In a move that many observers believe may cost him his job, Surgeon General David Satcher in June issued his long-awaited report, Call to Action to Promote Sexual Health and Responsible Sexual Behavior. Satcher describes the report, the release of which had been stalled for months, as a "first step—a call to begin a mature, thoughtful, and respectful discussion nationwide about sexuality." Citing published scientific evidence, Satcher endorses an approach to sexuality education that balances the importance of abstinence with assuring "awareness of optimal protection from sexually transmitted diseases and unintended pregnancy, for those who are sexually active" (see box). This endorsement places Satcher at odds with the Bush administration and with nearly 20 years of U.S. education policy that has increasingly emphasized abstinence. Federal involvement in efforts to promote abstinence rather than contraceptive use began on a small scale in 1981 with the enactment of the Adolescent Family Life Act (AFLA). Since then, Congress has added two new programs into the mix: a major freestanding program of abstinence-only education grants to the states, enacted as part of welfare reform in 1996; and a separate abstinence-only set-aside for community organizations (including those that are faith-based) within the maternal and child health (MCH) block grant, adopted last year.
The Surgeon General's Call to Action
In his report, Call to Action to Promote Sexual Health and Responsible Sexual Behavior, U.S. Surgeon General David Satcher states that becau
Regarding more comprehensive approaches to sexuality education, Satcher refers to a larger body of evaluation evidence, including a recent analysis of more than 100 teenage pregnancy prevention programs across the country ("Report Says Sex Ed Can Reduce Teen Pregnancy, Jury Out on Ab-Only," TGR, June 2001), indicating such programs either have no effect on or may actually delay adolescents' initiation of sexual activity. Satcher says such evidence supports the conclusion that informing adolescents about contraception "does not increase adolescent sexual activity, either by hastening the onset of sexual intercourse, increasing the frequency of sexual intercourse, or increasing the number of sexual partners." Furthermore, he says "some of these evaluated programs increased condom use or contraceptive use more generally for adolescents who were sexually active."
In light of this evidence, Satcher calls for education that balances the importance of abstinence with assuring "awareness of optimal protection from sexually transmitted diseases and unintended pregnancy, for those who are sexually active." In a chapter titled, "Vision for the Future," Satcher offers a "foundation for promoting sexual health and responsible sexual behavior in a manner that is consistent with the best available science." In addtion, Satcher outlines specific goals for improving public awareness of sexual health and responsible sexual behavior; implementing and strengthening health and social interventions; and expanding the research base in this area. To access the report on the Internet or to request a copy of the report, visit the Surgeon General's Web site at <https://www.hhs.gov/surgeongeneral/reports-and-publications/disease-prevention-wellness/index.html>.
For the current fiscal year, federal spending specifically earmarked for promoting abstinence-only education reached $80 million—$9 million through AFLA, $50 million through the program created with welfare reform (which brings with it an additional $38 million in matching funds from the states) and $20 million through the MCH set-aside.
However, because education policy in the United States is highly decentralized, the bulk of the detailed policymaking regarding sexuality and abstinence education takes place at the school district level. A 1998 nationally representative survey of local school superintendents by The Alan Guttmacher Institute (AGI) found that of the roughly two-thirds of districts that have a districtwide policy to teach sexuality education, only 14% require that abstinence be presented as one option "in a broader educational program to prepare adolescents to become sexually healthy adults." The remainder require that abstinence be promoted: Fifty-one percent require that abstinence be portrayed as the preferred option for adolescents (although information about contraception is permitted), but the remaining 35%—including half of school districts in the South—require that abstinence be taught as the only acceptable option outside of marriage.
When asked about how their policy was developed, the superintendents most often pointed to state directives as the most influential factors in crafting their policies. An AGI review of state laws and policies indicates, however, that states actually provide little in the way of detailed guidance to local districts about the content of their sexuality education and STD education. At the same time, the guidance states do provide is heavily geared toward promoting abstinence.
State Policy
According to AGI's review of states' laws and policies, most states have adopted laws governing sexuality education and STD education, with some states having separate laws for each area. To create an overall picture of state policy, this analysis examines sexuality education and STD education policies, including whether and how abstinence and contraception are to be treated within the context of this instruction.
Thirty-nine states require that some education related to sexuality be provided throughout the state (see table). Twenty-one require that both sexuality and STD education be provided. Seventeen require the provision of instruction on STDs, but not sexuality education. Only one, Maine, requires sexuality education but not STD education. Eleven states leave the decision to teach these subjects entirely to local school districts.
Parental Involvement
Whether or not they require sexuality education or STD education, 35 states guarantee some parental discretion over whether their children will participate in this instruction. Thirty-three states have an "opt-out" policy, which gives parents the option to withdraw their children from these classes. Three states go further, requiring that parents affirmatively provide consent before a child may participate in the instruction. One state, Arizona, has separate parental discretion policies for sexuality education and STD education, requiring parental consent for the former, while having an opt-out policy for the latter.
Most states where parents have the option to withdraw their children from a class allow them to exercise that option for any reason. However, five states—Alabama, Massachusetts, New Jersey, Pennsylvania and Vermont—require that the withdrawal of the student be based on religious or moral beliefs. New York, which allows parents to withdraw their child for any reason, requires parents who do so to assure the school "that the pupil will receive such instruction at home."
Abstinence and Contraception
Most state policies on sexuality education and STD education give little substantive direction beyond requiring that abstinence or contraception be covered or stressed. Sixteen states—including some that have statewide mandates that sexuality education, STD education or both be provided—give local school districts total discretion over whether and how to teach abstinence and contraception. The remaining 34, whether or not they have state-level mandates that instruction be provided, place some requirements on local districts, often by including one or the other topic on a list of subjects that must be taught, or by requiring that it be stressed. Here, the states' preferences are clear: All 34 of these states require that abstinence be taught, with nine requiring that it be covered and 25 insisting that it be stressed. In sharp contrast, 19 states require that contraception be covered in sexuality education or STD education, but none requires that it be stressed.
A few states do describe their policies on abstinence and contraception in somewhat more detail. Florida, for example, requires the "benefits of sexual abstinence" be presented as part of the requirements for graduation. South Carolina requires the instruction to "stress the importance of abstaining from sexual activity until marriage" and to "help students develop skills to...abstain from sexual activity." In Texas, abstinence is to be presented "as the preferred choice of behavior in relationship to all sexual activity for unmarried persons of school age" and more attention must be devoted to abstinence from sexual activity "than to any other behavior."
Similarly, some states' policies on contraception, such as Oregon's, mandate that students be provided with information on the "efficacy of contraceptives in preventing" HIV and other STDs. South Carolina requires an explanation of the "methods of contraception and the risks and benefits of each method"—but only within "the context of future family planning."
Four other states—Georgia, Mississippi, North Carolina and Texas—do not require that contraception be discussed statewide, but nonetheless apply strict limits on discussion of contraception, should local decisionmakers choose to include the topic in their curricula. North Carolina, for example, requires that any discussion of contraception include "accurate statistical information on [contraceptive methods'] effectiveness and failure rates for preventing pregnancy and sexually transmitted diseases, including AIDS, in actual use among adolescent populations and shall explain clearly the difference between risk reduction and risk elimination through abstinence."
Utah has the most stringent state policy, which prohibits "the advocacy or encouragement of the use of contraceptive methods or devices." The law specifically prevents teachers from responding to students' spontaneous questions in ways that conflict with the law's requirements to promote abstinence and to not encourage the use of contraception. By contrast, Tennessee's statute explicitly permits teachers to answer students' spontaneous questions about contraception.
Other Subject Areas
Abortion and sexual orientation are rarely mentioned in states' policies. Only five states specifically address abortion: Connecticut, Louisiana, Michigan and South Carolina prohibit any discussion of abortion within sexuality education or STD education. Vermont, on the other hand, includes abortion as part of a list of required topics to be covered.
Only nine states mention sexual orientation or homosexuality. South Carolina prohibits any discussion of sexual orientation and Utah prohibits "the advocacy of homosexuality." Both Massachusetts and New Jersey require discussion of sexual orientation but do not provide content standards. The other five states—Alabama, Arizona, Mississippi, North Carolina and Oklahoma—require that discussions of homosexuality treat it as abnormal or dangerous. For example, sexuality education classes in Alabama must include "an emphasis, in a factual manner and from a public health perspective, that homosexuality is not a lifestyle acceptable to the general public and that homosexual conduct is a criminal offense under the laws of the state."
Conflicting Views
In short, states have established only very broad parameters for sexuality and STD education. While most states mandate that some form of sexuality education be provided, they give local policymakers wide latitude in determining the content of the instruction. What substantive guidance states do provide, however, is heavily weighted toward stressing abstinence; while many states allow discussion of contraception, none requires that it be stressed.
In examining the evolution of federal, state and local policy together, it is clear that abstinence promotion has truly taken hold as a matter of education policy in the United States and is being reflected in classroom education. AGI surveys of public school teachers of sexuality education in grades 7-12 in 1988 and 1999 found that the percentage who teach an abstinence-only curriculum has increased from one in 50 in 1988 to one in four in 1999.
While this focus on abstinence—in policy and practice—may be in fashion politically, studies have found that it is far out of step with what parents and teachers believe should be taught ("Sex Education: Politicians, Parents, Teachers and Teens," TGR, February 2001). Although nine in 10 teachers believe that students should be informed about contraception, one in four say they are instructed not to teach the subject; in general, one in four teachers believe that they are not meeting their students' needs for information. Parents, too, want their children to have that information: Public opinion polls recently and in the past show that the vast majority of Americans favor broader sex education programs rather than those that teach only abstinence. And, according to the U.S. Surgeon General, an exclusive focus on abstinence is not in line with the weight of the best scientific evidence now available.
| State Laws and Policies on Sexuality and STD Education | ||||||||
| State | Statewide Policy to Teach | Parents May Opt-out | Parents Must Consent | Abstinence Must Be Covered/Stressed | Contraception Must Be Covered/Stressed | |||
| STD Education | Sex Education | STD Education | Sex Education | |||||
| Alabama | std | both | stressed | stressed | covered | covered | ||
| Alaska | both | |||||||
| Arizona | std | sex | stressed | stressed | ||||
| Arkansas | stressed | stressed | ||||||
| California | std | both1 | stressed | stressed | covered | covered | ||
| Colorado | ||||||||
| Connecticut | std | both | covered | |||||
| Delaware | both | covered | covered | covered | covered | |||
| Florida | both | both | covered | |||||
| Georgia | both | both | covered | covered | (2) | (2) | ||
| Hawaii | both | stressed | stressed | covered | covered | |||
| Idaho | std | both | ||||||
| Illinois | both | both | stressed | stressed | covered | |||
| Indiana | std | stressed3 | stressed | |||||
| Iowa | both | both | ||||||
| Kansas | both | both | ||||||
| Kentucky | both | covered | covered | |||||
| Louisiana | both | stressed | stressed | |||||
| Maine | sex | |||||||
| Maryland | both | both | stressed | stressed | covered | covered | ||
| Massachusetts | both | |||||||
| Michigan | std | both | covered | covered | ||||
| Minnesota | both | both | ||||||
| Mississippi4 | both | stressed | stressed | (2) | (2) | |||
| Missouri | std | both | stressed | stressed | covered | covered | ||
| Montana | std | |||||||
| Nebraska | ||||||||
| Nevada | both | both | ||||||
| New Hampshire | std | |||||||
| New Jersey | both | both | covered | covered | covered | covered | ||
| New Mexico | std | stressed | covered | |||||
| New York | std | std | stressed | covered | ||||
| North Carolina | both | both | stressed | stressed | (2) | (2) | ||
| North Dakota | std | |||||||
| Ohio | std | stressed | ||||||
| Oklahoma | std | both | covered | stressed | covered | |||
| Oregon | std | both | stressed | stressed | covered | covered | ||
| Pennsylvania | std | std | stressed | covered | ||||
| Rhode Island | both | both | stressed | stressed | covered | covered | ||
| South Carolina | both | both | stressed | stressed | covered | covered | ||
| South Dakota5 | ||||||||
| Tennessee | both | both | stressed | stressed | ||||
| Texas | both | stressed | stressed | (2) | (2) | |||
| Utah | both | both | stressed | stressed | (6) | (6) | ||
| Vermont | both | both | covered | covered | covered | covered | ||
| Virginia | both | covered | covered | covered | covered | |||
| Washington | std | both | stressed | covered | ||||
| West Virginia | both | both | stressed | stressed | covered | covered | ||
| Wisconsin | std | both | ||||||
| Wyoming | both | |||||||
| Notes to table: 1. Localities may require parental consent for HIV education, but not for sexuality education. 2. State specifically authorizes localities to teach about contraception, but, in MS, NC and TX, if taught, it must include failure rates or effectiveness and failure rates among adolescents. 3. AIDS education is included with communicable disease education and content is determined at the local level. 4. In Mississippi, localities may override the state's requirement that any topic, including abstinence, be included in instruction. However, a locality cannot contradict the law on a particular topic, as the law states, "no program or instruction may include anything that contradicts the excluded components." For example, while the law requires that abstinence be stressed as beneficial, a locality can choose not to teach it, but it cannot choose to teach that abstinence is not beneficial. The state board of education encourages parental consent for sexuality and HIV/STD education. 5. Abstinence is taught within character education. 6. Prohibits "the advocacy or encouragement of the use of contraceptive methods or devices." | ||||||||