A R T I C L E S

Changes in Formal Sex Education: 1995–2002

By Laura CONTEXT: Although comprehensive sex education is broadly supported by health professionals, funding for
Duberstein abstinence-only education has increased.
Lindberg, John S.
Santelli and METHODS: Using data from the 1995 National Survey of Adolescent Males, the 1995 National Survey of Family
Susheela Singh Growth (NSFG) and the 2002 NSFG, changes in male and female adolescents’ reports of the sex education they have
received from formal sources were examined. Life-table methods were used to measure the timing of instruction, and
t tests were used for changes over time.

Laura Duberstein
RESULTS: From 1995 to 2002, reports of formal instruction about birth control methods declined among both genders
Lindberg is senior
research associate, (males, from 81% to 66%; females, from 87% to 70%). This, combined with increases in reports of abstinence educa-
and Susheela Singh tion among males (from 74% to 83%), resulted in a lower proportion of teenagers’ overall receiving formal instruction
is vice president of about both abstinence and birth control methods (males, 65% to 59%; females, 84% to 65%), and a higher proportion
research, both at the of teenagers’ receiving instruction only about abstinence (males, 9% to 24%; females, 8% to 21%). Teenagers in 2002
Guttmacher Institute,
New York. John S.
had received abstinence education about two years earlier (median age, 11.4 for males, 11.8 for females) than they
Santelli is professor had received birth control instruction (median age, 13.5 for both males and females). Among sexually experienced
and chairman, Heil- adolescents, 62% of females and 54% of males had received instruction about birth control methods prior to first sex.
brunn Department of
Population and CONCLUSIONS: A substantial retreat from formal instruction about birth control methods has left increasing propor-
Family Health,
Columbia University,
tions of adolescents receiving only abstinence education. Efforts are needed to expand teenagers’ access to medically
New York. accurate and comprehensive reproductive health information.
Perspectives on Sexual and Reproductive Health, 2006, 38(4):182–189

Comprehensive sex education—teaching that provides bal- tionship in the context of marriage is the expected stan-
anced and accurate information on both abstinence and dard of human sexual activity”; discussion of the benefits
birth control—is a crucial part of equipping adolescents with of contraception is prohibited in these programs.4 Feder-
the necessary skills to achieve healthy sexuality through- al and matching state funding for these programs rose from
out their lives. Although comprehensive sex education is approximately $10 million in fiscal year 1997 to $167 mil-
broadly supported by U.S. health professionals,1 it is being lion in 2005.5 The expansions in federal support for
increasingly replaced by abstinence-only education. In 1999, abstinence-only education are occurring in the absence of
23% of secondary school sex education teachers taught substantial scientific evidence supporting the effectiveness
abstinence as the only way to prevent pregnancy and STDs; of this approach to reduce sexual risk behaviors among ado-
only 2% had done so in 1988. In 1999, one-quarter of sex lescents.6 In a rigorous review of sex education programs,
education teachers said they were prohibited from teach- Kirby found that none of the abstinence-only programs eval-
ing about contraception.2 In 2000, 92% of all U.S. middle uated demonstrated efficacy in delaying sexual debut or
and junior high schools and 96% of high schools had at reducing sexual risk behaviors among sexually experienced
least one required class that taught abstinence as the best teenagers.7
way to avoid pregnancy, HIV and STDs, while 62% This analysis examines changes between 1995 and 2002
and 87%, respectively, had a class about methods of in adolescents’ reports of the sex education they have re-
contraception.3 ceived from formal sources such as schools, churches and
Since 1996, there have been major expansions in feder- other community groups. We assess trends in the extent
al support for abstinence education programs, and the bal- to which adolescent men and women received instruction
ance of funding has shifted toward programs that teach only about one or both of two key topics, abstinence and birth
abstinence and restrict other information. Federally fund- control methods, as well as the proportion of adolescents
ed abstinence education programs are required by law to receiving instruction in neither topic. We describe differ-
teach “that sexual activity outside of the context of mar- ences in receipt of sex education by the following charac-
riage is likely to have harmful psychological and physical teristics: gender, age, race or ethnicity, household poverty
effects” and “that a mutually faithful, monogamous rela- status and residence.

182 Perspectives on Sexual and Reproductive Health

METHODS they first received the instruction.†10 We used life-table meth-
Data ods to calculate the proportion of adolescents who had re-
Data for this analysis were drawn from three nationally rep- ceived instruction by each age and the median age at first
resentative household surveys: the 1995 National Survey instruction.
of Adolescent Males (NSAM), which surveyed males aged Additionally, we assessed whether sexually experienced
15–19; the 1995 National Survey of Family Growth (NSFG), respondents had received instruction prior to first inter-
which surveyed women aged 15–44; and the 2002 NSFG, course. Following the approach used in earlier research,
which surveyed males and females aged 15–44. The method- instruction was considered to have preceded first inter-
ology of each survey has been described in detail elsewhere.8 course if age at first instruction (in whole years) was younger
In brief, each survey used a multistage, stratified, clustered than reported age at first intercourse; if the same age was
sampling frame. Our analytic sample was limited to re- reported for both, instruction was considered to have oc-
spondents aged 15–19 at the time of the interview—for the curred after first intercourse.11
1995 NSAM, 1,729 males; for the 1995 NSFG, 1,396 fe- •Demographic variables. We examined differences in
males; and for the 2002 NSFG, 1,150 females and 1,121 receipt of sex education according to key demographic
males. Each survey, using face-to-face interviews, focused characteristics, defined consistently across the three sur-
on sexual and family formation behaviors, and collected veys. We included age at interview (15–17, 18–19), race or
information about receipt of sex education. The NSAM was ethnicity (non-Hispanic white, non-Hispanic black,
designed as a counterpart to the NSFG, to collect data on Hispanic‡) and sexual experience (ever vs. never engaged
adolescent males. Substantial efforts were made when de- in vaginal intercourse). Residence (central city, other met-
signing the 2002 NSFG to maintain comparability over time ropolitan area, nonmetropolitan area) is based on the re-
and across gender. spondent’s address at the time of the interview, classified
according to the 1990 census (for the 1995 NSFG) or 2000
Measures census (for the 2005 NSFG). Place of residence was not
•Formal instruction. From each of the data sets examined, available for the NSAM respondents.
we developed measures of whether respondents had re- We also included a measure of household poverty level
ceived “formal instruction” before they were 18 years old (less than 200% of poverty, greater than or equal to 200%
about methods of birth control and abstinence.* The exact of poverty). Household poverty level was determined by
question wording varied slightly across the surveys. In the the respondent’s report of combined household income
1995 NSAM, respondents were asked whether they had from all sources in the year prior to the interview, divided
ever received “formal instruction in school or in an orga- by annual weighted average threshold incomes as defined
nized program,” while the 1995 and 2002 NSFGs asked by the U.S. Census Bureau for family size of the respondent’s
about “formal instruction at school, church, a community household. The 1995 and 2002 NSFG household poverty
center or some other place.” Analysis of the 1988 NSAM measures were calculated directly by the National Center
found that most males (91–96%) had received their for- for Health Statistics and made available on the public-use
mal instruction about birth control at school,9 suggesting data tape. For the 1995 NSAM, we calculated the house-
that the difference in question wording is of minimal sub- hold poverty level using the same formula.12 Household
stantive concern. In each survey, respondents were asked poverty data were missing for 5.3% of respondents in the
specifically about receipt of instruction on “methods of birth 1995 NSAM. Analysis revealed that sex education among
control.” In all but the 1995 NSFG, respondents were asked this group of respondents did not differ significantly from
about receipt of instruction on “how to say no to sex”; fe- males in any income group. We do not report separately
males in 1995 were asked about “abstinence or how to say on the respondents with missing income data, but include
no.” We use these terms interchangeably. them in all other measures.
In each survey, the measures of reproductive health in-
struction reflect adolescents’ recall of such instruction. Al- Analysis
though this information cannot be interpreted as a direct In the first component of the analysis, we examined changes
measure of school policies or of the specific content of cur- in the receipt of formal instruction on abstinence and birth
ricula, it is indicative of overall levels of and relative differ- control methods between 1995 and 2002. We measured
ences across time periods and subgroups in the provision the prevalence of each type of instruction, alone and in com-
of information on these two topics. bination, as well as the proportion of adolescents who had
•Timing. We calculated measures of the timing of formal
*In the 1995 NSAM, respondents aged 15–19 were asked about any in-
instruction about birth control methods and abstinence. struction ever received. Using estimated age at first instruction, we limit-
Respondents were asked in what grade they had first re- ed the NSAM reports to instruction received prior to age 18.
ceived instruction in each topic; since age at instruction was †In prior analysis of the 1995 NSAM, males’ reports of having repeated a
grade in school were incorporated into this calculation (source: reference
not reported directly, our age estimate was based on the 10); since this measure was not available for the other surveys, it was not
assumption that children in first grade are approximately included in this study. For this reason, the measures of timing reported
here differ from those reported previously.
six years old. Thus, we calculated respondents’ age at first
‡Respondents reporting “other” race or ethnicity are included in the to-
instruction by adding five to the grade in which they said tals, but excluded from the subgroup analysis because of small sample size.

Volume 38, Number 4, December 2006 183

Changes in Formal Sex Education

TABLE 1. Percentage distribution of respondents aged 15–19 in surveys assessing areas. Fewer than one-quarter of respondents in each sam-
receipt of formal sex education, by selected characteristics, according to survey ple resided in nonmetropolitan areas. In each sample, the
Characteristic Males Females majority of respondents resided in households with incomes
of 200% or more of the federal poverty line. In the 1995
1995 NSAM 2002 NSFG 1995 NSFG 2002 NSFG
(N=1,729) (N=1,121) (N=1,396) (N=1,150) NSAM, the household poverty measure could not be calcu-
lated for 5% of the sample. Slightly more than half of ado-
Race/ethnicity
Non-Hispanic white 67.4 63.7 66.4 63.6 lescents were sexually experienced in 1995 (52% of females
Hispanic 12.6 15.9 12.8 15.5 and 55% of males), but the proportions declined to 46–47%
Non-Hispanic black 14.3 14.4 15.6 15.2
Other 5.7 5.9 5.2 5.7 in 2002. For each sample, sexually experienced adolescents
were younger than their sexually inexperienced peers (not
Age shown).
15–17 61.8 56.3 60.0 59.2
18–19 38.3 43.7 40.0 40.8
Formal Instruction
Residence
Central city u 28.0 32.5 29.1
•Receipt of formal instruction. The content and prevalence
Other metropolitan u 52.8 43.8 48.5 of formal sex education shifted away from birth control in-
Nonmetropolitan u 19.2 23.7 22.5 struction between 1995 and 2002 (Table 2). The proportion
Household poverty level* of adolescents who had received any formal instruction about
<200% 38.1 40.7 38.9 49.1 methods of birth control declined significantly for each gen-
≥200% 56.6 59.3 61.1 51.0
Missing 5.3 0.0 0.0 0.0
der (from 81% to 66% of males, and from 87% to 70% of fe-
males); by 2002, one-third of adolescents of each gender had
Ever had sex not received any instruction about birth control methods.
Yes 55.3 46.0 51.7 46.8
No 44.7 54.0 48.3 53.2 The proportion of adolescents who had ever received in-
struction in “how to say no to sex” increased among males
Total 100.0 100.0 100.0 100.0
between 1995 and 2002 (from 74% to 83%), while declin-
*Percentage of federal poverty line. Notes: Percentages may not total 100.0 because of rounding. u=unavailable. ing significantly among females (from 92% to 86%). The
broader wording in 1995 for females (“abstinence or how to
received instruction in neither topic. In addition to testing say no”) may have elicited greater reporting. If so, some por-
for overall changes between 1995 and 2002, we tested for tion of the decline among females may be the result of the
differences within each period by gender, age, race or eth- change in wording. By 2002, both male and female teenagers
nicity, sexual experience, residence and poverty status. Next, were significantly more likely to have received instruction
using life-table methods, we measured changes over time about how to say no to sex than they were to have received
in the age at first instruction in each topic, by gender. Fi- instruction about birth control methods (p≤.001—not shown).
nally, to examine changes in the timing of instruction rel- Formal instruction for adolescents became less com-
ative to the timing of first intercourse, we measured changes prehensive between 1995 and 2002, as the proportion of
in the proportion of sexually experienced adolescents who adolescents who had received instruction on both birth
had received instruction in each topic prior to first inter- control methods and abstinence declined significantly, es-
course and tested for differences by demographic charac- pecially among females (84% to 65%). In contrast, for both
teristics using t tests. males and females, receipt of abstinence education alone
In all analyses, standard errors and tests of statistical sig- became significantly more common between 1995 and
nificance were calculated using the svy series of commands 2002, when it rose to more than one out of five adolescents
in Stata 8.2 to account for the stratified survey designs. We (males, from 9% to 24%; females, from 8% to 21%).* The
report only differences with a p value of 5% or less, given proportion of males who had received birth control in-
limitations of space and the number of tests performed. struction alone declined from 16% to 7%; the proportion
of females increased a small but significant amount, from
RESULTS 3% to 5%. Finally, the proportion of adolescents who had
Sample Characteristics received formal instruction about neither birth control meth-
About two-thirds of the adolescents in each sample were ods nor abstinence did not change significantly from 1995
white, and most of the rest were Hispanic or black; 5–6% to 2002 for males (about 10% for both years), but increased
identified their race or ethnicity as “other” (Table 1). About from 5% to 9% for females. These patterns of change in for-
60% of each sample were aged 15–17 at the time of the mal instruction occurred within nearly all of the popula-
interview. In each year, about three in 10 female respondents tion groups examined.
resided in central cities, while close to half resided in other In 2002, there were significant differences among sub-
metropolitan areas; three in 10 male respondents in 2002 groups of male adolescents in the receipt of formal instruc-
resided in central cities, and half lived in other metropolitan tion. Compared with other teenage males, black males, those
residing in nonmetropolitan areas and those living with in-
*Our measure of receiving only abstinence education is not directly com-
parable to the formal federal definition of abstinence-only education, a
comes of less than 200% of the federal poverty line were less
stringent eight-point definition that emphasizes abstinence until marriage. likely to have received both instruction about birth control

184 Perspectives on Sexual and Reproductive Health

TABLE 2. Percentage of males and females aged 15–19 who had received instruction on specific sex education topics by age
18, by selected characteristics, 1995 and 2002

Characteristic Birth control Abstinence Both Abstinence Birth control Neither

only only
1995 2002 1995 2002 1995 2002 1995 2002 1995 2002 1995 2002
MALES 81.2* 66.2† 74.1* 82.6† 64.8* 58.8*,† 9.3 23.8† 16.4* 7.4† 9.5* 10.0

Race/ethnicity
Non-Hispanic white (ref) 81.1 69.4† 74.0 84.2† 65.0 61.4 9.0 22.8† 16.1 7.9† 10.0 7.9
Hispanic 79.0 62.2† 75.2 77.8 65.2 54.0† 10.0 23.8† 13.7 8.1† 11.1 14.1‡
Non-Hispanic black 80.0 54.6†,‡ 75.8 79.3 63.6 48.3†,‡ 12.2 31.1† 16.5 6.3† 7.7 14.4

Age
15–17 (ref) 79.2 64.0† 75.2 83.8† 64.7 56.9 10.5 26.9† 14.5 7.1† 10.3 9.1
18–19 84.6 69.0† 72.3 81.0† 65.1 61.2 7.3 19.8†,‡ 19.5 7.8† 8.2 11.1

Residence
Central city (ref) u 71.0 u 83.6 u 62.8 u 20.8 u 8.2 u 8.2
Other metropolitan u 68.0 u 85.4 u 61.0 u 24.4 u 7.0 u 7.6
Nonmetropolitan u 54.1‡ u 73.5‡ u 46.7‡ u 26.8 u 7.4 u 19.1‡

Household poverty level§

<200% (ref) 78.7 56.9† 72.9 80.1† 61.5 49.3† 11.4 30.8† 17.2 7.7† 9.9 12.2
≥200% 83.9‡ 72.6†,‡ 75.7 84.3† 68.2 65.3‡ 7.5‡ 19.0†,‡ 15.7 7.2† 8.6 8.4

Ever had sex

Yes (ref) 83.1 65.1† 69.8 79.3† 62.7 56.1† 7.1 23.2† 20.4 9.0† 9.8 11.6
No 78.9 67.1† 79.3‡ 85.4†,‡ 67.4 61.1 11.9‡ 24.3† 11.5‡ 6.0† 9.1 8.6

FEMALES 87.1 69.9† 92.0 85.5† 84.4 64.9† 7.6 20.7† 2.8 5.1† 5.3 9.4†

Race/ethnicity
Non-Hispanic white (ref) 88.3 72.2† 92.7 86.8† 85.5 67.2† 7.2 19.7† 2.8 5.0 4.5 8.2†
Hispanic 84.9 64.9† 85.6 81.4 80.8 59.1† 4.8 22.3† 4.7 5.8 9.6 12.8
Non-Hispanic black 86.3 64.2†,‡ 93.5 84.4† 84.7 60.5† 8.8 23.8† 1.5 3.7 5.0 11.9†

Age
15–17 (ref) 87.3 66.6† 93.1 86.6† 85.1 61.9† 8.0 24.7† 2.3 4.7† 4.6 8.7†
18–19 86.7 74.8†,‡ 90.3 84.0† 83.3 69.2†,‡ 7.1 14.8†,‡ 3.5 5.6 6.2 10.5†

Residence
Central city (ref) 84.4‡ 68.4† 93.5 83.1† 87.4 63.0† 6.1 20.1† 3.3 5.4 3.2 11.6†
Other metropolitan 90.7 73.2† 90.0 89.9‡ 81.7‡ 69.5† 8.3 20.4† 2.7 3.7 7.3 6.4‡
Nonmetropolitan 83.9‡ 64.8† 92.0 79.2† 82.4 57.2† 9.5 22.0† 1.8 7.6† 6.2 13.2†

Household poverty level

<200% (ref) 84.1 67.5† 90.6 83.4† 81.4 62.0† 9.2 21.4† 2.6 5.5† 6.7 11.1†
≥200% 89.0‡ 72.2† 92.8 87.5† 86.2‡ 67.6† 6.6 19.9† 2.9 4.6 4.3 7.8†

Ever had sex

Yes (ref) 87.3 72.9† 90.6 83.5† 83.5 65.7† 7.1 17.7† 3.8 7.1† 5.8 9.4†
No 86.8 67.3† 93.5 87.3† 85.1 64.1† 8.2 23.3† 1.7‡ 3.2‡ 4.8 9.4†

*Significantly different from total percentage of females at p<.05. †Significantly different from percentage for 1995 at p<.05. ‡Significantly different from percent-
age for reference group at p<.05. §Percentage of federal poverty line. Notes: ref=reference group. u=unavailable.

methods and instruction addressing both topics. Among fe- proportion of males than of females had received only birth
males in 2002, there were fewer subgroup differences. control education or neither form of instruction. By 2002,
There were few differences in instruction by sexual ex- most of these differences were no longer significant. The
perience. In both 1995 and 2002, receipt of instruction about proportion who had received both forms of instruction re-
abstinence was significantly less common among sexually mained significantly smaller among males than among fe-
experienced than inexperienced males (in 1995, 70% vs. males (59% vs. 65%), but the difference was far smaller
79%; in 2002, 79% vs. 85%); there was no difference across than it had been in 1995.
these categories for females. However, in both years, sig- •Age at instruction. Our life-table analyses indicate that
nificantly higher proportions of sexually experienced females teenage males in 2002 had received abstinence education
than of virgins had received instruction only about birth at a younger age than had their counterparts in 1995; the
control (in 1995, 4% vs. 2%; in 2002, 7% vs. 3%). median age was 11.4 years in 2002 and 13.5 in 1995 (Fig-
Between 1995 and 2002, differences by gender overall ure 1, page 186). The timing of birth control education did
diminished. In 1995, a significantly lower proportion of not change significantly (median age, 13.3 in 1995 and 13.5
males than of females had received birth control education, in 2002), so by 2002, males had received abstinence edu-
abstinence education or both, and a significantly higher cation two years earlier than birth control instruction.

Volume 38, Number 4, December 2006 185

Changes in Formal Sex Education

FIGURE 1. Cumulative percentage of males aged 15–19 who had received instruction not differ by gender in 2002, when all adolescents report-
on specific sex education topics, by age, according to topic and year ed having received abstinence education two years earlier
than instruction about birth control methods.
%
Older teenagers were less likely to have received birth
100
control education in 2002 than 1995. In 1995, 70% of ado-
90 lescent males had obtained instruction about birth control
80 methods by age 14.5, and 80% by age 16; however, in 2002,
only 67% had obtained birth control education by age 18.
70
Similarly, nearly 90% of females had obtained formal in-
60 struction about birth control methods by age 18 in 1995,
50 compared with 71% in 2002.
•Timing of formal instruction relative to first intercourse. As
40
shown in Table 3, among sexually experienced males, the
30 decline in birth control education prior to first sex did not
20 reach statistical significance (61% vs. 54%, p=.06), and there
was a large increase in the share who had received absti-
10
nence education before first intercourse (52% vs. 70%). In
0
contrast, among sexually experienced adolescent females,
10 11 12 13 14 15 16 17 18
the share who had received instruction about methods of
Birth control, 2002 Birth control, 1995 birth control prior to first sex decreased significantly from
Abstinence, 2002 Abstinence, 1995 72% in 1995 to 62% in 2002, but the proportion of sexu-
ally experienced females who had received instruction about
Figure 2 shows that among females, there was no sig- abstinence before first sex did not change significantly. By
nificant difference between the timing of abstinence edu- 2002, significantly higher proportions of sexually experi-
cation and birth control education (median ages, 12.4 and enced adolescents of both genders had received abstinence
12.3) in 1995; half of females had received instruction on instruction than had received birth control instruction prior
both topics by 12.5 years of age (not shown). By 2002, ab- to first sex (not shown).
stinence education occurred earlier than in 1995 (median There were some significant differences by gender in both
age, 11.8), while the age at receipt of birth control educa- 1995 and 2002. Receipt of formal instruction about birth
tion increased by about one year (median age, 13.5). These control methods was significantly less common among
opposite trends resulted, by 2002, in female adolescents’ males than among females in both 1995 (61% vs. 72%) and
having received abstinence education about two years ear- 2002 (54% vs. 62%). A lower proportion of sexually ex-
lier than birth control education. The net result of these perienced males than females had received instruction about
different trends among males and females over the period abstinence prior to first sex in 1995 (52% vs. 73%). How-
is that the median ages at first instruction in each topic did ever, the substantial increase in abstinence instruction
among males resulted in no gender differences by 2002.
FIGURE 2. Cumulative percentage of females aged 15–19 who had received instruc- In 2002, there were significant differences by race or eth-
tion on specific sex education topics, by age, according to topic and year nicity and poverty status in the receipt of birth control in-
% struction prior to first intercourse. Only one out of three
100
sexually experienced black males and fewer than one in
two sexually experienced black females had received in-
90
struction about birth control methods prior to first sex, as
80 compared with two-thirds of their white peers; proportions
70 among Hispanic teenagers were also significantly lower than
those for white teenagers. For both males and females in
60
both years, those living below 200% of poverty were less
50 likely to have received birth control education before first
40 sex than were their higher income peers.
We focus our discussion of the results on the relative tim-
30
ing of instruction about birth control and first intercourse.
20 However, the general lack of demographic differences in
10 the timing of abstinence education prior to first sex is note-
worthy in its contrast to the differentials observed for birth
0
10 11 12 13 14 15 16 17 18 control education. In 2002, there were no differences by
gender in the receipt of abstinence education prior to first
Birth control, 2002 Birth control, 1995 sex. Among sexually experienced males, the only demo-
Abstinence, 2002 Abstinence, 1995 graphic difference was that a lower proportion of Hispan-

186 Perspectives on Sexual and Reproductive Health

ic males than of their white peers had received abstinence TABLE 3. Percentage of sexually experienced males and females aged 15–19 who
education before first sex. Among sexually experienced fe- had ever received instruction on specific sex education topics prior to first inter-
males, a lower proportion of blacks than of whites had re- course, by selected characteristics, 1995 and 2002
ceived abstinence education prior to first intercourse (64% Characteristic Birth control Abstinence
vs. 80%), while the proportion was greater among females
Males Females Males Females
who resided in a central city than among those in other met-
1995 2002 1995 2002 1995 2002 1995 2002
ropolitan areas (79% vs. 69%).
Total 61.2* 54.3* 72.4 61.8† 52.0* 70.3† 72.5 75.1
DISCUSSION
Race/ethnicity
Most adolescents, and their parents, believe that adoles- Non-Hispanic white (ref) 69.4 65.6 75.3 67.8 55.7 75.1† 74.8 79.8
cents need information about abstinence and birth control.13 Hispanic 52.8‡ 44.9‡ 65.8 50.8‡ 51.5 59.3‡ 64.0 69.9
Non-Hispanic black 41.9*,‡ 32.8‡ 68.2 45.1†,‡ 43.2‡ 68.5† 70.7 63.9‡
However, our study has found that in practice, there was a
substantial retreat from a comprehensive approach to sex Age
education from 1995 to 2002. Large declines in instruc- 15–17 (ref) 57.7 49.1 70.6 57.0† 50.8 70.2† 71.1 76.3
18–19 64.4 57.6 73.8 64.8† 53.1 70.4† 73.5 74.3
tion about birth control methods, combined with increas-
es in abstinence education, resulted in a lower proportion Residence
of teenagers’ having received formal instruction about both Central city (ref) u 55.9 75.8 56.5† u 71.2 75.1 68.9
Other metropolitan u 54.9 68.3 64.7 u 72.3 69.3 79.0†,‡
abstinence and birth control methods, and a higher pro- Nonmetropolitan u 49.6 72.6 63.5 u 63.4 72.7 76.3
portion of teenagers’ having received instruction only about
Household poverty level§
abstinence. Not only had a lower proportion of adolescents
<200% (ref) 55.6 43.5 65.2 56.2 46.1 66.2† 67.9 73.6
learned about birth control methods in school or through ≥200% 65.5‡ 61.7‡ 77.8‡ 66.9†,‡ 56.9*,‡ 73.0† 75.9‡ 76.5
other formal sources, but this instruction had occurred at
*Significantly different from total percentage of females at p<.05. †Significantly different from percentage for
later ages than previously, while the median age at absti- 1995 at p<.05. ‡Significantly different from percentage for reference group at p<.05. §Percentage of federal
nence education declined. A lower proportion of sexually poverty line. Note: u=unavailable.
experienced adolescents had received instruction about
birth control methods before first sex, and one-quarter of adolescent females, as reported in the 1995 NSFG.16
sexually experienced teenagers had not received instruc- An unexpected finding of this study is that while the pro-
tion about abstinence prior to first sex. Abstinence educa- portion of males who had received formal instruction about
tion was received relatively uniformly by adolescents, re- abstinence increased, this proportion decreased for females
gardless of their demographic characteristics. In contrast, (although neither change was large). The gap between males
declines from 1995 to 2002 in birth control instruction and and females in receipt of abstinence education was 18 per-
comprehensive education were particularly marked for black centage points in 1995, but had almost disappeared by 2002
males and males living below 200% of the poverty level; (females were still slightly more likely to report receipt of
as a result, these groups were less likely than their peers to abstinence instruction than males in 2002). Combined with
have received such instruction by 2002. Additionally, in the lack of other social and demographic differentials in
2002, males living in nonmetropolitan areas had signifi- the receipt of abstinence education, this suggests that in-
cantly lower levels of receipt of instruction about birth con- formation about abstinence, which used to be reserved for
trol, abstinence and both types of education when com- distinct groups of students, had become more widely in-
pared with males living in metropolitan areas. tegrated into reproductive health curricula.
The trend in formal instruction observed over the recent The alarming trends away from birth control instruction
decade pertains primarily to school-based education, and and comprehensive sex education for black males, males
is a continuation of the trend documented in national sur- living below 200% of poverty and males living in non-
veys showing that 2% of sex education teachers in 1988 metropolitan areas are of particular concern, as they create
taught abstinence only, but 23% did so in 1998. During growing inequities. In 2002, fewer than 60% of black males,
this same period, there were declines in broader instruc- males living below 200% poverty and males living in non-
tion about sexual orientation, abortion, and where to go metropolitan areas had received any formal instruction about
for birth control and STD services.14 Similar trends were birth control methods. Among sexually experienced males
documented by the Youth Risk Behavior Survey: The pro- in these groups, no more than half had received instruction
portion of students in grades 9–12 being taught about AIDS about birth control prior to first sex. National public health
or HIV infection in school declined between 1997 and 2003 goals set by the Department of Health and Human Services
(from 92% to 88%), following a period of increase between should seek, at a minimum, to return formal instruction to
1991 and 1997 (from 83% to 92%).15 Analyses of the 1988 its 1995 levels, as well as to reduce inequities.
and 1995 rounds of the NSAM had documented that ado-
lescent males were growing increasingly likely to have re- Limitations
ceived instruction on both abstinence and birth control This study has a number of limitations. The measures of
methods, and were receiving it at earlier ages; even so, they receipt of instruction are very narrow—they report if any
were less likely to have received this instruction than were instruction occurred, but tell us nothing about the quan-

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Changes in Formal Sex Education

tity or quality of this education. There is likely substantial CONCLUSIONS

variation in quantity and quality of the instruction provided Our analysis points to the need for a broader assessment
that we are not able to describe. Past reviews have identi- of trends in sex education, in terms of a range of key sub-
fied a range of program characteristics that influence the jects (including STDs) and the timing of instruction; a more
effectiveness of sexual risk reduction interventions for ado- specific assessment of where formal instruction is occur-
lescents, including a focus on curriculum development, con- ring also would be useful. Although the vast majority of
tent and implementation—all factors that likely varied across males (91–96%) in 1988 who had received formal in-
the formal instruction reported here by adolescents.17 struction said they had gotten it from school,20 this may
A more important limitation of these measures may be have changed with the expansion of and funding oppor-
that they do not provide information about the tone or the tunities for community-based programs. Given the differ-
content of instruction, which is particularly relevant for un- ences observed by residence, it is also necessary to assess
derstanding the measures of receipt of instruction about differences in coverage of topics among school districts
birth control. Abstinence instruction may include discus- across the country.
sions about birth control that emphasize its ineffectiveness, Any study measuring only the receipt of education does
as part of a focus on the risks of sexual activity.18 This tone not provide information about its effectiveness. There has
is far different from one that includes instruction about birth been little well-executed research on the effectiveness of
control as a means of pregnancy prevention and protec- abstinence-only education for adolescents. In a cross-
tion. Depending on the tone and content of information national review of 83 sex and HIV education programs for
provided about birth control, the reported proportion of adolescents, only six programs focused on abstinence
adolescents receiving comprehensive sex education may only or abstinence until marriage.21 The large shift away
be overestimated, as it may include some teenagers who from teaching teenagers about birth control methods as
were taught that birth control methods are generally inef- part of their formal instruction has occurred without firm
fective. Although we documented a downward trend in the evidence documenting the positive effects of abstinence
prevalence of birth control instruction, this negative trend only instruction. There is a continued need for research on
may be even more pervasive if some adolescents did not the direct causal links between education received and rel-
receive accurate information about birth control. evant behaviors that follows teenagers over an extended
Another limitation is that adolescents’ reports of what period of time. The large changes in the content of sex ed-
they were taught may not fully reflect actual instruction that ucation described here warrant substantial investigation
schools provide. Factors such as the perceived relevance of its impact on adolescents’ reproductive health knowl-
of the information and the quality of the teaching may af- edge, behaviors and outcomes.
fect the likelihood that individuals remember receiving in-
struction on particular topics. For example, past studies REFERENCES
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The research on which this article is based was supported by the
Risk Behavior Survey: 1991–2003, <http://www.cdc.gov/HealthyYouth/ Ford Foundation. The conclusions and opinions expressed here are
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of students who had ever been taught in school about AIDS or HIV for invaluable data analysis and Lawrence Finer and David Landry
infection, Youth Online: Comprehensive Results, <http://apps.nccd. for providing technical assistance and reviewing several drafts of
cdc.gov/yrbss/SelectLocyear.asp?cat=4&Quest=Q85 >, accessed Aug.
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16. Lindberg LD, Ku L and Sonenstein F, 2000, op. cit. (see reference
10). Author contact: LLindberg@guttmacher.org

N OT E TO AU T H O R S
Beginning with the March 2007 issue, Perspectives on Sexual
and Reproductive Health will be changing its style for number-
ing references, doing away with the use of “ibid.” and “op. cit.”
Details are in our Guidelines for Authors, which may be found
on page 236 of this issue and on our Web site, at <http://
www.guttmacher.org/guidelines/guidelines_psrh.html>.

Volume 38, Number 4, December 2006 189