped her “gain so much independence.”

“You can go and help people with the resources you obtained in this class,” Stone said. “And you can help the community. So, I think it definitely has given me just a lot more wisdom.”

Students with the Community Health Worker certificate program created posters for a health fair at Evolution Academy Charter School in Richardson.

Texas sex education policy recommendations

Alison Macklin, the director of policy and advocacy with SEICUS, said Texas is at a “D-” in terms of sex education in comparison to other states, mostly due to the “unnecessary barrier” of the opt-in policy.

“I have kids,” she said. “Half the time, I don’t know what’s coming home, I don’t get the permission slips, I don’t always see what’s in their backpack. That’s a barrier, and so putting up barriers, all you’re doing is setting up a young person to be unsuccessful, and that’s not the goal of public education.”

Macklin also believes that school districts and teachers need more resources to implement sex education curriculum.

“We’ve got to invest in preventative services,” she said. “Education is a really ‘easy’ preventative education. And the other piece of that is lawmakers have to fund public schools, not only when it comes to sex education, but across the board.”

WISE executive director Sherri Cook said she encourages parents to be the “primary sexuality educators of their children.”

“We’ve had parents who actually thought their kids would be afraid of what we were bringing,” she said. “Kids are not afraid. What they are is curious, and they need to have answers to their questions, honestly and accurately given.”

Participants laugh together during Sex Ed Trivia Night that benefits the nonprofit Wholly Informed Sex Ed on Thursday, Feb. 8, 2024, at Hello Dumpling in Dallas.

After Emily Cabral’s daughter went through WISE’s program, Cabral joined the organization to take a more active role in their work.

“A lot of questions we get are, ‘I really want to talk to my mom or I really want to talk to my dad about this, and I don’t know how to start the conversation,’” Cabral said. “I think parents are wanting that, too. But they’re not sure, they didn’t get sex ed when they were growing up. [It’s about] bridging that gap and helping people learn how to connect better in healthier ways.”

She hopes parents understand that sex education isn’t something that should be limited or dictated by people’s fears. Cabral said it’s ultimately about keeping kids safe now and as they grow up.

“I feel like the building’s on fire, and the firefighter is running to put out the flames” Cabral said. “And people are debating about what hose we're using. And it's like, we need to get water on this fire. Education is not the thing to be scared of, it's the lack of education that I think is really putting people in danger.”

But, she said, until Texas lawmakers prioritize comprehensive sex education, it’s up to her, and parents like her, to find ways to fill in the gaps for their kids.

Got a tip? Email Elena Rivera at  [email protected]

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research on sex education in schools

IMAGES

  1. (PDF) Research On Sex Education At Different Levels Of Education

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  2. (PDF) Sex education beyond school: Implications for practice and research

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  6. Shaping A Future: Pros and Cons of Sex Education in Schools

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COMMENTS

  1. Sex Education in the Spotlight: What Is Working? Systematic Review

    Results: 20 reviews met the inclusion criteria (10 in school settings, 9 using digital platforms and 1 blended learning program): they focused mainly on reducing risk behaviors (e.g., VIH/STIs and unwanted pregnancies), whilst obviating themes such as desire and pleasure, which were not included in outcome evaluations.

  2. Three Decades of Research: The Case for Comprehensive Sex Education

    Sexually Transmitted Diseases* Review of the literature of the past three decades provides strong support for comprehensive sex education across a range of topics and grade levels. Results provide evidence for the effectiveness of approaches that address a broad definition of sexual health and take positive, affirming, inclusive …

  3. Sex Education that Goes Beyond Sex

    A recent study from Columbia University's Sexual Health Initative to Foster Transformation (SHIFT) project suggests that comprehensive sex education protects students from sexual assault even after high school.

  4. State Policies on Sex Education in Schools

    Why Is Sexual Education Taught in Schools? A 2017 Centers for Disease Control and Prevention (CDC) survey indicates that nearly 40 percent of all high school students report they have had sex, and 9.7 percent of high school students have had sex with four or more partners during their lifetime.

  5. What else can sex education do? Logics and effects in classroom

    Three ethnographic cases from secondary schools in the Netherlands showed the school to be a space/time for sexuality, showed how sexual knowledge is produced and used in class, and how sex education plays into and depends on processes of (gendered) popularity.

  6. Three Decades of Research: The Case for Comprehensive Sex Education

    Abstract Purpose School-based sex education plays a vital role in the sexual health and well-being of young people. Little is known, however, about the effectiveness of efforts beyond pregnancy and sexually transmitted disease prevention.

  7. The State of Sex Education in the United States

    The Centers for Disease Control and Prevention's 2014 School Health Policies and Practices Study found that high school courses require, on average, 6.2 total hours of instruction on human sexuality, with 4 hours or less on HIV, other sexually transmitted infections (STIs), and pregnancy prevention [ 15 ].

  8. What Works In Schools: Sexual Health Education

    Print CDC's What Works In Schools Program improves the health and well-being of middle and high school students by: Improving health education, Connecting young people to the health services they need, and Making school environments safer and more supportive. What is sexual health education?

  9. Three decades of research: The case for comprehensive sex education

    Three decades of research: The case for comprehensive sex education. Journal of Adolescent Health, 68 (1), 13-27. https:// https://doi.org/10.1016/j.jadohealth.2020.07.036 Abstract Purpose: School-based sex education plays a vital role in the sexual health and well-being of young people.

  10. Sex Education in School, are Gender and Sexual Minority Youth Included

    Research conducted with heterosexual adolescents shows comprehensive sexual health education, medically accurate material that includes information on STIs, HIV, pregnancy, condoms, contraceptives as well as abstinence and sexual decision making, increases sexual health knowledge and decreases adverse health outcomes, STIs, HIV, and pregnancy an...

  11. Federally Funded Sex Education: Strengthening and Expanding Evidence

    PREP-funded curricula are not required to be comprehensive, but the majority incorporate elements of comprehensive sex education: healthy relationships (98%), healthy life skills (81%) and adolescent development (73%). Comprehensive sex education

  12. Sex Education in Schools

    Sex Education in Schools Jessica Smarr & Karen Rayne Reference work entry First Online: 01 January 2021 46 Accesses Download reference work entry PDF Synonyms Comprehensive sexuality education; Holistic sexuality education; Sex Ed; Sexuality education Definition

  13. Comprehensive Sex Education—Why Should We Care?

    Fonner et al 7 conducted a systematic review and meta-analysis of the existing evidence for school-based sex education interventions in low- and-middle-income countries to understand the efficacy of these services in changing HIV-related risk behaviors and knowledge.

  14. The effectiveness of school-based sex education programs in the

    The search for school-based sex education interventions resulted in 12 research studies that complied with the criteria to be included in the review and for which effect sizes could be estimated. The overall effect size ( d +) estimated from these studies was 0.05 and the 95% confidence interval about the mean included a lower bound of 0.01 to ...

  15. Effectiveness of relationships and sex education: A ...

    This paper presents a systematic review on published research on universal school-based relationships and sex education for children aged 4-18 years. The review excludes papers focused solely on targeted cohorts, specific content areas and approaches such as abstinence-only education.

  16. (PDF) SCHOOL-BASED SEXUALITY EDUCATION: AN OVERVIEW

    comprehensive sexuality education. Keywords: Sexual health, Sex education, Youth, Reproductive health, School-based sex education, Sex. Yen agoa Medical Journ al Vol. 3 No. 1, January...

  17. Three Decades of Research: The Case for Comprehensive Sex Education

    CSE comprehensive sex education Systematic Literature Review K-12 Public health practitioners and policy-makers have long considered school-based sex education to play a vital role in the sexual health and well-being of young people.

  18. (PDF) Assessing the effectiveness of school-based sex education in

    Objective: To systematically review and synthesise evidence on the effectiveness of school-based sex education interventions on sexual health behaviour outcomes and to identify Behaviour...

  19. Sex Education in Schools Needs an Upgrade

    The State of Sex Ed. Research has found that nearly all students receive some sort of sex education, but the subject matter often varies, particularly regarding issues of abstinence and gender. ... Rawcliffe, who has been teaching sex education for 28 years in high school and middle school and helped develop resources for schools in her state ...

  20. PDF Importance of sex education in schools: literature review

    Abstract. According to the National Association for the Education of Young Children, early childhood also includes infancy, making it age 0-8 instead of age 3-8. At this stage children are learning through observing, experimenting and communicating with others. Childhood is the age span two years to adolescence.

  21. PDF School-based Sexuality Education: a Review And

    The issue of school-based sexuality education is controversial, and the consequences of not providing adequate education to adolescents are serious. The purpose of this study will be to review research relevant to the topic of school-based sexuality education and offer critical analysis of relevant research.

  22. Race and LGBTQ Issues in K-12 Schools

    Amid national debates about what schools are teaching, we asked public K-12 teachers, teens and the American public how they see topics related to race, sexual orientation and gender identity playing out in the classroom.. A sizeable share of teachers (41%) say these debates have had a negative impact on their ability to do their job. Just 4% say these debates have had a positive impact, while ...

  23. (PDF) Sex Education in the 21st Century

    Sep 2022. Kakhaber George Lazarashvili. View. Show abstract. Article. One of the major philosophies of a junior high school sex-education course was to present information that the sex roles of ...

  24. School-based comprehensive sexuality education for prevention of

    Adolescent pregnancy is a global public health problem. Numerous approaches for Comprehensive Sexuality Education (CSE) delivery in schools have been implemented around the world. Previous reviews on CSE did not follow the International Technical Guidance on Sexuality Education (ITGSE) because CSE is very diverse in terms of population, interventions, settings and outcomes.

  25. Favor Sex Education in Public Schools

    By Russell Heimlich. Debates over sex education in schools often pit abstinence instruction against providing students information on birth control methods, but the public sees no conflict in pursuing both of these approaches — in an August 2005 Pew Forum survey, 78% favor allowing public schools to provide students with birth control ...

  26. U.S. States Tighten Restrictions On Sex Education In Classrooms

    The legislative trends have serious implications for children, especially LGBTQ+ youth.Research indicates that omitting LGBTQ+ content from sex education leaves these individuals ill-equipped to ...

  27. National divide on teaching race, LGBTQ issues in classrooms captured

    In a new survey, the Pew Research Center asked public K-12 teachers, teens, and the American public about teaching the topics of race and LGBTQ identities.

  28. 8 states restricted sex ed last year. More could join amid ...

    The National Sex Education Standards, developed by a coalition of groups including the Sexuality Information and Education Council, offers essential criteria schools can use to ensure they are ...

  29. Texas got a sex education update two years ago. Advocates say there are

    Since sex education isn't required in high school, and the state's TEKS are limited in terms of instruction, some parents have looked for resources outside of school districts. That's what ...