The case for starting sex education in kindergarten

BY Saskia de Melker  May 27, 2015 at 1:44 PM EDT

Teacher Janneke van den Heuvel leads her 8-year old students in a group discussion during Spring Fever week in the Netherlands. NewsHour photo by Saskia de Melker

“Who here has been in love?” Anniek Pheifer asks a crowd of Dutch elementary school students.
It’s a Spring morning in Utrecht, and the St. Jan de Doper elementary school gym is decked in heart-shaped balloons and streamers. Pheifer and Pepijn Gunneweg are hosts of a kids television program in the Netherlands, and they’re performing a song about having a crush.
Kids giggle at the question. Hands — little and bigger — shoot up.
Welcome to “Spring Fever” week in primary schools across the Netherlands, the week of focused sex ed classes… for 4-year olds.
Of course, it’s not just for 4-year-olds. Eight-year-olds learn about self-image and gender stereotypes. 11-year-olds discuss sexual orientation and contraceptive options. But in the Netherlands, the approach, known as “comprehensive sex education,” starts as early as age 4.

Kindergarteners attend the opening assembly for Spring Fever week at the St Jan de Doperschool in Utrecht, the Netherlands. NewsHour photo by Saskia de Melker

You’ll never hear an explicit reference to sex in a kindergarten class.In fact, the term for what’s being taught here is sexuality education rather than sex education. That’s because the goal is bigger than that, says Ineke van der Vlugt, an expert on youth sexual development for Rutgers WPF, the Dutch sexuality research institute behind the curriculum. It’s about having open, honest conversations about love and relationships.
By law, all primary school students in the Netherlands must receive some form of sexuality education. The system allows for flexibility in how it’s taught. But it must address certain core principles — among them, sexual diversity and sexual assertiveness. That means encouraging respect for all sexual preferences and helping students develop skills to protect against sexual coercion, intimidation and abuse. The underlying principle is straightforward: Sexual development is a normal process that all young people experience, and they have the right to frank, trustworthy information on the subject.
“There were societal concerns that sexualization in the media could be having a negative impact on kids,” van der Vlugt said. “We wanted to show that sexuality also has to do with respect, intimacy, and safety.”
Beyond risk prevention
The Dutch approach to sex ed has garnered international attention, largely because the Netherlands boasts some of the best outcomes when it comes to teen sexual health. On average, teens in the Netherlands do not have sex at an earlier age than those in other European countries or in the United States. Researchers found that among 12 to 25 year olds in the Netherlands, most say they had  “wanted and fun” first sexual experiences. By comparison, 66 percent of sexually active American teens surveyed said they wished that they had waited longer to have sex for the first time. When they do have sex, a Rutgers WPF study found that nine out of ten Dutch adolescents used contraceptives the first time, and  World Health Organization data shows that Dutch teens are among the top users of the birth control pill. According to the World Bank, the teen pregnancy rate in the Netherlands is one of the lowest in the world, five times lower than the U.S. Rates of HIV infection and sexually transmitted diseases are also low.

“We have to help young people navigate all the choices they face and stand up for themselves in all situations, sexual and otherwise,”

There are multiple factors that likely contribute to these numbers. Easy access to contraception is one. Condoms, for example, are available in vending machines, and the birth control pill is free for anyone under age 21. But there’s also a growing body of research that specifically credits comprehensive sexuality education. A recent study from Georgetown University shows that starting sex ed in primary school helps avoid unintended pregnancies, maternal deaths, unsafe abortions and STDs.

Courtesy of Rutgers WPF

Proponents of the Dutch model argue that their approach extends beyond those risks. Their brand of sex ed reflects a broader emphasis on young people’s rights, responsibility and respect that many public health experts say is the foundation of sexual health.
A 2008 United Nations report found that comprehensive sex ed, when taught effectively, allows young people to “explore their attitudes and values, and to practice the decision-making and other life skills they will need to be able to make informed choices about their sexual lives.” Students who had completed comprehensive sex education in the Netherlands were also found to be more assertive and better communicators, according to an independent health research agency that conducted a study of the Dutch programs.
“We have to help young people navigate all the choices they face and stand up for themselves in all situations, sexual and otherwise,” said Robert van der Gaag, a health promotion official at Central Holland’s regional public health center.
‘Little butterflies in my stomach’
At the St. Jan de Doper school, a group of kindergartners sit in a circle, as their teacher, Marian Jochems, flips through a picture book. The pages contain animals like bears and alligators hugging.
“Why are they hugging?” she asks the class.
“Because they like each other,” one girl answers.
Jochems asks them to think about who they like the most. Several kids say their mom or dad. One girl names her little sister. A few name other children at school.
“How does it feel when that person hugs you?” Jochems asks.
“I feel warm from the inside,” one boy replies. “It’s like there are little butterflies in my stomach.”
Lessons like this are designed to get kids thinking and talking about the kind of intimacy that feels good and the kind that doesn’t. Other early lessons focus on body awareness. For example, students draw boys’ and girls’ bodies, tell stories about friends taking a bath together, and discuss who likes doing that and who doesn’t. By age seven, students are expected to be able to properly name body parts including genitals. They also learn about different types of families, what it means to be a good friend, and that a baby grows in a mother’s womb.

CLICK HERE TO READ A LESSON PLAN taught to Dutch kindergarten and first graders. Courtesy of Rutgers WPF

“People often think we are starting right away to talk about sexual intercourse [with kindergartners],” van der Vlugt says. “Sexuality is so much more than that. It’s also about self image, developing your own identity, gender roles, and it’s about learning to express yourself, your wishes and your boundaries.”
That means the kindergartners are also learning how to communicate when they don’t want to be touched. The goal is that by age 11, students are comfortable enough to navigate pointed discussions about reproduction, safe sex, and sexual abuse.

Let’s not talk about sex
In the United States, sexual education varies widely from state to state. Fewer than half of U.S. states require schools to teach sex ed, according to the Guttmacher Institute, a global nonprofit that researches sexual and reproductive health. Just last month Congress extended the Personal Responsibility Education Program (PREP), which funds comprehensive adolescent sexual health initiatives across the country. At the same time they increased funding for programs that promote sexual abstinence until marriage to $75 million a year. And Deb Hauser, president of Advocates for Youth, a nonprofit dedicated to sexuality education, says that sex ed in the U.S. still overwhelmingly focuses on minimizing the risk of pregnancy and STDs from heterosexual intercourse.
And nearly four in 10 millennials report that the sex education they received was not helpful, according to a survey by the Public Religion Research Institute.
“We have failed to see that sexual health is far more than simply the prevention of disease or unplanned pregnancy,” says Hauser. That narrow focus, she says, leaves young people with few skills to cope with their feelings and make decisions in sexual encounters.
Not everyone agrees.  In fact, comprehensive sex ed has yet to take hold in most parts of the country. Utah, for example, requires that abstinence be the dominant message given to students. It bans discussing details of sexual intercourse and advocating for homosexuality, the use of contraceptives or sexual activity outside of marriage.
Utah state representative Bill Wright has further tried to restrict sex ed. In 2012, he proposed a bill requiring that abstinence only be taught and that it be an optional subject. It passed but was vetoed by the governor.
Sex ed is “not an important part of our curriculum,” Wright said. “ It is just basically something out there that takes away from the character in our schools and takes away from the character of our students.”
Utah is far from alone. Half of U.S. states require that abstinence be stressed. “We have created generations of people who are not comfortable with their own sexuality,” says Dr. David Satcher, the former U.S. Surgeon General. That extends to parents and teachers, he says.
In other places, the tide is shifting toward an approach closer to that of the Dutch. Two of the largest school districts in the country — Chicago Public Schools and Florida’s Broward County — have recently mandated sex education for elementary school students. Chicago Public Schools requires at least 300 minutes a year of sex education for kindergarten through fourth grade students and twice as much time for fifth through twelfth graders. In the fall of 2015,  schools in Broward County will teach sex education at least once a year in every grade, and the curriculum will include information about topics like body image, sexting and social media.

Courtesy of Rutgers WP

In the Netherlands, schools aim to educate parents too. Parents nights are held to give parents tools to talk to their kids about sex. Public health experts recommend that parents take cues from their kids and make it an ongoing conversation, rather than one awkward, all-encompassing “birds and the bees” talk. For example, they advise, if you walk in on your child masturbating, don’t react shocked; don’t punish or scold them. Have a talk about where it is appropriate for such behavior to occur.
“We talk about [sex] over dinner,” said one father at a Spring Fever Parents Night. Another said he recently answered questions about homosexuality posed by his twin 6-year-olds during bath time.
Lessons in love
Sabine Hasselaar teaches 11-year-olds. In a recent class, Hasselaar posed a series of hypothetical situations to her students: you’re kissing someone and they start using their tongue which you don’t want. A girl starts dancing close to a guy at a party causing him to get an erection. Your friend is showing off pornographic photos that make you feel uncomfortable.
The class discusses each scenario. “Everyone has the right to set their own limits and no one should ever cross those limits,” Hasselaar says.
There is an anonymous ‘Question Box.’ in her class during “Spring Fever” week. Students submit questions that teachers later address in class. “Nothing is taboo,” Hasselaar says. One of her students, for example, wrote: “I think I am lesbian. What should I do?”
Hasselaar addressed the issue in class: “It’s not strange for some girls to like other girls more than boys. It’s a feeling that you can’t change, just like being in love. The only difference is that it’s with someone that is the same sex as you.”
And in fact, most of the questions from her students aren’t about sex at all. “Mostly they are curious about love. I get a lot of questions like, “What do I do if I like someone?” or ‘How do I ask someone to go out with me?’”
Questions like these are taken just as seriously as the ones about sex.
“Of course we want kids to be safe and to understand the risks involved with sex, but we also want them to know about the positive and fun side of caring for someone and being in a healthy relationship,” van der Vlugt says.
That’s why you’ll find teachers discussing the difference between liking someone (as a friend) and liking someone. There’s even a lesson on dating during which a teacher talked about how to break up with someone in a decent way: “Please, do not do it via text message,” the teacher said.

“In the Netherlands, there’s a strong belief that young people can be in love and in relationships,”

After elementary school, these students will likely go on to receive lessons from a widely-used curriculum called Long Live Love.
“In the U.S., adults tend to view young people as these bundles of exploding hormones. In the Netherlands, there’s a strong belief that young people can be in love and in relationships,” says Amy Schalet, an American sociologist who was raised in the Netherlands and now studies cultural attitudes towards adolescent sexuality, with a focus on these two countries.
“If you see love and relationships as the anchor for sex, then it’s much easier to talk about it with a child,” Schalet says. “Even a young one.”

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Why is sexual education taught in schools?

Why is sexual education taught in schools?

A 2011 Centers for Disease Control and Prevention (CDC) survey indicates that more than 47 percent of all high school students say they have had sex, and 15 percent of high school students have had sex with four or more partners during their lifetime. Among students who had sex in the three months prior to the survey, 60 percent reported condom use and 23 percent reported birth control pill use during their last sexual encounter.
Sexual activity has consequences. Though the teen birth rate has declined to its lowest levels since data collection began, the United States still has the highest teen birth rate in the industrialized world. Roughly one in four girls will become pregnant at least once by their 20th birthday. Teenage mothers are less likely to finish high school and are more likely than their peers to live in poverty, depend on public assistance, and be in poor health. Their children are more likely to suffer health and cognitive disadvantages, come in contact with the child welfare and correctional systems, live in poverty, drop out of high school and become teen parents themselves. These costs add up, according to The National Campaign to Prevent Teen and Unplanned Pregnancy, which estimates that teen childbearing costs taxpayers at least $9.4 billion annually.
Adolescents are disproportionately affected by sexually transmitted infections (STIs). Young people ages 15 to 24 represent 25 percent of the sexually active population, but acquire half of all new STIs, which amounts to 9.8 million new cases a year. About 3.2 million adolescent females are infected with at least one of the most common STIs. Human papillomavirus is the most common STI among teens; some estimates find that up to 35 percent of teens ages 14 to 19 have HPV. Girls age 15 to 19 have the highest rates of Gonorrhea and the second highest rate of Chlamydia of any age group. Young males also get STIs, but their infections often are undiagnosed and unreported because they are less likely to have symptoms or seek medical care. The most recent data available, in 2000, indicates the estimated direct medical costs for treating young people with sexually transmitted infections was $6.5 billion annually, excluding costs associated with HIV/AIDS. In 2011, approximately 24 percent of new HIV diagnoses were young people age 13 to 24.

2015 Sex Education Legislation

(Updated status as of March 13, 2015)

State	Bill/ Summary/ Status
Arizona	HB 2476 Amends existing law to allow school districts to provide sex education unless a parent provides written permission for a student to opt out of instruction. Requires that school districts provide sex education that is medically accurate and age- and developmentally appropriate in grades kindergarten through 12. Creates additional requirements for sex education, including teaching the benefits of delaying sexual activity and the importance of using effective contraceptives to prevent unintended pregnancy, HIV/AIDS and other sexually transmitted diseases. Education requirements also include information to support students in developing healthy relationships and skills such as communication, critical thinking and decision making. Requires the Department of Education, among other things, to develop list of appropriate curricula and create rules for instructor qualifications. Introduced.
California	AB 329 States the intent of the Legislature to enact legislation that would review and update the current sexual health education curriculum that is provided to pupils in schools to reflect the advances in age-appropriate sexual health instruction, including, but, not limited to, healthy relationships and dating violence. Introduced. AB 517 Amends the State Comprehensive Sexual Health and HIV/AIDS Prevention Education Act that authorizes school districts to provide sexual health education that include HIV/AIDS prevention education. Requires district that elect to provide education taught by outside consultants, or elect hold to an assembly to deliver such education by guest speakers, to request written permission from a pupil's parent or guardian. Prohibits a student's attendance without such permission. Authorizes related alternative education. To Assembly Committee on Education. AB 827 Adds to additional laws related to requirements for school districts that offer comprehensive sexual education. Requires a school district that elects to offer comprehensive sexual education to also provide information on local resources for counseling for sexually transmitted diseases. To Assembly Committee on Education
Colorado	SB 77 Creates a parent’s bill of rights that includes the ability of a parent to withdraw their child from an activity, class or program that includes any material or activities to which he or she objects on the basis that it is harmful. Objection includes that the materials or activities question beliefs or practices in sex, morality or religion. Passed Senate; To House Committee on Public Health Care & Human Services.
Georgia	HB 406 Provides for age-appropriate sexual abuse and assault awareness and prevention education in kindergarten through grade 12. Also provides that professional learning and in-service training may include programs on sexual abuse and assault awareness and prevention. To House Committee on Education; Read second time.
Hawaii	HB 459 / SB 395 Amends existing sexuality health education law to specify additional requirements for information that helps students form healthy relationships and communication skills, as well as critical thinking, decision making and stress management skills, and encourages students to communicate with adults. Requires all public schools to implement sex education consistent with these requirements beginning in 2016-2017. Allows written permission by a parent or legal guardian to opt out of sexuality education. Allows the Department of Education to make modifications to ensure age-appropriate curricula in elementary school. Requires the Department to maintain a public list of curricula that meets requirements of law and to create standards for instructor qualifications. House version: Passed House; to Senate Committee on Education. Senate version: Referred to Committee on Education and Committee on Health; Subsequent referral set for Committee on Ways and Means. HB 595 Amends existing sexuality health education law to specify additional requirements for information that helps students form healthy relationships and communication skills, as well as critical thinking, decision making and stress management skills, and encourages students to communicate with adults. Allows written permission by a parent or legal guardian to opt out of sexuality education. Allows the Department of Education to make modifications to ensure age-appropriate curricula in elementary school. Requires the Board of Education to collaborate with the Department to maintain a public list of curricula that meets requirements of law. Requires the Department to create standards for instructor qualifications. Referred to House Committee on Health; Subsequent referral set for Committee on Education. SCR 29 Resolution encourages the Board of Education to amend its policies to require health education in public middle schools and to clarify sexual health education requirements, including that parents can opt their children out of sexual health education. Also encourages the Board of Education and Department of Education to rescind a ban on condom distribution for all public school students. Referred to Committee on Education; Subsequent referral set for Committee on Ways and Means.
Indiana	SB 497 Requires the state Department of Health and the Department of Education to cooperatively identify and report to the General Assembly appropriate academic standards and curricula concerning health education and sex education. The standards and curricula must be evidence based, age appropriate and must use established medical principles. Referred to Senate Committee on Education and Career Development.
Kansas	HB 2199 Requires parental consent for sexuality education and provides that sexuality education materials will be available for parental review. Also requires the boards of education of each school district to adopt policies and procedures related to sexuality education, including prohibiting the distribution of materials to any student whose parent has not consented. Referred to House Committee on Appropriations.
Kentucky	HB 231 Requires school districts, public schools or family resource and youth services centers that offer human sexuality education to use science-based standards with age-appropriate, culturally sensitive and medically accurate information. Information includes, but is not limited to abstinence education and contraception. Mandates the option for parent or guardian to opt out from human sexuality education and for content to be available for review upon request. Does not require school districts, public schools and family resource and youth services centers to provide human sexuality education. Also allows the Cabinet for Health and Family Services to refuse federal funding that requires teaching abstinence-only programs. If state funds are appropriated for human sexuality education, requires the Cabinet to meet the same science-based, age-appropriate, culturally sensitive and medically accurate standards as above. Any organization receiving state funds that offers human sexuality education or pregnancy prevention services must also use the same standards. Referred to House Committee on Education.
Mississippi	HB 318 Creates the Mississippi Comprehensive Communities of Color Teen Pregnancy Prevention Act, which requires the Department of Human Services and the Department of Health to develop certain programs and strategies promoting pregnancy prevention and providing information on the consequences of unprotected, uninformed and underage sexual activity. Programs and strategies include counseling and education about postponing sexual activity, information about consequences of pregnancy and parenthood, and medically accurate information about contraceptive options. Failed; Died in Committee.
Missouri	HB 353 Amends laws related to sex education in schools. In addition to existing criteria of medically and factually accurate, requires that curricula must also be age appropriate and based on peer review. Adds stipulations to cover certain topics, including helping students develop critical thinking, decision making, and stress management skills in order to support healthy relationships. Specifies that curricula promote communication with parents. Also adds to curricula information on sexual predators, internet safety and consequences of inappropriate text messaging. Introduced. SB 61 Creates the Teen Dating Violence Prevention Education Act to provide students with the knowledge, skills and information to prevent and respond to teen dating violence. Authorizes school districts and charter schools to provide teen dating violence education as part of the sexual health and health education program in grades seven through 12 and to establish related curriculum or materials. Also allows age-appropriate instruction on domestic violence. Referred to Senate Committee on Education.
New Jersey	AB 2379 Requires school districts to include information on reproductive coercion as part of the existing dating violence education program in grades seven through 12. Referred to Assembly Committee on Education.
New York	A 1037 Amends existing law to add prevention of sexual abuse and assault to health education in all public schools. Requires instruction to be based on current practice and standards and to include recognizing, avoiding, refusing and reporting sexual abuse and assault. Establishes teacher training and standards for instructors in elementary and secondary school. Referred to Assembly Committee on Education. A 1616 / S 700 Establishes an age-appropriate sex education grant program through the Department of Health. Requires that applicants teach information that is medically accurate and age appropriate and does not teach religion. Makes provisions for other components, which are not required but may not be contradicted by programs, including instruction that: teaches and stresses abstinence as well as provides information about contraceptives, teaches skills that support development of health life skills and decision making skills, and encourages communication with parents, among other things. Authorizes the commissioner to determine certain topics of instruction to be optional for age-appropriate reasons. Assembly Version: To Assembly Committee on Health.  Senate Version: To Senate Committee on Health. S 1889 Establishes an age-appropriate sex education grant program through the Department of Health. Requires that applicants teach information that is medically accurate and age appropriate and does not teach religion. Makes provisions for other components, which are not required but may not be contradicted by programs, including instruction that: teaches and stresses abstinence as well as provides information about contraceptives, teaches skills that support development of health life skills and decision making skills, and encourages communication with parents, among other things. Authorizes the commissioner to determine certain topics of instruction to be optional for age-appropriate reasons. Referred to Senate Committee on Health. S 905 Mandates comprehensive, medically accurate and age-appropriate sex education be taught in grades one through 12 in all public schools. Provides that the Commissioner of Education will create and establish a curriculum to accomplish such goal within one year of the effective date of this legislation. Allows boards of education to adopt their own curricula with approval of Commissioner of Education. Referred to Senate Committee on Education.
North Carolina	H 29 Repeals existing health education statute. Requires the same comprehensive health education and reproductive health education as existing law. Makes organizational to language of law. Referred to House Committee on Education.
South Carolina	HB 3447 Amends existing law related to comprehensive health education in schools to include that instruction must be medically accurate. Also requires school districts to publish on its website the title and author of health education materials used. Referred to House Committee on Education and Public Works.
Texas	HB 78 Amends education law related to human sexuality education in public schools. Mandates the State Board of Education to adopt the essential knowledge and skills for medically accurate, age-appropriate curriculum to be used by school districts in providing human sexuality education. Requires curricula to cover such topics as: emphasizing abstinence, providing information on contraceptives, promoting relationship, communication and decision making skills, and encouraging communication with adults. Requires school districts to make curricula reasonably publicly available and to provide written notice to parents about providing sexuality education. Students can be excused from sexuality education with written request of a parent or legal guardian. Referred to House Committee on Public Education. HB 467 Amends law related to education regarding AIDS and HIV infection to emphasize abstinence as only way to avoid pregnancy and sexually transmitted infections. Considered in public hearing; Left pending in House Committee on Public Health. SB 88 Amends and adds to existing sexuality education requirements that instruction must be age-appropriate, medically accurate and include information on contraceptives in addition to promoting abstinence. Also mandates that instruction cover, among other things, healthy life and decision making skills, and communication with family members. Referred to Senate Committee on Education. SB 297 Requires health education in public schools to be evidence based. Referred to Senate Committee on Education. SB 300 Adds requirements to existing law related to written notice to parents of a school district’s human sexuality instruction. Requires that school districts include in the notification information about the curricula’s required emphasis on abstinence and whether a school district is providing abstinence-only or comprehensive sexuality instruction. Referred to Senate Committee on Education.
Washington	SB 5506 Adds information on sexual assault and violence prevention and understanding consent to existing health education requirement. Public hearing scheduled.

 

State Laws on Medical Accuracy in Sex Education

Statutes	Summary
Arizona Ariz. Rev. Stat. § 15.716	Each school district may provide instruction on HIV/AIDS. It should be medically accurate and the Department of Health Services or the Department of Education can be consulted to review curriculum for medical accuracy and teacher training.
California Cal. Educ. Code § 51930-51939	School districts may provide comprehensive, age-appropriate sex education from kindergarten through grade 12. The information must be medically accurate, factual, and objective. In grade seven, information must be provided on the value of abstinence while also providing medically accurate information on other methods of preventing pregnancy and STIs. A school district that elects to offer comprehensive sex education earlier than grade seven may provide age-appropriate and medically accurate information.
Colorado Colo. Rev. Stat. § 22-1-110.5 Colo. Rev. Stat. § 22-1-128; 25-44-101-104; 22-25-110; 25.5-5-603	A school district that offers a human sexuality curriculum shall maintain content standards for the curriculum that are based on scientific research. Curriculum content standards shall also be age-appropriate, culturally sensitive, and medically accurate according to published authorities upon which medical professionals generally rely. Creates the comprehensive human sexuality education grant program in the department of public health and environment. The purpose of the program is to provide funding to public schools and school districts to create and implement evidence based, medically accurate, culturally sensitive and age appropriate comprehensive human sexuality education programs. Creates the interagency “youth sexual health team,” to function as the oversight entity of the grant program.
Hawaii Hawaii Rev. Stat. § 321-11.1	Sex education programs funded by the state shall provide medically accurate and factual information that is age appropriate and includes education on abstinence, contraception, and methods of disease prevention to prevent unintended pregnancy and STIs, including HIV. Medically accurate is defined as verified or supported by research conducted in compliance with accepted scientific methods and recognized as accurate and objective by professional organizations and agencies with expertise in the relevant field, such as the federal Centers for Disease Control and Prevention, the American Public Health Association, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists.
Illinois 105 ILCS 5/27-9.1 150 ILCS 110/3	If a school district chooses to provide sex education courses, curricula is required to be developmentally and age appropriate, medically accurate, evidence-based and complete. Requires comprehensive sex education offered in grades six through 12 to include instruction on both abstinence and contraception for the prevention of pregnancy and STDs. Requires course material and instruction replicate evidence-based programs or substantially incorporate elements of evidence-based programs. Requires the State Board of Education to make available sex education resource materials. Allows parents to opt out.
Iowa Iowa Code § 279.50	Each school board shall provide age-appropriate and research-based instruction in human growth and development including instruction regarding human sexuality, self-esteem, stress management, interpersonal relationships, domestic abuse, HPV and the availability of a vaccine to prevent HPV, and acquired immune deficiency syndrome in grades one through 12. Research-based includes information recognized as medically accurate and objective by leading professional organizations and agencies with relevant expertise in the field.
Maine Me. Rev. Stat. Ann. tit. 22 § 1902	Defines "comprehensive family life education" as education from kindergarten to grade 12 regarding human development and sexuality, including education on family planning and sexually transmitted diseases, that is medically accurate and age appropriate.
Michigan Mich. Comp. Laws § 380.1169	The superintendent of a school district shall cooperate with the Department of Public Health to provide teacher training and provide medically accurate materials for instruction of children about HIV/AIDS.
Minnesota Minn. Stat. § 121A.23	The commissioner of education and the commissioner of health shall assist school districts to develop a plan to prevent or reduce the risk of sexually transmitted diseases. Districts must have a program that has technically accurate information and curriculum.
Missouri Mo. Rev. Stat. § 170.015 Mo. Rev. Stat. § 191.668	Any course materials and instructions related to human sexuality and STIs shall be medically and factually accurate. The department of health and senior services shall prepare public education and awareness plans and programs for the general public, and the department of elementary and secondary education shall prepare educational programs for public schools, regarding means of transmission and prevention and treatment of the HIV virus.  Beginning with students in the sixth grade, materials and instructions shall also stress that STIs are serious, possible health hazards of sexual activity. The educational programs shall stress moral responsibility in and restraint from sexual activity and avoidance of controlled substance use whereby HIV can be transmitted. Students shall be presented with the latest medically factual and age-specific information regarding both the possible side effects and health benefits of all forms of contraception.
New Jersey*	Family life education curriculum must be aligned with the most recent version of the New Jersey Core curriculum Content Standards which requires that instructional material be current, medically accurate and supported by extensive research.
North Carolina N.C. Gen. Stat. § 115C-81	Reproductive health and safety education must provide factually accurate biological or pathological information that is related to the human reproductive system. Materials used must be age appropriate, objective and based upon scientific research that is peer reviewed and accepted by professional and credentialed experts in the field of sexual health education.
Oklahoma Okl. Stat. Ann. tit. 70 § 11-103.3	The State Department of Education shall develop curriculum and materials for AIDS prevention education in conjunction with the State Department of Health. A school district may also develop its own AIDS prevention education curriculum and materials. Any curriculum and materials developed for use in the public schools shall be approved for medical accuracy by the State Department of Health. The State Department of Health and the State Department of Education shall update AIDS education curriculum material as newly discovered medical facts make it necessary.
Oregon Or. Rev. Stat. § 336.455	Each school district shall provide age-appropriate human sexuality education courses in all public elementary and secondary schools as an integral part of the health education curriculum. Curriculum must also be medically accurate, comprehensive, and include information about responsible sexual behaviors and hygienic practices that eliminate or reduce the risks of pregnancy and the risks of exposure to HIV, hepatitis B, hepatitis C and other STIs. Information about those risks shall be presented in a manner designed to allay fears concerning risks that are scientifically groundless.
Rhode Island R.I. Gen. Laws § 16-22-17	The department of elementary and secondary education shall, pursuant to rules promulgated by the commissioner of elementary and secondary education and the director of the department of health, establish comprehensive AIDS (acquired immune deficiency syndrome) instruction, which shall provide students with accurate information and instruction on AIDS transmission and prevention, and which course shall also address abstinence from sexual activity as the preferred means of prevention, as a basic education program requirement.
Tennessee Tenn. Code Ann. § 49-6-1301 et seq.	Requires local education agencies to develop and implement a family life education program if the teen pregnancy rate in any county exceeds 19.5 pregnancies per 1,000 females aged 11 through 18. Requires curriculum be age-appropriate and provide factually and medically accurate information. Prohibits instruction and distribution of materials that promote “gateway sexual activity.” Requires that parents or guardians be notified in advance of a family life program, allowed to examine instruction materials, and provide written consent for a student to participate in or opt-out of family life education.
Texas Tex. Health and Safety Code § 85.004	The department shall develop model education programs to be available to educate the public about AIDS and HIV infection. The programs must be scientifically accurate and factually correct.
Utah**	The State Office of Education must approve all sexuality education programs through the State Instructional Material Commission.  Programs must be medically accurate.
Washington Wash. Rev. Code § 28A.230.070 Wash. Rev. Code § 28A.300.475	Schools shall adopt an AIDS prevention education program using model curriculum or district-designed curriculum approved for medical accuracy by the office on AIDS within the department of social and health services. The curriculum shall be updated as necessary to incorporate newly discovered medical facts. By September 1, 2008, every public school that offers sexual health education must assure that sexual health education is medically and scientifically accurate, age-appropriate, appropriate for students regardless of gender, race, disability status, or sexual orientation, and includes information about abstinence and other methods of preventing unintended pregnancy and sexually transmitted diseases. All sexual health information, instruction, and materials must be medically and scientifically accurate. Abstinence may not be taught to the exclusion of other materials and instruction on contraceptives and disease prevention.
Wisconsin Wis. Stat. § 118.019	A school board may provide an instructional program in human growth and development in grades kindergarten through 12. Program shall be medically accurate and age-appropriate. Abstinence will be presented as the sure way to prevent pregnancy and STIs.  Instruction must identify the skills necessary to remain abstinen

Sex Education That Works

What is sex education?

HIV and sex education for scouts in the Central African Republic

Sex education ('sex ed'), which is sometimes called sexuality education or sex and relationships education, is the process of acquiring information and forming attitudes and beliefs about sex, sexual identity, relationships and intimacy. Sex education is also about developing young people's skills so that they make informed choices about their behaviour, and feel confident and competent about acting on these choices.It is widely accepted that young people have a right to sex education. This is because it is a means by which they are helped to protect themselves against abuse, exploitation, unintended pregnancies, sexually transmitted diseases and HIV and AIDS. It is also argued that providing sex education helps to meet young people’s rights to information about matters that affect them, their right to have their needs met and to help them enjoy their sexuality and the relationships that they form. 1 2 3 4 5

What are the aims of sex education?

Sex education aims to reduce the risks of potentially negative outcomes from sexual behaviour, such as unwanted or unplanned pregnancies and infection with sexually transmitted diseases including HIV. It also aims to contribute to young people’s positive experience of their sexuality, by enhancing the quality of their relationships and their ability to make informed decisions over their lifetime. Sex education should be more than just puberty and reproductive biology; it should help young people to be safe and enjoy their sexuality. 6

What skills should sex education develop?

If sex education is going to be effective it needs to include opportunities for young people to develop skills, as it can be hard for them to act on the basis of only having information. 7 8 9
The skills young people develop as part of sex education are linked to more general life-skills. Being able to communicate, listen, negotiate with others, ask for and identify sources of help and advice, are useful life-skills which can be applied to sexual relationships. Effective sex education develops young people's skills in negotiation, decision-making, assertion and listening. Other important skills include being able to recognise pressures from other people and to resist them, dealing with and challenging prejudice and being able to seek help from adults - including parents, carers and professionals - through the family, community and health and welfare services.
Sex education that works also helps equip young people with the skills to be able to differentiate between accurate and inaccurate information, and to discuss a range of moral and social issues and perspectives on sex and sexuality, including different cultural attitudes and sensitive issues like sexuality, abortion and contraception. 10 11 12 13

Forming attitudes and beliefs

Young people can be exposed to a wide range of attitudes and beliefs in relation to sex and sexuality. For example, some health messages emphasise the risks and dangers associated with sexual activity and some media coverage promotes the idea that being sexually active makes a person more attractive and mature. Because sex and sexuality are sensitive subjects, young people and sex educators can have strong views on what attitudes people should hold, and what moral framework should govern people's behaviour.
Young people can be very interested in the moral and cultural frameworks that bind sex and sexuality. They often welcome opportunities to talk about issues where people have strong views, like abortion, sex before marriage, lesbian,  gay and contraception and birth control. It is important to remember that talking in a balanced way about differences in opinion does not promote one set of views over another, or mean that one agrees with a particular view. Part of exploring and understanding cultural, religious and moral views is finding out that you can agree to disagree.
People providing sex education have attitudes and beliefs of their own about sex and sexuality and it is important not to let these influence negatively the sex education that they provide. For example, even if a person believes that young people should not have sex until they are married, this does not imply withholding important information about safer sex and contraception. Attempts to impose narrow moralistic views about sex and sexuality on young people through sex education have failed. 14 15 16 Rather than trying to deter or frighten young people away from having sex, effective sex education includes work on attitudes and beliefs that enable young people to choose whether or not to have a sexual relationship, taking into account the potential risks of any sexual activity.

“Attempts to impose narrow moralistic views about sex and sexuality on young people through sex education have failed.”

Effective sex education also provides young people with an opportunity to explore the reasons why people have sex, and to think about how it involves emotions, respect for one self and other people and their feelings, decisions and bodies. Young people should have the chance to explore gender differences and how ethnicity and sexuality can influence people's feelings and options. 17 18 They should be able to decide for themselves what the positive qualities of relationships are. It is important that they understand how bullying, stereotyping, abuse and exploitation can negatively influence relationships.

So what information should be given to young people?

Young people get information about sex and sexuality from a wide range of sources including each other, through the media including advertising, television and magazines, as well as leaflets, books and websites (such as www.avert.org). Some of this will be accurate and some inaccurate. Providing information through sex education is therefore about finding out what young people already know and adding to their existing knowledge and correcting any misinformation they may have. For example, young people may have heard that condoms are not effective against HIV or that there is a cure for AIDS. It is important to provide information which corrects mistaken beliefs. Without correct information young people can put themselves at greater risk.
Information is also important as the basis on which young people can develop well-informed attitudes and views about sex and sexuality. Young people need to have information on all the following topics:

• Sexual development & reproduction - the physical and emotional changes associated with puberty and sexual reproduction, including fertilisation and conception, as well as sexually transmitted diseases and HIV.
• Contraception & birth control - what contraceptives there are, how they work, how people use them, how they decide what to use or not, how they can be obtained, and abortion.
• Relationships - what kinds of relationships there are, love and commitment, marriage and partnership and the law relating to sexual behaviour and relationships as well as the range of religious and cultural views on sex and sexuality and sexual diversity.
• Sexuality - including all the above for young people that are heterosexual or homosexual.

When should sex education start?

“Providing basic information provides the foundation on which more complex knowledge is built up over time.”

Sex education should start early, before young people reach puberty, and before they have developed established patterns of behaviour. 19 20 21 22 The precise age at which information should be provided depends on the physical, emotional and intellectual development of the young people as well as their level of understanding. What is covered and also how, depends on who is providing the sex education, when they are providing it, and in what context, as well as what the individual young person wants to know about. 23
It is important for sex education to begin at a young age and also that it is sustained. Giving young people basic information from an early age provides the foundation on which more complex knowledge is built up over time. For example, when they are very young, children can be informed about how people grow and change over time, and this provides the basis on which they understand more detailed information about puberty provided in the pre-teenage years. They can also be provided with information about viruses and germs that attack the body. This provides the basis for talking to them later about infections that can be caught through sexual contact.

Does sex education at an early age encourage young people to have sex?

Some people are concerned that providing information about sex and sexuality arouses curiosity and can lead to sexual experimentation. However, in a review of 48 studies of comprehensive sex and STD/HIV education programmes in US schools, there was found to be strong evidence that such programmes did not increase sexual activity. Some of them reduced sexual activity, or increased rates of condom use or other contraceptives, or both. 24 It is important to remember that young people can store up information provided at any time, for a time when they need it later on.

When should parents start talking to young people about sex?

Father and baby

Sometimes it can be difficult for adults to know when to raise issues, but the important thing is to maintain an open relationship with children which provides them with opportunities to ask questions when they have them. Parents and carers can also be proactive and engage young people in discussions about sex, sexuality and relationships. Naturally, many parents and their children feel embarrassed about talking about some aspects of sex and sexuality. The best basis to proceed on is a sound relationship in which a young person feels able to ask a question or raise an issue if they feel they need to. It has been shown that in countries like The Netherlands, where many families regard it as an important responsibility to talk openly with children about sex and sexuality, this contributes to greater cultural openness about sex and sexuality and improved sexual health among young people. 25The role of many parents and carers as sex educators changes as young people get older and are provided with more opportunities to receive formal sex education through schools and community-settings. However, it doesn't get any less important. Because sex education in school tends to take place in blocks of time, it can't always address issues relevant to young people at a particular time, and parents can fulfill a particularly important role in providing information and opportunities to discuss things as they arise. 26

Who should provide sex education?

Sex education can take place in a variety of settings, both in and out of school. In these different contexts, different people have the opportunity and responsibility to provide sex education for young people.

Parents/carers

At home, young people can easily have one-to-one discussions with parents or carers which focus on specific issues, questions or concerns. They can have a dialogue about their attitudes and views. Sex education at home also tends to take place over a long time, and involve lots of short interactions between parents and children. As young people get older, advantage can be taken of opportunities provided by things seen on television for example, as an opportunity to initiate conversation. It is also important not to defer dealing with a question or issue for too long as it can suggest that you are unwilling to talk about it. There is evidence that positive parent-child communication about sexual matters can lead to greater condom use among young men and a lower rate of teenage conception among young women. 27

Young people

In some countries, the involvement of young people themselves in developing and providing sex education has increased as a means of ensuring the relevance and accessibility of provision. Consultation with young people at the point when programmes are designed, helps ensure that they are relevant and the involvement of young people in delivering programmes may reinforce messages as they model attitudes and behaviour to their peers. 28 29 30 As part of their school-based Sex and Relationship Education programme, the UK-based organisation, Apause involves peer-educators to achieve positive behaviour change among students aged 13 and 14, with an aim to reduce the rates of first intercourse before the age of 16. 31

Teachers

In school the interaction between the teacher and young people takes a different form and is often provided in organised blocks of lessons. It is not as well suited to advising the individual as it is to providing information from an impartial point of view. The most effective sex education acknowledges the different contributions each setting can make. School programmes which involve parents, notifying them what is being taught and when, can support the initiation of dialogue at home.

Effective school-based sex education

School-based sex education can be an important and effective way of enhancing young people's knowledge, attitudes and behaviour. There is widespread agreement that formal education should include sex education. Evidence suggests that effective school programmes will include the following elements:

• A focus on reducing specific risky behaviours
• A basis in theories which explain what influences people's sexual choices and behaviour
• A clear, and continuously reinforced message about sexual behaviour and risk reduction
• Providing accurate information about, the risks associated with sexual activity, about contraception and birth control, and about methods of avoiding or deferring intercourse
• Dealing with peer and other social pressures on young people; providing opportunities to practise communication, negotiation and assertion skills
• Uses a variety of approaches to teaching and learning that involve and engage young people and help them to personalise the information
• Uses approaches to teaching and learning which are appropriate to young people's age, experience and cultural background
• Is provided by people who believe in what they are saying and have access to support in the form of training or consultation with other sex educators
• Focuses on both heterosexual and homosexual relations.

Formal programmes with all these elements have been shown to increase young people's levels of knowledge about sex and sexuality, put back the average age at which they first have sexual intercourse and decrease risk when they do have sex.
In addition to this, effective sex education is supported by links to sexual health services and takes into account the messages about sexual values and behaviour young people get from other sources (such as friends and the media). It is also responsive to the needs of the young people themselves - whether they are girls or boys, on their own or in a single sex or mixed sex group, and what they know already, their age and experiences.

Including sexuality in sex education

In some schools, sex education classes will be covered by a regular school teacher who has volunteered. Other schools have no sex education on their curriculum, and what little information the students receive comes under the umbrella of the biology syllabus.

“The discomfort of teachers and parents has been, for too long, allowed to frustrate the needs of pupils both gay and straight.”

Sexual health education should involve discussion of gay and straight issues. Often, when schools offer practical advice in avoiding HIV infection and STDs, it is aimed at straight pupils, with no mention of prevention methods for gay pupils. This may be because STD and HIV prevention for gay men and lesbians involves discussion of ‘ gay sex’.
Often, teachers are too embarrassed to discuss same-sex relations. However, no sexual health education class can be even remotely adequate without including this type of information. If regular teachers are too uncomfortable dealing with sexual issues, then an external specialist teacher should take some sessions.

Importance of sexuality in sex education

Given that gay men are disproportionately vulnerable to HIV infection and certain STDs, any comprehensive sexual health course should offer information about how gay men can protect themselves from infection. This necessarily involves discussing topics that need to be more explicit, such as safer sex for gay men. It is not possible to teach about safer sex without mention, and ideally discussion, of different sexual practices.
It is also important for young people to receive information about gay sexuality, in addition to just sexual health. Gay pupils need information that will give them an idea of the experience of living as a gay person in the wider world outside the classroom. This also helps to dispel ignorance and prejudice amongst other pupils. Lessons might include topics such as rights of gay spouses and same-sex parents.
Sexual health education, if it exists, offers the opportunity to begin providing education about different sexualities and different lifestyles. This needn’t be restricted to a sexual health class, and should discuss both heterosexual and homosexual relationships. 32

“I told a few other close friends but one day in an AS level history class we ended up discussing HIV/AIDS rather than the German Reformation. Well one person said 'Its all them who spread it- those gays' to which in outrage I shouted ‘WE DON'T SPREAD IT THANK YOU!’" - Tom

Teaching teachers

A UK survey found that less than half of teachers would feel confident in providing pupils with information on lesbian and gay issues. 33 A teacher who isn't trained in sexual health education is likely to feel uncomfortable when asked to teach a safer-sex lesson involving topics such as ‘oral sex’, ‘anal sex’, and ‘sex between women’. This discomfort will be picked up by the pupils, and often leads to important topics being brushed over. A teacher who knows their topic well is much more comfortable in the classroom, and thereby makes pupils much more comfortable with the topic. 34

“An uncomfortable teacher will have a dysfunctional class, with students giggling together behind cupped hands.”

Students need to be able to get on with group work, engage with their topic enthusiastically, and indulge their natural interest in learning about issues that ultimately will affect them. In a well-managed class, pupils' own interest will provide the motivation to learn. An uncomfortable teacher will have a dysfunctional class, with students giggling together behind cupped hands, whispering at the back of class, and trying to embarrass the teacher further by asking awkward questions. At the end of this class, students will be no better informed than they were at the beginning of it. 35
Teacher training is one obvious answer to this problem. Appropriate training for teachers can familiarise them with questions that they might have to deal with, and ensure that their knowledge of the subject is complete.
Another solution would be for the school to bring in teachers from outside the school to teach HIV, sexual health and sexuality education topics, or to have one teacher in the school who is designated with responsibility for these topics. Social education such as the awareness of prejudice should be present throughout the curriculum.
There is a serious lack of specific training for teachers in many countries, meaning that the majority of pupils receive extremely limited sexual health education with no information for gay pupils.

Barriers to providing sex education

Some schools have no sex education on their curriculum. This can be a result of the wider political climate and legislation in a country, or the stance of the school itself. Some academic planners fear that pupils who are taught about gay sexuality will want to rush out and try it. This is an argument that is often used by those who oppose comprehensive sex education in schools. On the contrary, an abundance of studies have shown that sex education reduces teenage pregnancies and STD infection rates. 36
Many schools that have a strong religious influence are opposed to comprehensive sex education. This can severely limit a pupil's education, with information only being provided in their biology class under the heading of ‘reproduction’. These classes can be about, literally, the ‘birds and the bees’. They often leave young people confused and ignorant, and communicate that human sexuality is embarrassing and shouldn't be discussed. 37 38 This not only means that homosexuality is unlikely to be adequately discussed (if at all), but furthermore, a teacher who communicates to the class that these topics are uncomfortable, will damage the self-respect of gay class-members, and amplify the prejudice they already experience.
The UK government makes sex and relationships education compulsory at primary and secondary level, and removes parents' right to opt their children out of these lessons until they are 15. 39 However, it is vital that this progress is reflected in the attitudes and capabilities of those who are carrying out sexual health education. Teachers shouldn’t feel uncomfortable about their topic, and certainly shouldn’t, themselves, be prejudiced against gay men and lesbians.
This is a problem that needs to be addressed by society as a whole – parents are often uncomfortable talking to their children about sex, and are little happier about the idea of their teacher providing the necessary information. 40 Parents need to know that sex and HIV education is ‘safe’, and that it won’t encourage any ‘immoral’ behaviour in their offspring, whether gay or straight.

Taking sex education forward

Providing effective sex education can seem daunting because it means tackling potentially sensitive issues and involving a variety of people – parents, schools, community groups and health service providers. However, because sex education comprises many individual activities, which take place across a wide range of settings and periods of time, there are lots of opportunities to contribute.
The nature of a person's contribution depends on their relationship, role and expertise in relation to young people. For example, parents are best placed in relation to young people to provide continuity of individual support and education starting from early in their lives. School-based education programmes are particularly good at providing information and opportunities for skills development and attitude clarification in more formal ways, through lessons within a curriculum. Community-based projects provide opportunities for young people to access advice and information in less formal ways. Sex education through the mass media, often supported by local, regional or national Government and non-governmental agencies and departments, can help to raise public awareness of sex health issues.
There is a need to pay more attention to the needs of specific groups of young people like young parents, young lesbian, gay and bisexual people, as well as those who may be out of touch with services and schools and socially vulnerable, like young refugees and asylum-seekers, young people in care, young people in prisons, and also those living on the street.
The circumstances and context available to parents and other sex educators are different from place to place. Practical or political realities in a particular country may limit people's ability to provide young people with comprehensive sex education. But the basic principles outlined here apply everywhere. By making contributions and valuing that made by others, and by being guided by these principles, more sex education and support for young people can be provided.