How to fill gaps in sexual health education

Fewer than half of US high schools and a fifth of middle schools teach all of the components of sexual health education recommended by the Centers for Disease Control and Prevention (CDC), according to a report released at the National HIV Prevention Conference in Atlanta and are based on CDC’s 2014 School Health Profiles, which surveys schools every other year about what they teach about human immunodeficiency virus (HIV), sexually transmitted diseases (STDs), pregnancy prevention, and more.

Additionally, while adolescent pregnancies are at a record low number-dropping 10% since 2012 and by about 50% since 1991-pregnancy rates are still higher in the United States than in other industrialized Western nations, and about a third of them end in abortion, according to CDC and American Academy of Pediatrics (AAP). The STD rates in the United States are among the highest in the industrialized world, adds AAP.

About a quarter of all new HIV infections occur in young people aged between 13 and 24 years, says CDC’s Kathleen LaPorte, and about half of the 20 million new STDs occur in those aged under 25 years.

“Physicians should be prepared to talk to their patients about their sexual health and provide them with the appropriate education and resources they need to remain healthy, including helping them understand how they can access health services such as HIV and STD testing, pregnancy testing, and contraceptives,” LaPorte says.

The number of teenagers having sex has remained the same over the last few decades, despite a reported decline in sexual risk behavior, says CDC. According to CDC’s Youth Risk Behavior Surveillance System, about 47% of teenagers admit to being sexually active, 15% in 2013 reported having 4 or more sexual partners-the same percentage as a decade before, and 30% of high school freshman say they are sexually active.

The CDC also reports that while many middle and high school students are engaging in sexual behavior, they are not necessarily doing so safely. Fewer teens today use condoms, with 59% saying they used condoms the last time they had intercourse compared to 63% in 2003, and roughly a quarter of the teenagers polled reported that they used drugs or alcohol during their last sexual encounter.

Adolescents with learning problems, low academic attainment, behavioral or emotional problems, low socioeconomic status, ethnic minorities, victims of abuse, and children with low levels of parental supervision are more likely to engage in early, risky sexual behavior, says AAP.

The CDC’s Kathleen LaPorte says the agency provides schools with a guide to develop and improve sexual education programs, such as the Health Education Curriculum Analysis Tool (HECAT) and the School Health Index.

“The HECAT allows educators to assess curricula to assure they are covering critical topics in a way that is likely to be effective in increasing students’ knowledge and skills,” says LaPorte. “The most recent School Health Profiles report was an evaluation of how schools are implementing CDC’s recommended curricula from the HECAT.”

Despite support from CDC, adoption of its recommended education content varies widely across the country. Only 21% of high schools in Arizona teach all 16 components recommended by the CDC, compared with 90% in New Jersey. In most participating states, CDC says fewer than half of the high schools teach all 16 topics, and only 3 states-New Jersey, New York, and New Hampshire-have more than 75% of schools achieving CDC’s goal of teaching all 16 topics.

NEXT: What about middle schools?

At the middle school level, even fewer schools comply with CDC’s recommendations. In fact, not a single state had more than half of its middle schools teach all 16 topics, and in most states, only 20% taught the full curriculum. State adoption rates varied widely, from a mere 4% teaching all 16 topics in Arizona to 46% in North Carolina.

The 16 sexual health education topics recommended by CDC include:

1. How to create and sustain healthy and respectful relationships.

2. Influences of family, peers, media, technology, and other factors on sexual risk behavior.

3. Benefits of being sexually abstinent.

4. Efficacy of condoms.

5. Importance of using condoms consistently and correctly.

6. Importance of using a condom at the same time as another form of contraception to prevent both STDs and pregnancy.

7. How to obtain condoms.

8. How to correctly use a condom.

9. Communication and negotiation skills.

10. Goal-setting and decision-making skills.

11. How HIV and other STDs are transmitted.

12. Health consequences of HIV, other STDs and pregnancy.

13. Influencing and supporting others to avoid or reduce sexual risk behaviors.

14. Importance of limiting the number of sexual partners.

15. How to access valid and reliable information, products and services related to HIV, STDs, and pregnancy.

16. Preventive care that is necessary to maintain reproductive and sexual health.

NEXT: How doctors can help

The CDC recommends that teachers responsible for sexual health education be provided educational materials and a curriculum that includes objectives and expected outcomes. Teaching strategies should include age-appropriate lessons and evidenced-based interventions, as well as opportunities for students to engage in the learning process, says CDC. Teacher should also have a way to assess student knowledge and skills related to sexual health education.

While CDC’s report emphasizes interventions in schools, a recent paper published in Pediatrics states that school-based programs are not as effective as strong parental influence.

The study found that higher parental monitoring and rule enforcement was associated with delayed intercourse, and greater condom and contraceptive use.

Study authors recommended healthcare providers, including pediatricians, initiate family-based interventions to encourage and support parental monitoring.

The report affirms earlier AAP recommendations that pediatricians have a unique role in supporting parents and educating adolescents on sexual health matters.

Physicians should keep in mind that while some schools do offer sexual health education, protecting adolescents requires a multi-tiered approach, LaPorte says.

“While schools provide an important avenue for reaching youth with critical knowledge and skills related to sexual health and reducing risk for HIV, STDs, and unintended pregnancy, healthcare providers offer a crucial medium for delivering this information as well,” she says. “It is important that physicians are thinking about the sexual health of their patients and providing them with age-appropriate information on sexual health. Physicians should be striving to reach youth with this information before they become sexually active, so when they do, they already have the skills and information they need.”

The AAP recommends that pediatricians integrate sexual health education into clinical practice beginning in early childhood; provide education materials to reinforce office-based messages; be knowledgeable and provide information to families about community services for additional sexual health services; and participate in developing and implementing sexual health programs in the local schools.

“Pediatricians are in an ideal position to provide longitudinal sexuality education to children and adolescents as part of preventive health care, and many tools are available to guide their efforts,” says AAP. “Additionally, pediatricians' efforts may be useful in complementing school or community-based programs.”

The pediatrician-patient relationship offers opportunities not available in school-based programs, adds AAP.

“Unlike school-based instruction, discussion of sexuality with pediatricians provides opportunities for personalized information, for confidential screening of risk status, and for health promotion and counseling,” the academy states. “Children and adolescents may ask questions, discuss potentially embarrassing experiences, or reveal highly personal information to their pediatricians. Families and children may obtain education together or in a separate but coordinated manner. Prevention and counseling can be targeted to the needs of youth who are and those who are not yet sexually active and to groups at high risk for early or unsafe sexual activity.”