Journal of Midwifery & Women’s Health
org
Commentary
Sex Education in America: Abstaining from Comprehensive
Facts
Kelly D. Lemon, CNM, WHNP-BC, MSN
Adolescence is an intense period of emotional, social, and sex-
ual development. Adolescent sexual health education should
assist teenagers in navigating these transformative years. Un-
fortunately, this is often not the case in the United States.
Since 1997, the federal government has invested more than
$1.5 billion in abstinence-only-until-marriage education pro-
grams, which do not provide comprehensive sexual health
education.1 Only 48% of states require students to receive in-
struction regarding sexuality, and only 32.2% require instruc-
tion regarding pregnancy prevention.2 Schools that require
pregnancy prevention topics typically spend 4.2 hours annu-
ally on the subject.3 In the current health care and political
climate, sexual health education requirements may not seem
a crucial topic of concern. However, the sequelae from flawed
education represent a significant risk factor to the future of
societal wellness and public health. In this commentary, the
history, current funding, and outcomes of abstinence-only ed-
ucation will be reviewed. Comprehensive sexual health educa-
tion programs, upcoming legislation, health care provider re-
sources, and opportunities for midwives and other health care
providers to enact change will be discussed.
INTRODUCTION
According to the National Vital Statistics System, the US teen
birth rate has been decreasing since 2007.4 In 2016, it reached
a record low of 20.3 births per 1000 girls and women aged
15 to 19 years.4 A perfunctory review of this trend implies
that the United States provides satisfactory sexual health
education and could be the basis for ongoing governmental
support of abstinence-only-until-marriage (AOUM) edu-
cation. President Trump’s budget, A New Foundation for
American Greatness, intends to extend AOUM education
and Personal Responsibility Education Program (PREP)
funding by $3 million in fiscal year 2018, with a total exten-
sion of $271 million by 2022.5 The 2 programs share the same
funding stream but offer contrasting content. PREP-funded
programs provide comprehensive sexual health education,
and research demonstrates they help adolescents and young
adults make healthier sexual choices. These programs help
reduce sexually transmitted infections (STIs), prevent vio-
lence and abuse, promote healthy relationships, and prevent
unintended pregnancy.6 AOUM education exclusively pro-
motes abstinence for pregnancy and STI prevention. It has
been cited as unethical, inaccurate, and ineffective by leading
health experts.1 The 2018 budget does not detail resource
Address correspondence to Kelly D. Lemon, CNM, WHNP-BC, MSN,
PO Box 9186, 1 Medical Center Drive, Morgantown, WV 26506. Email:
kellydlemon@gmail.com
1526-9523/09/$36.00 doi:10.1111/jmwh.12901
www.jmwh.
designation for AOUM education programs versus PREP. In
fiscal year 2015, state PREP reached 25% of all teens receiving
grant-funded education (98,520 teens). State abstinence grant
programs reached 399,000 teens.7
Funds within the federal budget expansion are used to re-
search, develop, and implement evidence-based, effective pro-
grams. There is no ranking system. If a program meets specific
criteria, it is deemed effective. Some AOUM education pro-
grams, such as Heritage Keepers, Promoting Health among
Teens, and Choosing the Best, have met these criteria.6 The
majority of effective programs stem from PREP. Grant fund-
ing supports sexual health education programs in both com-
munity and school-based settings.
ABSTINENCE-ONLY-UNTIL-MARRIAGE
PROGRAMS
A Brief History of Abstinence-Only-Until-Marriage
Education and Its Funding
Roots of AOUM education funding can be traced to the Rea-
gan administration, when the Adolescent Family Life Act,
which discouraged premarital intercourse and promoted ab-
staining from sex outside marriage, was signed.8 The federal
government started significantly investing in abstinence edu-
cation in 1996 with the signing of the Temporary Assistance
for Needy Families Act. Title V, Section 510(b) of this reform
created funding channels for AOUM programs, which inte-
grated the Adolescent Family Life Act, and established strict
criteria for education (Table 1).9 Sexual health education pro-
grams that received Title V funding were banned from re-
viewing specific contraceptive methods and could only men-
tion their failure rates.8 A 2007 US Department of Health
and Human Services (HHS) review and 13 state evaluations
of AOUM education revealed this model lacked benefit.8 De-
spite conservative attempts to intervene, funding for AOUM
education declined over time, then expired in 2009. AOUM
programs were reinstated as part of negotiations to integrate
PREP into the Patient Protection and Affordable Care Act in
2010; $250 million was invested in AOUM education over
5 years.8 The modern AOUM education program eliminated
some of the coercive language but is still barred from provid-
ing contraceptive education.9
Why Abstinence-Only-Until-Marriage Education
Doesn’t Work
Santelli and colleagues10 conducted a comprehensive review
of outcomes associated with increasing abstinence-only edu-
cation funding. They determined that AOUM education goals
to delay sexual intercourse until marriage do not support US

c 2018 by the American College of Nurse-Midwives 149
 Table 1. Definition of Abstinence Education for Title V,
Section 510 Programs
Has as its exclusive purpose teaching the social, psychological,
and health gains to be realized by abstaining from sexual
activity.
Teaches abstinence from sexual activity outside marriage as the
expected standard for all school-age children.
Teaches that abstinence from sexual activity is the only certain
way to avoid out-of-wedlock pregnancy, sexually transmitted
diseases, and other associated health problems.
Teaches that a mutually faithful, monogamous relationship in the
context of marriage is the expected standard of sexual activity.
Teaches that sexual activity outside the context of marriage is
likely to have harmful psychological and physical effects.
Teaches that bearing children out of wedlock is likely to have
harmful consequences for the child, the child’s parents, and
society.
Teaches young people how to reject sexual advances and how
alcohol and drug use increases vulnerability to sexual
advances.
Teaches the importance of attaining self-sufficiency before
engaging in sexual activity.
Source: Social Security Act § 510, 42 USC § 710.9
demographic trends.10 The median age at first sexual activity
for both men and women has remained stable between 17 and
19 years since 1960.10 However, the span from onset of sexual
activity to marriage has risen from 1.5 years in the 1960s to 8.7
years for women and 11.7 years for men.10 Data from the Cen-
ters for Disease Control and Prevention’s Youth Risk Behavior
Surveillance System indicate that 41.2% of all high school stu-
dents have had sex, and 11.5% have had 4 or more partners.11
Among those who were sexually active, 10.6% reported physi-
cal abuse by a significant other, and 22% used drugs or alcohol
prior to their most recent intercourse.11 Half of all annual STI
cases are among teenagers. Abstinence is the only 100% effec-
tive method to prevent pregnancy and STI; however, adher-
ence to abstinence until marriage is low across the life span.
Santelli and colleagues conclude that “in actual practice the
efficacy of AOUM interventions may approach zero.”10(p276)
The attempt to deter sexually physical aspects of adolescent
relationships has led to an education system that misses out
on a key concept—how to be physically safe. In a rapidly di-
verse and transformative age, AOUM education has failed to
evolve.
How Abstinence-Only-Until-Marriage Education Is
Harmful
Aside from failing to prevent pregnancy and delay onset
of intercourse, most AOUM education programs “violate
adolescent rights, stigmatize or exclude many youths, and
reinforce harmful gender stereotypes.”10(p1) The AOUM ed-
ucation model is heteronormative. Guidelines for abstinence
150
programming include teaching that “a mutually faithful
monogamous relationship in the context of marriage is the
expected standard of human sexual activity” and “sexual
activity outside the context of marriage is likely to have
harmful psychological and physical effects.”7(p1) AOUM
education teaches that sex outside of heterosexual marriage
is not normal or expected.7 This standard is contrary to the
beliefs of many people in the United States who do not agree
that sex is only acceptable for individuals who are married
and/or heterosexual. Students who have engaged in consen-
sual sex may feel chastised or judged for not conforming
to a narrowly defined standard of sexual activity. Content
has a delicate balance: adolescent sexual health education
programs should neither aim to promote adolescent sexual
activity nor villainize and distress students. The safety and
well-being of all adolescents, including those who were or are
sexually active, must be protected.
The exclusion of lesbian, gay, bisexual, transgender, and
queer (LGBTQ) topics in AOUM education further stigma-
tizes a vulnerable population; fails to address their health
concerns; and increases chances of discrimination, violence,
depression, and self-harm. In a 2013 survey, only 4.6% of
LGBTQ students reported their health class included LGBTQ-
positive representation.12 Only 9 states currently require in-
clusive sexual orientation information in sex education. Seven
states have laws that forbid discussing anything besides het-
erosexuality in a positive light; 3 of those states require nega-
tive same-sex relationship messages.12
AOUM education has also historically promoted cultures
of guilt and shame regarding students’ previous sexual activ-
ity, some of which may not have been consensual. It is insen-
sitive to individuals who have experienced sexual abuse and
assault, perpetuating the harmful effects by further ostraciz-
ing the victims.
HOW TO PREP(ARE) ADOLESCENTS
In contrast to the limited information provided in AOUM
education, PREP receives federal funding to provide
evidence-based, comprehensive sexual education. State
agencies receive grants to replicate programs that provide
education on abstinence; contraceptive use; STI prevention;
self-esteem growth; adolescent development; healthy body
image; relationship dynamics; racial, ethnic, and sexual
diversity; and self-sufficiency.7 Forty-one programs have
been vigorously reviewed, endorsed, and funded by the HHS5
(Appendix 1). The programs emphasize abstinence and con-
traception equally, promote age-appropriate education, and
focus on individualized decision making. PREP interventions
target youth aged 10 to 20 years, in hopes of beginning
education before sexual activity has been initiated.13 PREP
has been shown to prevent unplanned pregnancy and change
sexual behavior by increasing condom and contraception
use, delaying sexual activity, and reducing frequency of
intercourse.13 Among those who attended community-based
PREP interventions, 83% felt better prepared for adulthood
after the program.10 Most programs occur in schools, but
more than half can be formatted for a clinic or community
setting. PREP interventions can be implemented anywhere
that AOUM education is currently taught.
Volume 64, No. 2, March/April 2019
CURRENT ADVOCACY AND LEGISLATION
Health care providers invested in adolescent sexual health
have started to publicly advocate for comprehensive sex-
ual health education. In response to the 2018 budget pro-
posal, the Society for Adolescent Health and Medicine up-
dated its position statement to condemn AOUM education
and support the right for adolescents to access accurate, com-
prehensive sexual health information.10 The American Col-
lege of Nurse-Midwives (ACNM) shares its commitment to
supporting evidence-based, sensitive reproductive education
in 2 formal position statements.14,15 The American Medi-
cal Association (AMA), American Public Health Associa-
tion, American College of Obstetricians and Gynecologists
(ACOG), American Academy of Pediatrics (AAP), National
Education Association, and National School Boards Asso-
ciation also openly sanction comprehensive sexual health
education.16–18
This author was unable to locate professional health
care and public health organizations that support abstinence-
only education. Faith-based and nonprofit organizations,
such as the Abstinence Clearinghouse, Focus on Family, and
the Heritage Foundation, are prominent AOUM education
allies.
In 2017, 31 federal and state bills were introduced to ad-
vance sexuality education. Only 4 were enacted or passed.19
During the 2017 legislative session, the Real Education for
Healthy Youth Act of 2017 (REHYA; S 1653, HR 3602) was
introduced.19 This bill requires the HHS to provide grants
for comprehensive sexual health education. If passed, it will
establish culturally competent, evidence-based curricula re-
garding sexual anatomy and physiology, abstinence, con-
traception, growth and development, gender identity, and
safety. Programs that are insensitive, stereotypical, or incon-
sistent with public health and medicine essentials would be
excluded.18 Over 64 national organizations are in support of
REHYA, including Advocates for Youth, ACOG, the Trevor
Project, the American Psychological Association, Planned
Parenthood Federation of America, and the National Orga-
nization for Women.18 As of this writing, the bill is under
review by the Committee on Health, Education, Labor, and
Pensions.18
WHAT HEALTH CARE PROVIDERS CAN DO
It is unlikely that AOUM education will be fully dissolved be-
fore the fiscal year 2018 budget acceptance. However, those
who support comprehensive sexual health education can ad-
vocate for AOUM education to receive minimal proportions
of funding. Midwives can partner with ACNM’s Government
Affairs and Political Action committees to support grassroots
and advocacy endeavors.
Write to your state representatives and legislators to high-
light the importance of supporting comprehensive legisla-
tion, such as REHYA. Discuss how your state addresses sexual
health education. Offer evidence that supports comprehensive
sexual health education and share stories of how adolescent
sexual health education impacts your community and daily
Journal of Midwifery & Women’s Health r www.jmwh.org
practice. If possible, schedule a face-to-face meeting to discuss
your experience and concerns.
Health care providers, including midwives, can enact
community-level change. Local school boards may be un-
aware of AOUM education faults. Most school districts have
a health advisory council, which uses community stakehold-
ers to support health and wellness policies.21 Meet with board
officials, volunteer for your council, review evidence, and sug-
gest resources for comprehensive sexual health education pro-
grams. Offer to provide expert opinion or guest lectures for
health classes. If met with resistance within the school system,
midwives can host open community education sessions to in-
form interested individuals. A variety of resources to help lo-
cate or build a program within your community can be found
in Appendix 1.
Midwives who are not politically inclined can contribute
within their own clinical practices. The AMA and AAP rec-
ommend that all adolescents have time alone with a health
care provider to discuss sexuality.17 Given the historical lim-
itations of sexual health education discussed in this article, it
cannot be assumed that all patients understand comprehen-
sive sexual health. Feel empowered to talk with your patients
and ask questions regarding their sexual health. Take advan-
tage of the opportunity to provide the information they may
not have access to. Make sexuality a positive and acceptable
topic, as this may not be what was reinforced in a patient’s
home or school environment. Students can benefit from ob-
serving comprehensive sexual health education as a routine
component of clinical practice. Midwifery, physician assis-
tant, medical, and nursing students may have attended institu-
tions that used AOUM education. Exposure to inclusive sex-
ual health care in clinical rotations can help expand their own
health and future practice.
CONCLUSION
For years, the US government has invested in sexual health
education that is ineffective, heteronormative, and potentially
harmful. AOUM education has failed to transform with the
needs of the modern adolescent. Unless awareness is raised,
these programs will continue to receive funding. Midwives
and other health care providers are uniquely equipped to pro-
mote comprehensive sexual health education, rally support
for its enactment, develop factually accurate programs, and
provide the education to its intended audience. Through joint
efforts, we can help to abstain from harmful education for US
youth.
AUTHOR
Kelly D. Lemon, CNM, WHNP-BC, MSN, practices full-
scope midwifery at West Virginia University (WVU)
Medicine in Morgantown, West Virginia, and is an ad-
junct faculty instructor at the WVU School of Medicine,
Department of Obstetrics and Gynecology.
CONFLICT OF INTEREST
The author has no conflicts of interest to disclose.
151
REFERENCES
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american-teens-sources-information-about-sex. Accessed January 22,
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3.Centers for Disease Control and Prevention. Results from the
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whitehouse.gov/sites/whitehouse.gov/files/omb/budget/fy2018/budget
.pdf. Accessed September 11, 2017.
6.Office of Adolescent Health, US Department of Health and Human
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7.Family & Youth Services Bureau. State Abstinence Education
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Clearinghouse on Families & Youth; 2016. https://www.acf.
hhs.gov/fysb/resource/aegp-fact-sheet. Accessed January 22, 2018.
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org/wp-content/uploads/2018/07/CSE-Federal-Factsheet-May-2018-
FINAL.pdf. Accessed August 30, 2018.
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ssact/title05/0510.htm. Accessed September 11, 2017.
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updated review of US policies and programs and their impact. J Ado-
lesc Health. 2017;61(3):273-280.
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12.Kosciw JG, Greytak EA, Palmer NA, Boesen MJ, The 2013 National
School Climate Survey: The Experiences of Lesbian, Gay, Bisexual
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13.Advocates for Youth. Sexuality Education: Building an evidence-
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ton, DC: Advocates for Youth; 2014. http://www.advocatesforyouth.
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14.American College of Nurse-Midwives. Position Statement: Ado-
lescent Health Care. Silver Springs, MD: American College of
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CarePositionStatement2016FINAL.pdf. Reviewed & Updated Febru-
ary 2016. Accessed January 22, 2018.
15.American College of Nurse-Midwives. Position Statement: Access
to Comprehensive Sexual and Reproductive Health Care Services.
Silver Springs, MD: American College of Nurse-Midwives; 2016.
http://midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILE
NAME/000000000087/Access-to-Comprehensive-Sexual-and-
Reproductive-Health-Care-Services-FINAL-04-12-17.pdf. Accessed
January 22, 2018
16.Committee on Adolescent Health Care, American College of
Obstetricians and Gynecologists. Committee Opinion no. 678.
Comprehensive Sexuality Education. Washington, DC: American
College of Obstetricians and Gynecologists; 2016. https://www.acog.
org/Resources-And-Publications/Committee-Opinions/Committee-
on-Adolescent-Health-Care/Comprehensive-Sexuality-Education.
Accessed September 11, 2017.
17.Bruener CC. Talking about sex: AAP recommends evidence-based
education, with pediatricians’ help. AAP News. July 18, 2016.
http://www.aappublications.org/news/2016/07/18/SexEd071816?utm
_source=TrendMD&utm_medium=TrendMD&utm_campaign=
AAPNews_TrendMD_0. Accessed September 11, 2017.
18.Sexuality Information and Education Council of the United States.
Fact Sheet: The Real Education for Healthy Youth Act. Wash-
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the United States; 2017. https://siecus.org/wp-content/uploads/
2018/07/REHYA-Factsheet-Sept17.pdf. Accessed January 22, 2018.
19.Sexuality Information and Education Council of the United
States. 2017 Sex Ed State Legislative Year-End Report. Wash-
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the United States; 2017. https://siecus.org/wp-content/uploads/
2018/07/2017-State-Leg-Report.pdf. Accessed January 22, 2018.
20.Sorace D. Addressing Sexual Health in Schools: Policy Consid-
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advocatesforyouth.org/school-policy. Accessed January 22, 2018.
Volume 64, No. 2, March/April 2019
 Appendix 1: Resources for Health Care Providers
Resource or Tool
Sexual health education resources
PrEP Education for
Youth-Serving Primary
Care Providers Toolkit
Community Action Kit
Advocates for Youth
Answer
Evidence-Based Teen
Pregnancy Prevention
Programs at a Glance
Science and Success: Sex
Education and Other
Programs That Work to
Prevent Teen
Pregnancy, HIV, and
Sexually Transmitted
Infections
Legislative tools
State School Health Policy
Database
SIECUS State Profiles
Fiscal Year 2017
Addressing Sexual Health
in Schools: Policy
Considerations
Abbreviations: HHS, US Department of Health and Human Services; PrEP, pre-exposure prophylaxis; SIECUS, Sexuality Information and Education Council of the
United States; STI, sexually transmitted infection.
Journal of Midwifery & Women’s Health r www.jmwh.org
Source Description Website
SIECUS Policies, medication references, billing https://www.aidsetc.org/sites/default/
codes, sexual developmental stages, files/resources_files/PrEP%
HIV laws and policies, HIV resources, 20Toolkit.pdf
cultural competence tools, state
policies, and other resources.
SIECUS Step-by-step kit to help advocates of http://www.communityactionkit.org/
comprehensive sexual health
education become more involved.
Advocates for Policy updates, training sessions, http://www.advocatesforyouth.org/
Youth comprehensive sexual health
education program evaluations,
curricula, education tools, sample
advocacy tools/templates.
Rutgers University Resources for professionals, teenagers, http://answer.rutgers.edu/
and parents.
Online workshops, webinars, lesson
plans, and other resources to help
become comfortable with being a sex
educator in your community and
practice.
Office of A table-format overview of programs in https://www.hhs.gov/ash/oah/sites/
Adolescent the HHS Teen Pregnancy Prevention default/files/ebp-chart1.pdf
Health review. See also: http://www.hhs.gov/ash/oah/
oah-initiatives/tpp_program/db/
Advocates for Review of effective, evidence-based http://www.advocatesforyouth.org/
Youth programs that are available. Includes storage/advfy/documents/
program components, target thirdeditionexecutivesummary.pdf
population, methodology, evaluation,
and contact information for obtaining
it. Includes community and
clinic-based programs.
National Provides detailed information for each http://www.nasbe.org/healthy_schools/
Association of state’s health education curriculum hs/bytopics.php?topicid&catExpand=
State Boards of laws, as well as needs for parental acdnbtm_catA
Education notification for sexual health
education.
SIECUS Individual state profiles and summaries. https://siecus.org/state-profiles-2017/
Overview of sex/sexuality, education
laws, policies, and legislation, as well
as programs implemented in the state.
Advocates for Compendium of policy considerations. http://www.advocatesforyouth.org/
Youth Technical resource for schools. school-policy
Works as a primer to introduce providers
to the steps in changing education
policy.
153