Sex education

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people as to the importance of enhancing contraceptive etTorts. Many Swedish endeavors can be transformed for use in American society, keeping in mind the cultural differences. If such a transformation is to be made, there is need for knowledge and insight in both cultures, and that is a challenging task. Swedes cannot claim enough insight about the American culture, with its many sub- cultures, and Americans cannot claim enough insight about the Swedish culture. A team effort seems appropriate. D

Jan Trost is in the Department of Sociology at Uppsala Univer- sity in Sweden. He has been a visiting scholar at the Kinsey In- stitute and is the author of The Family in Change.

READINGS SUGGESTED BY THE AUTHOR: Baldwin, Wendy H. "Adolescent Sexual and Reproductive

Behavior." In Teen Parents and Their Children. Washington, D.C: U.S. Government Printing OfTice, 1984.

Christensen, Harold T "Recent Data Reflecting upon the Sexual Revolution in America." In J. Trost, ed. The Eamily in Change. Vasteras, Sweden: International Library, 1983.

Henshaw, Stanley K. and O'Reilly, Kevin. "Characteristics of Abortion Patients in the United States, 1979 and 1980." Eamily Planning Perspectives 15 (1983).

Orr, Margaret Terry "Sex Education and Contraceptive Education in U.S. Public High Schools." Family Planning Perspectives H {m2).

Rodman, Hyman; Lewis, Susan H. and GrifTith, Saralyn B. The Sexual Rights of Adolescents. New York: Columbia University Press, 1984.

Sex Education in High School

Madelon Lubin Finkel and Steven Finkel

T he offering of sex education in the public schools hasbeen the subject of often heated political and educa- tional debate. What should be taught, by whom, and when, are questions central to the controversy. Propo- nents of sex education argue that such instruction provides information that teens and preteens need to help prevent some of the serious negative consequences of sex- ual activity—that is, unwanted pregnancies and venereal diseases. Opponents of such instruction argue that stu- dents would be more likely to have sex after a course in sex education. Research shows that those who have had a course in sex education are no more likely to be sexually active than those who have not, that females are less likely to become pregnant and that they are more likely to use contraceptives.

The rationale behind formal instruction in sex educa- tion is that increased knowledge about human reproduc- tion, sexual behavior, and contraception could dispel misconceptions, myths, and half-truths while encourag- ing more informed, responsible decision-making about individual sexual activity and behavior; and it will help to create satisfying interpersonal relationships. The popular

misconception, that the less teenagers know about sex the less likely they are to experiment, has been shown repeat- edly to be fallacious. Sexual intercourse does not cure adolescents of ignorance regarding prevention of un- wanted or unintended pregnancies, and ignorance does not deter adolescents from sexual activity. Sex education programs are not intended to override or to replace the moral teaching of parents; rather, such instruction is de- signed to provide the adolescent with additional facts and knowledge of human sexual relationships. Many parents shy away from discussing sex-related matters with their children because either they are ignorant themselves or feel uneasy or uncomfortable talking about such matters with their offspring.

Most sex education courses include topics on human reproduction, venereal diseases, pregnancy, and child- birth; controversial issues such as abortion, con- traception, and homosexuality often are avoided. Although sex education is usually taught in the eighth and eleventh grades, topics on family planning services are not generally covered before high school. The actual number of public school systems offering sex education is

CONTRACEPriON FOR TEENAGERS / 49

difficult to assess. A recent survey of high school prin- cipals found that 36 percent of U.S. public high schools offer a course in sex education and that no particular type of school or community is most likely to offer a sex edu- cation course. Not surprisingly, the topics covered, the amount of time spent on each topic, and the quality of teachers assigned to teach the course vary among the schools; some schools offer a better program than others.

The need for a comprehensive course in human repro- duction and human sexuality is best reflected by the sta- tistics on teenage pregnancy, teenage abortions, and the use of contraceptives among adolescents. Of the 29 mil- lion teenagers between the ages of thirteen and nineteen, 12 million (41,1 percent) are estimated to have had sexual intercourse. The proportion of those sexually experienced rises sharply with increasing age, regardless of gender or

The number of abortions performed on teenagers nearly doubled from 1973

to 1978.

ethnicity. More than one-fifth of first premarital pregnan- cies among teenagers occurred within the first month after initiating sex. Of the 1,1 million pregnancies that occurred among teenagers in 1978, 77 percent were unin- tended. The younger the teenager, the more likely that her pregnancy was accidental or unintended. For many of the young girls who find themselves pregnant, an abortion is preferable to an unintended birth. Females aged fifteen to nineteen terminated nearly two-fifths of their pregnancies by abortion. The number of abortions obtained by teen- agers nearly doubled from 1973 to 1978; during this time period, nearly three out of every ten abortions were ob- tained by teenage girls.

Although there is evidence to indicate that more teen- agers are using effective methods of birth control now than a decade ago, there is still a high degree of risk- taking, particularly among those in the younger age groups. Part of the problem is that inaccuracies, distor- tions, and myths about human reproduction, pregnancy, and contraception are widespread among teenagers of both sexes. Forty-one percent of unmarried teenagers polled in a nationwide study thought that they could not become pregnant because they had mistakenly thought "it was the wrong time of the month," Of those who real- ized that they could become pregnant, the most fre- quently cited reason for not using a birth control method was that they had not expected to have sex. Ignorance and the unprotected, sporadic nature of teenage sexual en- counters contribute to a high pregnancy rate among the

adolescent population, especially among teenagers fifteen years old or younger.

Evidence shows that instruction in sex education can increase knowledge of human reproduction. Public opin- ion is solidly in support of the teaching of sex education in schools: a recent public opinion poll found that 83 percent of those polled felt that sex education courses should be taught in the schools. Support was especially strong (over 90 percent) among certain demographic groups; that is, the more educated, more affluent, Jewish individuals.

The Family Living/Sex Education Curriculum was es- tablished in 1967 in the New York City school system to provide instruction for all pupils in kindergarten through the twelfth grade. Among other things, this curriculum is designed to help pupils understand the psychological and physiological changes that are and will be taking place within themselves and to focus on a wholesome attitude toward sex and human sexuality as an important and integrated part of one's total being. Since the first publica- tion of this curriculum, there have been rapid social changes in society. As such, the New York City Board of Education revised its curriculum in 1981-82, The revised curriculum was implemented in the public schools in the fall of 1982. An evaluation of the revised course provided an excellent opportunity to assess how relevant the course of instruction was and to see what the strengths and weak- ness of the curriculum were.

The revised course focused not only on the factual as- pects of human reproduction, but also on the socio- psychological aspects of human sexuality. It was hoped that there would be changes in students' self-esteem, deci- sion-making capabilities, interpersonal communication, and sensitivity to others as a result of the course.

The purpose of this evaluation was to ascertain how successfully the revised curriculum achieved its goals. The study focused on the impact the new curriculum had on students' knowledge, attitudes, and behavior. Teacher reaction to the course was also assessed. Since the curricu- lum specifically delineated the concepts to be discussed in class, the evaluation focused on these topics only:

• Males and females experience emotional, behavioral, and physical changes during adolescence. The focus is on factors influencing self-esteem, attitudes toward one's self and toward others, decision-making, and communication of values,

• Sexual health requires responsibility. The focus is on the biological aspects of human reproduction, sexually transmitted diseases, personal hygiene, and forms of sexual expression.

• Awareness of the reproductive process is conducive to sound decision-making. The focus is on the role of ge- netics in human reproduction, pregnancy, and childbirth,

• Maintenance of a family involves responsibility. The focus is on sex roles, marriage, parenting, and family planning.

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The Board of Education, with funding from the March of Dimes Foundation, conducted teacher training ses- sions as a means of introducing the curriculum to those teachers involved in the teaching of hygiene.

A random selection was made of four high schools in the Bronx, New York. The high schools appeared to be representative in terms of demographic and economic characteristics of the public schools in that borough. All eleventh-grade students attending public high school in New York State are required to take a course in hygiene, which includes a unit on sex education; therefore, stu- dents enrolled in hygiene classes in the selected schools comprised the study population. The evaluation was con- ducted in the spring of 1983.

In the evaluation assessment, there was a need for com- parisons in order to reach valid conclusions. A pretest/ posttest study design was utilized. A survey questionnaire containing factual statements as well as scaled statements revealing attitudes was administered both prior to and several weeks after the unit on sex education was taught. Each student who completed the pretest survey was as- signed a unique identification number; the survey was completed anonymously while the researchers main- tained a code that permitted us to know the unique number for each student so that comparisons of the pre- test and the posttest scores could be made. This coded list was not available to anyone else associated with the study. The individual's responses to the same statements were compared to assess what changes, if any, resulted from the course. Only those students who completed both the pre- test and the posttest survey were included in this analysis.

Most of the statements have been used in other research studies and have been tested and validated. To insure that the questionnaires would be easily understood by senior high school students, a pilot testing was conducted in 1982 under the auspices of the Board of Education. Nine dimensions were included in the survey questionnaire:

• Responsibility: whether the student feels responsible for his or her actions;

• Peer pressure: how much the student seems influenced by or vulnerable to peer pressure;

• Attitudes toward self; • Interpersonal attitudes: how much the student seems to

care for others; • Gender roles: what the student feels is the proper be-

havior and social role for men and women; • Personal hygiene knowledge; • Knowledge of birth control; • Knowledge of human reproduction; • Knowledge of sexually transmitted diseases.

All knowledge statements were coded so that correct answers were given scores of 1 and incorrect answers scores of 2. In this way, the smaller the score on the knowl- edge scales, the more knowledge exhibited on the given dimension. The attitude statements were handled some-

what differently. For the responsibility scale, low scores indicate a high degree of personal responsibility while high scores indicate a perception that one is not responsi- ble for one's actions. Low scores on the peer pressure index indicate a large amount of vulnerability to peer pressure while low scores on the self and interpersonal attitudes dimensions signify the most positive regard for the self and others. The gender dimension was scaled so that low scores indicate belief in traditional sex roles and behavior (for example, "women's place is in the home" or

Ignorance does not deter adolescents from sexual activity.

"men should not show emotion"); a high score indicates more modern values. Because of these difference in scale construction, we would hope for increases on certain di- mensions (such as peer pressure and gender) and de- creases in the others if the course proved effective in changing student attitudes and knowledge.

A total of 416 students who completed both the pretest and the posttest were included in this anlysis, 82 percent of the total eligible student population. The mean age of the sample was 16.2 years with a range of 14 to 21 years. Two-thirds of the students were female because one of the schools had been an all female vocational high school and is still overwhelmingly female. The students did apprecia- bly better on the posttest knowledge scores than on the pretest, A larger proportion of students scored better on the true-false statements the second time around. Whereas both the males and the females scored higher on the posttest, the females scored higher than their male counterparts. The students also did much better on the posttest knowledge scores for the matching statements.

Students' knowledge of human genetics increased from the time of the pretest to the posttest. Nearly three-quar- ters, 73.9 percent, knew that an infant may be born with a birth defect if the pregnant female has rubella during the first trimester. An additional 14 percent who initially an- swered the statement incorrectly knew the correct answer at the posttest. The majority, 53.7 percent, knew that each normal human cell does not have forty-two chromosomes at the time of the posttest. Forty-two percent knew for both surveys that an X and Y chromosome will not de- velop as a female, while an additional 23 percent knew the correct answer at the posttest. The overwhelming ma- jority, 84,6 percent, knew that sickle cell is a hereditary condition; 89 percent of these knew the correct answer at the pretest and at the posttest.

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The students did not do as well on the statements per- taining to fertilization. The majority, 61.3 percent, did not know where fertilization takes place and over half, 57.5 percent, did not know that a female's menstrual cycle determines when she can conceive. At the posttest, the percentage of correct answers to these statements in- creased by one-third and one-fifth, respectively. The ma- jority of the students did not know when a female is at greatest risk of becoming pregnant. Only 11.8 percent knew both at the pretest and at the posttest that a female's time of greatest risk is not just before her monthly period begins. Almost 71 percent of the students still did not know the correct answer after taking the unit on sex edu- cation. Whereas 35.1 percent knew at the pretest and at the posttest that a female may become pregnant even if the male withdraws his penis before ejaculating, an addi- tional 40.4 percent knew the correct answer at the posttest.

The majority knew that there are risks associated with teenagers becoming pregnant. Specifically, the majority at the posttest knew that prematurity and low birth weight are associated with teenage pregnancy, and eight out of ten knew that pregnant teenagers are at greater medical risk because they often do not seek proper prenatal care.

The overwhelming majority knew that using a condom will help prevent a person from getting a sexually trans- mitted disease, and a similar percentage knew that there is not a cure for genital herpes. More than eight out often individuals knew that an important reason for the spread of sexually transmitted diseases is the failure of people to follow through with proper medical treatment. Of the 88 percent who knew the correct answer at the posttest, 81

Thirty-six percent of U.S. public high schools offer a course in sex education.

percent knew the correct answer at both surveys. More than half, 53.6 percent, at both the pretest and the posttest knew that a male's sperm are viable for up to three days after ejaculation, and an additional 26.4 percent knew the correct answer at the posttest.

Changes in individual attitude statements from the pre- test to the posttest were subtle. That is, responsibility, attitudes toward self, interpersonal attitudes, and gender roles scales did not show major shifts in attitudes from the pretest to the posttest. The responses to peer pressure statements were comparatively more diverse, indicating changing attitudes toward the importance and infiuence of the peer group. For example, the mixture of responses to the statement, "Teenagers are more likely to have sex if

their friends are having sex," indicates a lack of consensus among this sample. Almost as many agreed with the state- ment as disagreed with it.

Statistical tests performed on the group average for each dimension over time permit a more in-depth analy- sis of the findings. The tests show whether there was a significant difference on each dimension's average score before and after the course took place. In this analysis, the observations are paired—the same individual is measured before and after the course. Results of the comparison indicate that on six of the nine dimensions there was a significant change between the group averages over time. Students came to feel more personally responsible for their behavior; less traditional in their gender role orienta- tions; and more knowledgeable about personal hygiene, birth control, pregnancy, and sexually transmitted dis- eases. On the three other dimensions—peer pressure, at- titudes about one's self, and attitudes toward others—the differences went in the expected direction (that is, less peer pressure, more favorable self and other orientations) but failed to reach statistical significance. The most con- clusive scores were registered on the knowledge dimen- sions, especially regarding birth control, pregnancy, and sexually transmitted diseases. Students retained the infor- mation that was directly communicated in the course and which, presumably, had direct practical implications and applications to their own lives.

Further analysis was conducted to attempt to compare the differences in the dimensions over time for men and for women. Did men atid women increase their knowl- edge or change their attitudes at an equal rate, or did one sex dominate in the sex-oriented learning? There was, in general, no significant difference between the sexes in the amount learned or the amount of attitude change. For the peer pressure scale, there was a greater movement away from peer pressure among the men than among the women; the latter group registered a very slight move- ment toward more concern about their peers. Although this attitude showed no general shift in the entire sample, there appears to be a significant sex-related difference. The findings also show that the females learned more about pregnancy and sexually transmitted diseases than did their male counterparts. The difference in the sex- ually transmitted disease category is small and may not be substantively meaningful.

Teachers React The thirteen teachers generally felt that the new curric-

ulum worked well in terms of (1) helping the students understand basic male and female reproduction, (2) be- coming aware of contraceptive methods and their effec- tiveness, (3) understanding sexually transmitted diseases, (4) understanding the consequences of teenage pregnancy, and (5) providing the opportunity to clarify attitudes and feelings about sexuality. They felt that the curriculum was comparatively less successful in (I) providing approaches to aid in decision-making, (2) exploring similarities and

52/SOCIETY • NOVEMBER / DECEMBER 1985

differences in female and male roles, and (3) exploring the problem of sexual abuse of children.

When asked which unit topics were most successful, the majority of the teachers responded that the birth control and family planning unit was the best. The teachers thought that the curriculum's major strength was its fac- tual content. The only weakness in the curriculum was expressed by one teacher: more time was needed to com- plete the course. Eight of the thirteen teachers reported that they have taken courses or attended workshops rele- vant to human sexuality within the past two years. All but one teacher said that they read books or journals about issues in human sexuality. Several had masters degrees in health education.

Myths about reproduction and contraception are widespread among

teenagers of both sexes.

Evaluation of the revised sex education curriculum clearly showed that the course was very successful in in- creasing knowledge and somewhat successful in improv- ing attitudes. Whether the course will be successful in facilitating life-style changes (such as more consistent use of effective contraceptives) was beyond the scope of this evaluation and may be too much to expect from any school-based educational program. While educators and policymakers should be encouraged and pleased that a course in sex edueation can successfully achieve its eduea- tional objectives, knowledge alone is not enough to influ- ence behavior. The revised curriculum provides the basis for behavior changes by communicating information over a relatively short period of time—one semester; it alone cannot be expected to produce immediate, substan- tive behavioral changes. Sueh changes need the support and encouragement not only of the school system but also of the peer group, the family, the community, and the health profession.

Sex education courses can be powerful instruments for instilling knowledge about sex-related subjects and for changing sex role and gender orientations. On all of the knowledge dimensions included in this evaluation.

change was observed after the course was completed. Change was noted on two of the four attitudinal dimen- sions measured as well. In addition, there were significant gender differences on the scores for peer pressure and two knowledge dimensions, knowledge of pregnancy and knowledge of sexually transmitted diseases. Students at- tended to information that they found relevant to their own sexual lives and which could help them to make more intelligent sex-related decisions and to be aware of the risks of unwanted pregnancies. In these respects, the course must be considered successful in influencing both student knowledge and attitudes.

The results of this evaluation should be viewed with encouragement by educators and policymakers; however, by the time the course in family life, including sex educa- tion, is taught, in the eleventh grade, many of the young men and women have already engaged in sexual inter- course. The high school curriculum should therefore be more fully integrated into the junior high school family life curriculum including sex education. Topics on inter- personal relationships, the effects of peer pressure, self- esteem, birth control, and human reproduction should be included in the eighth-grade hygiene elass. By introducing these topics in the junior high school, before sexual ac- tivity commences, the concepts of responsible interper- sonal and sexual relations could be introduced and discussed. While the focus should be on educating stu- dents about the basics of human reproduction and family planning, class discussion could serve to allay fears, dispel myths, and clear up confusion about sexual intercourse among those who are not yet sexually experienced. Such action could also lay the foundation for responsible inter- personal and sexual behavior among this group. The Board of Education should consider requiring all teachers of hygiene either to hold a masters degree in health educa- tion or to receive a certificate indicating that they are trained to teach the course. Such action would insure that the teachers have attained a specialized level of expertise and are knowledgeable about the subject they are teaching. D

Madelon Lubin Finkel is clinical assistant professor of public health at Cornell University Medical College. She has written e.\- tcnsively on the epidemiology of pregnancy among teenagers and is a member of the American College of Epidemiology

Steven Finkel is assistant professor of political science at the University of Virginia. He has also served as a biostatistical con- sultant to many organizations.