Challenging Dogma - Fall 2009

Thursday, December 17, 2009

California Department of Education: Sexual Health Education in California Public Schools – Daniel Kurowski

Introduction: Current Policy on Sexual Health Education
Since 1992, the State of California requires that all public schools teach HIV/AIDS prevention at least once in middle school and once in high school. The California education code defines the education of HIV/AIDS as “instruction on the nature of HIV/AIDS, methods of transmission, strategies to reduce the risk of HIV infection, and social and public health issues related to HIV/AIDS.” (1) The definition of HIV/AIDS education in the California does not include sexual health education.
While sex education is not mandated in California, according to a 2003 survey, 96% of California public school districts provided some kind of sexual health education. (2) Should a district choose to implement sexual health education, California’s education code provides a policy structure for the implementation of curricula: (3)
1. Abstinence-only curricula may not be implemented
2. Curricula must be research based and medically accurate
3. Curricula may not promote religious doctrine
4. Curricula must be available to English learners on an equal basis
5. Curricula may not discriminate based on race, gender, sexual
orientation, ethnic and cultural background, or disability (4)
California’s policy on sexual health education in public schools has taken progressive steps in the last decade. However, it still misses several key issues that are critically important to reduce the risk of sexually transmitted diseases.
As of September 2008, the CDC reported that young adults ages 13 to 29 have the highest incidence rate of new HIV infections than any other age group, with most being infected by sexual transmission. (5) Dissecting this population further, ethnic minorities, specifically African Americans, comprise 60% of the infections in this age group. (6) Sexual minorities are also at increased risk to acquire an HIV infection. As of September 2009, the MSM/GBT population has experienced increases in the incidence of new infection. MSM and GBT men now account for 53% of new infections, with young men between the ages of 13 and 29 accounting for 38% to 52% of infections within the MSM/GBT population. (7)
The difference in HIV incidence among various demographic populations needs to be addressed in a constructive sexual health education policy. California’s current HIV/AIDS policy does not accomplish that. What follow are three key critiques of the current policy. This is not a comprehensive list of critiques, but does offer a starting point in assessing areas of improvement and detailing the effective measures that are in place.

Critique: An Incomplete Education
California’s HIV/AIDS education policy fails to integrate comprehensive sexual health education into its curriculum. This is arguably the biggest threat to an effective education policy that aims at reducing HIV transmission among young adults and adolescents. The current approach relies largely on the notion of self-efficacy and bases its curriculum on the health belief model. By using the health belief model as the basis for HIV education policy, HIV education misses the discussion of sexual health. The health belief model (to the detriment of HIV/AIDS prevention) avoids discussing sex in a serious and effective way. Other than discussing sex as a mode of HIV transmission, the California Department of Education neglects addressing the attitudes, emotions, and social stresses that involve adolescent and young adult sexual behavior.
The following are the parts that make up the health belief model, the application of the model to the current education policy (8), and the failings of the policy at that level of the model:

Perceived Susceptibility – people will not change their behavior unless they believe they are at risk; if young adults don’t believe they are at risk for acquiring HIV, they will not use a condom. What does this mean for health education policy in California? The policy focuses on teaching students modes of transmission, incidence rates, and HIV prevalence. It does not place the student as a firm player in the susceptible demographic. While some approaches to learning such as talks by HIV-positive young adults may be effective, these can be lost to students who do not identify with the speaker’s demographic.

Perceived Severity – behavior change depends on how serious the person considers the consequences of their actions to be; if young adults don’t understand what it means to be HIV-positive and the severe health outcomes of having AIDS, they will not take steps to prevent HIV infection. What does this mean for health education policy in California? Living with HIV and living with AIDS are very different form one another. With advancements in retro-viral therapy, HIV-positive individuals can lead fairly normal lives – to the point where adolescents may not perceive HIV infection as severe – where AIDS is too far in the future to be important – and where AIDS itself is not addressed in a meaningful enough way.

Perceived Benefits – changing behavior requires that the intervention provide a benefit so that the person believes that there is something ‘in it for them’; if young adults don’t think that using condoms will prevent HIV transmission, they will not use a condom. What does this mean for health education policy in California? Sex without condoms feels better than sex with condoms. By avoiding conversations dealing with sex, relationships, and intimacy, addressing concerns of the benefits of using protection and the trade off of not wearing protection is lost to feelings of pleasure (see the third critique for a more detailed discussion).

Perceived Barriers –the intervention needs to be able to help people overcome the things that prevent them from changing their behavior; if young people are not able to purchase or cannot afford condoms, they will not use them. What does this mean for health education policy in California? The barrier of obtaining condoms is a legitimate issue. Beyond availability, condoms carry social stigma’s that make them socially difficult to obtain. There are other barriers to safe sex that go beyond the availability of condoms and beyond the scope of health education policy. One example is body image and the willingness to use condoms. An adolescent may be coaxed out of using protection if issues of body image are being manipulated in the context of sexual contact, making body image a barrier that should be addressed in HIV education. A second example is the role of sexual fantasy and negotiation of that fantasy with condom use. Sexual fantasy and sexual reality must be discussed in a meaningful way to overcome that barrier.

The health belief model’s role of self-efficacy is a very important concept in HIV/AIDS education. Of all the points of the model, it is self-efficacy that has the most meaning, even within the context of the current education policy. Self-efficacy must be applied to a more complete model of sexual health education. This model should include more than just a discussion of safe sex practices.

Critique: Education Delivery – The Importance of Background and Setting
For an effective sexual health education intervention, the curriculum must acknowledge the importance of background of the target population. As Robinson points out, background characteristics directly impact the sexuality outcomes such as sexual satisfaction, sexual functioning, and sexual communication, as well as HIV risk reduction outcomes such as attitudes towards condoms, behavioral intentions to use condoms and committing to a monogamous relationship. (9)
California’s policy on HIV/AIDS education and sexual health education should be commended for its attempt to integrate differences in minority access to prevention education. With California’s large number of ESL students, it is important to recognize that language barriers need to be eliminated for the well being of every California student.
California’s anti-discrimination laws that apply to every state agency and includes language to protect minorities on the basis of race, gender, sexual orientation, ethnic and cultural background, and disability. While this coveted anti-discrimination law serves to protect minorities, it does not require inclusion on the order of fostering comprehensive sexual health education curriculum.
While the distinction is subtle, that problem becomes enhanced in the area of sexual health education curriculum. Each of the minority groups interacts differently to intimacy, relationships, sex, and consequently condom use. While all minorities deserve mention, two will be discussed in more detail.

Adolescents with Disabilities
In people with disabilities there is unwillingness for society to view physically and mentally handicap people as sexual. (10) In an effort to provide mentally handicapped students with appropriate sexual health education curricula, the state should set standards for a required comprehensive sexual health education.
In adolescents with mental handicaps, there is an overprotection that leads to a lack of knowledge, a habitual over-compliant nature, limited assertiveness, and increased trusting. (11) The overprotection translates to a higher risk of sexual abuse and higher risks of HIV transmission. The California public education system has failed to address these key issues in learning, development, and cognition, in regard to sexual health education for the mentally disabled population.
Sex related to disability is a taboo subject, and many institutions limit the kinds and types of sex education curriculum available to mentally disabled students. (12) A 2003 report on the status of sexual health education reveled that between 66-74% of students with mild mental disabilities and 38-39% of students with severe mental disabilities received some kind of instruction on contraception in a formal setting. The report compared the rates of structured learning to the rates at which sex is being discussed with peers. It was found that 73-83% of students with mild mental disabilities and 45-66% of students with severe mental disabilities were discussing sexual topics in a non-structured setting. (13) This study does not address any potential shortcomings of any curriculum that was in place. To truly address the disparity in health education in the disabled population, the curriculum cannot be afraid to discuss sexual actions and intimate relationships with this vulnerable population.

MSM, WSW, and LGBT Adolescents
LGBT adolescents experience sex and relationships in a way that struggles against the hetero-normative structure of relationships and intimacy. While California’s anti-discrimination policy prevents the discrimination of HIV/AIDS and sexual health education based on sexual orientation, it fails to discuss how LGBT adolescents engage in relationships differently than heterosexual students.
Marriage equality aside, LGBT adolescents experience friendship, dating, and sexual encounters differently than the hetero-normative population. The negotiation of gender roles in MSM or WSW relationships comes at a great disadvantage to LQBT identity. The harm to LGBT identity creates a situation where sexual practices become a product of the negative gender environment in which they exist. Essentially, being labeled ‘gay’ or ‘lesbian’ restricts what it means to be a man or a woman in our society. (14) As a result, HIV/AIDS education is eroded by negative gender stereotypes; sexual practices become secondary to the negotiation of conventional gender roles.
An example of the importance of background in teaching MSM/GBT sexual engagement can be found in some of the ethnic minority populations. For some Latino men who have sex with men, there is a common belief that one is not gay, and consequently not vulnerable to HIV, as long as one is the active-inserter. (15) In this case, traditional discussions of sex, relationships, gender roles, and HIV/AIDS prevention are ineffective as a means of creating a comprehensive sexual health education program. The California health education system does not include curriculum on negotiating gender roles, on cultural differences in gender interpretation, or training on healthy sexual outlets based in cultural negotiation of sexuality. Teaching these differences is critically important in HIV prevention education. Not only will serving to reduce LGBT stigmatization and marginalization, but also allowing a more open communication of gender behavior within the heterosexual community.
HIV/AIDS health education, and consequently sexual health education cannot be comprised solely of an anti-discriminatory policy, where the only rule is not to favor heterosexual sex over queer sex. To be effective, HIV/AIDS health education policy must include constructive conversations about queer sex and relationships as well as curriculum in gender identity in relationship making.

Critique: Failing to Identify Intimacy and Relationships
Applied to HIV/AIDS prevention, the health belief model allows the curriculum to avoid the most important parts of HIV prevention education: intimacy and relationships. California makes sexual health education optional and allows curriculum to avoid discussions of sex when engaging in HIV/AIDS education. It is impossible to effectively discuss HIV/AIDS prevention without a discussion of intimacy. Adolescents must negotiate an array of intimate situations without formal guidance, and consequently lack the proper tools necessary to navigate their own sexuality. Even when relationships are discussed in health education, the failure to recognize the different backgrounds of California students, leads to an education that is not accessible to all students.
Some schools do offer family planning curriculum. However, many that do offer family planning often miss relationships other than conventional partnered relationships. These lessons are attached to reproduction and the methods of negotiating long-term intimate relationships. However, it is also important to understand that for many adolescents, there is a wide array of sexual relationships that they may face. It is equally important for adolescents to understand what these relationships mean and to be able to engage in relating their values and comfort levels to these ‘unconventional’ relationships.
Young adults with different backgrounds, cultures, and sexualities will confront these relationships in different ways. Like the example of the Latino man who has sexual intercourse with another man, but does not consider himself gay, there are many ways of interpreting different relationships. Sexual fantasy and fetishism, multiple sex partners, casual sex, and non-sexual intimate relationships are a few of the different ways people may engage in a relationship with another person. Adolescents engage in these relationships in different ways, and it is important for young adults to be able to understand the boundaries of their comfort based on upbringing and spirituality. They must also be able to re-engage this question as their life moves forward and as they continue to grow emotionally. Confronting the arenas of intimate relationships allows the student to seriously engage in a relevant discussion of safer sex practices.
The California public education system fails to engage students in comprehensive relationship discussions. Adolescents need to be able to decide for themselves what the positive qualities of relationships are and how stereotyping, abuse and exploitation can negatively influence relationships. (16) Education in California needs to be able to help students navigate this exploratory stage in their lives by developing communication, listening, and life-skills applied to sexual relationships. Teaching respect is an essential aspect of sexual health education, and while respect is a core value in California public schools, it is not often addressed in relevance to sexuality. Respect is the key to a healthy relationship, to the development of a health sexuality, and physical respect, ultimately leading to an appropriate and confident use of condoms and contraception.
Allowing adolescents to explore their comfort with intimacy and relationships are important in an educational curriculum. A comprehensive sexual education curriculum provides an opportunity to explore the reasons why people have sex, and asks adolescents to understand differences in gender, ethnicity, and sexuality. (17) Sex cannot be taught value free, as just another biology lesson. Relationships and the values placed on the kinds of intimacy these relationships entail is an important part of HIV/AIDS prevention curriculum, a part that the California education system fails to address.

Sexual Health Policy Reform
Reducing the spread of HIV requires inclusive, comprehensive sexual health education. Current health education policy focuses on an illness-based approach to HIV. It fails to capture the vulnerabilities leading to the unsafe sexual practices of sexually active young adults. (18) Reducing the spread of HIV among adolescents requires a comprehensive approach to HIV education, one that includes a discussion of sexual health. This approach should not just focus on the mechanics of sex and risks of sexually transmitted infections, but needs to address the role of intimacy in relationships, and allow the student to explore their values and apply them to their sexuality. By allowing adolescents the opportunity to confront their sexuality, HIV/AIDS prevention curriculum can help students negotiate safer sex practices in their lives.
Comprehensive sex education is not a road to creating sexualized adolescents (they are already highly sexualized); it’s the way to help reduce adolescent susceptibility to HIV. A 2003 survey reported that 62% of 12th grade students had reported having sexual intercourse; this does not include data on sexual experiences other than intercourse. Among high school students, 63% reported using a condom during the most recent sexual encounter. (19)
The California Department of Education should amend its approach to HIV education by applying the principles and goals it has developed in its current model to a more group level approach. One example of an approach that can be used is the Sexual Health model articulated by Robinson. The model uses a ten-point approach to discussing sexual health, and ultimately helping prevent the spread of HIV. (NUM) What follows is an exploration of the model’s points and how they may be used to develop a sexual health education policy in California:
1. Talking about Sex: According to the Kaiser Family Foundation’s report on sexual patterns on U.S. youth, the median age at first intercourse is 16.9 years for males and 17.4 years for females. (20) Not only should the curriculum provide an open and comprehensive discussion on sex, but it should also begin early enough to be effective. An early and comprehensive discussion of sex gives adolescents the tools to negotiate safe sex practices with their partners (21). This includes a discussion of sex in different situations and at different intimacy levels.
2. Cultural and Sexual Identity: As already stressed, cultural variations of sex and sexual identity have big influences on safer sex practices. These differences need to be addressed at meaningful levels for all cultural and sexual identity backgrounds. Discussions of gender and sexuality are critical and need to pay attention to cultural preconceptions to be effective.
3. Sexual Anatomy: This point is of particular concern to trans-identity adolescents, MSM adolescents, and women, where misunderstanding sexual anatomy can inhibit the proper use of condoms (22). Curriculum should stress exploration of personal anatomy and a discussion of variations of sexual anatomy and sexual identity.
4. Sexual Health and Safe Sex: California should continue to discuss safe sex practices and HIV prevention. However, rather than focusing on telling adolescents what to do, sexual health education should focus on how sexual practices in different relationships carry respective risks.
5. Challenges: Alcohol and drug abuse, physical and mental abuse, need to be explored as challenges to making good safer-sex decisions when engaging in a relationship. Addressing these issues in a sexual context is important in reducing sexually transmitted diseases. It should focus on respect for the individual and others; the current education system’s approach to physical and substance abuse is important, but must relate to the sexual intimacy problems that create unsafe sex practices to be effective.
6. Body Image: Unattainable physical beauty that is a central part of our culture can become a hazard when mixed with sexuality. Concern with body image can attribute to unsafe sexual practices. This can be especially detrimental to transgender adolescents who must negotiate negative body image issues with their sexuality. (23)
7. Masturbation and Fantasy: encouraging an exploration of these sexual outlets can help students decrease the pressures of penetrative sex that carries a higher risk of HIV transmission. (24)
8. Positive Sexuality: By including discussions of gender identity, sexual orientation and discrimination against LGBT youth in the curriculum, schools can help to de-stigmatize non-heterosexual identities and can deconstruct gender role stereotypes that limit all students. (25) This discussion also includes an exploration of the student’s sexuality in a positive atmosphere; to be able to identify what is sexually pleasurable for them. (26)
9. Intimacy and Relationships: As discussed, it is vital that adolescents recognize the differences in the types of sexual relationships they may encounter. That a relationship in a causal setting has an increased risk of HIV transmission, and that abusive relationships also carry higher risks of HIV transmission.
10. Spirituality: In this instance, it is important to recognize moral and ethical concerns, as well as cultural traditions. (27) These issues, in the context of sex and sexuality, play an important part in developing an adolescent’s comfort with themselves and the role that safer sexual practices will take in their lives.

The Sexual Health Model provides a more expanded approach HIV risk reduction than the Health Belief model. It allows adolescents the opportunity to explore their sexuality and what that sexuality means in the context of their social and cultural surroundings.
The California Department of Education cannot and should not be only responsible player in teaching HIV prevention and sexual health education. The approach should involve parental and community involvement. These networks and support systems are vital to the development of a sexual identity. A healthy sexual identity should be supplemented by a continuation of HIV/AIDS and STI education that extends outside of the classroom and into the realm of community public health programs and other points of access.

1. California Department of Education, EC Section 51931 (d).
2. PB Consulting, 2003.
3. California Department of Education, EC Section 51933.
4. California Department of Education, EC Section 220.
5. Kaiser Family Foundation, Fact Sheet: Sexual Health of Adolescents and Young Adults in the United States.
6. Ibid.
7. Kaiser Family Foundation, Fact Sheet: The HIV/AIDS Epidemic in the United States.
8. Green and Kreuter (1999) Health Promotion and Planning : An Educational and Ecological Approach, 3rd edition. Mountain View, California. Mayfield Publishing Company.
9. Robinson, Beatrice E., et al. The Sexual Health Model: application of a sexological approach to HIV prevention. Health Education Research 2002; 17:51.
10. Boehning, Alison. Sex Education for Students with Disabilities. Law and Disorder 2006; 1:62.
11. Ibid., 62.
12. Ibid., 63.
13. Ibid., 63.
14. Macgillivary, Ian K. Educational Equality for Gay, Lesbian, Bisexual, Transgender, and Queer/Questioning Students: the Demands of Democracy and Social Justice for America’s Schools. Education and Urban Society 2000; 32:300
15. Robinson, Beatrice E., et al. The Sexual Health Model: application of a sexological approach to HIV prevention. Health Education Research 2002; 17:51.
16. AIDS & HIV Information from the International AIDS Charity, Avert. Sex Education that Works.
17. Ibid.
18. Mule, Nick J. et al. (2009) “Promoting LGBT health and wellbeing through inclusive policy development” International Journal for Equity in Health; 8:18.
19. Kaiser Family Foundation, Fact Sheet: Sexual Health of Adolescents and Young Adults in the United States.
20. Ibid.
21. Robinson, Beatrice E., et al. The Sexual Health Model: application of a sexological approach to HIV prevention. Health Education Research 2002; 17:48-51.
22. Ibid.
23. Ibid.
24. Ibid.
25. Macgillivary, Ian K. Educational Equality for Gay, Lesbian, Bisexual, Transgender, and Queer/Questioning Students: the Demands of Democracy and Social Justice for America’s Schools. Education and Urban Society 2000; 32:300
26. Robinson, Beatrice E., et al. The Sexual Health Model: application of a sexological approach to HIV prevention. Health Education Research 2002; 17:48-51.
27. Ibid.

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