Analysis Sexual Health

Mississippi Sex Ed Law Leads to Reshuffled, But Not Improved, Curricula

Martha Kempner

Having spent much of my career reviewing abstinence-only-until-marriage curricula and material, I can promise that just adding a lesson about contraception cannot turn a fear- and shame-based program into anything better.

In 2011, legislators in Mississippi passed a law (HB 999) requiring all schools to choose between a strict abstinence-only policy or one, called abstinence-plus, that includes all aspects of the abstinence-only approach but also teaches young people about contraception and disease-prevention. A new report published by Mississippi First, the Women’s Foundation of Mississippi, and the Sexuality Information and Education Council of the United States (SIECUS), found that of the 151 school districts and four special schools in Mississippi, 81 chose abstinence-only, 71 chose abstinence-plus, and three chose a combined approach.

While it is good news that some students in Mississippi, a state that ranks at the bottom of all sexual health indicators, may be taught something other than “just say no until marriage,” the report also notes an oddity in how the law has been interpreted and implemented, which means that some curricula have ended up (without alterations) on the “approved” list for schools with both abstinence-only and abstinence-plus policies. Having spent much of my career reviewing abstinence-only-until-marriage curricula and material, I can promise that just adding a lesson about contraception cannot turn a fear- and shame-based program into anything better.

The Choosing the Best series, which includes curricula for grades six through 12, can be used by schools that pick either policy. In fact, this series is overwhelmingly popular in Mississippi as it is being used by 74 percent of schools that chose an abstinence-only policy and 39 percent that chose the supposedly more expansive abstinence-plus approach. The point of schools adopting the abstinence-plus policy is to be allowed to discuss, in the words of the law, “other topics such as contraceptive options and the cause and effect of sexually transmitted diseases and HIV/AIDS.” Unfortunately, Choosing the Best does not do that. (Note: The examples below are from the SIECUS review of the 2006 editions of this series. Schools in Mississippi may be using a newer edition, though in my experience few things change between editions.)

The discussions of contraception and STDs within the Choosing the Best series are very limited and based more on fear than fact. For example, in the program designed for sixth graders, the teacher is told to hold up cauliflower and explain that this is like a genital wart, one of the many STDs young people are likely to get if they are sexually active. (Something green and oozy is used to represent chlamydia.) Though this representation might seem clever to program planners who have seen pictures of genital warts left untreated for many years, which do in fact resemble cauliflower, most cases of warts are tiny dots that are not visible to the naked eye. Young people should know this so they know what to look out for and do not just assume they are fine unless they see something as large and obviously problematic as what their teacher is holding up during this presentation.

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The program for older kids includes this story in lieu of education about chlamydia:

The first time I had sex with anybody, I got Chlamydia. So one week I was a virgin, and two weeks later, I had an STD….I became violently ill. I had a 105 fever, severe abdominal cramps, and throwing up. The conclusion was yes, that I was infertile. My tubes had been damaged beyond repair.

While it is entirely possible to get chlamydia from one’s first sexual experience, it would be nice if the curriculum clarified that a condom could have prevented this outcome. More importantly, though, the infection would not progress to irreversible tube damage in just a couple of weeks (which despite the clever use of ellipses is how the story reads). Chlamydia, which often has no symptoms, is easily curable with antibiotics. If not treated it can lead to pelvic inflammatory disease (PID), which is what would cause someone to have fever, cramps, and vomiting. PID can also be cured with antibiotics. It is when PID is left untreated that scar tissue builds up. This would not happen rapidly, and given the symptoms this character experienced, there would have been plenty of opportunity for her to seek help and get treatment long before permanent damage was done. In actuality, the danger with chlamydia and the reason why it leads to infertility is that there are usually no symptoms, and without testing a person doesn’t even know she has had it until damage has been done. Implausible stories like this do little to educate students.

My favorite story from Choosing the Best has always been this one in which a new bride tells of how she’s suffered because of her husband’s infidelity:

I was rushed to the hospital with intense abdominal pain. Emergency surgery revealed such an extensive infection that my uterus, tubes and ovaries all had to be removed. My husband of six months had infected me with gonorrhea, which he had contracted from a ‘one-night stand’ prior to our engagement. Our dreams of biological children will never be realized.

Throughout the lessons plans, the authors make it clear that the only way to protect yourself from STDs is to stay abstinent until marriage. This point is underscored so often that it almost seems like wedding rings themselves have some kind of magic protective properties. And yet, the author’s own story proves this wrong. The speaker here could very well have taken the program’s advice and stayed abstinent until her wedding night but she got gonorrhea anyhow. Clearly, she and her new husband would have been better off had they been given real information about how STDs are transmitted, prevented, and treated.If they had, perhaps her husband would have known to us a condom during his one night stand and get tested for STDs before he had unprotected sex with his wife.

Information on condoms and contraception is quite sparse and laser-focused on failure rates in Choosing the Best. The program tells students, for example, that the failure rate for condoms is 15 percent in preventing pregnancy which is more or less accurate though fails to note that this rate includes couples who used a condom incorrectly or didn’t use a condom at all when they became pregnant. When used consistently and correctly condoms are 98 percent effective in preventing pregnancy. The curricula then says: “Could you live with a 15% annual failure rate on: A roller coaster ride? “An airline flight? Skydiving?” Again, because the 15 percent includes non-use, to be accurate, the skydiving analogy would have to include all of those people who jumped out of an airplane without their parachute.

Of course, even if the curriculum provided decent information about condoms or contraception, this would be instantly undermined by the messages of shame that suggest young people who have sex lack character and values. Take the exercise “Mint for Marriage” in which the teacher passes around an unwrapped peppermint patty and asks each student to hold it for a second. When it is returned to the front of the room she says:  “Why is this patty no longer appealing?” The answer: “No one wants food that has been passed around and neither would you want your future husband or wife to have been passed around.” A similar exercise called “A Rose with No Petals” ends with the explanation “Each time a sexually active person gives that most personal part of himself or herself away, that person can lose a sense of personal value and worth. It all comes down to self-respect.”

Almost 60 percent of high school students in Mississippi have had sex. It’s hard to see how learning that they lack personal value, worth, and self-respect will be a good motivator for making sure they protect themselves from sexually transmitted diseases and pregnancy when they have sex in the future.

Jamie Bardwell, of the Women’s Foundation of Mississippi, one of the groups that authored the new report, told Rewire, “It is incredibly confusing that the law allows a sex education curriculum to be labeled as both abstinence-plus and abstinence-only. True abstinence-only-until-marriage programs like Choosing the Best, should not be labeled ‘abstinence-plus’ simply because they mention the word contraception.”

Bardwell added: “Programs like these that shame LGBT young people and include wedding ceremonies, inaccurate information, and gender stereotypes. They should not be taught in any Mississippi classrooms and certainly not in schools that want an abstinence-plus programs. Young people need and want good, medically accurate information to make healthy decisions.”

Advocates in Mississippi are trying to get the law changed so that better curricula are required, at least in schools that chose an abstinence-plus approach. In the meantime, a clear majority of students in the Magnolia State will be told by Choosing the Best that sexually active teenagers are like a pitcher of spit—dirty, gross, and not wanted.

Commentary Sexual Health

Parents, Educators Can Support Pediatricians in Providing Comprehensive Sexuality Education

Nicole Cushman

While medical systems will need to evolve to address the challenges preventing pediatricians from sharing medically accurate and age-appropriate information about sexuality with their patients, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Last week, the American Academy of Pediatrics (AAP) released a clinical report outlining guidance for pediatricians on providing sexuality education to the children and adolescents in their care. As one of the most influential medical associations in the country, AAP brings, with this report, added weight to longstanding calls for comprehensive sex education.

The report offers guidance for clinicians on incorporating conversations about sexual and reproductive health into routine medical visits and summarizes the research supporting comprehensive sexuality education. It acknowledges the crucial role pediatricians play in supporting their patients’ healthy development, making them key stakeholders in the promotion of young people’s sexual health. Ultimately, the report could bolster efforts by parents and educators to increase access to comprehensive sexuality education and better equip young people to grow into sexually healthy adults.

But, while the guidance provides persuasive, evidence-backed encouragement for pediatricians to speak with parents and children and normalize sexual development, the report does not acknowledge some of the practical challenges to implementing such recommendations—for pediatricians as well as parents and school staff. Articulating these real-world challenges (and strategies for overcoming them) is essential to ensuring the report does not wind up yet another publication collecting proverbial dust on bookshelves.

The AAP report does lay the groundwork for pediatricians to initiate conversations including medically accurate and age-appropriate information about sexuality, and there is plenty in the guidelines to be enthusiastic about. Specifically, the report acknowledges something sexuality educators have long known—that a simple anatomy lesson is not sufficient. According to the AAP, sexuality education should address interpersonal relationships, body image, sexual orientation, gender identity, and reproductive rights as part of a comprehensive conversation about sexual health.

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The report further acknowledges that young people with disabilities, chronic health conditions, and other special needs also need age- and developmentally appropriate sex education, and it suggests resources for providing care to LGBTQ young people. Importantly, the AAP rejects abstinence-only approaches as ineffective and endorses comprehensive sexuality education.

It is clear that such guidance is sorely needed. Previous studies have shown that pediatricians have not been successful at having conversations with their patients about sexuality. One study found that one in three adolescents did not receive any information about sexuality from their pediatrician during health maintenance visits, and those conversations that did occur lasted less than 40 seconds, on average. Another analysis showed that, among sexually experienced adolescents, only a quarter of girls and one-fifth of boys had received information from a health-care provider about sexually transmitted infections or HIV in the last year. 

There are a number of factors at play preventing pediatricians from having these conversations. Beyond parental pushback and anti-choice resistance to comprehensive sex education, which Martha Kempner has covered in depth for Rewire, doctor visits are often limited in time and are not usually scheduled to allow for the kind of discussion needed to build a doctor-patient relationship that would be conducive to providing sexuality education. Doctors also may not get needed in-depth training to initiate and sustain these important, ongoing conversations with patients and their families.

The report notes that children and adolescents prefer a pediatrician who is nonjudgmental and comfortable discussing sexuality, answering questions and addressing concerns, but these interpersonal skills must be developed and honed through clinical training and practice. In order to fully implement the AAP’s recommendations, medical school curricula and residency training programs would need to devote time to building new doctors’ comfort with issues surrounding sexuality, interpersonal skills for navigating tough conversations, and knowledge and skills necessary for providing LGBTQ-friendly care.

As AAP explains in the report, sex education should come from many sources—schools, communities, medical offices, and homes. It lays out what can be a powerful partnership between parents, doctors, and educators in providing the age-appropriate and truly comprehensive sexuality education that young people need and deserve. While medical systems will need to evolve to address the challenges outlined above, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Parents and Caregivers: 

  • When selecting a pediatrician for your child, ask potential doctors about their approach to sexuality education. Make sure your doctor knows that you want your child to receive comprehensive, medically accurate information about a range of issues pertaining to sexuality and sexual health.
  • Talk with your child at home about sex and sexuality. Before a doctor’s visit, help your child prepare by encouraging them to think about any questions they may have for the doctor about their body, sexual feelings, or personal safety. After the visit, check in with your child to make sure their questions were answered.
  • Find out how your child’s school approaches sexuality education. Make sure school administrators, teachers, and school board members know that you support age-appropriate, comprehensive sex education that will complement the information provided by you and your child’s pediatrician.

School Staff and Educators: 

  • Maintain a referral list of pediatricians for parents to consult. When screening doctors for inclusion on the list, ask them how they approach sexuality education with patients and their families.
  • Involve supportive pediatricians in sex education curriculum review committees. Medical professionals can provide important perspective on what constitutes medically accurate, age- and developmentally-appropriate content when selecting or adapting curriculum materials for sex education classes.
  • Adopt sex-education policies and curricula that are comprehensive and inclusive of all young people, regardless of sexual orientation or gender identity. Ensure that teachers receive the training and support they need to provide high-quality sex education to their students.

The AAP clinical report provides an important step toward ensuring that young people receive sexuality education that supports their healthy sexual development. If adopted widely by pediatricians—in partnership with parents and schools—the report’s recommendations could contribute to a sea change in providing young people with the care and support they need.

Commentary Sexual Health

Fewer Teens Are Having Sex, But Don’t Pop the Champagne Yet

Martha Kempner

The number of teens having sex may be less important than the number having protected sex. And according to recent data from the Centers for Disease Control and Prevention, condom use is dropping among young people.

Every two years, the Centers for Disease Control and Prevention’s Division of Adolescent and School Health (CDC-DASH) surveys high school students to gauge how often they engage in perceived risky behaviors. The national Youth Risk Behavior Surveillance (YRBS) is wide ranging: It asks about violence, guns, alcohol, drugs, seat belts, bicycle safety, and nutrition. It also asks questions about “sexual intercourse” (which it doesn’t define as a specific act) and sexual behaviors.

Started in 1991, this long-running study can provide both a picture of what high school students are doing right now and a historical perspective of how things have changed. But for more than a decade, the story it has told about sexual risk has been the virtually the same. Risk behaviors continually declined between 1991 and 2001, with fewer high school students having sex and more of them using condoms and contraception. But after the first 10 years, there has been little change in youth sexual risk behaviors. And, with each new release of almost unchanging data, I’ve reminded us that no news isn’t necessarily good news.

This year, there is news and it looks good—at least on the surface. The survey showed some significant changes between 2013 and 2015; fewer kids have ever had sex, are currently sexually active, or became sexually active at a young age. More teens are relying on IUDs and implants, which are virtually error-proof in preventing pregnancy.

In 2015, 41 percent of high school students reported ever having had sexual intercourse compared to 47 percent in 2013. The researchers say this is a statistically significant decrease, which adds to the decreases seen since 1991, when 54 percent of teens reported ever having had sexual intercourse.

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Another change is in the percentage of students who had sex for the first time before age 13. In 2015, 4 percent of high school students reported this compared to almost 6 percent in 2013. This is down from a full 10 percent in 1991. As for number of overall partners, that is down as well, with only 12 percent of students reporting four or more partners during their lifetime compared to 15 percent in 2013 and 19 percent in 1991. Finally, the percentage of students who are currently sexually active also decreased significantly between 2013 (34 percent) and 2015 (30 percent).

These are all positive developments. Delaying sex can often help prevent (at least temporarily) the risk of pregnancy or STIs. Having fewer partners, especially fewer concurrent partners, is frequently important for reducing STI risk. And those teens who are not currently having sex are not currently at risk for those things.

While I want to congratulate all teens who took fewer risks this year, I’m not ready to celebrate those statistics alone—because the number of teens having sex is less important to me than the percentage of teens having sex that is protected from both pregnancy and sexually transmitted infections. And that number is lower than it once was.

Among sexually active teens, there were no significant positive changes in measures of safer sex other than an increase in the number of sexually active high school students using the IUD or implant (up to 4 percent from 2 percent in 2013).

Moreover, some results indicate that today’s teens are using less protection than those who were teens a decade ago. The most telling finding might be the percentage of teens who used no method of contraception the last time they had sex. This decreased between 1991 and 2007 (from 17 percent to 12 percent), inched up to 14 percent in 2013, and stayed the same in 2015 (14 percent). There was also little to no change in the percentage of high school students who say that either they or their partner used birth control pills between 2013 (19 percent) and 2015 (18 percent) or those who say they used the contraceptive shot, patch, or ring (5 percent in 2013 and 2015).

For me, however, the most distressing finding is the backward progress we continue to see in condom use. The prevalence of high school students who used a condom at last sex went up from 45 percent in 1991 to 63 percent in 2003. But then it started to drop. In 2015, only 57 percent of sexually active high school students used condoms the last time they had sex, less than in 2013, when 59 percent said they used condoms.

It’s not surprising that teens use condoms less frequently than they did a decade ago. In the 1990s, the HIV epidemic was still front and center, and condoms were heavily promoted as a way to avoid infection. As this threat waned—thanks to treatment advances that now also serve as prevention—discussions of the importance of condoms diminished as well. The rise of abstinence-only-until-marriage programs may have also affected condom use, because these programs often include misinformation suggesting condoms are unreliable at best.

Unfortunately, some of the negative messages about condoms inadvertently came from public health experts themselves, whether they were promoting emergency contraception with ads that said “oops, the condom broke”; encouraging the development of new condoms with articles suggesting that current condoms are no fun; or focusing on teen pregnancy and the use of highly effective contraceptive methods such as long-acting reversible contraceptives (LARC). The end result is that condoms have been undersold to today’s teenagers.

We have to turn these condom trends around, because despite the decreases in sexual activity, young people continue to contract STIs at an alarming rate. In 2014, for example, there were nearly 950,000 reported cases of chlamydia among young people ages 15 to 24. In fact, young people in this age group represented 66 percent of all reported chlamydia cases. Similarly, in 2014, young women ages 15 to 19 had the second-highest rate of gonorrhea infection of any age group (400 cases per 100,000 women in the age group), exceeded only by those 20 to 24 (489 cases per 100,000 women).

While we can be pleased that fewer young people are having sex right now, we can’t fool ourselves into believing that this is enough or that our prevention messages are truly working. We should certainly praise teens for taking fewer risks and use this survey as a reminder that teens can and do make good decisions. But while we’re shaking a young person’s hand, we should be slipping a condom into it. Because someday soon (before high school ends, for more than half of them), that teenager will have sex—and when they do, they need to protect themselves from both pregnancy and STIs.