A Critique of Non-comprehensive Sexual Education in Public Schools in states lacking mandates. Doreen Gidali

Introduction

It is often speculated that the two things that separate humanity from most other animals, is our ability to think and to experience sexual pleasure. And though sexual expression and behavior is often considered one of adulthood, it is just as present in adolescents across the world. With puberty, comes the onset of sexual desire. But in recent decades, puberty is being reached at even younger ages; and in an era where sex has been freed from the constraints of procreation and marriage, and more so associated with its benefit of pleasure, we have seen an increase in sexual activity among the very young. Unfortunately, this promotion of sexual freedom preceded the effort to inform the youth on healthy sexual behavior. This has proven problematic in a time where sexually transmitted infections (STI) are rampant and carry significant morbidity, unstable economies with a greater percent of impoverished individuals: poorly informed sexual activity is becoming a significant concern for public health.

In 2009, data collected by the Center for Disease Control and Prevention (CDC) found that 46% of high school students reported having had sexual intercourse. 34% of them had it within 3months, of which 39% had unprotected sex (1-3). While it is assuring that more than half of those having sex used protection, the health consequences of having unprotected sex are unfortunate, both for the individual and for the overall state of public health. Nearly half of the 19 million new cases of STIs each year are among people aged 15-24 years, and about 8,300 new cases of HIV infection are in people aged 13-24years. In 2009 alone, 400,000 new mothers were between the ages of 15-19 (1-3). STIs are one of the main causes of morbidity in young people, and while HIV is now considered a chronic disease, acquiring it at such a young age is medically, and psychologically detrimental, not to mention financially draining. The weight of teen pregnancies is one that needs no further explanation.

Though these numbers may be alarming, it is important to note that since the 1990s, there has been a considerable decline in sexual activity, pregnancies, and births among teens, owing to “dramatic improvements in contraceptive use” through sexual education (4). But this very concept of sexual education is divisive to say the least. There are two methods of preventing the undesired outcomes of sexual activity: abstain, or engage with caution. These two divergent principles are the basis of the controversy surrounding how to implement sexual education, especially in public schools. “Abstinence only” proponents, emphasize abstaining from sex outside marriage, and suggest that education supporting the use of contraception promotes sexual activity, and should be discussed only in the context of “their failure rates” (5, 6). On the other hand, supporters of comprehensive sexual education (CHE henceforth), support an emphasis on abstinence as the only guaranteed method of protection, but in addition, strongly support scientific and medically accurate education around contraception, including social and psychological factors that influence sexual behavior. With a common goal in mind, both arguments are sound: but it is no surprise, that “targeting behaviors that are both reasonable and feasible” is often more successful in bringing about change in human behavior (7). It is therefore sensible to expect that, the comprehensive method would be preferable. In fact in 2001, the Surgeon General, Dr. David Satcher supported this in his “call to action” stating that sexual health education should “stress the value of abstinence…but assure awareness of optimal protection from sexually transmitted diseases and unintended pregnancy, for those who are sexually active” (8). Additionally, recent reviews of several interventions, demonstrate higher success rates in programs based on the comprehensive method. In fact, “research shows that abstinence-only strategies may deter contraceptive use among sexually active teens, increasing their risk of unintended pregnancy and STIs” (4, 7). So why then does this controversy still exist, and how does it affect the actual problem?

The answer lies in jurisdiction. While Washington can give its suggestions and recommendations, legislature on sexual education and the extent and manner of its enforcement is a matter of state and local governance. Though the Sexuality Information and Education Council of the United States published Guidelines for Comprehensive Sexuality Education (SIECUS), states are not required to follow these guidelines, or to mandate CHE. Current laws and policies ensure that at least some degree of sexual education is incorporated in public schools (4), but it is the degree of which it is incorporated that differs. This creates significant variability in the type of sexual education that adolescents are getting in schools across states, cities and even counties, and more so opens an opportunity for external pressures from special interest groups that have potential to influence policy. This is where our sexual education proponents come into play. Despite the data supporting the success of the comprehensive approach, proponents of “abstinence only” education remain avid. They are often financially endowed, aligned to the right, and have been known to use the political front to push their agenda (9). This does not suggest that state sexual education policy is dictated by special interest groups, but only attempts to demonstrate how lack of a national mandates on states to mandate CHE, allows for influence on state policy that results in implementation of, discredited and less-effective programs. The results is a deficit of quality programs needed to address a public health issue as considerable as this, especially in areas that are disproportionately affected, further contributing to disparities. New York City is an excellent example of this unfortunate predicament.

In 2005, New York City (NYC) was considered the “epicenter of the U.S HIV/AIDS epidemic, with almost 200,000 cases. We know that young people represent a considerable fraction of new HIV-cases; this places most of them in NYC (10-12). This is a heavy burden for any state to carry; but surprisingly, New York “has no law that mandates sex education or regulates its content if taught – it has not taken the necessary action to guarantee complete, comprehensive sex education for its students. However [it] does require that students be taught about HIV as part of health classes”(13). The state provides guidelines for HIV/AIDs curriculum that is “science-based, skills-driven, and standard-based”, but yet remains relatively vague, at most offering information about abstinence, HIV transmission and consequences, and prevention (10, 14). No wonder that even with this program in place, the STI rates among those of aged 15-24, have continued to rise, especially in New York City, disproportionately affecting African Americans and Latino young women (7,10,13). One would expect that this grim reality, would serve as impudence for the state of New York to adopt a comprehensive sexual education mandate; but in fact it hasn’t. New York is one of many states that limit sexual education to HIV only, within the greater scope of health education, and often offer limited, informatively scarce guidelines. As an outcome of the no state mandate, this limited approach and its poor guidelines, secondary are the subject of this critique using NYC as an example.

Critique Argument 1: Focus on individual level decision making

Most HIV/STI campaigns are based on models that focus on individualism and rational decision making, and the New York education curriculum for HIV/AIDS is no different. As a matter of fact the national standard for a sexual health education curriculum, of which most states attempt to emulate, is mostly based on traditional public health social theory; namely the Health Belief Model (HBM), and Theory of planned action (TPA). These are both models of behavior change that have indeed have been successful in health promotion, but unfortunately have limitations that render them less efficacious in the context of complex health problems, such as risky sexual behavior.

The HBM was developed in the late 1950s, generally to predict how individuals would respond to and use health services. It presumes that an individual will make a choice to carry out a health behavior, based on their perception of: the severity and susceptibility of disease, benefits of services and possible barriers to accessing such services. The theory assumes individuals are rational decision makers, and whilst equipped with the appropriate information (knowledge), will engage in ‘healthy’ behavior, given they value the associated outcome (15). Applying this to adolescents is inevitably futile, since most do not seem to approach the ‘AIDS [STI] issue from such a logical perspective, but seem quite capable of discounting risks and optimistically perceiving themselves as invulnerable to harm (16). Also the decisions of a teenager are highly influenced by disparities, and socio- environmental factors, of which HBM does not take into account (15, 16)

The theory of planned behavior (action) much like the HBM, posits behavior as planned and reasoned, but differs in that it does take social norms into consideration. However its limitation in this case is its assumption that behavior stems from a linear progression of attitude to action of which is determined by an individual’s intention. This process of linearity, and rationality while applicable to certain health issues, is certainly misplaced in the context of sexuality. The state of sexual excitement in itself is one of irrationality; when confounded with external factors such as non-sexual desires, power dynamic in society, structure of relationships, and most of all emotions, expecting rational behavior – simply from having knowledge of risks and benefits holds little promise. A critique of communication models for HIV/AIDs prevention seamlessly illustrates this:

“Two people who are about to begin sexual relationship typically avoid discussing their sexual past until they are more comfortable with each other at which point sexual intercourse commonly has occurred (Piskin, 1997). In this case, sexual behavior precedes sexual knowledge at least in the context of relationship, which is often the basis for most interventions on preventing HIV/AIDs. This reality of ‘behavior first’ renders the linear model of knowledge leading to attitude and behavior counterintuitive in the context of relationships and culture” (16)

This is no way insinuates that HBM and TPA are useless, as the information disseminated through the current program in high essential. This only suggests that, information only no matter how all encompassing it is, is not effective if delivered in the context of logic. Instead intervention development should be based on theory that embodies dynamic flow between thoughts, behavior and action, and explain behavior from an individual perspective and through the context of external/social factors that affect human behavior.

Critique Argument 2: Who is delivering the message

The rising HIV/STI rates in New York City were alarming. In 2006-2007, NYC implemented a training program to provide professional development for teachers, administrators and parent groups. But even with this effort, there has been an increase in the rates of Chlamydia, Gonorrheal and Syphillis in both young men and women. So even though NY is featured on the CDC spotlight for HIV prevention in adolescents, because of their new training efforts, the statistics paint a picture that suggests the changes ineffective. While there is no disagreement that individuals delivering sexual education should be well trained, it is compelling to inquire whether using teachers and administrators is the most effective mode of delivering this education to our audience: adolescents.

Consider a student who has a negative history with an instructor for whatever reasons, how do they take this message. Or perhaps a student that feels she/he can never identify with her instructor. We can only presume that such negative feelings or associations may deter how the message is perceived and accepted. This is suggested by the communications theory in the social sciences, which posits that the most important element in making a persuasive appeal/message is the messenger and the associations surrounding the messenger. If the messenger is seen in a positive light, his/her message is more likely to be considered. This was illustrated in a HIV/STI prevention study that found a decrease in unprotected sex and number of partners after an intervention where opinion leaders within the community endorsed safe sex practices (17). This suggests that perhaps introducing an influential person, a well known community member, or someone that students ‘get’, might be more effective in delivering this message. This is not to argue that all students view their teachers in a negative light, but rather to ruminate on the idea of changing who teaches sexual education.

Critique Argument 3: Generalized program, assuming a homogeneous group.

The disparities seen in the STI epidemics are marked, therefore making HIV/AIDs prevention simply part of the curriculum, with somewhat vague guidelines, implies that the information is generalized to the entire population. The STI epidemic is not homogeneous, suggesting what is already apparent: that the adolescent population is heterogeneous on many fronts. Generalizing the curriculum makes it impossible to target the factors responsible for the disparities seen in the STI epidemic. Indeed some aspects of the curriculum can be generalized – such as skills, reproduction concepts – others, such as sexual abuse, cultural factors, absent from this curriculum, can really only be addressed from a non-generalized approach. A review of current adolescent STI/HIV prevention interventions revealed that “interventions with the most success decreasing high risk sexual behavior were those that specifically tailored and delivered their intervention to a particular subgroup of adolescents”(research facts) A successful intervention carried out in South African adolescents took this additional step at tailoring: ‘Because girls in South Africa are vulnerable to rape and other aspects of male denomination, sex-specific module addressed sexuality, sexual maturation, appropriate sex roles and rape myth beliefs’. Its success as an intervention was in part attributed to considering the heterogeneity of its target population (7, 18).

New York City is home to an extremely global population, with historically harsh urban and inner cities. With such a diverse population, with individuals stemming from different walks of life, a tailored approach only seems fitting. Yet it is not clear that complex social and cultural factors such as, sexual abuse, substance abuse, single vs. dual parent homes are taken into consideration (14). Absence of this approach, in a population such as that of NYC public schools, only sets the stage for failure

Proposed Intervention

There are several non-school based programs in New York that are delivering effective programs to other disproportionately affected youth: such as those in detention centers, young women in health clinics, and substance users. It is up to individual schools whether they choose to adopt a curriculum on sexual education in addition to the HIV/AIDs program, or don’t. This creates a potential donut hole, of young adolescents – especially racial minorities, that may not have access to the non-school based programs, but attend a school that only enforces the HIV/AIDs curricular.

This intervention is targeted at urban schools (in this case NYC) with high proportion of racial minorities, interested in establishing a sexual-education curriculum in addition to the existing HIV/AIDs mandate The proposed intervention ‘Teens Loving Cautiously (TLC)’, is program based on the merging of multiple social science theories, taking into consideration how information is delivered, the power of norms, and multi-factorial social influence do deliver sexual education. The program would continue the information approach central to most sexual education programs, stressing abstinence, contraception use, but will additionally draw on the SIECU fundamentals of comprehensive sexuality education, exploring; biological, socio-cultural, psychological, and spiritual dimensions of sexuality, while addressing development, reproductive health, interpersonal relationships, and affection, intimacy, body image and gender roles (25). It differs by far in the approach it takes in delivering this information.

It will be a yearlong portion of the curriculum, allowing continuity of lessons across semester, and across grades. With permission from parents, the program involves voluntary trained peer-educators, who along with parents, teachers, and community members, will administer both large group and small group sessions throughout the course of the year. National celebrities and leaders, if willing, will be asked to occasionally participate in these lessons. A social media and telecommunication effort is employed to facilitate communication between students of certain groups

And most importantly, the HIV/STI epidemic is affecting young minority women at astoundingly rate. Because of this, TLC has a focus on reaching out to this subgroup population through a specially tailored approach, perhaps through after school sessions. This aspect of the curriculum mirrors an approach taken from a successful program knows as HORIZONS. “It is a group-level, gender and culturally tailored STD/HIV intervention with continued follow up. Group sessions are conducted by African American women health educators. Sessions foster a sense of cultural and gender pride and emphasize diverse factors contributing to adolescents’ STD/HIV risk, such as structural factors within relationships, socio-cultural factors, perceived peer norms supportive of condom use and skills” (19).

Defense Intervention 1: Moving past the individual

When designing an intervention, understanding the target population, beyond the individual is central to success. Adolescence is a unique stage of life, placing the teenage mind in a completely different state, compared to those of us creating interventions. As such we must consider the forces that influence their behavior and thoughts. Per the theorist Erickson, adolescence is the stage of ‘Identity versus Role Confusion’. This is a time of “radical change – the great body changes accompanying puberty, the ability of the mind to search one’s own intentions and the intentions of others, the suddenly sharpened awareness of the roles society has…” (20). Therefore teenagers are innately socially oriented individuals, with a potent awareness of what their peers are doing, and what society in general is doing, in pursuit of their own identity. They are absorbed in finding their role in society – in non Erickson’s terms, fitting in, being accepted, being ‘cool’. Their behaviors and actions, award them the feeling or status they seek and their individual behaviors, and beliefs are often and consistently a result of peer influences, as measured by perceptions of peer behaviors and attitudes” (21). Sexual behavior is no stranger to this social structure, as shown by the following study on adolescent oral sex and peer popularity:

Results indicate that sexually active adolescents enjoy higher status among peers or perhaps that popular adolescents feel more pressured or inclined to report that they are sexually active. Adolescents may believe that sexual activity best matches a prototype of popular, high-status adolescents…The desire to engage in, or simply report, sexual activity may reflect adolescent motivation to imitate the [popular] student (22).

These findings are concurrent with the presumption that “individual behavior is influenced by perceptions (often inaccurate) of what other people accept and expect, and how they behave: this is the premise of social norms theory, often employed in prevention strategies” (23). Using the basis these presumptions, we can address these group-level misperceptions and thereby foster individual behavioral change.

TLC does this by training voluntary high-status (popular) students to become co-facilitators of the small group sessions in the proposed CHE curriculum; Encouraging peer educators to voluntary open reporting of healthy sexual behaviors, including abstinence, and negotiation skills. As other students meet in these intimate group sessions that are being led by popular students, the association of sexy/risky behavior with popularity will become defunct, establishing a new social norm: that of healthy sexual habits.

Defense Intervention 2: Communications Theory

One unique approach that TLC offers is changing the configuration of sex health educators. As referenced to earlier, communication theory suggests that messages are likely to be taken in a positive manner, if delivered through a means that is well liked, familiar and carries positive associations. Teachers are associated with the routine day to day lessons, the jail that the classroom might be for some students, and the typical didactic approach to school. Thus, trending away from the traditional approach that mostly uses school teachers is worth exploring. The TLC approach involves carefully selected educators based on likeability, positivity and power of influence; the teams are composed of peers, community members, celebrities, and the use of social media to change the tempo of learning(5).

Using high-status peers as educators, not only sets a new norm, but also provides a messenger that shares similar characteristics as the audience. At an urban school, a peer educator will likely be from the neighborhood, culture, similar demographics…etc. At most, student will have some of familiarity with the peer-educator. Influential community members that make up the school population, to help facilitate small groups or present cases, and examples of. Celebrities passionate about sexual health, especially in minority groups, that can not only make a showing at the schools, but also place the efforts on a national media. The final approach uses text-messages and social media (face book, twitter), to spread information about sexual health among participants.

Defense Intervention 3: Tailored approach for specific at-risk subgroups

As previously alluded to, sexual behavior is a complex entity, and should be considered within the context of the influential interplays of external factors. As such, the different characteristics of individuals making up the population should be considered in order to design a tailored approach. Young African American, and Latino women are disproportionately affected by the STI/HIV epidemic; understanding and targeting factors leading to this disparity is pivotal in tailoring a solution. One of these factors is gender. While we have made considerable headway in the fight for gender equality, women continue to be subordinate to men, often objectified and depicted by social media as sexual entities. This view is even more apparent in underserved communities, demanding its attention by any sexual risk reduction program. While TLC hopes to tailor several sessions for the different groups, the young women in urban schools are an important target. The basis of the approach is routed in ‘The Theory of Gender and Power coined by Robert Connell, based on philosophical writings of sexual inequality, gender and power balance.

“ It is a social model that seeks to understand women’s risk as a function of different structures. [It] characterizes the gendered relationship between men and women: the sexual division of labor, sexual division of power, and the structure of cathexis…addressing the affective component of relationships….Each structure constitutes different risk factors and exposures that increase women’s vulnerability for adverse health outcomes. Thus is it critical to assess the exposures and risk factors of all three structures as they interact to cause an adverse impact on women’s health (24).

Two reports reviewing HIV sexual risk reduction for at-risk women both found that the most efficacious HIV prevention programs for women (1) are guided by social psychological theories; (2) include only women; (3) emphasize gender related influences, such as gender-based power imbalances and sexual assertiveness; (4) are peer led; and (5) require multiple sessions (24). This is the basis of TLCs tailored program, which borrows its structure from a current program known as HORIZONS, also based on the Theory of Gender and Power (19, 24)

Conclusion

Establishing a curriculum that promotes maintenance of a healthy sexual lifestyle and significantly reduces the rate of STI/HIV transmission, is a desirable goal, but inarguably simple at all. However we can look to evidence of previously successful programs, both within and outside the school setting, and apply these strategies to addressing this dire concern. One step towards this involves a call to politicians and special interest groups to view the world outside the context of their perspective, and accept that sexuality is innate to humanity and controlling or completely abstaining has proven difficult for the adult let alone the adolescent. That several other factors, many uncontrollable, unrecognizable and deeply institionalized that we cannot expect teenagers to just simply say no, but rather we should equip them with the psychological, social, and efficacious tools to manage their behaviors. This begins with acknowledging the most successful approach to behavioral change, equipping schools with funds, guidelines and structure on how to implement these strategies, and most of all mandating the states to actually do this. The problem of adolescence is one of role confusion—a reluctance to commit…but given the right conditions - space and time, a psychosocial moratorium, when a person can freely experiment and explore—what may emerge is a firm sense of identity, an emotional and deep awareness of who he or she is (20).

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