Sexuality Education Legislation and Policy

 Research  demonstrates that comprehensive sex education (CSE) results in improved sexual health outcomes for adolescents, which includes increased rates of contraceptive use, fewer teen pregnancies, lower rates of HIV and other sexually transmitted infections (STIs), and delayed sexual initiation. In addition to improved sexual health outcomes,  limited correlative research  shows that CSE:

• promotes social and emotional competencies that contribute to academic achievement, reduced risk-taking, and healthy relationships;
• supports the prevention of child sexual abuse;
• advances gender equity; and
• promotes healthy relationships and reduces risk of sexual assault and intimate partner violence.

 Comprehensive sex education  is defined by  SIECUS: Sex Ed for Social Change  as:

Programs that, in school-based settings, start by kindergarten and continue through 12th grade. High-quality comprehensive sex education programs include age, developmentally, and culturally appropriate, science-based, and medically accurate information on a broad set of topics related to sexuality, including human development, relationships, personal skills, sexual behaviors, including abstinence, sexual health, and society and culture. Comprehensive sex education programs provide students with opportunities for learning information, exploring their attitudes and values, and developing skills.

 Advocates for Youth ,  Answer , and  SIECUS: Sex Ed for Social Change  have partnered to create the  Future of Sex Education (FoSE)  initiative; this initiative has developed the  National Sex Education Standards  which provide guidance on the developmentally and age-appropriate, medically accurate, and culturally appropriate and unbiased core content that is recommended for all students grades K–12.

CSE begins in kindergarten, which includes talking with kids about gender, anatomically correct terms for body parts, safe touches, and relationships. Teaching young children about gender affirms the gender identity for those who identify along the gender spectrum and normalizes gender diversity for all youth, which ultimately results in  decreased bullying and violence . Additionally,  some experts  argue that teaching kids the anatomically correct terms for body parts normalizes sexuality from a young age, promotes body confidence, and empowers children with the terminology to describe sexual abuse should this ever occur.

CSE progresses via a grade-specific, evidence-informed approach and includes  topics  such as anatomy, physiology, sexual orientation, gender identity, healthy relationships, contraception, STIs and HIV, pregnancy options, families, and personal safety. This content is delivered by trained and qualified teachers.

The Netherlands demonstrates a particularly helpful model for comprehensive sex education. Dutch CSE curriculum is largely developed by  Rutgers International , a sexual and reproductive health research institute based in the Netherlands. Notably, Dutch youth have the  lowest teen pregnancy rates  in Europe and on average, engage in their  first partnered sexual experience  at seventeen years old, which is a year older than many other countries in Europe. Dutch youth are also more likely to describe their  first sexual experience as positive , whereas many American teens report they wished they’d waited longer before engaging in partnered sex. The following are videos that further describe the Dutch curriculum:

According to testimonials provided by  SIECUS: Sex Ed for Social Change ,  Diana Thu-Thao Rhodes , Director of Public Policy at  Advocates for Youth , states:

A world where everyone receives comprehensive sex education would mean everyone has the information they need to plan their futures and protect their health. If all young people received sex ed that is comprehensive, LGBTQ+ inclusive, and culturally responsive – then young queer students of color would feel seen and valued, and sexuality would be normalized, not stigmatized. While we still need to dismantle structural barriers like poverty and lack of access to healthcare, ensuring everyone gets quality sex ed is a crucial step towards a sexually healthy world. And a sexually healthy world where everyone receives comprehensive sex education is a world that acknowledges that young people have the right to lead healthy lives.

The following story map explores sex education legislation and policies by state, compared to each state’s respective health indicators. This story map can be used as a visually accessible advocacy tool to demonstrate the breadth of health indicators impacted by comprehensive sex education.

Much of the following data is from the Youth Risk Behavior Surveillance System (YRBSS), which is a national survey conducted by the Centers for Disease Control and Prevention (CDC) in public and private schools throughout the United States. The YRBSS monitors  six types of health behaviors , including behaviors that contribute to unintentional injuries and violence; sexual behaviors that contribute to unintended pregnancy and STIs, including HIV; alcohol and other drug use; tobacco use; unhealthy dietary behaviors; and inadequate physical activity. Not all states report on all health behaviors (as this is a voluntary survey), so you may notice significant data points missing from some of the following maps.

Some of the language used to describe sexual health indicators within this story map may seem cis, heteronormative (e.g. female, intercourse). This is due to phrasing borrowed from the Youth Risk Behavior Surveillance System (YRBSS), which serves as the primary dataset for many of the indicators below. Thus, in order for data to remain accurate in its representation within the story map, YRBSS terminology is used. It is the intention of these authors to be inclusive of the full spectrum of gender identity and sexual orientation. 

Lastly, it is important to note that all 7 health indicators presented in this story map are subject to numerous confounding variables. Though education policies and legislation are the primary emphasis of this story map, we acknowledge the significant health inequities present in our society that contribute to these health outcomes.

This map visually depicts the percentage of high school students who report being forced to do “sexual things” by anyone (e.g. kissing, touching, or being physically forced to have penetrative sex) during the 12 months prior to the Youth Risk Behavior Surveillance Survey.

There is an unclear relationship between sex ed legislation and sexual violence among high school students. Of the states that report in the YRBSS, Delaware and North Dakota have the lowest rates of sexual violence. Delaware mandates students be taught about sexual violence but does not require students be taught about consent or healthy relationships. North Dakota has no mandates about sexual violence, consent, or healthy relationships.

Of the states that report on sexual violence, only California and New Hampshire mandate students be taught about consent. Both California and New Hampshire have sexual violence rates below the national average, though there are many other states below the national average that do not mandate students be taught about consent.

Due to a large number of states who do not report on this measure in the YRBSS, observable patterns are limited.

This map visually depicts the percentage of high school students who report being intentionally harmed (e.g. hit, slammed into something, or injured with an object or weapon) by their dating or intimate partner during the 12 months prior to the Youth Risk Behavior Surveillance Survey.

The primary sex education theme that addresses physical dating violence is the curricular component related to healthy relationships. However, there is an unclear relationship between sex ed legislation and physical dating violence among high school students. The national average for physical dating violence reported among high school students is 8.53%. Interestingly, the highest (12.1% in Arkansas) and lowest (5.5% in Kansas) rates for physical dating violence are not that far from the mean.

Due to a large number of states who do not report on this measure in the YRBSS, observable patterns are limited.

Though there is an unclear relationship between sex ed legislation and physical dating violence based on limited YRBSS state-level data,  research  shows that when schools include curricula to teach students about dating violence, as well as enact strict policies aimed at violence prevention, then adolescents are less likely to be victimized and more likely to avoid perpetration of intimate partner violence.

This map visually depicts the percentage of LGBTQ+ high school students who report being bullied or harassed on school property (e.g. yelled or shouted at, insulted, threatened, subjected to unwanted physical contact) during the 12 months prior to the Youth Risk Behavior Surveillance Survey.

Observable patterns emerge between sex ed legislation and percentage of LGBTQ+ high school students who report being bullied. Of states who report to the YRBSS on this measure, Oklahoma has the highest rate of LGBTQ+ students who report being bullied – 48.3% – and Oklahoma also mandates that students be taught that homosexual behaviors are the primary cause for HIV/AIDS.

Alabama, Arizona, Mississippi, North Carolina, Oklahoma, and Utah mandate students be taught negative outcomes of homosexuality (e.g. teachers cannot “suggest that some methods of sex are safe methods of homosexual sex”). Notably, in Arizona, 40.9% of LGBTQ+ high school students report being bullied (compared to the national average of 34.01%). Alabama, Mississippi, and Utah have sex ed legislation that mandates students be taught negative outcomes of homosexuality, though these states do not report on bullying in the YRBSS. North Carolina includes language in their sex ed legislation that promotes a heterosexual standard but does not directly include negative outcomes of homosexuality. Notably, a previous law prohibited discussion of LGBTQ+ topics in South Carolina, though in March 2020, a United States district judge ruled this  unconstitutional . The rates of LGBTQ+ students who report being bullied in North and South Carolina are just below the national average (33.2% and 32.8%, respectively).

Due to a large number of states who do not report on this measure in the YRBSS, observable patterns are limited. These data do, however, showcase that many states lack formal mandates for sex education that is inclusive of the full spectrum of gender identity and sexual orientation.

The  GLSEN 2017 National School Climate Survey  provides further discussion on the school experiences of LGBTQ+ youth in the United States, and the survey consistently demonstrates that specific school-based supports result in safer school climates.  School-based supports  include LGBTQ-inclusive curriculum, inclusive and supportive policies, and supportive student clubs, such as Gay-Straight Alliances or Gender and Sexuality Alliances (GSAs).

This map visually depicts the percentage of high school students who report seriously considering suicide during the 12 months prior to the Youth Risk Behavior Surveillance Survey. This does not include percentage of students who developed a plan and attempted suicide.

As with all previously discussed indicators, there are a number of factors that influence suicidal ideation among adolescents. Given the breadth of this particular indicator, it is difficult to untangle the relationship between sex ed legislation and suicidal ideation.

Analyses of YRBSS data demonstrate that 13.3% of heterosexual high school students nationwide had seriously considered attempting suicide, compared to 47.7% of gay, lesbian, and bisexual students. Furthermore, the prevalence of suicidal ideation is higher among heterosexual female (16.9%) compared to heterosexual male (10.2%) students, as well as higher among lesbian and bisexual female (51.0%) than gay and bisexual male (37.0%) students.

These data demonstrate that suicidal ideation is higher among high school students who identify as women and high school students who identify as LGBTQ+. This is noteworthy since comprehensive sex education has the potential to address gender norms as well as LGBTQ+ stigma and oppression.

Contraceptive prevalence is the percentage of high school students who used any form of contraception before their last sexual intercourse (i.e. condom, oral contraceptives, IUD or implant, shot, patch, or hormonal ring); this does not include natural family planning. Research shows that heterosexual couples who do not use any form of contraception have approximately an  85% chance  of becoming pregnant in the next year.

This map visually depicts adolescent CPR by state, as well as the corresponding sex ed policies and legislation for each state. The United States CPR is compared to the Netherlands, as the  Netherlands  has set the bar for comprehensive sex education.

Because the data is limited, conclusions cannot be reached about associations between sex ed legislation and CPR. However, the primary observable pattern between sex ed legislation and CPR that emerges from this map of state-level data is the following: Texas, Arkansas, and Nevada have the lowest CPRs, and all 3 states do NOT mandate students be taught about contraception.

The rate of STIs is measured by the number of cases of chlamydia and gonorrhea per 100,000 persons aged 15-24 years. STI rates in the United States and the Netherlands are currently at all-time highs.

Observable patterns emerge between components of sex ed legislation and adolescent STI rate. STI rates are lowest in Vermont, New Hampshire, Maine, West Virginia, Utah, and Idaho—5 of these 6 states mandate sex education (Idaho being the exception). Interestingly, only half of these states require students be taught that condoms should be used as primary prevention for STIs.

Geographic observations reveal that STI rates are particularly high throughout much of the Southeast and Midwest regions, with Mississippi and Louisiana reporting the highest STI rates.

Teen birth rate is measured by the number of births per 1,000 female persons aged 15-19 years. TBR in the United States has historically been among the highest in the developed world, and though it has  dramatically decreased  over time, the United States TBR still remains high compared to other developed countries.

This map visually depicts TBR by state, as well as the corresponding sex ed policies and legislation for each state. The US TBR is compared to the Netherlands TBR, as the  Netherlands  has set the bar for comprehensive sex education.

Observable patterns emerge between sex ed legislation and TBR. Teen birth rates appear to be lowest in the Northeast, as well as in Minnesota. Of the states with the lowest TBRs (less than 12.5 births per 1,000 female persons aged 15-19), 6 out of 7 states mandate sex education (Connecticut, Minnesota, New Hampshire, New Jersey, New York, Vermont), whereas only 3 out of 7 states require students be taught about contraception (Massachusetts, New Jersey, Vermont). Interestingly, Minnesota mandates students be taught about the importance of sex only within marriage.

The primary limitation to this analysis is that sex education is largely determined at the district or individual school level. Though states may have various laws or policies in place, it is often at the discretion of local school systems to determine plans for curricular implementation and delivery, thereby making it difficult to tell the story about state-level data or policy. Thus, this analysis is purely observational, as there are many confounders that affect the health indicators discussed. Another limitation is unavailable YRBSS data for multiple states and health indicators; observations are less accurate with incomplete data.

Furthermore, in order for comprehensive sex education to be successfully implemented, there needs to be a trained workforce to deliver this curriculum. Teachers would ideally be trained during their undergraduate and/or graduate degree programs, though it may be decades before this universally occurs in the United States. Multiple organizations provide lesson plans for delivery of age-appropriate, medically accurate, and unbiased sex education curriculum, which are in accordance with the  National Sex Education Standards . Please visit the following websites for information on lesson plans:  Center for Sex Education ,  ETR , and  Rutgers International . The Future of Sex Education (FoSE) initiative has provided National Teacher Preparation Standards for Sexuality Education, which can be found  here .

Additional obstacles to implementation of CSE include a dearth of rigorous scientific data demonstrating its benefits, as well as a large gap that is often present between policymakers and education implementers, which results in a time lag from when legislation is passed and when delivery of the material occurs.

The  United Nations Educational, Scientific, and Cultural Organization (UNESCO)  recently published a  policy paper  with the following recommendations for CSE:

1. Invest in teacher education and support.
2. Make curricula relevant and evidence based.
3. Develop monitoring and evaluation mechanisms and ensure implementation.
4. Work with other sectors to bring about real change, particularly with the health sector to link schools with health services, thereby leveraging funds.
5. Engage with community and parent organizations to overcome resistance that is not based on facts.

Our story map is the first of its kind to integrate education policy with health indicators and is a valuable tool for educators and policymakers to consider when creating sex education legislation. Sex education is largely determined at the district or individual school level; though states have legislation in place, it is often at the discretion of local school systems to determine plans for curricular implementation and delivery. Nonetheless, state mandates affect local curricula, and understanding health indicator rankings may be influential for states as they develop education policy. States should continue to address the aforementioned health indicators in schools, and CSE is an important vehicle for delivery of this education.

Take-home points for Educators: It is normal for youth of all ages to ask questions about gender and sexuality. It may be useful to engage in values clarification to further understand and challenge one’s personal beliefs about gender and sexuality. The following values clarification activity is meant for parents, but it may also be adapted for use among educators to engage with:  Resource Center for Adolescent Pregnancy Prevention (ReCAPP) .

Take-home points for Public Health Professionals: In order for CSE implementation to be effective, oversight and accountability need to be written into sex education legislation. CSE implementation may also be improved by bridging the gap between policymakers and education implementors. Finally, public health professionals need access to rigorous scientific data as they develop policies that impact the health of communities.

Take-home points for Primary Care Physicians: Because sex education in schools varies dramatically, physicians should educate themselves on the curricula taught in their respective school districts in order to be more aware of the sexual and reproductive health information their patients are receiving. Furthermore, Primary Care Physicians should discuss gender and sexuality with all patients from a young age…this normalizes sexuality, instills body confidence, and empowers youth with the anatomically correct terminology for reproductive body parts. Physicians should also address safer sex practices with adolescent patients, particularly condom and other contraceptive use; this ultimately decreases risk for teen birth, thereby improving  maternal health . Physicians are encouraged to discuss gender and sexuality with ALL patients, as this impacts patients’  short- and long-term health outcomes .

Recommended citation:

Rollston, R., Grolling, D., Wilkinson, E. (2020). Sexuality education legislation and policy: a state-by-state comparison of health indicators. ArcGIS.  https://storymaps.arcgis.com/stories/2586bb2dc7d045c092eb020f43726765 

United States Data Sources:

Centers for Disease Control and Prevention (CDC). (2018). Sexually Transmitted Disease Surveillance 2017: STDs in Adolescents and Young Adults. Retrieved from:  https://www.cdc.gov/std/stats17/2017-STD-Surveillance-Report_CDC-clearance-9.10.18.pdf 

Centers for Disease Control and Prevention (CDC). (2018). Youth Risk Behavior Surveillance -- United States, 2017. Morbidity and Mortality Weekly Report Surveillance Summaries, 67(8). Retrieved from:  https://www.cdc.gov/healthyyouth/data/yrbs/pdf/2017/ss6708.pdf 

Guttmacher Institute. (2019). Sex and HIV Education. Retrieved from:  https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education 

Hall, WJ., et al. (2019). State Policy on School-based Sex Education: A Content Analysis Focused on Sexual Behaviors, Relationships, and Identities. American Journal of Health Behavior, 43(3): 506-519.

Martin, J.A., et al. (2018). Centers for Disease Control and Prevention (CDC). Births: Final Data for 2017. National Vital Statistics Reports, 67(8). Retrieved from:  https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_08-508.pdf 

Netherlands Data Sources:

Rutgers International and Soa Aids Nederland. (2017). Sex Under the Age of 25. Retrieved from:  https://www.rutgers.international/how-we-work/research/sex-under-age-25 

The World Bank. (2018). Adolescent Fertility Rate. Retrieved from:  https://data.worldbank.org/indicator/SP.ADO.TFRT 

Visser, M., et al. (2018). National Institute for Public Health and the Environment. Sexually transmitted infections in the Netherlands in 2017. Retrieved from:  https://www.soaaids.nl/sites/default/files/rapport-rivm-soas-in-nederland-2017.pdf