Each time health instructor Konstance McCaffree started her junior high unit on human sexuality, she would open it up to questions from the 15-year-old students.
Shy and embarrassed about the "taboo" subject, they'd either stay quiet or protest that they'd heard it all before. So, she handed out 3x5 cards and asked them to write down their now-anonymous questions.
"I kept every single one of those cards for years," says McCaffree, a certified sexuality educator with more than 35 years of school-teaching experience. "I had hundreds and hundreds of those cards, in case anybody came back and said, 'Why are you teaching this?' (I could say) 'Here's the card. This is what kids are asking me.'"
McCaffree's students were always inquisitive, but one question came up over and over throughout her career, and remains a pertinent question today, she says.
"How does someone get pregnant, or not get pregnant?"
"That kind of question doesn't get answered a lot," she said. "The answer is 'just don't do it and you won't get pregnant,' instead of taking the time to explain it."
But the "right way" to explain sex and healthy sexuality to teenagers has been a decades-long debate involving parents, teachers, school districts and advocates with a variety of opinions.
Some worry about giving too much information, others worry about sharing too little, and many parents fear that any conversation will plant ideas and push kids to try stuff or "take away their innocence," says McCaffree, who also served on the board of directors of SIECUS, the Sexuality Information and Education Council of the United States.
This heated discussion has become its own culture war with labels for each side abstinence education versus comprehensive sex ed and has left in its wake an ideologically diverse curriculum patchwork in schools and communities across the country.
But it doesn't have to be that way, experts say.
In fact, relying on polarizing labels or perpetuating an "us versus them" mentality regarding sex ed may prevent a deeper discussion of what's actually going on in the complicated lives of today's youths and what can be done to help them.
While the numbers of teens having sex is going down, according to the Centers for Disease Control and Prevention, rates of sexually transmitted infections are at record-high levels, and sexual issues like sexting, sexual assault and revenge porn are omnipresent, leading experts to call for more unity, education and support for teens than ever before.
Experts say the first step toward a productive, teen-focused discussion requires recognizing that sex-ed programs across the ideological spectrum are working for different kids, with different needs, in different areas and that successful evidenced-based programs may be more alike than people think, as they focus on broadening the sex-ed discussion and teaching real-world skills.
Many experienced people who have worked in the field realize theres no one-size-fits-all answer, says Leah Robin, lead health scientist in the CDCs Division of Adolescent and School Health. You have to really take into account (the kids) communities, cultural context, developmental stage all of these things add up to the need for a variety of different approaches to help our youth make healthy decisions.
Cutting through criticism
But when neither side can even agree on what to call the other, it's difficult to find the middle ground Robin describes.
Previously called "abstinence only until marriage education," this side teaches that avoiding all sexual interaction is the only 100 percent safe way to avoid STDs and pregnancy, as well as heartbreak and rejection, and now prefers the term sexual-risk avoidance education. They refer to the other side as sexual-risk reduction education.
We dont like the term comprehensive sex education because it (projects) that it provides an even-handed approach that gives young people all the information to make healthy choices, when it fact it normalizes teen sex, and puts the emphasis on reducing the risk, rather than eliminating it, says Valerie Huber, president and CEO of Ascend, formerly the National Abstinence Education Association. You cant blend the two (approaches) when you have underlying differences in foundation and the measure for success.
Huber and others opposed to comprehensive sex-ed point out that while curriculum topics may seem similar between the two camps, the approaches are very different, and that comprehensive sex-ed's message is: "theres really no red light as long as you do it right," she says.
Those in the comprehensive sex-ed camp (who are still OK with that label) reject the idea they are pushing teens toward sex. They say they provide crucial health information which includes the benefits of delaying sex as well as medical information for sexually active teens without adding values that are "shaming and stigmatizing," said Jen Slonaker, vice president of education and training at Planned Parenthood League of Massachusetts.
Many comprehensive programs specifically state that values and morals should come from the child's parents not the teacher.
Abstinence-based classes have also been criticized for relying on medically inaccurate information or scare tactics to curb risky behavior, Slonaker said.
One of the most oft-cited studies against abstinence-based education is a 2007 report from Mathematica Policy Research, which studied four different abstinence programs and found that teens in those programs were no more likely to delay sexual behavior than those in control groups.
The report has been cited for years as evidence to abandon abstinence education and divert government funding to comprehensive sex-ed instead.
Yet such a shift is unwarranted, argues Stan Weed of the Institute for Research and Evaluation and a leading authority on and reviewer of abstinence education curricula.
The Mathematica study did not examine safer sex programs, nor suggest that they are the obvious default if abstinence programs are not successful, he wrote in a lengthy rebuttal.
Weed argued that four programs cannot be generalized to the entire body of abstinence curricula many of which have proven successful in other studies.
Besides, he says, no program, abstinence-based or comprehensive, has ever been proven to have an impact (without reinforcement) three to five years after taking the program the length of time studied by Mathematica.
Most programs are considered successful and impactful if teens show effects one year after program involvement.
Our research shows, not surprisingly, that some programs work and some dont, Weed wrote. The important questions are which ones do and why?
Finding what works
In a review of sex-ed programs, Child Trends, a leading nonprofit research organization focused on children, youths and their families, identified 56 programs that proved to be effective on some levels and dozens more that failed.
The suprising thing for us was that theres all kinds of effective programs, said Jennifer Manlove, one of the lead authors for the 2015 report and a senior research scientist at Child Trends. We cant put them into one convenient category that is THE effective program approach. Abstinence, comprehensive, clinic programs, youth development, parent involvement program every program group has at least a couple of programs that showed effectiveness.
The U.S. Department of Health and Human Services labels a program effective if it shows, through evaluation, at least one statistically significant positive impact in at least one of the following categories: delay of sexual activity, abstinence, reduced frequency of sexual activity, fewer sexual partners, increased contraceptive use and/or consistency of use, lower STD rates or lower pregnancy/birth rates.
For the past five years, more than two dozen programs have been funded through the federal Teen Pregnancy Prevention Program, and last month, the American Journal of Public Health released a special publication detailing results of the reviews.
The findings add to a growing body of evidence about what works for what populations, says Amy Farb, Office of Adolescent Health evaluation specialist.
"We should not expect any one program to be a magic bullet, effective with anyone, anywhere," Farb and her co-authors wrote. "Communities need to spend more time selecting programs that are the best fit and ensuring quality implementation."
The OAH has listed all the effective programs on its website and has "tried to make it easy for decision-makers and parents to see how each program stacks up," she said.
For example, a program designed for eighth-grade African-American boys and girls in an afterschool setting, but implemented by a school for 10th grade Caucasian students, may not produce the desired outcomes. Or if a school can't commit to a full nine-month, school-based program, it should pick something else, Farb said, rather than try to adapt it and hope it still works.
Once a program is chosen, it's important that educators make the message relevant for everyone in the classroom, and don't assume their students are either A. sexually active or B. not-sexually active, says Kim Miller, senior adviser for Youth Prevention at the CDC's Center for Global Health.
Instead, youths can be delayers or anticipators those who plan to avoid or initiate sex in the next year. Other teens are one-timers, meaning they've had sex once, while others may be having ongoing sex with a committed partner, or sex with multiple partners.
"Abstinence-based messages about sexual behavior may be effective for adolescents who do not see themselves as ready for sex (delayers), but not for adolescents who do (anticipators)," Miller wrote in 2000. "If anticipators initiate sex in a short time, as longitudinal studies suggest they do, they may need messages that focus on the potential consequences of having sex, peer pressure, (as well as) skills in safer-sex negotiation and condom use."
Relationship education
During a recent sex-ed lesson, instructor Paley Martin drew three columns on the white board in blue marker. At the top of the first one she wrote "dating," then asked the students what words came to mind.
She wrote down their answers: chocolate, going places, flowers, kissing, holding hands, trust, "Netflix and chill" a euphemism for "having sex."
Her next column was friendship, which brought out words like talking, hanging out, honesty, there for you, advice, nice, supportive.
The third column was marriage and another list: committment, kids, arguing, rings, children, money, sex, romance, trust, reliable.
Stepping back, Martin pointed to the first list. "Does this look like a good relationship?"
"Uh, some things could be left out," one boy said.
"Not compared to marriage," called another boy.
Martin, a sex-ed instructor from the Pregnancy Resource Center of Salt Lake City, Utah who teaches the effective Heritage Keepers Abstinence Education, asked the class which words on the first list made the relationship valuable.
"I'm glad we got 'trust' up there," Martin said. "It's one positive word. The rest are just a lot of fun activities."
She paused, then erased the second column headline "friendship" and replaced it with the word "dating." "What if dating looked like friendship?" Martin asked.
"Yeah, I like that," one boy said quietly.
"Friendship is a good relationship, and you're not having sex, but still having all these amazing benefits," Martin said, pointing to the long list. "Something to think about."
Traditionally, "sex-ed class" conjures up images of anatomical displays, discussions of STDs and the controversial condom demonstration. While often present, those topics are really just a sliver of an effective sexuality education curricula, experts say.
The best programs move beyond body parts and sexual behaviors (or no sexual behaviors) to a much broader picture of life-long health, which includes learning how to recognize healthy and unhealthy relationships, how to evaluate media messages, how to communicate effectively, think critically and make decisions consistent with personal values and beliefs.
"My goal is to change the paradigm for sex-ed/pregnancy/STD prevention in this country," said Marline Pearson, a sociologist at Madison Area Technical College and a developer of teen and young adult relationship and sexuality curriculum. "It's not just a body, health issue."
Pearson's "Love Notes," which she calls a relationship-based pregnancy prevention program, was recently added to the federal list of effective programs, after showing that participants were significantly less likely than a control group of peers to have ever had sex or ever been pregnant, as well as a few other high risk activities.
Teens are hungry for intimacy, she says, but without instruction on how to form healthy relationships first, they'll often turn to casual sex, then continue to be disappointed when they don't find intimacy.
"My message is that sex education from both camps should highlight relationship education," she said at a marriage conference several years ago. "Our programs need to have as much concern for the heart as for health."
Life skills
In Boston, school nurse and health teacher Jennifer Ryan begins her comprehensive sex-ed health class with a hypothetical situation.
"Imagine there is a girl or boy that you really like and want to date, but they're already dating your best friend," she tells the class. "Then one day, this person you like asks you to meet them after school at the Dunkin' Donuts across the street. What do you do?"
Ryan has the class break down the situation into three possible decisions to help students identify the pros and cons of each choice: A. Go to Dunkin' Donuts. B. Don't go. C. Tell your best friend that you were asked to go.
"I'm letting them know that decisions aren't always yes/no," Ryan said. "They usually have an action that goes with them what happens when you make the choice."
This "decision-making model" is a foundational piece of the Get Real curriculum, a TPP-approved evidence-based program created by Planned Parenthood League of Massachusetts for middle-schoolers, and something Ryan refers to often as she teaches students at Boston Collegiate Charter School.
While biological information about sex is important and relationship skills crucial, Ryan also wants to ensure that her students can evaluate information, make informed decisions and recognize consequences needed skills to navigate an increasingly sexualized world.
And it works. A review of the program found that in schools where students completed "Get Real," 16 percent fewer boys and 15 percent fewer girls had had sex by the end of eighth grade, compared to their peers at comparable schools.
The program also has a family homework component, and when families did the assignments together, boys who had taken the class in sixth grade were less likely than their non-program peers to have had sex by eighth grade.
And that, in a nutshell, is the goal of Kahana Bigelow, a health teacher at a junior high school who also teaches the Heritage Abstinence curriculum.
"I don't want them to think that sex is this absolutely terrible thing, because it's not," she said. "But at the age they're at, it just causes so many more problems for them than they need. Having them understand the consequences it can have for them now if I can do that, it's great for me, no matter what the program is. Just get them thinking about their futures."
Shy and embarrassed about the "taboo" subject, they'd either stay quiet or protest that they'd heard it all before. So, she handed out 3x5 cards and asked them to write down their now-anonymous questions.
"I kept every single one of those cards for years," says McCaffree, a certified sexuality educator with more than 35 years of school-teaching experience. "I had hundreds and hundreds of those cards, in case anybody came back and said, 'Why are you teaching this?' (I could say) 'Here's the card. This is what kids are asking me.'"
McCaffree's students were always inquisitive, but one question came up over and over throughout her career, and remains a pertinent question today, she says.
"How does someone get pregnant, or not get pregnant?"
"That kind of question doesn't get answered a lot," she said. "The answer is 'just don't do it and you won't get pregnant,' instead of taking the time to explain it."
But the "right way" to explain sex and healthy sexuality to teenagers has been a decades-long debate involving parents, teachers, school districts and advocates with a variety of opinions.
Some worry about giving too much information, others worry about sharing too little, and many parents fear that any conversation will plant ideas and push kids to try stuff or "take away their innocence," says McCaffree, who also served on the board of directors of SIECUS, the Sexuality Information and Education Council of the United States.
This heated discussion has become its own culture war with labels for each side abstinence education versus comprehensive sex ed and has left in its wake an ideologically diverse curriculum patchwork in schools and communities across the country.
But it doesn't have to be that way, experts say.
In fact, relying on polarizing labels or perpetuating an "us versus them" mentality regarding sex ed may prevent a deeper discussion of what's actually going on in the complicated lives of today's youths and what can be done to help them.
While the numbers of teens having sex is going down, according to the Centers for Disease Control and Prevention, rates of sexually transmitted infections are at record-high levels, and sexual issues like sexting, sexual assault and revenge porn are omnipresent, leading experts to call for more unity, education and support for teens than ever before.
Experts say the first step toward a productive, teen-focused discussion requires recognizing that sex-ed programs across the ideological spectrum are working for different kids, with different needs, in different areas and that successful evidenced-based programs may be more alike than people think, as they focus on broadening the sex-ed discussion and teaching real-world skills.
Many experienced people who have worked in the field realize theres no one-size-fits-all answer, says Leah Robin, lead health scientist in the CDCs Division of Adolescent and School Health. You have to really take into account (the kids) communities, cultural context, developmental stage all of these things add up to the need for a variety of different approaches to help our youth make healthy decisions.
Cutting through criticism
But when neither side can even agree on what to call the other, it's difficult to find the middle ground Robin describes.
Previously called "abstinence only until marriage education," this side teaches that avoiding all sexual interaction is the only 100 percent safe way to avoid STDs and pregnancy, as well as heartbreak and rejection, and now prefers the term sexual-risk avoidance education. They refer to the other side as sexual-risk reduction education.
We dont like the term comprehensive sex education because it (projects) that it provides an even-handed approach that gives young people all the information to make healthy choices, when it fact it normalizes teen sex, and puts the emphasis on reducing the risk, rather than eliminating it, says Valerie Huber, president and CEO of Ascend, formerly the National Abstinence Education Association. You cant blend the two (approaches) when you have underlying differences in foundation and the measure for success.
Huber and others opposed to comprehensive sex-ed point out that while curriculum topics may seem similar between the two camps, the approaches are very different, and that comprehensive sex-ed's message is: "theres really no red light as long as you do it right," she says.
Those in the comprehensive sex-ed camp (who are still OK with that label) reject the idea they are pushing teens toward sex. They say they provide crucial health information which includes the benefits of delaying sex as well as medical information for sexually active teens without adding values that are "shaming and stigmatizing," said Jen Slonaker, vice president of education and training at Planned Parenthood League of Massachusetts.
Many comprehensive programs specifically state that values and morals should come from the child's parents not the teacher.
Abstinence-based classes have also been criticized for relying on medically inaccurate information or scare tactics to curb risky behavior, Slonaker said.
One of the most oft-cited studies against abstinence-based education is a 2007 report from Mathematica Policy Research, which studied four different abstinence programs and found that teens in those programs were no more likely to delay sexual behavior than those in control groups.
The report has been cited for years as evidence to abandon abstinence education and divert government funding to comprehensive sex-ed instead.
Yet such a shift is unwarranted, argues Stan Weed of the Institute for Research and Evaluation and a leading authority on and reviewer of abstinence education curricula.
The Mathematica study did not examine safer sex programs, nor suggest that they are the obvious default if abstinence programs are not successful, he wrote in a lengthy rebuttal.
Weed argued that four programs cannot be generalized to the entire body of abstinence curricula many of which have proven successful in other studies.
Besides, he says, no program, abstinence-based or comprehensive, has ever been proven to have an impact (without reinforcement) three to five years after taking the program the length of time studied by Mathematica.
Most programs are considered successful and impactful if teens show effects one year after program involvement.
Our research shows, not surprisingly, that some programs work and some dont, Weed wrote. The important questions are which ones do and why?
Finding what works
In a review of sex-ed programs, Child Trends, a leading nonprofit research organization focused on children, youths and their families, identified 56 programs that proved to be effective on some levels and dozens more that failed.
The suprising thing for us was that theres all kinds of effective programs, said Jennifer Manlove, one of the lead authors for the 2015 report and a senior research scientist at Child Trends. We cant put them into one convenient category that is THE effective program approach. Abstinence, comprehensive, clinic programs, youth development, parent involvement program every program group has at least a couple of programs that showed effectiveness.
The U.S. Department of Health and Human Services labels a program effective if it shows, through evaluation, at least one statistically significant positive impact in at least one of the following categories: delay of sexual activity, abstinence, reduced frequency of sexual activity, fewer sexual partners, increased contraceptive use and/or consistency of use, lower STD rates or lower pregnancy/birth rates.
For the past five years, more than two dozen programs have been funded through the federal Teen Pregnancy Prevention Program, and last month, the American Journal of Public Health released a special publication detailing results of the reviews.
The findings add to a growing body of evidence about what works for what populations, says Amy Farb, Office of Adolescent Health evaluation specialist.
"We should not expect any one program to be a magic bullet, effective with anyone, anywhere," Farb and her co-authors wrote. "Communities need to spend more time selecting programs that are the best fit and ensuring quality implementation."
The OAH has listed all the effective programs on its website and has "tried to make it easy for decision-makers and parents to see how each program stacks up," she said.
For example, a program designed for eighth-grade African-American boys and girls in an afterschool setting, but implemented by a school for 10th grade Caucasian students, may not produce the desired outcomes. Or if a school can't commit to a full nine-month, school-based program, it should pick something else, Farb said, rather than try to adapt it and hope it still works.
Once a program is chosen, it's important that educators make the message relevant for everyone in the classroom, and don't assume their students are either A. sexually active or B. not-sexually active, says Kim Miller, senior adviser for Youth Prevention at the CDC's Center for Global Health.
Instead, youths can be delayers or anticipators those who plan to avoid or initiate sex in the next year. Other teens are one-timers, meaning they've had sex once, while others may be having ongoing sex with a committed partner, or sex with multiple partners.
"Abstinence-based messages about sexual behavior may be effective for adolescents who do not see themselves as ready for sex (delayers), but not for adolescents who do (anticipators)," Miller wrote in 2000. "If anticipators initiate sex in a short time, as longitudinal studies suggest they do, they may need messages that focus on the potential consequences of having sex, peer pressure, (as well as) skills in safer-sex negotiation and condom use."
Relationship education
During a recent sex-ed lesson, instructor Paley Martin drew three columns on the white board in blue marker. At the top of the first one she wrote "dating," then asked the students what words came to mind.
She wrote down their answers: chocolate, going places, flowers, kissing, holding hands, trust, "Netflix and chill" a euphemism for "having sex."
Her next column was friendship, which brought out words like talking, hanging out, honesty, there for you, advice, nice, supportive.
The third column was marriage and another list: committment, kids, arguing, rings, children, money, sex, romance, trust, reliable.
Stepping back, Martin pointed to the first list. "Does this look like a good relationship?"
"Uh, some things could be left out," one boy said.
"Not compared to marriage," called another boy.
Martin, a sex-ed instructor from the Pregnancy Resource Center of Salt Lake City, Utah who teaches the effective Heritage Keepers Abstinence Education, asked the class which words on the first list made the relationship valuable.
"I'm glad we got 'trust' up there," Martin said. "It's one positive word. The rest are just a lot of fun activities."
She paused, then erased the second column headline "friendship" and replaced it with the word "dating." "What if dating looked like friendship?" Martin asked.
"Yeah, I like that," one boy said quietly.
"Friendship is a good relationship, and you're not having sex, but still having all these amazing benefits," Martin said, pointing to the long list. "Something to think about."
Traditionally, "sex-ed class" conjures up images of anatomical displays, discussions of STDs and the controversial condom demonstration. While often present, those topics are really just a sliver of an effective sexuality education curricula, experts say.
The best programs move beyond body parts and sexual behaviors (or no sexual behaviors) to a much broader picture of life-long health, which includes learning how to recognize healthy and unhealthy relationships, how to evaluate media messages, how to communicate effectively, think critically and make decisions consistent with personal values and beliefs.
"My goal is to change the paradigm for sex-ed/pregnancy/STD prevention in this country," said Marline Pearson, a sociologist at Madison Area Technical College and a developer of teen and young adult relationship and sexuality curriculum. "It's not just a body, health issue."
Pearson's "Love Notes," which she calls a relationship-based pregnancy prevention program, was recently added to the federal list of effective programs, after showing that participants were significantly less likely than a control group of peers to have ever had sex or ever been pregnant, as well as a few other high risk activities.
Teens are hungry for intimacy, she says, but without instruction on how to form healthy relationships first, they'll often turn to casual sex, then continue to be disappointed when they don't find intimacy.
"My message is that sex education from both camps should highlight relationship education," she said at a marriage conference several years ago. "Our programs need to have as much concern for the heart as for health."
Life skills
In Boston, school nurse and health teacher Jennifer Ryan begins her comprehensive sex-ed health class with a hypothetical situation.
"Imagine there is a girl or boy that you really like and want to date, but they're already dating your best friend," she tells the class. "Then one day, this person you like asks you to meet them after school at the Dunkin' Donuts across the street. What do you do?"
Ryan has the class break down the situation into three possible decisions to help students identify the pros and cons of each choice: A. Go to Dunkin' Donuts. B. Don't go. C. Tell your best friend that you were asked to go.
"I'm letting them know that decisions aren't always yes/no," Ryan said. "They usually have an action that goes with them what happens when you make the choice."
This "decision-making model" is a foundational piece of the Get Real curriculum, a TPP-approved evidence-based program created by Planned Parenthood League of Massachusetts for middle-schoolers, and something Ryan refers to often as she teaches students at Boston Collegiate Charter School.
While biological information about sex is important and relationship skills crucial, Ryan also wants to ensure that her students can evaluate information, make informed decisions and recognize consequences needed skills to navigate an increasingly sexualized world.
And it works. A review of the program found that in schools where students completed "Get Real," 16 percent fewer boys and 15 percent fewer girls had had sex by the end of eighth grade, compared to their peers at comparable schools.
The program also has a family homework component, and when families did the assignments together, boys who had taken the class in sixth grade were less likely than their non-program peers to have had sex by eighth grade.
And that, in a nutshell, is the goal of Kahana Bigelow, a health teacher at a junior high school who also teaches the Heritage Abstinence curriculum.
"I don't want them to think that sex is this absolutely terrible thing, because it's not," she said. "But at the age they're at, it just causes so many more problems for them than they need. Having them understand the consequences it can have for them now if I can do that, it's great for me, no matter what the program is. Just get them thinking about their futures."
