WIXLIB

c. BullyingBullying remains an urgent public healthconcern with 20% of high school studentsreporting being bullied on school propertyin the last year.12 People bully for manyreasons, though primary motives includelow self-esteem, emotional neglect, andsome bullies may be victims of violencethemselves.13Discriminatory school policies furtherexacerbate the adverse conditions manyLGBTQ youth are forced to tolerate on adaily basis. Right now, only 11 states havepolicies that include affirming instructionon LGBTQ identities.5Of the states that report in the YRBSS,the story map indicates Oklahoma has thehighest rate of LGB students who reportbeing bullied (48.3%), and Oklahoma alsomandates students be taught thathomosexual behaviors are the primarycause for HIV/AIDS.1Alabama, Arizona, Mississippi, Oklahoma,and Utah mandate students be taughtnegative outcomes of homosexuality(e.g. teachers cannot “suggest that somemethods of sex are safe methods ofhomosexual sex”).1 Notably, in Arizona,840.9% of LGB high school students reportbeing bullied (compared to the nationalaverage of 34.01%).2 Alabama, Mississippi,and Utah have sex education legislationthat mandates students be taught negativeoutcomes of homosexuality, though thesestates do not report on bullying in theYRBSS.1 North Carolina includes languagein their sex education legislation thatpromotes a heterosexual standard but doesnot directly mandate negative depictions ofhomosexuality.1 Notably, a previous lawprohibited discussion of LGBTQ topics inSouth Carolina, though in March 2020, a U.S.district judge ruled this unconstitutional.14While students of all demographics reportbeing bullied, LGB students report beingbullied at significantly higher rates than theirheterosexual peers. For instance, 70.1% ofLGB youth reported experiencing verbalharassment in 2017.15 Additionally, 77% ofthose who were perceived as transgenderreport having one or more negativeexperiences at school because of theirperceived transgender identity, includingverbal harassment and physical violence.3Increased rates of bullying can contribute toadverse health outcomes for LGB youth.16Though observable patterns within thestory map are limited due to many statesnot reporting in the YRBSS, the datademonstrate that many states lack formalmandates for sex education that areinclusive of the full spectrum of genderidentity and sexual orientation.112Preventing bullying. (2019). Centers for Disease Control andPrevention (CDC). ying-factsheet508.pdf13Swearer, S.M., Hymel, S. (2015). Understanding the psychologyof bullying: moving toward a social-ecological diathesis–stressmodel. American Psychologist. 38929.pdf14Knox, L. (2020). S. Carolina law banning LGBTQ sex ed isunconstitutional, judge rules. NBC. les-n115650115Kosciw, J.G., Greytak, E.A., Zongrone, A.D., et al. (2018).The 2017 National School Climate Survey: the experiences oflesbian, gay, bisexual, transgender, and queer youth in ournation’s schools. GLSEN. -Report.pdf162018 LGBTQ Youth Report. (2018). Human Rights urces/2018-YouthReport-NoVid.pdf? ga 243

d. Suicidecompared to gay and bisexual malestudents (37.0%).2 Transgender youth alsoexperience disparate rates of suicidalideation, with an overwhelming 35% oftransgender youth reporting that theyhave attempted suicide.3Suicide was the second leading cause ofdeath among young people in 2017.17Between 2008 to 2015, hospital admissionsfor suicidal ideation and attempts amongyoung people more than doubled.18 Youngwomen report seriously considering suicideat nearly twice the rate of their male peers,and LGB youth report seriously consideringsuicide at over three times the rate oftheir heterosexual peers.2 Such devastatingindicators do not exist in a vacuum, asassociated health factors like bullying anddating violence underscore this disparateimpact on young women and lesbian, gay,and bisexual youth.As noted in the story map, it is difficult tountangle the relationship between sexeducation legislation and suicidal ideationgiven the breadth of this particular indicator.1Analyses of YRBSS data demonstrate that47.7% of LGB youth had seriously consideredattempting suicide compared to 13.3% oftheir heterosexual peers.2 Further, theprevalence of suicidal ideation is higheramong heterosexual female students (16.9%)compared to heterosexual male (10.2%)students.2 It is also higher among lesbianand bisexual female students (51.0%)9Because comprehensive sex educationprovides affirming instruction on sexualorientation and gender identity, along withinstruction on healthy relationships,self-esteem, body confidence, and personalsafety, it has the powerful potential to actas a method of suicide prevention.Again, the lack of rigorous, large-scalescientific research that demonstrates thecorrelation between comprehensive sexeducation and suicide is likely a byproductof the inability to recognize the power ofsex education as violence prevention. Whileearly data suggest that comprehensive sexeducation can successfully address violenceprevention, further data is needed tounderscore this correlation.1 17Heron, M. (2019). Deaths: leading causes for 2017. Centersfor Disease Control and Prevention (CDC) NVSR, 68(6). https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68 06-508.pdf18Plemmons, G., Hall, M., Doupnik, S., et al. (2018).Hospitalization for suicide ideation or attempt: 2008-2015.Pediatrics, 141(6). /6/e20172426PHOTO BYCOTTONBRO

Sexual and reproductive healtha. Contraceptive useContraceptive prevalence refers to thepercentage of high school students whoreported using any form of contraceptionprior to their last sexual intercourse. Whilethe rate of contraceptive prevalence is againmultifactorial, the nationwide patchwork ofsex education requirements likely influencescontraceptive use. Right now, only 16states require instruction on condoms orcontraception, if sex education is provided.5The primary observable pattern thatemerges within the story map is that stateswith the lowest rates of contraceptiveprevalence—Texas, Arkansas, and Nevada—do not mandate contraceptive education.1Further, an overwhelming 35 states requireschools to stress abstinence when sexeducation or HIV/STI instruction is provided.5Moreover, while contraceptive use isessential in preventing unintended pregnancyand the spread of STIs when condoms areused, access to health centers that offer the10full range of contraceptives varies greatlyacross the United States. Nineteen millionwomen currently live in counties where theylack reasonable access to health centersthat offer the full range of contraceptivemethods.19 These areas are referred to ascontraceptive deserts. Even further,1.6 million women live in counties withouta single health center that offers the fullrange of contraceptive options.19to such legislative advancements, it isessential that young people have the meansto access healthcare providers in theirrespective communities that allow themto obtain said contraception. Without themeans to access reproductive healthcareservices, education on contraception isrendered ineffective.19While contraceptive use among youngpeople has increased since the 1990s,contraceptive prevalence continues to beinconsistent. In 2017, 18% of U.S. highschool women reported they were eitherunsure if they used birth control or theyused no method at all during their lastsexual intercourse.2As indicated by observable patterns withinthe story map, legislation that requiresstudents be taught about contraception hasthe potential to improve contraceptiveprevalence among adolescents.1 In additionBirth control access. (2020). Power to Decide. control-access

b. Sexually transmitted infections (STIs)In recent years, reported rates of sexuallytransmitted infections have continued toincrease across the United States. In 2018,nearly 2.5 million cases of chlamydia,gonorrhea, and syphilis were reported.20Young people aged 15-24 made up almosttwo thirds of all reported chlamydiacases.20 While STIs have impactedcommunities nationwide, young people inparticular continue to be disproportionatelyrepresented among reported cases.Currently, young people represent anestimated half of all reported STI casesannually and 62% of all chlamydia cases,despite representing only 13% of thepopulation.20However, STI education continues to beneglected in schools nationwide. Fifteenstates do not require sex education orHIV/STI instruction to be age-appropriate,medically accurate, culturally responsive,or evidence-based.5 Fourteen states donot require HIV/STI education at all.5Further, observable patterns within thestory map demonstrate that STI rates arelowest in Vermont, New Hampshire, Maine,West Virginia, Utah, and Idaho—five ofthese six states mandate sex education(Idaho being the exception).1 Geographic11observations within the story map revealthat STI rates are particularly high throughout much of the country’s Southeast andMidwest regions.1 Mississippi and Louisiana,in particular, report the highest STI ratescompared to other states. Mississippi doesnot mandate HIV/STI education, andLouisiana does not mandate sex educationor HIV/STI education at all.1,5Moreover, additional disparities exist amongreported STI cases that demonstrate thestark gap in access to preventive care forcommunities of color and men who havesex with men (MSM). In 2018, the rate ofreported chlamydia cases among Blackmen aged 15-19 was 9.1 times higher thanthe rate of their white peers.21 The rateamong Black women aged 15-19 was 4.5times higher than the rate reported amongtheir white peers.21 Similar racial disparitiesare reported for American Indians/AlaskaNatives (3.7 times the rate among whites),Native Hawaiians and other Pacific Islanders(3.3 times the rate among whites and 5.3times the rate among Asians) and Hispanics(1.9 times the rate among whites).21 Whilesimilar rates regarding young men who havesex with men are not readily available, MSMaccounted for 68.2% of reported primaryand secondary syphilis cases in 2017.22As indicated by observable patterns withinthe story map, legislation that requires sexeducation and HIV/STI instruction to bemedically accurate, culturally responsive,and evidence-based directly addresses thisepidemic that disproportionately impactsyoung people, communities of color, andmen who have sex with men.120Sexually Transmitted Disease Surveillance 2018. Centers forDisease Control and Prevention (CDC). https://www.cdc.gov/std/stats18/toc.htm21Sexually Transmitted Disease Surveillance 2018: Racial andethnic minorities. Centers for Disease Control and Prevention(CDC). xually Transmitted Disease Surveillance 2017: Men whohave sex with men. Centers for Disease Control and Prevention(CDC). https://www.cdc.gov/std/stats17/msm.htm

While the explanation for the decline inteen birth rate is multifactorial, some of therationale may be attributed to stronger sexeducation policies across the country andaccess to contraception options madeavailable through services such as theAffordable Care Act. c. Teen birthTeen birth rate in the United States hashistorically been among the highest in thedeveloped world. While it has dramaticallydecreased over time, the United Statesteen birth rate still remains high comparedto other developed countries.1 Between1991-2005, the U.S. teen birth rate declinedby more than a third, from 62 births per1,000 women aged 15-19 years to 40 birthsper 1,000 women aged 15-19 years old.23Despite rapid declines in teen birth ratesacross all major racial and ethnic groups,disparities continue to persist. In 2018, thebirth rate among Hispanic and Black teensaged 15-19 was almost double the rate ofwhite teens and more than five times therate among Asians and Pacific Islanders.2423Key facts about teen births. (2019). Child -births24Trends in teen pregnancy and childbearing. (2019).U.S. Department of Health & Human Services Office ofPopulation Affairs. ncy-and-childbearing/trends/index.htmlObservable patterns emerge within the storymap between sex education legislation andteen birth rate. Teen birth rates appear tobe lowest in the Northeast, as well as inMinnesota.1 Of the states with the lowestteen birth rates (less than 12.5 births per1,000 women aged 15-19), six out of sevenstates mandate sex education (Connecticut,Minnesota, New Hampshire, New Jersey,New York, Vermont).112PHOTO BYPANDU DUNIA

Policy and researchrecommendationsAccess to comprehensive sex education can be a reality foryoung people nationwide through implementation ofcomprehensive policies at the federal, state, and local levels.Advanced sex education policies, coupled with substantialfunding, educator training and development, and robustreporting requirements, can provide the quantitative dataneeded to further demonstrate the relationship betweencomprehensive sex education and health outcomes amongyoung people.PHOTO BYOLADIMEJI AJEGBILE13

Federal Demand Congress pass the RealEducation for Healthy Youth Act (S.1524/H.R. 2720), which would create thefirst-ever federal funding stream forcomprehensive sex education nationwideand would prohibit funding for failedabstinence-only programming. Demand Congress pass the Youth Accessto Sexual Health Services Act (S.1530/H.R.2701), which would provide communitygrants to increase and improve access tosexual and reproductive healthcare andrelated services for young people of color,immigrant youth, LGBTQ youth, youth infoster care, youth experiencinghomelessness, youth in juvenile detention,and otherwise marginalized young people. Ensure that the Centers for DiseaseControl and Prevention (CDC) Divisionof Adolescent and School Health (DASH)expands the Youth Risk BehaviorSurveillance System (YRBSS) to includequestions related to gender identity andsexual orientation, following results fromthe 2017 pilot question on genderidentity implemented across 19 statesand localities.14 Demand Congress include appropriationsto increase federal funding for programsthat advance sex education nationwide(e.g. DASH) and eliminate funding forabstinence-only, “sexual risk avoidance”programming.State Pass statewide comprehensive sexeducation mandates. Require the State Department ofEducation to align statewide sex educationcurriculum requirements with the NationalSex Education Standards. Allocate additional funding for theimplementation of comprehensive sexeducation and educator training inappropriations for each fiscal year. Mandate accountability and oversightrequirements to track the implementationprogress of sex education and collectaggregate data on topics taught. Allocate substantial funding to ensureeducators are trained in accordance withthe National Teacher PreparationStandards for Sexuality Education.Local Work with local school boards toimplement comprehensive sex educationpolicies. Utilize the SIECUS Community ActionToolkit to foster community involvementin advancing sex education requirements. Ensure educators are trained accordingto the National Teacher PreparationStandards for Sexuality Education.Research recommendations Advocate to make sex education-relatedYRBS questions mandatory for all states. Advocate for additional surveillance andmonitoring questions on national andstatewide CSE program evaluations inorder to track health and behavioroutcomes beyond pregnancy anddisease prevention. Issue a call to action for research thatfocuses on positive health, behavior,and social inclusion outcomes ofcomprehensive sex education.

ConclusionThe Sexuality Education Legislation and Policy: A State-byState Comparison of Health Indicators story mapdemonstrates a range of health indicators that are affectedby comprehensive sex education policies nationwide.While many observable patterns emergewhen comparing health indicators and sexeducation requirements, clear gaps in datainhibit the definitive analysis of the impactof comprehensive sex education on sexualviolence, physical dating violence, bullyingand harassment of LGB youth, suicide,contraceptive prevalence rates, STI rates,and teen birth rates.Through the advancement of uniformstatewide and national comprehensive sexeducation policies and continuedparticipation in surveys like the YRBSS,these correlations may be further clarifiedto underscore the importance ofcomprehensive sex education. 25To build upon current research thatdemonstrates the correlation betweencomprehensive sex education and positivehealth outcomes among young people, thecollection of additional data is essential.2515Building a foundation for sexual health is a K-12 endeavor:evidence underpinning the National Sexuality EducationStandards. (2019). Future of Sex Education -Health.pdfPHOTO BYRENEE CLANCY

16www.siecus.org

dating violence at 13.1%.2 Similar to data surrounding sexual violence, LGB students report experiencing physical dating violence at over double the rate of their heterosexual peers.2 The story map demonstrates that a large number of states do not report on physical dating violence in th