Olubunmi Orekoya, Kellee White, and Marsha Samson are with the Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia. Alyssa G. Robillard is with the Department of Health Promotion, Education, and Behavior, Arnold School of Public Health.
Corresponding author.Correspondence should be sent to Kellee White, PhD, MPH, Assistant Professor, Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Discovery Building, 915 Greene Street, Columbia, SC 29208 (e-mail: ude.cs.xobliam@etihWk). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.
CONTRIBUTORSO. Orekoya and K. White conceptualized and drafted the article. M. Samson and A. G. Robillard provided critical feedback on the article. All authors approved the final version.
Accepted July 7, 2016. Copyright © American Public Health Association 2016The rate of sexual risk behaviors (i.e., earlier sexual debut, inconsistent condom use, greater number of partners), unintended adolescent pregnancies, forced sexual intercourse, and sexually transmitted infections (STI) among South Carolina adolescents exceeds national averages. African American, Latino, rural, low-income, disabled, and lesbian, gay, bisexual, transgender, queer, and questioning adolescents are disproportionately affected with a higher incidence of STIs and increased vulnerability to HIV/AIDS. South Carolina’s higher rankings in sexual risk behaviors and STIs and disparities underscore the critical need for sexual health education policy that promotes responsible sexual well-being among all adolescents.
In 1988, South Carolina legislators signed into law the Comprehensive Health Education Act (CHEA). This legislation mandated that school boards and public schools develop age-appropriate academic standards for health education, including instruction on physical activity; nutrition; alcohol, tobacco, and drug use; and sexual health. State legislators are proposing to amend several sections of CHEA (see the box on the next page). The amendments relate to the inclusion of evidence-based and medically accurate information, training and certification requirements for teachers, and strengthened oversight of school district compliance with the law. Although the proposed amendments will appreciably improve the quality of sexual health education, they are still insufficient to foster strategies for comprehensive sexual health education and, more importantly, to reduce disparities in sexual risk and unplanned pregnancies by race/ethnicity, socioeconomic status, geography, disability, and gender identity.
| Section | Current Legislation a | Proposed Amendments b | Additional Recommendations |
| 59–32-10 | Definition of terms: comprehensive health education, reproductive health education, family life education, pregnancy prevention education | Amend existing definitions to include definition for “medically accurate information” | Amend existing definitions to include definitions for “comprehensive sexual health education” and “culturally appropriate and unbiased health education” |
| 59–32-20 | Selection or adoption of instruction units required by the state board of education | Amend requirement that the state board of education shall select or develop a medically accurate instructional unit in comprehensive health education (e.g., reproductive health education, pregnancy prevention, family life education) | Amend requirement that state board of education shall select or develop medically accurate, culturally appropriate, and unbiased instructional units |
| Amend requirement that allows local school districts to request medically accurate available information about programs developed by other states | Amend requirement that allows local school districts to request medically accurate and culturally appropriate and unbiased instructional units developed by other states | ||
| 59–32-30 | Local school boards to implement comprehensive health education program; guidelines and restrictions | Amend requirement that reproductive health instruction be medically accurate and change grade levels in which instruction is offered | Delete the requirement that instruction may not include a discussion of alternate sexual lifestyles from heterosexual relationships except in the context of instruction concerning sexually transmitted diseases |
| Delete the requirement that instruction in pregnancy prevention education be presented separately to male and female students | |||
| 59–32-40 | Staff development | Amend requirement to provide certification requirements for teachers of comprehensive health education, reproductive health, and pregnancy prevention instruction | Amend certification requirements to additionally include cultural competency training for teachers of comprehensive health education, reproductive health, and pregnancy prevention instruction |
The World Health Organization defines sexual health as “a state of physical, emotional, mental, and social well-being in relation to sexuality.” 1 A comprehensive sexual health education approach aligns with the World Health Organization definition and is consistent with the adolescent development and sexuality evidence–based approach rather than an abstinence-based approach. 2 It places less emphasis on risk-based approaches and focuses on health promotion, sexual well-being, expanded access to sexual health resources and services, empowerment, formation and management of healthy relationships, and connections between sexual health and social determinants of health. 2
There is evidence to suggest that this approach helps adolescents develop the self-efficacy necessary to navigate and negotiate sexual encounters and manage healthier relationships. 3 The incorporation of life skills into sexual health curricula provides an opportunity to equip students with the critical thinking skills needed to establish healthy behaviors, decision-making, and communication. Increasingly, state policies and programs are transitioning from an abstinence-only model to a comprehensive sexual health model that reflects the scientific evidence base. 3 Comprehensive sexual health education, compared with abstinence-based education, has been shown to more effectively help adolescents delay the initiation of sexual activities, use protection, and reduce the number of partners, pregnancy, and STIs. 4
South Carolina is one of 36 states, including Washington, DC, that mandates sex or HIV education. 5 There is considerable variation across states, and potentially greater variations within school districts, in sexual health curricula and content. General requirements for state-level sex and HIV education comprise content that is medically accurate, age appropriate, culturally appropriate, and unbiased; does not promote religion; and includes information on sexual orientation, abstinence, the importance of sex only within marriage, and life skills (e.g., avoiding coercion, health decision-making). 5
Currently, these requirements are not fully met in South Carolina, although the inclusion of medically accurate information is one of the proposed amendments to CHEA. South Carolina is 1 of 28 states that does not require culturally appropriate and unbiased content. 5 South Carolina adolescents on average have higher rates of STIs, sexual risk behaviors, and unintended pregnancies than do states with policies mandating a comprehensive curriculum. Our recommendation for policy and programmatic action that has implications for improving sexual health education policy is to mandate the inclusion of culturally appropriate content.
A culturally appropriate curriculum has the potential to reduce disparities by race/ethnicity, geography, socioeconomic status, disability, and sexual orientation. There are aspects of the current and proposed amendments that are exclusionary and stigmatizing. For example, the current legislation does not allow instructional units to include discussions of sexual lifestyles that alternate from heterosexual relationships, except in the context of STI transmission. Moreover, previous studies suggest that sex education curricula and educators may “explicitly or inadvertently” stigmatize groups by reinforcing racial/ethnic, class, or gender stereotypes. 6
Culturally grounded prevention programs take into account how responses to reproductive and sexual health education are shaped by social, economic, and cultural context. 6 Compelling evidence demonstrates the efficacy of culturally appropriate behavioral interventions to reduce STI disparities among adolescents. 7 Additionally, a rights-based curriculum, which emphasizes sexuality, human rights, and gender, is associated with increased knowledge about sexual health, sexual health services, and sexual relationship rights and improved self-efficacy in negotiating high-risk situations. 8 Yet, few states have mandated culturally appropriate curricula that include marginalized, disadvantaged, and isolated adolescents in statewide policies and programs that may better serve all students and contribute to minimizing disparities.
Although we acknowledge the improvements the proposed amendments to the CHEA legislation will make on sexual health education, South Carolina continues to rank among the states with the worst adolescent reproductive and sexual health outcomes. Persistent disparities by race/ethnicity, socioeconomic status, geography, disability, and gender identity in part reflect gaps in the existing curriculum content. Several organizations (i.e., New Morning Foundation, State Alliance for Adolescent Sexual Health, South Carolina Campaign to Prevent Teen Pregnancy, Advocates for Youth, and the South Carolina Coalition for Healthy Families) continue to play a critical role in advancing sexual health education reform.
These groups already provide community-level capacity (i.e., offer technical assistance, build partnerships across agencies and organizations, and provide resources for students, educators, providers, and activists) and advocate comprehensive sexual health education initiatives that support sexual health equity among all youths via rights-based policies and empowerment efforts. The South Carolina Department of Education has a responsibility to meet educational and curriculum standards that address sexual and reproductive health that is responsive to the needs of all students. Optimizing sexual health education will involve the development of policies and programs that embrace a comprehensive sexual health education approach, that are inclusive, and that equip students with skills to promote responsible sexual health and well-being.
M. Samson is supported by National Institutes of Health–National Institute of General Medicine Sciences (grant T32-GM081740).
Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health–National Institute of General Medicine.
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