Even though teen pregnancy rates are at an all-time low in the United States, the country has still experienced more pregnancies and sexually transmitted diseases amongst teens than other developed nations.
So how are kids being taught to avoid pregnancy and protect themselves against sexually transmitted diseases?
From flour baby activities, to condom demos on bananas, to lessons equating sex with sin, sex education has long been an awkward experience. Or confusing. Or nonexistent. It has also been really controversial. Divisions in how to teach the topic tend to fall along party lines. It means that oftentimes, as administrations change, so too do related policies and programs.
The Obama administration took a big turn from its predecessors. Money that had long been reserved for abstinence-only, or what's now called sexual risk avoidance education, was no longer a guarantee. New resources, some of which were authorized under the Affordable Care Act, instead went toward more comprehensive sexual risk reduction approaches and toward developing a stronger evidence base for best practices.
Tracing the history
"Most people that are my age and around my age, they know about sex, and it's like, around you, it's like a lot of pressure," said Tishara Morton, a high school sophomore in Philadelphia.
Morton is referring to pressure to have sex. She first took sex ed in sixth grade and again last year. She wasn't a huge fan. She wished it were more inclusive of LGBTQ issues, but she says some of it was helpful.
"It was slightly informative," she said. "They went into detail about what happens to your body when you get a certain STI."
They covered what happens during puberty and pregnancy, as well as contraception options to some degree.
Morton has been through a couple of different sex ed classes, but the big one she remembers from middle school was based on the abstinence-only approach to sex education, which really focuses on the importance of not having sex.
Over the last few decades, hundreds of millions of federal dollars have gone towards this approach. It was only recently, under the Obama administration, that that has been challenged.
The idea of abstinence as a primary focus of sex ed in public schools really got started back in the early 80s under President Ronald Reagan.
"Have we been teaching sex as a purely physiological function, like eating when you're hungry?" he said during a radio address in 1979, in response to rising teen birth rates and the current state of sex eduation. "Can we completely divorce sex education, as I'm afraid we do, from any association with moral behavior without implanting in young minds that it has no more significance than eating a sandwich, so why not?"
This vision and the federal funding that went with it for abstinence education has continued up until this day, to some extent.
"We want to help young people avoid the risks altogether, by waiting for sex," said Valerie Huber, director of Ascend. Formerly called the National Abstinence Education Association, it's a national group representing abstinence or sexual risk avoidance education programs. "And among those who are currently sexually active, [we want them] to return to a risk-free lifestyle."
That's the underlying philosophy, but Huber says curriculums also focus on healthy decision-making and relationships, and even address contraception. During George W. Bush's two terms, support for this approach went up a lot. But many in the public health sector have not been on board.
"They will have sex eventually," said Emmy Stup, with the Public Health Management Corporation in Philadelphia.
Stup, who oversees sex education programs there, starts with the premise that kids are going to have sex.
"And we want them to do it safely, and we want them to know where to go so that they can do it safely," she said. "But by pretending they're not making that choice, we become irrelevant to them."
Educators like Stup point to the lack of scientific evidence that abstinence-only programs affect teen behavior. There's also a concern that some of these programs contain inaccurate information, like on the reliability of birth control.
Kathrin Stanger-Hall agrees. While she's a professor of biology at the University of Georgia, she fell into studying science and sex education after noticing how unaware so many of her college-aged students were about their own bodies. For example, she kept finding that "students have no idea during which part of the female cycle pregnancy is most likely. They just basically have learned in school that having sex is something bad, which kind of prevents them from making educated health decisions as well as family planning decisions."
Stanger-Hall didn't dig into specific programs, but she used data from 2005 to map out teen pregnancy rates in states that had an increased emphasis on abstinence education. She found they also had higher teen pregnancy and birth rates. She worries that one factor in why those teens might be more likely to become pregnant is not knowing how to protect themselves when they do it.
A changing approach
The Centers for Disease control recommends schools cover 16 topics to help their students protect themselves. Those topics range from the efficacy of condoms all the way to the benefits of abstinence. But a report released just over a year ago found that fewer than half of high schools, and only a fifth of middle schools, covered all of those topics. While sexual abstinence is taught in the majority of schools, for example, where to find and how to use condoms is often excluded from the curriculum.
Bill Albert, with the National Campaign to Prevent Teen and Unplanned Pregnancy, says programs need to shift from ideological to evidence-based approaches.
"And that is finding out through good evaluation what interventions work to change teens' behavior, not just their knowledge or their intentions, but their actual behavior," Albert said.
In other words, it doesn't matter whether the program is abstinence-only or a more comprehensive approach. It's about building a base of scientific evidence to show that it works.
Albert says under The Obama administration, that has been happening. The big shift took place in 2010 with the establishment of the Teen Pregnancy Prevention Program. This meant tens of millions of federal dollars annually went into programs that didn't fall into that specific abstinence till marriage box. Albert says it's a "modest sum," given how many resources would be needed to reach all teens, but a big focus went toward developing and studying the effectiveness of such programs in different settings, and then seeing if they held up over time. This teen pregnancy program and other complimentary federal funding streams have translated to some $200 million annually going toward supporting these approaches.
"HHS did amazing things in generating evidence and transparency," said Meredith Kelsey, a researcher with Abt Associates which has been evaluating several Teen Pregnancy Prevention-funded programs. "I have not seen that in other programs before. Paying attention to quality and the strength of evidence, I think it's really remarkable."
At the same time, there was an effort to reduce federal dollars for abstinence only programs. That didn't sit well with Valerie Huber, director of Ascend.
"It has been a very disappointing time in the history of sex education over the last eight years," said Huber. "This marked the first administration, Republican or Democrat, who has sought to eliminate totally one approach to sex education."
Complete elimination did not happen. Funding for abstinence programs still exists at lower levels, with about $50 million annually coming in through the Title V State Abstinence Education fund. Many states have opted for it. But Huber's outlook has become more upbeat with a new administration coming in. She has seen sexual risk avoidance programs diminish under the Obama administration and questions the effectiveness of the programs that have taken their place.
"We're hopeful for the future, and we're looking forward to taking advantage of every opportunity to help young people thrive," she said.
While Huber is optimistic with a new administration settling in, for others like Emmy Stup, who oversees comprehensive sex education programs in Philadelphia, this is a worrying time.
"We're very concerned," Stup said.
Under President Obama's administration, Stup has built up and expanded new programs, receiving millions of federal dollars that hadn't been available before. Some of that funding was initially authorized through the Affordable Care Act, some has come in the form of multi-year grants. Funding was also set up through other budget moves, but it all means that like other health and social service programs, it will all need to be reauthorized in the coming year under new political leadership.
It's unclear what could happen. Many are hesitant to weigh in just yet. The Republican Platform calls for a return to sexual risk avoidance education, and so for Stup, the future seems more uncertain.
"We appear to be facing a government that is particularly unfriendly toward this kind of work or fundamentally doesn't understand this work," said Stup.
Beyond the classroom
Meredith Kelsey, the evaluator of several programs funded under the Obama administration's teen pregnancy prevention initiative, stresses that the task of changing, let alone, studying behavior over time is tricky, so identifying programs that have demonstrated even some positive behavior change has been "an amazing accomplishment."
"But is the task done? That's not what I would take away from this. It gives us information and questions," she said. "It's an amazing first step in the learning process."
Classrooms aside, there is another place where this kind of education is happening. And it's outside of federal and state funding, politics or much in the way of oversight. The rise of the internet, smartphones, social media, TV shows like MTV's "16 and Pregnant," and YouTube have completely transformed the way people, teens included, get information.
Take Laci Green for example. She's 27 and is a sex education activist on the internet. She has a really popular sex ed show on YouTube. She turned to the online space ten years ago.
"I did not have access to the information I needed as a teenager, and basically took to the internet to disperse the information that I was finding to my peers," she said.
Green thinks as long as sex ed in school continues to be lacking, the internet will only grow in its sway. Her posts get anywhere from 200,000 to three million views. She hears from a lot of teens directly.
"You know this morning, I've been emailing back some kids - 12, 13 years old - who were asking about puberty and what's normal for their bodies, like how to deal with unwanted erections at school," she said. "Basically things where you have young adults, or even kids sometimes, who don't really have anyone else to ask."
And somehow, they find her. Green takes it seriously, but she worries about the internet being full of all sorts of wacky stuff. It's "the wild west," she says. In fact, she thinks the ideal space to learn about it all is back at school.
"In a safe, physical space with someone they can talk to face to face that they can trust, who's giving them comprehensive medically accurate information about sexuality," she said. "But that is not the reality that exits, so we're really left with the only viable alternative, which is the internet. And it's not perfect."
For Tisharah Morton, who's 15 years old and went through two different approaches to sex ed at school, the experiences "did and didn't" affect the way she thought about sex. She says her outlook stems from a combination of things: yes, what she learned in school, plus the internet and television.
But at the end of the day, she says the biggest influence on her decisions, came one day last year. Someone she knew had a pregnancy scare.
"It scared me as much as it scared her," she said. "Because what if she really was pregnant? And at one point, I was thinking 'Dang. Like what if that was myself? What if it was me?"