Excerpts from the Surgeon General's Call to Action 

IV. Risk and Protective Factors for Sexual Health

Human beings are sexual beings throughout their lives and human sexual development involves many other aspects of development- physical, behavioral, intellectual, emotional, and interpersonal. Human sexual development follows a progression that, within certain ranges, applies to most persons. The challenge of achieving sexual health begins early in life and continues throughout the lifespan. The actions communities and health care professionals must take to support healthy sexual development vary from one stage of development to the next. Children need stable environments, parenting that promotes healthy social and emotional development, and protection from abuse. Adolescents need education, skills training, self-esteem promoting experiences, and appropriate services related to sexuality, along with positive expectations and sound preparation for their future roles as partners in committed relationships and as parents. Adults need continuing education as they achieve sexual maturity--to learn to communicate effectively with their children and partners and to accept continued responsibility for their sexuality, as well as necessary sexual and reproductive health care services.

There are also a number of more variable risk and protective factors that shape human sexual behavior and can have an impact on sexual health and the practice of responsible sexual behavior. These include biological factors, parents and other family members, schools, friends, the community, the media, religion, health care professionals, the law, and the availability of reproductive and sexual health services.

Parents and Other Family Members

A number of family factors are known to be associated with adolescent sexual behavior and the risk of pregnancy. Adolescents living with a single parent are more likely to have had sexual intercourse than those living with both biological parents (Miller, 1998). Having older siblings may also influence the risk of adolescent pregnancy, particularly if the older siblings have had sexual intercourse, and if an older sister has experienced an adolescent pregnancy or birth (East, 1996; Widmer, 1997). For girls, the experience of sexual abuse in the family as a child or adolescent is linked to increased risk of adolescent pregnancy (Browning, 1997; Roosa, 1997; Miller, 1998). In addition, adolescents whose parents have higher education and income are more likely both to postpone sexual intercourse and to use contraception if they do engage in sexual intercourse (Miller, 1998).

The quality of the parent-child relationship is also significant. Close, warm parent-child relationships are associated with both postponement of sexual intercourse and more consistent contraceptive use by sexually active adolescents (Jaccard, 1996; Resnick, 1997). Parental supervision and monitoring of children are also associated with adolescents postponing sexual activity or having fewer sexual partners if they are sexually active (Hogan and Kitagawa, 1985; Miller, 1998; Upchurch et al, 1999). However, parental control can be associated with negative effects if it is excessive or coercive (Miller, 1998).

Schools

Evidence suggests that school attendance reduces adolescent sexual risk-taking behavior. Around the world, as the percentage of girls completing elementary school has increased, adolescent birth rates have decreased. In the United States, youth who have dropped out of school are more likely to initiate sexual activity earlier, fail to use contraception, become pregnant, and give birth (Mauldon and Luker, 1996; Brewster et al, 1998, Manlove, 1998; Darroch et al, 1999). Among youth who are in school, greater involvement with school-including athletics for girls--is related to less sexual risk-taking, including later age of initiation of sex, and lower frequency of sex, pregnancy, and childbearing (Holden et al, 1993; Billy et al, 1994; Resnick et al, 1997).

Schools may have these effects on sexual risk-taking behavior for any of several reasons. Schools structure students' time; they create an environment which discourages unhealthy risk-taking--particularly by increasing interactions between youth and adults; and they affect selection of friends and larger peer groups. Schools can increase belief in the future and help youth plan for higher education and careers, and they can increase students' sense of competence, as well as their communication and refusal skills (Manlove, 1998; Moore et al, 1998).

Schools often have access to training and communications technology that is frequently not available to families or clergy. This is important because parents vary widely in their own knowledge about sexuality, as well as their emotional capacity to explain essential sexual health issues to their children. Schools also provide an opportunity for the kind of positive peer learning that can influence social norms.

The Community

Community can be defined in several ways: through its geographic boundaries; through the predominant racial or ethnic makeup of its members; or through the shared values and practices of its members. Most persons are part of several communities, including neighborhood, school or work, religious affiliation, social groups, or athletic teams. Whatever the definition, community influence on the sexual health of those who comprise it is considerable, as is its role in determining what responsible sexual behavior is, how it is practiced and how it is enforced.

The measurable physical characteristics of neighborhoods and communities, such as economic conditions, racial and ethnic composition, residential stability, level of social disorganization, and service availability have demonstrated associations with the sexual behavior of their residents-initiation of sexual activity, contraceptive use, out-of-wedlock childbearing and risk of STD infection (Billy and Moore, 1992; Brewster et al, 1993; Grady, 1993; Billy et al, 1994; Grady et al, 1998; Tanfer et al, 1999). An understanding of these characteristics and their impact on individuals is important in planning and developing services and other interventions to improve the sexual health and promote the responsible sexual behavior of community residents.

A shared culture, based either on heritage or on beliefs and practices, is another form of community. Each of these communities possesses norms and values about sexuality and these norms and values can influence the sexual health and sexual behavior of community members. For example, strong prohibitions against sex outside of marriage can have protective effects with respect to STD/HIV infection and adolescent pregnancy (Comas-Diaz, 1987; Kulig, 1994; Savage and Tchombe, 1994; Sudarkasa, 1997; Tiongson, 1997; Abraham, 1999; Amaro, 2001). On the other hand, undue emphasis on sexual restraint and modesty can inhibit family discussion about sexuality and perhaps contribute to reluctance to seek sexual and reproductive health care (Hiatt et al, 1996; Schuster et al, 1996; He et al, 1998; Tang et al, 1999). Gender roles that accord higher status and more permissiveness for males and passivity for females can have a negative impact on the sexual health of women if they are unable to protect themselves against unintended pregnancy or STD/HIV infection (Amaro and Raj, 2000; Bowleg et al, 2000; Castaneda, 2000).

When a community--defined by its culture--also has minority status, its members are potential objects of economic or social bias which can have a negative impact on sexual health. Economic inequities, in the form of reduced educational and employment opportunities, and the poverty that often results, has obvious implications for accessing and receiving necessary health education and care. In addition, a history of exploitation has, in some cases, led to distrust and suspicion of public health efforts in some minority communities (Tafoya, 1989; Thomas and Quinn, 1991; Wyatt, 1997).

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V. Evidence-based Intervention Models

School Based Programs

A majority of Americans favor some form of sexuality education in the public schools and also believe that some sort of birth control information should be available to adolescents (Smith, 2000). School based sexuality education programs are generally of two types: abstinence-only programs that emphasize sexual abstinence as the most appropriate choice for young people; and sexuality and STD/HIV education programs that also cover abstinence but, in addition, include condoms and other methods of contraception to provide protection against STDs or pregnancy.

To date, there are only a few published evaluations of abstinence-only programs (Christopher and Roosa, 1990; St Pierre et al, 1995; Kirby et al, 1997; Kirby, 2001). Due to this limited number of studies it is too early to draw definite conclusions about this approach. Similarly, the value of these programs for adolescents who have initiated sexual activity is not yet understood. More research is clearly needed.

Programs that typically emphasize abstinence, but also cover condoms and other methods of contraception, have a larger body of evaluation evidence that indicates either no effect on initiation of sexual activity or, in some cases, a delay in the initiation of sexual activity (Kirby, 1999; Kirby, 2001). This evidence gives strong support to the conclusion that providing information about contraception does not increase adolescent sexual activity, either by hastening the onset of sexual intercourse, increasing the frequency of sexual intercourse, or increasing the number of sexual partners. In addition, some of these evaluated programs increased condom use or contraceptive use more generally for adolescents who were sexually active (Kirby et al, 1991; Rotheram-Borus et al, 1991; Jemmott et al, 1992; Walter and Vaughn, 1993; Magura et al, 1994; Main et al, 1994; St Lawrence et al, 1995; Hubbard et al, 1998; Jemmott et al, 1998; Coyle et al, 1999).

Despite the available evidence regarding the effectiveness of school-based sexuality education, it remains a controversial issue for many- in terms of whether schools are the most appropriate venue for such education, as well as curriculum content. Few would disagree that parents should be the primary sexuality educators of their children or that sexual abstinence until engaged in a committed and mutually monogamous relationship is an important component in any sexuality education program. It does seem clear, however, that providing sexuality education in the schools is a useful mechanism to ensure that this Nation's youth have a basic understanding of sexuality. Traditionally, schools have had a role in ensuring equity of access to information that is perhaps greater than most other institutions. In addition, given that one-half of adolescents in the United States are already sexually active-and at risk of unintended pregnancy and STD/HIV infection-it also seems clear that adolescents need accurate information about contraceptive methods so that they can reduce those risks.

Clinic Based Programs

Prevention programs based in health clinics that have an impact on sexual health and behavior are of three types: counseling and education; condom or contraceptive distribution; and STD/HIV screening. Successful counseling and education programs have several elements in common: they have a clear scientific basis for their design; they require a commitment of staff time and effort, as well as additional time from clients; they are tailored to the individual; and they include building clients' skills through, for example, exercises in negotiation. Even brief risk-reduction messages have been shown, in some studies, to lead to substantial increases in condom use (Cohen et al, 1991; Cohen et al, 1992; Mansfield et al, 1993; Kamb et al, 1998;) although other studies have shown little effect (Wenger et al, 1992; Clark et al, 1998). More extensive counseling, either individual or small group, can produce additional increases in consistent condom use (Boyer et al, 1997; Shain et al, 1999).

Most school clinic based condom and contraceptive availability programs include some form of abstinence or risk-reduction counseling to address the concern that increased condom availability could lead to increased sexual behavior (Kirby and Brown, 1996). The evidence indicates these programs, while still controversial in some communities, do not increase sexual behavior and that they are generally accepted by adolescents, parents, and school staff (Guttmacher et al, 1995; Wolk and Rosenbaum, 1995).

Because many STDs have no clear symptoms, STD/HIV screening promotes sexual health and responsible sexual behavior by detecting these diseases and preventing their unintentional spread. Routine screening in clinics has also been shown to reduce the incidence of some STDs, particularly chlamydia infection (Hillis et al, 1995; Scholes et al, 1996).

Religion Based Programs

Religion based sexuality education programs have been developed and cover a wide spectrum of different belief systems. Taken as a whole, they cover all age ranges, from early elementary school to adults, as well as youth with different sexual orientations and identities. Although it is reasonable to expect that religion based programs would have an impact on sexual behavior, the absence of scientific evaluations precludes arriving at a definitive conclusion on the effectiveness of these programs. More research is needed.

VI. Vision for the Future

1. Increasing Public Awareness of Issues Relating to Sexual Health and Responsible Sexual Behavior

• Begin a national dialogue on sexual health and responsible sexual behavior that is honest, mature and respectful, and has the ultimate goal of developing a national strategy that recognizes the need for common ground.

• Encourage opinion leaders to address issues related to sexual health and responsible sexual behavior in ways that are informed by the best available science and that respect diversity.

• Provide access to education about sexual health and responsible sexual behavior that is thorough, wide-ranging, begins early, and continues throughout the lifespan. Such education should:

• recognize the special place that sexuality has in our lives;

• stress the value and benefits of remaining abstinent until involved in a committed, enduring, and mutually monogamous relationship; but

• assure awareness of optimal protection from sexually transmitted diseases and unintended pregnancy, for those who are sexually active, while also stressing that there are no infallible methods of protection, except abstinence, and that condoms cannot protect against some forms of STDs.

• Recognize that sexuality education can be provided in a number of venues-homes, schools, churches, other community settings-but must always be developmentally and culturally appropriate.

• Recognize that parents are the child's first educators and should help guide other sexuality education efforts so that they are consistent with their values and beliefs.

• Recognize, also, that families differ in their level of knowledge, as well as their emotional capability to discuss sexuality issues. In moving toward equity of access to information for promoting sexual health and responsible sexual behavior, school sexuality education is a vital component of community responsibility.

For the full text of this document, please visit: http://www.surgeongeneral.gov/library/sexualhealth/call.htm