Classroom Voices: Youth Perspectives to Direct School-based Sexual Health Education

Abstract

Sexual health education is a well-known, evidence-based intervention that can improve adolescent health outcomes, increase protective health behaviours, and decrease risky health behaviours. Providing sexual health education in school settings offers opportunities for discussion of critical health topics and can improve the school environment for all students. However, not all sexual health education is taught equitably across classroom environments. As part of a mixed-methods study to describe school-based sexual health education, we conducted focus groups and interviews with recently graduated high school students in New Mexico, a geographically and ethnically diverse state in the US Southwest. Thirty-one young people shared their experiences, explored the sexual health education content they had been taught, and offered recommendations to improve sexual health education. Three key themes were developed: young people wanted and needed sexual health education taught in school settings; the sexual health education currently taught in school is not helpful and sometimes harmful; and the individuals who teach sexual health education are critically important. These findings can inform and support school staff and administrators addressing barriers to school-based sexual health education delivery, particularly in schools within marginalised communities with limited resources. The results support including youth as stakeholders in the planning, delivery and evaluation of school-based sexual health education; and the development of sexual health education training for teachers, with the goal of improving health outcomes for all youth populations.

Introduction

Young people in US middle and high schools receive less formal sexual health education now than at any time in the past 25 years, with youth of colour; youth living in rural communities; and lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) youth receiving even less sexual health education than their counterparts (Lindberg, Firestein, and Beavin 2021). More than half of US adolescents (15–19 years old) report being sexually active, and more than 70% engage in sexual activity by age 19 (Lindberg et al. 2021). Evidence has demonstrated that a comprehensive approach to evidence-based sexual health education can positively influence adolescent health outcomes such as reducing the incidence of risky sexual behaviour, strengthening protective sexual behaviours (Chin et al. 2012; Kedzior, et al. 2020; Mark and Wu 2022), and reducing reports of bullying and sexual violence in school settings (Goldfarb and Lieberman 2021; O’Farrell, Corcoran, and Davoren 2021). Sexual health education can also be one part of a larger strategy to improve school climate and create a safer school environment for all students, including the offering of LGBTQ+ inclusive sexual health education (Kosciw, Clark, and Menard, 2022). This makes sexual health education of vital importance for LGBTQ youth who experience disproportionate rates of bullying and physical/sexual assault and for youth from historically marginalised communities of colour who experience inequitable sexual health outcomes and have poorer access to health care services (CDC 2021b; Lindberg and Kantor 2022).

State and local education policies frequently dictate if and how sexual health education can be taught in schools. Within the USA, 39 states and the District of Columbia mandate some type of sexual health education and HIV education in schools (Guttmacher Institute 2019), but only 36% of US youth report receiving comprehensive sexual health education (Guttmacher Institute 2022). School personnel who are responsible for teaching sexual health education have identified multiple barriers to teaching sexual health education in school environments, including lack of resources, training and professional development, time, administrative support, and community resources (Dickson, Parshall, and Brindis 2020, 2021; Walker et al. 2021). As stakeholder groups (e.g., school administrators, teachers, health care professionals, parents, advocates and policymakers) continue the sexual health education debates, the voices of youth, whose lives should be positively influenced by sexual health education, are missing.

Students are seldom included or consulted when sexual health education is discussed (Ellis and Bentham 2020), despite being the specific group that sexual health education is intended to impact (Bauer, Hämmerli, and Leeners 2020). An integrative review from 2008 to 2019 found that young people were routinely excluded from sexual health education development (Corcoran et al. 2020). Good quality sexual health education has demonstrated positive influence on youth behaviours and health outcomes, and improvement to school environments by reducing bullying and harassment, increasing bystander behaviour, and reducing dating violence (Goldfarb and Lieberman 2021; Kosciw, Clark, and Menard 2022; Peterson et al. 2019). Fundamentally, therefore, it is critical to understand youth experiences and perspectives when planning and designing sexual health education that seek to address and meet their needs in life.

This article describes the qualitative arm of a mixed-methods study designed to better understand sexual health education in secondary schools across New Mexico, a US state in which sexual health education is required within health education standards mandated for high school graduation. Statute required sexual health education content includes pregnancy prevention, STI/HIV prevention, birth control, condom use, and access to sexual health services but following a request in writing, parents may excuse (“opt-out”) their student from courses teaching sexual health education (NMPED 2005; 2007; 2020). Despite unique demographic and cultural strengths, New Mexico struggles with deep structural inequities that impact the health of young people in all communities (NMDOH 2019): the second highest poverty rate in the country (19%) (U.S. Census Bureau n.d.), an 8.4% unemployment rate (USDA 2022); health care provider shortages in 97% of state counties (NMDOH 2019); and child well-being rate that ranks 49 out of the 50 US states (The Annie E. Casey Foundation 2022). Considering these social determinants related to adolescent sexual health (Garrido et al. 2018), it is not surprising that rates of sexually transmitted infections and unintended pregnancies for New Mexico youth are consistently higher than their peers nationally (CDC 2021a, 2021b). In this study, we aimed to explore the perspectives and experiences of young people who received school-based sexual health education in New Mexico. The study was approved by the University of New Mexico Health Sciences Centre (UNM HSC) Human Research Review Committee.

Methods

We employed descriptive qualitative methods to answer the research question: What are the sexual health education experiences and perspectives of students who recently graduated from New Mexico secondary schools? We collected data from youth representing different communities (e.g. rural, urban, tribal and border) and different types of schools (e.g. public, private).

Recruitment/Participants

We employed convenience sampling to recruit young adults to the study with the goal of reaching participants who represented the state’s diverse demographic groups. We distributed recruitment flyers, advertised on social media, and reached across networks of youth-facing organisations, school health, public health, and education professional networks, and community colleges and universities. When contacted by potential participants, we asked them to share the study information with their social network providing a snowball recruitment effect. We carefully screened potential participants by phone to ensure they met the inclusion criteria: they were 18 years of age or older, had graduated from a New Mexico high school in the previous two years (2018, 2019), had received sexual health education in middle and/or high school in New Mexico, and spoke English.

The study was designed to conduct in-person focus groups across the state. As such, individuals who met the inclusion criteria were required to attend an in-person meeting. We completed half of the focus groups when COVID-19 travel restrictions forced the cancellation of in-person meetings in 2020. We obtained permission from the UNM HSC Human Research Review Committee to pivot to individual virtual and telephone interviews. Refocusing our recruitment efforts for this purpose, the new inclusion criteria required participants to have access to a phone or computer to participate. Everyone who enrolled prior to travel restrictions participated in focus groups; everyone who enrolled after these restrictions participated in individual interviews. Recruitment continued until we reached data saturation (Patton 2015).

Protocol

Focus groups were held in private meeting venues, centrally located and accessible in each community, and facilitated by the research team members. Individual interviews were conducted virtually via Zoom (virtually or by telephone) using unique meeting codes with passwords and waiting room functions to pre-screen attendees. Focus groups and interviews were conducted with a semi structured interview guide, audio-recorded, and transcribed by a professional transcription company.

Participants provided verbal consent for participation and completed an anonymous demographic questionnaire asking age, race, ethnicity, gender identity, language spoken at home, and geographic rurality; participants were encouraged to select all categories of race that described them. Focus group participants completed paper questionnaires and their responses were entered into an electronic database (REDCap) (Harris et al. 2009) by a research team member; interview participants completed the questionnaire online using a secure, REDCap link prior to the interview. Research team members alternated between the facilitator and note-taking role. The interview questions were developed based on a comprehensive review of the sexual health education literature that focused on youth experiences, and analysis of secondary data collected from New Mexico health educators regarding sexual health education topics taught in secondary school (CDC 2021c). As all participants screened positive that they had received sexual health education in middle and/or high school, interview questions asked participants to describe regularity of sexual health education classes, grade(s) in which sexual health education was offered, the instructor/teacher role(s), and types of learning materials used. Additionally, participants were asked to describe their thoughts, opinions and comfort with the sexual health education taught, how sexual health education impacted their lives before and after high school graduation, and any suggestions for sexual health education improvement. All participants received a list of local mental health resources in case they experienced discomfort from the focus groups or interview. Each participant received a $25 electronic merchandise card for their participation in the study.

Data Analysis

The research team analysed transcripts using a team-based, iterative data analysis process. We uploaded transcripts into NVivo software¹. After creating a preliminary coding structure, research team members each coded one transcript, then met together to discuss and compare results. After agreeing on the preliminary structure, team members independently coded each transcript and met multiple times to discuss the coding process, referring to associated field notes and memos, until consensus was reached for codes within each transcript. We created coding summaries of the most relevant themes generated from the analysis and agreed upon accompanying quotes from participants. To increase the validity of the study results, we contacted five, randomly selected study participants by phone, shared preliminary results, and received feedback that helped with our interpretations of the findings (Saldaña 2021). We also reviewed preliminary results with a local sexual health education expert who provided context and feedback to support the rigour of the data analysis.

Results

Thirty-one individuals participated in qualitative data collection: 24 participated in focus groups and seven participated via virtual interviews. Demographic characteristics are summarised in Table 1. The mean age of participants was 19 years, with 52% identifying as female, 32% as male, 13% as nonbinary, and 3% as other. Forty-two percent of participants identified as Hispanic/Latinx ethnicity. When asked to describe their race, 32% identified as American Indian/Alaska Native, 58% as White, 3% identifying respectively as either Asian/Pacific Islander, Black, or Other. Of those that identified as Hispanic/Latinx, 62% identified as Hispanic/Latinx-White, 23% identified as Hispanic/Latinx-Native American, 8% identified as Hispanic/Latinx-Black, and 8% as only Hispanic/Latinx. While the majority (94%) reported English language spoken at home, 19% spoke Spanish, 10% Navajo, and 7% other languages. When asked where the school they received sexual health education was located geographically, 45% of the participants reported suburban communities, 29% rural, 29% urban, and 13% frontier (some participants received sexual health education in more than one location).

Table 1:

Demographic characteristics of participants (N = 31)

Characteristic	M (SD)	n (%)
Age (years)	19.26 (.89)
Gender
Female		16 (51.6)
Male		10 (32.3)
Nonbinary		4 (12.9)
Other		1 (3.2)
Ethnicity
Hispanic/Latinx*		13 (41.9)
Non-Hispanic/Latinx		18 (58.1)
Race **
American Indian/Alaska Native		10 (32.3)
Asian/Pacific Islander		1 (3.2)
Black/African American		1 (3.2)
White		18 (58.1)
Other		1 (3.2)
Languages spoken at home **
Spanish		6 (19.4)
Navajo		3 (9.7)
English		29 (93.5)
Other		2 (6.5)
Geographic rurality of school(s) attended **
Urban		12 (38.7)
Suburban		14 (45.2)
Rural		9 (29)
Frontier		4 (12.9)

^*Of those that identified as Hispanic/Latinx ethnicity, 62% identified as Hispanic/Latinx-White, 23% as Hispanic/Latinx-Native American, 8% as Hispanic/Latinx-Black, and 8% as only Hispanic/Latinx.

^**For these questions, participants could select more than one category and percentages may equal more than 100%

Three key themes were generated from our qualitative analysis: young people want and need sexual health education in school; current sexual health education offered in schools is not helpful; and the individual who is teaching sexual health education matters. A summary of themes and subthemes are presented with quotations from participants with more detail provided in Table 2.

Table 2:

Main themes, subthemes and participant quote examples

Themes	Subthemes	Additional quote examples
Youth want and need sexual health education in school	Youth seek out their own sources if they believe what they need isn’t taught in class	“A lot of the education I had to do I had to do outside of class like go talk to other people or do my own research on it.” “Yeah, I found out through the internet, mostly my own research.”
	Less fear, more awareness	“I was scared to even get sexual active or do anything like that. So I just remember being scared the entire time.” “Talk to us like we’re people. Don’t try to scare us.” “Just be safe. The keyword is be safe about it.”
	Topics of gender roles, consent, pleasure	“In the very male-dominated culture that I live in, I’m here to make a child, and that is all I am here for. So I think that should have been addressed. I’ve been completely neglected.” “I wish (the topic of) consent was focused on more of just like sexual intercourse … just a general life thing. Especially when it comes to relationships and how public you want to be and what not with that.” “I would also add how to get to the pleasure because that’s something that (we) basically learned how to do all of that stuff from porn.”
	Represent all types of relationships, including LGBTQ	“We need LGBTQ representation. . . . It was very heterosexual, heteronormative, and there was a certain structure, and when I had my first girlfriend, I had no idea what I was doing.” “They never talked about same-sex relationships. They never really made it too much of a safe space. I learned maybe a year or two after that that same-sex partners still need contraceptives regardless of the fear of pregnancy is what they were mostly teaching us.” “Me, personally, I would have loved to know other ways to prevent like getting STDs with someone with the same gender.”
	Birth control, abortion, other reasons people use contraception	“But what they didn’t talk about was how expensive (birth control) is, why it’s so expensive, and where to get it. Because they were like, ‘It’s expensive. You don’t need it. Just don’t have sex.’” “There’s definitely a lot of people there that believed that abortion was horrible, you should never do it. That wasn’t really talked about.” “I was never allowed to have birth control. I really needed it for things other than being sexually active.”
	Confidential services	“Letting you know your rights, too. Your rights as a person. Because in high school, no one ever told me that once you turn a certain age, but if you want to have a specific conversation with your practitioner . . . that your parents can leave the room. That you don’t have to have anybody else in that room with the doctor with you. I think that would be also a good tool and resource for high schoolers to know.”
	Taking care of their body	“It just kind of made it harder to ask the questions that we needed answered. I couldn’t raise my hand in front of a boy and be like, “How do you clean your vagina?” “Hygiene. I don’t think I was ever taught how to take care of my body aside from take a shower and deodorant. And there is so much more than that, and no one ever talks about it.”
Current sexual health education has not been helpful	Barriers to teaching sexual health education	“It was almost like the school system itself wasn’t well-equipped to be teaching it.” “My teacher just started the class by saying, ‘I will not teach you how to put on a condom.’ I think she kind of used the fact that, ‘Well, teenagers are teenagers, and they’re going to laugh at everything, basically.’ But I think she kind of used that as a way to not teach us something that we should learn how to do.”
	Focusing on abstinence is not helpful	“I wish they’d talked more about stuff that wasn’t abstinence.” “I remember there was also a lot of abstinence preaching, and that was all there ever really has been.” “But their whole idea about both sex and drugs was like, ‘Don’t do it,’ which, I think, when teaching teenagers, is unrealistic.”
	Felt shame, unsafe	“I had already lost my virginity. And I was confused about everything. It just made my self-esteem plummet.” “I mean, I would rather have been informed about the choices that I was making and had the facts, because the scaring really didn’t work, it just made me confused when it actually happened.”
The person who teaches sexual health education matters	Instructors need to be trained to teach sexual health education, be comfortable with talking about sex	“When they teach these classes, look at us like, ‘Oh, you guys are small people. You don’t need to know about this. I’m just going to tell you not to do it and you’re not going to do it, right?’ I mean, that’s not the way it works. I think it needs to not be biased to anyone’s personal views. I think it should be truly educational.” “It seems like my teacher taught it the way that he probably learned it in high school. And it’s not even like they told him or gave him a set script to do it. They were just like, ‘You’ve got to teach sex ed. Go for it.’ And he’s like, ‘OK. I’m going to just tell them what I know.’ And that may not be enough information.”
	Instructors need to have community understanding, empathy	“Like my teacher, she knew about community, how people are scared to get condoms, and how people end up with kids because a lot of stuff happens to them. . . . She was very open and understood everybody in the class.” “Understanding that there’s a mixture of cultures. That some people’s families may feel this way or some may feel this way. And to kind of, not necessarily generalise information, but say, give them a path and resources for that area, specifically.”
	Instructors need to be someone students trust and are someone who’s comfortable answering questions from students	“Once it got to the talking a little bit about the sex education, she was letting us know that we have no shame in talking about it. It’s our own bodies and that we have every right and consent to talk about it and to know about it. Her teaching was pretty good, honestly.” “Making sure that everybody knows that it’s a safe space, that they can ask a question. Because even if you don’t ask questions, knowing that you’re able to in a judgment-free zone is going to help people feel more comfortable with the material.” “But she was talking so much about safety, and she cared about everybody. She made it seem like I need to be safe. And ever since then, I’ve just been safe.”
	Expert guest speakers are important resources to include	“He came in, he was talking about his personal experience of having HIV. And he was pretty cool because he survived going through AIDS, and it made me think about it more because he actually went through that kind of stuff, and he wasn’t my teacher.” “We had this guest speaker. She was really big on consent for four days straight.” “I understand that a lot of schools don’t have the money to hire somebody, but there [are] a lot of community members who are willing to volunteer and teach.”

Youth Want and Need Sexual Health Education in School Settings

Participants overwhelmingly stated that sexual health education was education they not only wanted, but needed in the school setting. One participant explained why sexual health education was important content to learn during high school:

This is stuff that you’re going to be doing regardless of what happens, whether you’re going to wait till marriage or whether you’re going to go and do it throughout high school. It’s definitely something that’s going to happen in your life. So being able to know what works is something that I think is super important for people to learn.

It was important to have a place in school to discuss sexual health topics, as many participants explained they did not have a trusted space or person with whom to share that type of information. One participant emphasised this point: “If you don’t give these kids the information, they’re going to see it somewhere else. And then they’re not going to either get the facts, right? Or they’re going to get confused.” While some of the participants reported having a safe home environment to ask questions, adults at home were not always knowledgeable or comfortable discussing sexual health education, as described by one participant: “Growing up, it’s kind of a taboo subject you don’t bring up. I mean my parents didn’t talk with me about [sex].” Another participant described the value of learning sexual health education in school:

It’s just like walking in a dark room with a candle kind of thing. It’s like I know some of it. But it’s more along the lines of, ‘What if it does happen to me? What do I do then? Who do I run to? How does this affect my life?’ Then that day when I had that class, it really opened my mind. I learned a lot. I pay attention because it was new and something that I had lots of questions for.

An important subtheme described by participants was the desire to be aware of the risks of sex, but not be afraid of it. Sexual health education needed to acknowledge that they are sexual beings, that they may engage in sexual relationships one day, and not everything is a frightening experience to avoid. One participant compared this to teaching about underage alcohol drinking: “. . . They tell you [to] be safe when you’re drinking. Why can’t we have that same conversation about sex education? Because we know people under 21 drink. It’s common. So is sex.”

Participants overall said they needed sexual health education to focus less on what can go wrong in sex and more on what can go right, what is enjoyable, and why it is normal to engage in sexual relationships. In particular, participants identified a need to be less heteronormative and more inclusive about different types of relationships, including LGBTQ relationships. One participant explained:

Same sex relationships are very real, they’re very much common, and they deserve the same attention that a heteronormative relationship gets in a sex ed course, [and] gender doesn’t always define your sex, and that there [are] more types of relationships that are not heterosexual. They’re very much just a relationship. They’re not labelled. They’re not in a box.

Discussion among participants about pregnancy prevention affirmed that while some classmates might intend to have children during high school, most did not. One participant described the positive value of learning sexual health education during school: “you can have sex and have it be safe and also reduce the risk of pregnancy. I think that was positive. I feel like it’s good knowledge to have, you know?” It was also important for participants to understand where to go for health services (e.g., birth control, screening, etc.), how to access services, what the cost may be, reasons for certain health services (e.g., abortion), and legal age of consent to access sexual and reproductive health care in New Mexico. One participant expressed a need to understand the nuances of contraception that were rarely addressed in class: “Birth control isn’t just for birth control. It’s for periods, acne, anaemia, so many different things that can happen. People should know their rights when it comes to their health situation.”

Participants also said that attending a sexual health education class should not be optional: “I think it should be required [for] every student. I’d rather them be educated on those things instead of just being like, ‘Oh you know what, I don’t want to take that class because it’s going to make me uncomfortable.’” Requiring attendance would provide opportunities to engage in a variety of sexual health discussions participants identified as important, topics that they were unable to discuss in other spaces or felt they needed to know. These topics ranged from how to care for their changing body, hygiene and understanding menstrual periods, to more complex topics including gender roles, consent, pleasure and the confusion around why there is shame talking about sex. One participant’s comment emphasised this point:

It [sexual health] is not a stagnant topic. It changes throughout generations, the opinions and things surrounding it change throughout generations as well. I genuinely think that they should have added LGBTQ, pleasure for women and men, the things that happened with contraception, how to properly keep yourself clean, the shame that surrounds having sex. We need to address the fact that there’s shame surrounding sex for whatever reason.

Current Sexual Health Education is Not Helpful

Many participants described sexual health education in school as not helpful before and after they graduated from school. They identified many challenges and negative issues associated with sexual health education including teacher’s lack of time, skill or willingness to engage in in-depth discussion related to sexual health; an overemphasis on abstinence; and an undercurrent of shame and fear for any previous sexual encounters (including sexual assault), or if they identified as LGBTQ. One person said, ‘It [sexual health education] is really installed as fearful [and] has held me back.” Some participants said they wished their education could have helped them understand or deal with future relationships, characterised by one participant: “I was fearful, in general, about doing anything that has to do with intimacy. And it definitely impacted me. I never felt important, and it removed my sense of being a human being to tell you the truth.” Some participants said the sexual health education they received in school had a lasting negative impact. When describing how their experiences made them fear sex and intimacy later in life, unable to express their needs, one participant shared, “It definitely impacted me. I was never able to voice my opinion. I was never able to speak in the way I wanted to speak or get the things that I wanted.”

Participants identified reasons why sexual health education was not helpful, such as the intentional avoidance of “off limit” topics for discussion, and the use of parental permission required to “opt out” or remove students from a course teaching sexual health education, a common state policy requirement (Garg and Volerman 2020). Religious and cultural beliefs were also discussed as barriers to teaching sexual health education; one participant reported that their religiously conservative community discouraged the provision of any sexual health education in school: “It was almost like the school system itself wasn’t well equipped to be teaching it, and they felt uncomfortable teaching it.” Many participants were clear that the emphasis on abstinence or abstinence-only in sexual health education classes was not helpful. A participant shared: “The more you preach abstinence, the more likely they are to have sex, the more likely they are to have unsafe sex. So if you’re only going to teach abstinence-only, you should not be teaching the sex ed class.”

Many participants reported that when sexual health education was not helpful, they relied on their friends, the internet, or watching pornography for other information, even though they later realised those sources were often incorrect. One participant summarised: “I had to figure out anything useful for myself by myself. Nothing I learned in that class actually applied to me at all.”

The Person Who Teaches Sexual Health Education Matters

Having an instructor who was competent to teach sexual health education and who was comfortable talking about sex and sexual relationships with young people was important. When the person teaching sexual health education (who may be a teacher, school nurse, school staff, or guest speaker) avoided or rushed through difficult content and information, it could reinforce shame and stigma and limit how much students were willing to discuss topics. Participants said the person teaching sexual health education needed to be “someone who’s comfortable speaking about it…just someone who knows what they’re talking [about] and someone that can deal with an uncomfortable question and not make others feel uncomfortable.”

Traits that participants wanted in a sexual health education instructor included: being knowledgeable and comfortable with the subject, nonshaming, culturally humble, able to separate personal views from instruction, inclusive of LGBTQ students, informed of state laws impacting youth lives, and familiar with resources students might need. Participants described a larger impact the instructor had when they were open to discussing sensitive topics, creating a safe, inclusive space for everyone. A participant described how instructors could assure students: “everybody knows that it’s a safe space, that they can ask a question. . . . Because even if you don’t ask questions, knowing that you’re able to in a judgment-free zone is going to help people feel more comfortable.”

Participants were clear that instructors were not expected to have all the answers but would be able to provide trusted resources. “Even if they don’t know what they’re talking about, just have a resource for the students. . . . Like, if you don’t know the answer to a question, the student has access to someone who does.” Participants also valued opportunities to provide guidance or feedback to teachers about sexual health education. One participant shared: “So I kind of taught her a little bit of things specifically from the queer perspective that I learned that I thought that other people should learn as well.” Another participant echoed why providing feedback on sexual health education was important: “I’m just going to tell you…understand a teenager’s mind a little more, so they know how to actually speak to it.”

Many participants shared experiences of guest speakers who came to class to teach sexual health education, individuals who were often school health staff or outside community members. Participants who had positive experiences with sexual health education guest speakers identified them as approachable, knowledgeable and unbiased in presentation of information and well-trained to teach the subject. Often having someone other than their teacher helped participants feel more comfortable disclosing and asking questions. One participant said: “There was something about not being taught by your teacher about this kind of thing that made it easy to engage with the topic and open up about it.”

Discussion

The themes from this study represent youth experiences with sexual health education in secondary school from a specific southwestern region of the USA. Many of the participants’ perspectives paralleled other young people experiences reported in literature. Participants said they believed that sexual health education they received in secondary school did not meet their needs and the content was not relevant and not important to their lives (Astle et al. 2021; Fisher et al. 2019; Goldfarb, Lieberman, and Bible 2022). The participants noted that poorly delivered sexual health education could perpetuate fear, shame and stigma, supporting the importance of a trauma-informed approach to teaching sexual health education (Fava and Bay-Cheng 2013; Panisch et al. 2020). The predominate focus of abstinence and risk prevention, while important to include, are not helpful: rather over-emphasis on abstinence could be harmful by excluding currently or previously sexually active youth or delivering heteronormative messages that were not inclusive of LGBTQ students (Bible et al. 2022; Gegenfurtner and Gebhardt 2017).

Content and topics that study participants requested for inclusion in sexual health education have been identified and prioritised in other studies: instructional materials inclusive of all sexual orientations, gender identities, and racial and ethnic backgrounds; trauma-informed instruction for those who have experienced physical or sexual assault or abuse; discussion of accurate online information that is widely accessible by youth (including pornography); review of community resources and trusted websites; different types of sexual and asexual relationships; and emotional components of sexual relationships and how to recognise unhealthy behaviour and seek help (Corcoran et al. 2020; Jarpe-Ratner and Marshall 2021; Kantor and Lindberg 2020; Warwick et al. 2022). Participants also emphasised the need for more comprehensive LGBTQ content, a universal gap found in sexual health education (Bible et al 2022: Goldfarb and Lieberman 2021; O’Farrell, Corcoran, and Davoren 2021; Pampati et al. 2021; Snapp et al. 2015).

Normalising sexual behaviour while discussing sexual health education was important. Participants said they needed instructors to acknowledge that, now or in the future, they likely would engage in consenting, pleasurable sexual relationships, and that this is a normal expectation for individuals. The participants do not want to be scared or discouraged from relationships or sexual activity, but rather they want to have a safe place to safely discuss sexual health education issues with their peers with trusted adults who will provide relevant, accurate information and help them critically evaluate what they have experienced, read, heard or seen online (Goldfarb and Lieberman 2021; Kantor and Lindberg 2020; Shorey and Chua 2022).

Participants’ observations about instructors who lacked sexual health education training or professional development confirmed what educators themselves have reported in previous studies about being unprepared to teach sexual health education and their need for specialised training (Clayton, 2018; Dickson, Parshall, and Brindis 2020; O’Farrell , Corcoran, and Davoren 2021; Sondag, Johnson, and Parrish 2022). Participants identified skills that would help instructors avoid sending negative messages about sexual health and about perpetuating trauma. How an instructor mitigates shame and stigma is critical; participants emphasised the importance of developing opportunities for students to be heard, to be positively represented in the learning materials, and to build skills around consent (Broussard, Eitmann, and Shervington 2019; Panisch et al. 2020). Participants shared positive experiences when an instructor showed dedicated knowledge about sexual health and comfort in talking about it with young people. They expressed appreciation for guest speakers with specialised knowledge who helped participants feel more comfortable asking questions, an effective element in sexual health education validated in prior studies (Jarpe-Ratner 2020; Jarpe-Ratner and Marshall 2021; Sondag, Johnson, and Parrish 2022).

Finally, several participants recommended the inclusion of young people’s own perspectives when planning sexual health education instruction in schools, which is echoed as a successful approach (Kosciw, Clark, and Menard 2022, Narushima et al. 2020). Given that the ultimate goal of teaching sexual health education to young people is to improve their health outcomes, schools would benefit from creating mechanisms to incorporate youth perspectives into their sexual health education planning.

Limitations

This study was limited by multiple recruitment efforts across communities with multiple populations and geographic demographics. We also did not account for unique school district environments, school settings and policy realities that exist across communities in New Mexico. We collected perspectives and experiences from former students who had received sexual health education in the previous two years, but did not include students who did not graduate from high school. Our study included only English-speaking participants within a state with a predominantly Hispanic/Latinx and Native American population. While we did collect participant’s gender identity, we did not collect data on their sexual orientation thus limiting assessment of sexual health education inclusivity. Finally, the pandemic-related travel restrictions were an unanticipated limitation to recruitment and data collection. While we successfully pivoted from focus groups to individual interviews, interview participant data lacked the peer group discussion from the focus groups. Individual interviews allowed us to continue data collection, created flexibility in scheduling interviews, provided a larger sample from which to recruit, and included youth perspectives that might have been excluded had we only held focus groups. We did not find any differences between the two groups. However, the small sample size and inherent differences between data collection methods made it challenging to compare data, which is another limitation.

Implications

These study findings offer a unique understanding of the perspectives and experience of young people who received school-based sexual health education, young people facing considerable structural inequities, from a rural region of the USA where communities of colour represent the majority population. The findings also echo evidence collected from other US youth populations regarding school-based sexual health education, and recommendations to improve it.

The results from this study illuminate the need to engage and listen to youth not only to understand issues regarding current sexual health education content, but also what information young people need to live healthy, productive lives as they mature into adulthood (Fisher et al. 2019). When implementing an evidence-based public health intervention, it is a logical step to seek the perspective of the end users of that intervention (Lam and Mattson 2020). In the case of sexual health education in school settings, young people are the key stakeholders. Information they do or do not receive can influence their health outcomes (Corcoran et al. 2020). School administrators and individual instructors who seek to meet national health educational standards (Future of Sex Education Initiative 2012; SHAPE America 2020) or their state or local policy requirements should consider these recommendations while planning sexual health education programmes. These recommendations can also inform future sexual health education training and professional development for instructors, incorporating and normalising the presence of trained and vetted guest speakers as content experts (Dickson, Parshall, and Brindis 2020; Rose et al. 2019; Sondag, Johnson, and Parrish 2022) and including students’ perspectives (Corcoran et al. 2020; Fisher et al. 2019). The value of incorporating youth perspective into the planning, delivery and evaluation of school-based sexual health education has the potential to not only improve sexual health education quality, but also support the health of youth people and improve the many inequities they experience.