Sexual Health Education in Schools
It is the position of the National Association of School Nurses (NASN) that developmentally appropriate evidence-based sexual health education should be included as part of a comprehensive school health education program and be accessible to all students. NASN recognizes the role of parents and families as the primary source of education about sexual health. The registered professional school nurse (hereinafter referred to as school nurse) is a valuable resource to parents and educators in this area and supports the implementation of evidence-based sexual health education programs that promote healthy sexual development for all students.
The social and health risks of adolescent sexual activity are well known (Dee et al., 2017). While teen pregnancy and birth rates in the United States continue to decline, rates remain higher than in other industrialized countries; and racial, ethnic and geographic disparities persist (Centers for Disease Control and Prevention [CDC], 2016a). In addition, the rates of sexually transmitted infections (STIs) are at an unprecedented high in the United States, and more than half of newly acquired infections occur among adolescents and young adults (CDC, 2016b).
Sexual health as defined by the World Health Organization (WHO) is “… a state of physical, emotional, mental and social well-being in relation to sexuality...” (WHO, 2015, pp. 5), suggesting a whole child approach to sexual health education and not merely the absence of unplanned pregnancy or sexually transmitted infections. For decades, studies have shown that the majority of parents in the United States support sexual health education in schools. In addition, findings indicated that most parents supported abstinence-based rather than abstinence-only programs (Barr, Moore, Johnson, Forrest , Jordan , 2014). Finally, a May 2016 nationwide survey of middle and high school parents found that 70% believe sex education and pregnancy prevention should “definitely be covered” in sexual health education programs (Singer, 2016).
According to the 2014 School Health Policies and Practices Study (CDC, 2015a), 72% of high schools in the United States required students to receive education on pregnancy prevention, and 83.1% required instruction on STI prevention. Topics listed as part of required instruction by order of frequency included abstinence as the most effective method to avoid pregnancy and STIs, the relationship between alcohol or other drug use and risk for STIs and pregnancy, and resisting peer pressure to engage in sexual behavior. A worrisome trend is that the percentage of schools in which students are required to receive instruction on human sexuality, pregnancy, and STI prevention has steadily declined since 2000 (CDC, 2015a)
Healthy students are more likely to achieve academic success (CDC, 2014). Szydlowski (2015b) asserts that when teens receive accurate sexual health education information and skills, they can reduce health risk factors that may impact their success in school. Data from the 2015 Youth Risk Behavior Surveillance Survey (YRBSS) indicated that, among high school students, 41% have had sexual intercourse at least once; and 30% had sexual intercourse in the three months prior to participating in the survey, reflective of a decline from previous surveys (CDC, 2015b). Although teens may be having less sex, condom use and HIV testing are declining (CDC, 2015b). Of those who had intercourse in the past three months, 43% did not use a condom the last time they had sex; 14% did not use any method to prevent pregnancy; and 21% used substances before last sexual intercourse (CDC, 2015b).
For the first time, the CDC analysis of national data gathered from the 2015 YRBS included information on the health risks of lesbian, gay, and bisexual (LGB) high school students. These findings demonstrate that LGB youth report a higher incidence of bullying at school or online, physical and sexual dating violence, drug and alcohol use, and suicide-related behaviors than their straight peers (Kann, Olsen, & McManus, 2016). In the most recent Gay, Lesbian, and Straight Network (GLSEN) National School Climate Survey, over 31% of LGBTQ students reported missing at least one day of school during the past month due to safety concerns. Students who attended schools with LGBTQ-inclusive curriculum were less likely to miss school (18% vs. 35%) for safety reasons (Kosciw, Greytak, Giga, Villenas, & Danischewski, 2016). Although not a direct measure of school performance, absenteeism has been linked to low graduation rates, which can impact future success in life (CDC, 2014).
In addition to the disparities of risk for sexual minority youth, there are racial/ethnic differences. Black high school students are more likely to have had intercourse than white and Latino students; and more black high school students and Latino students initiated sex before the age of 13 compared to white students (Kaiser Family Foundation, 2014).
Students with disabilities defined as “... a physical or mental impairment that substantially limits one or more major life activities” (Americans with Disabilities Act of 1990 [ADA], Title II Regulations, 2016, p. 187), and those with intellectual disabilities (ID) as characterized by “...signiﬁcant limitations both in intellectual functioning and in adaptive behaviour as expressed in conceptual, social, and practical adaptive skills” (Luckasson & Schalock, 2013, pp. 96) benefit from sexual health information. Low levels of knowledge can impede the recognition of sexual abuse situations, safe sex practices, and the development of positive attitudes toward sexuality (Schaafsma, Kok, Stoffelen, & Curfs, 2015). Szydlowski (2016) compiled general guidelines for sexual health educators for those with disabilities. Sexual health education needs to be tailored to the students with disabilities based on their ability, learning style, and maturity, in addition to parent values and beliefs (Szydlowski, 2016).
School nurses support sexual health education that is accessible, inclusive, and developmentally and culturally appropriate for all students. Academic achievement is linked to student health (CDC, 2014). Health risk behaviors, such as early sexual initiation, are associated with lower grades and test scores, and lower educational attainment (CDC, 2016c). Evidence-based sexual health education provides accurate, complete, and developmentally appropriate information and skill development that allow young people to make decisions that are informed, responsible, and healthy (Szydlowski, 2015b). Evidence-based sexual health education can improve academic success; prevent dating violence, and bullying; help youth develop healthier relationships; delay sexual initiation; reduce unplanned pregnancy, HIV, and other STIs; and reduce sexual health disparities among LGBTQ youth (Szydlowski, 2015b). Evidence-based sexual health education reduces sexual risk behavior by delaying sexual initiation, reducing pregnancy and STIs, and increasing contraceptive use -- thereby protecting student health (Szydlowski, 2015b).
The National Sexuality Education Standards (Future of Sex Education Initiative [FOSE],2012) support a strategic and coordinated approach that includes family and community involvement, skill development and school health services. Furthermore, the Sexuality Information and Education Council of the United States (SIECUS) (2017) supports sexual health education that is appropriate to the student’s age, developmental level, cultural background, and community values. SIECUS further advocates for sexual health education to augment the sexual health education provided by the family and their healthcare professionals. SIECUS specifies that sexual health education provided in an educational setting needs to be taught by an instructor trained on the principles, content and best practices of sexual health education. On behalf of Advocates for Youth, Szydlowski (2015a) emphasizes youth friendly sexual health education to assist with the positive development of sexual health, beginning in youth and continuing throughout adulthood.>
The National Sexuality Education Standards recommend that an evidence-based sexual health education program include the following characteristics (FOSE, 2012, p.9):
- Focuses on specific behavioral outcomes;
- Addresses individual values and group norms that support health‐enhancing behaviors;
- Focuses on increasing personal perceptions of risk and harmfulness of engaging in specific health risk behaviors, as well as reinforcing protective factors;
- Addresses social pressures and influences;
- Builds personal and social competence;
- Provides functional knowledge that is basic, accurate and directly contributes to health‐promoting decisions and behaviors;
- Uses strategies designed to personalize information and engage students;
- Provides age‐ and developmentally appropriate information, learning strategies, teaching methods and materials;
- Incorporates learning strategies, teaching methods, and materials that are culturally inclusive;
- Provides adequate time for instruction and learning;
- Provides opportunities to reinforce skills and positive health behaviors;
- Provides opportunities to make connections with other influential persons; and
- Includes teacher information and plan for professional development and training to enhance effectiveness of instruction and student learning.
In addition, in terms of specific content, an emerging model for sexual health education is the rights-based approach, which employs a vast, comprehensive sexual education program with a focus on human rights, gender equality, access to healthcare services, and critical thinking (Constantine et al., 2015). Preliminary findings have supported that education based on theories of human rights, gender equality, and sexual development can positively impact healthy sexual behavior among adolescents (Constantine et al.).
Health education and promotion, disease prevention, and risk reduction are essential practice components for the 21st century school nurse to help students stay healthy, safe and ready to learn (NASN, 2016). School nurse leaders advocate for and support the delivery of evidence-based sexual health education that is “...medically accurate, developmentally appropriate, and … provides students with the skills and resources that help them make informed and responsible decisions” (FOSE, 2012, p.8). School nurses -- working in collaboration with parents, students, health educators, curriculum specialists, and other school and community stakeholders -- strive to dismantle barriers and support access to evidence-based sexual health education that allows all students to make informed, responsible, and healthy decisions.
Americans With Disabilities Act of 1990, Pub. L. No. 101-336, 104 Stat. 328 (1990), Title II Regulations. (2016). Part 35 Nondiscrimination on the Basis of Disability in State and Local Government Services (as amended by the final rule published on August 11, 2016). Retrieved from https://www.ada.gov/regs2010/titleII_2010/titleII_2010_regulations.htm
Barr E., Moore M., Johnson T., Forrest J., Jordan M. (2014). New evidence: Data documenting parental support for earlier sexuality education. Journal of School Health, 84(1), 10-17. doi:http://dx.doi.org/10.1111/josh.12112
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. (2014). Health and academic achievement. Retrieved from https://www.cdc.gov/healthyyouth/health_and_academics/pdf/health-academic-achievement.pdf
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Centers for Disease Control and Prevention. (2015b). Youth risk behavior surveillance system (YRBSS). Retrieved from https://www.cdc.gov/healthyyouth/data/yrbs/results.htm
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Centers for Disease Control and Prevention. (2016c). Adolescent and school health: Health and academics. http://www.cdc.gov/HealthyYouth/health_and_academics/
Constantine, N. A., Jerman, P., Berglasi, N. F., Angulo-Olaiz, F., Chou, C., & Rohrbach, L. A. (2015). Short-term effects of a rights-based sexuality education curriculum for high-school students: A cluster-randomized trial. BMC Public Health, 15(293),1-13. doi:10.1186/s12889-015-1625-5
Dee, D.L., Pazol, K., Cox, S., Smith, R.A., Bower, K., & Kapaya, M. (2017). Trends in repeat births and use of postpartum contraception among teens-United States, 2004-2015. Morbidity Mortality Weekly Report, 4/28/2017; 66(16), 422-426, 5. doi: http://dx.doi.org/10.15585/mmwr.mm6616a3
Future of Sex Education Initiative. (2012). National sexuality education standards: Core content and skills, K-12 [a special publication of the Journal of School Health]. Retrieved from http://www.futureofsexeducation.org/documents/josh-fose-standards-web.pdf
Kaiser Family Foundation. (2014). Sexual health of adolescents and young adults in the United States. Menlo Park, CA: Henry J. Kaiser Family Foundation. Retrieved from http://kff.org/womens-health-policy/fact -sheet/sexual-health-of-adolescents-and-young-adults-in-the-united-states/
Kann, L., Olsen, E.O., & McManus, T. (2016). Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9–12 — United States and selected sites, 2015. MMWR Surveillance Summary 2016,65(No. SS-9), 1–202. doi: http://dx.doi.org/10.15585/mmwr.ss6509a1
Kosciw, J. G., Greytak, E. A., Giga, N. M., Villenas, C. & Danischewski, D. J. (2016). The 2015 national school climate survey: The experiences of lesbian, gay, bisexual, transgender, and queer youth in our nation’s schools. New York: GLSEN.
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Schaafsma, D., Kok, G., Stoffelen, J. M. T., & Curfs, L. M. G. (2015). Identifying effective methods for teaching sex education to individuals with intellectual disabilities: A systematic review. Journal of Sex Research, 52(4), 412-432. doi: 10.1080/00224499.2014.919373.
Sexuality Information and Education Council of the United States. (2017). Human sexuality (Position Paper). Retrieved from http://www.siecus.org/index.cfm?fuseaction=Page.ViewPage&pageId=494
Singer, D.C. (Ed.). (2016). Beyond sex ed: Parents want more health topics covered in school. Retrieved from http://mottnpch.org/reports-surveys/beyond-sex-ed-parents-want-more-health-topics-covered-school
Szydlowski, M.B. (2015a). Sexual health education; research and results. School Health Equity/Advocates for Youth. Retrieved from http://www.advocatesforyouth.org/storage/advfy/documents/school-health-equity/sexual-healthed-research-and-results.pdf
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Szydlowski, M. B. (2016). Sexual health education for young people with disabilities - Research and resources for educators. School Health Equity/Advocates for Youth. Retrieved from http://www.advocatesforyouth.org/publications/publications-a-z/2559
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Acknowledgement of Authors:
Lisa Kern MSN, RN, NCSN
Gina Emge MSN, RN
Kathy Reiner BSN, MPH, RN
Darla Rebowe BSN, RN
Adopted: October 2002
Revised: November 2005, June 2012, June 2017
(Formerly titled “School Health Education about Human Sexuality”)
Suggested Citation: National Association of School Nurses. (2016). Sexual health education in schools (Position Statement). Silver Spring, MD: Author.
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.