Each year, over 4 million girls 15–19 years old seek obstetric or gynecologic care in the United States.1 Rates of sexual activity among U.S. teens are similar to or lower than those reported in other developed nations,2 but rates of teen pregnancy, births, and abortions in the United States are among the highest.3 Although the overall rate of adolescent pregnancy has decreased, by 12th grade, nearly two thirds of U.S. high school students have engaged in sexual intercourse.4
Adolescents with accurate knowledge about abstinence and contraception are more likely to delay sexual debut and to use condoms and other contraception when they do become sexually active.5 Effective parent-initiated and sustained communication has also been shown to positively influence adolescents' behavior.6 Sex education in schools also plays an important role. Most parents support school-based sex education,7 which has been part of U.S. public schooling for decades8 and is regarded by teens as an important source of information on sexual health.9 Physicians are also considered an important source of sexual health information for young people, although physicians often neglect this topic.10
Since 1996, over $1 billion has been jointly invested by the U.S. federal government and individual states to encourage the development of “abstinence-only-until-marriage” programs.11 These programs are supported by three sources of funding: Title V, Section 510 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996,12 the Community-Based Abstinence Education Grant Program,13 and the Adolescent Family Life Act of 1981.14 To qualify for funding, the programs must adhere to an 8-point definition of abstinence that includes “a mutually faithful monogamous relationship in the context of marriage as the expected standard of human sexual activity.”12 Additional “abstinence-only-until-marriage” regulations have discouraged and limited teaching of contraceptive methods.13 Despite 30 years of advocacy for comprehensive sex education by leading health organizations, including the American College of Obstetricians and Gynecologists (ACOG) (Table 1),15–30 no dedicated federal funding has been available for such efforts.
Topics deemed integral to a comprehensive program vary by organization, but there is general agreement that adolescents should be provided, at minimum, medically accurate information about abstinence, contraception, HIV/AIDS, and other sexually transmitted diseases (STDs).
Little is known about the content of sex education in public schools, particularly from sex education teachers' perspective. The purpose of this study is to examine sex education in the United States using Illinois as a case study. Illinois is the nation's fifth most populous state and reflects the sociodemographic diversity of the nation.31 This study examines the content, quality of, and influences on sex education and determines predictors of a comprehensive sex education curriculum. These data will assist physicians in identifying and filling gaps in adolescent knowledge and skills important for preventing unwanted pregnancy and STDs and for promoting reproductive and sexual aspects of young people's health.
MATERIALS AND METHODS
A probability sample representative of Illinois public school sex education teachers was selected from public middle and high schools across Illinois. The state was first divided into mutually exclusive geographic regions. Within each region, sampling was performed based on a three-stage design with school districts as the primary sampling unit (n=112), schools within the selected districts as secondary units (n=201), and sex education teachers within the schools as the final units of analysis (n=335). A self-administered survey questionnaire concerning the 2003–2004 school year was mailed with $10 to the selected teachers between October and December 2004. A second copy of the questionnaire was mailed 3 weeks later to nonresponders. The analysis was limited to respondents who taught sex education during the 2003–2004 school year. The survey questionnaire was designed and administered by NORC, Chicago, IL. A diverse panel of experts in the areas of adolescent health, secondary education, clinical medicine, and health survey research formed a review team that iteratively advised on questionnaire development and content. The questionnaire was developed to maximize comparability to existing literature.8,32 The protocol was approved by the NORC institutional review board. Completion and return of the survey questionnaire constituted informed consent. The questionnaire assessed teacher demographic and professional characteristics and teachers' perception of the racial composition of their sex education classes.
The contents of the sex education curricula were assessed by asking about topics taught, how abstinence was taught, and what curriculum was used. Teachers were asked to indicate all of the topics they taught during the 2003–2004 school year from a list of 17 topics adapted from a prior survey32 (Fig. 1). For every topic not taught, the respondent indicated the main reason for omission: 1) “you felt pressured by the community and parents not to teach it,” 2) “it is school or district policy not to teach it,” 3) “you felt pressured by the principal not to teach it,” 4) “you personally felt this shouldn't be taught,” 5) “there wasn't enough time in the curriculum,” 6) “the topic was covered in an earlier grade,” 7) “the topic will be covered in a later grade,” 8) “not part of the curriculum,” and 9) “funding limitations.”
For comparability to prior studies,8,32 teachers were also asked “Which of the following best describes the way you taught about abstaining from intercourse in your sex education instruction?” Teachers chose from the following options: “Abstinence is presented as” 1) “one alternative,” 2) “the best alternative,” or 3) “the only alternative for preventing pregnancy and STDs,” or 4) “I don't teach about abstinence from intercourse.”
Respondents were asked “What curriculum do you use [to teach sex education]?” and instructed to check all that apply from a list of seven abstinence-only and six “other” curricula most commonly used in Illinois public schools (see the Box, “Categorization of Curricula Used by Illinois Sex Education Teachers”). Respondents were also given a write-in option to indicate curricula not listed; those not classifiable were excluded from the curriculum-based analyses. Each teacher was identified as teaching an 1) abstinence-only curriculum alone, 2) abstinence-only curriculum in conjunction with an “other” curriculum, or 3) “other” curriculum alone. A curriculum was considered “abstinence-only” if it satisfied at least one of the following three criteria: 1) funded by one of the three aforementioned federal abstinence education programs (Title V, Section 510,12 Community-Based Abstinence Education,33 or Adolescent Family Life Act14), 2) the content adhered to the federal 8-point definition of abstinence-only education in Title V,12 and/or 3) it focused on abstinence as the sole method of pregnancy and STD prevention, with little or no discussion of contraceptive options.
To assess what factors influence the curriculum taught, teachers were asked “How much influence did each of the following have on deciding the sex education topics you taught?” Respondents rated each of seven areas of influence on a 4-point scale (Fig. 2). This question was also adapted for comparability to a prior study.32
To ascertain quality of sex education in Illinois public schools, teacher training was assessed by a yes or no question: “Were you trained to teach sex education?” Respondents were also asked, “With A meaning excellent and E meaning very poor, what grade would you give the sex education curriculum you most recently taught (during the 2003–2004 school year) in terms of how well it prepared students” in nine topic areas.32 The question “How comfortable were you teaching sex education?” assessed respondents' overall comfort on a 4-point scale ranging from “Very comfortable” to “Not at all comfortable.”
Comprehensiveness was defined as coverage of, at a minimum, all of the following topics: abstinence (either until older or marriage), HIV/AIDS, other STDs, and contraception. This definition derives from commonalities among prevailing definitions of comprehensive sex education (Table 1). The number of topics taught (out of 17) was additionally analyzed as an alternative marker of comprehensiveness (more topics suggesting a more comprehensive approach). These complementary analytic approaches were used due to lack of a uniform definition of comprehensive sex education.
All analyses were carried out using STATA 9 (StataCorp, College Station, TX). Demographic characteristics and the teaching experience, practices, and beliefs of teachers were described using mean±standard error for continuous variables and percentages for categorical variables. To generalize the findings for all Illinois sex education teachers, weights were employed to account for unequal probability of selection and nonresponse. Standard errors were calculated using the linearization method.34 Factors associated with teaching various topics were examined by means of χ2 tests. The Wilcoxon signed-rank test was used to compare the influential effects of various factors on which topics were taught. Multivariable logistic and linear regression were used to model the likelihood of teaching a comprehensive program and the number of topics covered, respectively, as a function of covariates of interest, including gender, teacher training, general teaching experience, and proportion of nonwhite students. These covariates were chosen based on a two-stage model-building procedure. First, covariates found to be associated with comprehensiveness (by either definition) in univariable analyses were included in the models. Second, the remaining covariates were added, one at a time, to detect any significant associations not evident in the first stage. P≤.05 was used to indicate statistical significance.
Of the 335 sex education teachers surveyed, 209 teachers completed the survey, yielding a response rate of 62.4%, representing 91.3% of sampled schools. Of these respondents, 166 taught sex education during the 2003–2004 school year, predominantly to students in grades 7 through 10. Demographic information about nonresponders was not available.
Table 2 summarizes the demographic and professional characteristics of Illinois public school sex education teachers. Overall, 93% of Illinois public schools offered sex education, either by their own teachers and/or with the help of outside agencies. Of all teachers reporting identifiable sex education curricula (n=100), 26 (24.3%, weighted) indicated that they teach an abstinence-only curriculum in combination with, or supplemented by, other curricular materials. Of all teachers reporting use of any abstinence-only curriculum (n=73), 26 of these (or about a third) were teaching information in addition to abstinence.
Figure 1 summarizes the frequencies of 17 sex education topics taught across eight domains (domains are groups of closely related topics). Nearly 70% of teachers reported that they covered 10 or more of the 17 topics, but only 23% covered at least one topic in each of the eight domains. Topics common to both abstinence-only and other sex education curricula (eg, HIV/AIDS and abstinence) were among the most frequently covered. Practical skills (eg, how to use condoms and other forms of birth control, decision-making and communication skills) and morally debated topics (eg, abortion and homosexuality and sexual orientation) were among the least frequently taught. Overall, topics relating to accessing reproductive and sexual health services, factual information about contraception, and homosexuality and sexual orientation were only covered by a minority of teachers. Among those teaching abstinence, 57% emphasized abstinence as the “best alternative,” “the only alternative” (39%), or “one alternative” (4%).
Male teachers trained in sex education were significantly more likely to teach about homosexuality and sexual orientation as compared with trained females (53% compared with 21%, respectively, P<.01). Among untrained teachers, no such gender difference was found, but the likelihood of teaching about this topic was significantly lower among all untrained teachers as compared with trained male teachers (27% compared with 53%, respectively, P=.03). Males were also more likely than females to cover abortion (52% compared with 28%, P=.01). White teachers were more likely than others to teach about abstaining from sex until older (91% compared with 45%, P<.01). Additionally, teachers with more than 7 years of sex education experience were more likely to teach abstinence until marriage, or until older, than those with less experience (97% compared with 80%, P<.01).
Nearly a third of sex education teachers indicated that they had not received sex education training and about half reported 7 or fewer years of experience teaching sex education (Table 2). Each of the 17 topics was more likely to be taught by teachers with sex education training than by those without, although this difference was not statistically significant in all cases (Fig. 1). Among the reasons given for omitting a specific topic, the most common reason cited by teachers for most topics was that it was “not part of the curriculum.” The most commonly cited reason for omitting HIV/AIDS and other STDs was that they were “covered later.” “School or district policy” was most commonly cited as the reason for omitting the topic of condom use. The quality of coverage of topics frequently taught by teachers of both abstinence-only and other curricula, including the basics of reproduction and abstaining from sex until later in life, was graded higher than less frequently taught topics, such as communication about sex and contraceptive use skills (Table 3). Furthermore, training was significantly associated with comfort in teaching sex education: 85% of trained teachers felt “very comfortable” compared with only 56% of those not trained (P<.01).
Availability of curricular and related materials was the only factor rated by a majority of teachers as having “a great deal of influence” on the topics taught (Fig. 2), and this factor was perceived to have significantly more influence compared with each of the other factors (P≤.01 for each comparison). Overall, parental input was consistently cited by a majority of teachers as having “not too much” or “no influence” on the topics taught. Nearly two thirds of teachers reported that their school or district had a policy on the teaching of sex education. Among this group, 63% had to follow some guidelines, 14% had to follow very strict guidelines, and 23% could select the topics they wanted to teach rather than follow external guidelines.
Almost two thirds of teachers (65.1%) reported covering the four topics (abstinence until marriage or older, HIV/AIDS, other STDs, and contraception) required to meet the minimum criteria for program comprehensiveness (Table 2). Predictors of educational program comprehensiveness, using the two approaches, are summarized in the multivariable analyses presented in Table 4. Those reporting training in sex education were nearly 2.5 times more likely to teach a comprehensive program (Model 1), and they taught a significantly greater number of topics (Model 2), after controlling for other factors. A third model (not shown) added the topic “where to get condoms, birth control, and health related services” to the comprehensiveness definition (42% of teachers covered all five topics) as most health organization guidelines include this criterion. Adding this topic strengthened the association between teaching a comprehensive curriculum and training in sex education (odds ratio 4.11, 95% confidence interval 1.61–10.52, P<.01) and had minimal effect on the other associations.
The ACOG Committee on Adolescent Health Care recommends that “the first visit to the obstetrician-gynecologist take place between 13 and 15 years of age.”35 In addition to advocating parental involvement in adolescent sex education, the Committee encourages increasing the availability of confidential reproductive health services and the effective use of contraceptives through the provision of scientifically accurate information on contraception, STDs, and preventive health care.15 Obstetrician-gynecologists caring for adolescents (and/or for patients who are mothers of young children and adolescents) have a critical role in identifying and filling important, health-related gaps in adolescent knowledge about sexuality.
The current study focuses on the content of sex education and the determinants of comprehensiveness to help health care providers understand possible gaps in adolescent patient knowledge. We found that most adolescents in Illinois public schools receive some form of sex education, although the content, perceived quality, and comprehensiveness of sex education programs varies across teachers. Topics common to abstinence-only and other sex education curricula are the most frequently taught; the minority of teachers cover domains related to accessing health care for sexual concerns, communication about sex-related matters, how to use contraception, and sexual orientation. The availability of curricular material plays an important role in influencing the topics teachers cover. A third of teachers providing sex education in Illinois public schools are not trained, yet training is the most significant factor in determining the comprehensiveness of the sex education program and the number of topics taught.
Our findings in Illinois corroborate those of recent national studies,8,36 indicating wide use of an abstinence-only approach to sex education in U.S. public schools. These findings may reflect a temporal trend due to aggressive federal incentivization of abstinence-only education during the same period, as suggested by a notable decline in teaching about topics such as contraception, abortion, and sexual orientation since 1995.8,36 Interestingly, although 74% of all teachers reporting a classifiable curriculum in this study used abstinence-only curricula, a third of these teachers supplemented their abstinence lessons with other curricula or resources. Similar to that reported in a prior national study,32 more than 60% of teachers in our sample who used abstinence-only curricula alone also reported teaching about contraception. The prevalence of Illinois teachers presenting abstinence as the only alternative for STD and pregnancy prevention (38%) is somewhat higher than the 23%8 and 34%32 estimates in two national studies. Findings from a recent study conducted as part of the congressionally mandated evaluation of Title V, Section 510 abstinence education programs call into question the effectiveness of this approach.37
We found that several medically relevant topics and skills important for adolescent health and patient-physician communication about sexuality are omitted from most Illinois public school sex education curricula. Teachers themselves give poor quality ratings to the coverage of many of these topics and a substantial number, particularly those without training, feel uncomfortable teaching sex education. The proportion of untrained sex education teachers in Illinois (30%) is higher than the national average (18%).32 This difference may partly explain the relatively higher prevalence of abstinence-only curricula use in Illinois, particularly given our finding that training is a significant independent predictor of both teaching a comprehensive sexuality program and covering a greater number of topics.
Discomfort discussing matters of sexuality is of course not limited to teachers. A good deal of evidence suggests physicians38 and parents39 also avoid discussing matters of sexuality, particularly with youth. Although adolescents may be reluctant to initiate discussion about sexuality with their physician,40 studies suggests that both parents41 and adolescents10 desire greater physician initiative in these areas. However, physician training and confidence in communication about sexuality42,43 and providing confidential care for adolescents44 is poor (see Ford et al45 for a review of confidentiality in adolescent health care). The American Academy of Pediatricians (AAP),16 ACOG,15 and the American Medical Association46 recommendations concur that physicians have an obligation to educate young people about sexuality and the positive and negative health consequences of sexual engagement. Obstetrician-gynecologists and other physicians may also have a role to play by working with public schools, patients who are parents, community organizations, and policy makers to support medically accurate and health-relevant sex education for young people.47,48 Our study describes several areas, including training of sex education teachers, where physicians' knowledge about adolescent health and sexuality could be helpful.
The study may be limited by generalizability to other states in the United States, although the probability sampling design, a relatively high response rate, and data from a state that largely reflects demographic diversity at the national level may mitigate this limitation. Furthermore, because only public schools were surveyed, we are unable to account for the experiences of adolescents in private schools. We also acknowledge the lack of, in the medical or other literature, a standardized definition of sex education “comprehensiveness.” To address this deficit, we use a least-common-denominator approach and define this measure by criteria common across major medical, health, and professional associations' definitions. We also use an alternative measure, number of topics taught. Overall, our definition of comprehensiveness is not as strict as that used by others. For example, Planned Parenthood includes abortion education among the essential components of a comprehensive program,17 and they and AAP16 also include discussion of sexual violence. Guidelines from Sexuality Information and Education Council of the U.S. (SIECUS), an advocacy group, delineate 23 items necessary for comprehensive sex education.18
Adolescent sexuality is both a reality of human development and a subject that can incite debate and discomfort.49 Obstetrician-gynecologists, parents, young people, and policy makers share an interest in preventing unwanted teen pregnancy, sexually transmitted diseases and their sequelae, and sexual violence. Understanding what our patients learn in school (or do not learn) about sexuality may promote improved physician-initiated communication with adolescents and help reduce the burden of these preventable and burdensome sexual health problems.
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