Comprehensive risk reduction sexual education
Comprehensive risk reduction sexual education programs provide information regarding contraception and protection against sexually transmitted infections (STIs). Many efforts emphasize abstinence and delayed initiation of sex in addition to broader risk reduction components, these are often called abstinence-plus programs. Such programs can take place in schools (e.g., as part of the health curriculum) or in community settings; program components vary by implementer and specific model1.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Reduced risky sexual behavior
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Increased condom use
Increased use of contraception
Reduced sexual activity
Reduced teen pregnancy
Reduced incidence of STIs
What does the research say about effectiveness?
There is strong evidence that comprehensive risk reduction sexual education programs decrease sexual risk behaviors among adolescents in both the short-term and the long-term2, 3, 4, 5.
Comprehensive risk reduction programs have been shown to reduce risk behaviors such as engagement in sexual activity, frequency of sexual activity, number of partners, and frequency of unprotected sexual activity3, 4, 6. Such programs can also increase use of contraception3, 7, 8, 9.
Comprehensive risk reduction programs may reduce pregnancy3, 4, 6 and sexually transmitted infections (STIs) among adolescents3. There is no evidence that providing comprehensive information regarding contraception in sexual education programs increases sexual activity or encourages initiation of sex4, 9, 10.
Research suggests that effective comprehensive risk reduction programs focus on specific behaviors, provide basic and accurate information regarding the risks and methods of protection, and include opportunities to address peer norms and practice communication, negotiation, and refusal skills within the program2, 5. Effective programs are usually conducted within groups3 over the course of multiple sessions with multiple activities7.
How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.
It is unclear what impact comprehensive risk reduction sexual education programs have on disparities in HIV and STI incidence or teen pregnancy rates.
Inequalities by sexuality, gender, race, geographical location, and economic status persist in HIV diagnosis and care13, and racial and geographic disparities in teen pregnancy rates continue14. Birth rates remain high for young women of color14, 15; American Indian and Alaska Native teens have the highest birth rates, and Hispanic and Black teens’ birth rates are two times higher than that of white teens14. In 2019, just over 20% of new HIV diagnoses were in those aged 13 to 24 years old16; young gay and bisexual males accounted for approximately 80% of new infections in the age group, with a majority among Black and Hispanic youth17. Chlamydia, gonorrhea, and syphilis also disproportionally affect racial and sexual minority groups. In 2021, chlamydia and gonorrhea rates were highest in young women 15 to 24 years old, and rates of gonorrhea were highest in young men 20 to 24 years old18.
Additionally, many sex education programs overlook the needs of LGBTQ+ students in the classroom; while some programs do provide affirming education, others actively discriminate against LGBTQ individuals. Anti-LGBTQ policies actively harm students by perpetuating stigma and exacerbating negative mental health outcomes19, while inclusive programs may decrease bullying, depression, and suicidality20.
What is the relevant historical background?
Before the 1960s, social norms largely prevented teaching sex education and sexual health outside the home21. Sex education in schools began receiving widespread support in the 1960s but it was met with resistance from more socially conservative groups. By the 1980s a majority of people supported incorporating sex education into public school curriculums, though persistent disagreements around the use of comprehensive sex education approaches or abstinence only programs became prominent and have persisted into present day politics22.
Teen pregnancy rates have been declining since 199123, which may be due to teens delaying or not engaging in sexual activity24, 25, decreasing overall numbers of sexual partners, more consistent use of contraception24, and increased use of long-acting reversible contraceptives25. During this time period, many communities implemented evidence-based programs designed to prevent teen pregnancies, which had a positive impact on youth behavior26. However, teen pregnancy rates in the U.S. are still higher than in the industrialized world and racial and geographic disparities exist within the country14.
HIV infections among 13- to 24-year-olds declined by 34% between 2017 and 2021, largely among gay and bisexual males. Declines were lower among Black and Hispanic men who have sex with men (MSM) than among white MSM and infection rates remain higher in the southern U.S.17. HIV infection decline is associated with many efforts including education about and accessibility of pre-exposure prophylaxis (PrEP), a biomedical approach to preventing HIV17, 27.
There is no federal mandate for sex education and existing sex education programs are vulnerable to amendments that could dismantle and eradicate them28. Sex education programs provide individuals with accurate resources about options for preventing unwanted and unintended pregnancies29. In July 2022, the U.S. Supreme Court overturned Roe v. Wade, the 1973 landmark decision which federally protected a woman’s right to choose to have an abortion29. With 50 years of precedent gone, some state legislatures have enacted legislation to restrict and ban abortion, which has many negative implications for women’s reproductive care and existing sex education programs28. States that have limited abortion access often also experience high teen birth rates30, 31 and have strong political powers working to ban comprehensive sexual education in schools or opting for abstinence-only instruction32, 33. In a post-Roe world, strengthening sex education programs in schools is especially important to reduce unintended pregnancies, teen pregnancy, and to educate youth on STI prevention33.
Equity Considerations
- Do adolescents in your community have access to the necessary knowledge and resources to prevent pregnancy and STI infections? Are programs culturally and linguistically appropriate, and inclusive of all gender identities and sexual orientations?
- Where can comprehensive risk reduction programs be implemented in your community (i.e., school vs. community setting)?
- How can you identify and adapt a comprehensive risk reduction program to meet your community’s needs?
- Are there any systematic barriers to accessibility?
- Who might prove resistant to implementing a comprehensive risk reduction program? What can you do to alleviate concerns while still providing quality sexual and reproductive health information?
Implementation Examples
There is no national standard for sex education, and legislation varies from state to state. As of 2023, 28 states and the District of Columbia mandate sexual education in public schools, 35 states and the District of Columbia mandate HIV education, and 17 states require medically accurate sexual education11. As of 2022, only 5 states require comprehensive sexual education that is inclusive of sexual orientation, gender identity, and expression, ten states include inclusive instruction for LGBTQ people, and six states continue to require anti-LGBTQ policies that discriminate in sex education instruction12.
Implementation Resources
‡ Resources with a focus on equity.
Alford 2012 - Alford S. Science and success, 3rd edition: Sex education and other programs that work to prevent teen pregnancy, HIV and sexually transmitted infections. Washington, D.C.: Advocates for Youth; 2012.
Kirby 2007 - Kirby D. Emerging answers 2007: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases. Washington, D.C.: National Campaign to Prevent Teen and Unplanned Pregnancy; 2007.
NCSL-Sex ed - National Conference of State Legislatures (NCSL). State policies on sex education in schools.
CDC-Compendium of risk reduction interventions‡ - Centers for Disease Control and Prevention (CDC). Complete list of risk reduction evidence-based interventions. Compendium.
GLSEN- Inclusive sexual health education for LGBTQ - GLSEN. Inclusive sexual health education for lesbian, gay, bisexual, transgender.
Footnotes
* Journal subscription may be required for access.
1 CG-Comprehensive risk reduction - The Guide to Community Preventive Services (The Community Guide). HIV, other STIs, and teen pregnancy: Group-based comprehensive risk reduction interventions for adolescents.
2 Denford 2017 - Denford S, Abraham C, Campbell R, Busse H. A comprehensive review of reviews of school-based interventions to improve sexual-health. Health Psychology Review. 2017;11(1):33-52.
3 Chin 2012 - Chin HB, Sipe TA, Elder R, et al. The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, Human Immunodeficiency Virus, and sexually transmitted infections: Two systematic reviews for the Guide to Community Preventive Services. American Journal of Preventive Medicine. 2012;42(3):272-294.
4 Cochrane-Underhill 2008 - Underhill K, Montgomery P, Operario D. Abstinence-plus programs for HIV infection prevention in high-income countries. Cochrane Database of Systematic Reviews. 2008;(1):CD007006.
5 Kirby 2007 - Kirby D. Emerging answers 2007: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases. Washington, D.C.: National Campaign to Prevent Teen and Unplanned Pregnancy; 2007.
6 Underhill 2007 - Underhill K, Operario D, Montgomery P. Systematic review of abstinence-plus HIV prevention programs in high-income countries. PLoS Medicine. 2007;4(9):e275.
7 Cochrane-Lopez 2016a - Lopez LM, Bernholc A, Chen M, Tolley EE. School-based interventions for improving contraceptive use in adolescents. Cochrane Database of Systematic Reviews. 2016;(6):CD012249.
8 Campbell-Scher 2006 - Scher L, Maynard RA, Stagner M. Interventions intended to reduce pregnancy-related outcomes among adolescents. Campbell Systematic Reviews. 2006:12.
9 Bennett 2005 - Bennett SE, Assefi NP. School-based teenage pregnancy prevention programs: A systematic review of randomized controlled trials. Journal of Adolescent Health. 2005;36(1):72-81.
10 Smoak 2006 - Smoak N, Scott-Sheldon LA, Johnson BT, et al. Sexual risk reduction interventions do not inadvertently increase the overall frequency of sexual behavior: A meta-analysis of 174 studies with 116,735 participants. Journal of Acquired Immune Deficiency Syndromes. 2006;41(3):374-384.
11 Guttmacher-Sex and HIV education 2023 - Guttmacher Institute. State Laws and Policies: Sex and HIV education. New York: Guttmacher Institute; September 1, 2023.
12 NPR-Quiroz 2022 - Quiroz L. Sex education often leaves out queer people. Here’s what to know. National Public Radio (NPR). August 30, 2022.
13 Taggart 2021 - Taggart T, Ritchwood TD, Nyhan K, Ransome Y. Messaging matters: Achieving equity in the HIV response through public health communication. Lancet HIV. 2021;8(6):e376-e386.
14 CDC-About teen pregnancy - Centers for Disease Control and Prevention (CDC). About teen pregnancy.
15 Fuller 2018 - Fuller TR, White CP, Chu J, et al. Social determinants and teen pregnancy prevention: Exploring the role of nontraditional partnerships. Health Promotion Practice. 2018;19(1):23-30.
16 CDC-HIV diagnosis - Centers for Disease Control and Prevention (CDC). HIV diagnoses, deaths, and prevalence.
17 CDC-HIV declines in youth - Centers for Disease Control and Prevention (CDC). HIV declines among young people and drives overall decrease in new HIV infections.
18 CDC-STI Surveillance - Centers for Disease Control and Prevention (CDC). Sexually Transmitted Infections Surveillance.
19 Child Trends-LGBTQ sex ed - Child Trends. Only 17 states and D.C. report LGBTQ-inclusive sex ed curricula in at least half of schools, despite recent increases.
20 Proulx 2019 - Proulx CN, Coulter RWS, Egan JE, Matthews DD, Mair C. Associations of LGBTQ-inclusive sex education with mental health outcomes and school-based victimization in U.S. high school students. Journal of Adolescent Health. 2019;64(5):608-614.
21 Elia 2009 - Elia J. Chapter 3: School-based sexuality education: A century of sexual and social control. In: Schroeder E, Kuriansky J, eds. Sexuality education: Past, present, and future, Vol 4: Emerging techniques and technologies. Westport: Praeger; 2009:33-57.
22 Kantor 2008 - Kantor LM, Santelli JS, Teitler J, Balmer R. Abstinence-only policies and programs: An overview. Sexuality Research & Social Policy. 2008;5(3):6-17.
23 CDC-Teen pregnancy - Centers for Disease Control and Prevention (CDC). Reproductive health: Teen pregnancy.
24 Brindis 2020 - Brindis CD, Decker MJ, Gutmann-Gonzalez A, Berglas NF. Perspectives on adolescent pregnancy prevention strategies in the United States: Looking back, looking forward. Adolescent Health, Medicine and Therapeutics. 2020;11:135-145.
25 Brookings-Sawhill 2019a - Sawhill IV, Guyot K. Preventing unplanned pregnancy: Lessons from the states. Washington, D.C.: Brookings Institution; 2019.
26 Salas-Wright 2019 - Salas-Wright CP, AbiNader MA, Vaughn MG, Sanchez M, De La Rosa M. Trends in participation in teen pregnancy and STI prevention programming, 2002–2016. Preventive Medicine. 2019;126:105753.
27 CDC-HIV PrEP care system - Centers for Disease Control and Prevention (CDC). HIV pre-exposure prophylaxis (PrEP) care system.
28 Prism-Ellenbogen 2022 - Ellenbogen X. Roe’s fall puts sex education in jeopardy, especially for low-income students. Prism. 2022.
29 Berg 2023 - Berg JA, Woods NF. Overturning Roe v. Wade: Consequences for midlife women’s health and well-being. Women’s Midlife Health. 2023;9(2).
30 CDC-Teen birth rate by state - Centers for Disease Control and Prevention (CDC). Teen birth rate by state.
31 Guttmacher-Nash 2023 - Nash E, Guarnieri I. Six months post-Roe, 24 U.S. states have banned abortion or are likely to do so: A roundup. New York: Guttmacher Institute; 2023.
32 Fielding 2022 - Fielding S. Why sex ed matters in a post-Roe America. Very Well Mind. 2022.
33 Landman 2022 - Landman K. 6 things sex educators want you to know about a post-Roe America. Vox: Science. 2022.
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