Let’s Talk About Sex – Maybe?

But other important aspects of the sexual health of Colorado’s youth have received less attention. Trends around sexual assault and dating violence are stagnant, rates of sexually transmitted infections (STIs) are increasing, and there are wide disparities between lesbian, gay, or bisexual (LGB) youth and their heterosexual peers. (2)

A bill passed during Colorado’s 2019 legislative session seeks to address these issues. House Bill 1032 strengthens state standards for comprehensive sexual health education, referred to in this brief as “sex ed,” and provides funding to help school districts update sexual health programs (see Figure 1).

The bill does not require school districts to offer sex ed classes. If they do, however, the classes must be comprehensive — meaning that they include information on consent, the health needs of lesbian, gay, bisexual, transgender, or intersex Coloradans, and other issues that might not be covered in abstinence-only curricula.

HB 1032 updates a 2013 law that some policymakers felt left gaps in the curriculum and resources for sex education. It was one of the most divisive bills of the 2019 session, with more than 20 hours of committee testimony and only two Republican votes across both chambers.

Sex Ed in Colorado

Before HB 1032, health education in Colorado did not meet standards for comprehensive sex ed.

Colorado is a local-control state, which means that the Colorado Department of Education creates comprehensive health education standards and supports school districts in aligning their curriculum with these standards. But the department does not require sex ed to be taught or monitor the extent to which the standards are implemented. In fact, Colorado is the only state that does not require a health education course to graduate. (4)

That will not change under HB 1032. Districts will still determine whether to offer sex ed. Still, supporters of comprehensive sex ed hope that the stronger language will allow parents and students to hold their districts accountable for the quality and contents of the programs they do offer.  

Comprehensive sex ed and the standards included in HB 1032 are about much more than sex. An effective sexual health curriculum encourages students to maintain healthy relationships, be sexually abstinent, prevent or reduce sexually transmitted infections (STIs) and unintended pregnancies, and use appropriate health services to promote their sexual health. (5) The Centers for Disease Control and Prevention (CDC) also suggests a sex ed curricula that includes information on the effective use of contraceptives, abstinence, healthy relationships, anatomy, respecting differences in sexuality, and understanding sexual coercion. (6) The CDC notes that effective health education, including sex ed, is research-based, provides age-appropriate information, and includes a plan for ongoing professional development of instructors. (7)

According to 2017 Colorado Department of Public Health and Environment (CDPHE) data, 92 percent of secondary schools that offered sex ed discussed abstinence and 93 percent covered HIV/STI awareness. Fewer — 83 percent — discussed contraception. (8)

Almost all secondary schools (95 percent) covered safe relationships, a range of topics that can, but does not necessarily, include consent, defined in the bill as “affirmative, unambiguous, voluntary, continuous knowing agreement between all participants in each physical act” during sex or in an interpersonal relationship. Just half (55 percent) of secondary schools reported that their curriculum included LGBTQ+ inclusive instruction. And less than a third (31 percent) of school districts in Colorado had a comprehensive sex ed policy on record in 2016. (9)

Moreover, students in schools with more low-income students were less likely to offer a sexual health component within their health education program. (10) These schools were also less likely to include LGBTQ+ inclusive instruction. (See Figure 4.)

HB 1032 addresses some of these disparities, because it provides funds that will go first to rural schools and schools without comprehensive sexual health programs. However, the initial grant is predicted to only reach 17 school districts. (11) More funding would be needed to provide all schools with the opportunity to update their curricula.  

Sexual Health in Colorado

Colorado still has gaps in youth sexual health. HB 1032 has potential to address them.

Fewer Colorado high school students are having sex than just a few years ago. The percentage of sexually active high school students has declined to 22 percent in 2017 from 29 percent in 2013, according the Healthy Kids Colorado Survey. (12,13) That lines up with national trends, according to the CDC. (14)

This might suggest that gaps in Colorado’s sex ed curricula haven’t had an impact on the health of young people. An expanded view of youth sexual health, however, reveals a much more nuanced picture. 

While the percentage of sexually active Colorado students using some method of birth control has increased slightly, fewer students reported using a condom the last time they had sexual intercourse. At the same time, rates of STIs — which can be more effectively prevented by using condoms than by other commonly used forms of birth control — are increasing. Chlamydia rates have gone up 24 percent since 2013, and gonorrhea rates have grown 182 percent. 

Risk behaviors and STIs are just one part of sexual health. Healthy relationships are another important consideration, and Colorado has not made recent progress in this area. 

In 2017, nearly one in 10 high schoolers in a relationship said they experienced dating violence, and more than one in 20 high schoolers experienced sexual assault (see Figure 2). Both figures are close to their 2013 and 2015 values.

HB 1032 adds education about consent to Colorado’s definition of comprehensive sex ed, an important step for advocates concerned about these rates. Comprehensive sex ed may also act as a protective factor against sexual assault later in life. (15)

LGBT students fare worse on many health measures.

LGBT students face more challenges in sexual and mental health than their heterosexual peers.

In 2017, LGB youth were nearly two-and-a-half-times more likely than their heterosexual peers to report physical violence from a dating partner in the past year and four times more likely to report ever being physically forced to have sex, with nearly one in five LGB students reporting each of these events (see Figure 3). Sexuality-based discrimination and internalized homophobia have both been associated with increased likelihood of experiencing physical and sexual intimate partner violence among gay and bisexual men. (16) Experiences of discrimination might explain the higher rates of sexual and physical violence for LGB youth in Colorado. 

While publicly available Healthy Kids Colorado Survey data does not have information on these outcomes for transgender youth specifically, a 2015 national survey found that nearly half (47 percent) of transgender people have experienced sexual assault. It is likely that transgender high school students in Colorado experience higher rates of sexual violence than their cisgender peers. (17)

LGB students are also more likely than non-LGB students to report ever having had sex, having sex before age 13, and being currently sexually active. These students had much higher rates of poor mental health and suicidal feelings (see Figure 3). Research shows that perceived discrimination accounts for increased prevalence of depressive symptoms and risk for self-harm among LGBTQ+ youth. (18)Minority stress, or the experience of stigma, prejudice, and discrimination that creates a stressful social environment and causes mental health issues, offers an explanation for worse health outcomes for the LGBTQ+ population. (19)

These disparities between heterosexual and LGB youth were one source of motivation for supporters of HB 1032, which emphasizes that sexual health education cannot explicitly or implicitly exclude the health needs of LGBTI individuals. 

There is limited quantitative research on the impact of comprehensive sex ed on sexual health outcomes of non-heterosexual students. But one study finds an association between students reporting feeling safe at school and LGBTQ+ inclusive curricula. (20) Other research shows that LGBTQ+ students in schools with inclusive curricula were less likely to report hearing homophobic comments, experienced lower levels of victimization due to their sexual orientation or gender identity, and felt greater belonging in their school community. (21) Bullying over sexual orientation has been linked to poor mental health outcomes and risk for STIs and HIV later in life. (22)

How Does Colorado Compare With Other States?

With HB 1032, Colorado leads in some content requirements. But the state lacks a health education mandate.

Colorado occupies an odd place among the states when it comes to sex ed. It has some of the strongest curriculum standards, but it does not require schools to offer sex ed at all.

The 2013 law made Colorado one of eight states that require sex ed to be culturally appropriate and unbiased, one of nine requiring it to be inclusive of all sexual orientations, and one of 13 requiring it to be medically accurate. (23) With HB 1032, Colorado joins a group of eight states that require education about consent. (24)

However, Colorado is the only state without a health education mandate (25) and it is one of 26 states without a sex ed mandate. (26) More than one in five (21 percent) secondary schools reported in 2017 that they do not teach human sexuality or sexual health. (27)

Comparing Colorado to a handful of states with various sex ed policies (see Figure 5) provides a sense of which policies seem to be associated with certain health outcomes (see Figures 6 and 7). 

A sex ed mandate on its own is not enough to drive change in sexual health outcomes, but sex ed policy still influences these outcomes. Other factors, such as access to sexual health services, general education funding, and support resources for LGBTQ+ youth, also greatly influence these measures.

Maine, the only state in the group that does not require LGBTQ+-inclusive sex ed, has the highest mental health disparities between LGB and heterosexual youth (see Figure 6). 

New Mexico, which mandates sex ed but does not require the curriculum to be medically accurate, has the highest STI and teen pregnancy rates among these five states (see Figure 7) — in line with the evidence that comprehensive sex ed is correlated with better health outcomes. (28) Supporters of comprehensive sex ed in Colorado who do not want a sex ed mandate believe that without enough funding or resources for implementation, such a mandate would expand non-inclusive, abstinence-only sex ed and harm youth. 

In Colorado, LGB youth experience concerning levels of sexual and dating violence. (see Figure 6). Mandating sex ed for all school districts on its own, however, does not seem to be associated with reducing inequity in these markers. 

Comprehensive sexuality education can help improve health outcomes. But it’s a divisive issue.

Public health research suggests that the expansion of comprehensive sex ed could positively impact youth sexual health. However, any expansion is likely to be contentious. 

Public health studies often contrast comprehensive sex ed with approaches such as abstinence-only, abstinence-only-until-marriage (AOUM), and sexual risk avoidance (SRA), which teach that sex should be delayed until marriage and limit discussion of birth control methods to descriptions of its ineffectiveness. (31)

A systematic review of comprehensive sexuality education programs found that these programs increased abstinence and use of protection and decreased the number of sexual partners, frequency of sexual activity, STIs, and pregnancy. (32) On the other hand, several reviews of abstinence-only, AOUM, and SRA programs do not show any impact on the same markers of sexual health. (33)

Those in favor of a comprehensive curriculum also worry that abstinence-only education harms LGBTQ+ youth and sexual assault survivors. Many abstinence-only programs focus exclusively on heterosexual relationships and describe homosexuality as deviant and unnatural. (34) This language can create more stigma for LGBTQ+ youth, which has been linked to suicide, feelings of isolation, substance use, and violence. (35)

Many abstinence-only programs state that all premarital sexual activity is shameful and leads to guilt about sex. (36) Advocates for comprehensive sex ed say these assertions might blame sexual assault survivors and contribute to poor mental health.

Supporters of HB 1032 also often cite less tangible benefits to comprehensive sex ed. Alison Macklin of Planned Parenthood of the Rocky Mountain (PPRM) argues that “young people’s social and emotional well-being is why sex ed matters. It’s about skills and behavioral health for all young people.” Jolene Cardenas of the Colorado Coalition Against Sexual Assault posits that learning personal boundaries and consent at a young age is important for all interpersonal relationships, not just romantic ones. For these supporters, the benefits of comprehensive sex ed go beyond health outcomes that can be demonstrated by quantitative data.

As the lengthy debate over HB 1032 during the 2019 legislative session makes clear, however, many people who oppose comprehensive sex ed in schools have a different vision of what these policies and curricula should look like. Many frame their concerns as a moral issue grounded in values, arguing that providing too much information on contraception endorses premarital sex, of which they do not approve. Some worry that the discussion of homosexuality and transgender identities in the classroom discredits their belief systems and promotes sexual activities they oppose, tacitly endorsing one view of sex and sexuality over another. 

Other opponents of HB 1032 are concerned that it takes some local control away from schools. They feel that decisions about sex ed should be made locally, where parents’ voices are often the strongest. The Colorado Catholic Conference, for instance, believes that “parents are the primary educators of their children and education policy must be crafted in a manner that places the needs of the children and parents first.” The perceived loss of local control was one of their main motivations for opposing the bill. (37)  While schools can still choose not to teach sexual health education at all, the legislation adds more standards for the schools that do choose to include it.

Other Policy Options

Advocates for HB 1032 did not argue that the new legislation addresses all concerns around sexual health for Colorado’s youth. Other policy options may further the goals of improving sexual health outcomes. 

For example, Colorado could consider adding a teacher certification program, reaching out to local school districts to inform them of existing resources, or expanding the Comprehensive Human Sexuality Grant Program.

A teacher certification program would allow instructors to get trained on how to teach sexual health more effectively. The CDC recommends professional development programs for health education instructors. (38) Such a program would give teachers more clarification about how to implement the requirements of the new law and more guidance on the state standards. However, such a program would require funding. While it would likely be an optional program, it could raise the same concerns around usurping local control as HB 1032.

For supporters of comprehensive sex education, encouraging their school district to apply for the grant program could be one way to expand sexual health education in their area. Each school district would be able to decide for itself if its leadership wished to access existing resources for expanding sex education programs. Conversations about this issue at the local level would allow both opponents and supporters of comprehensive sex ed to be heard. With or without the grant money, though, schools that offer sex ed will have to follow the new comprehensive standards in HB 1032.

Finally, expanding the grant program would give more schools the resources to update their curricula. The initial $1 million appropriation for the Comprehensive Human Sexuality Grant Program is predicted to fund updates to sexual health education in about 17 school districts. CDPHE, which runs the grant program, will collect data on the effectiveness of the initial appropriation. Lawmakers can use this data to inform next steps for the program, including future funding.

Conclusion

Rates of teen sex and pregnancy are dropping in Colorado, and the state’s standards for sex education are now among the most comprehensive in the nation. At the same time, Colorado youth are experiencing concerning rates of STIs and dating violence. LGB students in particular experience more sexual and intimate partner violence. And many school districts do not offer sex ed at all.

Sexual health education matters deeply for the health and future of Colorado’s youth. A new comprehensive sexuality education law passed this year aims to improve the quality of sex ed in the state and to put a focus on consent and the needs of LGBTQ+ students. 

School classes alone aren’t likely to solve all of the challenges related to sexual health faced by Colorado’s youth: Access to sexual health services and supportive spaces for LGBTQ+ youth can also help.  

But there are proven benefits associated with research-based comprehensive health education. As the legislation is implemented, policymakers and parents should pay attention to its impact on STIs, dating and sexual violence, and on the sexual health and well-being of Colorado’s young people. These results not only matter for future policy, but for the future health of Coloradans across the state.

Endnotes

¹Turnbull, L. (2019). ”How Colorado Halved Abortion and Teen Birth Rates”. YES! Magazine.  https://www.yesmagazine.org/peace-justice/abortion-teen-pregnancy-decline-colorado-20190605 ; Brown, J. (2017) “IUD program leads to big decline in teen pregnancies, abortions in Colorado.” The Denver Post. https://www.denverpost.com/2017/11/30/colorado-teen-pregnancy-abortion-rates-drop-free-low-cost-iud/

²Center for Disease Control and Prevention (CDC). (2019). “Teen Birth Rate by State.” Retrieved from https://www.cdc.gov/nchs/pressroom/sosmap/teen-births/teenbirths.htm. July 2019.

³GLAAD. (n.d.). “GLAAD Media Reference Guide - Lesbian / Gay / Bisexual Glossary Of Terms.” https://www.glaad.org/reference/lgbtq 

⁴Colorado General Assembly. (2019). House Bill 19-1032: Comprehensive Human Sexuality Education

⁵Center for Disease Control and Prevention (CDC). (2019). “HECAT: Module SH Sexual Health Curriculum.” https://www.cdc.gov/healthyyouth/hecat/pdf/hecat_module_sh.pdf 

⁶Center for Disease Control and Prevention (CDC). (2019). “HECAT: Module SH Sexual Health Curriculum.” https://www.cdc.gov/healthyyouth/hecat/pdf/hecat_module_sh.pdf

⁷Center for Disease Control and Prevention (CDC) (2018). “Characteristics of an Effective Health Education Curriculum.” Retrieved from  https://www.cdc.gov/healthyschools/sher/characteristics/index.htm. July 2019.  

⁸Colorado Department of Public Health & Environment (CDPHE) (2017). “Smart Source.” https://www.colorado.gov/pacific/cdphe/smart-source. NOTE: This data was selected as one of the only existing Colorado-specific sources on school-based health. However, only about a third of schools across Colorado are represented in this survey, as schools choose to opt into the survey for evaluation of whether they are meeting best practices in school health. It is likely that these estimates are higher than the actual number. 

⁹Falls, M. (2016). “Sexual Education Policies in Colorado School Districts”. https://tpc.seemysite.us/wp-content/uploads/2018/10/Sexual-Education-in-Colorado-School-Districts-5.19.16.pdf

¹⁰Colorado Department of Public Health & Environment (CDPHE). “Smart Source.” https://www.colorado.gov/pacific/cdphe/smart-source. 

¹¹Colorado General Assembly. (2019). HB 19 1032: Comprehensive Human Sexuality Education – Revised Fiscal Note. 

¹²Colorado Department of Public Health & Environment (CDPHE) (2017). “Healthy Kids Colorado Survey.” https://www.colorado.gov/pacific/cdphe/healthy-kids-colorado-survey-data-tables-and-reports NOTE: Health Statistics Region 14 did not complete the full survey and Region 21 had a low response rate in 2017. It is possible that some of these trends are influenced by school districts not participating in more recent years. The current statistics also may not be reflective of the state, given the low participation rates in some areas of the state. 

¹³Defined as students that reported having had intercourse at least once over the past three months.

¹⁴Center for Disease Control and Prevention (CDC) (2018). “Fewer U.S. High School Students Having Sex, Using Drugs” https://www.cdc.gov/media/releases/2018/p0614-yrbs.html

¹⁵Santelli, J. et al. (2018). “Does sex education before college protect students from sexual assault in college?” Plos One, 13(11). doi:10.1371/journal.pone.0205951.; Schneider, M., & Hirsch, J. S. (2018). “Comprehensive Sexuality Education as a Primary Prevention Strategy for Sexual Violence Perpetration”. Trauma, Violence, & Abuse. https://journals.sagepub.com/doi/abs/10.1177/1524838018772855

¹⁶Finneran, C., and R. Stephenson. (2014). “Intimate Partner Violence, Minority Stress, and Sexual Risk-Taking Among U.S. Men Who Have Sex With Men.” Journal of Homosexuality, 61(2), 288-306. doi:10.1080/00918369.2013.839911 ; Stephenson, R., and C. Finneran. (2016). “Minority Stress and Intimate Partner Violence Among Gay and Bisexual Men in Atlanta.” American Journal of Men’s Health, 11(4), 952-961. doi:10.1177/1557988316677506

¹⁷National Center for Transgender Equality. (2016). “The Report of the 2015 U.S. Transgender Survey.” https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf

¹⁸Almeida, J. et al. (2009). “Emotional Distress Among LGBT Youth: The Influence of Perceived Discrimination Based on Sexual Orientation.” Journal of Youth and Adolescence, 38(7), 1001-1014. doi:10.1007/s10964-009-9397-9

¹⁹Meyer, I. (2003). “Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence.” Psychological Bulletin, 129(5), 674-697. doi:10.1037/0033-2909.129.5.674

²⁰Snapp, S. et al. (2015). “LGBTQ-inclusive curricula: Why supportive curricula matter.” Sex Education, 15(6), 580-596. https://www.tandfonline.com/doi/full/10.1080/14681811.2015.1042573?src=recsys

²¹GLSEN. (2015). “The 2015 National School Climate Survey.” https://www.glsen.org/article/2015-national-school-climate-survey

²²Russell, S. et al. (2011). “Lesbian, Gay, Bisexual, and Transgender Adolescent School Victimization: Implications for Young Adult Health and Adjustment.” Journal of School Health, 81(5), 223-230. doi:10.1111/j.1746-1561.2011.00583.x; Marshal, M. et al. (2011). “Suicidality and Depression Disparities Between Sexual Minority and Heterosexual Youth: A Meta-Analytic Review.” Journal of Adolescent Health, 49(2), 115-123. doi:10.1016/j.jadohealth.2011.02.0

²³Guttmacher Institute. (2019) “Sex and HIV Education.” Retrieved from https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education. July 2019.

²⁴Shapiro, S., and C. Brown. (2018). “Sex Education Standards Across the States.” https://www.americanprogress.org/issues/education-k-12/reports/2018/05/09/450158/sex-education-standards-across-states/

²⁵Colorado General Assembly. (2019). House Bill 19-1032: Comprehensive Human Sexuality Education

²⁶Guttmacher Institute. https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education

²⁷Colorado Department of Public Health & Environment (CDPHE). “Smart Source.” https://www.colorado.gov/pacific/cdphe/smart-source. 

²⁸Santelli, J. et al. (2017). “Abstinence-Only-Until-Marriage: An Updated Review of U.S. Policies and Programs and Their Impact.” Journal of Adolescent Health, 61(3), 273-280. doi:10.1016/j.jadohealth.2017.05.031, Chin, H.et al. (2012). “The Effectiveness of Group-Based Comprehensive Risk-Reduction and Abstinence Education Interventions to Prevent or Reduce the Risk of Adolescent Pregnancy, Human Immunodeficiency Virus, and Sexually Transmitted Infections.” American Journal of Preventive Medicine, 42(3), 272-294. doi:10.1016/j.amepre.2011.11.006R

²⁹Center for Disease Control and Prevention (CDC) (2017). “High School Youth Risk Behavior Survey”. Retrieved from https://nccd.cdc.gov/youthonline/App/Results.aspx?LID=XX. July 2019.; Colorado Department of Public Health & Environment (CDPHE) (2017). “Healthy Kids Colorado Survey.” https://www.colorado.gov/pacific/cdphe/healthy-kids-colorado-survey-data-tables-and-reports  

³⁰Center for Disease Control and Prevention (CDC) (2017). “Teen Birth Rate by State” Retrieved from https://www.cdc.gov/nchs/pressroom/sosmap/teen-births/teenbirths.htm. July 2019; Center for Disease Control and Prevention (CDC) (2017). ”STDs in Adolescents and Young Adults.” Retrieved from https://www.cdc.gov/std/stats17/adolescents.htm. July 2019.; United States Census Bureau. (2016). “Annual Estimates of the Resident Population, 2016 Population Estimates.” Retrieved from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=PEP_2018_PEPANNRES&src=pt. July 2019.

³¹Kohler, P. K., Manhart, L. E., & Lafferty, W. E. (2008). “Abstinence-Only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy.” Journal of Adolescent Health,42(4), 344-351. doi:10.1016/j.jadohealth.2007.08.026 

³²Chin, H.et al.

³³Santelli, J. et al. “Abstinence-Only-Until-Marriage”; Chin, H.et al.

³⁴Santelli, J. et al. “Abstinence-Only-Until-Marriage”; United States House of Representatives Committee on Government Reform – Minority Staff: Special Investigations Division. (2004). “The Content of Federally Funded Abstinence-Only Education Programs.” https://spot.colorado.edu/~tooley/HenryWaxman.pdf

³⁵Santelli, J. et al. “Abstinence-Only-Until-Marriage”; Russell, S. et al.; Marshal, M. et al.; Meyer, I. 

³⁶Else-Quest, et al. (2005). “Context counts: Long-term sequelae of premarital intercourse or abstinence.” Journal of Sex Research, 42(2), 102-112. https://www.tandfonline.com/doi/abs/10.1080/00224490509552263; Santelli, J. et al. “Abstinence-Only-Until-Marriage”

³⁷Colorado Catholic Conference (2019). “Oppose HB 19 1032 Concerning Comprehensive Human Sexuality Education.” https://www.cocatholicconference.org/oppose-hb-19-1032-concerning-comprehensive-human-sexulaity-education/

³⁸Center for Disease Control and Prevention (CDC) (2018). “Characteristics of an Effective Health Education Curriculum.” Retrieved from  https://www.cdc.gov/healthyschools/sher/characteristics/index.htm.July 2019.