notes

Brief Research Report

Sex Education, Condom Access, and Contraceptive Referral in U.S. High Schools

Lauren N. Maziarz, PhD, RN1 , Joseph A. Dake, PhD, MPH2, and Tavis Glassman, PhD, MPH, MCHES2

Abstract

In the United States, sex education in schools varies significantly across districts. Many schools operate without state-guided health education curricula, leaving decisions up to individual districts. The purpose of this study was to explore what type of sex education is being offered in U.S. high schools in addition to assessing the frequency of condom access and contraceptive referral. A total of 772 high school superintendents were surveyed with a response rate of 40.4% (n ¼ 297). Data show most districts teach comprehensive sex education (63%), while only 7% of districts offer condoms to high school students. Twenty- nine percent of superintendents reported their district refers out for contraceptive services to a variety of agencies. School nurses can use this information to inform health policy discussions in their district as well as advocate for awareness among district officials regarding existing health service offerings.

Keywords

condoms, condom access, sex education, contraceptive referral, school nurses

Background

While teen pregnancy is at its lowest rate ever recorded in

the United States (Centers for Disease Control and Preven-

tion [CDC], 2019a), rates of sexually transmitted diseases

(STDs) have continued to increase among youth ages 15–24

(CDC, 2019b). Gonorrhea, chlamydia, and syphilis are of

particular concern, as reported cases are at all-time highs

(CDC, 2019b).

The reasons for an increase in STDs among youth are

numerous and complex. The United States does not require

sex education at the federal level, instead leaving policy up

to individual states, districts, or school boards. In fact, only

24 states mandate sex education for youth (Guttmacher Insti-

tute, 2019). More states are voluntarily teaching sex educa-

tion, but state policies are heavily weighted against

standardized, mandated curriculum. Since sex education

requirements are not standardized, curricula and education

access differ widely. A 2016 study highlighted the dispari-

ties in formal sex education in the United States, with rural

adolescents receiving significantly less sex education than

adolescents in metropolitan areas (Lindberg, Maddow-

Zimmet, & Boonstra, 2016). Declines have also been evi-

dent across time, with less adolescents receiving formal sex

education now than 15 years ago (Lindberg et al., 2016).

Sex education is typically categorized as being either

abstinence-only, abstinence-plus, or comprehensive (Kaiser

Family Foundation [KFF], 2018). The definitions are not

absolute but usually consist of the following: Abstinence-

only education, also called sexual risk avoidance education

(SRAE), emphasizes that abstinence is the expected norm

for teens and is usually devoid of contraceptive and barrier-

use education; abstinence-plus stresses abstinence education

while also teaching about contraception and barrier protec-

tion; and comprehensive sex education includes medically

accurate information about abstinence in addition to safe

sex, STDs, unintended pregnancy, contraception, condom

use, consent, relationships, intimate partner violence, sexual

orientation, and gender (KFF, 2018). As of April 2019, there

were 27 states that mandate a focus on abstinence-only edu-

cation when sex education is taught, while only 20 states

require information about condoms or contraceptives

(Guttmacher Institute, 2019).

1 Department of Public and Allied Health, Bowling Green State University,

OH, USA 2 School of Population Health, The University of Toledo, OH, USA

Corresponding Author:

Lauren N. Maziarz, PhD, RN, Department of Public and Allied Health,

Bowling Green State University, 120 Health and Human Services Bld.,

Bowling Green, OH 43403, USA.

Email: [email protected]

The Journal of School Nursing 2020, Vol. 36(5) 325-329 ª The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1059840519872785 journals.sagepub.com/home/jsn

Over the last 30 years, the federal government has backed

abstinence-only education as opposed to comprehensive sex

education. While abstinence-only education waned with the

Obama Administration, the Trump Administration has

renewed federal support with a 67% increase in state- based competitive funding for SRAE curriculum with the

2018 Appropriations Act (KFF, 2019). Additional federal

funding streams for sex education include grants such as the

Personal Responsibility Education Program (PREP), which

emphasize evidence-based, medically accurate sex educa-

tion, which are still available to state entities. Moreover,

evidence has repeatedly shown abstinence-only programs

are not effective in increasing abstinence, delaying sex, or

decreasing STDs and unwanted pregnancy (Santelli et al.,

2017; Trenholm et al., 2007).

Since there is little to no federal or state guidance regard-

ing what, if any, sex education curriculum is taught, there is

much room for individual district interpretation. District per-

sonnel and school boards can choose to implement curricula

or textbooks that are deemed appropriate for the district,

even while adhering to broader state policies on sex

education.

In terms of contraceptive access, only 7.2% of high schools and 2.3% of middle schools make condoms avail- able to students (CDC, 2018). Condom availability is typi-

cally not well supported among school district

administrators (Maziarz, Dake, Glassman, Telljohann, &

Beekley, 2017), yet evidence has shown no increases in

sexual activity when condoms are made available in schools

(Charania et al., 2011). While school-based health centers

(SBHCs) are the most common place to obtain condoms as

well as other contraceptives, half (50%) of SBHCs are pro- hibited from dispensing contraceptives according to school

district, state, or other policy regulations (Society-Based

Health Alliance, 2014). For districts hesitant to make contra-

ceptives available on school grounds, referrals for contra-

ceptive services to outside agencies are one way to increase

contraceptive access, although policies remain rare. Just

9.1% of districts have a policy for referring students to an outside agency for condoms and 10.2% of districts have a policy in place for referring students for contraceptives other

than condoms (CDC, 2018). Thus, the purpose of this study

was to explore what type of sex education is being offered in

U.S. high schools in addition to assessing the frequency of

condom access and contraceptive referral to better under-

stand current practices within the school setting.

Method

Design

This study was a secondary data analysis of a cross-sectional

survey. The University of Toledo’s Institutional Review

Board approved the protocol before data collection began.

Participants

We used the same sample surveyed in Maziarz, Dake, Glass-

man, Telljohann, and Beekley (2017). While the original

article examined superintendent perceptions, in this study,

we expand on these concepts by analyzing districts’ prac-

tices related to sex education, condom access, and contra-

ceptive referral. A list of potential participants (N ¼ 10,315) was gathered from the National Center for Education Statis-

tics database. Using this database, strata were determined

based on geographical location (West, Northeast, Midwest,

South), district size (small, medium, large), and locale (city,

suburb, town, rural). In order to reach statistical power, it

was estimated we needed 371 completed surveys in order to

generalize to the population. Assuming an estimated 50% return rate, a stratified random sample of 772 high school

superintendents were mailed the survey.

Procedures

The survey included 6 items to assess sex education cur-

ricula offerings, condom access, and contraceptive refer-

ral services. To assess these variables, superintendents

were asked the following: “Has your district adopted a

sex education curriculum that includes both abstinence

and contraceptive education for high school students?”,

“Has your district adopted an abstinence-only sex educa-

tion curriculum for high school students? (abstinence-

only curriculums must have abstinence as their exclusive

purpose),” “Does your district make condoms available to

high school students?”, and “Does your district refer high

school students to an off-site clinic or health center that

provides contraceptive services?” Dichotomous yes/no

responses were given. Two check-all-that-apply items

were used to explore where condoms are made available

as well as which agencies are being used for contracep-

tive referral.

Data were collected in four waves using a mailed survey.

The initial wave included a personalized cover letter with an

explanation of the research, a $1 bill, a copy of the survey,

and a self-addressed stamped return envelope all sent

through first-class mail. Three additional waves, all occur-

ring 2 weeks apart, included a reminder postcard for non-

responders. Finally, phone calls were made to a random

sample of nonresponders (n ¼ 30) in order to recruit any final responders.

Data Analysis

Data were analyzed using SPSS 18.0. Frequencies were used

to describe responses to the survey items. Kruskal–Wallis

tests were used to explore differences between district demo-

graphics and the dependent variables. Differences were

considered significant at a p value of � .05.

326 The Journal of School Nursing 36(5)

Results

Demographics and Background Characteristics of Respondents

Thirty-seven of the 772 questionnaires were returned as

nondeliverable and removed from the sample with a result-

ing final response rate of 40.4% (n ¼ 297). A priori power analysis estimated we needed 371 surveys to reach statistical

power, which means our final response rate of 297 limits

generalizability to all districts. Respondents came from dis-

tricts that were predominately medium and large in size

(36% and 34%, respectively), while 31% came from districts that were small in size (Table 1). Districts were fairly evenly

split based on region of the country with 27% of districts located in the Midwest, 25% in the Northeast, 25% in the West, and 24% in the South. In terms of locale, most districts were located in a town (31%), while 30% were in a rural location, 23% in a suburb, and 17% in a city.

Type of Sex Education and Current Condom Availability

Superintendents were asked two questions on whether their

district used a combination of contraceptive and abstinence

education (i.e., comprehensive sex education) or abstinence-

only education for their high school students. When asked

whether their district used comprehensive sex education,

most superintendents (63%) marked yes, saying their district used a comprehensive approach, while 37% denied their district used comprehensive sex education. What is interest-

ing is that when subsequently asked whether their district

used an abstinence-only approach, only 18% marked yes, saying their district used abstinence-only education, while

82% denied using abstinence-only approach. There is an obvious discrepancy between these findings where more

superintendents are denying using abstinence-only educa-

tion than are agreeing to using a comprehensive approach.

A Kruskal–Wallis test found a significant difference

between geographical region and reported comprehensive

sex education (H ¼ 15.182, p < .01). Adjusted pairwise comparisons found districts in the South reported statisti-

cally significantly less comprehensive sex education (18%) than districts in both the Midwest (29%), w2(3) ¼ �2.67, p < .05, and the Northeast (30%), w2(2) ¼ �3.79, p < .001. There was no significant difference in comprehensive sex

education by size of the district or whether the district was in

a city, suburb, town, or rural location.

When asked whether the district made condoms available

to high school students, 93% of respondents said condoms were not available, whereas 7% said condoms were avail- able (Table 2). Of those who said condoms were available

(n ¼ 22), the most commonly accessed places were school- based health clinics (45%), followed by school nurses (27%) and health class (14%). A fewer number of respondents said condoms were available in a school counselor’s office (9%), another designated place (9%), or the main office (5%). Condom availability did not differ significantly by geogra-

phical region, size of the district, or whether the district was

in a city, suburb, town, or rural location.

Outside Agency Referral for Contraceptives

Superintendents were asked whether their district referred

students for contraceptive services outside of the school

setting. The majority of respondents reported their district

does not refer to an outside agency for contraceptive services

(71%), as shown in Table 3. Of those that do refer (n ¼ 85), the most common agencies were a local health department

(58%), health clinic (57%), or family planning clinic (56%). Superintendents whose districts make referrals also wrote in

additional responses indicating referrals were made to a

physician (1%) and Planned Parenthood (1%). Outside agency referrals did not differ significantly by geographical

region, size of the district, or whether the district was in a

city, suburb, town, or rural location.

Table 1. Demographics and Background Characteristics of Respondents.

Item n (%)

Size of the district Small (<947 students) 91 (31) Medium (947–2,397) 106 (36) Large (>2,739) 100 (34)

Geographical region West 73 (25) Northeast 73 (25) Midwest 79 (27) South 72 (24)

Locale of district City 49 (17) Suburb 67 (23) Town 91 (31) Rural 90 (30)

Note. Percentages may not equal 100% or 297 due to rounding and/or nonreported answer.

Table 2. Condom Availability.

Item n (%)

Are condoms available? Yes 22 (7) No 274 (93)

If yes, where are they available? School-based clinic 10 (45) School nurse’s office 6 (27) Health class 3 (14) School counselor 2 (9) Other 2 (9) Main office 1 (5)

Note. Percentages may not equal 100% or 297 due to rounding and/or nonreported answer.

Maziarz et al. 327

Discussion

Our findings show a discrepancy in reported sex education

practices when asked about abstinence-only sex education

versus a comprehensive approach. The two questions used

for assessing the type of curricula were, “Has your district

adopted a sex education curriculum that includes both absti-

nence and contraceptive education for high school

students?” (i.e., comprehensive sex education) and “Has

your district adopted an abstinence-only sex education cur-

riculum for high school students? (abstinence-only curricu-

lums must have abstinence as their exclusive purpose).”

Question wording could prove significant in assessing cur-

ricula as there may be a stigma associated with the type of

sex education being offered since 82% denied using an absti- nence approach, while only 63% agreed to using a compre- hensive approach. More research is needed to assess these

disparities. Variances remain dependent on geographical

location, however, as districts in the South reported signif-

icantly less comprehensive sex education than other regions

of the country. What is startling is that the pattern of

abstinence-only education mirrors that of the STD burden

among youth, where 15- to 24-year-olds in the South have

the highest rates of gonorrhea and chlamydia compared to

anywhere else in the United States (CDC, 2019b).

In terms of condom access, the results from this study

regarding the percentage of districts that make condoms

available (7%) are in line with the results from the 2014 School Health Policies and Practices Study (SHPPS) that

indicated 7.2% of high schools make condoms available for students (CDC, 2018). Sponsored by the CDC, the SHPPS

study utilizes a nationally representative survey to gather

information about health education policies, physical educa-

tion, nutrition services, and other health-related services

within schools. The 2014 SHPPS was the most recent to

include a question regarding actual condom availability

practices. Findings from the 2016 SHPPS study, which

asked about condom policies as opposed to actual condom

availability, show only 1% of districts have a specific policy

requiring condoms are available to high schoolers. More

surprising is that 50% of districts surveyed in the 2016 SHPPS study had a policy specifically prohibiting condom

availability to both middle schoolers and high schoolers.

Having policies in place represents only one aspect of

implementation, however, as evidenced by the discrepancies

between the 2014 SHPPS condom availability data (7.2% of districts make condoms available) and the 2016 condom pol-

icy data (1% of districts have a policy requiring condom availability). The low number of districts reporting condom

availability may also be the result of superintendents being

unaware of current condom availability practices or it could

represent a more realistic picture of how many schools make

condoms accessible to high schoolers. Since the results of this

study are in line with the findings of the 2014 SHPPS study

regarding condom availability, it is likely very few schools

have a condom availability program in place.

Referrals for contraception are also rare, as only 29% of superintendents in our study said their district used outside

agencies to provide contraceptive services. The lack of refer-

ral for contraceptives and condoms presents an opportunity

for education and advocacy among supportive school

employees, especially among care providers such as school

nurses, local physicians, or health departments. It should be

mentioned that the 2019 final regulations for Title X funding

include blocking the availability of federal funds to clinics

that also provide abortion services (KFF, 2019). The regu-

lations also emphasize funding for providers that specialize

in comprehensive primary care as opposed to those that

specialize in reproductive health services. These changes

have the potential to limit referral options for districts where

a majority of reproductive services are offered by agencies

such as Planned Parenthood. Thus, school nurses may need

to help fill in the gaps of reproductive care by providing

contraceptive education and making condoms available at

the school level.

School Nursing Implications

School nurses are often the leading expert on health and

disease prevention in the school setting. Since sex education

and sexual health resource decisions are commonly made at

the local level, there are opportunities for promotion and

implementation of evidence-based interventions. In fact, the

National Association of School Nurses’ (2017) Sexual

Health Education position statement emphasizes the impor-

tance of advocating for medically accurate, evidence-based

sexual health education. While comprehensive sex educa-

tion was the most commonly reported sex education curri-

culum in our study, abstinence-only education is still

endorsed by many districts.

Nurses working in schools can also be an important

resource for making condoms and contraceptives accessible

for students. As our findings show, school health clinics and

the school nurse’s office are the most common places to

Table 3. Outside Agency Referral for Contraceptives.

Item n (%)

Does your district refer high school students to an off-site clinic or health center?

Yes 85 (29) No 209 (71)

If yes, what agencies do your schools refer students to? Health department 48 (58) Health clinic 47 (57) Family planning agency 46 (56) Other physician 4 (1) Planned Parenthood 3 (1)

Note. Percentages may not equal 100% or 297 due to rounding and/or nonreported answer.

328 The Journal of School Nursing 36(5)

make condoms available. For district personnel who are

reticent to make condoms or contraceptives available in

school, nurses can partner with local health departments,

health clinics, and family planning agencies to increase

referral options for students.

Limitations

This study was designed to explore the types of sex educa-

tion being offered in U.S. high schools in addition to asses-

sing both condom access and contraceptive referral services.

Since superintendents are the top district administrator, they

may be unaware of how sex education, condom access, and

contraceptive referrals are implemented at the school level.

Furthermore, due to the sensitive nature of the topic, there is

the potential for social desirability bias among participants.

Finally, the responses to the items listed may not be repre-

sentative of all districts since a response rate of 40% was not enough to achieve statistical power, limiting generalizability

of these findings.

Author Contributions

All authors contributed to the conception of the manuscript, anal-

ysis of the data, drafting the manuscript, critically reviewing the

manuscript, and gave final approval on the text. They also agreed to

be accountable for all aspects of work ensuring integrity and

accuracy.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect

to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, author-

ship, and/or publication of this article.

ORCID iD

Lauren N. Maziarz, PhD, RN https://orcid.org/0000-0003-4444-

5100

References

Centers for Disease Control and Prevention. (2018). Adolescent

and school health: SHPPS results. Retrieved from https://

www.cdc.gov/healthyyouth/data/shpps/results.htm

Centers for Disease Control and Prevention. (2019a). About teen

pregnancy. Retrieved from https://www.cdc.gov/teenpreg

nancy/about/index.htm

Centers for Disease Control and Prevention. (2019b). Sexually

transmitted diseases: Adolescents and young adults. Retrieved

from https://www.cdc.gov/std/life-stages-populations/adoles

cents-youngadults.htm

Charania, M. R., Crepaz, N., Guenther-Gray, C., Liau, A., Willis,

L. A., & Lyles, C. M. (2011). Efficacy of structural-level con-

dom distribution interventions: A meta-analysis of U.S. and

international studies, 1998–2007. AIDS and Behavior, 15,

1283–1297.

Guttmacher Institute. (2019). Sex and HIV education: State laws

and policies. Retrieved from https://www.guttmacher.org/state-

policy/explore/sex-and-hiv-education

Kaiser Family Foundation. (2018). Abstinence education pro-

grams: Definition, funding, and impact on teen sexual behavior.

Retrieved from https://www.kff.org/womens-health-policy/

fact-sheet/abstinence-education-programs-definition-funding-

and-impact-on-teen-sexual-behavior/

Kaiser Family Foundation. (2019). New Title X regulations: Impli-

cations for women and family planning providers. Retrieved

from https://www.kff.org/womens-health-policy/issue-brief/

new-title-x-regulations-implications-for-women-and-family-

planning-providers/

Lindberg, L. D., Maddow-Zimet, I., & Boonstra, H. (2016).

Changes in adolescents’ receipt of sex education, 2006-2013.

Journal of Adolescent Health, 48, 621–627.

Maziarz, L. N., Dake, J. A., Glassman, T., Telljohann, S. K., &

Beekley, C. (2017). Superintendents perceptions of condom

availability in US high schools. Health Behavior and Policy

Review, 4, 389–398.

National Association of School Nurses. (2017). Sexual health edu-

cation in schools (Position Statement). Silver Spring, MD:

National Assocation of School Nurses.

Santelli, J. S., Kantor, L. M., Grilo, S. A., Speizer, I. S., Lindberg,

L. D., Heitel, J., . . . Ott, M. A. (2017). Abstinence-only-until-

marriage: An updated review of U.S. policies and programs and

their impact. Journal of Adolescent Health, 61, 273–280.

School-Based Health Alliance. (2014). Findings from the 2013-

2014 census of school-based health centers. Retrieved from

http://www.sbh4all.org/wp-content/uploads/2015/12/2013-14-

Census-Webinar.pdf

Trenholm, C., Devaney, B., Fortson, K., Quay, L., Wheeler, J., &

Clark, M. (2007). Impacts of four Title V, Section 510 absti-

nence education programs: Final report. Retrieved from https://

files.eric.ed.gov/fulltext/ED496286.pdf

Author Biographies

Lauren N. Maziarz, PhD, RN, is an assistant professor at Bowling

Green State University.

Joseph A. Dake, PhD, MPH, is a professor and chair at The Uni-

versity of Toledo.

Tavis Glassman, PhD, MPH, MCHES, is a professor at The Uni-

versity of Toledo.

Maziarz et al. 329

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