We have argued that Evidence Based Interventions often do not reflect factors that the broad scientific literature identifies as key to health behaviors and risks, and do not approach individual behavior in the broad context of adolescents’ lives. As such, there is a disconnect between research and theoretical advances on one hand, and sexual health education programs and policies on the other (Romero et al.
2011). For instance, social and behavioral science research documents the significance of the sexual orientation of young people, the gender beliefs and inequities that shape their sexual agency and relationships, and the economic and racial inequalities that constrain their options, as crucial to a holistic understanding of adolescent sexual health. But many EBIs do not fully address or even acknowledge the psychosocial and structural factors that shape the ways in which adolescents conduct their sexual lives. Thus, while consensus has emerged across disciplines that gender, racism, stigmatization of LBGTQ youth, and poverty are critical to adolescent health, we lack programmatic emphasis and EBIs that address these inequalities. Moreover, when EBIs fail to address non-EBI scientific data about the role of poverty, race, and gender in adolescent sexual health they create the potential for reinforcing cultural stereotypes.
In the remainder of this article, we turn to evidence from across the social and behavioral sciences that should be central to all adolescent sexual health education. We show how the emerging research on LGBTQ youth calls for inclusiveness in adolescent sexual health education programming. Drawing from an extensive literature on the harmful effects of gender inequity and stereotypes, we demonstrate the need for sexual health education to address these issues. Finally, we illustrate how poverty and inequality intersect with adolescent sexual health education in a myriad of ways that have distinct implications for policy and programming.
LGBTQ Education and Health
Contemporary LGBTQ and gender nonconforming youth “come out” or disclose their identities at younger ages than prior cohorts and have distinct sexual health needs (Floyd and Bakeman
2006). It is now commonly understood that LGBTQ students may face victimization at school, or generally hostile school climates (Birkett et al.
2009). Their needs are often invisible in sexual and reproductive health services, and they are typically excluded from sexual health education programs (Bay-Cheng
2003; Cianciotto and Cahill
2003; Sanchez
2012). Yet the known risks for LGBTQ youth are clear: greater rates of HIV for males and transgender youth; higher rates of high-risk sexual behavior for males, females, and transgender youth; and higher rates of pregnancy for both girls and boys (results for transgender youth are unknown) (Mustanski et al.
2011; Saewyc et al.
1999; Saewyc et al.
2009).
The focus of sexual health education historically has been on heterosexual sexuality, with emphasis on procreation, presumably or explicitly directed to the confines of marriage (Carter
2001). For more than 100 years, educators have grappled with the issue of how to teach youth about sexuality while promoting premarital chastity and marital monogamy, a dilemma that has often led to sacrifices of scientific accuracy in favor of ideology (Carter
2001). As a result LGBTQ youth are often excluded or left without relevant and necessary information to make safe and effective choices. Despite potential breadth, the dominant focus of sexuality education programs initially focused on the public health outcomes such as the prevention of unintended pregnancy, and since the mid-1980s, prevention of HIV/AIDS and STIs. Before HIV/AIDS, there was mostly silence on LGBTQ sexualities in sexual health education. Debates in the late 1990s became dominated by abstinence in sexual health education, a stark contrast to growing scientific knowledge about the efficacy of comprehensive sexuality education. In addition to other faults described above, the introduction of AOUM programs actively thwarted momentum to include LGBTQ youth needs in sexual health education by emphasizing abstinence until heterosexual marriage among high-school youth in different-sex relationships. Only since 2004 has marriage for same-sex couples been possible (to date more than a dozen states and the District of Columbia permit same-sex couples to marry); thus, for many LGBTQ youth, the AOUM message actively erases potential for comprehensive sexual health education. Moreover, some abstinence-only program content includes unequivocally hostile messages about LGBTQ people (Cianciotto and Cahill
2003).
Several empirical studies have begun to document the ways that abstinence programs may undermine LGBTQ youth sexual health and well-being (Kosciw et al.
2012). One report showed that compared to schools with other types of sexuality education, LGBTQ students who attended schools that taught abstinence-only programs faced greater harassment in the form of anti-LGBTQ remarks. Further, by excluding sexual minorities (or in some cases giving disparaging information about them), abstinence-only programs may produce feelings of rejection and being disconnected to school (Kosciw et al.
2012). These feelings may lead to negative mental health outcomes such as depression and anxiety and serve as precursors for other health risk behaviors (Almeida et al.
2009; Kosciw et al.
2012). On the other hand, there is evidence that inclusive strategies can promote sexual health for LGBTQ students. For example, Blake et al. (
2001) found that LGB students in schools with gay-sensitive HIV instruction reported lower sexual risk taking and substance use.
Not only may LGBTQ students be invisible or marginalized in sexuality education, but their health needs may not align with the sexual health education needs of students involved in different-sex relationships or sexual activity. If the risk for disease is presented only with reference to penile-vaginal sexual behaviors, there may be deleterious consequences for the health of those who engage in same-sex relationships or sexual activity. For example, HPV poses a threat to all male and female youth, including cancer risk stemming from same- as well as different-sex sexual activity. However, if education only refers to heterosexual vaginal transmission, youth may erroneously conclude that HPV risk pertains only to heterosexual vaginal sex. Such an approach would obscure other sexual behaviors that pose risk for HPV, such as non-penetrative sexual contact, even though the prevalence of HPV among women who have never engaged in vaginal intercourse is high, as is the risk for anal cancer associated with HPV among men who engage in receptive anal intercourse (Mayer et al.
2008). Heterosexual bias in sexuality education will leave some youth without critical knowledge they need to make safe sexual choices.
Only nine states require that sexual health education programs provide inclusive information on sexual orientation (Guttmacher Institute
2013). Seven states (and multiple localities) have laws that expressly forbid discussion of LGBTQ issues (including sexual health and HIV/AIDS awareness) in a positive light, if at all; of those, three states (Alabama, South Carolina, and Texas) require that sexuality education programs include negative messages about same-sex sexuality (Guttmacher Institute
2013; McGovern
2012). Alabama law criminalizes same-sex relationships and sexual behavior and proclaims them to be “not a lifestyle acceptable to the general public.” Additionally, the law asserts that this position comes from a “factual manner and from a public health perspective.” This discriminating law is not unique; there are other laws throughout the country that work to stigmatize LGBTQ people, including youth in the classroom, by expressly forbidding discussion of LGBTQ issues in a positive manner (McGovern
2012). Meanwhile, two proposed federal laws have languished; the
Safe Schools Improvement Act (2013 S. 403) and the
Student Non-
Discrimination Act (2013 HR 1652) would explicitly provide protection to LGBTQ students in US schools, and create a supportive policy context for inclusive health policies and programs.
In spite of this discouraging context for sexuality education, the pace of social change regarding LGBTQ inclusion has been extraordinary, as evidenced, for example, by the growing number of US states and other nations that permit marriage for same-sex couples. Beyond sexuality education programs, there is an emerging body of evidence that documents specific educational practices and strategies that create positive school climates for LGBTQ youth, including inclusive anti-discrimination and anti-bullying policies and laws, school personnel training and advocacy, access to LGBTQ-related resources and curricula, and gay-straight alliance (GSA) school clubs (Russell et al.
2010). A number of studies show that these strategies are linked to adolescent academic achievement and mental and behavioral health (Blake et al.
2001; Goodenow et al.
2006; Poteat et al.
2013).Thus, a growing body of evidence points to principles for promoting adolescent health in ways that respect and include LGBTQ youth, and that respond to known inequities many LGBTQ youth experience. These principles should inform the evidence base for federal sexual health education programs and policies.
Gender and Sexual Health Education
A second area in which current scientific thinking and sexual health education policy and programs are not aligned concerns the impact of gender (in)equity and gender norms. Research across disciplines has demonstrated that gender norms and inequities are key factors in shaping health generally, and sexual health in particular (Rogow and Haberland
2005). International health organizations have recognized that promoting gender equity is critical to advancing health across the life course (World Health Organization
2002). Domestically, Healthy People 2020 includes gender and gender identity as dimensions linked to health disparities—that is, systematic obstacles to health—and it aspires to reduce those disparities. But in the “Adolescent Health” section, the document is silent about the need to address gender inequities or harmful gender beliefs.
3 Establishing gender equity and challenging gender beliefs that research has shown to be harmful to adolescent sexual health have never been central goals in US adolescent sexual health and education policy (DeLamater
2007). In fact, many abstinence-only and abstinence-only-until-marriage programs have taught gender stereotypes as facts (Curran
2011; Delamater
2007; Fine and McClelland
2006). Even approaches that include information beyond abstinence have perpetuated gender inequities through gender stereotyping implicit in curricula or teachers’ informal communications (Curran
2011; Fields
2008; Garcia
2009,
2012).
It has long been established among researchers that gender inequities, and the gender ideologies that uphold them, are key factors in shaping sexual and reproductive health globally and domestically, affecting STIs, HIV/AIDS, unintended pregnancies, and sexual violence (Rogow and Haberland
2005; Santana et al.
2006). Scholars have documented how traditional gender roles impede women’s sexual autonomy and self-efficacy, and thereby increase their vulnerability to STIs and HIV, intimate partner violence, unwanted sex, and unintended pregnancy (Amaro and Raj
2000; Amaro et al.
2001; Impett et al.
2006; Jewkes
2010; Phillips
2000). Gender-based relational power imbalances impact women’s capacity to advocate for their own sexual safety (Phillips
2000; Rosenthal and Levy
2010). For instance, compared to women who report low levels of relationship power, women with higher levels are five times as likely to report consistent condom use (Pulerwitz et al.
2002). Cultural beliefs about gender can also have negative health consequences for men by, for instance, encouraging risk behavior (Higgins et al.
2010).
Gender ideologies shape how youth view and experience themselves and each other. Researchers have documented how schools, peer culture and other institutions overtly and covertly communicate distinct gender ideologies about sex and romance to young people (Chambers et al.
2004; Eder et al.
1995; Fields
2008; Pascoe
2007). Traditional gender ideologies frequently link masculinity with heterosexual sexual activity, sex drive, sexual initiation, and lack of emotional involvement, and femininity with sexual passivity, sexual restraint, responsibility for controlling boys’ desires, and emotional over-involvement (Allen
2003; Bay-Cheng
2003). The sexual double standard, which encourages and celebrates heterosexual sexual experience in teenage boys but censures and stigmatizes sexual experience in teenage girls, is endemic in the United States, though it varies by local context and culture (Crawford and Popp
2003; Greene and Faulkner
2005; Marston and King
2006).
The sexual double standard harms girls by stigmatizing their sexual desires and experiences, reducing their negotiating power within sexual encounters, and conditioning girls to believe that their own desires and wishes are less significant than those of their male partners (Hamilton and Armstrong
2009; Holland et al.
1998; Martin
1996; Tolman
2002). Negative cultural beliefs about girls’ sexuality can make it difficult for them to disclose their sexual histories to partners, parents, or adult care providers (Greene and Faulkner
2005; Schalet
2011a,
b). Traditional gender roles can also hinder girls in refusing unwanted sex and insisting on condom use (Impett et al.
2006; Kirkman et al.
1998; Petitifor
2012). Possessing a sense of sexual self-efficacy—a sense that one has power over one’s sexual decision making—seems to be especially important in aiding girls to engage in safer sex behaviors (Gutierrez et al.
2000; Pearson
2006). There is additional evidence to suggest that when girls know about, and feel entitled to, sexual pleasure, they are better able to advocate for themselves and their sexual health, leading scholars to call on sexual health education to challenge the double standard and emphasize the value of girls’ desires and pleasure (Hirst
2013; Horne and Zimmerbeck 2006; Impett et al.
2006; Martin
1996; Tolman
2002).
Boys are also disadvantaged by prevailing gender ideologies. The sexual double standard can make it appear as if boys should always desire sex, and never say no to sex, even risky sex (Bowleg et al.
2000). The prevailing ideologies stigmatize boys’ emotional vulnerabilities and needs, including their needs for intimate friendships and romantic relationships, making them less prepared to have intimate relationships (Giordano et al.
2006; Way et al.
2013). They also stigmatize homosexuality and behaviors associated with homosexuality (Kimmel
2008; Klein
2012; Pascoe
2007). Norms about appropriate male behavior affect all males. But those who adhere most to “traditional” beliefs about masculinity—for instance, that men should be tough, have status in society, not behave in ways marked as “feminine,” and regularly have heterosexual sex— are most at risk for negative consequences compared to other boys and men. Those who embrace such traditional attitudes toward masculinity tend to also report more sexual partners, engage in more unprotected vaginal sex, and show less self-efficacy and consistency in condom use (Noar and Morokoff
2002; Pleck et al.
1993,
1994; Santana et al.
2006; Shearer et al.
2005).
There is growing evidence that among adult men some masculine gender norms are linked to violence in intimate relationships (Gallagher and Parrott
2011; Murnen et al.
2002). For example, compared to other men, men who report more traditional masculinity ideologies are more likely to report having perpetrated violence or sexual coercion (Marín et al.
1997; Santana et al.
2006). Conversely, compared to less egalitarian men, men whose gender role ideologies are more egalitarian report fewer instances of physical aggression against their intimate partners (Fitzpatrick et al.
2004). Gender norms also shape young people’s capacities to resist, report, and recover from sexual violation. Boys are unlikely to report sexual coercion due to homophobia as well as masculinity norms that emphasize male sexual desire and strength and obfuscate boys’ capacity to be coerced or intimately violated (Bullock and Beckson
2011). For girls, the pressure to be normatively feminine (sexually passive, accommodating, “nice”) can make resistance to unwanted sexual advances difficult (Armstrong et al.
2006; Hamilton and Armstrong
2009; Phillips
2000). The stigma around girls’ sexuality also prevents many from seeking help, a barrier that is heightened for low-income girls and girls of color (Collins
2005; Froyum
2010).
In short, there is strong and consistent evidence that gender beliefs and (in)equities shape sexual health (Rogow and Haberland
2005). However, until recently, these areas have received very little attention in US adolescent sexual health policy and programming (Grose et al.
2014; Rolleri
2013a; Rolleri
2013b). There is no requirement for federally-funded sexuality education to work toward gender equity, avoid explicit or implicit gender stereotyping, or include modules that help students challenge harmful gender beliefs. Abstinence-oriented programs have often taught gender stereotypes as fact (DeLamater
2007; Fine and McClelland
2006; Curran
2011).
4 Approaches that include information beyond abstinence can also perpetuate gender ideologies through the topics they cover and leave out, or include implicit gender stereotyping in apparently gender-neutral exercises and role plays (Bay-Cheng
2003; Curran
2011; Fields
2008). Unless harmful gender beliefs are explicitly addressed and challenged, sexual health education runs the risk of reinforcing those beliefs through the taken-for-granted assumptions teachers and students bring into the classroom (Fields
2008; Garcia
2009,
2012; Froyum
2010). Yet, of the 35 designated (Tier 1) “evidence-based” programs, only a handful (all of which target youth of color) even mention gender in their program description, suggesting incorrectly that only minority groups contend with harmful gender beliefs (Office of Adolescent Health
2014a).
5 The research record shows the advisability of ensuring that all sexual health programs are free from harmful gender beliefs—which may be explicit or implicit in the curricula—and include tools to help students address and challenge these beliefs.
Poverty, Inequality, and Sexual Health Education
Considerable literature has demonstrated that poverty and economic inequalities are fundamental barriers to positive youth development. Youth subject to these inequalities have lower academic achievement, and are more likely to leave school early, thereby compounding cumulative socioeconomic effects on health. Youth in poverty are also more likely to engage in delinquent behavior, to become sexually active early, and to have elevated risk of STIs, unintended pregnancies, and non-marital births (Brooks-Gunn et al.
1997; Dinkelman et al.
2008; Duncan and Rodgers
1988; Duncan et al.
2010; Grantham-McGregor et al.
2007). Youth in poverty also lack access to quality health services (National Research Council
2009). The effects of persistent poverty are especially pernicious, affecting socio-emotional development and health, and increasing the likelihood of enduring ill effects into adulthood.
The deleterious effects of poverty are critical considerations for adolescent health and development in the United States, where low-income students now comprise a near majority of public school children in the United States.
6 About one in six of all youth and one in three African American youth ages 12–17 live in families with incomes below the official poverty level.
7 In addition to the close linkage between minority racial/ethnic status and poverty, there are major racial disparities in long-term exposure to neighborhood poverty. Analyses of data from the Panel Study of Income Dynamics indicate that 40 % of African Americans experience sustained exposure to high-poverty neighborhoods, versus 5 % of non-Blacks (Wodtke
2013).
The negative consequences of poverty are a function of the structural and experiential inequalities that typify the life contexts of impoverished youth. Poor youth are more likely to live in neighborhoods characterized by adverse physical and social environments, with higher rates of crime and limited access to recreational facilities and after-school programs, and are more likely to attend lower quality schools with fewer resources (Murry et al.
2011). They are also less likely to have access to mental and physical health services. Exposure to poverty during adolescence may be especially important, given adolescents’ expanding social world. Recent analyses suggest that sustained exposure to neighborhood poverty substantially increases the risk of becoming an adolescent parent, and that exposure during adolescence may have a greater effect than exposure earlier in childhood (Wodtke
2013). Further, poverty shapes sexual network structure, increasing the likelihood of STIs (Fichtenberg et al.
2010). These contexts mold adolescents’ sexual knowledge, perceptions about and access to contraception, and their hope for the future.
Poverty intersects with individual and structural characteristics to generate significant health disparities, the cumulative health differences that result from obstacles linked to factors such as race/ethnicity, gender, disability, sexual orientation, and gender identity. A recent review of health disparities in the United States (CDC
2013d) documented persistent race/ethnicity disparities in health outcomes, access to health care, adoption of health promoting behavior, and exposure to health promoting environments, with no evidence of a temporal decrease between 2005 and 2009. Documented disparities, beyond those related to sexual and reproductive health, include differences in chronic conditions such as asthma, diabetes and hypertension, as well as differences in mortality from causes such as coronary heart disease, stroke, drugs, homicide, suicide, and vehicle related injuries (CDC
2013d).
Thus, the adverse impact of poverty is compounded by racism, sexism, heterosexism, and discrimination against individuals with disabilities. These prejudicial belief systems reflect irrational biases toward members of a certain race, biological sex, sexual orientation, gender identity, or level of ability on the basis that a certain group is “superior/inferior” or “normal/abnormal.” Structural racism/sexism/heterosexism, that is, “macrolevel systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among… groups” (Gee and Ford
2011; p. 116), normalizes and legitimizes unequal treatment and discrimination Structural discrimination can take many forms, including social segregation (e.g., neighborhood, schools, health care facilities) and exclusionary immigration policy, and can persist across generations through the cumulative effects of interacting systems. For example, because of racial discrimination in the real estate industry African Americans are considerably more likely to live in poor neighborhoods, even if economic resources would permit residing in non-poor neighborhoods (Iceland and Scopilliti
2008).
The Intersectionality Framework (see for example, Weber and Parra-Medina
2003) proposes that characteristics such as race, class and gender are not distinct social categories. They reflect multidimensional and overlapping experiences that are a function of mutually reinforcing social processes and institutions. The intersection of microlevel identities and macrolevel structural factors can affect health by producing and sustaining economic inequality via groups’ access to social, economic, and political resources and privileges. The effects of neighborhood disadvantage on school dropout, for example, are twice as large for African American youth versus their White peers (Crowder and South
2003). Community poverty levels also contribute to LGBT youth’s experiences in school; youth in higher poverty communities report more victimization in school because of sexual orientation and gender expression than those in more affluent communities (Kosciw et al.
2009). Poverty and racial segregation can also affect the sexual expectations and behavior of youth, leading youth in these contexts to consider early sexual activity as normal and even expected. Youth in low income neighborhoods may not have access to educational and occupational opportunities, and may view sexual activity as a pathway to social status rather than an obstacle to socioeconomic achievement (Ramirez-Valles et al.
2002).
The intersections of poverty, inequality, structural discrimination, and adolescent sexual and reproductive health are numerous. Sexual health education exists within a variety of structural and social contexts (Fine and McClelland
2006). Sexuality affects, and is affected by, complex interactions between individual biopsychosocial factors and a host of economic, political and cultural factors. Sexuality and sexual rights are thus interwoven with broader human rights and the sociopolitical issues that affect those rights, such as economic inequality and structural racism. Approaching adolescent sexual health with an eye toward poverty and its intersections with diverse social identities means attention to not only material deprivation but also to social and political exclusion and restrictions on rights, including sexual rights (Armas
2007), that are linked to behavior. Poverty limits knowledge about and access to sexual and reproductive health services, constrains positive sexual expression and feelings of self-efficacy, and makes disadvantaged youth vulnerable to sexual exploitation and violence. This is why the experience of poverty is associated with greater sexual risk-taking (e.g., early sexual onset, multiple sexual partnerships, lack of condom use) in both the United States and global contexts (Brooks-Gunn et al.
1997; Dodoo et al.
2007; Duncan and Rodgers
1988).
US policy makers must understand and address the importance of poverty’s complex intersections with diverse identities and the impact on how youth respond to sexuality education. Sexual health education paradigms and curricula often assume adolescents are in school and that they live in homogeneous social and physical environments free of economic or other social barriers. Sexuality education may explicitly or inadvertently reinforce cultural stereotypes about young people of color, who are more likely to be poor, as sexually irresponsible (Fine and McClelland
2006; Fields
2008; Garcia
2009,
2012). Similarly, sexual health education may presume “proper” relationships and family forms that are less common among low income youth or youth of color. With few economic opportunities and resources to develop positive sexual identities, low income or minority youth may rely on rigid, exclusionary, and ultimately counterproductive frameworks to assert self- and group-worth (Froyum
2007). Failure to recognize erroneous assumptions and the lived reality of youth can lead to unintended effects on adolescent sexuality, promoting exclusion of teens who do not conform to expected gender and sexual norms and ultimately failing to reduce inequality (Bedford
2008; Drucker
2009). Sexual health education must thus recognize the diverse life course trajectories and family formations that characterize students’ lives. In addition, scholars have argued, sexual health education must create opportunities for students to discuss sexual agency and risks in the context of their broader life aspirations and the multifold factors that constraints those aspirations (Fields
2008; Fine and McClelland
2006; Rogow and Haberland
2005). Although sexual health education cannot remove the structural disparities, by giving young people the opportunity to critically examine the inequalities they encounter, it can bolster their ability to respond to them.
Policy makers must also promote adolescent sexual and reproductive health by investing in youth through multi-faceted and multi-level poverty alleviation efforts that build youth assets and promote health. Despite frequently voiced concerns about the intractable nature of poverty (and by extension, hopelessness), the United States has a track record of intentional and effective large-scale implementation of poverty alleviation. In the late 1950s 22 % of US residents lived in poverty; after the launch of the War on Poverty in the 1960s, that percentage had dropped to 11 % by 1973 (Council of Economic Advisors
2014). Changes were even more drastic among the elderly, who once had the country’s highest poverty rates, but whose chances of living in poverty have been sharply reduced through programs such as Social Security and Medicare (Fischer et al.
1996).
Today, the poverty rate of US children and teens is among the highest in the industrial world. Given the pervasive detrimental effects on youth development, poverty alleviation programs are vital to improving adolescent sexual and reproductive health. Indeed, comparing across five developed nations, where rates of sexual activity among youth were similar, Singh and colleagues report a strong association between the higher US teen birth rate and the greater proportion of teens who grow up poor (Singh et al.
2001). Yet there is strong evidence that structural interventions can both directly and indirectly improve adolescent health, and that large-scale implementation is both feasible and successful (Snell et al.
2013). In many European, Latin American, and African countries, governments offer a variety of income supplements, especially to families with children. Singh et al. (
2001) point toward policies that are likely to affect adolescent sexual and reproductive health specifically, including national health care systems and government investment in job training and opportunities for young people, easing the transition into adulthood, facilitating long-term planning, and reducing the motivation to have a child prematurely. The authors conclude “improving adolescents’ socioeconomic status is a way to prevent their having poor reproductive health outcomes—not only unplanned or early pregnancies or births, but also STDs” (p. 258).
Policy makers should heed lessons learned from our country’s success in reducing poverty among the elderly, and from other countries’ successes in better promoting adolescent sexual and reproductive health by investing in multi-faceted and multi-level poverty alleviation efforts that build youth assets and promote health. For individual adolescents, efforts are needed to enhance adolescents’ motivation for personal and professional achievement (e.g., healthy interpersonal relationships, education and occupation), and avoid behaviors that increase risks of STIs, poor emotional and physical health, and early pregnancy and childbearing. We also need to target structural barriers created by economic, racial and ethnic inequalities (e.g., increase resources for high-poverty schools), and offer support services to help families and their children (e.g., adequate funding for Title X family planning clinics) as they move toward better financial security, without predication of assistance on particular family structures that may not be feasible for or desired by all individuals.