This article is written by Venkatraman Chandra-Mouli and Margaret Smith
Chandra (66 years) retired last year after a long and distinguished career at the World Health Organization in August 2023 and added to it with a PhD on sexuality education from the University of Ghent, Belgium in May 2024. Margaret Smith, Maggie (22 years), was born and raised in the USA, and is currently studying Reproductive and Sexual Health Research at the London School of Hygiene and Tropical Medicine, University of London, England.
This blog post also led to an engaging discussion on the SRHM Podcast between SRHM Chief Executive Eszter Kismödi and Dr. Venkatraman Chandra-Mouli which is available on Spotify and Apple Podcast.
In this article, I set out the sorry state of comprehensive sexuality education[1] (CSE) in the USA based on authoritative sources and compare the situation in the USA to that in other countries of the world. From the scientific literature and technical experts, I then move to a young American woman – to learn about her personal experiences, and her reflections as to why a Harris-Walz win is so desperately needed both for the sexual and reproductive health of young people in the USA like herself and her peers, and in the wider world.
What is the state of comprehensive sexuality education (CSE) in the USA?
In 2019, I contributed to an analytic case study of a CSE programme in San Antonio, Texas: Managing Sex Education Controversy Deep in the Heart of Texas: A Case Study of the North East Independent School District (NEISD). The paper explained how, in Texas – one of the country’s largest and most populous states in the USA – in the absence of direction or guidance from the national, state or country/municipality levels, decisions on what CSE to provide and how to do so are made at the school level, and often need to navigate loud opposition from a small but vocal minority of parents. It then describes how local champions of CSE have worked – with some success – with school authorities and advisory committees to build support for the integration of evidence-based curricula in a school district, and to stand up to opposition to it, as and when it occurs.
Researching and co-authoring that paper with people working on the ground in San Antonio, Texas was a huge eye-opening experience for me. Since then, I have kept in touch with my collaborators in Texas and elsewhere in the USA, and remained up to date on the evolving situation.
While there has been strong and consistent support for CSE from medical bodies such as the American Academy of Paediatrics and the American College of Obstetricians and Gynaecologists, political and governmental support have wavered.
As Hall and colleagues noted in 2016, “…adolescents’ receipt of sex education improved greatly between 1988 and 1995.” They recall that “In the late 1990s, as part of the “welfare reform,” abstinence only until marriage (AOUM) sex education was adopted by the U.S. government as a singular approach to adolescent sexual and reproductive health. AOUM was funded within a variety of domestic and foreign aid programs, with 49 of 50 states accepting federal funds to promote AOUM in the classroom. Since then, rigorous research has documented both the lack of efficacy of AOUM in delaying sexual initiation, reducing sexual risk behaviors, or improving reproductive health outcomes and the effectiveness of comprehensive sex education in increasing condom and contraceptive use and decreasing pregnancy rates. Today, despite great advancements in the science, implementation of a truly modern, equitable, evidence-based model of comprehensive sex education remains precluded by sociocultural, political, and systems barriers operating in profound ways across multiple levels of adolescents’ environments.”
Since 2016, the situation has worsened. According to a report by the Guttmacher Institute (2022), a leading research and policy organization: “Young people (in the USA) are not getting the sex education they need: About half of adolescents (53% of females and 54% of males) reported in 2015–2019 that they had received sex education that meets the minimum standard articulated in Healthy People 2030; among teens reporting penile-vaginal intercourse, fewer than half (43% of females and 47% of males) received this instruction before they first had sex. In 2015–2019, more adolescents reported that they had received instruction about saying no to sex (81% of females and 79% of males) or waiting until marriage (67% and 58%, respectively) than about where to obtain birth control (48% of females and 45% of males) or how to use a condom (55% and 60%, respectively).”
In March this year, I was invited to participate in the USA’s Society for Adolescent Health and Medicine’s Annual Meeting in San Diego, California. The organizers invited me to provide a global overview on sexuality education in schools. As part of this, they asked me to speak to the situation in the USA. Here is a snapshot of the state of CSE in the USA I put together from scientific articles, and from discussions with ten close collaborators – Americans who live and work on CSE internationally and domestically, and care deeply about what is happening in their country. I would like to add that the USA is a huge and diverse country. This snapshot is in broad brush strokes and will not accurately/fairly represent the situation in every school and in the county/municipality or state it is set in.
- There are no national government formulated policies (CSE like education more generally, is a state subject)
- There are no statutory national curricula (Sexuality Information and Education Council, SIECUS, and Advocates for Youth have developed standards. The Center for Diseases Control, CDC has developed guidance but there is no obligation to use them.)
- Some (not all) states have policies requiring CSE to be provided in schools. They vary in content. (SIECUS and The Guttmacher Institute have published status reports on the state of these policies)
- Some states that have policies requiring the provision of CSE in schools provide funding and technical assistance for implementation, and track progress. Many other states don’t. (There is a network of not-for-profits (Sex Education Collaborative) which provide such support.)
- In states that have policies requiring the provision of CSE in schools, enabling policies, counties/municipalities are obliged to provide them. This varies greatly. (CDC and Planned Parenthood have published a report on how many counties/municipalities are providing SE whose content meets a certain minimum standard).
- In many places the final decision on whether to provide CSE, what to provide, who will provide and how they do so are made by school boards. (In some places, CSE providers with dubious curricula are engaged by school boards).
- Not-for-profit organizations try to fill these gaps.
- The majority of parents still support the provision of CSE. But a vocal and loud minority do not and claim the public space.
- In recent years, promoting paedophilia and gender fluidity are used as arguments to attack CSE.
- Resistance to CSE is also linked to the push back on the role of the government, on what education to provide children, and on what books libraries should stock.
How does this relate to the state of comprehensive sexuality education worldwide?
In 2021, five United Nations agencies published a report taking stock of the global situation on CSE, titled: The journey towards CSE: A global status report. Its key message was that: “Data from 155 countries found that 85% report that they have policies, laws or legal frameworks related to sexuality education. Despite this favourable policy background, there remains a significant gap between policy and implementation on the ground.” For example, it found that the curricular content in government- approved school curricula are generally set too little (contain important gaps), too late (intended for secondary school students), and of limited match to students’ interests and concerns (does not address what students want to know).
The global situation mirrors the situation in the USA. A Planned Parenthood USA report noted that: “Although almost every state has some guidance on how and when sex education should be taught, decisions are often left up to individual school districts, creating a patchwork of inconsistent policies and practices within states. The sex education someone receives can come down to what school district they live in or which school they attend.” (What’s the state of sex education in the US)
To sum up, while there are some schools, counties and states in the USA in which CSE is well-designed and well-delivered, overall the situation is worse than it is in many countries in the global South and is far from the situation of countries in Northern Europe such as Germany, which has had mandatory school-based sexuality education in place for many decades, and periodic large-scale surveys that show that young people are initiating sex later; are more likely to use condoms or other contraceptives when they have sex; and are more likely to recall their first sexual intercourse as pleasurable: (See Sexuality education for young people in Germany. Results of the ‘Youth Sexuality’ representative repeat survey).
Let me move from scientific papers and expert opinion to the experiences and voices of a young person.
Maggie, how does what I have said thus far in this article, relate to your personal experience in getting comprehensive sexuality education in the USA?
Margaret Smith: Speaking from my own experience as a 22-year-old woman from Pittsburgh, Pennsylvania in the United States currently studying Reproductive and Sexual Health Research at LSHTM, I did not receive CSE at my school. I grew up attending Catholic schools, where I was not taught safe sexual practices or about my sexuality in the school system for religious reasons. Abstinence was preached to me at a time where many other young people had already made decisions about whether to engage in sexual activity. Many of my peers felt frustrated, as they would be stigmatized for speaking up, asking questions, and admitting that they had engaged in sexual practices.
While lucky enough to have a support system in the form of my mother to take me to programmes at the local hospital to learn about my own changing body as an adolescent, not everyone has the resources outside of their school to acquire reliable knowledge about their own sexual and reproductive health. My mother made sure, whether it was through conversations with her, books, or physician-led programmes that I learned about the reproductive systems, my menstrual cycle, and my changing body throughout my adolescent years. She always made sure I felt comfortable approaching her with concerns and questions about my sexuality and my reproductive health, often encouraging me and reassuring me through open conversations about my body. However, I did not feel comfortable opening up conversations about my sexuality or my reproductive health with my peers. While I did attend an all-girls Catholic school and young women were comfortable speaking up about their menstrual cycles in one-to-one or small group conversations, these conversations did not extend into the classroom.
Growing up, I would have liked to have experienced less stigma and silence. I would like to have felt comfortable speaking about my sexuality and my reproductive health with my peers and in the classroom. I believe that open conversations about how to have a healthy relationship with your body and your mind are vital for young people to feel safe and make informed decisions about their bodies.
Maggie, the whole world is watching with bated breath, the upcoming USA presidential election. As a young American, and one who is studying reproductive and sexual health research, why do you believe that the election of Harris-Walz could be good for the sexual and reproductive health of young people in the USA?
I believe that the election of Harris-Walz will be good for young people in the United States, because, well… they actually talk about sexual health and reproductive rights! Vice President Harris and Governor Walz want to hear from their citizens. They want to hear their stories and the trials and tribulations they have faced in regards to their reproductive health. Hearing from them, they want to make a change. They do not treat reproductive and sexual health as taboo, but instead freely speak about safeguarding a woman’s right to make autonomous decisions about her own body. To speak openly about a historically hushed topic on a national level is the first step towards improved reproductive and sexual health for young people, as they will feel comfortable opening up conversations themselves.
Vice President Kamala Harris has taken great lengths to better understand the Supreme Court overturning of Roe v. Wade in Dobbs v. Jackson Women’s Health Organization’s far-reaching consequences on young people. In 2022, Vice President Harris convened seventy-five student leaders from universities across thirty-three states to learn more about their experiences following the Supreme Court ruling. The students shared how the change of laws has created confusion among young people attempting to access reproductive health services, unsure of what was available to them. Harris recognizes the impact of governmental policies on young people’s sexual health, and it is clear that she wants to work as a team, bringing young people into the conversation about their sexual health, to defend rights and freedoms. She realizes that the abortion ban does not stop at the ban, rather states with strict abortion laws tend to have higher infant and maternal mortality rates and women have overall less access to obstetrical/gynecological care. A Harris-Walz win will not only reinstate the ability to receive an abortion but will support all aspects of reproductive and sexual health for young Americans.
Additionally, throughout her time as Vice President, her team proposed an expansion of contraception coverage to build upon their work to protect reproductive freedom. This initiative worked to provide more options for affordable contraceptive care for women, including a no-cost over-the-counter contraception without prescription. Working to lower contraception costs for citizens to make them more widely available promotes the idea that young people have the ability to make safe and informed decisions about their own bodies. If this level of accessibility is taken away following the 2024 election, it will be difficult for young people to access necessary reproductive health services.
Governor Tim Walz has also taken initiative to protect women’s rights, leading Minnesota to be the first state to pass a law protecting a woman’s right to choose after the Supreme Court overturning Roe v Wade. Since the law passed, Minnesota has continued to strengthen policies surrounding reproductive healthcare, becoming a beacon of hope for expanded access for the rest of the states. They have made great strides in providing unbiased medical information for patients that is unbridled by religious and cultural rhetoric.
Vice President Harris has expressed explicit support for intellectual freedom in the classroom, particularly in regards to LGBTQIA+[2] content. In choosing Governor Tim Walz, she has expressed empathy for the LGBTQIA+ community, as Walz was the first faculty advisor of the Gay Straight Alliance at the high school he worked at as a teacher and football coach. Her willingness to discuss topics surrounding LGBTQIA+ issues demonstrates her support for the community. She has spoken out against book bans, stating that most books banned are written by a LGBTQIA+ author or contain subject matters related to LGBTQIA+ people. She believes it is important to draw upon diverse communities and unify. Vice President Harris and Governor Walz look to expand access to reliable information in support of intellectual freedom, trusting young people to make safe and informed decisions.
Why is their election likely to be good for young people around the world?
Discomfort with and resistance to CSE is not new in the USA or elsewhere. What is new is that now it is better organized, increasingly well-funded, and more aggressive. In the USA it has morphed into a viscous fight on an expanding range of issues using tactics that only be described as dirty.
SIECUS, a leading voice for CSE in the USA for 60 years notes in a recent report: “When it comes to sex education, the Regressive Minority staunchly supports ineffective and harmful Sexual Risk Avoidance (SRA) programs—which are rebranded Abstinence Only Until Marriage (AOUM) programs—and works to inhibit the adoption of CSE. This movement operates under an ideology of homophobia, transphobia, misogyny, patriarchal ideals, and white supremacy that has proliferated into broader attacks against public education. Under the guise of concerns such as “parental rights” and “school transparency,” the Regressive Minority has carried out targeted attacks against CSE, critical race theory (CRT), inclusive LGBTQ programs, access to a diverse selection of books, and even the use of face masks during a global pandemic” It is not an exaggeration to say that battles on CSE are or will be fought in every state legislature and in every school.
The battles in the USA have a huge influence around the world. (A wider discussion on this is outside the scope of this article). Suffice to say that the Federal Government’s lack of strong and explicit support for CSE and its unwillingness or inability to curb the activities of non-state actors means that deliberate misinformation and outright lies are being exported to countries as far apart and as diverse as England, Mexico and Uganda (I have provided links below for further information)[3]. In some cases the issues that have polarized the USA are being introduced into – and tainting – national discourses, in others the tactics that have been used to push back progress on access to safe abortion care and other issues are being imitated, and in still others there is direct funding. (See Flaws and Errors Identified in the Institute for Research and Evaluation Report That Challenges Non-United States, School-Based Comprehensive Sexuality Education Evidence Base).
We do not know if Harris-Walz will win the 2024 presidential election. However, we are hopeful. If they do win, we look forward to bearing witness to their commitment to improving sexual and reproductive health for young people in America and as a byproduct, young people around the world.
Authors
Dr Venkatraman Chandra-Mouli was a staff member in the World Health Organization’s headquarters staff team from 1993 to 2023. Of these 30 years, he worked on adolescent health, with a particular focus on adolescent sexual and reproductive health for 27 years. Following his retirement, he continues to work on issues that he is passionate about – such as comprehensive sexuality education, with a range of organizations on his time and his terms.
Ms Margaret Smith is currently studying to receive her MSc in Reproductive and Sexual Health Research at the London School of Hygiene and Tropical Medicine as a Rotary Global Grant Scholar. She was born and raised in Pittsburgh, Pennsylvania, USA and attended College of the Holy Cross in Worcester, MA for university, graduating Summa Cum Laude with a degree in Health Studies. Maggie is passionate about improving access to services and information surrounding reproductive and sexual health for adolescents as an aspiring Obstetrician-Gynecologist.
References
[1] I have used the term comprehensive sexuality education (CSE), recognizing very well that the programmes in place in most countries of the world are not comprehensive in nature. As a United Nations report cited in this article notes, countries are on a journey towards CSE with some closer to the goal than others.
[2] Lesbian, Gay, Bisexual, Transexual, Queer, Intesex, Asexual+
[3] Links to case studies of ongoing battles in England, Mexico and Uganda
Mexico: https://pubmed.ncbi.nlm.nih.gov/29602869/
Uganda: https://www.devex.com/news/ngos-turn-to-courts-to-unravel-uganda-s-ban-on-sexual-education-89979