Sometimes things are not as they seem. Sometimes the illusion occurs by accident, but sometimes it is by design. This is clearly the case when it comes to our cultural narrative surrounding sex education. “‘Comprehensive’ sex education” we are told, “is proven effective, and Sexual Risk Avoidance has been proven ineffective.” It’s a worn-out, disingenuous mantra: “abstinence education just doesn’t work.”
In 2009, the Obama administration created an (allegedly) “evidence-based” list of sex education programs that promise to produce positive results. Since creating the list, the US Department of Health and Human Services (HHS) has revised and added to it four times. In 2016, the list was expanded to include forty-four programs. To earn a place on the list, each program must conduct rigorous research showing a statistically significant impact on at least one of the following: sexual activity, number of sexual partners, contraceptive use, sexually transmitted infections (STIs), or pregnancy. While the rigor required for the quality and execution of research designs is strong, other concerns undercut the usefulness of the list as a compilation of national models of effective sex education programs. If we truly want to reach adolescents with effective programs addressing their sexual health and well-being, we must take an honest look at the findings of these programs.
Improving Sex Ed
HHS requires most federally funded sex education programs to select a program from the list and strongly urges states and others to implement these programs. Many communities and states have also begun to require that only programs on the list be presented to their students. But only two of the forty-four programs on the list focus on Sexual Risk Avoidance (SRA). SRA programs are uniquely valuable, since they help youth eliminate risk by avoiding teen sex. Even if they would prefer to teach students SRA, many communities feel forced to select a non-SRA program from the list and somehow make it work for their purposes. Unfortunately, they do not realize that this sort of adaptation erases the research effect for the program.
Although this list is often cited as “proof” that only “comprehensive” sex education is effective, it is actually nothing of the sort. The truth is that sex education research, particularly in schools, is difficult, and there is insufficient evidence to make any unequivocal claims about the effectiveness of any approach as the sole method for communicating sexual health messages to youth.
Ascend, the organization of which I am president and CEO, is serious about improving sex education programs across the nation. And we want you to know: research confirms that SRA is a realistic approach to sex education and it offers the healthiest outcomes for youth.
A growing body of social science research demonstrates that later sexual debut is associated with a variety of protective benefits, particularly for teens. Teens who choose to delay sexual initiation are able to invest more of their time and energy in activities that put them on a path for future success. They tend to devote more time to furthering their educations, volunteering for community service, nurturing healthy relationships, learning from mentors, and planning for their futures. The decision to engage in or to delay sex is not made in isolation. It has an impact that extends far beyond the risks of pregnancy or infection. Behavioral trend data confirm that avoiding sex is a reasonable goal for teens, because most teens have not had sex; in fact, the number of teens not having sex has increased by more than 15 percent in the past two decades.
So the question should not be “Does SRA education work?” The question should be: “How can we assure that SRA education is implemented in the most effective manner possible?” Even though President Obama and Planned Parenthood have sought to eliminate all federal funding for SRA education (and have already lowered it from over $100 million to only $10 million per year), a recent Guttmacher Institute study showed that, nationwide, support for SRA education has actually increased in recent years.
What’s Wrong with the HHS List?
The research on sex education is too thin for us to make definitive statements about the comparative effectiveness of “comprehensive” sex education and SRA education. Further research must take place. In the meantime, neither approach can claim that its programs have amassed the level of research that would truly merit being designated as the “national model.”
There are serious flaws in the research protocols used to compile the HHS list. In fact, some of these flaws are so serious that they should discredit many of the programs entirely. In particular:
– The CDC confirms that only correct and consistent condom use has a meaningful impact on reducing STD transmission, yet some programs earned a spot on the list despite a finding of inconsistent condom use. USAID, a government agency that is trying to alleviate the HIV pandemic in Africa, has reported that inconsistent condom use may actually increase the risk of contracting a sexually transmitted disease.
– Although research protocols insist that a national model have at least one replication of the same results from the same program, only 16 percent of the programs on the list have actually been replicated. Of those with additional studies, many of their results are bleak, providing a compelling reason to remove them from the list. Of the seven programs for which positive results have been replicated, six also have additional studies that showed either negative or neutral results. In three cases, students in the follow-up studies fared worse than those who did not receive the program at all. Some were less likely to use contraception when they had sex; some had more sexual partners, and some students were more likely to have sex than those who didn’t receive the program.
– Location matters. Although most sex education takes place in a school setting, only 18 percent of all programs on the list showed an impact on sexual initiation or contraceptive use in school. It is a bad research practice to make generalizations to a setting or audience different from that of the original study. It’s worth noting that the research for the two SRA programs on the list was conducted in school.
– The research evaluating 75 percent of the programs on the list was conducted by the program developer or publisher. In fact, a single developer conducted research on eight of the forty-four programs! Clearly, there is a conflict of interest here: there are significant financial gains to be had when a program is included on a very small government-endorsed list of “effective” sex education programs. Again, it’s worth noting that the research for the two SRA programs on the list was conducted by an independent evaluator.
There is no evidence that communities that implement programs on the HHS “evidence-based list” can actually expect their students to decrease their sexual risk. The threshold for inclusion is just too low. In fact, there is some evidence that the implementation of some programs on the list may actually expose students to additional risk. This list should not be used to give credibility to the claim that so-called “comprehensive” sex education works and SRA education doesn’t. Too many research protocols have been ignored to make such careless claims.
For the sake of the health of youth, we must have an honest conversation about sex education research. The narrative surrounding the HHS list must change. The programs on the list are not national models. Communities should not be misled into believing that programs will deliver effective sex education to their students, merely because they have earned a place on the list. School boards across the nation are being intimidated into accepting one of these programs because they have been duped by the constantly repeated “effectiveness” narrative. They don’t understand that, in this case, “science” has become the pawn of a larger agenda—an agenda that could be harmful to their students.
HHS has a responsibility to correct misinformation surrounding the use and promised results of the curricula on its list, to implement consistent research protocols, and to ensure that the sexual health of American teenagers is prioritized above politics or ideology. HHS is in a unique position to lead the conversation in a healthier and decidedly more honest direction. I hope they will aggressively seize this opportunity to do so.