FEATURE

The Sexuality Education Initiative: a programme involving teenagers,

schools, parents and sexual health services in Los Angeles, CA, USA
Magaly Marques,a Nicole Ressab
a Vice-President of Community Education, Planned Parenthood Los Angeles, Los Angeles, CA, USA.
Correspondence: magaly.marques@pp-la.org
b Director of Youth Programmes, Planned Parenthood Los Angeles, Los Angeles, CA, USA

Abstract: In response to abstinence-only programmes in the United States that promote myths and
misconceptions about sexuality and sexual behaviour, the comprehensive sexuality education community
has been sidetracked from improving the sexuality education available in US schools for almost two decades
now. Much work is still needed to move beyond fear-based approaches and the one-way communication
of information that many programmes still use. Starting in 2008 Planned Parenthood Los Angeles
developed and launched a teen-centred sexuality education programme based on critical thinking,
human rights, gender equality, and access to health care that is founded on a theory of change that
recognises the complex relationship between the individual and broader environment of cultural norms,
socio-economic inequalities, health disparities, legal and institutional factors. The Sexuality Education
Initiative is comprised of a 12-session classroom sexuality education curriculum for ninth grade students;
workshops for parents; a peer advocacy training programme; and access to sexual health services. This
paper describes that experience and presents the rights-based framework that was used, which seeks to
improve the learning experience of students, strengthen the capacity of schools, teachers and parents to
help teenagers manage their sexuality effectively and understand that they have the right to health care,
education, protection, dignity and privacy. 2013 Reproductive Health Matters
Keywords: sexuality education, adolescent pregnancy, HIV/STI prevention, rights-based approaches,
gender issues, equity, United States
Between 1996 and 2010, the United States government spent over one billion dollars supporting
abstinence-only-until-marriage programmes.1 In
that period, the community supporting comprehensive sexuality education in the United States
has been deeply involved in efforts to prevent the
advance of these programmes because they promote myths and misconceptions about sexuality
and sexual behaviour. While these efforts have
had some success in exposing the lack of effectiveness of abstinence-only programmes in reducing
unintended teen pregnancies and sexually transmitted infections, many researchers, advocates and
educators were sidetracked from their primary focus
on improving the sexuality education available in
US schools. Much work is still needed to move
beyond fear-based approaches and the one-way
communication that many programmes still use.
Later, millions of dollars have been spent in
research to prove the effectiveness of comprehen-

sive sexuality education. Many advocates, such as

the Sexuality Information and Education Council
of the United States (SIECUS), Answer, Sex Ed, honestly, Advocates for Youth, the National Campaign
to Prevent Teen Pregnancy, and Planned Parenthood, have played a vital role in this work. SIECUSs
advocacy work, for example, has focused on protecting young peoples right to sexuality education by working closely with policymakers and
collaborating with key partners. These efforts led
to the introduction in 2011 of a bill to repeal
ineffective and incomplete abstinence-only programme funding (S.578, H.R.1085), which would
allow for the transfer of US$75 million in federal
funds to the Personal Responsibility Education
Program, which supports prevention of teen pregnancy and sexually transmitted diseases. More
recently, policy makers introduced the Real Education for Healthy Youth Act, which recognizes for
the first time in federal legislation young peoples

124 Contents online: www.rhm-elsevier.com

Doi: 10.1016/S0968-8080(13)41702-0

M Marques, N Ressa. Reproductive Health Matters 2013;21(41):124135

right to sexual health information. Both very

promising political developments. After two
decades of valuable resources being used to
assess who should be responsible for teaching
sexuality to teens, and when and where such
education should happen, it is refreshing to
see a shift in the debate even though this bill
has not yet been passed.
Of the approximately 750,000 teen pregnancies that occur each year in the US, 82% are
unintended. In the last two decades, however,
improvements in contraceptive use have led to
a decline in pregnancy rates from 117 pregnancies per 1,000 women aged 1519 in 1990 to
68 per 1,000 in 2008.2 The majority (86%) of this
decline was due to contraceptive use, and 14%
to decreased sexual activity.3 The 2008 teenage
abortion rate was 17.8 abortions per 1,000 women,
or 59% lower than at its peak in 1988.2
Yet, teenage pregnancy is still the leading cause
of high school drop-out among teenage girls. Less
than half of teens who give birth before the age
of 18 ever graduate from high school, and less
than 2% graduate from college. Furthermore,
young women and men who become parents
experience lower educational attainment, greater
financial hardship, and less stable marriage patterns. For young fathers, parenting is more likely
to lead to economic and employment difficulties
and to more economic hardships than among
men who become fathers as adults.4
Four articles in the American Journal of Sexuality
Education in 2012 reflect new trends in the field:
the need for school-based sexuality education,5
inclusion of lesbian, gay, bisexual, transgender
(LGBT) themes,6 the power of using film clips to
teach teen pregnancy prevention,7 and an analysis
of the portrayal of gender and sexuality in the
media.8 Most researchers, educators and health
professionals now seem to agree that when it
comes to promoting healthy sexual behaviours,
information alone no longer suffices. Instead, it is
argued that sexuality education policies and
programmes must be based in human rights
and respond to the interests, needs and experiences of young people themselves.9 Addressing
social messages, and understanding the complexity of the dynamics between gender identity,
gender norms and sexuality have appeared as
effective 21st century programme components.
The purpose of this paper is to share the
experience of Planned Parenthood Los Angeles
(PPLA) in testing the effectiveness of a rights-based

approach to sexuality education, using best practices, and to show how and why this approach
strengthens the capacity of schools, teachers and
parents to help young people manage and enjoy
their sexuality responsibly.

Comprehensive sexuality education in

California since 2004
In 2004, the California state legislature enacted a
law to guide schools on the provision of comprehensive sexual health education. The California
Comprehensive Sexual Health and HIV/AIDS Prevention Act (SB 71), replaced a patchwork of confusing and often contradictory statutes on sexuality
education with a clear and comprehensive new
law with two purposes:

To provide pupils with the knowledge and

skills necessary to protect their sexual and
reproductive health from unintended pregnancy and sexually transmitted infections; and
To encourage pupils to develop healthy attitudes concerning adolescent growth and development, body image, gender roles, sexual
orientation, dating, marriage, and family.

The law says California public schools may offer

sexuality education to students in fifth, seventh
and ninth grades, but if they do so, it must be
comprehensive. Many schools do not provide sex
education because the law does not mandate it;
What the law says is that schools that choose
to provide sexuality education must comply
with the requirements of the law and must notify
parents about it, with an opt-out clause. Still,
according to a 2010 report, the 50% decrease in
the teen birth rate that California experienced
between 1991 and 2008, from 70.9 per 1,000 in
1991 to 32.1 per 1,000 in 2009, can be attributed
in large part to the substantial investment in teen
pregnancy prevention education, programmes,
and services in California.10 Other reasons identified by research for the drop in teen birth rates
are expanded access to contraceptive services,
laws and policies that facilitate access to contraceptive information and care, and investment
by private foundations in unintended teen pregnancy prevention.
California the only state that never accepted
federal abstinence-only dollars has made teen
pregnancy prevention a high public policy priority,
with a strong emphasis on comprehensive sexuality
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education and access to information and health

care services teens need to prevent pregnancy
and protect their health. 11
Unfortunately, prevalence of sexually transmitted
infections (STIs) among teens has not improved.
The rates of reportable bacterial STIs among
Californias youth 1519 years of age rose
between 2000 and 2009, with racial and ethnic
disparities, especially among African American
teens. Chlamydia rates among all youth in the state
increased, totalling 65% of chlamydia cases among
all age groups, with the rate for 1519 year-old
African American girls eight times higher than
among their white counterparts.12 Furthermore,
nationally, one in three teenage girls experiences dating violence,13 which adds to their risk
of infection.

The Responsible Choices curriculum:

comprehensive but not enough
The Los Angeles Unified School District, the
second largest in the country, with approximately 770,000 students, of which more than
400,000 are in high school, has adopted SB 71
and requires schools to offer HIV prevention
classes. Planned Parenthood LA has been an
approved provider of sexuality education to the
LA school district for 18 years, and in that time
has served more than 80 middle and high schools
each year using a structured speakers bureau
model, by which college students and volunteers
are trained to teach sexuality education using
a six-session curriculum called Responsible
Choices. While the Responsible Choices curriculum is science-based and comprehensive, the
methodology employed was less engaging and
more centred on giving information. The main
topics were: expressing sexuality, healthy relationships (mostly focused on heterosexual relationships and assertive communication), healthy
bodies (anatomy), teen pregnancy, STIs and birth
control. Responsible Choices, like many sexuality
education programmes, believed that information
is powerful, and that once teens had information,
they would act on it to protect themselves from
health risks. Its major limitation was the assumption that accurate information was sufficient to
change behaviour, and therefore little attention
was placed on the influence of the broader
cultural and social context in which teens were
making sexuality-related decisions.
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Although comprehensive sexuality education

programmes may at least be available in California,
in our experience many comprehensive programmes have not moved beyond fear-based
approaches (showing students pictures of STIs)
and one-way communication (informing students
about condoms and contraceptives).
Our own programmes also suffered from some
of these flaws until 2008 when PPLA worked closely
with Roosevelt High School to offer the Responsible Choices curriculum, weekly after-school peer
training, sporadic parent education, and reproductive health care at the school-based clinic once
a week. The experience was eye-opening, and the
results, while by no means scientific, were inspiring. Pregnancy tests recorded by the school nurse
pre- and post-12 months of the intervention, saw
a sharp drop in positive pregnancy tests from
32 to 3 between AprilJune 2008 and 2009. In
addition, the nurse noticed that students were
coming to the clinic because they had heard about
the sexual health services available in their peer
advocacy groups. These results prompted the
school to extend provision of sexual health services
on campus, including pregnancy and STI testing
and counselling, condoms and birth control, to
five days a week.
This experience led us to discuss how to change
from a programme focused primarily on reducing
risk of adverse health outcomes to one enabling
teens to feel confident in their ability to negotiate
an intimate relationship safely.
We knew that six hours of classroom sexuality
education, once during middle school and once
during high school, wasnt enough to prepare students to engage in respectful intimate relationships,
stay healthy and achieve their reproductive intentions. We also realized that interventions with students, parents, and school-wide should be based
on the same curriculum and approach to promoting
synergies and fostering opportunities for conversations about sexual health at school and at home.
We looked at dozens of effective programmes
used in the United States and internationally and
at studies that addressed young peoples sexual
health and well-being more holistically.9 Why reinvent the wheel? To the extent possible, we would
gladly have adopted an existing programme.
Instead, we settled on combining best practices
from the field and created a new curriculum that
would resonate with Los Angeles diverse youth
population, could be adopted by state schools,
and was consistent with SB 71.

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The Sexuality Education Initiative for

Los Angeles: building on best practices
The initiative was envisioned as a dynamic partnership between teens who know and understand
their rights and trusted adults and institutions
that have the capacity to protect teens rights and
deliver on their obligations to teens. This represented a critical shift in how to connect with youth
because it recognized their right to learn, to be
healthy and to have access to services. It also spells
out the responsibilities of duty bearers14 (usually
institutions) to respect, protect and guarantee
teens rights to information, education, health care
and protection. From this perspective, learning
occurs as an intentional exercise that enables the
learner to be capable of claiming their right to
sexual health care by, for example, providing a
safe environment, unbiased information, protection against abuse, and confidentiality in schools
and in health care settings.

The Initiative is comprised of four components: a classroom sexuality education curriculum with 12 sessions for ninth grade
students; workshops for parents; a peer advocacy programme; and access to reproductive
and sexual health care. The goals and intended
outcomes of the programme are summarised in
Box 1.
The topics covered in the 12 sessions of the
classroom curriculum, eight additional topics
offered to students who join the peer advocate training in an after-school club, and seven
topics offered to parents in weekly gatherings
on evenings or weekends are summarised in
Box 2. Each component includes lesson plans
and activities.
The four key concepts that served as pillars
of the Initiative are:

Evidence-based as defined in The Future of Sex

Education15 by SIECUS, Answer, and Advocates

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for Youth, which builds on the 3Rs approach

(rights, respect, responsibility), used in Western
Europe and disseminated in the United States
by Advocates for Youth.
Gender aware addressing the gender power
dynamics that impact teens, particularly girls
ability to be assertive on sexual matters, and
emphasizing the rights of youth to manage
their own sexuality. Of particular interest was
the pioneer work of the Population Council,
Its All One Curriculum, which articulates
gender and rights concepts and connects
them to on-the-ground experiences such as
the empowerment work of the Girls Power
Initiative in Nigeria, that uses critical thinking about gender roles and sexuality with
teenage girls. Its All One includes a set of
guidelines and activities for a unified approach
to sexuality, gender, HIV, and human rights
education (www.popcouncil.org/publications/
books/2010_ItsAllOne.asp).
Contextualized based on a theory of change
that ponders the complex social context that
emits multiple messages about gender roles
and expectations influencing sexual behaviour.
The Social Ecological Model16 developed by
Bronfenbrenner in the late 1970s explains
the complex relationship between the individual and cultural norms, socio-economic
status and inequality, legal and institutional

128

factors, and the media. We used this model

to look at how interpersonal relations and
interactions with peers, family members, school
teachers and other social networks and support systems influence sexual behaviour. The
model provides an opportunity for clarification
of ones own values, feelings, beliefs and attitudes, which exist in a social context, and to
question assumptions that are prevalent in
the cultural environment.
Rights-based embracing the UN Population
Funds rights-based framework, which argues
that the rights of the individual are enforced
when institutions assume responsibility for
respecting, protecting and promoting them.
UNFPAs Framework for Action on Adolescents
and Young Adults focuses on how to enable
youth to be rights holders by ensuring access
to sexual health education to all youth, making
health services available to teens, and facilitating opportunities for youth participation in a
leadership capacity (www.unfpa.org/webdav/
site/global/shared/documents/publications/
2007/framework_youth.pdf).

Field-testing the programme

Before starting the programme in full in LA schools,
we decided to do pilot studies to compare the

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impact of the new classroom curriculum of 12 sessions to a basic curriculum of three sessions.
A randomized evaluation has been under way
since 2008, conducted by the Center for Adolescent
Health and Development at the Public Health
Institute in collaboration with the University of
Southern California Keck School of Medicine.
PPLA and several public schools signed an
agreement allowing for ten high schools to
participate in the formal study. Eight schools
were independent charter schools (not part of
the LA school district) that do not offer health
classes but have autonomy to expand on the
required curriculum. Two schools were in the LA
school district and offered health classes that
could include sexuality education. During the
formative part of the evaluation, the classroom
curriculum was tested in two large public high
schools in 2008/09, and a revised curriculum
was tested in one public charter high school in
2009/10. In 2010/11, a further field test of all four
programme components took place in six schools.
The formal randomized evaluation of the full programme started in 2011/12. It employed a twotrack randomization design in which four schools
received all four programme components, and four
schools received only the classroom curriculum,
and simultaneously all classrooms in the eight
schools were randomized for two types of curriculum, 12 sessions or three sessions. In 2012/13 two
more schools were added and randomized in the
same fashion. The study will end in 2014 with a
final year of follow-up data collection, results analysis and dissemination. To date, 2,608 students
and 1,915 parents have participated in the study,
and another 1,560 students will be added in the
spring of 2013.
As we approach the end of the second year of
the evaluation, we have begun to see consistent
patterns in the impact of the programme on both
students and parents, e.g. preliminary data have
shown increases in students carrying condoms
with them, and reporting feeling more comfortable
talking about sexuality.

tionship, both teen boys and girls cited respect,

honesty, privacy and freedom.
Most students strongly agreed that human
rights are important and cited the right to selfexpression, to vote, to equal education, and to
access health care. They also mentioned LGBT
and womens rights, and the right to speak
Spanish. But when prompted to talk about rights
violations, they didnt mention violations of the
same rights they had just listed. Instead, they
brought up violations of workers rights and immigration issues like sexual slavery, or the working
conditions in sweatshops in which workers usually
immigrants are subjected to extreme exploitation and forced to work long hours at low wages
and under oppressive conditions, including threats
and abuse.
When presented with the IPPF Charter of Sexual
and Reproductive Rights, students agreed with
most of the rights, but identified grey areas, e.g.
in differentiating between assertiveness and being
abusive. Students seemed clear about social rights,
but when applied to relationships, things became
blurred for them.
Thats not how it is in real life, like with the
right to have friends, and space away from your
girlfriend. What really goes on is the cheating, the
no trust, the following you around in school.
Girls feel that if they say no the guy is going to
take it the wrong way and stuff is going to
happen. So its like their power is taken away,
the will to say no is taken from them because
theyre thinking about the guy.
Some girls feel that if a guy buys them a very
expensive meal, that is as if he was saying:
Look I bought this, what am I going to get
in return?

Sexuality education in the classroom

Testing the key concepts

When addressing issues like these in the classroom, SEI facilitators validate students concerns
by voicing them to the class, launching a dialogue,
and offering suggestions.

The key curriculum concepts were tested in eight

focus group discussions with 50 teens and three
focus group discussions with 21 parents, which
gave invaluable insights into how American teens
understand rights in an intimate relationship.
When asked about whats important in a rela-

So you are saying that some people dont respect

your right to be yourself and have your own
space. How might someone feel if their partner
is following them around or checking up on them?
How could someone talk to a partner about their
right to have their own space?
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You could talk about what trust means to you,

because it might mean different things to different
people. It is okay if jealousy comes up, if people are
willing to talk openly about it. How might someone
respectfully express that they are jealous?
The curriculum offers a good balance of evidence and interactive and critical learning, and is
designed so that facilitators can take students back
to earlier activities once they have gained a deeper
understanding of key concepts. The gender box
activity is one example that is frequently referred
to in later sessions. In this activity facilitators
draw two boxes with the titles masculinity and
femininity. Students are asked to list typical
characteristics that make up conventional, social
understandings of these concepts. (image below)
Following the anatomy session halfway through
and the last session of the curriculum, facilitators
ask students to write down anonymous questions,
which are then screened and answered by topic.
In a preliminary analysis of 673 questions, 36%
were about anatomy, followed by sexual behaviour
(27%). Pregnancy and contraception represented
16% of teens concerns, and 14% referred to doubts
about the value of condoms for protection against
STIs. In general, boys had more questions about
anatomy while girls asked more about behaviour.
Overall, teens seemed concerned or curious about
whats normal and whats not. Am I normal
questions and questions about perceived sexual
norms from the media or from friends (i.e.
penis size, pain at first intercourse, bleeding
and virginity) usually surface during these questionand-answer sessions.
Facilitators give direct, science-based answers
while protecting student identity. They also use

High school students fill in the Gender Box for

femininity during curriculum activity
130

this opportunity to correct common myths about

sexuality as well as the prevalence of sexual activity
among ninth grade students. Entering high school,
students tend to assume that most of their peers
are sexually active and are often surprised to learn
that nationwide only 33%17 of ninth grade students in 2007 had ever had sexual intercourse.

Peer advocacy training

The peer advocacy programme trains students to
be resources for sexual and reproductive health
information to the student body. This structured
after-school club is sponsored by a teacher and
facilitated by skilled PPLA trainers. Each spring
students apply to participate in the programme,
and approximately ten students are selected
at each school. They attend a 30-hour intensive,
hands-on training held in the summer, which
includes role-playing, sharing of experiences and
critical discussions.
Peer advocates are high-achieving students
who are involved in extracurricular activities like
music, student council and sports. Some have
part-time jobs at retail stores or fast food restaurants. Most of them are considering attending
in-state colleges, and all are looking forward to
graduation and being out in the real world.
PPLA educators meet weekly with these students
throughout the school year for further training
and to plan a minimum of four sexual health
awareness-raising events against bullying LGBT
people for national Coming Out Day, and hosting workshops for World AIDS Day and National
Condom Week. For each of these events students
develop information sessions, posters, and videos
for the student body.

Students attend training to become Peer Advocates.

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Engaging parents
Surveys with teens in the programme schools
have shown that they want to talk to their
parents about sexuality, but its not easy for
them and challenging for parents too. Many
parents dont feel prepared for those conversations, and to appear ignorant to a child on matters of anatomy can be dreadful. Parent classes
offer information that is relevant to adults and
facilitate conversations about how to convey to
teens their personal or family values about sexuality and sexual behaviour. Additionally, parent
coordinators volunteer to advertise parent education classes to the families of students at regular
parent gatherings.
The classes and materials used, including the
Parent Guide, are intended to remind parents
that teens are becoming sexually mature, and
that they have rights but still have a lot to learn.
Among other tips on how to frame the conversation are the following:
Even teens who are not having sex still have to
make decisions about sex. Saying no takes skills.
Loving relationships and intimacy are an important part of adult life.
Dont try to scare your teen into not having sex.
It doesnt work and may leave them with the
wrong information.
Remember you dont have to have all the
answers, and you dont need to share your own
sexual experiences. Listen, be open, and dont
focus on bad experiences only.
If your teen tells you they are interested in
dating people of the same sex, you may not know
how to respond to them. But there are resources
that can help. Keep talking. The more open you
are, the more you can support your teen.
If parents or guardians cant attend the classes,
the Guide is mailed to them, to ensure that each
household of a ninth grader (age 1416) receives
information on parent/child communication.
This is how one mother described the changes
in her own household after the programme had
been operating for some time:
With my older daughter I tried to protect her
from everything that happens these days, and
never talked to her about sexuality, but when
my son got involved in SEI, and came home and
talked to his sister and us about safe sex and

contraception, the whole family started talking.

He shares what hes learned with us, at first it
was weird, but then I also came to the parent
sessions, and now I know what he knows, and
we talk, and I trust him to make good decisions!

Involving teachers
High school students are often sexually active
before they have accurate information about
sexuality. The curriculum seeks to normalize sexuality education throughout the school. To that
end it secures buy-in from the Principal and
Assistant Principal at each site, and PPLA staff
connect to teachers and faculty who assist in
programme scheduling and implementation. Five
to seven ninth grade teachers give up their class
time for sexuality education. A teacher advisor on
each campus sponsors the Peer Advocate Club,
opening their classroom after school and assisting students in obtaining proper permission for
events. Counsellors and teachers help with peer
advocate recruitment each year, in addition to
reminding students about the five clinical events
on campus described below. Two teachers at
each school make their classrooms available for
the after-school clinical events so that health services can be provided near a private bathroom.
Five to ten self-selecting teachers become trained
condom distributors.

Sexual health services on campus

Our experience at Roosevelt High was unique
in the sense that it has a full on-site clinic, and
the local principal and school nurse understood
the benefit of offering sexual health services
to students. Unfortunately, most schools do not
have a clinic on the premises, and when they
do, nurses dont provide sexual health services.
Based on the Roosevelt experience, we worked
with other schools to bring minimal health services to each campus and assess whether and
how that would make a difference to how students acted on the information they received in
the classroom.
In all the schools involved in the SEI study,
Planned Parenthood brought health care to
students. Our premise was that some teenagers
may not feel comfortable going to a health center, and having services on campus would make
it less foreign and cumbersome for teens to
access care.
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Each participating school hosts a health

care event five times a year after school hours
(36 pm) offering students confidential and
friendly care that includes pregnancy and STI
testing, counselling, prescriptions for contraceptives, referrals, individualized follow-up in
the case of positive tests, and condoms. The easy
access to health services is part of our strategy
to integrate learning and practice, as well as
to promote a supportive environment where
adults care for and can be trusted by teens.
In addition to these limited health care events
on campus, educators inform students at every
classroom session and through peer advocates
about the nearest Planned Parenthood clinic in
their community, including PPLAs free phoneline
and website.

Tools and methodology: films and

critical discussions
The Initiative uses films to engage students in
critical thinking. Teens are presented with scenarios that are easy to relate to, but complex
and nuanced. Facilitators emphasize to students how encompassing sexuality is, and how
inter-related feelings and behaviours towards
sex and other people are. Building on real life

132

situations, the curriculum uses two films, Bitter

Memories and Reflections, which depict the
conflicts and difficult decisions teens face in
intimate relationships. These were produced by
Scenarios USA, an organization that works with
teens who write stories from their perspective,
in response to the question: Whats the real
deal? The films are then directed by Hollywood
film-makers (www.scenariosusa.org/films/film/
the-shortest-of-the-shorts/).
The first sexuality education session uses
Bitter Memories, a film about masculinity and
the cycle of violence. For example, facilitators
may start the conversation by saying:
In the film Bitter Memories, when we saw
Rob becoming increasingly irritated and jealous,
when he witnessed his partners behaviour, he
tried to communicate with Ashley, but she dismissed his concern by saying it was cute that he
was jealous. She confuses jealousy with caring.
That can create misunderstandings.
The film is shown to teens again in session four
when students discuss whether or not the characters in the film are respecting each others rights.
Reflections, a film about three friends who
get tested for HIV and the complex relationships
and decisions that lead up to that moment, is

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The training covers social-behavioural norms

based on gender, how values are attributed to
them, and how gender roles and stereotypes
impact sexual behaviours and intimate relationships. Facilitators learn how to question traditional views about men and women, especially
with respect to sexual behaviour, sexuality and
sexual identity. Facilitators learn to ask question
such as:

In this scene from Reflections, best friends learn to

take the risk of HIV/AIDS seriously as they navigate
romantic relationships.
used in session nine to highlight HIV prevention,
testing and treatment. The film focuses on a
young woman who intended to use a condom
but then hesitantly decides to have unprotected
sex with her older boyfriend. The fact that she
abandons her original intention is used as a
springboard to a discussion about consent and
coercion when one partner has more power than
the other, thus allowing students to explore
assumptions about consent vs. actual consent,
issues of right or wrong in the context of personal
values and beliefs, as well as legal implications
of rape (which constitutes a crime) and abusive
behaviour (as not acceptable).

Training of facilitators
The Initiative relies on skilled facilitators who,
in addition to serving as sexuality educators, are
trained to guide students through the curriculum, and facilitate the learning process. For the
formal evaluation, facilitators were PPLA educators on staff, but they can be volunteers, teachers
or community leaders as long as they receive
appropriate training in how to make connections between health and social norms, personal
behaviour and power dynamics, respect and trust,
and so on. Their training includes a structured
three-day workshop in a group of 1215 people,
followed by 18 additional hours of shadowing
a skilled facilitator at a school, and then individual coaching and practice. The aim is to improve
their ability to draw meaningful links that can
break gender stereotypes and sharpen teens critical thinking about social norms.

How does a couple decide if they are going to

have sex? Does it just happen? Or maybe the
guy takes the lead? How does that put pressure
on guys? How does that put pressure on girls?
How do same-sex couples decide to have sex?
How could a couple share responsibility when it
comes to having sex?
If a couple goes out, how do they decide who
pays? Are they deciding together who is going to
pay? Do you think girls worry more about what
their partner is going to think if they say no to
sex? What do girls worry about? What about
guys? How is this related to being inside or outside the gender boxes? Feeling that you have
to conform to the gender boxes can feel really
limiting that you dont have much power to do
or say what you want.
In answering these questions, facilitators remind
students that social norms are not necessarily
fair. They remind teens that boys and girls have
the same rights; LGBT rights are also brought to
students attention. Sexual orientation is explicitly
addressed in the sexuality session and facilitators
are trained on how to reference LGBT identity in
other sessions. Facilitators are trained to discuss
the difference between sex and gender, as well
as sexual orientation, and highlight the different
ways that people might identify themselves, including heterosexual, homosexual and/or bisexual.
When processing activities with students, facilitators
expand on each comment to help students see a
range of orientations, behaviours and feelings.

Implementation and challenges

Implementing and evaluating the programme
in real time, in public schools where schedules
change, principals and teachers leave, schools go
on lock down mode, or students break into fist
fights, has been a huge challenge. Often research
studies are implemented in a controlled environment with no unpredictable situations. The
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M Marques, N Ressa. Reproductive Health Matters 2013;21(41):124135

Initiative was evaluated under every-day circumstances including last-minute changes to

classroom schedules and regular disruption
by students with serious behavioural issues
or even extreme discomfort with the subject
matter. On occasion, entire school campuses have
been locked down due to neighbourhood crime.
Additionally, students are not used to a learnercentred approach and struggle when asked directly
about what they think.
On the positive side, the results will be a
real measure of what the programme can do.
The four components are working well together.
In our experience the new programme is by
far the best way to move the needle towards
behaviour change. We have worked intently
to distil complex concepts and deliver a
product that fits into the public school structure and balances information and analytical
thinking, including all required evidence-based
information, using simple terms and a linear
structure. While we are just scratching the
surface of these concepts, we are confident
that students will come out of the programme
better prepared to understand human sexuality
as a normal, healthy aspect of human development, that all individuals have human
rights, and that teenagers have the right to
health care, education, information, protection
under the law, dignity and privacy. We aim for
them to be able to engage in conversations
with parents/guardians or other trusted adults
about their personal, family and community
beliefs about sexual behaviours, differentiate
between an unhealthy and a healthy relationship and be better able to communicate and

understand what others communicate in their

personal relationships.

Conclusion
By celebrating diversity and promoting understanding of social justice and rights PPLAs Sexuality
Education Initiative seeks to enable young people
to question harmful assumptions and to stand
up against the abuse of power and discrimination. Without critical questioning, girls and young
women may remain in a subordinate position to
a male partner, and LGBT youth may be either
excluded or ridiculed. Our hope is that more and
more educational programmes for teens will
question assumptions about gender and sexuality
that will eventually result in a more respectful and
accepting environment for the safe expression of
diverse sexual identities.
Acknowledgements
The authors wish to acknowledge the contributions of the following colleagues: Andrea Irvin,
Eva Goldfarb, and Ernestine Heldring in the development of the SEI curriculum; the input from
the SEI Project Advisory Group; the expertise of
Norm Constantine and Luanne Rohrbach in the
design and implementation of the SEI research;
and PPLA educators who developed and delivered
the full programme. Planned Parenthood thanks
its institutional partners in the launching of
SEI: Green Dot Public Charter Schools, Los Angeles
Unified School District, Partnership for Los Angeles
Schools, and Scenarios USA. The authors are grateful to the Ford Foundation and many other donors
for their support for this programme.

References
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www.guttmacher.org/pubs/FB-Teens-Sex-Ed.html#6.
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pregnancy in the United States: the contribution of
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Rsum
Suite aux programmes uniquement fonds sur
labstinence aux tats-Unis, qui encouragent
des mythes et ides fausses sur la sexualit et
le comportement sexuel, la communaut de
lducation sexuelle globale a t carte de
lamlioration de lducation sexuelle disponible
dans les coles amricaines depuis prs de vingt
ans. Il reste encore beaucoup faire pour
dpasser les approches dictes par la peur et
la communication sens unique des informations
que beaucoup de programmes utilisent encore.
Depuis 2008, Planned Parenthood Los Angeles
a labor et lanc un programme dducation
sexuelle des adolescents, bas sur la pense
critique, les droits de lhomme, lgalit entre les
sexes et laccs aux soins de sant. Ce programme
repose sur une thorie du changement qui
reconnat les relations complexes entre les
individus et les normes culturelles, le statut
socio-conomique, les disparits sanitaires et les
facteurs juridiques et institutionnels. Linitiative
dducation la sexualit consiste en un programme
de 12 sances pour les lves de neuvime
anne, un atelier pour les parents, un programme
de formation des pairs au plaidoyer et laccs
aux services de sant sexuelle. Larticle dcrit le
dveloppement et lvaluation de cette initiative,
et le cadre de droits ayant t utilis, qui cherche
amliorer lapprentissage, renforcer les capacits
des coles, des enseignants et des parents
aider les adolescents prendre efficacement
en charge leur sexualit et comprendre quils
ont droit des soins de sant, une ducation,
des informations et une protection, dans la dignit
et la confidentialit.

Resumen
En respuesta a los programas de abstinencia
exclusiva de Estados Unidos que promueven
mitos e ideas errneas sobre la sexualidad y el
comportamiento sexual, la comunidad de educacin
sexual integral se ha descarrilado de mejorar
la educacin sexual disponible en escuelas
estadounidenses durante casi dos dcadas. An
falta mucho trabajo por hacer para trascender
los enfoques basados en temor y la comunicacin
unidireccional de informacin que continan
utilizando muchos programas. Comenzando en
2008, Planned Parenthood Los Angeles cre y
puso en marcha un programa de educacin sexual
centrado en adolescentes y basado en pensamiento
crtico, derechos humanos, igualdad de gnero y
acceso a servicios de salud, fundado en una teora
de cambio que reconoce la compleja relacin
entre cada persona y las normas culturales,
condicin socioeconmica, disparidades de
salud y factores jurdicos e institucionales. La
Iniciativa de educacin sexual consiste en un
currculo de 12 sesiones de educacin sexual
para estudiantes de noveno grado; talleres para
sus padres; un programa de capacitacin de pares
en promocin y defensa; y acceso a servicios de
salud sexual. En este artculo se describe cmo se
elabor esta iniciativa y cmo se est evaluando,
as como el marco utilizado, basado en los
derechos, cuya finalidad es mejorar la experiencia
de aprendizaje, fortalecer la capacidad de las
escuelas, maestros y padres para ayudar a la
adolescencia a manejar su sexualidad con eficacia
y a entender que tienen derecho a servicios
de salud, educacin, informacin, proteccin,
dignidad y privacidad.
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