Get 20M+ Full-Text Papers For Less Than $1.50/day. Subscribe now for You or Your Team.

Learn More →

Invited Commentary: Broadening the Evidence for Adolescent Sexual and Reproductive Health and Education in the United States

Invited Commentary: Broadening the Evidence for Adolescent Sexual and Reproductive Health and... J Youth Adolescence (2014) 43:1595–1610 DOI 10.1007/s10964-014-0178-8 EDITORIAL Invited Commentary: Broadening the Evidence for Adolescent Sexual and Reproductive Health and Education in the United States • • • Amy T. Schalet John S. Santelli Stephen T. Russell • • • Carolyn T. Halpern Sarah A. Miller Sarah S. Pickering Shoshana K. Goldberg Jennifer M. Hoenig Received: 17 August 2014 / Accepted: 22 August 2014 / Published online: 9 September 2014 The Author(s) 2014. This article is published with open access at Springerlink.com Abstract Scientific research has made major contribu- contraceptive use, or number of partners). Although the tions to adolescent health by providing insights into factors transition from primarily AOUM to EBI is important pro- that influence it and by defining ways to improve it. gress, this definition of evidence is narrow and ignores However, US adolescent sexual and reproductive health factors known to play key roles in adolescent sexual and policies—particularly sexuality health education policies reproductive health. Important bodies of evidence are not and programs—have not benefited from the full scope of treated as part of the essential evidence base, including scientific understanding. From 1998 to 2009, federal research on lesbian, gay, bisexual, transgender, queer, and funding for sexuality education focused almost exclusively questioning (LGBTQ) youth; gender; and economic on ineffective and scientifically inaccurate abstinence- inequalities and health. These bodies of evidence under- only-until-marriage (AOUM) programs. Since 2010, the score the need for sexual health education to approach largest source of federal funding for sexual health educa- adolescent sexuality holistically, to be inclusive of all tion has been the ‘‘tier 1’’ funding of the Office of Ado- youth, and to address and mitigate the impact of structural lescent Health’s Teen Pregnancy Prevention Initiative. To inequities. We provide recommendations to improve US be eligible for such funds, public and private entities must sexual health education and to strengthen the translation of choose from a list of 35 programs that have been desig- science into programs and policy. nated as ‘‘evidence-based’’ interventions (EBIs), deter- mined based on their effectiveness at preventing teen pregnancies, reducing sexually transmitted infections, or Introduction reducing rates of sexual risk behaviors (i.e., sexual activity, Science is an essential foundation for adolescent sexual and reproductive health. Researchers, policy makers, advo- cates, and citizens accept science as a basis for policies and A. T. Schalet  S. A. Miller Department of Sociology, University of Massachusetts Amherst, programs related to adolescent sexual and reproductive Amherst, MA, USA health. Scientific methods are used to identify the magni- tude of adolescent health problems, contributing factors J. S. Santelli  S. S. Pickering and health consequences, and to develop and evaluate Heilbrunn Department of Population and Family Health, Columbia University, New York, NY, USA health education and prevention programs. Scientific understanding of adolescent sexual and reproductive health S. T. Russell (&)  J. M. Hoenig encompasses general and discipline-specific scientific the- Norton School of Family and Consumer Sciences, University of ory, qualitative and quantitative data, and scientific find- Arizona, Tucson, AZ, USA e-mail: strussell@arizona.edu ings from diverse fields, including the medical, health, social, and behavioral sciences. C. T. Halpern  S. K. Goldberg Adolescent sexual and reproductive health policy in the Department of Maternal and Child Health, Gillings School of United States has failed to benefit from the full scope of Global Public Health, University of North Carolina at Chapel science. From 1998 to 2009, federal funding for sexuality Hill, Chapel Hill, NC, USA 123 1596 J Youth Adolescence (2014) 43:1595–1610 education focused almost exclusively on ineffective and conclusion, we provide recommendations to improve scientifically inaccurate abstinence-only-until marriage adolescent sexuality education programs and policy, and (AOUM) programs (Santelli et al. 2006). President Oba- the link between research and policy. ma’s 2010 teen pregnancy prevention initiative requires funded programs to be based in scientific evidence, but the implementation of this initiative has led to a new problem: Adolescents and Their Sexual and Reproductive Health ‘‘Evidence’’ is now narrowly defined to include only cer- tain kinds of scientific findings. Currently, this initiative is The World Health Organization definition of health is ‘‘a the largest federal funding program addressing the sexual state of complete physical, mental, and social well-being health needs of adolescents. The US Department of Health and not merely the absence of disease or infirmity’’ (World and Human Services has approved funding for 35 ‘‘evi- Health Organization 1946). Definitions of reproductive dence-based’’ programs selected on the basis of studies that health and sexual health mirror and expand upon this have shown their effectiveness at preventing teen preg- definition of health. Central to our conception of adolescent nancies, reducing sexually transmitted infections (STIs), or sexual and reproductive health is an understanding of reducing rates of sexual risk behaviors (i.e., sexual activity, adolescence as a life stage defined by physiological, psy- contraceptive use, or number of partners). These ‘‘evi- chological, social, and cultural transitions marking the dence-based-interventions’’ (EBIs) are modeled after clin- movement from childhood to adulthood. Adolescents are ical trials and implemented with the intention to effect emerging as adults, embodying a tension between the need targeted behavior change. for protection and guidance by parents and adult caregiv- While a clear advance over previous policy, current ers, on one hand, and the rights to autonomy and agency on adolescent sexual and reproductive health policy and pro- the other. gramming remain uninformed by the scientific base in Over the past 60 years, important changes have occurred profound ways. First, federal policy continues to fund in the timing of adolescent transitions, including age at first abstinence programs that remain at odds with scientific sex, length of educational preparation, age at marriage and thinking about adolescent sexual health. Second, key timing of childbearing. In the United States, as in other bodies of science are not treated as part of the essential developed countries, adolescents typically initiate sexual evidence base for policy and programming. The exclusive contact during their mid or late teens or early 20s (Finer focus on pregnancy and disease prevention in the definition 2007; Halpern and Haydon 2012). The establishment of of sexual health leaves out aspects of adolescent sexual constructive and satisfying romantic relationships is a key development and health that researchers argue are critical, developmental task of adolescence and an important con- tributor to sexuality and sexual health (Mayer et al. 2008). such as sexual orientation and gender beliefs. The focus on individual-level proximate causes of pregnancy and dis- We define sexuality to include the feelings, identities, ease, such as sexual activity and contraceptive use, largely relationships, and interactions that form the foundations of eclipses the systematic, society-level structural inequities sexual development, and a variety of non-coital and coital that shape adolescent sexual behavior and risk. Finally, sexual experiences. Important aspects of adolescent sexual defining ‘‘evidence’’ as evaluations of program effective- development include maintaining a positive body image, ness for changing specific individual behaviors excludes developing self-efficacy in sexual decision-making and broader evidence regarding psychological, cultural, and interactions, and forming mutually respectful romantic economic factors known to shape adolescent sexual health. relationships (Schalet 2011a; Tolman 2002). Multiple and We begin our critique by reviewing the sexual and multi-level factors influence personal attitudes, motiva- reproductive health needs of adolescents, with attention to tions, and experiences, and can bolster or hinder the the role of schools in promoting sexual health. We then development of sexual self-efficacy, resiliency, healthy discuss the emergence of evidence-based interventions as a relationships, and positive body image, as well as behav- guiding force in US adolescent sexual and reproductive iors that promote and protect or threaten health. Bodies of health policies and programs. With this background, we knowledge related to inter-personal dynamics, school cli- examine three bodies of science—lesbian, gay, bisexual, mate, social norms, and cultural values and beliefs all transgender, queer and questioning (LGBTQ) youth and provide information about the motives for adolescent sex- health; gender; and economic inequalities—identifying key ual behavior (Russell 2005; Schalet 2011b). At the macro findings that should inform adolescent sexual health and level, social and cultural forces including daily realities education programs. These bodies of evidence underscore such as poverty or economic inequality, structural racism the need for sexual health education to approach adolescent and stigmatization of youth who do not conform to rigid sexuality holistically, to be inclusive of all youth, and to gender and sexual orientation norms, as well as medical address and mitigate the impact of structural inequities. In technologies and access to health care and education, all 123 J Youth Adolescence (2014) 43:1595–1610 1597 profoundly shape adolescent health (Resnick et al. 2012). Discomfort with adolescent sexuality runs throughout the Social and behavioral science research on adolescent health diverse institutions of American society, and it is perhaps has defined the important roles of families and peers, no surprise that this discomfort has shaped our political media, schools, life opportunities, demographic transitions, conversations and policymaking. This discomfort and its and cultural forces in shaping young people’s health status impact on policy are not, however, inevitable. Other (Sawyer et al. 2012). Research in medicine and public developed nations, such as the Netherlands and Denmark, health has documented the importance of health services, have shifted away from a historical discomfort with ado- sexual health education, access to screening and treatment lescent sexuality, fostering national dialogue and policies for STIs, and public policies in improving health. aimed at supporting youth in their development—both sexual and socioeconomic—and seeing better overall Adolescent Sexual Health Challenges adolescent sexual and reproductive health outcomes (Rose 2005; Singh et al. 2001; Schalet 2011b). In the United The need for more broad and effective translation of sci- States, by contrast, multiple factors have contributed to ence into sexual and reproductive health policy is under- ongoing controversy around adolescent sexuality, includ- scored by the significant sexual health burdens among ing its explicit politicization in recent decades, particularly youth. Comprising only 25 % of the sexually active pop- with regard to the teaching of sexual health education ulation in the United States, young people (13–24 years) within schools (Irvine 2004; Luker 2007). account for approximately half of the 20 million STIs contracted annually, including one in four of the estimated Adolescent Sexual Health Education 50,000 new human immunodeficiency virus (HIV) infec- tions diagnosed each year (CDC 2013a; Weinstock et al. Schools have an essential role in promoting adolescent 2004). Racial, ethnic, and gender disparities are striking. sexual and reproductive health, and science is essential in The majority of new adolescent cases (57 %) are among guiding the development of school health policies. As of Blacks/African-Americans, with an additional 20 % fall 2013, about 50.1 million children and young people occurring among Hispanics/Latinos (CDC 2012a, b). were enrolled in public elementary and secondary schools Women accounted for one in four new HIV cases in 2009; across the United States (National Center for Education the incidence rate for Black/African American females Statistics 2013). Schools offer a practical and efficient (38.1/100,000) is 20 times the rate for White females (1.9) means to reach young people with health information and (CDC 2012b). However, men who have sex with men health services. Because they include students across the (MSM) are the population most affected by HIV in the socioeconomic spectrum, public schools can educate and serve children and youth who may not have access to United States; the estimated number of new HIV infections among adolescent and emerging adult Black/African education and services elsewhere. Schools are also an American MSM (aged 13–29 years) increased 48 % from opportunity to educate all young people about health and 2006 to 2009 (CDC 2011). Moreover, the US Centers for sexuality before they initiate health risk behaviors, and to Disease Control and Prevention (CDC) reports that nearly provide health services that prevent disease and promote 1.5 million high school students are affected by dating health. Thus schools can help young people establish violence annually, with rates of violence and sexual coer- healthy behaviors that endure into adulthood (CDC 2013b; cion especially high among LGBTQ youth and female Kirby 2002). In addition to promoting healthy behaviors, adolescents (CDC 2006). Finally, despite historic declines schools are important venues for the development of norms in adolescent pregnancy and teen births, US teen birth rates and values and for fostering positive self-concept and remain the highest among the developed nations (National agency around sex, sexuality, and relationships (Center for Research Council 2013) even though levels of sexual School, Health, and Education, 2011). experience are similar. Within the United States, poor, Educators, psychologists, and sociologists have argued, rural and minority women have higher teen birth rates. moreover, that sexual health education also has an impor- These disparities (by poverty and by race and ethnicity) tant role to play in combating the health and social dis- demonstrate the critical need for effective and medically parities that young people face. They note that structural accurate sexuality education, accessible adolescent health racism, poverty, gender inequality, and the stigmatization care, and policy initiatives that reshape the educational and of LGBTQ people all negatively impact health outcomes, work opportunities for disadvantaged youth. including sexual health outcomes, and have argued that it is Despite the omnipresence of sexual messages in US incumbent upon educators not to perpetuate inequalities media, frank public conversations about sexual and within the classroom through explicit or implicit stereo- reproductive health, as holistically defined by organizations typing (Fine and McClelland 2006). They point to prob- such as the World Health Organization, are rare. lems not only in formal curricula, but also in the informal 123 1598 J Youth Adolescence (2014) 43:1595–1610 or hidden curricula—the implicit messages embedded in heterosexual youth, and harm to traditional sexual health sexual health education—through which educators may education (American Academy of Pediatrics Committee on inadvertently promote class, gender, and race stereotypes Psychosocial Aspects of Child and Family Health and (Fields 2008; Morris 2007). Sexual health education has Committee on Adolescence 2001; American Civil Liberties the potential to give young people the opportunity to crit- Union 2008; American Public Health Association 2006; ically examine the societal inequalities linked to gender, Santelli et al. 2006). race, sexuality, and poverty (Fields 2008; Fine and McC- Rigorous evaluations of AOUM or abstinence-based lelland 2006). Thus, while sexual health education cannot curricula have failed to demonstrate efficacy in delaying remove the inequalities in society at large, it can aid stu- initiation of sexual intercourse, reducing number of part- dents in acquiring the critical thinking skills that will allow ners, increasing condom use, or promoting secondary them to more effectively confront and challenge them. abstinence (i.e., cessation of sexual intercourse among sexually experienced youth) (Kirby 2008; Trenholm et al. 2008). In contrast to abstinence approaches, a 2012 CDC From ‘‘Ab-only’’ to ‘‘EBI-only’’: US Federal Sexual meta-analysis of 66 comprehensive risk reduction pro- Health Education Policy grams for youth showed favorable effects on current sexual activity, frequency of sexual activity, number of sex part- The history of sexuality education in the United States ners, frequency of unprotected sexual activity, use of pro- reflects philosophical clashes and alternating domination of tection (either condoms and/or hormonal contraception), competing approaches stemming from those philosophical pregnancy, and STIs (Chin et al. 2012). In the same report, differences (Irvine 2004; Luker 2007; Moran 2002). the CDC found insufficient scientific evidence for change Opponents of sexual health education have argued that in behaviors or other outcomes from abstinence education teaching young people about sex encourages them to be programs (Chin et al. 2012). sexually active, even though there is no evidence to support Since 2010, there has been a shift in federal approaches such claims; rather sexual health education helps some to sexual health education away from AOUM programs, young people delay initiation of sex (Kirby et al. 2007a). In and towards ‘‘evidence-based interventions’’ (EBI), led by the 1990s the CDC provided significant funds to promote the US federal Office of Adolescent Health (OAH) HIV/AIDS prevention education, which greatly expanded (AOUM programs have still received substantial funding youth exposure to sexual health education but emphasized through the Title V State Abstinence Education Grant prevention of STIs and HIV. Beginning in 1998, federal Program). EBIs are treatments or interventions designed to funding shifted increasingly to a narrow focus on absti- effect behavior change that have been evaluated using randomized or quasi-experimental designs. nence as the primary program and policy solution for ‘‘the US Federal problem’’ of adolescent sexuality. AOUM programs reflect health policy has increasingly relied on these EBIs (CDC the strong moral and religious beliefs of their authors. Key 2013c; Evidence Based Intervention Network 2011). The among those are the beliefs that sex outside of heterosexual authorizing language for the Office of Adolescent Health marriage is sinful and that teaching about the health ben- specifically describes ‘‘replication’’ of evidence-based efits of condoms and contraception is morally wrong approaches to teen pregnancy prevention programs and because it encourages premarital sex. These beliefs are a requires medical accuracy in all funded programs. In critical feature of the ‘‘conceptual’’ basis for AOUM pol- practice this means that to be eligible for the largest icies (Santelli et al. 2006). funding stream (termed ‘‘Tier 1’’), grantees must select From 1998 to 2009 the US government spent almost 2 from and replicate with fidelity the now 35 programs that billion dollars on assistance to states, community-based, have been designated as EBIs. (A second group of funded and faith-based organizations for AOUM educational pro- programs, Tier 2, develops and tests new approaches to grams [Sexuality Information and Education Council of the prevent teen pregnancy, including emphasis on under- United States (SIECUS 2014)]. Since 2009, US funding for served populations.) domestic and international AOUM programs has decreased. However, federal and state-funded AOUM programs remain widespread in many parts of the United Such research designs are particularly useful in evaluating behav- States, despite multiple scientific and human right concerns ioral interventions where effect sizes are small or where the efficacy of an intervention is unknown. that have been raised by mainstream medical and public The Personal Responsibility Education Program (PREP) of the US health organizations, including concerns about scientific Office of the Administration for Children and Families is a distinct accuracy, the withholding of life-saving information from funding stream for teen pregnancy prevention; it does not require use young people, a lack of program efficacy, promotion of of an EBI, however grantees are highly encouraged to use programs gender and racial stereotypes, insensitivity to non- on the EBI list. 123 J Youth Adolescence (2014) 43:1595–1610 1599 Current emphasis on EBIs has been an important sci- inequalities. Moreover, when EBIs fail to address non-EBI entific and translational advance over prior federal efforts; scientific data about the role of poverty, race, and gender in however, a number of limitations have become evident adolescent sexual health they create the potential for with this approach. Current policy has focused on repli- reinforcing cultural stereotypes. cation of specific curricula rather than the theory derived In the remainder of this article, we turn to evidence from from research on EBIs, which provides a guide for across the social and behavioral sciences that should be understanding efficacy and adapting programs to new cir- central to all adolescent sexual health education. We show cumstances (Kirby et al. 2007b; UNESCO 2009). Further, how the emerging research on LGBTQ youth calls for the definitions of the health problems to be addressed and inclusiveness in adolescent sexual health education pro- the types of evidence brought to bear on those problems gramming. Drawing from an extensive literature on the omit central bodies of research. A narrow focus on disease harmful effects of gender inequity and stereotypes, we and pregnancy prevention—and on the individual-level demonstrate the need for sexual health education to address behavioral antecedents—undermines a more holistic these issues. Finally, we illustrate how poverty and approach to adolescent sexual health, and also ignores inequality intersect with adolescent sexual health education decades of scientific evidence of the ways that structural in a myriad of ways that have distinct implications for inequities shape adolescent sexual behavior and risk policy and programming. (Anderson et al. 2005). By defining the ‘‘evidence base’’ as evaluation research about program success in effecting LGBTQ Education and Health specific (often small) behavior changes, the broader sci- entific record about factors known to shape adolescent Contemporary LGBTQ and gender nonconforming youth sexual health outcomes has been relegated to a discre- ‘‘come out’’ or disclose their identities at younger ages than tionary rather than central position. Grantees may use the prior cohorts and have distinct sexual health needs (Floyd breadth of scientific thinking to design tier two programs and Bakeman 2006). It is now commonly understood that but they are not required—nor are those tasked with exact LGBTQ students may face victimization at school, or replication able—to integrate it into their programming. generally hostile school climates (Birkett et al. 2009). Their Thus, federal program requirements have had the unin- needs are often invisible in sexual and reproductive health tended consequence of ignoring and marginalizing a services, and they are typically excluded from sexual broader body of scientific principles and evidence regard- health education programs (Bay-Cheng 2003; Cianciotto ing adolescent sexual health and behavior. 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 Toward Holistic Adolescent Sexual Health for males, females, and transgender youth; and higher rates of pregnancy for both girls and boys (results for trans- We have argued that Evidence Based Interventions often gender youth are unknown) (Mustanski et al. 2011; Saewyc do not reflect factors that the broad scientific literature et al. 1999; Saewyc et al. 2009). identifies as key to health behaviors and risks, and do not The focus of sexual health education historically has approach individual behavior in the broad context of ado- been on heterosexual sexuality, with emphasis on procre- lescents’ lives. As such, there is a disconnect between ation, presumably or explicitly directed to the confines of research and theoretical advances on one hand, and sexual marriage (Carter 2001). For more than 100 years, educators health education programs and policies on the other (Ro- have grappled with the issue of how to teach youth about mero et al. 2011). For instance, social and behavioral sci- sexuality while promoting premarital chastity and marital ence research documents the significance of the sexual monogamy, a dilemma that has often led to sacrifices of orientation of young people, the gender beliefs and ineq- scientific accuracy in favor of ideology (Carter 2001). As a uities that shape their sexual agency and relationships, and result LGBTQ youth are often excluded or left without the economic and racial inequalities that constrain their relevant and necessary information to make safe and options, as crucial to a holistic understanding of adolescent effective choices. Despite potential breadth, the dominant sexual health. But many EBIs do not fully address or even focus of sexuality education programs initially focused on acknowledge the psychosocial and structural factors that the public health outcomes such as the prevention of shape the ways in which adolescents conduct their sexual unintended pregnancy, and since the mid-1980s, prevention lives. Thus, while consensus has emerged across disci- of HIV/AIDS and STIs. Before HIV/AIDS, there was plines that gender, racism, stigmatization of LBGTQ youth, mostly silence on LGBTQ sexualities in sexual health and poverty are critical to adolescent health, we lack pro- education. Debates in the late 1990s became dominated by grammatic emphasis and EBIs that address these abstinence in sexual health education, a stark contrast to 123 1600 J Youth Adolescence (2014) 43:1595–1610 growing scientific knowledge about the efficacy of com- (Mayer et al. 2008). Heterosexual bias in sexuality edu- prehensive sexuality education. In addition to other faults cation will leave some youth without critical knowledge described above, the introduction of AOUM programs they need to make safe sexual choices. actively thwarted momentum to include LGBTQ youth Only nine states require that sexual health education needs in sexual health education by emphasizing absti- programs provide inclusive information on sexual orien- nence until heterosexual marriage among high-school tation (Guttmacher Institute 2013). Seven states (and youth in different-sex relationships. Only since 2004 has multiple localities) have laws that expressly forbid dis- marriage for same-sex couples been possible (to date more cussion of LGBTQ issues (including sexual health and than a dozen states and the District of Columbia permit HIV/AIDS awareness) in a positive light, if at all; of those, same-sex couples to marry); thus, for many LGBTQ youth, three states (Alabama, South Carolina, and Texas) require the AOUM message actively erases potential for compre- that sexuality education programs include negative mes- hensive sexual health education. Moreover, some absti- sages about same-sex sexuality (Guttmacher Institute 2013; nence-only program content includes unequivocally hostile McGovern 2012). Alabama law criminalizes same-sex messages about LGBTQ people (Cianciotto and Cahill relationships and sexual behavior and proclaims them to be 2003). ‘‘not a lifestyle acceptable to the general public.’’ Addi- Several empirical studies have begun to document the tionally, the law asserts that this position comes from a ways that abstinence programs may undermine LGBTQ ‘‘factual manner and from a public health perspective.’’ youth sexual health and well-being (Kosciw et al. 2012). This discriminating law is not unique; there are other laws One report showed that compared to schools with other throughout the country that work to stigmatize LGBTQ types of sexuality education, LGBTQ students who atten- people, including youth in the classroom, by expressly ded schools that taught abstinence-only programs faced forbidding discussion of LGBTQ issues in a positive greater harassment in the form of anti-LGBTQ remarks. manner (McGovern 2012). Meanwhile, two proposed fed- Further, by excluding sexual minorities (or in some cases eral laws have languished; the Safe Schools Improvement giving disparaging information about them), abstinence- Act (2013 S. 403) and the Student Non-Discrimination Act only programs may produce feelings of rejection and being (2013 HR 1652) would explicitly provide protection to disconnected to school (Kosciw et al. 2012). These feelings LGBTQ students in US schools, and create a supportive may lead to negative mental health outcomes such as policy context for inclusive health policies and programs. depression and anxiety and serve as precursors for other In spite of this discouraging context for sexuality edu- health risk behaviors (Almeida et al. 2009; Kosciw et al. cation, the pace of social change regarding LGBTQ 2012). On the other hand, there is evidence that inclusive inclusion has been extraordinary, as evidenced, for exam- ple, by the growing number of US states and other nations strategies can promote sexual health for LGBTQ students. For example, Blake et al. (2001) found that LGB students that permit marriage for same-sex couples. Beyond sexu- in schools with gay-sensitive HIV instruction reported ality education programs, there is an emerging body of lower sexual risk taking and substance use. evidence that documents specific educational practices and Not only may LGBTQ students be invisible or margin- strategies that create positive school climates for LGBTQ alized in sexuality education, but their health needs may youth, including inclusive anti-discrimination and anti- not align with the sexual health education needs of students bullying policies and laws, school personnel training and involved in different-sex relationships or sexual activity. If advocacy, access to LGBTQ-related resources and curric- the risk for disease is presented only with reference to ula, and gay-straight alliance (GSA) school clubs (Russell penile-vaginal sexual behaviors, there may be deleterious et al. 2010). A number of studies show that these strategies consequences for the health of those who engage in same- are linked to adolescent academic achievement and mental sex relationships or sexual activity. For example, HPV and behavioral health (Blake et al. 2001; Goodenow et al. poses a threat to all male and female youth, including 2006; Poteat et al. 2013).Thus, a growing body of evidence cancer risk stemming from same- as well as different-sex points to principles for promoting adolescent health in sexual activity. However, if education only refers to het- ways that respect and include LGBTQ youth, and that erosexual vaginal transmission, youth may erroneously respond to known inequities many LGBTQ youth experi- conclude that HPV risk pertains only to heterosexual ence. These principles should inform the evidence base for vaginal sex. Such an approach would obscure other sexual federal sexual health education programs and policies. behaviors that pose risk for HPV, such as non-penetrative sexual contact, even though the prevalence of HPV among Gender and Sexual Health Education women who have never engaged in vaginal intercourse is high, as is the risk for anal cancer associated with HPV A second area in which current scientific thinking and among men who engage in receptive anal intercourse sexual health education policy and programs are not 123 J Youth Adolescence (2014) 43:1595–1610 1601 aligned concerns the impact of gender (in)equity and documented how schools, peer culture and other institu- gender norms. Research across disciplines has demon- tions overtly and covertly communicate distinct gender strated that gender norms and inequities are key factors in ideologies about sex and romance to young people shaping health generally, and sexual health in particular (Chambers et al. 2004; Eder et al. 1995; Fields 2008; (Rogow and Haberland 2005). International health orga- Pascoe 2007). Traditional gender ideologies frequently link nizations have recognized that promoting gender equity is masculinity with heterosexual sexual activity, sex drive, critical to advancing health across the life course (World sexual initiation, and lack of emotional involvement, and Health Organization 2002). Domestically, Healthy People femininity with sexual passivity, sexual restraint, respon- 2020 includes gender and gender identity as dimensions sibility for controlling boys’ desires, and emotional over- linked to health disparities—that is, systematic obstacles to involvement (Allen 2003; Bay-Cheng 2003). The sexual health—and it aspires to reduce those disparities. But in the double standard, which encourages and celebrates hetero- ‘‘Adolescent Health’’ section, the document is silent about sexual sexual experience in teenage boys but censures and the need to address gender inequities or harmful gender stigmatizes sexual experience in teenage girls, is endemic beliefs. Establishing gender equity and challenging gender in the United States, though it varies by local context and beliefs that research has shown to be harmful to adolescent culture (Crawford and Popp 2003; Greene and Faulkner sexual health have never been central goals in US adoles- 2005; Marston and King 2006). cent sexual health and education policy (DeLamater 2007). The sexual double standard harms girls by stigmatizing In fact, many abstinence-only and abstinence-only-until- their sexual desires and experiences, reducing their nego- marriage programs have taught gender stereotypes as facts tiating power within sexual encounters, and conditioning (Curran 2011; Delamater 2007; Fine and McClelland girls to believe that their own desires and wishes are less 2006). Even approaches that include information beyond significant than those of their male partners (Hamilton and abstinence have perpetuated gender inequities through Armstrong 2009; Holland et al. 1998; Martin 1996; Tolman gender stereotyping implicit in curricula or teachers’ 2002). Negative cultural beliefs about girls’ sexuality can informal communications (Curran 2011; Fields 2008; make it difficult for them to disclose their sexual histories Garcia 2009, 2012). to partners, parents, or adult care providers (Greene and It has long been established among researchers that Faulkner 2005; Schalet 2011a, b). Traditional gender roles gender inequities, and the gender ideologies that uphold can also hinder girls in refusing unwanted sex and insisting them, are key factors in shaping sexual and reproductive on condom use (Impett et al. 2006; Kirkman et al. 1998; health globally and domestically, affecting STIs, HIV/ Petitifor 2012). Possessing a sense of sexual self-efficacy— AIDS, unintended pregnancies, and sexual violence (Ro- a sense that one has power over one’s sexual decision gow and Haberland 2005; Santana et al. 2006). Scholars making—seems to be especially important in aiding girls to have documented how traditional gender roles impede engage in safer sex behaviors (Gutierrez et al. 2000; women’s sexual autonomy and self-efficacy, and thereby Pearson 2006). There is additional evidence to suggest that increase their vulnerability to STIs and HIV, intimate when girls know about, and feel entitled to, sexual plea- partner violence, unwanted sex, and unintended pregnancy sure, they are better able to advocate for themselves and (Amaro and Raj 2000; Amaro et al. 2001; Impett et al. their sexual health, leading scholars to call on sexual health 2006; Jewkes 2010; Phillips 2000). Gender-based rela- education to challenge the double standard and emphasize tional power imbalances impact women’s capacity to the value of girls’ desires and pleasure (Hirst 2013; Horne advocate for their own sexual safety (Phillips 2000; Ro- and Zimmerbeck 2006; Impett et al. 2006; Martin 1996; senthal and Levy 2010). For instance, compared to women Tolman 2002). who report low levels of relationship power, women with Boys are also disadvantaged by prevailing gender ide- higher levels are five times as likely to report consistent ologies. The sexual double standard can make it appear as condom use (Pulerwitz et al. 2002). Cultural beliefs about if boys should always desire sex, and never say no to sex, gender can also have negative health consequences for men even risky sex (Bowleg et al. 2000). The prevailing ide- by, for instance, encouraging risk behavior (Higgins et al. ologies stigmatize boys’ emotional vulnerabilities and 2010). needs, including their needs for intimate friendships and Gender ideologies shape how youth view and experi- romantic relationships, making them less prepared to have ence themselves and each other. Researchers have intimate relationships (Giordano et al. 2006; Way et al. 2013). They also stigmatize homosexuality and behaviors One of the goals in this section is to increase the proportion of associated with homosexuality (Kimmel 2008; Klein 2012; secondary schools that ‘‘prohibit harassment based on a student’s Pascoe 2007). Norms about appropriate male behavior sexual orientation or gender identity.’’ This goal is important but does affect all males. But those who adhere most to ‘‘tradi- not in itself encourage schools to promote gender equity or address tional’’ beliefs about masculinity—for instance, that men the effects of harmful gender beliefs in sexual health education. 123 1602 J Youth Adolescence (2014) 43:1595–1610 should be tough, have status in society, not behave in ways stereotyping in apparently gender-neutral exercises and marked as ‘‘feminine,’’ and regularly have heterosexual role plays (Bay-Cheng 2003; Curran 2011; Fields 2008). sex— are most at risk for negative consequences compared Unless harmful gender beliefs are explicitly addressed and to other boys and men. Those who embrace such traditional challenged, sexual health education runs the risk of attitudes toward masculinity tend to also report more sex- reinforcing those beliefs through the taken-for-granted ual partners, engage in more unprotected vaginal sex, and assumptions teachers and students bring into the class- show less self-efficacy and consistency in condom use room (Fields 2008; Garcia 2009, 2012; Froyum 2010). (Noar and Morokoff 2002; Pleck et al. 1993, 1994; Santana Yet, of the 35 designated (Tier 1) ‘‘evidence-based’’ et al. 2006; Shearer et al. 2005). programs, only a handful (all of which target youth of There is growing evidence that among adult men some color) even mention gender in their program description, masculine gender norms are linked to violence in intimate suggesting incorrectly that only minority groups contend relationships (Gallagher and Parrott 2011; Murnen et al. with harmful gender beliefs (Office of Adolescent Health 2002). For example, compared to other men, men who 2014a). The research record shows the advisability of report more traditional masculinity ideologies are more ensuring that all sexual health programs are free from likely to report having perpetrated violence or sexual harmful gender beliefs—which may be explicit or implicit coercion (Marın et al. 1997; Santana et al. 2006). Con- in the curricula—and include tools to help students versely, compared to less egalitarian men, men whose address and challenge these beliefs. gender role ideologies are more egalitarian report fewer instances of physical aggression against their intimate Poverty, Inequality, and Sexual Health Education partners (Fitzpatrick et al. 2004). Gender norms also shape young people’s capacities to resist, report, and recover Considerable literature has demonstrated that poverty and from sexual violation. Boys are unlikely to report sexual economic inequalities are fundamental barriers to positive coercion due to homophobia as well as masculinity norms youth development. Youth subject to these inequalities that emphasize male sexual desire and strength and have lower academic achievement, and are more likely to obfuscate boys’ capacity to be coerced or intimately vio- leave school early, thereby compounding cumulative lated (Bullock and Beckson 2011). For girls, the pressure to socioeconomic effects on health. Youth in poverty are also be normatively feminine (sexually passive, accommodat- more likely to engage in delinquent behavior, to become ing, ‘‘nice’’) can make resistance to unwanted sexual sexually active early, and to have elevated risk of STIs, advances difficult (Armstrong et al. 2006; Hamilton and unintended pregnancies, and non-marital births (Brooks- Armstrong 2009; Phillips 2000). The stigma around girls’ Gunn et al. 1997; Dinkelman et al. 2008; Duncan and sexuality also prevents many from seeking help, a barrier Rodgers 1988; Duncan et al. 2010; Grantham-McGregor that is heightened for low-income girls and girls of color et al. 2007). Youth in poverty also lack access to quality (Collins 2005; Froyum 2010). health services (National Research Council 2009). The In short, there is strong and consistent evidence that effects of persistent poverty are especially pernicious, gender beliefs and (in)equities shape sexual health (Ro- affecting socio-emotional development and health, and gow and Haberland 2005). However, until recently, these increasing the likelihood of enduring ill effects into areas have received very little attention in US adolescent adulthood. sexual health policy and programming (Grose et al. 2014; The deleterious effects of poverty are critical consider- Rolleri 2013a; Rolleri 2013b). There is no requirement for ations for adolescent health and development in the United federally-funded sexuality education to work toward States, where low-income students now comprise a near gender equity, avoid explicit or implicit gender stereo- majority of public school children in the United States. typing, or include modules that help students challenge About one in six of all youth and one in three African harmful gender beliefs. Abstinence-oriented programs American youth ages 12–17 live in families with incomes have often taught gender stereotypes as fact (DeLamater Without a systematic content analysis of these programs, it is 2007; Fine and McClelland 2006; Curran 2011). difficult to assess whether they merely mention gender or actively Approaches that include information beyond abstinence seek to change unhealthy gender norms. One tier 1, evidence-based can also perpetuate gender ideologies through the topics intervention that does the latter is SiHLE (Rolleri 2013a). Encour- they cover and leave out, or include implicit gender agingly, under its Tier 2 funding, the Office of Adolescent Health has funded Gender Matters, an ‘‘innovative gender transformative program,’’ noting that ‘‘addressing gender norms is essential to improving the health of teens, but often prevention programs leave One recent study of popular abstinence-only program content found out these discussions’’ (Office of Adolescent Health 2014b, p. 1). a softening of some older gender stereotypes alongside the emergence of new ones, including the manipulative female leading a male astray Defined by eligibility for the federal free and reduced-price meals (Lamb et al. 2013). program in the 2010–2011 school year; Suitts et al. 2013. 123 J Youth Adolescence (2014) 43:1595–1610 1603 below the official poverty level. In addition to the close sexism/heterosexism, that is, ‘‘macrolevel systems, social linkage between minority racial/ethnic status and poverty, forces, institutions, ideologies, and processes that interact there are major racial disparities in long-term exposure to with one another to generate and reinforce inequities neighborhood poverty. Analyses of data from the Panel among… groups’’ (Gee and Ford 2011; p. 116), normalizes Study of Income Dynamics indicate that 40 % of African and legitimizes unequal treatment and discrimination Americans experience sustained exposure to high-poverty Structural discrimination can take many forms, including neighborhoods, versus 5 % of non-Blacks (Wodtke 2013). social segregation (e.g., neighborhood, schools, health care The negative consequences of poverty are a function of facilities) and exclusionary immigration policy, and can the structural and experiential inequalities that typify the persist across generations through the cumulative effects of life contexts of impoverished youth. Poor youth are more interacting systems. For example, because of racial dis- likely to live in neighborhoods characterized by adverse crimination in the real estate industry African Americans physical and social environments, with higher rates of are considerably more likely to live in poor neighborhoods, crime and limited access to recreational facilities and after- even if economic resources would permit residing in non- school programs, and are more likely to attend lower poor neighborhoods (Iceland and Scopilliti 2008). quality schools with fewer resources (Murry et al. 2011). The Intersectionality Framework (see for example, They are also less likely to have access to mental and Weber and Parra-Medina 2003) proposes that characteris- physical health services. Exposure to poverty during ado- tics such as race, class and gender are not distinct social lescence may be especially important, given adolescents’ categories. They reflect multidimensional and overlapping expanding social world. Recent analyses suggest that sus- experiences that are a function of mutually reinforcing tained exposure to neighborhood poverty substantially social processes and institutions. The intersection of mi- increases the risk of becoming an adolescent parent, and crolevel identities and macrolevel structural factors can that exposure during adolescence may have a greater effect affect health by producing and sustaining economic than exposure earlier in childhood (Wodtke 2013). Further, inequality via groups’ access to social, economic, and poverty shapes sexual network structure, increasing the political resources and privileges. The effects of neigh- likelihood of STIs (Fichtenberg et al. 2010). These contexts borhood disadvantage on school dropout, for example, are mold adolescents’ sexual knowledge, perceptions about twice as large for African American youth versus their and access to contraception, and their hope for the future. White peers (Crowder and South 2003). Community pov- Poverty intersects with individual and structural char- erty levels also contribute to LGBT youth’s experiences in acteristics to generate significant health disparities, the school; youth in higher poverty communities report more cumulative health differences that result from obstacles victimization in school because of sexual orientation and gender expression than those in more affluent communities linked to factors such as race/ethnicity, gender, disability, sexual orientation, and gender identity. A recent review of (Kosciw et al. 2009). Poverty and racial segregation can health disparities in the United States (CDC 2013d) doc- also affect the sexual expectations and behavior of youth, umented persistent race/ethnicity disparities in health out- leading youth in these contexts to consider early sexual comes, access to health care, adoption of health promoting activity as normal and even expected. Youth in low income behavior, and exposure to health promoting environments, neighborhoods may not have access to educational and with no evidence of a temporal decrease between 2005 and occupational opportunities, and may view sexual activity as 2009. Documented disparities, beyond those related to a pathway to social status rather than an obstacle to sexual and reproductive health, include differences in socioeconomic achievement (Ramirez-Valles et al. 2002). chronic conditions such as asthma, diabetes and hyper- The intersections of poverty, inequality, structural dis- tension, as well as differences in mortality from causes crimination, and adolescent sexual and reproductive health such as coronary heart disease, stroke, drugs, homicide, are numerous. Sexual health education exists within a suicide, and vehicle related injuries (CDC 2013d). variety of structural and social contexts (Fine and McC- Thus, the adverse impact of poverty is compounded by lelland 2006). Sexuality affects, and is affected by, com- racism, sexism, heterosexism, and discrimination against plex interactions between individual biopsychosocial individuals with disabilities. These prejudicial belief sys- factors and a host of economic, political and cultural fac- tems reflect irrational biases toward members of a certain tors. Sexuality and sexual rights are thus interwoven with race, biological sex, sexual orientation, gender identity, or broader human rights and the sociopolitical issues that level of ability on the basis that a certain group is ‘‘supe- affect those rights, such as economic inequality and rior/inferior’’ or ‘‘normal/abnormal.’’ Structural racism/ structural racism. Approaching adolescent sexual health with an eye toward poverty and its intersections with diverse social identities means attention to not only mate- More than one in three of all young people, 12–17, live in ‘‘near- rial deprivation but also to social and political exclusion poverty’’ (often considered a more accurate measure). 123 1604 J Youth Adolescence (2014) 43:1595–1610 and restrictions on rights, including sexual rights (Armas implementation of poverty alleviation. In the late 1950s 2007), that are linked to behavior. Poverty limits knowl- 22 % of US residents lived in poverty; after the launch of edge about and access to sexual and reproductive health the War on Poverty in the 1960s, that percentage had services, constrains positive sexual expression and feelings dropped to 11 % by 1973 (Council of Economic Advisors of self-efficacy, and makes disadvantaged youth vulnerable 2014). Changes were even more drastic among the elderly, to sexual exploitation and violence. This is why the who once had the country’s highest poverty rates, but experience of poverty is associated with greater sexual whose chances of living in poverty have been sharply risk-taking (e.g., early sexual onset, multiple sexual part- reduced through programs such as Social Security and nerships, lack of condom use) in both the United States and Medicare (Fischer et al. 1996). global contexts (Brooks-Gunn et al. 1997; Dodoo et al. Today, the poverty rate of US children and teens is among 2007; Duncan and Rodgers 1988). the highest in the industrial world. Given the pervasive det- US policy makers must understand and address the rimental effects on youth development, poverty alleviation importance of poverty’s complex intersections with diverse programs are vital to improving adolescent sexual and identities and the impact on how youth respond to sexuality reproductive health. Indeed, comparing across five devel- education. Sexual health education paradigms and curricula oped nations, where rates of sexual activity among youth often assume adolescents are in school and that they live in were similar, Singh and colleagues report a strong associa- homogeneous social and physical environments free of tion between the higher US teen birth rate and the greater economic or other social barriers. Sexuality education may proportion of teens who grow up poor (Singh et al. 2001). Yet explicitly or inadvertently reinforce cultural stereotypes there is strong evidence that structural interventions can both about young people of color, who are more likely to be directly and indirectly improve adolescent health, and that poor, as sexually irresponsible (Fine and McClelland 2006; large-scale implementation is both feasible and successful Fields 2008; Garcia 2009, 2012). Similarly, sexual health (Snell et al. 2013). In many European, Latin American, and education may presume ‘‘proper’’ relationships and family African countries, governments offer a variety of income forms that are less common among low income youth or supplements, especially to families with children. Singh youth of color. With few economic opportunities and et al. (2001) point toward policies that are likely to affect resources to develop positive sexual identities, low income adolescent sexual and reproductive health specifically, or minority youth may rely on rigid, exclusionary, and including national health care systems and government ultimately counterproductive frameworks to assert self- investment in job training and opportunities for young peo- and group-worth (Froyum 2007). Failure to recognize ple, easing the transition into adulthood, facilitating long- erroneous assumptions and the lived reality of youth can term planning, and reducing the motivation to have a child prematurely. The authors conclude ‘‘improving adolescents’ lead to unintended effects on adolescent sexuality, pro- moting exclusion of teens who do not conform to expected socioeconomic status is a way to prevent their having poor gender and sexual norms and ultimately failing to reduce reproductive health outcomes—not only unplanned or early inequality (Bedford 2008; Drucker 2009). Sexual health pregnancies or births, but also STDs’’ (p. 258). education must thus recognize the diverse life course tra- Policy makers should heed lessons learned from our jectories and family formations that characterize students’ country’s success in reducing poverty among the elderly, lives. In addition, scholars have argued, sexual health and from other countries’ successes in better promoting education must create opportunities for students to discuss adolescent sexual and reproductive health by investing in sexual agency and risks in the context of their broader life multi-faceted and multi-level poverty alleviation efforts aspirations and the multifold factors that constraints those that build youth assets and promote health. For individual aspirations (Fields 2008; Fine and McClelland 2006; Ro- adolescents, efforts are needed to enhance adolescents’ gow and Haberland 2005). Although sexual health educa- motivation for personal and professional achievement (e.g., tion cannot remove the structural disparities, by giving healthy interpersonal relationships, education and occupa- young people the opportunity to critically examine the tion), and avoid behaviors that increase risks of STIs, poor inequalities they encounter, it can bolster their ability to emotional and physical health, and early pregnancy and respond to them. childbearing. We also need to target structural barriers Policy makers must also promote adolescent sexual and created by economic, racial and ethnic inequalities (e.g., reproductive health by investing in youth through multi- increase resources for high-poverty schools), and offer faceted and multi-level poverty alleviation efforts that support services to help families and their children (e.g., build youth assets and promote health. Despite frequently adequate funding for Title X family planning clinics) as voiced concerns about the intractable nature of poverty they move toward better financial security, without predi- (and by extension, hopelessness), the United States has a cation of assistance on particular family structures that may track record of intentional and effective large-scale not be feasible for or desired by all individuals. 123 J Youth Adolescence (2014) 43:1595–1610 1605 Conclusions and Recommendations Based on these considerations, we offer several recom- mendations for federal sexual health education policy, as US federal sexual health policy has come a long way since well as for more effective translation of science into poli- the introduction of AOUM policies when federally funded cymaking and programming. First, adolescent sexual and programs were often medically inaccurate, were prohibited reproductive health policy should be based on scientific from teaching the health benefits of condoms and contra- input from a broad range of disciplines, including social, ception, and were required to teach students that sex outside behavioral, medical, and public health sciences. The full of heterosexual marriage would damage them. In providing range of scientific evidence should guide adolescent sexual our critique we acknowledge the strides that have been and reproductive health policies, including adolescent made in current federal policies and initiatives, and we also sexual health education. Federally-funded programs must acknowledge that US sexual health education programs and address gender, poverty, and lesbian, gay, bisexual, trans- policies exist in a cultural and political context that is not gender, queer, and questioning (LGBTQ) youth. Federal fully conducive to holistic approaches to adolescent sexual policy makers should engage in conversation with the health education, or to the full range of contemporary sci- broad range of scientific communities and professional ence in this field. The current ‘‘evidence-based’’ policy, societies. Policy makers and federal program administra- while a significant leap forward, is limited in a number of tors must draw on scientific advisors to help translate the ways. The US federal policy continues to fund abstinence- broader evidence base, and guide the development of only programs as part of its Teen Pregnancy Prevention interventions that reflect current scientific thinking. Fur- Initiative as well as other funding streams. But more ther, scientists must become actively engaged in the important, the definition of scientific evidence is limited to a translation of their work for policy and practice. narrow understanding of what constitutes the broad scien- Second, sexual health education should be inclusive of tific evidence for adolescent sexual and reproductive health. a wide range of viewpoints and populations without The current policy does not require programs to be engaged stigmatizing any group. It should avoid heteronormative with the breadth of current scientific thinking about ado- approaches and aim to strengthen young people’s capacity lescents and their sexual health. to challenge harmful stereotypes. In cooperation with We have sought to highlight the limitations of EBIs by scientists and health professional associations, content examining three bodies of literature on topics about which guidelines should be established for federally-funded there is growing scientific consensus. This evidence indi- sexuality education programs to assure medical accuracy cates that adolescent sexual health is undermined by the as well as gender equity and inclusion of LGBTQ youth. exclusion and stigmatization of LGBTQ youth, gender This should be a priority across federal agencies and inequities and stereotypes, and poverty and structural rac- throughout the Department of Health and Human Ser- ism. Likewise, the research shows that greater inclusive- vices, including the CDC, Administration for Children ness, more gender and economic equity, and freedom from and Families, and the Office of Adolescent Health (in harmful stereotypes, all benefit young people and their particular, in its next round of teen pregnancy prevention sexual health. And yet, although there are some excellent programs). programs that approach adolescent sexuality holistically Finally, sexuality education programs and policies must (see for instance, International Sexuality and HIV Curric- acknowledge the role that structural and contextual factors ulum Working Group 2011), federal policy does not play in sexual risk. Comprehensive sexuality education require its recipients of funds to address these critical should recognize personal, interpersonal, social, economic topics, and indeed very few federally funded programs do. and cultural factors that shape adolescents’ sexual moti- When federally funded sexual health education does not vations and behaviors. A fundamental goal must be the intentionally address these topics, it may overtly or inad- removal of economic, gender and LGBTQ disparities in vertently promulgate gender, sexual orientation, class, and adolescent sexual and reproductive health through laws, racial stereotyping, and fail to give youth resources to regulations, and funding requirements. combat them. Gender, heterosexual, economic and racial Structural inequalities that are critical barriers to ado- biases in sexual health education leave youth without the lescent sexual health promotion are at the heart of some of personal agency and the critical knowledge they need to the most contested issues in American society: the sexual make safer sexual choices. orientation of adolescents, concepts of gender, and eco- nomic and racial inequalities. When federally funded health interventions do not engage directly with these Encouragingly, the federal government has, under its tier 2 funding issues, and thus ignore the broader scientific consensus for experimental programs, supported program development and regarding adolescent sexual and reproductive health, they evaluation in some of research areas we have highlighted, including a run the risk of reproducing these inequalities (Fine and program to address and change harmful gender beliefs. 123 1606 J Youth Adolescence (2014) 43:1595–1610 Bay-Cheng, L. Y. (2003). The trouble of teen sex: The construction of McClelland 2006). By incorporating the full range of sci- adolescent sexuality through school-based sexuality education. entific evidence regarding adolescent sexual and repro- Sex Education: Sexuality, Society and Learning, 3(1), 61–74. ductive health, federal, state, and local efforts will be best Bedford, K. (2008). Holding it together in a crisis: Family strength- positioned to promote adolescent health and well-being. ening and embedding neoliberalism. IDS Bulletin, 39(6), 60–66. Birkett, M., Espelage, D. L., & Koenig, B. (2009). LGB and questioning students in schools: The moderating effects of Acknowledgments This paper began as a series of conversations homophobic bullying and school climate on negative outcomes. about the role of science in sexuality education and adolescent health Journal of Youth and Adolescence, 38(7), 989–1000. policy among the four primary authors and leaders of the Future of Blake, S. M., Ledsky, R., Lehman, T., Goodenow, C., Sawyer, R., & Sex Education group. We thank our insightful colleagues who Hack, T. (2001). Preventing sexual risk behaviors among gay, reviewed various drafts and provided invaluable insights, including lesbian, and bisexual adolescents: The benefits of gay-sensitive Heather Boonstra, Jesseca Boyer, Kurt Conklin, Nicole Cushman, HIV instruction in schools. American Journal of Public Health, Jessica Fields, Debra Hauser, Barbara Huberman, Leslie M. Kantor, 91(6), 940–946. Arik V. Marcell, Ann Meier, Anthony Paik, Pat Paluzzi, Monica Bowleg, L., Belgrave, F. Z., & Reisen, C. A. (2000). Gender roles, Rodriguez, Elizabeth Schroeder, and Danene Sorace, as well as the power strategies, and precautionary sexual self-efficacy: Impli- JYA Editor and anonymous peer reviewers. We acknowledge modest cations for Black and Latina women’s HIV/AIDS protective stipends from the Future of Sex Education to the four junior authors, behaviors. Sex roles, 42(7–8), 613–635. and additional support from the Frances McClelland Institute for Brooks-Gunn, J., Duncan, G. J., & Aber, J. L. (1997). Neighborhood Children, Youth, and Families at the University of Arizona for open poverty. Context and consequences for children (Vol. 1). New access to this article. York: Russell Sage Foundation. Bullock, C. M., & Beckson, M. (2011). Male victims of sexual Open Access This article is distributed under the terms of the assault: Phenomenology, psychology, physiology. Journal of the Creative Commons Attribution License which permits any use, dis- American Academy of Psychiatry and the Law Online, 39(2), tribution, and reproduction in any medium, provided the original 197–205. author(s) and the source are credited. Carter, J. B. (2001). Birds, bees, and venereal disease: toward an intellectual history of sex education. Journal of the History of Sexuality, 10(2), 213–249. References Center for School, Health, and Education. (2011). The health, well- being and educational success of school-aged youth and school- based health care. Retrieved from http://www.schoolbasedhealth Allen, L. (2003). Girls want sex, boys want love: Resisting dominant care.org/wp-content/uploads/2011/09/APHA4_article_Health_Rev_ discourses of (hetero)sexuality. Sexualities, 6, 215–236. 9_14_FINAL2.pdf. Almeida, J., Johnson, R. M., Corliss, H. L., Molnar, B. E., & Azrael, Centers for Disease Control and Prevention. (2006). Physical dating D. (2009). Emotional distress among LGBT youth: The influence violence among high school students—United States, 2003. of perceived discrimination based on sexual orientation. Journal Morbidity and Mortality Weekly Report, 55(19), 529–552. of Youth and Adolescence, 38(7), 1001–1014. Centers for Disease Control and Prevention. (2011). HIV among Amaro, H., & Raj, A. (2000). On the margin: Power and women’s youth. Retrieved from http://www.cdc.gov/hiv/pdf/library_fact HIV risk reduction strategies. Sex Roles, 42(7–8), 723–749. sheet_HIV_amongYouth.pdf. Amaro, H., Raj, A., & Reed, E. (2001). Women’s sexual health: the Centers for Disease Control and Prevention. (2012a). Vital signs: HIV need for feminist analyses in public health in the decade of infection, testing, and risk behaviors among youth—United behavior. Psychology of Women Quarterly, 25(4), 324–334. States. Morbidity and Mortality Weekly Report, 61(47), American Academy of Pediatrics: Committee on Psychosocial 971–976. Aspects of Child and Family Health and Committee on Centers for Disease Control and Prevention. (2012b). Estimated HIV Adolescence. (2001). Sexuality education for children and incidence in the United States, 2007–2010. HIV Surveillance adolescents. Pediatrics, 108(2), 498–502. Supplemental Report 17 (No. 4). Retrieved from http://www.cdc. American Civil Liberties Union. (2008). What the research shows: gov/hiv/topics/surveillance/resources/reports/#supplemental. Government-funded abstinence-only programs don’t make the Centers for Disease Control and Prevention. (2013a). Incidence, grade. American Civil Liberties Union. Retrieved from https://www. Prevalence, and Cost of Sexually Transmitted Infections in the aclu.org/reproductive-freedom/what-research-shows-government- United States. Retrieved from http://www.cdc.gov/std/stats/sti- funded-abstinence-only-programs-don%E2%80%99t-make-grade. estimates-fact-sheet-feb-2013.pdf. American Public Health Association. (2006). Abstinence and U.S. Centers for Disease Control and Prevention. (2013b). CDC Health abstinence-only education policies: Ethical and human rights Disparities and Inequalities Report—United States. 2013. Mor- concerns. (Policy Statement 200610). Retrieved from http://www. bidity and Mortality Weekly Report, 62(Suppl 3), 1–187. apha.org/advocacy/policy/policysearch/default.htm?id=1334. Centers for Disease Control and Prevention. (2013b). Results from the Anderson, L. M., Brownson, R. C., Fullilove, M. T., Teutsch, S. M., School Health Policies and Practices Study 2012. Retrieved from Novick, L. F., Fielding, J., et al. (2005). Evidence-based public http://www.cdc.gov/healthyyouth/shpps/2012/pdf/shpps-results_ health policy and practice: Promises and limits. American 2012.pdf. Journal of Preventive Medicine, 28(5S), 226–230. Centers for Disease Control and Prevention. (2013c). Compendium of Armas, H. (2007). Whose sexuality counts? Poverty, participation, Evidence-Based HIV Behavioral Interventions. Retrieved from and sexual rights (Working Paper No. 294). Institute of http://www.cdc.gov/hiv/prevention/research/compendium/index. Development Studies at the University of Sussex. Retrieved html. from http://www2.ids.ac.uk/gdr/cfs/pdfs/Wp306.pdf. Chambers, D., Tincknell, E., & Van Loon, J. (2004). Peer regulation Armstrong, E. A., Hamilton, L., & Sweeney, B. (2006). Sexual assault of teenage sexual identities. Gender and Education, 16(3), on campus: A multilevel, integrative approach to party rape. 397–415. Social Problems, 53(4), 483–499. 123 J Youth Adolescence (2014) 43:1595–1610 1607 Chin, H. B., Sipe, T. A., Elder, R., Mercer, S. L., Chattopadhyay, S. Fitzpatrick, M. K., Salgado, D. M., Suvak, M. K., King, L. A., & K., Jacob, V., et al. (2012). The effectiveness of group-based King, D. W. (2004). Associations of gender and gender-role comprehensive risk-reduction and abstinence education inter- ideology with behavioral and attitudinal features of intimate ventions to prevent or reduce the risk of adolescent pregnancy, partner aggression. Psychology of Men & Masculinity, 5, human immunodeficiency virus, and sexually transmitted infec- 91–102. tions: Two systematic reviews for the guide to community Floyd, F. J., & Bakeman, R. (2006). Coming-out across the life preventive services. American Journal of Preventive Medicine, course: Implications of age and historical context. Archives of 42(3), 272–294. Sexual Behavior, 35(3), 287–296. Cianciotto, J., & Cahill, S. R. (2003). Education policy: Issues Froyum, C. M. (2007). ‘At Least I’m Not Gay’: Heterosexual identity affecting lesbian, gay, bisexual and transgender youth. National making among poor black teens. Sexualities, 10(5), 603–622. Gay and Lesbian Task Force Policy Institute. Washington, DC. Froyum, C. M. (2010). Making ‘good girls’: Sexual agency in the Collins, P. (2005). Black sexual politics: African Americans, gender, sexuality education of low income black girls. Culture, Health and the new racism (New Ed edition.). New York: Routledge. and Sexuality, 12(1), 59–72. Council of Economic Advisers. (2014). The war on poverty 50 years Gallagher, K. E., & Parrott, D. J. (2011). What accounts for men’s later: A progress report. Retrieved from http://www.whitehouse. hostile attitudes toward women? The influence of hegemonic gov/sites/default/files/docs/50th_anniversary_cea_report_-_final_ male role norms and masculine gender role stress. Violence post_embargo.pdf. against women, 17(5), 568–583. Crawford, M., & Popp, D. (2003). Sexual double standards: A review Garcia, L. (2009). ‘‘Now why do you want to know about that?’’ and methodological critique of two decades of research. Journal Heteronormativity, sexism, and racism in the sexual (mis) of Sex Research, 40(1), 13–26. education of Latina youth. Gender & Society, 23(4), 520–541. Crowder, K., & South, S. J. (2003). Neighborhood distress and school Garcia, L. (2012). Respect yourself, protect yourself: Latina girls and dropout: The variable significance of community context. Social sexual identity. New York: NYU Press. Science Research, 32, 659–698. Gee, G. C., & Ford, C. L. (2011). Structural racism and health Curran, L. B. (2011). What’s missing? Discourses of gender and inequities: Old issues, new directions. Du Bois Review, 8(1), sexuality in federally-funded sex education. The George Wash- 115–132. ington University. Retrieved from http://gradworks.umi.com/34/ Giordano, P. C., Manning, W. D., & Longmore, M. A. (2006). Gender 68/3468516.html. and the meanings of adolescent romantic relationships: A focus DeLamater, J. (2007). Gender equity in formal sexuality education. In on boys. American Sociological Review, 71(2), 260–287. S. S. Klein, et al. (Eds.), Handbook for achieving gender equity Goodenow, C., Szalacha, L., & Westheimer, K. (2006). School through education (pp. 411–420). New York: Routledge. support groups, other school factors, and the safety of sexual Dinkelman, T., Lam, D., & Leibbrandt, M. (2008). Linking poverty minority adolescents. Psychology in the Schools, 43(5), and income shocks to risky sexual behaviour: Evidence from a 573–589. panel study of young adults in Cape Town. South African Grantham-McGregor, S., Cheung, Y. B., Cueto, S., Glewwe, P., Journal of Economics, 76(s1), S52–S74. Richter, L., & Strupp, B. (2007). Developmental potential in the Dodoo, F., Zulu, E. M., & Ezeh, A. C. (2007). Urban–rural first 5 years for children in developing countries. Lancet, differences in the socioeconomic deprivation—Sexual behavior 369(9555), 60–70. link in Kenya. Social Science and Medicine, 64(5), 1019–1031. Greene, K., & Faulkner, S. (2005). Gender, belief in the sexual double Drucker, P. (2009). Changing families and communities: An LGBT standard, and sexual talk in heterosexual dating relationships. contribution to an alternative development path. Development in Sex Roles, 53(3/4), 239–251. Practice, 19(7), 825–836. Grose, R. G., Grabe, S., & Kohfeldt, D. (2014). Sexual education, Duncan, G. J., & Rodgers, W. L. (1988). Longitudinal aspects of gender ideology, and youth sexual empowerment. Journal of Sex childhood poverty. Journal of Marriage and the Family, 50(4), Research, 51(7), 742–753. 1007. Gutierrez, L., Oh, H. J., & Gillmore, M. R. (2000). Toward an Duncan, G. J., Ziol-Guest, K. M., & Kalil, A. (2010). Early-childhood understanding of (em)power(ment) for HIV/AIDS prevention poverty and adult attainment, behavior, and health. Child with adolescent women. Sex Roles, 42(7/8), 581–611. Development, 81(1), 306–325. Guttmacher Institute. (2013). Sex and HIV education, state policies in Eder, D., Evans, C. C., & Parker, S. (1995). School talk: Gender and brief. Retrieved from http://www.guttmacher.org/statecenter/ adolescent culture. New Brunswick, NJ: Rutgers University spibs/spib_SE.pdf. Accessed July 5, 2013. Press. Halpern, C. T., & Haydon, A. (2012). Sexual timetables for oral- Evidence Based Intervention Network. (2011). What are evidence genital, vaginal, and anal sex: Sociodemographic comparisons in based interventions (EBI)? Retrieved from: http://ebi.missouri. a nationally representative sample. American Journal of Public edu/?page_id=52. Health, 102(6), 1221–1228. Fichtenberg, C. M., Jennings, J. M., Glass, T. A., & Ellen, J. M. Hamilton, L., & Armstrong, E. (2009). Gendered sexuality in young (2010). Neighborhood socioeconomic environment and sexual adulthood: Double binds and flawed options. Gender and network position. Journal of Urban Health-Bulletin of the New Society, 23(5), 589–616. York Academy of Medicine, 87(2), 225–235. Higgins, J., Hoffman, S., & Dworkin, S. (2010). Rethinking gender, Fields, J. (2008). Risky lessons: Sex education and social inequality. heterosexual men, and women’s vulnerability to HIV/AIDS. New Brunswick, NJ: Rutgers University Press. American Journal of Public Health, 100(3), 435–445. Fine, M., & McClelland, S. I. (2006). Sexuality education and desire: Hirst, J. (2013). It’s got to be about enjoying yourself: Young people, Still missing after all these years. Harvard Educational Review, sexual pleasure, and sex and relationships education. Sex 76(3), 297–338. Education, 13(4), 423–436. Finer, L. (2007). Trends in premarital sex in the United States, Holland, J., Ramazanglou, C., Sharpe, S., & Thomson, R. (1998). The 1954–2003. Public Health Reports, 122(1), 73–78. male in the head: Young people, heterosexuality and power (p. Fischer, C. S., Jankowski, M. S., Hout, M., Lucas, S. R., Swidler, A., 1998). London: Tufnell Press. & Voss, K. (1996). Inequality by design: Cracking the bell curve Iceland, J., & Scopilliti, M. (2008). Immigrant residential segregation myth. Princeton, NJ: Princeton University Press. in US metropolitan areas, 1990–2000. Demography, 45, 79–94. 123 1608 J Youth Adolescence (2014) 43:1595–1610 Impett, E. A., Schooler, D., & Tolman, D. L. (2006). To be seen and Morris, E. W. (2007). ‘‘Ladies’’ or ‘‘loudies’’? Perceptions and not heard: Femininity ideology and adolescent girls’ sexual experiences of black girls in classrooms. Youth & Society, 38(4), health. Archives of Sexual Behavior, 35(2), 129–142. 490–515. International Sexuality and HIV Curriculum Working Group. (2011). Murnen, S., Wright, C., & Kaluzny, G. (2002). If ‘‘boys will be It s All one curriculum: Guidelines and activities for a unified boys’’, then girls will be victims? A meta-analytic review of the approach to sexuality, gender, HIV, and human rights. New York: research that relates masculine ideology to sexual aggression. Population Council. Retrieved from http://www.itsallone.org. Sex Roles, 46(11/12), 359–375. Irvine, J. M. (2004). Talk about sex: The battles over sex education in Murry, V. M., Heflinger, C. A., Suiter, S. V., & Brody, G. H. the United States. Oakland: University of California Press. (2011). Examining perceptions about mental health care and Jewkes, R. (2010). Gender inequities must be addressed in HIV help-seeking among rural African American families of prevention. Science, 329(5988), 145–147. adolescents. Journal of Youth and Adolescence, 40(9), Kimmel, M. (2008). Guyland: The perilous world where boys become 1118–1131. men. New York: Harper. Mustanski, B. S., Newcomb, M. E., Du Bois, S. N., Garcia, S. C., & Kirby, D. B. (2002). Effective approaches to reducing adolescent Grov, C. (2011). HIV in young men who have sex with men: A unprotected sex, pregnancy, and childbearing. Journal of sex review of epidemiology, risk and protective factors, and research, 39(1), 51–57. interventions. Journal of Sex Research, 48(2–3), 218–253. Kirby, D. B. (2008). The impact of abstinence and comprehensive sex National Center for Education Statistics. (2013). Back to school and STD/HIV education programs on adolescent sexual behav- statistics. Retrieved from http://nces.ed.gov/fastfacts/display. ior. Sexuality Research & Social Policy, 5(3), 18–27. asp?id=372. Kirby, D. B., Laris, B. A., & Rolleri, L. A. (2007a). Sex and HIV National Research Council. (2009). Adolescent health services: education programs: Their impact on sexual behaviors of young Missing opportunities. Washington, DC: The National Acade- people throughout the world. Journal of Adolescent Health, 40, mies Press. 206–217. National Research Council. (2013). U.S. Health in international Kirby, D. B., Rolleri, L., & Wilson, M. (2007b). Tool to assess the perspective: Shorter lives, poorer health. Washington, DC: characteristics of effective sex and STD/HIV education pro- National Academy Press. grams. Washington, DC: Healthy Teen Network. Noar, S. M., & Morokoff, P. J. (2002). The relationship between Kirkman, M., Rosenthal, D., & Smith, A. M. (1998). Adolescent sex masculinity ideology, condom attitudes, and condom use stage and the romantic narrative: Why some young heterosexuals use of change: A structural equation modeling approach. Interna- condoms to prevent pregnancy but not disease. Psychology, tional Journal of Men’s Health, 1(1), 43–58. Health & Medicine, 3(4), 355–370. Office of Adolescent Health. (2014a). Teen Pregnancy Prevention Klein, J. (2012). The bully society: School shootings and the crisis of Resource Center: Evidence-based programs database. Rockville, bullying in America’s schools. New York: NYU Press. MD: Department of Health and Human Services. Retrieved from Kosciw, J. G., Greytak, E. A., Bartkiewicz, M. J., Boesen, M. J., & http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/db/ Palmer, N. A. (2012). The 2011 National School Climate Survey: tpp-searchable.html. The experiences of lesbian, gay, bisexual and transgender youth Office of Adolescent Health. (2014b). Success story: Engender in our nation’s schools. New York: Gay, Lesbian and Straight health- gender matters: Changing teen’s perspective on gender Education Network (GLSEN). roles and working to decrease teen pregnancy in Travis County, Kosciw, J. G., Greytak, E. A., & Diaz, E. M. (2009). Who, what, Texas. Rockville, MD: Department of Health and Human where, when, and why: Demographic and ecological factors Services. Retrieved from http://www.hhs.gov/ash/oah/oah-initia contributing to hostile school climate for lesbian, gay, bisexual, tives/teen_pregnancy/successes/print/engenderhealth.pdf. and transgender youth. Journal of Youth and Adolescence, 38, Pascoe, C. J. (2007). Dude you’re a fag: Masculinity and sexuality in 976–988. high school. Berkeley, CA: University of California Press. Lamb, S., Lustig, K., & Graling, K. (2013). The use and misuse of Pearson, J. (2006). Personal control, self-efficacy in sexual negoti- pleasure in sex education curricula. Sex Education: Sexuality, ation, and contraceptive risk among adolescents: The role of Society and Learning, 13(3), 305–318. gender. Sex Roles, 54(9–10), 615–625. Luker, K. (2007). When sex goes to school: Warring views of sex—and Petitifor, A. (2012). ‘If I buy the Kellogg’s then he should [buy] the sex education—since the sixties. New York: W.W. Norton & Co. milk’: Young women’s perspectives on relationship dynamics, Marı ´n, B. V., Go ´ mez, C. A., Tschann, J. M., & Gregorich, S. E. gender power and HIV risk in Johannesburg, South Africa. (1997). Condom use in unmarried Latino men: A test of cultural Culture, Health and Sexuality, 14(5), 477–490. constructs. Health Psychology, 16(5), 458. Phillips, L. (2000). Flirting with danger: Young women’s reflections Marston, C., & King, E. (2006). Factors that shape young people’s on sexuality and domination. New York: NYU Press. sexual behaviour: A systematic review. The Lancet, 368(9547), Pleck, J. H., Sonenstein, F. L., & Ku, L. C. (1993). Masculinity 1581–1586. ideology: Its impact on adolescent males’ heterosexual relation- Martin, K. (1996). Puberty, sexuality and the self: Girls and boys at ships. Journal of Social Issues, 49(3), 11–29. adolescence. New York: Routledge. Pleck, J. H., Sonenstein, F. L., & Ku, L. C. (1994). Attitudes toward Mayer, K. H., Bradford, J. B., Makadon, H. J., Stall, R., Goldhammer, male roles among adolescent males: A discriminant validity H., & Landers, S. (2008). Sexual and gender minority health: analysis. Sex roles, 30(7–8), 481–501. What we know and what needs to be done. American Journal of Poteat, V. P., Sinclair, K. O., DiGiovanni, C. D., Koenig, B. W., & Public Health, 98(6), 989–995. Russell, S. T. (2013). Gay-straight alliances are associated with McGovern, A. E. (2012). When schools refuse to ‘‘say gay’’: The student health: A multischool comparison of LGBTQ and constitutionality of anti-LGBTQ ‘‘no promo-homo’’ public Heterosexual Youth. Journal of Research on Adolescence, school policies in the United States. Cornell Journal of Law 23(2), 319–330. and Public Policy, 22(2), 465–490. Pulerwitz, J., Amaro, H., Jong, W. D., Gortmaker, S. L., & Rudd, R. Moran, J. P. (2002). Teaching sex: The shaping of adolescence in the (2002). Relationship power, condom use and HIV risk among 20th century. Cambridge, MA: Harvard University Press. women in the USA. AIDS care, 14(6), 789–800. 123 J Youth Adolescence (2014) 43:1595–1610 1609 Ramirez-Valles, J., Zimmerman, M. A., & Juarez, L. (2002). Gender Singh, S., Darroch, J., & Frost, J. (2001). Socioeconomic disadvan- differences of neighborhood and social control processes: A study tage and adolescent women’s sexual and reproductive behavior: of the timing of first intercourse among low-achieving, urban, The case of five developed countries. Family Planning Perspec- African American youth. Youth and Society, 33(3), 418–441. tives, 33(6), 251–289. Resnick, M. D., Catalano, R. F., Sawyer, S. M., Viner, R., & Patton, Snell, E. K., Castells, N., Duncan, G., Gennetian, L., Magnuson, K., G. C. (2012). Seizing the opportunities of adolescent health. The & Morris, P. (2013). Promoting the positive development of Lancet, 379(9826), 1564–1567. boys in high-poverty neighborhoods: Evidence from four anti- Rogow, D., & Haberland, N. (2005). Sexuality and relationships poverty experiments. Journal of Research on Adolescence, education: Toward a social studies approach. Sex Education: 23(2), 357–374. Sexuality, Society and Learning, 5(4), 333–344. Suitts, S., Sabree, N., & Dunn, K. (2013). A new majority: Low Rolleri, L. A. (2013a). Can gender norms change? Research facts and income students in the South and Nation. Southern Education findings. Ithaca, NY: ACT for Youth. Foundation. Retrieved from http://www.southerneducation.org/ Rolleri, L. A. (2013b). gender norms and sexual health behaviors. getattachment/0bc70ce1-d375-4ff6-8340-f9b3452ee088/A-New- Research facts and findings. Ithaca, NY: ACT for Youth. Majority-Low-Income-Students-in-the-South-an.aspx. Romero, L. M., Galbraith, J. S., Wilson-Williams, L., & Gloppen, K. Tolman, D. L. (2002). Dilemmas of desire: teenage girls talk about M. (2011). HIV prevention among African American youth: sexuality. Cambridge, MA: Harvard University Press. How well have evidence-based interventions addressed key Trenholm, C., Devaney, B., Fortson, K., Clark, M., Quay, L., & theoretical constructs? AIDS and Behavior, 15(5), 976–991. Wheeler, J. (2008). Impacts of abstinence education on teen Rose, S. (2005). Going too far? Sex, sin and social policy. Social sexual activity, risk of pregnancy, and risk of sexually transmit- Forces, 84, 1207–1232. ted diseases. Journal of Policy Analysis and Management, 27(2), Rosenthal, L., & Levy, S. R. (2010). Understanding women’s risk for 255–276. HIV infection using social dominance theory and the four bases UNESCO. 2009. International technical guidance on sexuality of gendered power. Psychology of Women Quarterly, 34(1), education: An evidence-informed approach for schools, teachers 21–35. and health educators. Paris, France. Russell, S. T. (2005). Conceptualizing positive adolescent sexuality Way, N., Pascoe, C. J., Mccormack, M., Schalet, A., & Oeur, F. development. Sexuality Research and Social Policy., 2(3), 4–12. (2013). The hearts of boys. Contexts, 12(1), 14–23. Russell, S. T., Kosciw, J., Horn, S., & Saewyc, E. M. (2010). Safe Weber, L., & Parra-Medina, D. (2003). Intersectionality and schools policy for LGBTQ students. SRCD Policy Report, 24(4), women’s health: Charting a path to eliminating health dispar- 1–17. ities. In M. T. Segal & D. V. Kronenfeld (Eds.), Gender Saewyc, E. M., Bearinger, L. H., Blum, R. W., & Resnick, M. D. Perspectives on Health and Medicine (Advances in Gender (1999). Sexual intercourse, abuse and pregnancy among adoles- Research (Vol. 7, pp. 181–230). Bingley, UK: Emerald Group cent women: Does sexual orientation make a difference? Family Publishing. Planning Perspectives, 31(3), 127–131. Weinstock, H., Berman, S., & Cates, W. (2004). Sexually transmitted Saewyc, E. M., Homma, Y., Skay, C. L., Bearinger, L. H., Resnick, diseases among American youth: Incidence and prevalence M. D., & Reis, E. (2009). Protective factors in the lives of estimates, 2000. Perspectives on sexual and reproductive health, bisexual adolescents in North America. American Journal of 36(1), 6–10. Public Health, 99(1), 110–117. Wodtke, G. T. (2013). Duration and timing of exposure to neighbor- Sanchez, M. (2012). Providing inclusive sex education in schools will hood poverty and the risk of adolescent parenthood. Demogra- address the health needs of LGBT Youth. UCLA: Center for the phy, 50, 1765–1788. Study of Women. Retrieved from http://www.csw.ucla.edu/ World Health Organization. (1946). Constitution of the World Health publications/policy-briefs/policy-briefs/CSWPolicyBrief11.pdf. Organization as adopted by the International Health Conference. Santana, M. C., Raj, A., Decker, M. R., La Marche, A., & Silverman, Official Records of the World Health Organization, 2, 100. J. G. (2006). Masculine gender roles associated with increased World Health Organization. (2002). WHO Gender Policy: integrating sexual risk and intimate partner violence perpetration among gender perspectives in the work of WHO. Geneva: World Health young adult men. Journal of Urban Health, 83(4), 575–585. Organization. Santelli, J., Ott, M. A., Lyon, M., Rogers, J., Summers, D., & Schleifer, R. (2006). Abstinence and abstinence-only education: Amy T. Schalet is Associate Professor of Sociology at the University A review of US policies and programs. Journal of Adolescent of Massachusetts Amherst. Her research interests include culture, Health, 38(1), 72–81. adolescent sexual and reproductive health, gender, qualitative meth- Sawyer, S. M., Afifi, R. A., Bearinger, L. H., Blakemore, S. J., Dick, ods, and political sociology. B., Ezeh, A. C., et al. (2012). Adolescence: A foundation for future health. The Lancet, 379(9826), 1630–1640. Schalet, A. T. (2011a). Beyond abstinence and risk: A new paradigm John S. Santelli is the Harriet and Robert H. Heilbrunn Professor in for adolescent sexual health. Women’s Health Issues. 21(3S), the Heilbrunn Department of Population and Family Health at S5–S7. Columbia University and a past President of the Society for Schalet, A.T. (2011b). Not under my roof: Parents, teens, and the Adolescent Health and Medicine. His research interests include the culture of sex. Chicago: University of Chicago Press. sexual and reproductive health of youth, including social determinants Shearer, C. L., Hosterman, S. J., Gillen, M. M., & Lefkowitz, E. S. and clinical and structural interventions, and the ethical inclusion of (2005). Are traditional gender role attitudes associated with risky adolescents in health research. sexual behavior and condom-related beliefs? Sex Roles, 52(5–6), 311–324. Stephen T. Russell is Distinguished Professor, Fitch Nesbitt SIECUS. (2014). A History of Federal Funding for Abstinence-Only- Endowed Chair, and Interim Director of the Norton School of Family Until-Marriage Programs. SIECUS. Retrieved from http://www. and Consumer Sciences at the University of Arizona, and past siecus.org/document/docWindow.cfm?fuseaction=document.view President of the Society for Research on Adolescence. He studies Document&documentid=115&documentFormatId=133. cultural differences in parent-adolescent relationships, and the health 123 1610 J Youth Adolescence (2014) 43:1595–1610 of sexual minority adolescents focusing on structural conductions that interests include adolescent sexual and reproductive health, gender, promote their healthy development. and human rights. Carolyn T. Halpern is Professor in the Department of Maternal & Shoshana K. Goldberg has an MPH from the University of North Child Health in the Gillings School of Global Public Health at the Carolina at Chapel Hill and is a doctoral student in Maternal & Child University of North Carolina at Chapel Hill. Her research focuses on Health in the Gillings School of Global Public Health at the adolescent sexual and reproductive health and implications for the University of North Carolina at Chapel Hill. Her research interests transition to adulthood. include sociocultural determinants of domestic adolescent sexual health and sexual development, with a focus on structural determi- nants of the health and well-being of sexual minority youth. Sarah A. Miller is a doctoral candidate in Sociology at University of Massachusetts Amherst and has an MA in Women’s Studies from San Francisco State University. Her research interests include youth, Jennifer M. Hoenig has an MPH from Emory University and is a sexuality, social inequality, and culture. doctoral candidate in Family Studies and Human Development at the University of Arizona. Her research focuses on health and education inequity among lesbian, gay, bisexual, transgender, and questioning Sarah S. Pickering has an MPH from the Heilbrunn Department of (LGBTQ) youth. Population and Family Health at Columbia University. Her research http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Youth and Adolescence Pubmed Central

Invited Commentary: Broadening the Evidence for Adolescent Sexual and Reproductive Health and Education in the United States

Loading next page...
 
/lp/pubmed-central/invited-commentary-broadening-the-evidence-for-adolescent-sexual-and-axCjyxCVK0

References (114)

Publisher
Pubmed Central
Copyright
© The Author(s) 2014
ISSN
0047-2891
eISSN
1573-6601
DOI
10.1007/s10964-014-0178-8
Publisher site
See Article on Publisher Site

Abstract

J Youth Adolescence (2014) 43:1595–1610 DOI 10.1007/s10964-014-0178-8 EDITORIAL Invited Commentary: Broadening the Evidence for Adolescent Sexual and Reproductive Health and Education in the United States • • • Amy T. Schalet John S. Santelli Stephen T. Russell • • • Carolyn T. Halpern Sarah A. Miller Sarah S. Pickering Shoshana K. Goldberg Jennifer M. Hoenig Received: 17 August 2014 / Accepted: 22 August 2014 / Published online: 9 September 2014 The Author(s) 2014. This article is published with open access at Springerlink.com Abstract Scientific research has made major contribu- contraceptive use, or number of partners). Although the tions to adolescent health by providing insights into factors transition from primarily AOUM to EBI is important pro- that influence it and by defining ways to improve it. gress, this definition of evidence is narrow and ignores However, US adolescent sexual and reproductive health factors known to play key roles in adolescent sexual and policies—particularly sexuality health education policies reproductive health. Important bodies of evidence are not and programs—have not benefited from the full scope of treated as part of the essential evidence base, including scientific understanding. From 1998 to 2009, federal research on lesbian, gay, bisexual, transgender, queer, and funding for sexuality education focused almost exclusively questioning (LGBTQ) youth; gender; and economic on ineffective and scientifically inaccurate abstinence- inequalities and health. These bodies of evidence under- only-until-marriage (AOUM) programs. Since 2010, the score the need for sexual health education to approach largest source of federal funding for sexual health educa- adolescent sexuality holistically, to be inclusive of all tion has been the ‘‘tier 1’’ funding of the Office of Ado- youth, and to address and mitigate the impact of structural lescent Health’s Teen Pregnancy Prevention Initiative. To inequities. We provide recommendations to improve US be eligible for such funds, public and private entities must sexual health education and to strengthen the translation of choose from a list of 35 programs that have been desig- science into programs and policy. nated as ‘‘evidence-based’’ interventions (EBIs), deter- mined based on their effectiveness at preventing teen pregnancies, reducing sexually transmitted infections, or Introduction reducing rates of sexual risk behaviors (i.e., sexual activity, Science is an essential foundation for adolescent sexual and reproductive health. Researchers, policy makers, advo- cates, and citizens accept science as a basis for policies and A. T. Schalet  S. A. Miller Department of Sociology, University of Massachusetts Amherst, programs related to adolescent sexual and reproductive Amherst, MA, USA health. Scientific methods are used to identify the magni- tude of adolescent health problems, contributing factors J. S. Santelli  S. S. Pickering and health consequences, and to develop and evaluate Heilbrunn Department of Population and Family Health, Columbia University, New York, NY, USA health education and prevention programs. Scientific understanding of adolescent sexual and reproductive health S. T. Russell (&)  J. M. Hoenig encompasses general and discipline-specific scientific the- Norton School of Family and Consumer Sciences, University of ory, qualitative and quantitative data, and scientific find- Arizona, Tucson, AZ, USA e-mail: strussell@arizona.edu ings from diverse fields, including the medical, health, social, and behavioral sciences. C. T. Halpern  S. K. Goldberg Adolescent sexual and reproductive health policy in the Department of Maternal and Child Health, Gillings School of United States has failed to benefit from the full scope of Global Public Health, University of North Carolina at Chapel science. From 1998 to 2009, federal funding for sexuality Hill, Chapel Hill, NC, USA 123 1596 J Youth Adolescence (2014) 43:1595–1610 education focused almost exclusively on ineffective and conclusion, we provide recommendations to improve scientifically inaccurate abstinence-only-until marriage adolescent sexuality education programs and policy, and (AOUM) programs (Santelli et al. 2006). President Oba- the link between research and policy. ma’s 2010 teen pregnancy prevention initiative requires funded programs to be based in scientific evidence, but the implementation of this initiative has led to a new problem: Adolescents and Their Sexual and Reproductive Health ‘‘Evidence’’ is now narrowly defined to include only cer- tain kinds of scientific findings. Currently, this initiative is The World Health Organization definition of health is ‘‘a the largest federal funding program addressing the sexual state of complete physical, mental, and social well-being health needs of adolescents. The US Department of Health and not merely the absence of disease or infirmity’’ (World and Human Services has approved funding for 35 ‘‘evi- Health Organization 1946). Definitions of reproductive dence-based’’ programs selected on the basis of studies that health and sexual health mirror and expand upon this have shown their effectiveness at preventing teen preg- definition of health. Central to our conception of adolescent nancies, reducing sexually transmitted infections (STIs), or sexual and reproductive health is an understanding of reducing rates of sexual risk behaviors (i.e., sexual activity, adolescence as a life stage defined by physiological, psy- contraceptive use, or number of partners). These ‘‘evi- chological, social, and cultural transitions marking the dence-based-interventions’’ (EBIs) are modeled after clin- movement from childhood to adulthood. Adolescents are ical trials and implemented with the intention to effect emerging as adults, embodying a tension between the need targeted behavior change. for protection and guidance by parents and adult caregiv- While a clear advance over previous policy, current ers, on one hand, and the rights to autonomy and agency on adolescent sexual and reproductive health policy and pro- the other. gramming remain uninformed by the scientific base in Over the past 60 years, important changes have occurred profound ways. First, federal policy continues to fund in the timing of adolescent transitions, including age at first abstinence programs that remain at odds with scientific sex, length of educational preparation, age at marriage and thinking about adolescent sexual health. Second, key timing of childbearing. In the United States, as in other bodies of science are not treated as part of the essential developed countries, adolescents typically initiate sexual evidence base for policy and programming. The exclusive contact during their mid or late teens or early 20s (Finer focus on pregnancy and disease prevention in the definition 2007; Halpern and Haydon 2012). The establishment of of sexual health leaves out aspects of adolescent sexual constructive and satisfying romantic relationships is a key development and health that researchers argue are critical, developmental task of adolescence and an important con- tributor to sexuality and sexual health (Mayer et al. 2008). such as sexual orientation and gender beliefs. The focus on individual-level proximate causes of pregnancy and dis- We define sexuality to include the feelings, identities, ease, such as sexual activity and contraceptive use, largely relationships, and interactions that form the foundations of eclipses the systematic, society-level structural inequities sexual development, and a variety of non-coital and coital that shape adolescent sexual behavior and risk. Finally, sexual experiences. Important aspects of adolescent sexual defining ‘‘evidence’’ as evaluations of program effective- development include maintaining a positive body image, ness for changing specific individual behaviors excludes developing self-efficacy in sexual decision-making and broader evidence regarding psychological, cultural, and interactions, and forming mutually respectful romantic economic factors known to shape adolescent sexual health. relationships (Schalet 2011a; Tolman 2002). Multiple and We begin our critique by reviewing the sexual and multi-level factors influence personal attitudes, motiva- reproductive health needs of adolescents, with attention to tions, and experiences, and can bolster or hinder the the role of schools in promoting sexual health. We then development of sexual self-efficacy, resiliency, healthy discuss the emergence of evidence-based interventions as a relationships, and positive body image, as well as behav- guiding force in US adolescent sexual and reproductive iors that promote and protect or threaten health. Bodies of health policies and programs. With this background, we knowledge related to inter-personal dynamics, school cli- examine three bodies of science—lesbian, gay, bisexual, mate, social norms, and cultural values and beliefs all transgender, queer and questioning (LGBTQ) youth and provide information about the motives for adolescent sex- health; gender; and economic inequalities—identifying key ual behavior (Russell 2005; Schalet 2011b). At the macro findings that should inform adolescent sexual health and level, social and cultural forces including daily realities education programs. These bodies of evidence underscore such as poverty or economic inequality, structural racism the need for sexual health education to approach adolescent and stigmatization of youth who do not conform to rigid sexuality holistically, to be inclusive of all youth, and to gender and sexual orientation norms, as well as medical address and mitigate the impact of structural inequities. In technologies and access to health care and education, all 123 J Youth Adolescence (2014) 43:1595–1610 1597 profoundly shape adolescent health (Resnick et al. 2012). Discomfort with adolescent sexuality runs throughout the Social and behavioral science research on adolescent health diverse institutions of American society, and it is perhaps has defined the important roles of families and peers, no surprise that this discomfort has shaped our political media, schools, life opportunities, demographic transitions, conversations and policymaking. This discomfort and its and cultural forces in shaping young people’s health status impact on policy are not, however, inevitable. Other (Sawyer et al. 2012). Research in medicine and public developed nations, such as the Netherlands and Denmark, health has documented the importance of health services, have shifted away from a historical discomfort with ado- sexual health education, access to screening and treatment lescent sexuality, fostering national dialogue and policies for STIs, and public policies in improving health. aimed at supporting youth in their development—both sexual and socioeconomic—and seeing better overall Adolescent Sexual Health Challenges adolescent sexual and reproductive health outcomes (Rose 2005; Singh et al. 2001; Schalet 2011b). In the United The need for more broad and effective translation of sci- States, by contrast, multiple factors have contributed to ence into sexual and reproductive health policy is under- ongoing controversy around adolescent sexuality, includ- scored by the significant sexual health burdens among ing its explicit politicization in recent decades, particularly youth. Comprising only 25 % of the sexually active pop- with regard to the teaching of sexual health education ulation in the United States, young people (13–24 years) within schools (Irvine 2004; Luker 2007). account for approximately half of the 20 million STIs contracted annually, including one in four of the estimated Adolescent Sexual Health Education 50,000 new human immunodeficiency virus (HIV) infec- tions diagnosed each year (CDC 2013a; Weinstock et al. Schools have an essential role in promoting adolescent 2004). Racial, ethnic, and gender disparities are striking. sexual and reproductive health, and science is essential in The majority of new adolescent cases (57 %) are among guiding the development of school health policies. As of Blacks/African-Americans, with an additional 20 % fall 2013, about 50.1 million children and young people occurring among Hispanics/Latinos (CDC 2012a, b). were enrolled in public elementary and secondary schools Women accounted for one in four new HIV cases in 2009; across the United States (National Center for Education the incidence rate for Black/African American females Statistics 2013). Schools offer a practical and efficient (38.1/100,000) is 20 times the rate for White females (1.9) means to reach young people with health information and (CDC 2012b). However, men who have sex with men health services. Because they include students across the (MSM) are the population most affected by HIV in the socioeconomic spectrum, public schools can educate and serve children and youth who may not have access to United States; the estimated number of new HIV infections among adolescent and emerging adult Black/African education and services elsewhere. Schools are also an American MSM (aged 13–29 years) increased 48 % from opportunity to educate all young people about health and 2006 to 2009 (CDC 2011). Moreover, the US Centers for sexuality before they initiate health risk behaviors, and to Disease Control and Prevention (CDC) reports that nearly provide health services that prevent disease and promote 1.5 million high school students are affected by dating health. Thus schools can help young people establish violence annually, with rates of violence and sexual coer- healthy behaviors that endure into adulthood (CDC 2013b; cion especially high among LGBTQ youth and female Kirby 2002). In addition to promoting healthy behaviors, adolescents (CDC 2006). Finally, despite historic declines schools are important venues for the development of norms in adolescent pregnancy and teen births, US teen birth rates and values and for fostering positive self-concept and remain the highest among the developed nations (National agency around sex, sexuality, and relationships (Center for Research Council 2013) even though levels of sexual School, Health, and Education, 2011). experience are similar. Within the United States, poor, Educators, psychologists, and sociologists have argued, rural and minority women have higher teen birth rates. moreover, that sexual health education also has an impor- These disparities (by poverty and by race and ethnicity) tant role to play in combating the health and social dis- demonstrate the critical need for effective and medically parities that young people face. They note that structural accurate sexuality education, accessible adolescent health racism, poverty, gender inequality, and the stigmatization care, and policy initiatives that reshape the educational and of LGBTQ people all negatively impact health outcomes, work opportunities for disadvantaged youth. including sexual health outcomes, and have argued that it is Despite the omnipresence of sexual messages in US incumbent upon educators not to perpetuate inequalities media, frank public conversations about sexual and within the classroom through explicit or implicit stereo- reproductive health, as holistically defined by organizations typing (Fine and McClelland 2006). They point to prob- such as the World Health Organization, are rare. lems not only in formal curricula, but also in the informal 123 1598 J Youth Adolescence (2014) 43:1595–1610 or hidden curricula—the implicit messages embedded in heterosexual youth, and harm to traditional sexual health sexual health education—through which educators may education (American Academy of Pediatrics Committee on inadvertently promote class, gender, and race stereotypes Psychosocial Aspects of Child and Family Health and (Fields 2008; Morris 2007). Sexual health education has Committee on Adolescence 2001; American Civil Liberties the potential to give young people the opportunity to crit- Union 2008; American Public Health Association 2006; ically examine the societal inequalities linked to gender, Santelli et al. 2006). race, sexuality, and poverty (Fields 2008; Fine and McC- Rigorous evaluations of AOUM or abstinence-based lelland 2006). Thus, while sexual health education cannot curricula have failed to demonstrate efficacy in delaying remove the inequalities in society at large, it can aid stu- initiation of sexual intercourse, reducing number of part- dents in acquiring the critical thinking skills that will allow ners, increasing condom use, or promoting secondary them to more effectively confront and challenge them. abstinence (i.e., cessation of sexual intercourse among sexually experienced youth) (Kirby 2008; Trenholm et al. 2008). In contrast to abstinence approaches, a 2012 CDC From ‘‘Ab-only’’ to ‘‘EBI-only’’: US Federal Sexual meta-analysis of 66 comprehensive risk reduction pro- Health Education Policy grams for youth showed favorable effects on current sexual activity, frequency of sexual activity, number of sex part- The history of sexuality education in the United States ners, frequency of unprotected sexual activity, use of pro- reflects philosophical clashes and alternating domination of tection (either condoms and/or hormonal contraception), competing approaches stemming from those philosophical pregnancy, and STIs (Chin et al. 2012). In the same report, differences (Irvine 2004; Luker 2007; Moran 2002). the CDC found insufficient scientific evidence for change Opponents of sexual health education have argued that in behaviors or other outcomes from abstinence education teaching young people about sex encourages them to be programs (Chin et al. 2012). sexually active, even though there is no evidence to support Since 2010, there has been a shift in federal approaches such claims; rather sexual health education helps some to sexual health education away from AOUM programs, young people delay initiation of sex (Kirby et al. 2007a). In and towards ‘‘evidence-based interventions’’ (EBI), led by the 1990s the CDC provided significant funds to promote the US federal Office of Adolescent Health (OAH) HIV/AIDS prevention education, which greatly expanded (AOUM programs have still received substantial funding youth exposure to sexual health education but emphasized through the Title V State Abstinence Education Grant prevention of STIs and HIV. Beginning in 1998, federal Program). EBIs are treatments or interventions designed to funding shifted increasingly to a narrow focus on absti- effect behavior change that have been evaluated using randomized or quasi-experimental designs. nence as the primary program and policy solution for ‘‘the US Federal problem’’ of adolescent sexuality. AOUM programs reflect health policy has increasingly relied on these EBIs (CDC the strong moral and religious beliefs of their authors. Key 2013c; Evidence Based Intervention Network 2011). The among those are the beliefs that sex outside of heterosexual authorizing language for the Office of Adolescent Health marriage is sinful and that teaching about the health ben- specifically describes ‘‘replication’’ of evidence-based efits of condoms and contraception is morally wrong approaches to teen pregnancy prevention programs and because it encourages premarital sex. These beliefs are a requires medical accuracy in all funded programs. In critical feature of the ‘‘conceptual’’ basis for AOUM pol- practice this means that to be eligible for the largest icies (Santelli et al. 2006). funding stream (termed ‘‘Tier 1’’), grantees must select From 1998 to 2009 the US government spent almost 2 from and replicate with fidelity the now 35 programs that billion dollars on assistance to states, community-based, have been designated as EBIs. (A second group of funded and faith-based organizations for AOUM educational pro- programs, Tier 2, develops and tests new approaches to grams [Sexuality Information and Education Council of the prevent teen pregnancy, including emphasis on under- United States (SIECUS 2014)]. Since 2009, US funding for served populations.) domestic and international AOUM programs has decreased. However, federal and state-funded AOUM programs remain widespread in many parts of the United Such research designs are particularly useful in evaluating behav- States, despite multiple scientific and human right concerns ioral interventions where effect sizes are small or where the efficacy of an intervention is unknown. that have been raised by mainstream medical and public The Personal Responsibility Education Program (PREP) of the US health organizations, including concerns about scientific Office of the Administration for Children and Families is a distinct accuracy, the withholding of life-saving information from funding stream for teen pregnancy prevention; it does not require use young people, a lack of program efficacy, promotion of of an EBI, however grantees are highly encouraged to use programs gender and racial stereotypes, insensitivity to non- on the EBI list. 123 J Youth Adolescence (2014) 43:1595–1610 1599 Current emphasis on EBIs has been an important sci- inequalities. Moreover, when EBIs fail to address non-EBI entific and translational advance over prior federal efforts; scientific data about the role of poverty, race, and gender in however, a number of limitations have become evident adolescent sexual health they create the potential for with this approach. Current policy has focused on repli- reinforcing cultural stereotypes. cation of specific curricula rather than the theory derived In the remainder of this article, we turn to evidence from from research on EBIs, which provides a guide for across the social and behavioral sciences that should be understanding efficacy and adapting programs to new cir- central to all adolescent sexual health education. We show cumstances (Kirby et al. 2007b; UNESCO 2009). Further, how the emerging research on LGBTQ youth calls for the definitions of the health problems to be addressed and inclusiveness in adolescent sexual health education pro- the types of evidence brought to bear on those problems gramming. Drawing from an extensive literature on the omit central bodies of research. A narrow focus on disease harmful effects of gender inequity and stereotypes, we and pregnancy prevention—and on the individual-level demonstrate the need for sexual health education to address behavioral antecedents—undermines a more holistic these issues. Finally, we illustrate how poverty and approach to adolescent sexual health, and also ignores inequality intersect with adolescent sexual health education decades of scientific evidence of the ways that structural in a myriad of ways that have distinct implications for inequities shape adolescent sexual behavior and risk policy and programming. (Anderson et al. 2005). By defining the ‘‘evidence base’’ as evaluation research about program success in effecting LGBTQ Education and Health specific (often small) behavior changes, the broader sci- entific record about factors known to shape adolescent Contemporary LGBTQ and gender nonconforming youth sexual health outcomes has been relegated to a discre- ‘‘come out’’ or disclose their identities at younger ages than tionary rather than central position. Grantees may use the prior cohorts and have distinct sexual health needs (Floyd breadth of scientific thinking to design tier two programs and Bakeman 2006). It is now commonly understood that but they are not required—nor are those tasked with exact LGBTQ students may face victimization at school, or replication able—to integrate it into their programming. generally hostile school climates (Birkett et al. 2009). Their Thus, federal program requirements have had the unin- needs are often invisible in sexual and reproductive health tended consequence of ignoring and marginalizing a services, and they are typically excluded from sexual broader body of scientific principles and evidence regard- health education programs (Bay-Cheng 2003; Cianciotto ing adolescent sexual health and behavior. 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 Toward Holistic Adolescent Sexual Health for males, females, and transgender youth; and higher rates of pregnancy for both girls and boys (results for trans- We have argued that Evidence Based Interventions often gender youth are unknown) (Mustanski et al. 2011; Saewyc do not reflect factors that the broad scientific literature et al. 1999; Saewyc et al. 2009). identifies as key to health behaviors and risks, and do not The focus of sexual health education historically has approach individual behavior in the broad context of ado- been on heterosexual sexuality, with emphasis on procre- lescents’ lives. As such, there is a disconnect between ation, presumably or explicitly directed to the confines of research and theoretical advances on one hand, and sexual marriage (Carter 2001). For more than 100 years, educators health education programs and policies on the other (Ro- have grappled with the issue of how to teach youth about mero et al. 2011). For instance, social and behavioral sci- sexuality while promoting premarital chastity and marital ence research documents the significance of the sexual monogamy, a dilemma that has often led to sacrifices of orientation of young people, the gender beliefs and ineq- scientific accuracy in favor of ideology (Carter 2001). As a uities that shape their sexual agency and relationships, and result LGBTQ youth are often excluded or left without the economic and racial inequalities that constrain their relevant and necessary information to make safe and options, as crucial to a holistic understanding of adolescent effective choices. Despite potential breadth, the dominant sexual health. But many EBIs do not fully address or even focus of sexuality education programs initially focused on acknowledge the psychosocial and structural factors that the public health outcomes such as the prevention of shape the ways in which adolescents conduct their sexual unintended pregnancy, and since the mid-1980s, prevention lives. Thus, while consensus has emerged across disci- of HIV/AIDS and STIs. Before HIV/AIDS, there was plines that gender, racism, stigmatization of LBGTQ youth, mostly silence on LGBTQ sexualities in sexual health and poverty are critical to adolescent health, we lack pro- education. Debates in the late 1990s became dominated by grammatic emphasis and EBIs that address these abstinence in sexual health education, a stark contrast to 123 1600 J Youth Adolescence (2014) 43:1595–1610 growing scientific knowledge about the efficacy of com- (Mayer et al. 2008). Heterosexual bias in sexuality edu- prehensive sexuality education. In addition to other faults cation will leave some youth without critical knowledge described above, the introduction of AOUM programs they need to make safe sexual choices. actively thwarted momentum to include LGBTQ youth Only nine states require that sexual health education needs in sexual health education by emphasizing absti- programs provide inclusive information on sexual orien- nence until heterosexual marriage among high-school tation (Guttmacher Institute 2013). Seven states (and youth in different-sex relationships. Only since 2004 has multiple localities) have laws that expressly forbid dis- marriage for same-sex couples been possible (to date more cussion of LGBTQ issues (including sexual health and than a dozen states and the District of Columbia permit HIV/AIDS awareness) in a positive light, if at all; of those, same-sex couples to marry); thus, for many LGBTQ youth, three states (Alabama, South Carolina, and Texas) require the AOUM message actively erases potential for compre- that sexuality education programs include negative mes- hensive sexual health education. Moreover, some absti- sages about same-sex sexuality (Guttmacher Institute 2013; nence-only program content includes unequivocally hostile McGovern 2012). Alabama law criminalizes same-sex messages about LGBTQ people (Cianciotto and Cahill relationships and sexual behavior and proclaims them to be 2003). ‘‘not a lifestyle acceptable to the general public.’’ Addi- Several empirical studies have begun to document the tionally, the law asserts that this position comes from a ways that abstinence programs may undermine LGBTQ ‘‘factual manner and from a public health perspective.’’ youth sexual health and well-being (Kosciw et al. 2012). This discriminating law is not unique; there are other laws One report showed that compared to schools with other throughout the country that work to stigmatize LGBTQ types of sexuality education, LGBTQ students who atten- people, including youth in the classroom, by expressly ded schools that taught abstinence-only programs faced forbidding discussion of LGBTQ issues in a positive greater harassment in the form of anti-LGBTQ remarks. manner (McGovern 2012). Meanwhile, two proposed fed- Further, by excluding sexual minorities (or in some cases eral laws have languished; the Safe Schools Improvement giving disparaging information about them), abstinence- Act (2013 S. 403) and the Student Non-Discrimination Act only programs may produce feelings of rejection and being (2013 HR 1652) would explicitly provide protection to disconnected to school (Kosciw et al. 2012). These feelings LGBTQ students in US schools, and create a supportive may lead to negative mental health outcomes such as policy context for inclusive health policies and programs. depression and anxiety and serve as precursors for other In spite of this discouraging context for sexuality edu- health risk behaviors (Almeida et al. 2009; Kosciw et al. cation, the pace of social change regarding LGBTQ 2012). On the other hand, there is evidence that inclusive inclusion has been extraordinary, as evidenced, for exam- ple, by the growing number of US states and other nations strategies can promote sexual health for LGBTQ students. For example, Blake et al. (2001) found that LGB students that permit marriage for same-sex couples. Beyond sexu- in schools with gay-sensitive HIV instruction reported ality education programs, there is an emerging body of lower sexual risk taking and substance use. evidence that documents specific educational practices and Not only may LGBTQ students be invisible or margin- strategies that create positive school climates for LGBTQ alized in sexuality education, but their health needs may youth, including inclusive anti-discrimination and anti- not align with the sexual health education needs of students bullying policies and laws, school personnel training and involved in different-sex relationships or sexual activity. If advocacy, access to LGBTQ-related resources and curric- the risk for disease is presented only with reference to ula, and gay-straight alliance (GSA) school clubs (Russell penile-vaginal sexual behaviors, there may be deleterious et al. 2010). A number of studies show that these strategies consequences for the health of those who engage in same- are linked to adolescent academic achievement and mental sex relationships or sexual activity. For example, HPV and behavioral health (Blake et al. 2001; Goodenow et al. poses a threat to all male and female youth, including 2006; Poteat et al. 2013).Thus, a growing body of evidence cancer risk stemming from same- as well as different-sex points to principles for promoting adolescent health in sexual activity. However, if education only refers to het- ways that respect and include LGBTQ youth, and that erosexual vaginal transmission, youth may erroneously respond to known inequities many LGBTQ youth experi- conclude that HPV risk pertains only to heterosexual ence. These principles should inform the evidence base for vaginal sex. Such an approach would obscure other sexual federal sexual health education programs and policies. behaviors that pose risk for HPV, such as non-penetrative sexual contact, even though the prevalence of HPV among Gender and Sexual Health Education women who have never engaged in vaginal intercourse is high, as is the risk for anal cancer associated with HPV A second area in which current scientific thinking and among men who engage in receptive anal intercourse sexual health education policy and programs are not 123 J Youth Adolescence (2014) 43:1595–1610 1601 aligned concerns the impact of gender (in)equity and documented how schools, peer culture and other institu- gender norms. Research across disciplines has demon- tions overtly and covertly communicate distinct gender strated that gender norms and inequities are key factors in ideologies about sex and romance to young people shaping health generally, and sexual health in particular (Chambers et al. 2004; Eder et al. 1995; Fields 2008; (Rogow and Haberland 2005). International health orga- Pascoe 2007). Traditional gender ideologies frequently link nizations have recognized that promoting gender equity is masculinity with heterosexual sexual activity, sex drive, critical to advancing health across the life course (World sexual initiation, and lack of emotional involvement, and Health Organization 2002). Domestically, Healthy People femininity with sexual passivity, sexual restraint, respon- 2020 includes gender and gender identity as dimensions sibility for controlling boys’ desires, and emotional over- linked to health disparities—that is, systematic obstacles to involvement (Allen 2003; Bay-Cheng 2003). The sexual health—and it aspires to reduce those disparities. But in the double standard, which encourages and celebrates hetero- ‘‘Adolescent Health’’ section, the document is silent about sexual sexual experience in teenage boys but censures and the need to address gender inequities or harmful gender stigmatizes sexual experience in teenage girls, is endemic beliefs. Establishing gender equity and challenging gender in the United States, though it varies by local context and beliefs that research has shown to be harmful to adolescent culture (Crawford and Popp 2003; Greene and Faulkner sexual health have never been central goals in US adoles- 2005; Marston and King 2006). cent sexual health and education policy (DeLamater 2007). The sexual double standard harms girls by stigmatizing In fact, many abstinence-only and abstinence-only-until- their sexual desires and experiences, reducing their nego- marriage programs have taught gender stereotypes as facts tiating power within sexual encounters, and conditioning (Curran 2011; Delamater 2007; Fine and McClelland girls to believe that their own desires and wishes are less 2006). Even approaches that include information beyond significant than those of their male partners (Hamilton and abstinence have perpetuated gender inequities through Armstrong 2009; Holland et al. 1998; Martin 1996; Tolman gender stereotyping implicit in curricula or teachers’ 2002). Negative cultural beliefs about girls’ sexuality can informal communications (Curran 2011; Fields 2008; make it difficult for them to disclose their sexual histories Garcia 2009, 2012). to partners, parents, or adult care providers (Greene and It has long been established among researchers that Faulkner 2005; Schalet 2011a, b). Traditional gender roles gender inequities, and the gender ideologies that uphold can also hinder girls in refusing unwanted sex and insisting them, are key factors in shaping sexual and reproductive on condom use (Impett et al. 2006; Kirkman et al. 1998; health globally and domestically, affecting STIs, HIV/ Petitifor 2012). Possessing a sense of sexual self-efficacy— AIDS, unintended pregnancies, and sexual violence (Ro- a sense that one has power over one’s sexual decision gow and Haberland 2005; Santana et al. 2006). Scholars making—seems to be especially important in aiding girls to have documented how traditional gender roles impede engage in safer sex behaviors (Gutierrez et al. 2000; women’s sexual autonomy and self-efficacy, and thereby Pearson 2006). There is additional evidence to suggest that increase their vulnerability to STIs and HIV, intimate when girls know about, and feel entitled to, sexual plea- partner violence, unwanted sex, and unintended pregnancy sure, they are better able to advocate for themselves and (Amaro and Raj 2000; Amaro et al. 2001; Impett et al. their sexual health, leading scholars to call on sexual health 2006; Jewkes 2010; Phillips 2000). Gender-based rela- education to challenge the double standard and emphasize tional power imbalances impact women’s capacity to the value of girls’ desires and pleasure (Hirst 2013; Horne advocate for their own sexual safety (Phillips 2000; Ro- and Zimmerbeck 2006; Impett et al. 2006; Martin 1996; senthal and Levy 2010). For instance, compared to women Tolman 2002). who report low levels of relationship power, women with Boys are also disadvantaged by prevailing gender ide- higher levels are five times as likely to report consistent ologies. The sexual double standard can make it appear as condom use (Pulerwitz et al. 2002). Cultural beliefs about if boys should always desire sex, and never say no to sex, gender can also have negative health consequences for men even risky sex (Bowleg et al. 2000). The prevailing ide- by, for instance, encouraging risk behavior (Higgins et al. ologies stigmatize boys’ emotional vulnerabilities and 2010). needs, including their needs for intimate friendships and Gender ideologies shape how youth view and experi- romantic relationships, making them less prepared to have ence themselves and each other. Researchers have intimate relationships (Giordano et al. 2006; Way et al. 2013). They also stigmatize homosexuality and behaviors One of the goals in this section is to increase the proportion of associated with homosexuality (Kimmel 2008; Klein 2012; secondary schools that ‘‘prohibit harassment based on a student’s Pascoe 2007). Norms about appropriate male behavior sexual orientation or gender identity.’’ This goal is important but does affect all males. But those who adhere most to ‘‘tradi- not in itself encourage schools to promote gender equity or address tional’’ beliefs about masculinity—for instance, that men the effects of harmful gender beliefs in sexual health education. 123 1602 J Youth Adolescence (2014) 43:1595–1610 should be tough, have status in society, not behave in ways stereotyping in apparently gender-neutral exercises and marked as ‘‘feminine,’’ and regularly have heterosexual role plays (Bay-Cheng 2003; Curran 2011; Fields 2008). sex— are most at risk for negative consequences compared Unless harmful gender beliefs are explicitly addressed and to other boys and men. Those who embrace such traditional challenged, sexual health education runs the risk of attitudes toward masculinity tend to also report more sex- reinforcing those beliefs through the taken-for-granted ual partners, engage in more unprotected vaginal sex, and assumptions teachers and students bring into the class- show less self-efficacy and consistency in condom use room (Fields 2008; Garcia 2009, 2012; Froyum 2010). (Noar and Morokoff 2002; Pleck et al. 1993, 1994; Santana Yet, of the 35 designated (Tier 1) ‘‘evidence-based’’ et al. 2006; Shearer et al. 2005). programs, only a handful (all of which target youth of There is growing evidence that among adult men some color) even mention gender in their program description, masculine gender norms are linked to violence in intimate suggesting incorrectly that only minority groups contend relationships (Gallagher and Parrott 2011; Murnen et al. with harmful gender beliefs (Office of Adolescent Health 2002). For example, compared to other men, men who 2014a). The research record shows the advisability of report more traditional masculinity ideologies are more ensuring that all sexual health programs are free from likely to report having perpetrated violence or sexual harmful gender beliefs—which may be explicit or implicit coercion (Marın et al. 1997; Santana et al. 2006). Con- in the curricula—and include tools to help students versely, compared to less egalitarian men, men whose address and challenge these beliefs. gender role ideologies are more egalitarian report fewer instances of physical aggression against their intimate Poverty, Inequality, and Sexual Health Education partners (Fitzpatrick et al. 2004). Gender norms also shape young people’s capacities to resist, report, and recover Considerable literature has demonstrated that poverty and from sexual violation. Boys are unlikely to report sexual economic inequalities are fundamental barriers to positive coercion due to homophobia as well as masculinity norms youth development. Youth subject to these inequalities that emphasize male sexual desire and strength and have lower academic achievement, and are more likely to obfuscate boys’ capacity to be coerced or intimately vio- leave school early, thereby compounding cumulative lated (Bullock and Beckson 2011). For girls, the pressure to socioeconomic effects on health. Youth in poverty are also be normatively feminine (sexually passive, accommodat- more likely to engage in delinquent behavior, to become ing, ‘‘nice’’) can make resistance to unwanted sexual sexually active early, and to have elevated risk of STIs, advances difficult (Armstrong et al. 2006; Hamilton and unintended pregnancies, and non-marital births (Brooks- Armstrong 2009; Phillips 2000). The stigma around girls’ Gunn et al. 1997; Dinkelman et al. 2008; Duncan and sexuality also prevents many from seeking help, a barrier Rodgers 1988; Duncan et al. 2010; Grantham-McGregor that is heightened for low-income girls and girls of color et al. 2007). Youth in poverty also lack access to quality (Collins 2005; Froyum 2010). health services (National Research Council 2009). The In short, there is strong and consistent evidence that effects of persistent poverty are especially pernicious, gender beliefs and (in)equities shape sexual health (Ro- affecting socio-emotional development and health, and gow and Haberland 2005). However, until recently, these increasing the likelihood of enduring ill effects into areas have received very little attention in US adolescent adulthood. sexual health policy and programming (Grose et al. 2014; The deleterious effects of poverty are critical consider- Rolleri 2013a; Rolleri 2013b). There is no requirement for ations for adolescent health and development in the United federally-funded sexuality education to work toward States, where low-income students now comprise a near gender equity, avoid explicit or implicit gender stereo- majority of public school children in the United States. typing, or include modules that help students challenge About one in six of all youth and one in three African harmful gender beliefs. Abstinence-oriented programs American youth ages 12–17 live in families with incomes have often taught gender stereotypes as fact (DeLamater Without a systematic content analysis of these programs, it is 2007; Fine and McClelland 2006; Curran 2011). difficult to assess whether they merely mention gender or actively Approaches that include information beyond abstinence seek to change unhealthy gender norms. One tier 1, evidence-based can also perpetuate gender ideologies through the topics intervention that does the latter is SiHLE (Rolleri 2013a). Encour- they cover and leave out, or include implicit gender agingly, under its Tier 2 funding, the Office of Adolescent Health has funded Gender Matters, an ‘‘innovative gender transformative program,’’ noting that ‘‘addressing gender norms is essential to improving the health of teens, but often prevention programs leave One recent study of popular abstinence-only program content found out these discussions’’ (Office of Adolescent Health 2014b, p. 1). a softening of some older gender stereotypes alongside the emergence of new ones, including the manipulative female leading a male astray Defined by eligibility for the federal free and reduced-price meals (Lamb et al. 2013). program in the 2010–2011 school year; Suitts et al. 2013. 123 J Youth Adolescence (2014) 43:1595–1610 1603 below the official poverty level. In addition to the close sexism/heterosexism, that is, ‘‘macrolevel systems, social linkage between minority racial/ethnic status and poverty, forces, institutions, ideologies, and processes that interact there are major racial disparities in long-term exposure to with one another to generate and reinforce inequities neighborhood poverty. Analyses of data from the Panel among… groups’’ (Gee and Ford 2011; p. 116), normalizes Study of Income Dynamics indicate that 40 % of African and legitimizes unequal treatment and discrimination Americans experience sustained exposure to high-poverty Structural discrimination can take many forms, including neighborhoods, versus 5 % of non-Blacks (Wodtke 2013). social segregation (e.g., neighborhood, schools, health care The negative consequences of poverty are a function of facilities) and exclusionary immigration policy, and can the structural and experiential inequalities that typify the persist across generations through the cumulative effects of life contexts of impoverished youth. Poor youth are more interacting systems. For example, because of racial dis- likely to live in neighborhoods characterized by adverse crimination in the real estate industry African Americans physical and social environments, with higher rates of are considerably more likely to live in poor neighborhoods, crime and limited access to recreational facilities and after- even if economic resources would permit residing in non- school programs, and are more likely to attend lower poor neighborhoods (Iceland and Scopilliti 2008). quality schools with fewer resources (Murry et al. 2011). The Intersectionality Framework (see for example, They are also less likely to have access to mental and Weber and Parra-Medina 2003) proposes that characteris- physical health services. Exposure to poverty during ado- tics such as race, class and gender are not distinct social lescence may be especially important, given adolescents’ categories. They reflect multidimensional and overlapping expanding social world. Recent analyses suggest that sus- experiences that are a function of mutually reinforcing tained exposure to neighborhood poverty substantially social processes and institutions. The intersection of mi- increases the risk of becoming an adolescent parent, and crolevel identities and macrolevel structural factors can that exposure during adolescence may have a greater effect affect health by producing and sustaining economic than exposure earlier in childhood (Wodtke 2013). Further, inequality via groups’ access to social, economic, and poverty shapes sexual network structure, increasing the political resources and privileges. The effects of neigh- likelihood of STIs (Fichtenberg et al. 2010). These contexts borhood disadvantage on school dropout, for example, are mold adolescents’ sexual knowledge, perceptions about twice as large for African American youth versus their and access to contraception, and their hope for the future. White peers (Crowder and South 2003). Community pov- Poverty intersects with individual and structural char- erty levels also contribute to LGBT youth’s experiences in acteristics to generate significant health disparities, the school; youth in higher poverty communities report more cumulative health differences that result from obstacles victimization in school because of sexual orientation and gender expression than those in more affluent communities linked to factors such as race/ethnicity, gender, disability, sexual orientation, and gender identity. A recent review of (Kosciw et al. 2009). Poverty and racial segregation can health disparities in the United States (CDC 2013d) doc- also affect the sexual expectations and behavior of youth, umented persistent race/ethnicity disparities in health out- leading youth in these contexts to consider early sexual comes, access to health care, adoption of health promoting activity as normal and even expected. Youth in low income behavior, and exposure to health promoting environments, neighborhoods may not have access to educational and with no evidence of a temporal decrease between 2005 and occupational opportunities, and may view sexual activity as 2009. Documented disparities, beyond those related to a pathway to social status rather than an obstacle to sexual and reproductive health, include differences in socioeconomic achievement (Ramirez-Valles et al. 2002). chronic conditions such as asthma, diabetes and hyper- The intersections of poverty, inequality, structural dis- tension, as well as differences in mortality from causes crimination, and adolescent sexual and reproductive health such as coronary heart disease, stroke, drugs, homicide, are numerous. Sexual health education exists within a suicide, and vehicle related injuries (CDC 2013d). variety of structural and social contexts (Fine and McC- Thus, the adverse impact of poverty is compounded by lelland 2006). Sexuality affects, and is affected by, com- racism, sexism, heterosexism, and discrimination against plex interactions between individual biopsychosocial individuals with disabilities. These prejudicial belief sys- factors and a host of economic, political and cultural fac- tems reflect irrational biases toward members of a certain tors. Sexuality and sexual rights are thus interwoven with race, biological sex, sexual orientation, gender identity, or broader human rights and the sociopolitical issues that level of ability on the basis that a certain group is ‘‘supe- affect those rights, such as economic inequality and rior/inferior’’ or ‘‘normal/abnormal.’’ Structural racism/ structural racism. Approaching adolescent sexual health with an eye toward poverty and its intersections with diverse social identities means attention to not only mate- More than one in three of all young people, 12–17, live in ‘‘near- rial deprivation but also to social and political exclusion poverty’’ (often considered a more accurate measure). 123 1604 J Youth Adolescence (2014) 43:1595–1610 and restrictions on rights, including sexual rights (Armas implementation of poverty alleviation. In the late 1950s 2007), that are linked to behavior. Poverty limits knowl- 22 % of US residents lived in poverty; after the launch of edge about and access to sexual and reproductive health the War on Poverty in the 1960s, that percentage had services, constrains positive sexual expression and feelings dropped to 11 % by 1973 (Council of Economic Advisors of self-efficacy, and makes disadvantaged youth vulnerable 2014). Changes were even more drastic among the elderly, to sexual exploitation and violence. This is why the who once had the country’s highest poverty rates, but experience of poverty is associated with greater sexual whose chances of living in poverty have been sharply risk-taking (e.g., early sexual onset, multiple sexual part- reduced through programs such as Social Security and nerships, lack of condom use) in both the United States and Medicare (Fischer et al. 1996). global contexts (Brooks-Gunn et al. 1997; Dodoo et al. Today, the poverty rate of US children and teens is among 2007; Duncan and Rodgers 1988). the highest in the industrial world. Given the pervasive det- US policy makers must understand and address the rimental effects on youth development, poverty alleviation importance of poverty’s complex intersections with diverse programs are vital to improving adolescent sexual and identities and the impact on how youth respond to sexuality reproductive health. Indeed, comparing across five devel- education. Sexual health education paradigms and curricula oped nations, where rates of sexual activity among youth often assume adolescents are in school and that they live in were similar, Singh and colleagues report a strong associa- homogeneous social and physical environments free of tion between the higher US teen birth rate and the greater economic or other social barriers. Sexuality education may proportion of teens who grow up poor (Singh et al. 2001). Yet explicitly or inadvertently reinforce cultural stereotypes there is strong evidence that structural interventions can both about young people of color, who are more likely to be directly and indirectly improve adolescent health, and that poor, as sexually irresponsible (Fine and McClelland 2006; large-scale implementation is both feasible and successful Fields 2008; Garcia 2009, 2012). Similarly, sexual health (Snell et al. 2013). In many European, Latin American, and education may presume ‘‘proper’’ relationships and family African countries, governments offer a variety of income forms that are less common among low income youth or supplements, especially to families with children. Singh youth of color. With few economic opportunities and et al. (2001) point toward policies that are likely to affect resources to develop positive sexual identities, low income adolescent sexual and reproductive health specifically, or minority youth may rely on rigid, exclusionary, and including national health care systems and government ultimately counterproductive frameworks to assert self- investment in job training and opportunities for young peo- and group-worth (Froyum 2007). Failure to recognize ple, easing the transition into adulthood, facilitating long- erroneous assumptions and the lived reality of youth can term planning, and reducing the motivation to have a child prematurely. The authors conclude ‘‘improving adolescents’ lead to unintended effects on adolescent sexuality, pro- moting exclusion of teens who do not conform to expected socioeconomic status is a way to prevent their having poor gender and sexual norms and ultimately failing to reduce reproductive health outcomes—not only unplanned or early inequality (Bedford 2008; Drucker 2009). Sexual health pregnancies or births, but also STDs’’ (p. 258). education must thus recognize the diverse life course tra- Policy makers should heed lessons learned from our jectories and family formations that characterize students’ country’s success in reducing poverty among the elderly, lives. In addition, scholars have argued, sexual health and from other countries’ successes in better promoting education must create opportunities for students to discuss adolescent sexual and reproductive health by investing in sexual agency and risks in the context of their broader life multi-faceted and multi-level poverty alleviation efforts aspirations and the multifold factors that constraints those that build youth assets and promote health. For individual aspirations (Fields 2008; Fine and McClelland 2006; Ro- adolescents, efforts are needed to enhance adolescents’ gow and Haberland 2005). Although sexual health educa- motivation for personal and professional achievement (e.g., tion cannot remove the structural disparities, by giving healthy interpersonal relationships, education and occupa- young people the opportunity to critically examine the tion), and avoid behaviors that increase risks of STIs, poor inequalities they encounter, it can bolster their ability to emotional and physical health, and early pregnancy and respond to them. childbearing. We also need to target structural barriers Policy makers must also promote adolescent sexual and created by economic, racial and ethnic inequalities (e.g., reproductive health by investing in youth through multi- increase resources for high-poverty schools), and offer faceted and multi-level poverty alleviation efforts that support services to help families and their children (e.g., build youth assets and promote health. Despite frequently adequate funding for Title X family planning clinics) as voiced concerns about the intractable nature of poverty they move toward better financial security, without predi- (and by extension, hopelessness), the United States has a cation of assistance on particular family structures that may track record of intentional and effective large-scale not be feasible for or desired by all individuals. 123 J Youth Adolescence (2014) 43:1595–1610 1605 Conclusions and Recommendations Based on these considerations, we offer several recom- mendations for federal sexual health education policy, as US federal sexual health policy has come a long way since well as for more effective translation of science into poli- the introduction of AOUM policies when federally funded cymaking and programming. First, adolescent sexual and programs were often medically inaccurate, were prohibited reproductive health policy should be based on scientific from teaching the health benefits of condoms and contra- input from a broad range of disciplines, including social, ception, and were required to teach students that sex outside behavioral, medical, and public health sciences. The full of heterosexual marriage would damage them. In providing range of scientific evidence should guide adolescent sexual our critique we acknowledge the strides that have been and reproductive health policies, including adolescent made in current federal policies and initiatives, and we also sexual health education. Federally-funded programs must acknowledge that US sexual health education programs and address gender, poverty, and lesbian, gay, bisexual, trans- policies exist in a cultural and political context that is not gender, queer, and questioning (LGBTQ) youth. Federal fully conducive to holistic approaches to adolescent sexual policy makers should engage in conversation with the health education, or to the full range of contemporary sci- broad range of scientific communities and professional ence in this field. The current ‘‘evidence-based’’ policy, societies. Policy makers and federal program administra- while a significant leap forward, is limited in a number of tors must draw on scientific advisors to help translate the ways. The US federal policy continues to fund abstinence- broader evidence base, and guide the development of only programs as part of its Teen Pregnancy Prevention interventions that reflect current scientific thinking. Fur- Initiative as well as other funding streams. But more ther, scientists must become actively engaged in the important, the definition of scientific evidence is limited to a translation of their work for policy and practice. narrow understanding of what constitutes the broad scien- Second, sexual health education should be inclusive of tific evidence for adolescent sexual and reproductive health. a wide range of viewpoints and populations without The current policy does not require programs to be engaged stigmatizing any group. It should avoid heteronormative with the breadth of current scientific thinking about ado- approaches and aim to strengthen young people’s capacity lescents and their sexual health. to challenge harmful stereotypes. In cooperation with We have sought to highlight the limitations of EBIs by scientists and health professional associations, content examining three bodies of literature on topics about which guidelines should be established for federally-funded there is growing scientific consensus. This evidence indi- sexuality education programs to assure medical accuracy cates that adolescent sexual health is undermined by the as well as gender equity and inclusion of LGBTQ youth. exclusion and stigmatization of LGBTQ youth, gender This should be a priority across federal agencies and inequities and stereotypes, and poverty and structural rac- throughout the Department of Health and Human Ser- ism. Likewise, the research shows that greater inclusive- vices, including the CDC, Administration for Children ness, more gender and economic equity, and freedom from and Families, and the Office of Adolescent Health (in harmful stereotypes, all benefit young people and their particular, in its next round of teen pregnancy prevention sexual health. And yet, although there are some excellent programs). programs that approach adolescent sexuality holistically Finally, sexuality education programs and policies must (see for instance, International Sexuality and HIV Curric- acknowledge the role that structural and contextual factors ulum Working Group 2011), federal policy does not play in sexual risk. Comprehensive sexuality education require its recipients of funds to address these critical should recognize personal, interpersonal, social, economic topics, and indeed very few federally funded programs do. and cultural factors that shape adolescents’ sexual moti- When federally funded sexual health education does not vations and behaviors. A fundamental goal must be the intentionally address these topics, it may overtly or inad- removal of economic, gender and LGBTQ disparities in vertently promulgate gender, sexual orientation, class, and adolescent sexual and reproductive health through laws, racial stereotyping, and fail to give youth resources to regulations, and funding requirements. combat them. Gender, heterosexual, economic and racial Structural inequalities that are critical barriers to ado- biases in sexual health education leave youth without the lescent sexual health promotion are at the heart of some of personal agency and the critical knowledge they need to the most contested issues in American society: the sexual make safer sexual choices. orientation of adolescents, concepts of gender, and eco- nomic and racial inequalities. When federally funded health interventions do not engage directly with these Encouragingly, the federal government has, under its tier 2 funding issues, and thus ignore the broader scientific consensus for experimental programs, supported program development and regarding adolescent sexual and reproductive health, they evaluation in some of research areas we have highlighted, including a run the risk of reproducing these inequalities (Fine and program to address and change harmful gender beliefs. 123 1606 J Youth Adolescence (2014) 43:1595–1610 Bay-Cheng, L. Y. (2003). The trouble of teen sex: The construction of McClelland 2006). By incorporating the full range of sci- adolescent sexuality through school-based sexuality education. entific evidence regarding adolescent sexual and repro- Sex Education: Sexuality, Society and Learning, 3(1), 61–74. ductive health, federal, state, and local efforts will be best Bedford, K. (2008). Holding it together in a crisis: Family strength- positioned to promote adolescent health and well-being. ening and embedding neoliberalism. IDS Bulletin, 39(6), 60–66. Birkett, M., Espelage, D. L., & Koenig, B. (2009). LGB and questioning students in schools: The moderating effects of Acknowledgments This paper began as a series of conversations homophobic bullying and school climate on negative outcomes. about the role of science in sexuality education and adolescent health Journal of Youth and Adolescence, 38(7), 989–1000. policy among the four primary authors and leaders of the Future of Blake, S. M., Ledsky, R., Lehman, T., Goodenow, C., Sawyer, R., & Sex Education group. We thank our insightful colleagues who Hack, T. (2001). Preventing sexual risk behaviors among gay, reviewed various drafts and provided invaluable insights, including lesbian, and bisexual adolescents: The benefits of gay-sensitive Heather Boonstra, Jesseca Boyer, Kurt Conklin, Nicole Cushman, HIV instruction in schools. American Journal of Public Health, Jessica Fields, Debra Hauser, Barbara Huberman, Leslie M. Kantor, 91(6), 940–946. Arik V. Marcell, Ann Meier, Anthony Paik, Pat Paluzzi, Monica Bowleg, L., Belgrave, F. Z., & Reisen, C. A. (2000). Gender roles, Rodriguez, Elizabeth Schroeder, and Danene Sorace, as well as the power strategies, and precautionary sexual self-efficacy: Impli- JYA Editor and anonymous peer reviewers. We acknowledge modest cations for Black and Latina women’s HIV/AIDS protective stipends from the Future of Sex Education to the four junior authors, behaviors. Sex roles, 42(7–8), 613–635. and additional support from the Frances McClelland Institute for Brooks-Gunn, J., Duncan, G. J., & Aber, J. L. (1997). Neighborhood Children, Youth, and Families at the University of Arizona for open poverty. Context and consequences for children (Vol. 1). New access to this article. York: Russell Sage Foundation. Bullock, C. M., & Beckson, M. (2011). Male victims of sexual Open Access This article is distributed under the terms of the assault: Phenomenology, psychology, physiology. Journal of the Creative Commons Attribution License which permits any use, dis- American Academy of Psychiatry and the Law Online, 39(2), tribution, and reproduction in any medium, provided the original 197–205. author(s) and the source are credited. Carter, J. B. (2001). Birds, bees, and venereal disease: toward an intellectual history of sex education. Journal of the History of Sexuality, 10(2), 213–249. References Center for School, Health, and Education. (2011). The health, well- being and educational success of school-aged youth and school- based health care. Retrieved from http://www.schoolbasedhealth Allen, L. (2003). Girls want sex, boys want love: Resisting dominant care.org/wp-content/uploads/2011/09/APHA4_article_Health_Rev_ discourses of (hetero)sexuality. Sexualities, 6, 215–236. 9_14_FINAL2.pdf. Almeida, J., Johnson, R. M., Corliss, H. L., Molnar, B. E., & Azrael, Centers for Disease Control and Prevention. (2006). Physical dating D. (2009). Emotional distress among LGBT youth: The influence violence among high school students—United States, 2003. of perceived discrimination based on sexual orientation. Journal Morbidity and Mortality Weekly Report, 55(19), 529–552. of Youth and Adolescence, 38(7), 1001–1014. Centers for Disease Control and Prevention. (2011). HIV among Amaro, H., & Raj, A. (2000). On the margin: Power and women’s youth. Retrieved from http://www.cdc.gov/hiv/pdf/library_fact HIV risk reduction strategies. Sex Roles, 42(7–8), 723–749. sheet_HIV_amongYouth.pdf. Amaro, H., Raj, A., & Reed, E. (2001). Women’s sexual health: the Centers for Disease Control and Prevention. (2012a). Vital signs: HIV need for feminist analyses in public health in the decade of infection, testing, and risk behaviors among youth—United behavior. Psychology of Women Quarterly, 25(4), 324–334. States. Morbidity and Mortality Weekly Report, 61(47), American Academy of Pediatrics: Committee on Psychosocial 971–976. Aspects of Child and Family Health and Committee on Centers for Disease Control and Prevention. (2012b). Estimated HIV Adolescence. (2001). Sexuality education for children and incidence in the United States, 2007–2010. HIV Surveillance adolescents. Pediatrics, 108(2), 498–502. Supplemental Report 17 (No. 4). Retrieved from http://www.cdc. American Civil Liberties Union. (2008). What the research shows: gov/hiv/topics/surveillance/resources/reports/#supplemental. Government-funded abstinence-only programs don’t make the Centers for Disease Control and Prevention. (2013a). Incidence, grade. American Civil Liberties Union. Retrieved from https://www. Prevalence, and Cost of Sexually Transmitted Infections in the aclu.org/reproductive-freedom/what-research-shows-government- United States. Retrieved from http://www.cdc.gov/std/stats/sti- funded-abstinence-only-programs-don%E2%80%99t-make-grade. estimates-fact-sheet-feb-2013.pdf. American Public Health Association. (2006). Abstinence and U.S. Centers for Disease Control and Prevention. (2013b). CDC Health abstinence-only education policies: Ethical and human rights Disparities and Inequalities Report—United States. 2013. Mor- concerns. (Policy Statement 200610). Retrieved from http://www. bidity and Mortality Weekly Report, 62(Suppl 3), 1–187. apha.org/advocacy/policy/policysearch/default.htm?id=1334. Centers for Disease Control and Prevention. (2013b). Results from the Anderson, L. M., Brownson, R. C., Fullilove, M. T., Teutsch, S. M., School Health Policies and Practices Study 2012. Retrieved from Novick, L. F., Fielding, J., et al. (2005). Evidence-based public http://www.cdc.gov/healthyyouth/shpps/2012/pdf/shpps-results_ health policy and practice: Promises and limits. American 2012.pdf. Journal of Preventive Medicine, 28(5S), 226–230. Centers for Disease Control and Prevention. (2013c). Compendium of Armas, H. (2007). Whose sexuality counts? Poverty, participation, Evidence-Based HIV Behavioral Interventions. Retrieved from and sexual rights (Working Paper No. 294). Institute of http://www.cdc.gov/hiv/prevention/research/compendium/index. Development Studies at the University of Sussex. Retrieved html. from http://www2.ids.ac.uk/gdr/cfs/pdfs/Wp306.pdf. Chambers, D., Tincknell, E., & Van Loon, J. (2004). Peer regulation Armstrong, E. A., Hamilton, L., & Sweeney, B. (2006). Sexual assault of teenage sexual identities. Gender and Education, 16(3), on campus: A multilevel, integrative approach to party rape. 397–415. Social Problems, 53(4), 483–499. 123 J Youth Adolescence (2014) 43:1595–1610 1607 Chin, H. B., Sipe, T. A., Elder, R., Mercer, S. L., Chattopadhyay, S. Fitzpatrick, M. K., Salgado, D. M., Suvak, M. K., King, L. A., & K., Jacob, V., et al. (2012). The effectiveness of group-based King, D. W. (2004). Associations of gender and gender-role comprehensive risk-reduction and abstinence education inter- ideology with behavioral and attitudinal features of intimate ventions to prevent or reduce the risk of adolescent pregnancy, partner aggression. Psychology of Men & Masculinity, 5, human immunodeficiency virus, and sexually transmitted infec- 91–102. tions: Two systematic reviews for the guide to community Floyd, F. J., & Bakeman, R. (2006). Coming-out across the life preventive services. American Journal of Preventive Medicine, course: Implications of age and historical context. Archives of 42(3), 272–294. Sexual Behavior, 35(3), 287–296. Cianciotto, J., & Cahill, S. R. (2003). Education policy: Issues Froyum, C. M. (2007). ‘At Least I’m Not Gay’: Heterosexual identity affecting lesbian, gay, bisexual and transgender youth. National making among poor black teens. Sexualities, 10(5), 603–622. Gay and Lesbian Task Force Policy Institute. Washington, DC. Froyum, C. M. (2010). Making ‘good girls’: Sexual agency in the Collins, P. (2005). Black sexual politics: African Americans, gender, sexuality education of low income black girls. Culture, Health and the new racism (New Ed edition.). New York: Routledge. and Sexuality, 12(1), 59–72. Council of Economic Advisers. (2014). The war on poverty 50 years Gallagher, K. E., & Parrott, D. J. (2011). What accounts for men’s later: A progress report. Retrieved from http://www.whitehouse. hostile attitudes toward women? The influence of hegemonic gov/sites/default/files/docs/50th_anniversary_cea_report_-_final_ male role norms and masculine gender role stress. Violence post_embargo.pdf. against women, 17(5), 568–583. Crawford, M., & Popp, D. (2003). Sexual double standards: A review Garcia, L. (2009). ‘‘Now why do you want to know about that?’’ and methodological critique of two decades of research. Journal Heteronormativity, sexism, and racism in the sexual (mis) of Sex Research, 40(1), 13–26. education of Latina youth. Gender & Society, 23(4), 520–541. Crowder, K., & South, S. J. (2003). Neighborhood distress and school Garcia, L. (2012). Respect yourself, protect yourself: Latina girls and dropout: The variable significance of community context. Social sexual identity. New York: NYU Press. Science Research, 32, 659–698. Gee, G. C., & Ford, C. L. (2011). Structural racism and health Curran, L. B. (2011). What’s missing? Discourses of gender and inequities: Old issues, new directions. Du Bois Review, 8(1), sexuality in federally-funded sex education. The George Wash- 115–132. ington University. Retrieved from http://gradworks.umi.com/34/ Giordano, P. C., Manning, W. D., & Longmore, M. A. (2006). Gender 68/3468516.html. and the meanings of adolescent romantic relationships: A focus DeLamater, J. (2007). Gender equity in formal sexuality education. In on boys. American Sociological Review, 71(2), 260–287. S. S. Klein, et al. (Eds.), Handbook for achieving gender equity Goodenow, C., Szalacha, L., & Westheimer, K. (2006). School through education (pp. 411–420). New York: Routledge. support groups, other school factors, and the safety of sexual Dinkelman, T., Lam, D., & Leibbrandt, M. (2008). Linking poverty minority adolescents. Psychology in the Schools, 43(5), and income shocks to risky sexual behaviour: Evidence from a 573–589. panel study of young adults in Cape Town. South African Grantham-McGregor, S., Cheung, Y. B., Cueto, S., Glewwe, P., Journal of Economics, 76(s1), S52–S74. Richter, L., & Strupp, B. (2007). Developmental potential in the Dodoo, F., Zulu, E. M., & Ezeh, A. C. (2007). Urban–rural first 5 years for children in developing countries. Lancet, differences in the socioeconomic deprivation—Sexual behavior 369(9555), 60–70. link in Kenya. Social Science and Medicine, 64(5), 1019–1031. Greene, K., & Faulkner, S. (2005). Gender, belief in the sexual double Drucker, P. (2009). Changing families and communities: An LGBT standard, and sexual talk in heterosexual dating relationships. contribution to an alternative development path. Development in Sex Roles, 53(3/4), 239–251. Practice, 19(7), 825–836. Grose, R. G., Grabe, S., & Kohfeldt, D. (2014). Sexual education, Duncan, G. J., & Rodgers, W. L. (1988). Longitudinal aspects of gender ideology, and youth sexual empowerment. Journal of Sex childhood poverty. Journal of Marriage and the Family, 50(4), Research, 51(7), 742–753. 1007. Gutierrez, L., Oh, H. J., & Gillmore, M. R. (2000). Toward an Duncan, G. J., Ziol-Guest, K. M., & Kalil, A. (2010). Early-childhood understanding of (em)power(ment) for HIV/AIDS prevention poverty and adult attainment, behavior, and health. Child with adolescent women. Sex Roles, 42(7/8), 581–611. Development, 81(1), 306–325. Guttmacher Institute. (2013). Sex and HIV education, state policies in Eder, D., Evans, C. C., & Parker, S. (1995). School talk: Gender and brief. Retrieved from http://www.guttmacher.org/statecenter/ adolescent culture. New Brunswick, NJ: Rutgers University spibs/spib_SE.pdf. Accessed July 5, 2013. Press. Halpern, C. T., & Haydon, A. (2012). Sexual timetables for oral- Evidence Based Intervention Network. (2011). What are evidence genital, vaginal, and anal sex: Sociodemographic comparisons in based interventions (EBI)? Retrieved from: http://ebi.missouri. a nationally representative sample. American Journal of Public edu/?page_id=52. Health, 102(6), 1221–1228. Fichtenberg, C. M., Jennings, J. M., Glass, T. A., & Ellen, J. M. Hamilton, L., & Armstrong, E. (2009). Gendered sexuality in young (2010). Neighborhood socioeconomic environment and sexual adulthood: Double binds and flawed options. Gender and network position. Journal of Urban Health-Bulletin of the New Society, 23(5), 589–616. York Academy of Medicine, 87(2), 225–235. Higgins, J., Hoffman, S., & Dworkin, S. (2010). Rethinking gender, Fields, J. (2008). Risky lessons: Sex education and social inequality. heterosexual men, and women’s vulnerability to HIV/AIDS. New Brunswick, NJ: Rutgers University Press. American Journal of Public Health, 100(3), 435–445. Fine, M., & McClelland, S. I. (2006). Sexuality education and desire: Hirst, J. (2013). It’s got to be about enjoying yourself: Young people, Still missing after all these years. Harvard Educational Review, sexual pleasure, and sex and relationships education. Sex 76(3), 297–338. Education, 13(4), 423–436. Finer, L. (2007). Trends in premarital sex in the United States, Holland, J., Ramazanglou, C., Sharpe, S., & Thomson, R. (1998). The 1954–2003. Public Health Reports, 122(1), 73–78. male in the head: Young people, heterosexuality and power (p. Fischer, C. S., Jankowski, M. S., Hout, M., Lucas, S. R., Swidler, A., 1998). London: Tufnell Press. & Voss, K. (1996). Inequality by design: Cracking the bell curve Iceland, J., & Scopilliti, M. (2008). Immigrant residential segregation myth. Princeton, NJ: Princeton University Press. in US metropolitan areas, 1990–2000. Demography, 45, 79–94. 123 1608 J Youth Adolescence (2014) 43:1595–1610 Impett, E. A., Schooler, D., & Tolman, D. L. (2006). To be seen and Morris, E. W. (2007). ‘‘Ladies’’ or ‘‘loudies’’? Perceptions and not heard: Femininity ideology and adolescent girls’ sexual experiences of black girls in classrooms. Youth & Society, 38(4), health. Archives of Sexual Behavior, 35(2), 129–142. 490–515. International Sexuality and HIV Curriculum Working Group. (2011). Murnen, S., Wright, C., & Kaluzny, G. (2002). If ‘‘boys will be It s All one curriculum: Guidelines and activities for a unified boys’’, then girls will be victims? A meta-analytic review of the approach to sexuality, gender, HIV, and human rights. New York: research that relates masculine ideology to sexual aggression. Population Council. Retrieved from http://www.itsallone.org. Sex Roles, 46(11/12), 359–375. Irvine, J. M. (2004). Talk about sex: The battles over sex education in Murry, V. M., Heflinger, C. A., Suiter, S. V., & Brody, G. H. the United States. Oakland: University of California Press. (2011). Examining perceptions about mental health care and Jewkes, R. (2010). Gender inequities must be addressed in HIV help-seeking among rural African American families of prevention. Science, 329(5988), 145–147. adolescents. Journal of Youth and Adolescence, 40(9), Kimmel, M. (2008). Guyland: The perilous world where boys become 1118–1131. men. New York: Harper. Mustanski, B. S., Newcomb, M. E., Du Bois, S. N., Garcia, S. C., & Kirby, D. B. (2002). Effective approaches to reducing adolescent Grov, C. (2011). HIV in young men who have sex with men: A unprotected sex, pregnancy, and childbearing. Journal of sex review of epidemiology, risk and protective factors, and research, 39(1), 51–57. interventions. Journal of Sex Research, 48(2–3), 218–253. Kirby, D. B. (2008). The impact of abstinence and comprehensive sex National Center for Education Statistics. (2013). Back to school and STD/HIV education programs on adolescent sexual behav- statistics. Retrieved from http://nces.ed.gov/fastfacts/display. ior. Sexuality Research & Social Policy, 5(3), 18–27. asp?id=372. Kirby, D. B., Laris, B. A., & Rolleri, L. A. (2007a). Sex and HIV National Research Council. (2009). Adolescent health services: education programs: Their impact on sexual behaviors of young Missing opportunities. Washington, DC: The National Acade- people throughout the world. Journal of Adolescent Health, 40, mies Press. 206–217. National Research Council. (2013). U.S. Health in international Kirby, D. B., Rolleri, L., & Wilson, M. (2007b). Tool to assess the perspective: Shorter lives, poorer health. Washington, DC: characteristics of effective sex and STD/HIV education pro- National Academy Press. grams. Washington, DC: Healthy Teen Network. Noar, S. M., & Morokoff, P. J. (2002). The relationship between Kirkman, M., Rosenthal, D., & Smith, A. M. (1998). Adolescent sex masculinity ideology, condom attitudes, and condom use stage and the romantic narrative: Why some young heterosexuals use of change: A structural equation modeling approach. Interna- condoms to prevent pregnancy but not disease. Psychology, tional Journal of Men’s Health, 1(1), 43–58. Health & Medicine, 3(4), 355–370. Office of Adolescent Health. (2014a). Teen Pregnancy Prevention Klein, J. (2012). The bully society: School shootings and the crisis of Resource Center: Evidence-based programs database. Rockville, bullying in America’s schools. New York: NYU Press. MD: Department of Health and Human Services. Retrieved from Kosciw, J. G., Greytak, E. A., Bartkiewicz, M. J., Boesen, M. J., & http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/db/ Palmer, N. A. (2012). The 2011 National School Climate Survey: tpp-searchable.html. The experiences of lesbian, gay, bisexual and transgender youth Office of Adolescent Health. (2014b). Success story: Engender in our nation’s schools. New York: Gay, Lesbian and Straight health- gender matters: Changing teen’s perspective on gender Education Network (GLSEN). roles and working to decrease teen pregnancy in Travis County, Kosciw, J. G., Greytak, E. A., & Diaz, E. M. (2009). Who, what, Texas. Rockville, MD: Department of Health and Human where, when, and why: Demographic and ecological factors Services. Retrieved from http://www.hhs.gov/ash/oah/oah-initia contributing to hostile school climate for lesbian, gay, bisexual, tives/teen_pregnancy/successes/print/engenderhealth.pdf. and transgender youth. Journal of Youth and Adolescence, 38, Pascoe, C. J. (2007). Dude you’re a fag: Masculinity and sexuality in 976–988. high school. Berkeley, CA: University of California Press. Lamb, S., Lustig, K., & Graling, K. (2013). The use and misuse of Pearson, J. (2006). Personal control, self-efficacy in sexual negoti- pleasure in sex education curricula. Sex Education: Sexuality, ation, and contraceptive risk among adolescents: The role of Society and Learning, 13(3), 305–318. gender. Sex Roles, 54(9–10), 615–625. Luker, K. (2007). When sex goes to school: Warring views of sex—and Petitifor, A. (2012). ‘If I buy the Kellogg’s then he should [buy] the sex education—since the sixties. New York: W.W. Norton & Co. milk’: Young women’s perspectives on relationship dynamics, Marı ´n, B. V., Go ´ mez, C. A., Tschann, J. M., & Gregorich, S. E. gender power and HIV risk in Johannesburg, South Africa. (1997). Condom use in unmarried Latino men: A test of cultural Culture, Health and Sexuality, 14(5), 477–490. constructs. Health Psychology, 16(5), 458. Phillips, L. (2000). Flirting with danger: Young women’s reflections Marston, C., & King, E. (2006). Factors that shape young people’s on sexuality and domination. New York: NYU Press. sexual behaviour: A systematic review. The Lancet, 368(9547), Pleck, J. H., Sonenstein, F. L., & Ku, L. C. (1993). Masculinity 1581–1586. ideology: Its impact on adolescent males’ heterosexual relation- Martin, K. (1996). Puberty, sexuality and the self: Girls and boys at ships. Journal of Social Issues, 49(3), 11–29. adolescence. New York: Routledge. Pleck, J. H., Sonenstein, F. L., & Ku, L. C. (1994). Attitudes toward Mayer, K. H., Bradford, J. B., Makadon, H. J., Stall, R., Goldhammer, male roles among adolescent males: A discriminant validity H., & Landers, S. (2008). Sexual and gender minority health: analysis. Sex roles, 30(7–8), 481–501. What we know and what needs to be done. American Journal of Poteat, V. P., Sinclair, K. O., DiGiovanni, C. D., Koenig, B. W., & Public Health, 98(6), 989–995. Russell, S. T. (2013). Gay-straight alliances are associated with McGovern, A. E. (2012). When schools refuse to ‘‘say gay’’: The student health: A multischool comparison of LGBTQ and constitutionality of anti-LGBTQ ‘‘no promo-homo’’ public Heterosexual Youth. Journal of Research on Adolescence, school policies in the United States. Cornell Journal of Law 23(2), 319–330. and Public Policy, 22(2), 465–490. Pulerwitz, J., Amaro, H., Jong, W. D., Gortmaker, S. L., & Rudd, R. Moran, J. P. (2002). Teaching sex: The shaping of adolescence in the (2002). Relationship power, condom use and HIV risk among 20th century. Cambridge, MA: Harvard University Press. women in the USA. AIDS care, 14(6), 789–800. 123 J Youth Adolescence (2014) 43:1595–1610 1609 Ramirez-Valles, J., Zimmerman, M. A., & Juarez, L. (2002). Gender Singh, S., Darroch, J., & Frost, J. (2001). Socioeconomic disadvan- differences of neighborhood and social control processes: A study tage and adolescent women’s sexual and reproductive behavior: of the timing of first intercourse among low-achieving, urban, The case of five developed countries. Family Planning Perspec- African American youth. Youth and Society, 33(3), 418–441. tives, 33(6), 251–289. Resnick, M. D., Catalano, R. F., Sawyer, S. M., Viner, R., & Patton, Snell, E. K., Castells, N., Duncan, G., Gennetian, L., Magnuson, K., G. C. (2012). Seizing the opportunities of adolescent health. The & Morris, P. (2013). Promoting the positive development of Lancet, 379(9826), 1564–1567. boys in high-poverty neighborhoods: Evidence from four anti- Rogow, D., & Haberland, N. (2005). Sexuality and relationships poverty experiments. Journal of Research on Adolescence, education: Toward a social studies approach. Sex Education: 23(2), 357–374. Sexuality, Society and Learning, 5(4), 333–344. Suitts, S., Sabree, N., & Dunn, K. (2013). A new majority: Low Rolleri, L. A. (2013a). Can gender norms change? Research facts and income students in the South and Nation. Southern Education findings. Ithaca, NY: ACT for Youth. Foundation. Retrieved from http://www.southerneducation.org/ Rolleri, L. A. (2013b). gender norms and sexual health behaviors. getattachment/0bc70ce1-d375-4ff6-8340-f9b3452ee088/A-New- Research facts and findings. Ithaca, NY: ACT for Youth. Majority-Low-Income-Students-in-the-South-an.aspx. Romero, L. M., Galbraith, J. S., Wilson-Williams, L., & Gloppen, K. Tolman, D. L. (2002). Dilemmas of desire: teenage girls talk about M. (2011). HIV prevention among African American youth: sexuality. Cambridge, MA: Harvard University Press. How well have evidence-based interventions addressed key Trenholm, C., Devaney, B., Fortson, K., Clark, M., Quay, L., & theoretical constructs? AIDS and Behavior, 15(5), 976–991. Wheeler, J. (2008). Impacts of abstinence education on teen Rose, S. (2005). Going too far? Sex, sin and social policy. Social sexual activity, risk of pregnancy, and risk of sexually transmit- Forces, 84, 1207–1232. ted diseases. Journal of Policy Analysis and Management, 27(2), Rosenthal, L., & Levy, S. R. (2010). Understanding women’s risk for 255–276. HIV infection using social dominance theory and the four bases UNESCO. 2009. International technical guidance on sexuality of gendered power. Psychology of Women Quarterly, 34(1), education: An evidence-informed approach for schools, teachers 21–35. and health educators. Paris, France. Russell, S. T. (2005). Conceptualizing positive adolescent sexuality Way, N., Pascoe, C. J., Mccormack, M., Schalet, A., & Oeur, F. development. Sexuality Research and Social Policy., 2(3), 4–12. (2013). The hearts of boys. Contexts, 12(1), 14–23. Russell, S. T., Kosciw, J., Horn, S., & Saewyc, E. M. (2010). Safe Weber, L., & Parra-Medina, D. (2003). Intersectionality and schools policy for LGBTQ students. SRCD Policy Report, 24(4), women’s health: Charting a path to eliminating health dispar- 1–17. ities. In M. T. Segal & D. V. Kronenfeld (Eds.), Gender Saewyc, E. M., Bearinger, L. H., Blum, R. W., & Resnick, M. D. Perspectives on Health and Medicine (Advances in Gender (1999). Sexual intercourse, abuse and pregnancy among adoles- Research (Vol. 7, pp. 181–230). Bingley, UK: Emerald Group cent women: Does sexual orientation make a difference? Family Publishing. Planning Perspectives, 31(3), 127–131. Weinstock, H., Berman, S., & Cates, W. (2004). Sexually transmitted Saewyc, E. M., Homma, Y., Skay, C. L., Bearinger, L. H., Resnick, diseases among American youth: Incidence and prevalence M. D., & Reis, E. (2009). Protective factors in the lives of estimates, 2000. Perspectives on sexual and reproductive health, bisexual adolescents in North America. American Journal of 36(1), 6–10. Public Health, 99(1), 110–117. Wodtke, G. T. (2013). Duration and timing of exposure to neighbor- Sanchez, M. (2012). Providing inclusive sex education in schools will hood poverty and the risk of adolescent parenthood. Demogra- address the health needs of LGBT Youth. UCLA: Center for the phy, 50, 1765–1788. Study of Women. Retrieved from http://www.csw.ucla.edu/ World Health Organization. (1946). Constitution of the World Health publications/policy-briefs/policy-briefs/CSWPolicyBrief11.pdf. Organization as adopted by the International Health Conference. Santana, M. C., Raj, A., Decker, M. R., La Marche, A., & Silverman, Official Records of the World Health Organization, 2, 100. J. G. (2006). Masculine gender roles associated with increased World Health Organization. (2002). WHO Gender Policy: integrating sexual risk and intimate partner violence perpetration among gender perspectives in the work of WHO. Geneva: World Health young adult men. Journal of Urban Health, 83(4), 575–585. Organization. Santelli, J., Ott, M. A., Lyon, M., Rogers, J., Summers, D., & Schleifer, R. (2006). Abstinence and abstinence-only education: Amy T. Schalet is Associate Professor of Sociology at the University A review of US policies and programs. Journal of Adolescent of Massachusetts Amherst. Her research interests include culture, Health, 38(1), 72–81. adolescent sexual and reproductive health, gender, qualitative meth- Sawyer, S. M., Afifi, R. A., Bearinger, L. H., Blakemore, S. J., Dick, ods, and political sociology. B., Ezeh, A. C., et al. (2012). Adolescence: A foundation for future health. The Lancet, 379(9826), 1630–1640. Schalet, A. T. (2011a). Beyond abstinence and risk: A new paradigm John S. Santelli is the Harriet and Robert H. Heilbrunn Professor in for adolescent sexual health. Women’s Health Issues. 21(3S), the Heilbrunn Department of Population and Family Health at S5–S7. Columbia University and a past President of the Society for Schalet, A.T. (2011b). Not under my roof: Parents, teens, and the Adolescent Health and Medicine. His research interests include the culture of sex. Chicago: University of Chicago Press. sexual and reproductive health of youth, including social determinants Shearer, C. L., Hosterman, S. J., Gillen, M. M., & Lefkowitz, E. S. and clinical and structural interventions, and the ethical inclusion of (2005). Are traditional gender role attitudes associated with risky adolescents in health research. sexual behavior and condom-related beliefs? Sex Roles, 52(5–6), 311–324. Stephen T. Russell is Distinguished Professor, Fitch Nesbitt SIECUS. (2014). A History of Federal Funding for Abstinence-Only- Endowed Chair, and Interim Director of the Norton School of Family Until-Marriage Programs. SIECUS. Retrieved from http://www. and Consumer Sciences at the University of Arizona, and past siecus.org/document/docWindow.cfm?fuseaction=document.view President of the Society for Research on Adolescence. He studies Document&documentid=115&documentFormatId=133. cultural differences in parent-adolescent relationships, and the health 123 1610 J Youth Adolescence (2014) 43:1595–1610 of sexual minority adolescents focusing on structural conductions that interests include adolescent sexual and reproductive health, gender, promote their healthy development. and human rights. Carolyn T. Halpern is Professor in the Department of Maternal & Shoshana K. Goldberg has an MPH from the University of North Child Health in the Gillings School of Global Public Health at the Carolina at Chapel Hill and is a doctoral student in Maternal & Child University of North Carolina at Chapel Hill. Her research focuses on Health in the Gillings School of Global Public Health at the adolescent sexual and reproductive health and implications for the University of North Carolina at Chapel Hill. Her research interests transition to adulthood. include sociocultural determinants of domestic adolescent sexual health and sexual development, with a focus on structural determi- nants of the health and well-being of sexual minority youth. Sarah A. Miller is a doctoral candidate in Sociology at University of Massachusetts Amherst and has an MA in Women’s Studies from San Francisco State University. Her research interests include youth, Jennifer M. Hoenig has an MPH from Emory University and is a sexuality, social inequality, and culture. doctoral candidate in Family Studies and Human Development at the University of Arizona. Her research focuses on health and education inequity among lesbian, gay, bisexual, transgender, and questioning Sarah S. Pickering has an MPH from the Heilbrunn Department of (LGBTQ) youth. Population and Family Health at Columbia University. Her research

Journal

Journal of Youth and AdolescencePubmed Central

Published: Sep 9, 2014

There are no references for this article.