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Does Sex Education Work?

Should sex education be taught in schools?

The question is no longer should sex education be taught, but rather how should it be taught. Over 93% of all public high schools currently offer courses on sexuality or HIV.(1) More than 510 junior or senior high schools have school-linked health clinics, and more than 300 schools make condoms available on campus. The question now is are these programs effective, and if not, how can we make them better?

Why do youth need sex education?

Kids need the right information to help protect themselves. The US has more than double the teenage pregnancy rate of any western industrialized country, with more than a million teenagers becoming pregnant each year.(2) Teenagers have the highest rates of sexually transmitted diseases (STDs) of any age group, with one in four young people contracting an STD by the age of 21.(3) STDs, including HIV, can damage teenagers' health and reproductive ability. And there is still no cure for AIDS.

HIV infection is increasing most rapidly among young people. One in four new infections in the US occurs in people younger than 22.(4) In 1994, 417 new AIDS cases were diagnosed among 13-19 year olds, and 2,684 new cases among 20-24 year olds.(5) Since infection may occur up to 10 years before an AIDS diagnosis, most of those people were infected with HIV either as adolescents or pre-adolescents.

Why has sex education failed to help our children?

Knowledge alone is not enough to change behaviors.(6) Programs that rely mainly on conveying information about sex or moral precepts-how the body's sexual system functions, what teens should and shouldn't do-have failed. However, programs that focus on helping teenagers to change their behavior-using role playing, games, and exercises that strengthen social skills-have shown signs of success.(7)

In the US, controversy over what message should be given to children has hampered sex education programs in schools. Too often statements of values ("my children should not have sex outside of marriage") come wrapped up in misstatements of fact ("sex education doesn't work anyway"). Should we do everything possible to suppress teenage sexual behavior, or should we acknowledge that many teens are sexually active, and prepare them against the negative consequences? Emotional arguments can get in the way of an unbiased assessment of the effects of sex education.(8)

Other countries have been much more successful than the US in addressing the problem of teen pregnancies. Age at first intercourse is similar in the US and five other countries: Canada, England, France, the Netherlands, and Sweden, yet all those countries have teen pregnancy rates that are at least less than half the US rate.(9) Sex education in these other countries is based on the following components: a policy explicitly favoring sex education; openness about sex; consistent messages throughout society; and access to contraception.

Often sex education curricula begin in high school, after many students have already begun experimenting sexually. Studies have shown that sex education begun before youth are sexually active helps young people stay abstinent and use protection when they do become sexually active.(10) The sooner sex education begins, the better, even as early as elementary school.

What kinds of programs work best?

Reducing the Risk, a program for high school students in urban and rural areas in California, used behavior theory-based activities to reduce unprotected intercourse, either by helping teens avoid sex or use protection. Ninth and 10th graders attended 15 sessions as part of their regular health education classes and participated in role playing and experimental activities to build skills and self-efficacy. As a result, a greater proportion of students who were abstinent before the program successfully remained abstinent, and unprotected intercourse was significantly reduced for those students who became sexually active.(11)

Postponing Sexual Involvement, a program for African-American 8th graders in Atlanta, GA, used peers (11th and 12th graders) to help youth understand social and peer pressures to have sex, and to develop and apply resistance skills. A unit of the program also taught about human sexuality, decision-making, and contraceptives. This program successfully reduced the number of abstinent students who initiated intercourse after the program, and increased contraceptive use among sexually experienced females.(12)

Healthy Oakland Teens (HOT) targets all 7th graders attending a junior high school in Oakland, CA. Health educators teach basic sex and drug education, and 9th grade peer educators lead interactive exercises on values, decision-making, communication, and condom-use skills. After one year, students in the program were much less likely to initiate sexual activities such as deep kissing, genital touching, and sexual intercourse.(13)

AIDS Prevention for Adolescents in School, a program for 9th and 11th graders in schools in New York City, NY, focused on correcting facts about AIDS, teaching cognitive skills to appraise risks of transmission, increasing knowledge of AIDS-prevention resources, clarifying personal values, understanding external influences, and teaching skills to delay intercourse and/or consistently use condoms. All sexually experienced students reported increased condom use after the program.(14)

A review of 23 studies found that effective sex education programs share the following characteristics:(10)

1. Narrow focus on reducing sexual risk-taking behaviors that may lead to HIV/STD infection or unintended pregnancy.

2. Social learning theories as a foundation for program development, focusing on recognizing social influences, changing individual values, changing group norms, and building social skills.
3. Experimental activities designed to personalize basic, accurate information about the risks of unprotected intercourse and methods of avoiding unprotected intercourse.
4. Activities that address social or media influences on sexual behaviors.
5. Reinforcing clear and appropriate values to strengthen individual values and group norms against unprotected sex.
6. Modeling and practice in communication, negotiation, and refusal skills.

What still needs to be done?

Although sex education programs in schools have been around for many years, most programs have not been nearly as effective as hoped. Schools across the country need to take a rigorous look at their programs, and begin to implement more innovative programs that have been proven effective. Educators, parents, and policy-makers should avoid emotional misconceptions about sex education; based on the rates of unwanted pregnancies and STDs including HIV among teenagers, we can no longer ignore the need for both education on how to postpone sexual involvement, and how to protect oneself when sexually active. A comprehensive risk prevention strategy uses multiple elements to protect as many of those at risk of pregnancy and STD/HIV infection as possible. Our children deserve the best education they can get.

Says who?

1. Kirby DJ. Sex Education in the Schools. In: Garrison JA, Smith MD, Besharov DJ, eds. Sexuality and American Social Policy. Henry J. Menlo Park, CA: Kaiser Family Foundation; 1994.

2. Centers for Disease Control and Prevention. Youth risk behavior surveillance-United States, 1993. Morbidity and Mortality Weekly Report. 1995;44:1-56.

3. Department of Health and Human Services. Healthy People 200: National Health Promotion and Disease Prevention Objectives. DHHS Publication No. 91-50212. Washington, DC: US Government Printing Office; 1990.

4. Rosenberg PS, Biggar RJ, Goedert JJ. Declining age at HIV infection in the United States (letter). New England Journal of Medicine. 1994;330:789-790.

5. Centers for Disease Control and Prevention. HIV AIDS Surveillance Report. 1995;6:14.

6. DiClemente RJ, Durbin M, Siegel D, et al. Determinants of condom use among junior high school students in a minority, inner-city school district. Pediatrics. 1992;89:197-202.

7. Ubell E. Sex-education programs that work-and some that don't. Parade Magazine. February 12, 1995:18-20.

8. Ehrhardt A. Sex education for young people. National AIDS Bulletin. July 1993:32-35.

9. Dryfoos J. What the United States can learn about prevention of teenage pregnancy from other developed countries. SIECUS Reports. 1985;14:1-7.

10. Kirby D, Short L, Collins J, et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports. 1994;109:339-360.

11. Kirby D, Barth R, Leland N, et al. Reducing the Risk: a new curriculum to prevent sexual risk-taking. Family Planning Perspectives. 1991;23:253-263.

12. Howard M, McCabe J. Helping teenagers postpone sexual involvement. Family Planning Perspectives. 1990;22:21-26.

13. Ekstrand M, Siegel D, Krasnovsky F, et al. A school-based, peer-led AIDS prevention program delays the onset of sexual behaviors among adolescents. Presented at Second International Conference on Biopsychosocial Aspects of HIV Infection, Brighton, UK; 1994. Abstract P004.

14. Walter HJ, Vaugh RD. AIDS risk reduction among a multi-ethnic sample of urban high school students. Journal of the American Medical Association. 1993;270:725-730.

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