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Altidor C, Davis J. Ensuring health equity in adolescent sexual health education. HPHR. 2021;46. DOI:10.54111/0001/TT1
The content and design of sexual health education varies widely by state. Some jurisdictions require a comprehensive sexual health education for youth that includes a health equity focus, however there are still far too many youth who do not receive this. Youth face unique challenges, especially as it pertains to their sexual health, and the sex education they receive should speak to those challenges. These include discrimination based on race or sexual orientation, disparities in rates of STDs and teen pregnancy, and poverty. A health equity-focused sexual health education provides information that acknowledges these challenges and provides relevant resources to help youth to make healthy decisions. Currently, 30 states and the District of Columbia mandate that when provided, both sex and HIV education meet certain general requirements that include cultural sensitivity and information that is free of bias. Strategies to ensure health equity in sexual health education include using inclusive language, encouraging sex positivity, reducing stigma, and conducting regular trainings for staff or educators.
Sexual health education is vital to the overall health and wellbeing of young people. According to Advocates for Youth, comprehensive sex education helps youth avoid negative health consequences, communicate about sexuality and sexual health, understand healthy and unhealthy relationships, show dignity and respect for all people, and protect their academic success. These benefits are especially important for youth in marginalized groups as these youth face unique challenges and disparities.
Lesbian, gay, bisexual, transgender, queer, intersex, asexual (LGBTQIA+) youth face discrimination, violence, stigma, and social rejection, all of which affect their ability to make healthy decisions.
Adolescent gay and bisexual males have disproportionately high rates of HIV and STDs, while adolescent lesbian and bisexual females are more likely to have been pregnant than adolescent heterosexual females. Transgender youth are also more likely to report violence, risky sexual behavior, and being tested for HIV.
Non-white youth are disproportionately affected by HIV and sexually transmitted diseases. In 2018, Black youth and adults made up 42% of newly diagnosed HIV infections in the United States. Black male and female youth experience higher rates of chlamydia (9.1 times and 4.5 times higher, respectively), gonorrhea (9.4 and 8.8 times higher, respectively), and syphilis (4.7 times higher) than Non-Hispanic White youth.
These disparities also exist among the Hispanic population, accounting for 27% of all new HIV diagnoses in 2018 and experiencing rates of chlamydia, gonorrhea, and syphilis that are 1.9, 1.6, and 2.2 times higher than those experienced by Non-Hispanic Whites. Black and Hispanic youth report lower prevalence of contraception use or use of any pregnancy prevention method.
Adolescents living in poverty experience challenges with access to services, and research has shown an association between adolescents attending a high poverty school and low levels of sexual health knowledge. These disparities highlight the necessity of utilizing a health equity lens in sexual health education interventions to support youth in marginalized groups where all backgrounds are considered, including an adolescent’s race, ethnicity, income, gender, religion, sexual identity, and disability.
Studies show that utilizing a health equity lens is a critical component to inform policies and practice related to comprehensive sexual health education. This can be achieved by incorporating instruction, learning strategies materials that are trauma-informed, culturally responsive, sex positive, and grounded in social justice and equity. However, sexual health education curriculums, whose goal should be to ensure all youth have a chance to be healthy and make healthy decisions, vary widely in jurisdictions across the country.
Currently, 27 states and the District of Columbia mandate both sex education and HIV education, 2 mandate sex education only, and 9 mandate HIV education only. 30 states and the District of Columbia mandate that when provided, both sex and HIV education meet certain general requirements. These include providing content and instruction that is medically accurate, age appropriate, culturally sensitive and not biased against any race, ethnicity, or sex. The CDC’s School Health Profiles 2018 also lists a number of topics important for sexual health education for adolescents.
The Michigan Department of Education (MDE), in partnership with the Michigan Organization on Adolescent Sexual Health (MOASH), serves as a good example of successfully incorporating health equity as a best practice for HIV and sex education. This past year, MDE LGBTQIA+ Students Project offered a variety of inclusive virtual trainings and resources for school personnel to ensure LGBTQIA+ students feel safe and connected at school. Additionally, the deputy superintendent shared resources (which can be found here) for school personnel and parents, including the law and best practices for sex education in school (found here). The MDE website also provides considerations for implementing health education, including sex education, at a distance as well as information regarding standards and curricula.
On the other hand, adolescents in states where sex education is not mandated often lack information vital to their wellbeing. Leaving the decision to offer sex education up to local school districts opens the door for the implementation of certain policies and curriculums that further stigmatize marginalized groups and allow for biased instruction. For example, in Texas, where neither sex nor HIV education is required, about 45% of LGBTQIA+ students feel unsafe at school due to their gender expression and even more (about 60%) feel unsafe because of their sexual orientation. In Montana, where sex education is required but decisions on content and curriculum are left up local school districts, only 42% of secondary schools provided instruction or resources that were relevant to LGBTQIA+ youth. Inclusive, equity-focused education curriculum supports safe and supportive environments in schools and benefits all youth regardless of their sexual orientation.
Comprehensive sexual health education provides youth with the appropriate information, valuable skills, and motivation to help them make healthy decisions for themselves about sex and sexuality. It should cover a wide variety of topics not simply limited to sex and sexuality, but also include human development, relationships (both romantic and platonic), personal skills, values, boundaries, sexual behavior, sexual health, and society and culture.
The benefit of comprehensive sexual health education ensures that all youth are equipped with tools and resources that work specifically for them regardless of individual choices and circumstances, such as inclusive and affordable providers, services, and education materials. It also ensures youth are taught about sexual health and personal behaviors in a way that is affirming by providing them with a safe space to ask questions and share personal challenges. When youth are allowed the opportunity to learn in a way that feels safe to them, they will be more receptive to the information presented and use that to make the appropriate decisions for themselves. Combined with a comprehensive curriculum, this is a great formula for leading youth to optimal sexual health and wellbeing.
An equity focused curriculum should aim to understand and expound upon the impact of systemic racism on sexual health equity in youth of color. The COVID-19 pandemic serves as the most recent example of the racial disparities that have historically disproportionately affected youth of color. Individuals that experience the effects of racism and disparities as youth often have poorer health outcomes as adults.
For example, chronic racism and discrimination can lead to chronic stress, which can have negative health implications that lead to chronic disease. Youth of color also have lower rates of high school graduation, with 76% of African-American youth graduating high school in the 2015-2016 school year as compared to 88% of white students. This can also lead to negative health implications later in life as adults with college degrees live longer and experience lower rates of chronic disease.
Teen girls of color experience higher birth rates than white teens, leading to socioeconomic challenges and low educational attainment as teen moms are more likely to drop out of school. Children of teen moms are also more likely to drop out of school and experience chronic health issues.
Acknowledgement of the unequal distribution of resources and understanding the mistrust of the health care system and medical providers by people of color is important. Historically, people of color have mistrusted medical providers due to a long history of medical mistreatment, discrimination, and experimentation such as the Tuskegee Syphilis Study.
One study that surveyed white medical students and residents found that half of the participants held false beliefs around pain and race, namely that black people have a higher tolerance for pain than white people. These false beliefs lead to discrimination around pain management and treatment in health care.
An equity-focused curriculum should speak directly to the experiences of the adolescents and acknowledge that these disparities are directly related to the historical and current unequal distribution of social, environmental, economic, and political resources in communities of color.
Another example of the need for an equity-focused curriculum can be seen in LGBTQIA+ youth, who face other discrimination challenges as it relates to health policy. While 42% of the LGBTQIA+ population lives in states that include insurance protections for sexual orientation and gender identity, 45% of the population lives in states that do not. These laws and policies protect LGBTQIA+ people from being unfairly denied coverage for certain procedures or insurance policies because of their sexual orientation or gender identity. Policy considerations also include policies at the local and school district levels. Some school districts may lack necessary policies around the use of inclusive language in schools or important protections for transgender and LGBTQIA+ students. The policies of individual jurisdictions and schools should be examined for their specific policies and regulations around these topics.
Nationally, state legislation influences how sexual health education is governed by various policy efforts and decision-making. As of July 2021, over 120 bills were introduced related to sexual health education instruction and curriculum in schools. Over half of the bills sought to advance the quality of sexual health education, however a quarter of them still sought to restrict instruction in schools. Additionally, 22 states have considered legislation that would ban best practice medical care for transgender youth, and one state has passed this legislation. Despite this, 2021 saw an increase in legislative efforts to adapt state sexual health education requirements to have inclusive instruction, school activities and affirming medical care for LGBTQIA+ youth. Advocacy efforts to combat regressive legislation is key in advancing quality, equity focused sexual health education.
A number of strategies can be used when developing, revising, or teaching a sexual health education curriculum through a health equity lens. Those strategies include the following:
Use respectful language that acknowledges diversity and is sensitive to everyone’s differences. Address youth using their preferred pronouns, use gender neutral terms such as “folks” or “you all”, and avoid derogatory slang terms. If there combis uncertainty around a term or concept, ask youth for their preferences. Encourage heterosexual and non-BIPOC youth to learn and use proper terminology and preferred pronouns and discourage negative language.
Sex positivity is the idea of allowing space for open discussion of topics around human sexuality, health, and pleasure without shame or stigma. Examples include exploring personal sexual wants and needs, prioritizing a healthy sex life, setting healthy sexual boundaries, and accepting the consenting sexual behavior of others, rather than judging
According to the CDC, “stigma is discrimination against an identifiable group of people, a place, or a nation.” Recognize and acknowledge the differences of everyone and treat everyone in an equitable manner. Combat the lack of knowledge that is often the root of stigma by correcting negative language and inaccurate information that can cause harm. Ensure that images used show diversity and do not reinforce stereotypes and utilize news and social media channels to speak out against stereotyping and advocate for those experiencing stigma.
Offer resources and information that will help adolescents feel comfortable with the information being presented. These resources can include inclusive and gender-affirming clinics or providers, where youth can access free and confidential STD/HIV testing and treatment and pregnancy testing, and information on contraception and pregnancy counseling. This can also include utilizing materials that showcase people who look like them.
Efforts at the state and local level should focus on a comprehensive sex education for youth that is age and developmentally appropriate, culturally sensitive, medically accurate, sex positive, and addresses personal beliefs, values, attitudes, and group norms that support healthy behaviors.
Educate youth on ways to speak up for themselves and encourage them to use their voice to promote health equity for themselves and others. Provide them with ways to advocate for themselves with providers and other adults, educate them on how to seek out care that is appropriate for their needs, and allow them to practice these skills so that they can be comfortable recognizing and speaking out against any form of discrimination or mistreatment. Educate heterosexual and non-BIPOC youth on the importance of allies and encourage them to also speak out against discrimination or mistreatment being experienced by others.
Listening to youth and allowing them to share their needs is essential when designing instruction for them. Allowing them to voice their concerns can help fill gaps and ensure that they are getting what they need.
Trainings allow staff and instructors to regularly evaluate material and curriculums and make any changes to ensure quality and relevance. It also helps instructors to feel comfortable teaching the material, as well as gives them the opportunity to dig deeper into topics they may not fully understand themselves.
Adolescents today face a number of unique challenges, especially as it pertains to their sexual health. A health equity-focused sexual education can ensure that they have the tools and skills they need to face and overcome those challenges. By utilizing the appropriate strategies and continuing to keep equity at the forefront, we can all help secure a healthier future for all adolescents.
We would like to thank our colleagues at NCSD for their continued support of our work and guidance throughout this process. We also would like to thank all of our partners for their shared expertise and many contributions to the work of the Adolescent Health Team.
The authors have no personal, commercial, academic, or financial interests that influence the research and opinions represented in this manuscript. This submission is not under consideration by another publication and has not previously been published elsewhere. Both authors have contributed to the creation of this submission and grant HPHR permission to review and (if selected) publish this work.
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Christy Altidor serves as Director, Adolescent Health Policy at the National Coalition of STD Directors (NCSD) where she supports capacity building and technical assistance on adolescent sexual health to NCSD partners throughout the country. She also serves as a subject matter expert in the development and delivery of online training content for DIS. Prior to joining NCSD, Christy worked as a DIS and DIS frontline supervisor with the Florida Department of Health for over five years. She is passionate about STD/HIV prevention and an advocate for sexual and reproductive health. She received her BS in Health Services Administration from the University of Central Florida and her MPH from the University of South Florida.
Jerrica Davis serves as Senior Manager, Adolescent Health at the National Coalition of STD Directors (NCSD) where she supports capacity building and technical assistance on adolescent sexual health to NCSD partners throughout the country. Prior to joining NCSD, Jerrica worked for Crittenton Services of Greater Washington where she facilitated school-based social-emotional learning and sexual health programs for teen girls throughout the D.C Metro area. She received a dual BS in Kinesiology and BA in Spanish from The University of North Carolina at Greensboro and her MPH from The George Washington University.
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