Comprehensive sex education
Comprehensive sex education (CSE) is a sex education instruction method based on-curriculum that aims to give students the knowledge, attitudes, skills and values to make appropriate and healthy choices in their sexual lives. The intention is that this understanding will prevent students from contracting sexually transmitted infections in the future, including HIV and HPV. CSE is also designed with the intention of reducing teenage and unwanted pregnancies, as well as lowering rates of domestic and sexual violence, thus contributing to a healthier society, both physically and mentally. Comprehensive sex education ultimately promotes sexual abstinence as the safest sexual choice for young people. However, CSE curriculums and teachers are still committed to teaching students about topics connected to future sexual activity, such as age of consent, safe sex, contraception such as: birth control, abortion, and use of condoms. This also includes discussions which promote safe behaviors, such as communicating with partners and seeking testing for sexually transmitted infections. Additionally, comprehensive sex education curricula may include discussions surrounding pregnancy outcomes such as parenting, adoption, and abortion. The most widely agreed benefit of using comprehensive sex education over abstinence-only sex education is that CSE acknowledges the student population will be sexually active in their future. By acknowledging this, CSE can encourage students to plan ahead to make the healthiest possible sexual decisions. This ideology of arming students to most successfully survive their future sexual experiences underlies the majority of topics within CSE, including condoms, contraception, and refusal skills.
Benefits of CSEEdit
Studies have found that comprehensive sex education is more effective than receiving no instruction and/or those who receive abstinence-only instruction. Acknowledging that people may engage in premarital sex rather than ignoring it (which abstinence-only is often criticized for) allows educators to give the students the necessary information to safely navigate their future sexual lives.
CSE advocates argue that promoting abstinence without accompanied information regarding safe sex practices is a disregard of reality, and is ultimately putting the student at risk. For example, programs funded under AEGP are reviewed for compliance with the 8 standards (listed below in "Abstinence Education Grant Program (AGEP) Requirements), but are not screened for medical accuracy. Therefore, critics believe that students under these educational programs are put at a disadvantage because it prevents them from making informed choices about their sexual health. Additionally, under these AEGP programs, health educators have referred to those that engage in sex, especially females, as "dirty" and "used." They have also used phrases such as "stay like a new toothbrush, wrapped up and unused" and "chewed-up gum" to teach abstinence. Under a CSE model, language would be more sensitive.
There is clear evidence that CSE has a positive impact on sexual and reproductive health (SRH), notably in contributing to reducing STIs, HIV and unintended pregnancy. Sexuality education does not hasten sexual activity but has a positive impact on safer sexual behaviours and can delay sexual debut. A 2014 review of school-based sexuality education programmes has demonstrated increased HIV knowledge, increased self-efficacy related to condom use and refusing sex, increased contraception and condom use, a reduced number of sexual partners and later initiation of first sexual intercourse. A Cochrane review of 41 randomized controlled trials in Europe, the United States, Nigeria and Mexico also confirmed that CSE prevents unintended adolescent pregnancies. CSE is very beneficial in regards to teen pregnancy because studies show that, teen pregnancy and childbearing have a significant negative impact on high school success and completion, as well as future job prospects. A study in Kenya, involving more than 6,000 students who had received sexuality education led to delayed sexual initiation, and increased condom use among those who were sexually active once these students reached secondary school compared to more than 6,000 students who did not receive sexuality education. CSE also reduces the frequency of sex and the number of partners which in turn also reduces the rates of sexually transmitted infections.
UNAIDS and the African Union have recognized CSE’s impact on increasing condom use, voluntary HIV testing and reducing pregnancy among adolescent girls and have included comprehensive, age-appropriate sexuality education as one of the key recommendations to fast track the HIV response and end the AIDS epidemic among young women and girls in Africa.
As the field of sexuality education develops, there is increasing focus on addressing gender, power relations and human rights in order to improve the impact on SRH outcomes. Integrating content on gender and rights makes sexuality education even more effective. A review of 22 curriculum- based sexuality education programmes found that 80 per cent of programmes that addressed gender or power relations were associated with a significant decrease in pregnancy, childbearing or STIs. These programmes were five times as effective as those programmes that did not address gender or power. CSE empowers young people to reflect critically on their environment and behaviours, and promotes gender equality and equitable social norms, which are important contributing factors for improving health outcomes, including HIV infection rates. The impact of CSE also increases when delivered together with efforts to expand access to a full range of high- quality, youth-friendly services and commodities, particularly in relation to contraceptive choice.
A global review of evidence in the education sector also found that teaching sexuality education builds confidence, a necessary skill for delaying the age that young people first engage in sexual intercourse, and for using contraception, including condoms. CSE has a demonstrated impact on improving knowledge, self-esteem, changing attitudes, gender and social norms, and building self-efficacy.
Criticism of CSEEdit
How comprehensive is CSEEdit
While CSE implementation is on the rise in the United States, it remains difficult for state officials to regulate what is and is not taught in the classroom. This is due in large part to the undefinability of CSE; CSE has the potential to comprise such a wide range of sexual information, and over-all focus varies widely between curriculums. Educators have also accused CSE as fundamentally operating as a form of "abstinence-plus," due to the reality that CSE often involves minimal body related information and excessive promotions of abstinence. "So-called Comprehensive Sex Ed" says Sharon Lamb, a professor at the University of Massachusetts Boston, "has been made less comprehensive as curricula are revised to meet current federal, state, and local requirements."
LGBTQIA+ community not included CSEEdit
The term "comprehensive" is also often misleading because some comprehensive programs do not show the holistic picture of human sexuality. LGBTQIA+ advocates have long been critical of the ways in which comprehensive sex education generally promotes marriage as the end goal for students. Even when curriculums claim to be inclusive of LGBT experiences, they often promote heteronormative lifestyles as "normal."  Inclusion of LGBT identities and health topics is necessary for LGBTQIA+ students to feel safe and seen in their sex ed classrooms. When these students do not have access to or an interest in marriage they are practically erased from the CSE narrative.
A cross sectional study done in New York City analyzed the sexual behaviors of high school girls. Studies found that, "high school girls who identified as LGBTQIA+ were more likely to report substance use such as: alcohol, marijuana, cocaine, heroin, meth, ecstasy and prescription drugs. They also had higher rates of contemplating and/or attempting suicide." Another study found that "the LGBTQIA+ youth accesses health information online five times more than the heterosexual population, and these rates are even higher for LGBTQIA+ youth that identify as a person of color which stems from the fact that they lack health resources. 
In fact, as of May 2018, only 12 states require discussion of sexual orientation and of these, only 9 states require that discussion of sexual orientation be inclusive. Additionally, several states have passed legislation that bans teachers from discussing gay and transgender issues, such as sexual health and HIV/AIDS awareness, in a positive light. Furthermore, three states require that teachers only portray LGBTQIA+ people in a negative light.
In a Canada, a federal report showed that LGBTQIA+ community has less access to health services and faces more comprehensive health challenges compared to the general population. As a result of lack of support for the LGBTQIA+ population, the Comprehensive Health Education Workers (CHEW) Project emerged in October 2014. Their goal is to educate the LGBTQIA+ community about topics such sexual and gender identity, sexually transmitted infections (STIs), healthy social relationships, and depression. They do this though workshops, arts‐based projects, and one‐on‐one meetings.
Who's role is it to deliver sexual educationEdit
Many people regard health education as a moral or religious issue," and therefore should be taught not in schools. "Before the late 1800s, delivering sex education in the United States and Canada was primarily seen as a parent’s responsibility. Today, programs under the Sexuality Information and Education Council of the United States (SIECUS) begin comprehensive sex education in pre-kindergarten, which many people believe is not age appropriate. Many of those in favor of abstinence only education, usually fear any type of sexual education that encourages sexual behavior at a young age.
Is it necessaryEdit
Although CSE is seen as the polar opposite of abstinence only education, some critics believe that they are very similar. They both aim at preventing STIs and teen pregnancy. The only way in which they differ is through their primary goal. Abstinence only education aims at reducing premarital sex while comprehensive sex education acknowledges that premarital sex may happen and therefore seeks to reduce the unintended consequences of premarital sex through education. Studies in developing counties surrounding sex education have also shown that comprehensive sex education is not needed. General education, such as literacy skills, was seen to delay sexual initiation and reduced the likelihood of pregnancy. Therefore, some people believe general education is of more importance.
Federal funding for sexual educationEdit
Although there is no federal mandate that requires states to teach sexual education, there is federal funding available to assist with sexual education programs.
Abstinence Education Grant Program (AGEP)Edit
Historically, funding for abstinence education has always been favored over CSE. In 1996, during Bill Clinton's presidency, legislation was passed to promote abstinence in education programs. Under Title V Section 510 of the Social Security Act, the Abstinence Education Grant Program (AGEP), was passed. AEGP has always been renewed before its expiration date, and each time funds gradually increase from fifty million dollars per year to seventy-five and as high as $6.75 million in 2015. The way the funds are disbursed are based on the proportion of low-income children in each state. So far, thirty-six states have been given AEGP funds.
Abstinence Education Grant Program (AGEP) RequirementsEdit
Part of Section 510(b) of Title V of the Social Security Act, contains the "A-H guidelines," which are the eight criteria that programs must abide by order to be eligible to receive federal funding. They are as follows:
A. Has as its exclusive purpose teaching the social, psychological, and health gains to be realized by abstaining from sexual activity;
B. Teaches abstinence from sexual activity outside marriage as the expected standard for all school-age children;
C. Teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;
D. Teaches that a mutually faithful, monogamous relationship in the context of marriage is the expected standard of sexual activity;
E. Teaches that sexual activity outside the context of marriage is likely to have harmful psychological and physical effects; F. Teaches that bearing children out of wedlock is likely to have harmful consequences for the child, the child's parents, and society;
G. Teaches young people how to reject sexual advances and how alcohol and drug use increase vulnerability to sexual advances; and
H. Teaches the importance of attaining self-sufficiency before engaging in sexual activity;
In addition to abiding by these 8 conditions, AGEP compliant programs cannot discuss contraception, STIs, or methods for protecting against STIs, except only when describing failure rates.
Teen Pregnancy Prevention Program (TPP)Edit
More recently legislation has pushed for funding that goes beyond abstinence only education. In 2010, President Obama introduced the Teen Pregnancy Prevention Program (TPP), which provides a total of $114.5 million annually to sex education programs that are "medically accurate and age-appropriate." TPP falls under a subsection of United States Department of Health and Human Services ("HHS") which is overseen by the Office of Adolescent Health. Funding for TPP is dispersed if "they emulate specific evidence-based programs promulgated under TPP."
California Comprehensive Sexual Health and HIV/AIDS Prevention Education ActEdit
In January 2016, the California Healthy Youth Act, amended the California Comprehensive Sexual Health and HIV/AIDS Prevention Education Act to include minority groups and expand health education. Before it authorized schools to provide comprehensive sex education and required that all materials are made accessible to students with a variety of needs. It also focused solely on marital relationships. It now mandates that schools provide comprehensive sex education and states that "materials cannot be biased and must be appropriate for students of all races, genders, sexual orientations, and ethnic and cultural backgrounds, as well as those with disabilities and English language learners." Additionally, education must now include "instruction about forming healthy and respectful committed relationships," regardless if marital status. Furthermore, it is now required to have discussions about all FDA-approved contraceptive methods in preventing pregnancy, including the morning after pill.
In conclusion now requires that all sex education programs promulgated in the state should
- normalize sexuality as part of human development;
- ensure people receive integrated, comprehensive, accurate, and unbiased sexual health and HIV prevention and instruction; and
- provide pupils with the knowledge and skills to have healthy, positive, and safe relationships.
CSE as a human rightEdit
Some critics state that young people’s access to CSE is grounded in internationally recognized human rights, which require governments to guarantee the overall protection of health, well-being and dignity, as per the Universal Declaration on Human Rights, and specifically to guarantee the provision of unbiased, scientifically accurate sexuality education.
These rights are protected by internationally ratified treaties, and lack of access to sexual and reproductive health (SRH) education remains a barrier to complying with the obligations to ensure the rights to life, health, non-discrimination and information, a view that has been supported by the Statements of the Committee on the Rights of the Child, the Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) Committee, and the Committee on Economic, Social and Cultural Rights.
The commitment of individual states to realizing these rights has been reaffirmed by the international community, in particular the Commission on Population and Development (CPD), which – in its resolutions 2009/12 and 2012/13 – called on governments to provide young people with comprehensive education on human sexuality, SRH and gender equality.
Other analysis show that comprehensive sex education is not an international right nor a human right because it not clearly stated in either a treaty nor custom. By international law, states are required to provide access to information and education about reproductive health, but this does not require a sex education curriculum. It may take different forms such as mandating that local school districts create a system for providing information to students, or mandating that health clinics and practitioners dispense information to patients.
CSE in curriculaEdit
CSE teaching methodsEdit
As CSE gains momentum and interest at international, regional and national levels, governments are increasingly putting in place measures to scale-up their delivery of some form of life skills-based sexuality education, as well as seeking guidance on best practice, particularly regarding placement within the school curriculum. Sexuality education may be delivered as a stand-alone subject or integrated across relevant subjects within the school curricula. These options have direct implications for implementation, including teacher training, the ease of evaluating and revising curricula, the likelihood of curricula being delivered, and the methods through which it is delivered.
Within countries, choices about implementing integrated or stand-alone sexuality education are typically linked to national policies and overall organization of the curricula. The evidence base on the effectiveness of stand-alone vs. integrated sexuality education programming is still limited. However, there are discernible differences for policy-makers to consider when deciding the position of CSE within the curriculum.
As a stand-alone subject, sexuality education is set apart from the rest of the curriculum, whether on its own or within a broader stand-alone health and life skills curriculum. This makes it more vulnerable to potentially being sacrificed due to time and budget constraints, since school curricula are typically overcrowded.
However, a stand-alone curriculum also presents opportunities for specialized teacher training pathways, and the use of non-formal teaching methodologies that aim to build learners’ critical thinking skills. The pedagogical approaches promoted through sexuality education – such as learner-centred methodologies, development of skills and values, group learning and peer engagement – are increasingly being recognized as transformative approaches that impact on learning and education more widely. As a standalone subject, it is also significantly easier to monitor, which is crucial in terms of evaluating the effectiveness of programming, and revising curricula where it is not delivering the desired learning outcomes.
When sexuality education is integrated or infused, it is mainstreamed across a number of subject areas, such as biology, social studies, home economics or religious studies. While this model may reduce pressure on an overcrowded curriculum, it is difficult to monitor or evaluate, and may limit teaching methodologies to traditional approaches.
Apart from the different teaching methods, termiology also differs. Abortion, homosexuality, abstinence have connotations and definitions that vary state. For example, the word "abstinence" may refer to disengaging from all forms of sexual activities until marriage or may refer to only disengaging from sexual intercourse. Furthermore, the degree of sexual activity that "abstinence" connotates is often unclear, because sexual behavior that is not sexual intercourse may or may not be included in its definition. As a result, students are left confused about what activities are risky and teachers do not know what they can and cannot teach.
The term "comprehensive," is also falls on spectrum, therefore can be considered an umbrella term. CSE means something radical for some institutions while it can mean something moderate and even conservative for others.
According to the Sexuality Information and Education Council of the United States (SIECUS), the guidelines for comprehensive sexuality education are as follows:
- appropriate to the age, developmental level, and cultural background of students;
- respects the diversity of values and beliefs represented in the community;
- complements and augments the sexuality education children receive from their families, religious and community groups, and healthcare professionals;
- teaches not only about abstinence, but also contraception, including emergency contraception and reproductive choice;
- teaches about lesbian, gay, bisexual, transgender (LGBT) issues and questions issues;
- teaches anatomy, development, puberty, and relationships;
- teaches all of the other issues one would expect to be covered in a traditional sexuality education class; and
- should be science-based and medically accurate
Sexual education exemptionEdit
Just as teaching methods and curricula vary by state, excusal from sex education also varies by state. States may have with an opt out or opt in produce. In some states, students can opt out of receiving sexual education without specifying a particular reason. In other states, students can only opt out for religious or moral reasons. In an opt-in provision, parents must actively agree to allow their children to receive sex education prior to the start of the sexual education.
How to move towards CSEEdit
Achieving universal access to good quality CSE requires specific strategies for reaching marginalized young people who are out of school. Young people who face discrimination and abuse of their human rights – including the right to education – are at greatest risk of poor SRH outcomes. Young people who face particular challenges in accessing education may also be at increased risk of HIV (re)infection and sexual and gender-based violence. This includes young people with disabilities, young people without parental care, young migrants, young workers, pregnant and married girls, and those from key populations such as young people who sell sex, young people living with HIV, young transgender people, young people using drugs and young men who have sex with men.
Failing to provide marginalized adolescents and young people with CSE can deepen the social exclusion that many experience, limiting their potential and putting their health, futures and lives at greater risk. NGOs have played an important role in developing innovative strategies for reaching vulnerable and hard-to-reach young people through internet and mobile technologies, new media, community and youth centres, as well as sport. Many of the most successful interventions have been developed in partnership with young people. These complementary delivery methods capitalize on existing CSE mechanisms by accurately assessing what young people want, use and can currently access. CSE that includes community-based components – including involving young people, parents and teachers in the design of interventions – results in the most significant change.
Further steps and outcomes of moving towards CSE are listed below:
Mandate Sex Education in each stateEdit
- providing guidelines for instruction would improve access to appropriate sex education for the students who need it most;
- will promote consistency within states; and
- will promote accountability
Require Medical AccuracyEdit
- will set a national standard;
- reduce the amount of inaccurate information being given; and
- prevent programs from expressing religious bias
Passive Consent with an Opt-Out ProvisionEdit
- will be broad enough to allow parents/guardians with religious objections to curricula to shield their children from material they consider objectionable;
- will be narrow enough that students still receive components of sex education;
- would respect families' religious beliefs; and
- ensure that students have access to important materials
Address the Needs of LGBTQIA+ YouthEdit
- remove discriminatory language and factually incorrect information about LGBTQIA+ people.
Sexual content in the mediaEdit
Since 1997, the amount of sexual content on TV has nearly doubled in the United States. Additionally, a study done in 2008 showed that nearly 40% of popular music lyrics contained sexual references which were often sexually degrading. These lyrics were also often accompanied with mentions of other risk behaviors, such as substance use and violence. 
Teens (ages 13-15) in the United States, use entertainment media as their top source for education in regards to sexuality and sexual health. Additionally, a study found that 15-19 year olds in the U.S use media far more than parents or schools to obtain information about birth control. Some studies have found that, "very few teen television shows mention any of the responsibilities or risks (e.g., using contraception, pregnancy, STIs) associated with sex and almost none of the shows with sexual content include precaution, prevention, or negative outcomes as the primary theme."  Television shows 16 and Pregnant and its spin-off, Teen Mom, which first aired on MTV in 2009 received major disapproval from some parents as they thought the shows glamorized teen pregnancy and motherhood. However, 16 and Pregnant actually led to a 4.3 percent reduction in teen pregnancy, mostly as a result of increased contraceptive use. In contrast, other data shows that exposure to high levels of sexual content on the television causes adolescents to have twice the risk of becoming pregnant in the following 3 years, compared to those who were exposed to low levels.
The film Mean Girls, directed by Mark Waters shed light on the state sex education in some parts of the United States. In the film the health instructor states, "At your age, you're going to have a lot of urges. You're going to want to take off your clothes and touch each other. But if you do touch each other, you will get chlamydia and die." This line is meant to be satirical, but it illustrates common flaws within sex education in the U.S. It depicts simplistic descriptions of sexual activity and implementation of fear without any legitimate basis.
Comprehensive sex education is the main topic in the documentary The Education of Shelby Knox released in 2005 about Lubbock, Texas, which has one of the highest teen pregnancy and STD rates in the nation. The "solution" to which is a strict abstinence-only sex education curriculum in the public schools and a conservative preacher who urges kids to pledge abstinence until marriage.
In 2013, How to Lose Your Virginity was released, a documentary that questioned the effectiveness of the abstinence-only sex education movement and observed how sexuality continues to define a young woman's morality and self-worth. The meaning and necessity of virginity as a social construct is also examined through narration and interviews with notable sexuality experts, such as former Surgeon General Dr. Joycelyn Elders, "Scarleteen" creator and editor Heather Corinna, historian Hanne Blank, author Jessica Valenti, and comprehensive sex education advocate Shelby Knox.
Not only have films portrayed sex education, but so has social media. Platforms such as YouTube, Facebook, Vine, and others been be used as a tool to uplift the narratives of marginalized communities such as persons of color and LGBTQIA+ persons in hopes to "strengthen sexual health equity for all."
As a result of the mass amount of sex content in media, media literacy education (MLE) has emerged. It was created to address the influence of unhealthy media messages on risky health decisions, such as intention to use substances, body image issues, and eating disorders. A study analyzed the effectiveness of a teacher-led MLE program, called Media Aware Sexual Health (MASH), which provides students with accurate health information and teaches them how to apply that information to critical analysis of media messages. This comprehensive sex education resulted in increased intentions to talk to a parent, partner and medical professional prior to sexual activity, and intentions for condom use.
Due to knowledge gaps in most sex education curricula for teens, free online resources like Sex, Etc. and teensource.org have been created to promote comprehensive, inclusive sex education for teenagers.
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