Pleasure and Sex Education: The Need for Broadening Both Content and Measurement

Abstract

Sex education in the United States is limited in both its content and the measures used to collect data on what is taught. The risk-reduction framework that guides the teaching of sex education in the United States focuses almost exclusively on avoiding unintended pregnancy and sexually transmitted diseases, overlooking other critical topics such as the information and skills needed to form healthy relationships and content related to sexual pleasure.

Young people express frustration about the lack of information on sexuality and sexual behavior that is included in sex education programs; sexual and gender minority youths, in particular, feel overlooked by current approaches.

International guidance provides a more robust framework for developing and measuring sex education and suggests a number of areas in which US sex education can improve to better meet the needs of youths.

Sex education is the one school subject that is supposed to provide adolescents with the information and skills they need to navigate relationships, understand sex and sexuality, and find the resources they need for obtaining additional information and relevant health services. Despite often being framed in the United States as a tool for risk reduction, quality sex education should be guided by the broader goals of supporting young people’s sexual health and well-being and helping them grow into sexually healthy adults.^1,2

In the United States, available guidelines for sex education include the Guidelines for Comprehensive Sexuality Education, K-12, which were first published by the Sexuality Information and Education Council of the United States (SIECUS) in 1991 and have been updated twice (most recently in 2004),³ and the National Sexuality Education Standards, published by the Future of Sex Education Initiative in 2011.⁴ These guidelines, as well as international guidelines for sex education, especially the recent UNESCO International Technical Guidance on Sexuality Education, identify learning objectives in key areas that embrace a broad view of sexuality, including relationships, gender, skills for health and well-being, and sexuality and sexual behavior.⁵ The available research on sex education in the United States reveals that most young people receive instruction on only a small subset of these topics, with greatest attention given to more narrowly focused risk-reduction topics; even the measures used to ascertain what young people are learning are largely confined to these risk-reduction topics.^6,7 Focusing on these topics and measures overlooks many key aspects of young people’s current and future sexual lives, including the ability to form and maintain healthy relationships; the right to decide whether, when, and with whom to engage in sexual behavior; and the fact that sex should be pleasurable, to name just a few.

Thus, the narrow content of sex education in the United States needs to expand to focus more on sexual health than sexual risk⁸; surveillance metrics also need parallel expansion beyond risk prevention. Traditional public health goals for sex education in the United States have largely focused on helping young people to avoid unintended pregnancy and sexually transmitted infections (STIs), and the proximate sexual and contraceptive behaviors related to these outcomes. The federal government’s Healthy People 2020 objectives related to sex education only include target levels for adolescents’ receipt of formal instruction about abstinence, birth control methods, HIV/AIDS, and STIs.⁹ These narrow objectives both reflect and inform the collection of national surveillance data.

CURRENT NATIONAL SURVEILLANCE EFFORTS

The three main data sets that are used to gather information about the receipt of sex education in the United States are the School Health Profiles (SHP),¹⁰ the School Health Policies and Practices Study (SHPPS),^6,11 and the National Survey of Family Growth (NSFG).^7,12 These are broad federal data collection efforts with a limited set of sex education measures. The NSFG, conducted by the US National Center for Health Statistics, is a nationally representative household survey that has tracked young people’s receipt of sex education since 1982. It has interviewed adolescents directly about receipt of different topics over time, with a focus on instruction about saying no to sex, waiting until marriage to have sex, birth control methods, and STI/HIV prevention.¹³ The NSFG measures are not designed to collect information about the quality of instruction, the amount of instruction, or even much about its content or tone.¹⁴ For example, the survey item that asks if adolescents were taught about “methods of birth control” does not distinguish between instruction that presents contraception in a positive or negative manner. Further, the pedagogical approach used is completely ignored. For example, a didactic presentation on methods of contraception is very different from asking students to role-play talking to a potential partner about using birth control. However, for either of these approaches, an NSFG respondent would be expected to answer that they were taught about birth control. Additionally, young people are only asked to report on the age at which they first receive sex education, providing no information about instruction as they get older. Despite these limitations, in addition to its use in general surveillance, multiple studies have used NSFG data to link receipt of formal sex education to adolescent sexual and reproductive health behaviors and outcomes.^15,16

The Centers for Disease Control and Prevention (CDC) conducts two key surveillance efforts—the SHP and the SHPPS—that monitor many school health policies and practices, including health education, and collect data on the provision of sex education. The SHP monitors school health policies and practices in 48 states, 21 large urban school districts, and 4 territories. It covers a broader range of sex education topics than the NSFG, monitoring provision of 19 specific sexual health topics in grades 6 through 12 and some information about instruction prior to the sixth grade, as well as some measures of relevant teacher training.¹⁰ The complementary SHPPS is a national survey conducted periodically at the state, district, school, and classroom levels. The SHPPS includes measures of requirements for sex education on topics focused around pregnancy prevention, STI/HIV prevention, and human sexuality, including some indicators of teacher training and classroom time spent on these topics.¹¹ Both the SHP and SHPPS data are collected from school administrators and teachers, not from young people themselves, so they likely reflect what is supposed to be taught rather than what students actually receive. Additionally, the CDC collects the Youth Risk Behavior Surveillance System (YRBS), a nationally representative survey of high school students. From 1993 to 2013 the YRBS asked a single item about receipt of HIV/AIDS education, but this question was removed in 2015.¹⁷

All of these US surveillance systems focus on topics using a risk-reduction framework and do not examine many broader sexual health promotion topics such as communication or relationships, despite national guidelines for sex education that include these topics. For example, one of the only communication measures in the SHP is, “Use interpersonal communication skills to avoid or reduce sexual risk behaviors.”¹⁰ The SHP has a single measure to ascertain what middle and high school students receive in sex education related to relationships: “how to create and sustain healthy and respectful relationships.”¹⁰ The NSFG measures of instruction about “how to say no to sex” or “waiting until marriage to have sex” might generously be construed as indicators of communication and relationship topics.

EXPANDING SURVEILLANCE TO INCLUDE PLEASURE

By contrast, the recent UNESCO guidance suggests numerous learning objectives related to the topic “friendship, love, and romantic relationships,” which is only one of four topics included in the section on relationships. There are 14 objectives related to “friendship, love and romantic relationships” for children aged 5 to 8 years, 10 objectives for ages 9 to 12 years, 11 for ages 12 to 15 years, and 7 for ages 15 to 18 years.⁵

Both the older SIECUS Guidelines for Comprehensive Sexuality Education³ and the National Sexuality Education Standards⁴ identify the importance of including topics related to communication and healthy relationships, although they offer a narrower and less detailed set of objectives than the recent UNESCO guidance. Still, none of these three sets of guidelines could be adequately monitored with current US surveillance measures given their narrow focus on risk-reduction topics.

An examination of the UNESCO-recommended topics related to sexual pleasure shows even more of a discrepancy between important sexuality topics and what is taught and measured in the United States. There are several learning recommendations related to pleasure in the UNESCO technical guidance, including “describe ways that human beings feel pleasure from physical contact (e.g. kissing, touching, caressing, sexual contact) throughout their life,” which is a learning objective for children aged 9 to 12 years; “state that sexual feelings, fantasies and desires are natural and not shameful, and occur throughout life,” which is a learning objective for those aged 12 to 15 years; “understand that sexual stimulation involves physical and psychological aspects, and people respond in different ways, at different times,” which is a learning objective for those aged 12 to 15 years, and which includes as a key idea for ages 15 and older that “Engaging in sexual behaviours should feel pleasurable and comes with associated responsibilities for one’s health and well-being.”⁵ The SIECUS guidelines do not include pleasure as a separate topic, although some messages related to pleasure are included (e.g., under the topic of “shared sexual behavior,” a suggested message is “Couples have varied ways to share sexual pleasure with each other”).³ Regardless, the US surveillance systems ignore topics related to pleasure completely. Ignoring pleasure not only leaves out a salient component of sexual health but may also put young people at risk for reduced use of contraception and condoms, as there is evidence that concerns about reductions in pleasure act as a barrier to both contraception and condom use.^18,19 Further, failing to address pleasure may have implications for sexual coercion, as sex education may be one of the only places that young people learn that sex should be pleasurable and not used in manipulative and harmful ways. Indeed, a recent study found that school-based sex education that included instruction in refusal skills prior to college was protective against the likelihood of experiencing sexual assault once in college.²⁰

YOUTH PERSPECTIVES AND THE CURRENT LANDSCAPE

If we look beyond these national surveillance systems, we find that when asked about sex education, young people are dissatisfied with the dearth of messages related to positive aspects of sexuality and the narrow ways that sex is discussed. For example, in a qualitative analysis of stakeholders, including youths, adolescents frequently mentioned the lack of discussion about pleasure as a reason they were frustrated with sex education.²¹ The experience of sexual and gender minority youths is even worse, with young people feeling either overlooked or subjected to information that is exclusively heteronormative.^22,23 Providing instruction that is inclusive of lesbian, gay, bisexual, and transgender (LGBT) youths is important, and surveillance measures should monitor it. There are no measures in the NSFG about whether sex education is LGBT inclusive. The SHP has only a single yes–no item in the teacher questionnaire: “Does your school provide curricula or supplementary materials that include HIV, STD [sexually transmitted disease], or pregnancy prevention information that is relevant to lesbian, gay, bisexual, transgender, and questioning youth (e.g., curricula or materials that use inclusive language or terminology)?”¹⁰ This single item excludes other pertinent issues, including ensuring that all students are taught about sexual orientation and gender identity, that LGBT relationships are recognized throughout the curriculum, and that prevention information is conveyed in a manner that does not alienate or overlook sexual and gender minority students.

What we do know about what young people receive in schools reveals that many receive a dearth of sex education and that what is received can vary considerably by state. For example, the SHP data show that in grades 6 though 8, the percentage of schools that reported teaching all 19 sexual health topics examined varied widely, from 5.1% of schools in Arizona to 40.2% in New Mexico.¹⁰ In high schools, the percentage of schools that covered all 19 topics varied from 4.5% in Utah to 84.4% in New Jersey.¹⁰ The NSFG documents that although 80% or more of adolescents aged 15 to 19 years report receipt of instruction about HIV/AIDS, STIs, or abstinence-focused topics, instruction about birth control methods, including where to obtain a method and how to use a condom, is less common. In the years 2011 to 2013, only 57% of sexually experienced girls and 43% of sexually experienced boys reported receiving instruction about birth control methods prior to first sex.⁷

The situation in the United States reflects our particular cultural and political framing of sex education. Both receipt of sex education and surveillance in some other countries are more robust. For example, in Australia, the National Survey of Australian Secondary Students has been undertaken about every five years since 1992.²⁴ This sexual health survey asks youths a wide range of knowledge, self-efficacy, and behavior questions about topics ranging from confidence in talking to parents about subjects related to sexuality to whether they have engaged in a variety of sexual behaviors, including kissing, oral sex, and intercourse. The survey also asks students about sources of information, including what they received in schools, in which classes they received the instruction, and how relevant they found the information to be. In Canada, although there is no ongoing government monitoring of sex education, the national civil society organization, Action Canada for Sexual Health and Rights, is currently undertaking a comprehensive assessment of sex education in all provinces, with a tool they developed using the UNESCO technical guidance as an underpinning (Frederique Chabot, e-mail, March 11, 2019). The British National Survey of Sexual Attitudes & Lifestyles asks about receipt of 14 sex education topics, including masturbation, how to make sex more satisfying, and “sexual feelings, emotions and relationships.” Additionally, young people are asked about their perceived unmet information needs.²⁵

Young people deserve sex education that is relevant to their lives and includes the knowledge, attitudes, and skills they need in both their current stage of development and throughout their lives. Guidelines, programs, and measures of sex education ought to include the full range of sex education topics and should also include items related to the pedagogy of sex education, including teaching approaches and student engagement. Recent international guidance provides a road map for broadening the US approach to sex education. The United States should join other countries in making an effort to strengthen sex education provision and surveillance, including updating available guidelines for sex education and broadening the measures used to assess sex education.