Harm reduction and sexual health have been linked since harm reduction’s birth as a means to decrease the spread of HIV during the 1980s. Early harm reductionists championed the use of condoms and dental dams among high-risk communities. Over time, harm reduction has expanded its scope from illicit drugs and HIV prevention to include areas such as tobacco and alcohol—and its lens is even being applied to the current pandemic. Yet, despite its roots, harm reduction remains unexpectedly controversial in a seemingly obvious area in the United States: sexuality education.
As of March 1, the National Council of State Legislatures reports that only 29 states require sex education, and only 22 of those states require that sexuality education curriculums present “medically, factually or technically accurate” content.
It is concerning enough that 21 states have no requirement for sexuality education or HIV prevention education. But even in those that have such requirements, “medically, factually or technically accurate” content is not always well-defined and, in some states, allows for a range of interpretations.
Often, these programs do not discuss prevention of HIV and avoid discussion of contraceptives and condoms.
Amid different definitions of “accurate” and varied state and local laws, sexuality education programs in the US exist on a spectrum that ranges between two paradigms: abstinence-only until marriage and comprehensive sexuality education.
In their purest form, abstinence-only until marriage programs are exactly what the name implies. Often, these programs also do not discuss prevention of HIV or other sexually transmitted infections (STIs) and avoid discussion of contraceptives and condoms. Another hallmark is that abstinence is often presented as the only morally acceptable option.
These programs are also sometimes called sexual risk avoidance education or abstinence-centered education, versions that often include some information about STIs and contraception while still emphasizing abstinence until marriage. Similarly toward the abstinence end of the spectrum is what some refer to as “abstinence-plus” education, which emphasizes abstinence but includes some information about contraception.
States whose curriculums could be considered abstinence-centered include, for example, North Carolina, Illinois and Texas. All three states cover contraception and condom usage to prevent HIV; however, their curriculums must also stress abstinence, the importance of abstinence until marriage and the negative outcomes of teen sex.
The other paradigm, comprehensive sexuality education, features information about pregnancy prevention (including abstinence), unintended pregnancy, contraceptive methods, STI prevention, reproductive development, sexual/gender identity and expression, healthy sexual and nonsexual relationships, sexual and dating violence prevention, consent and communication.
These programs outperform abstinence-only programs on measures of behavior modification and of biological outcomes.
Needless to say, it is comprehensive sexuality education that represents a harm reduction approach to sexual health and behavior. Much like syringe exchange programs acknowledge that some people will choose to inject substances regardless of education and prevention efforts, comprehensive sexuality education acknowledges that some young people will engage in sexual activity regardless of adults’ wishes, and equips them with ways to reduce their risks if they do.
These programs outperform abstinence-only programs on measures of behavior modification—like delay of first sex, use of condoms, number of partners—and of biological outcomes, such as STIs or unwanted pregnancies.
But pushback against comprehensive sexuality education tends to center more on morality arguments than facts. Opponents often insist that comprehensive sexuality education encourages sexual risk-taking. Of course, we also know from other areas of harm reduction practice that providing information and tools to prevent harm does not result in more risk-taking behavior.
Surveys consistently find that comprehensive sexuality education is broadly acceptable to American parents. A survey of parents in North Carolina, where the current standard was abstinence-only education, showed that 89 percent supported comprehensive sexuality education in public schools. Similarly, when California parents were surveyed, 96 percent opposed abstinence-only education. These results were consistent across ethnic and religious groups, indicating that different cultural standards do not prevent consensus about the need for young people to receive information about preventing unwanted outcomes from sexual activity.
Of course, public sentiment and public policy do not always align. Still, the limited adoption of comprehensive sexuality education is particularly odd from a policy standpoint, since major medical organizations have advanced and support such programs. The American College of Obstetricians and Gynecologists, American Public Health Association, the American Medical Association and the American Academy of Pediatrics encourage school systems to adopt these curriculums—a consensus that one would expect to be persuasive.
Although comprehensive sexuality education is harm reduction, other strategies from the harm reduction playbook could further improve upon this already effective program. For one, sexual education should try to meet young people where they are at, by reaching them not only through traditional classroom instruction.
Making condoms available for free, at after-school school functions or in completely different settings, could be one example. This does not have to be as ostentatious as setting out a bowl of condoms at prom, but taking the extra step of making barrier methods of contraception readily available destigmatizes their use and is a form of education in itself.
Another way that comprehensive sexuality education programs can expand their reach is to include parents. State laws vary regarding parental consent laws for receiving prescription contraception and the morning after pill and participating in school-based sexuality education programs, but one vital harm reduction tool almost universally requires parental consent: human papilloma virus (HPV) vaccination. The CDC recommends that all young people receive this two-vaccine series between the ages of 11 and 12, because the vaccine is more effective if received prior to becoming sexually active.
In 2019, New Jersey experienced a measles outbreak, which inspired legislation that would allow young people to receive vaccinations, including for HPV, without parental consent. Unfortunately, the legislation failed, just as similar legislation in New York has failed multiple times since 2009. When Canadian parents were asked why they opposed HPV vaccination, 20 percent feared that it would discourage their children from using condoms.
Providing safer ways to engage in risky behaviors does not encourage greater risk-taking.
Again, as harm reductionists know, providing safer ways to engage in risky behaviors does not encourage greater risk-taking—and this was confirmed for HPV vaccination by a study that found no difference between new STI infections in young women vaccinated for HPV compared to their unvaccinated peers. Given the prevalence of misinformation about sexual risk-taking among parents, and the power they have over their children’s sexual health outcomes, it makes sense to include parents in parts of the sexuality education curriculum.
Parents, schools and lawmakers also must realize that a one-size-fits-all approach to sexuality education may not be the most effective way to help young people have healthier sexual and non-sexual relationships. Advocates for Youth recommend a three-tiered approach to sexual education that begins with comprehensive sexuality education as the foundation for all students, with provision of sexual health services and targeted interventions for students at higher risk of negative sexual health outcomes.
Just as not every person who uses drugs needs methadone, not every young person needs a targeted after-school program about sexual health; however, both forms of harm reduction should be available to those who do need and want them.
Comprehensive sexuality education in no way merits the controversy that persistently prevents progress in improving young people’s sexual health outcomes. Existing evidence specific to sexuality education, as from other areas of harm reduction, shows that information and access are tools of protection—not nefarious instruments of immorality.
For many negative sexual health outcomes, the consequences are lifelong. If a young person misses an opportunity to decrease (or eliminate) the risk of contracting an STI or preventing an unplanned pregnancy because they do not have the information they need to protect themselves and make their own healthiest choices, we have failed them.
Comprehensive sexuality education early and often is harm reduction, giving young people the best chance of a healthy future.
The author’s employer, the R Street Institute, has provided restricted grants to The Influence Foundation, which operates Filter, to support the production of four reports on harm reduction topics.