Education and the Path to a Sexually Healthy Nation
Science and evidence are making a comeback in many of America's classrooms, and not a moment too soon. After a decade of denial in which more than $1 billion in federal money was spent on failed abstinence-only-until-marriage programs, many local communities are moving toward a model of evidence-based sex education that helps young people delay too-early sexual activity while also providing accurate information about condoms and birth control. This welcome news provides educators and advocates with an opportunity to assess our progress and chart a path toward further improving sexual health education for America's youths.
The recent shift by many communities from the ideology of abstinence-only programs to an increased emphasis on science and evidence is a giant step in the right direction fueled by a congressionally mandated study demonstrating abstinence-only programs to be ineffective in helping youths delay sexual initiation; a growing number of states' rejection of federal abstinence-only funds; and numerous public-opinion polls indicating widespread support for a more comprehensive approach to sex education.
Perhaps the greatest vote of confidence in the much-needed shift is two new sources of federal funding: the Personal Responsibility Education Program, or PREP, funded in mandatory appropriations dollars at $75 million a year from 2010 to 2015, and President Barack Obama's Teen Pregnancy Prevention Initiative, or TPPI, which has been allotted $110 million annually starting in 2010, but which must go through the congressional appropriation process each year. These funds represent the first-ever dedicated sources of federal funding for evidence-based sex education, and they are accelerating program implementation across the country. The initiatives represent a watershed not just in funding, but also in sex education messaging and strategy.
Yet for all this promise, some fundamental factors are impeding our success: 1) the limited number of programs approved by the U.S. Department of Health and Human Services for use by communities receiving PREP or TPPI funds; 2) the narrow focus and content of most of these programs; 3) the high cost of obtaining and replicating these programs; and 4) the interpretation by some government agencies that these programs must be replicated with complete fidelity.
While PREP-funded projects are encouraged to replicate evidence-based efforts on an approved list, they are given leeway to create programs that "substantially incorporate elements of projects that have been proven to delay sexual activity, increase condom or contraceptive use for sexually active youth, or reduce pregnancy among youth." The emphasis is on identifying evidence-based best practices that are culturally and developmentally appropriate for the youths targeted.
TPPI grantees, however, must replicate the approved programs with complete fidelity. Programs must include the same lesson plans in the same order and in the same setting (school vs. community-based, etc.) as the original. There is very little room for educators to make modifications. In fact, we were told, when one educator receiving training on an approved program asked recently if she could provide information to students on emergency contraception if asked, she was told that she could not, and that she needed to "stick to the script" and only include information that was part of the original program. Complete fidelity denies communities the opportunity to supplement or customize lesson plans to meet cultural, linguistic, or developmental needs and inhibits communities from being able to scale and often sustain these programs across school districts and grade levels.
The limited number of programs approved by the Health and Human Services Department for implementation further hampers success. Only five of the 31 approved programs are designed for use in high schools. Of these, only two are classroom sex education programs; two are programs for special populations (such as students in alternative schools or teen parents); and the last is a youth-development program. Only five were designed for middle schools. Of these, only two are sexuality education programs. How can so few curricula meet the cultural, developmental, and social needs of students living in diverse communities?
Further examination reveals a narrow focus in many curricula. In one approved high school curriculum, the lesson plans focus on abstinence, refusal skills, and getting and using protection. Omitted is any discussion of healthy relationships, adolescent sexual development, body image, and bullying, among many other vital topics.
An additional problem is the cost of the programs on the approved list. A small number of companies have come to "own" most of these approved programs. Our research shows many are charging acquisition and training fees of up to $27,000 to train only eight trainers. Some prohibit the purchase of their programs without a concurrent purchase of their training, making it difficult for those without federal funding to afford these programs.
The shift toward evidence-based sexuality education is a move in the right direction, but it is currently shackled. Instead of the inflexible replication of a small number of programs, we should glean evidence-based strategies from these and other research findings and incorporate them into programs that meet the developmental and cultural needs of the youths we serve. In other words, we should use the evidence base to inform our approaches, rather than interpret the evidence so narrowly that we inhibit our ability to reach our intended goals by restricting implementation to faithful replication of a small number of programs.
To address some of these issues and to promote a more flexible and comprehensive approach, a group of leading education and public-health organizations, including ours, recently released the National Sexuality Education Standards, Core Content, and Skills Grades K–12. The standards provide nonbinding guidelines for the minimum content young people need to receive in sex education in kindergarten through 12th grade. They are based on scientific evidence, child and adolescent development, and learning theory, and outline the information and skills that research tells us students need to acquire by each grade. The standards do not preclude the use of evidence-based programs from the approved list, but they enable communities to go further, freeing them of the inflexibility of faithful replication and helping them identify additional core content and skills young people truly need.
Communities can construct developmentally appropriate curricula that are sequential, provide foundational information and skills in early grades, and build toward more complex concepts as students grow older. Lessons usually omitted in narrowly fashioned pregnancy- and disease-prevention programs, such as puberty, communication, body image, bullying, and healthy relationships, can be added as supplements to an evidence-based program, or communities can use the standards as guidance to create a new curriculum that incorporates evidence-based best practices and strategies.
The laser-like focus on the implementation of evidence-based programs with fidelity is a classic example of making the perfect the enemy of the possible. Specifically, the misguided emphasis on the faithful implementation of a small list of narrowly conceived teen-pregnancy and disease-prevention programs inhibits communities from meeting diverse educational, cultural, and developmental needs of young people. It is not enough for programs to include only abstinence and contraception or to help young people avoid unintended pregnancy or disease. Sexual health education must do more. It must provide young people with all of the information and skills necessary to become sexually healthy adults.
Vol. 31, Issue 30, Pages 26-27